Early days of life are crucial for child survival in Gamo Gofa Zone, Southern Ethiopia: A community based study

Unacceptably, every day 17,000 children die before their fifth birthday in the world, mostly from preventable and treatable causes. In actual number, only in 2013, 6.3 million children died before their fifth birth date. This is despite the existence of knowledge and technologies for life-saving interventions [1]. In 2012, about 75 % of all child deaths were attributable to just six conditions: child birth related neonatal causes, pneumonia, diarrhea, malaria, measles, and HIV/AIDS [2].

Inequities in child mortality between high income and low income countries continue to exist. For instance, in 2013 the under five-mortality rate in sub-Saharan African Region was the highest in the world, 92 deaths per 1000 live births, nearly 15 times the average in developed countries [1].

In Ethiopia, under-five mortality was reported to decline by 47 % over the 15-year period between the 2000 and the 2011 Ethiopian Demographic and Health Survey (EDHS) (declined from 166 to 88 deaths per 1000 live births). Infant mortality also decreased by 39 % over the same period, from 97 to 59 deaths per 1000 live births [3]. Although such decline has been reported, child mortality rate in Ethiopia has been among the highest in the world, that about one in every 17 Ethiopian children dies before the first birthday, and one in every 12 children dies before the fifth birthday [3].

The neonatal (37 per 1000 live births) and post-neonatal (22 per 1000 live births) mortality rates were also high in the country, where relatively slow reduction was observed. Childhood mortality in the country is higher in rural areas than in urban areas [3]. Mortalities in Southern Nations, Nationalities and People’s Region (SNNPR) were among the highest in the country. Under five, child, infant, post neonatal and neonatal mortalities in the Region were 116, 41, 78, 41 and 38 per 1000 live births, respectively [3].

Besides the periodic EDHS reports, few pocket studies which have been conducted in other parts of the country showed varying figures. Under-five mortality was ranging from 76 to 130 per 1000 live births, whereas infant mortality was ranging from 62 to 93.5 per 1000 live births [4‐7]. However, these studies were basing only on few kebeles (lowest administrative units in Ethiopia) of DSS sites or they were not meant to assess the magnitude of childhood mortalities. For example, a study at the DSS site of Butajira, Ethiopia, reported an infant mortality rate of 62/1000 live births [4], though its main objective was not to assess the magnitude of infant mortality. In another DSS based study done in Dabat, Northern Ethiopia, the risk of infant death was 93.5 per 1000 live births, whereas under five mortality was 130 per 1000 live births [5]. A relatively recent study in the same DSS site (Dabat) showed infant mortality of 88 per 1000 person-years [8].

Another community based study in the northern part of the country reported, neonatal, post neonatal, infant, child and under five mortality rates of 37, 30, 67, 33 and 99 per 1000 live births respectively [6]. A study in the South West part of the country also reported neonatal and infant mortality rates of 38 and 76.4 per 1000 live births, respectively [7].

As the Arba Minch DSS (study site of the current study, which is located extreme south of the country) is new, under-five mortality studies are lacking in the area. The above mentioned studies are concentrated around central or northern part of the country that it may not be possible to have nationally representative summary of magnitude of the problem from these studies. Overall, Ethiopia has shown progress in the reduction of under-five mortality in the last few years; however, the problem is still among the highest in the world and warrants for continuous investigation of the problem for sustained interventions to maintain the reduction beyond the millennium development goals (MDGs). Therefore, this study was conducted with the objective of determining the magnitude of childhood mortalities in the designated community.

The overall weighted under five, child, infant, post neonatal and neonatal mortalities were calculated to be 42.76, 8.87, 33.89, 15.22 and 18.68 per 1000 live births, respectively. These figures are lower than the national and regional reports of the latest EDHS 2011report [3]. The mortality rates identified by the current study are also lower than other pocket studies conducted in other parts of the country [4‐8]. This may be because of socio-cultural differences in child caring and feeding practices of study populations. This was reflected by low prevalence of malnutrition (which is one of the leading causes of under-five mortality) in the study area (Zone) of the current study [11, 12]. The other reason may be due to time variation between the studies, as potential health service coverage has increased dramatically in the country in recent years. This was demonstrated by the current study that there were 100 % coverage of at least one health post and one health extension worker operating in the study kebeles of the current study and almost all the kebeles had access of health centers’ service within 10kms distance. Though, the other studies were basing on only few DSS kebeles (unlike the current study which covered larger population including DSS kebeles), most of them were either based on retrospective birth experiences of mothers [5‐7] or prospective data of DSS kebeles [4, 8]. However, still there might be under reporting of deaths (survivor selection bias) in the current study as most of the data were collected retrospectively in a longer duration (within the past seven years before the survey).

About 79 and 44 % of all under-five mortalities occurred before their first birth date and within the first one month of age, respectively. Relatively, similar trend was observed in the 2011 EDHS report [3], in which 67 and 42 % of all under-five mortalities occurred before their first birth date and within the first one month of age, respectively. The occurrence of high mortality especially during post neonatal period might be attributed to infection mainly diarrheal disease, since this is the time when supplementary foods are started (given the poor hygienic condition of rural population of developing countries).

On the other hand, about 82 % of neonatal deaths occurred within the first 7 days of life. This was in spite of the above mentioned high potential health coverage of the study kebeles. It may be because of poor quality of maternal and child health services provided to the community, as health service delivery systems in developing countries have been criticized for failing to bring expected results at expected level, partly because of poor quality [13]. All these may signify importance of investigating quality of health services to improve and strengthen maternal and child health interventions during pregnancy, during and immediately after birth (through antenatal care (ANC), skilled birth attendance and early post natal care). This may help to avert majority of neonatal mortalities, as early neonatal mortalities are mainly caused by pregnancy and child birth related problems; including birth asphyxia, prematurity, maternal hypertension and obstetric hemorrhage [14‐16].

Significantly, higher rate of under-five mortality was encountered among rural kebeles than in urban kebeles. Similar observation was found in the EDHS 2011 [3] report. This may be due to the relatively better access to health services and utilization of the services by urban population as a result of a relatively better awareness of the benefit of the health service.

Similar to the EDHS 2011 report [3], under-five mortality rate was significantly higher among males than in females in the current study. Similar finding was observed in a study which analyzed DHS data from sub Saharan African countries including Ethiopia’s EDHS 2011 data [17]. This may be owing to biologic differences of the two sexes, as genetic factors were reported to be reasons for higher mortality among males than females [18‐20].

Unlike the other kebeles, under-five mortality significantly decreased in DSS kebeles during the study period. More or less similar trends were observed in infant and neonatal mortality, i.e., fluctuating trends in the overall and in non-DSS rural and urban kebeles but sharp reduction in DSS kebeles. Relatively low under-five mortality was also observed in DