Erosion of the Capital City Advantage in Child Survival and Reproductive, Maternal, Newborn, and Child Health Intervention Coverage in Sub-Saharan Africa.

The place of residence is a major determinant of RMNCH outcomes, with rural areas often lagging in sub-Saharan Africa. This long-held pattern may be changing given differential progress across areas and increasing urbanization. We assessed inequalities in child mortality and RMNCH coverage across capital cities and other urban and rural areas. We analyzed mortality data from 163 DHS and MICS in 39 countries with the most recent survey conducted between 1990 and 2020 and RMNCH coverage data from 39 countries. We assessed inequality trends in neonatal and under-five mortality and in RMNCH coverage using multilevel linear regression models. Under-five mortality rates and RMNCH service coverage inequalities by place of residence have reduced substantially in sub-Saharan Africa, with rural areas experiencing faster progress than other areas. The absolute gap in child mortality between rural areas and capital cities and that between rural and other urban areas reduced respectively from 41 and 26 deaths per 1000 live births in 2000 to 23 and 15 by 2015. Capital cities are losing their primacy in child survival and RMNCH coverage over other urban areas and rural areas, especially in Eastern Africa where under-five mortality gap between capital cities and rural areas closed almost completely by 2015. While child mortality and RMNCH coverage inequalities are closing rapidly by place of residence, slower trends in capital cities and urban areas suggest gradual erosion of capital city and urban health advantage. Monitoring child mortality and RMNCH coverage trends in urban areas, especially among the urban poor, and addressing factors of within urban inequalities are urgently needed.

Effective multi-sectoral approach for rapid reduction in maternal and neonatal mortality: the exceptional case of Bangladesh.

BACKGROUND: Bangladesh experienced impressive reductions in maternal and neonatal mortality over the past several decades with annual rates of decline surpassing 4% since 2000. We comprehensively assessed health system and non-health factors that drove Bangladesh's success in mortality reduction. METHODS: We operationalised a comprehensive conceptual framework and analysed available household surveys for trends and inequalities in mortality, intervention coverage and quality of care. These include 12 household surveys totalling over 1.3 million births in the 15 years preceding the surveys. Literature and desk reviews permitted a reconstruction of policy and programme development and financing since 1990. These were supplemented with key informant interviews to understand implementation decisions and strategies. RESULTS: Bangladesh prioritised early population policies to manage its rapidly growing population through community-based family planning programmes initiated in mid-1970s. These were followed in the 1990s and 2000s by priority to increase access to health facilities leading to rapid increases in facility delivery, intervention coverage and access to emergency obstetric care, with large contribution from private facilities. A decentralised health system organisation, from communities to the central level, openness to private for-profit sector growth, and efficient financing allocation to maternal and newborn health enabled rapid progress. Other critical levers included poverty reduction, women empowerment, rural development, and culture of data generation and use. However, recent empirical data suggest a slowing down of mortality reductions. CONCLUSION: Bangladesh demonstrated effective multi-sectoral approach and persistent programming, testing and implementation to achieve rapid gains in maternal and neonatal mortality reduction. The slowing down of recent mortality trends suggests that the country will need to revise its strategies to achieve the Sustainable Development Goals. As fertility reached replacement level, further gains in maternal and neonatal mortality will require prioritising universal access to quality facility delivery, and addressing inequalities, including reaching the rural poor.

Learning from success: the main drivers of the maternal and newborn health transition in seven positive-outlier countries and implications for future policies and programmes.

Currently, about 8% of deaths worldwide are maternal or neonatal deaths, or stillbirths. Maternal and neonatal mortality have been a focus of the Millenium Development Goals and the Sustainable Development Goals, and mortality levels have improved since the 1990s. We aim to answer two questions: What were the key drivers of maternal and neonatal mortality reductions seen in seven positive-outlier countries from 2000 to the present? How generalisable are the findings?We identified positive-outlier countries with respect to maternal and neonatal mortality reduction since 2000. We selected seven, and synthesised experience to assess the contribution of the health sector to the mortality reduction, including the roles of access, uptake and quality of services, and of health system strengthening. We explored the wider context by examining the contribution of fertility declines, and the roles of socioeconomic and human development, particularly as they affected service use, the health system and fertility. We analysed government levers, namely policies and programmes implemented, investments in data and evidence, and political commitment and financing, and we examined international inputs. We contextualised these within a mortality transition framework.We found that strategies evolved over time as the contacts women and neonates had with health services increased. The seven countries tended to align with global recommendations but could be distinguished in that they moved progressively towards implementing their goals and in scaling-up services, rather than merely adopting policies. Strategies differed by phase in the transition framework-one size did not fit all.

Challenges in reducing maternal and neonatal mortality in Niger: an in-depth case study.

INTRODUCTION: Recent modelled estimates suggest that Niger made progress in maternal mortality since 2000. However, neonatal mortality has not declined since 2012 and maternal mortality estimates were based on limited data. We researched the drivers of progress and challenges. METHODS: We reviewed two decades of health policies, analysed mortality trends from United Nations data and six national household surveys between 1998 and 2021 and assessed coverage and inequalities of maternal and newborn health indicators. Quality of care was evaluated from health facility surveys in 2015 and 2019 and emergency obstetric assessments in 2011 and 2017. We determined the impact of intervention coverage on maternal and neonatal lives saved between 2000 and 2020. We interviewed 31 key informants to understand the factors underpinning policy implementation. RESULTS: Empirical maternal mortality ratio declined from 709 to 520 per 100 000 live births during 2000-2011, while neonatal mortality rate declined from 46 to 23 per 1000 live births during 2000-2012 then increased to 43 in 2018. Inequalities in neonatal mortality were reduced across socioeconomic and demographic strata. Key maternal and newborn health indicators improved over 2000-2012, except for caesarean sections, although the overall levels were low. Interventions delivered during childbirth saved most maternal and newborn lives. Progress came from health centre expansion, emergency care and the 2006 fee exemptions policy. During the past decade, challenges included expansion of emergency care, continued high fertility, security issues, financing and health workforce. Social determinants saw minimal change. CONCLUSIONS: Niger reduced maternal and neonatal mortality during 2000-2012, but progress has stalled. Further reductions require strategies targeting comprehensive care, referrals, quality of care, fertility reduction, social determinants and improved security nationwide.

Delays in accessing high-quality care for newborns in East Africa: An analysis of survey data in Malawi, Mozambique, and Tanzania.

Background: Despite the existence of evidence-based interventions, substantial progress in reducing neonatal mortality is lagging, indicating that small and sick newborns (SSNs) are likely not receiving the care they require to survive and thrive. The 'three delays model' provides a framework for understanding the challenges in accessing care for SSNs. However, the extent to which each delay impacts access to care for SSNs is not well understood. To fill this evidence gap, we explored the impact of each of the three delays on access to care for SSNs in Malawi, Mozambique, and Tanzania. Methods: Secondary analyses of data from three different surveys served as the foundation of this study. To understand the impact of delays in the decision to seek care (delay 1) and the ability to reach an appropriate point of care (delay 2), we investigated time trends in place of birth disaggregated by facility type. We also explored care-seeking behaviours for newborns who died. To understand the impact of delays in accessing high-quality care after reaching a facility (delay 3), we measured facility readiness to manage care for SSNs. We used this measure to adjust institutional delivery coverage for SSN care readiness. Results: Coverage of institutional deliveries was substantially lower after adjusting for facility readiness to manage SSN care, with decreases of 30 percentage points (pp) in Malawi, 14 pp in Mozambique, and 24 pp in Tanzania. While trends suggest more SSNs are born in facilities, substantial gaps remain in facilities' capacities to provide lifesaving interventions. In addition, exploration of care-seeking pathways revealed that a substantial proportion of newborn deaths occurred outside of health facilities, indicating barriers in the decision to seek care or the ability to reach an appropriate source of care may also prevent SSNs from receiving these interventions. Conclusions: Investments are needed to overcome delays in accessing high-quality care for the most vulnerable newborns, those who are born small or sick. As more mothers and newborns access health services in low- and middle-income countries, ensuring that life-saving interventions for SSNs are available at the locations where newborns are born and seek care after birth is critical.

Identifying and Characterizing the Poorest Urban Population Using National Household Surveys in 38 Cities in Sub-Saharan Africa.

Identifying and classifying poor and rich groups in cities depends on several factors. Using data from available nationally representative surveys from 38 sub-Saharan African countries, we aimed to identify, through different poverty classifications, the best classification in urban and large city contexts. Additionally, we characterized the poor and rich groups in terms of living standards and schooling. We relied on absolute and relative measures in the identification process. For absolute ones, we selected people living below the poverty line, socioeconomic deprivation status and the UN-Habitat slum definition. We used different cut-off points for relative measures based on wealth distribution: 30%, 40%, 50%, and 60%. We analyzed all these measures according to the absence of electricity, improved drinking water and sanitation facilities, the proportion of children out-of-school, and any household member aged 10 or more with less than 6 years of education. We used the sample size, the gap between the poorest and richest groups, and the observed agreement between absolute and relative measures to identify the best measure. The best classification was based on 40% of the wealth since it has good discriminatory power between groups and median observed agreement higher than 60% in all selected cities. Using this measure, the median prevalence of absence of improved sanitation facilities was 82% among the poorer, and this indicator presented the highest inequalities. Educational indicators presented the lower prevalence and inequalities. Luanda, Ouagadougou, and N'Djaména were considered the worst performers, while Lagos, Douala, and Nairobi were the best performers. The higher the human development index, the lower the observed inequalities. When analyzing cities using nationally representative surveys, we recommend using the relative measure of 40% of wealth to characterize the poorest group. This classification presented large gaps in the selected outcomes and good agreement with absolute measures.

Climate shocks and nutrition: The role of food security policies and programs in enhancing maternal and neonatal survival in Niger.

Niger is afflicted with high rates of poverty, high fertility rates, frequent environmental crises, and climate change. Recurrent droughts and floods have led to chronic food insecurity linked to poor maternal and neonatal nutrition outcomes in vulnerable regions. We analyzed maternal and neonatal nutrition trends and subnational variability between 2000 and 2021 with a focus on the implementation of policies and programs surrounding two acute climate shocks in 2005 and 2010. We used four sources of data: (a) national household surveys for maternal and newborn nutritional indicators allowing computation of trends and differences at national and regional levels; (b) document review of food security reports; (c) 30 key informant interviews and; (d) one focus group discussion. Many food security policies and nutrition programs were enacted from 2000 to 2020. Gains in maternal and neonatal nutrition indicators were more significant in targeted vulnerable regions of Maradi, Zinder, Tahoua and Tillabéri, from 2006 to 2021. However, poor access to financial resources for policy execution and suboptimal implementation of plans have hindered progress. In response to the chronic climate crisis over the last 20 years, the Nigerien government and program implementers have demonstrated their commitment to reducing food insecurity and enhancing resilience to climate shocks by adopting a deliberate multisectoral effort. However, there is more that can be achieved with a continued focus on vulnerable regions to build resilience, targeting high risk populations, and investing in infrastructure to improve health systems, food systems, agriculture systems, education systems, and social protection.

The impact of the COVID-19 pandemic on trends in stillbirths, under-5 and maternal mortality in Brazil: Excess deaths and regional inequalities.

Background: Despite the proliferation of studies on the impact of the coronavirus disease 2019 (COVID-19) pandemic, there is less evidence on the indirect death toll compared to the health system and service provision disruptions. We assessed the impact of the COVID-19 pandemic on national and regional trends and differences in stillbirths, under-5 and maternal deaths in Brazil. Methods: We used the nationwide routine health information system data from January 2017 to December 2021, to which we applied descriptive and advanced mixed effects ordinary least squared regression models to measure the percent change in mortality levels during the COVID-19 pandemic (March 2020 to December 2021). We carried out counterfactual analyses comparing the observed and expected mortality levels for each type of mortality at national and regional levels. Results: Stillbirths increased 4.8% (3.1% in 2020 and 6.2% in 2021) and most noticeably maternal deaths increased 71.6% (35.3% in 2020 and 103.3% in 2021) over the COVID-19 period. An opposite pattern was observed in under-5 mortality, which dropped -10.2% (-12.5% in 2020 and -8.1% in 2021). We identified regional disparities, with a higher percent increase in stillbirths observed in the Central-West region and in maternal deaths in the South region. Discussion: Based on pre-pandemic trends and expected number of deaths in the absence of the COVID-19, we observed increases in stillbirths and maternal deaths and reductions in under-5 deaths during the pandemic. The months with the highest number of deaths (stillbirths and maternal deaths) coincided with the months with the highest mortality from COVID-19. The increase in deaths may also have resulted from indirect effects of the pandemic, such as unavailability of health services or even reluctance to go to the hospital when necessary due to fear of contagion. Conclusions: In Brazil, the COVID-19 outbreak and subsequent restrictions had a detrimental impact on stillbirths and maternal deaths. Even before the pandemic, mortality trends highlighted pre-existing regional inequalities in the country's health care system. Although there were some variations, increases were observed in all regions, indicating potential weaknesses in the health system and inadequate management during the pandemic, particularly concerning pregnant and postpartum women.

Experiences of parents and caretakers going through the consent process to perform minimally invasive tissue sampling (MITS) on their deceased children in Quelimane, Mozambique: A qualitative study.

BACKGROUND: In Mozambique, the Countrywide Mortality Surveillance for Action (COMSA) Program implemented a child mortality surveillance to strengthen vital events registration (pregnancies, births, and deaths) and investigate causes of death using verbal autopsies. In Quelimane district, in addition to the abovementioned cause of death determination approaches, minimally invasive tissue sampling (MITS) was performed on deceased children <5years of age. This study focused on understanding deceased children parents' and caretakers' experiences of the consent process to perform MITS in order to contribute to the improvement of approaches to cause of death investigation and inform efforts to maximize acceptability of mortality surveillance activities. METHODS: A qualitative study was conducted in six urban and semi-urban communities in Quelimane district. A total of 40 semi-structured interviews with family members of deceased children and 50 non-participant observations of the consent process were conducted to explore their experience with informed consent request to perform MITS on their child. Data analysis of the interviews and observations was thematic, being initially deductive (predetermined codes) followed by the generation of new codes according to the data (inductive).The Consolidated criteria for reporting qualitative research (COREQ) guidelines for reporting qualitative studies were performed. FINDINGS: Although most participants consented to the performance of MITS on their deceased child, some stated they had not fully understood the MITS procedure despite the informed consent process due to unclear information and their state of mind after their loss. Consenting to MITS and doing so with family members disagreeing were also identified as stress-enhancing factors. Participants also described dissatisfaction of family members, resulting from the condition of the body delivered after tissue collection. In addition, the waiting time to receive the body and resulting delays for the funeral were considered additional factors that may increase stress and compromise the acceptability of MITS. CONCLUSION: Family experiences were influenced by operational and logistical issues linked to the procedure itself and by it being in tension with social and cultural issues, which caused stress and discontentment on parents and caretakers of deceased children. The main factors that contributed to the experience of going through the MITS process were the state of mind after the death, complex decision making processes within the family, washing of the body for purification after MITS and seepage, and limited understanding of consent for MITS. When requesting consent for MITS, emphasis should be placed on transmitting clear and understandable information about MITS procedures to participants.

Maternal mortality, stillbirths, and neonatal mortality: a transition model based on analyses of 151 countries.

BACKGROUND: Maternal mortality, stillbirths, and neonatal mortality account for almost 5 million deaths a year and are often analysed separately, despite having overlapping causes and interventions. We propose a comprehensive five-phase mortality transition model to improve analyses of progress and inform strategic planning. METHODS: In this empirical data-driven study to develop a model transition, we used UN estimates for 151 countries to assess changes in maternal mortality, stillbirths, and neonatal deaths. On the basis of ratios of maternal to stillbirth and neonatal mortality, we identified five phases of transition, in which phase 1 has the highest mortality and phase 5 has the lowest. We used global databases to examine phase-specific characteristics during 2000-20 for causes of death, fertility rates, abortion policies, health workforce and financing, and socioeconomic indicators. We analysed 326 national surveys to assess service coverage and inequalities by transition phase. FINDINGS: Among 116 countries in phases 1 to 4 in 2000, 73 (63%) progressed at least one phase by 2020, six advanced two phases, and three regressed. The ratio of stillbirth and neonatal deaths to maternal deaths increased from less than 10 in phase 1 to well over 50 in phase 4 and phase 5. Progression was associated with a declining proportion of deaths caused by infectious diseases and peripartum complications, declining total and adolescent fertility rates, changes in health-workforce densities and skills mix (ie, ratio of nurses or midwives to physicians) from phase 3 onwards, increasing per-capita health spending, and reducing shares of out-of-pocket health expenditures. From phase 1 to 5, the median coverage of first antenatal care visits increased from 66% to 98%, four or more antenatal care visits from 44% to 94%, institutional births from 36% to 99%, and caesarean section rates from 2% to 25%. The transition out of high-mortality phases involved a major increase in institutional births, primarily in lower-level health facilities, whereas subsequent progress was characterised by rapid increases in hospital births. Wealth-related inequalities reduced strongly for institutional birth coverage from phase 3 onwards. INTERPRETATION: The five-phase maternal mortality, stillbirth, and neonatal mortality transition model can be used to benchmark the current indicators in comparison to typical patterns in the transition at national or sub-national level, identify outliers to better assess drivers of progress, and inform strategic planning and investments towards Sustainable Development Goal targets. It can also facilitate programming for integrated strategies to end preventable maternal mortality and neonatal mortality and stillbirths. FUNDING: Bill & Melinda Gates Foundation.

A Qualitative Assessment of Community Acceptability and Its Determinants in the Implementation of Minimally Invasive Tissue Sampling in Children in Quelimane City, Mozambique.

The Countrywide Mortality Surveillance for Action project aims to implement a child mortality surveillance program through strengthening vital registration event reporting (pregnancy, birth, and death) and investigating causes of death (CODs) based on verbal autopsies. In Quelimane (central Mozambique), Minimally Invasive Tissue Sampling (MITS) procedures were added to fine-tune the COD approaches. Before the implementation of MITS, an evaluation of the acceptability and ethical considerations of child mortality surveillance was considered fundamental. A socio-anthropological study was conducted in Quelimane, using observations, informal conversations, semi-structured interviews, and focus group discussions with healthcare providers, nharrubes (traditional authorities who handle bodies before the funeral), community and religious leaders, and traditional birth attendants to understand the locally relevant potential facilitators and barriers to the acceptability of MITS. Audio materials were transcribed, systematically coded, and analyzed using NVIVO12®. The desire to know the COD, intention to discharge the elders from accusations of witchcraft, involvement of leaders in disseminating project information, and provision of transport for bodies back to the community constitute potential facilitators for the acceptability of MITS implementation. In contrast, poor community mobilization, disagreement with Islamic religious practices, and local traditional beliefs were identified as potential barriers. MITS was considered a positive innovation to determine the COD, although community members remain skeptical about the procedure due to tensions with religion and tradition. Therefore, the implementation of MITS in Quelimane should prioritize the involvement of a variety of influential community and religious leaders.

From External to Local: Opportunities and Lessons Learned from Transitioning COMSA-Mozambique.

Donor transitions, where externally funded programs transfer to country ownership and management, are increasingly common. The Countrywide Mortality Surveillance for Action - Mozambique (COMSA) project established a nationwide surveillance system capturing vital events at the community level with funding from the Bill and Melinda Gates Foundation. COMSA was implemented in partnership between Johns Hopkins University (a U.S.-based academic institution) and the Instituto Nacional de Saúde (National Institute for Health) and Instituto Nacional de Estatística (National Institute for Statistics), two Mozambican public institutions. Midway through the project, the Gates Foundation directed COMSA's partners to develop and implement a transition plan that ensured COMSA's activities could be institutionalized after Gates Foundation funding ended. Here we describe the process and activities that COMSA underwent for transition planning, including stakeholder engagement and advocacy, securing financial commitments, documenting operational activities, capacity building, and supporting strategic planning. Facilitators included a project model that already embedded significant implementation and management responsibility with local agencies, high-level commitment to COMSA's activities from local stakeholders, establishing dedicated personnel and budget to manage transition, and fortuitous timing for financing. Challenges included needing to engage multiple government agencies to ensure buy-in, navigating tensions around future roles and responsibilities, reviewing and adjusting existing implementation structures, and the reality that this transition involved shifting financing from one development partner to another. Transition implementation was also constrained by the COVID-19 pandemic because key stakeholders were engaged in response efforts. COMSA's experience highlights lessons and threats for future programs facing donor transition in uncertain environments.

Multi-Cause Calibration of Verbal Autopsy-Based Cause-Specific Mortality Estimates of Children and Neonates in Mozambique.

The Countrywide Mortality Surveillance for Action platform is collecting verbal autopsy (VA) records from a nationally representative sample in Mozambique. These records are used to estimate the national and subnational cause-specific mortality fractions (CSMFs) for children (1-59 months) and neonates (1-28 days). Cross-tabulation of VA-based cause-of-death (COD) determination against that from the minimally invasive tissue sampling (MITS) from the Child Health and Mortality Prevention project revealed important misclassification errors for all the VA algorithms, which if not accounted for will lead to bias in the estimates of CSMF from VA. A recently proposed Bayesian VA-calibration method is used that accounts for this misclassification bias and produces calibrated estimates of CSMF. Both the VA-COD and the MITS-COD can be multi-cause (i.e., suggest more than one probable COD for some of the records). To fully use this probabilistic COD data, we use the multi-cause VA calibration. Two different computer-coded VA algorithms are considered-InSilicoVA and EAVA-and the final CSMF estimates are obtained using an ensemble calibration that uses data from both the algorithms. The calibrated estimates consistently offer a better fit to the data and reveal important changes in the CSMF for both children and neonates in Mozambique after accounting for VA misclassification bias.

Implementing the Countrywide Mortality Surveillance in Action in Mozambique: How Much Did It Cost?

Complete sample registration systems are almost inexistent in sub-Saharan Africa. The Countrywide Mortality Surveillance in Action (COMSA) project in Mozambique, a national mortality and cause of death surveillance system, was launched in January 2017, began data collection in March 2018, and covers over 800,000 population. The objectives of this analysis are to quantify the costs of establishing and maintaining the project between 2017 and 2020 and to assess the cost per output of the surveillance system using data from financial reports produced by the National Institute of Health in Mozambique. The program cost analysis consists of start-up (fixed) costs and average annual operating costs covering the period of maximum implementation in 700 clusters. The cost per output analysis quantifies the annual operating cost of surveillance outputs during the same period. Approximately two million dollars were spent on setting up the system, with infrastructure, technological investments, and training making up over 80% of these start-up costs. The average annual operating costs of maintaining COMSA was $984,771 per year, of which 66% were spent on wages and data collection incentives. The cost per output analysis indicates costs of $37-$42 per vital event captured in the surveillance system (deaths, pregnancies, pregnancy outcomes), $303-$340 per verbal and social autopsy conducted on a reported death, and a per capita cost of $1-$1.3. In conclusion, establishing COMSA required large costs associated with infrastructure and technological investments. However, the system offers long-term benefits for real-time data generation and informing government decision-making for health.

Completeness and Factors Affecting Community Workers' Reporting of Births and Deaths in the Countrywide Mortality Surveillance for Action in Mozambique.

Since March 2018, the Countrywide Mortality Surveillance for Action project, implemented as a national sample registration system by the Mozambique Instituto Nacional de Saude and the Instituto Nacional de Estatistica in 700 geographic clusters randomly distributed across the 11 provinces, has trained and deployed community surveillance agents (CSAs) to report births and deaths in each cluster prospectively. An independent, retrospective data collection was conducted to assess the completeness of surveillance data. Record linkage procedures were used to match households and vital events reported in the two data sources. We calculated birth and death reporting rates and used a regression model to determine factors associated with the likelihood of vital events being reported by the CSAs. Between March 2018 and December 2019, CSAs reported 54% of births (8,787/16,421) and 45% of deaths (1,726/3,867). Births of smaller cluster sizes (< 1,000 people) were more likely to be reported (adjusted odds ratio [aOR] = 1.45; 95% CI = 1.15-1.83) compared with those of larger cluster sizes (> 1,500 people). Deaths of rural clusters were more likely to be reported (aOR = 1.41; 95% CI = 1.07-1.85) than those of urban clusters. Adult deaths were more likely to be reported (aOR = 1.49; 95% CI = 1.10-2.02) than child deaths. Our findings suggest that a fully functioning sample vital registration system must adopt a dual system with high-quality surveys or other ways to estimate underregistration periodically, consider a smaller cluster size manageable by a community worker, and pay special attention to urban clusters as underreporting is larger.

Verbal and Social Autopsy of Adult Deaths and Adult Care-Seeking Pattern in Mozambique, 2019-2020.

In sub-Saharan Africa, recent data about causes of adult death and care-seeking during illnesses are limited. This analysis examines adult deaths using verbal and social autopsy data from a nationally and provincially representative sample registration system in Mozambique. Causes of death among those 18 years and older were assigned using the InSilicoVA algorithm, and underlying social causes were examined using the pathway to survival model. Care-seeking was analyzed in different groups to determine if care was sought from formal providers (doctor, nurse/midwife, and trained community health worker) or other providers (traditional provider, family member, and pharmacist), using χ2 tests and multinomial regression models. Among the 4,040 adult deaths reported during 2019-2020, the major causes were HIV (17%), cancer (13%), injury (10%), cardiovascular diseases (9%), pneumonia (7%), tuberculosis (5%), and maternal causes (3%). Formal care-seeking was more likely among adults who had primary or higher level education (relative risk ratio [RRR]: 1.6, P < 0.001; RRR: 1.7, P < 0.01), were married (RRR: 1.3, P < 0.01), and had highest household wealth (RRR: 3.1, P < 0.001). Formal care-seeking was less likely among adults who were male (RRR: 0.7, P < 0.001), had social capital (RRR: 0.7, P < 0.05), or resided in the southern region (RRR: 0.4, P < 0.001). Information about adult causes of death is useful for formulating policy and for developing, monitoring, and evaluating programs to improve adult health in Mozambique. Care-seeking-related information helps identify barriers for seeking care from formal health providers while emphasizing the need for generating local resources and strengthening outreach health systems service delivery.

Correcting for Verbal Autopsy Misclassification Bias in Cause-Specific Mortality Estimates.

Verbal autopsies (VAs) are extensively used to determine cause of death (COD) in many low- and middle-income countries. However, COD determination from VA can be inaccurate. Computer coded verbal autopsy (CCVA) algorithms used for this task are imperfect and misclassify COD for a large proportion of deaths. If not accounted for, this misclassification leads to biased estimates of cause-specific mortality fractions (CSMFs), a critical piece in health-policy making. Recent work has demonstrated that the knowledge of the CCVA misclassification rates can be used to calibrate raw VA-based CSMF estimates to account for the misclassification bias. In this manuscript, we review the current practices and issues with raw COD predictions from CCVA algorithms and provide a complete primer on how to use the VA calibration approach with the calibratedVA software to correct for verbal autopsy misclassification bias in cause-specific mortality estimates. We use calibratedVA to obtain CSMFs for child (1-59 months) and neonatal deaths using VA data from the Countrywide Mortality Surveillance for Action project in Mozambique.

Countrywide Mortality Surveillance for Action in Mozambique: Results from a National Sample-Based Vital Statistics System for Mortality and Cause of Death.

Sub-Saharan Africa lacks timely, reliable, and accurate national data on mortality and causes of death (CODs). In 2018 Mozambique launched a sample registration system (Countrywide Mortality Surveillance for Action [COMSA]-Mozambique), which collects continuous birth, death, and COD data from 700 randomly selected clusters, a nationally representative population of 828,663 persons. Verbal and social autopsy interviews are conducted for COD determination. We analyzed data collected in 2019-2020 to report mortality rates and cause-specific fractions. Cause-specific results were generated using computer-coded verbal autopsy (CCVA) algorithms for deaths among those age 5 years and older. For under-five deaths, the accuracy of CCVA results was increased through calibration with data from minimally invasive tissue sampling. Neonatal and under-five mortality rates were, respectively, 23 (95% CI: 18-28) and 80 (95% CI: 69-91) deaths per 1,000 live births. Mortality rates per 1,000 were 18 (95% CI: 14-21) among age 5-14 years, 26 (95% CI: 20-31) among age 15-24 years, 258 (95% CI: 230-287) among age 25-59 years, and 531 (95% CI: 490-572) among age 60+ years. Urban areas had lower mortality rates than rural areas among children under 15 but not among adults. Deaths due to infections were substantial across all ages. Other predominant causes by age group were prematurity and intrapartum-related events among neonates; diarrhea, malaria, and lower respiratory infections among children 1-59 months; injury, malaria, and diarrhea among children 5-14 years; HIV, injury, and cancer among those age 15-59 years; and cancer and cardiovascular disease at age 60+ years. The COMSA-Mozambique platform offers a rich and unique system for mortality and COD determination and monitoring and an opportunity to build a comprehensive surveillance system.

Mixed-methods analysis of select issues reported in the 2016 World Health Organization verbal autopsy questionnaire.

BACKGROUND: Use of a standardized verbal autopsy (VA) questionnaire, such as the World Health Organization (WHO) instrument, can improve the consistency and reliability of the data it collects. Systematically revising a questionnaire, however, requires evidence about the performance of its questions. The purpose of this investigation was to use a mixed methods approach to evaluate the performance of questions related to 14 previously reported issues in the 2016 version of the WHO questionnaire, where there were concerns of potential confusion, redundancy, or inability of the respondent to answer the question. The results from this mixed methods analysis are discussed across common themes that may have contributed to the underperformance of questions and have been compiled to inform decisions around the revision of the current VA instrument. METHODS: Quantitative analysis of 19,150 VAs for neonates, children, and adults from five project teams implementing VAs predominately in Sub-Saharan Africa included frequency distributions and cross-tabulations to evaluate response patterns among related questions. The association of respondent characteristics and response patterns was evaluated using prevalence ratios. Qualitative analysis included results from cognitive interviewing, an approach that provides a detailed understanding of the meanings and processes that respondents use to answer interview questions. Cognitive interviews were conducted among 149 participants in Morocco and Zambia. Findings from the qualitative and quantitative analyses were triangulated to identify common themes. RESULTS: Four broad themes contributing to the underperformance or redundancy within the instrument were identified: question sequence, overlap within the question series, questions outside the frame of reference of the respondent, and questions needing clarification. The series of questions associated with one of the 14 identified issues (the series of questions on injuries) related to question sequence; seven (tobacco use, sores, breast swelling, abdominal problem, vomiting, vaccination, and baby size) demonstrated similar response patterns among questions within each series capturing overlapping information. Respondent characteristics, including relationship to the deceased and whether or not the respondent lived with the deceased, were associated with differing frequencies of non-substantive responses in three question series (female health related issues, tobacco use, and baby size). An inconsistent understanding of related constructs was observed between questions related to sores/ulcers, birth weight/baby size, and diagnosis of dementia/presence of mental confusion. An incorrect association of the intended construct with that which was interpreted by the respondent was observed in the medical diagnosis question series. CONCLUSIONS: In this mixed methods analysis, we identified series of questions which could be shortened through elimination of redundancy, series of questions requiring clarification due to unclear constructs, and the impact of respondent characteristics on the quality of responses. These changes can lead to a better understanding of the question constructs by the respondents, increase the acceptance of the tool, and improve the overall accuracy of the VA instrument.

Strengthening effectiveness evaluations to improve programs for women, children and adolescents.

A full understanding of the pathways from efficacious interventions to population impact requires rigorous effectiveness evaluations conducted under realistic scale-up conditions at country level. In this paper, we introduce a deductive framework that underpins effectiveness evaluations. This framework forms the theoretical and conceptual basis for the 'Real Accountability: Data Analysis for Results' (RADAR) project, intended to address gaps in guidance and tools for the evaluation of projects being implemented at scale to reduce mortality among women and children. These gaps include needs for a framework to guide decisions about evaluations and practical measurement tools, as well as increased capacity in evaluation practice among donors and program planners at global, national and project levels. RADAR aimed to improve the evidence base for program and policy decisions in reproductive, maternal, newborn and child health and nutrition (RMNCH&N). We focus on five linked methodological steps - presented as core evaluation questions - for designing and implementing effectiveness evaluation of large-scale programs that support both the needs of program managers to improve their programs and the needs of donors to meet their accountability responsibilities. RADAR has operationalized each step with a tool to facilitate its application. We also describe cross-cutting methodological issues and broader contextual factors that affect the planning and implementation of such evaluations. We conclude with proposals for how the global RMNCH&N community can support rigorous program evaluations and make better use of the resulting evidence.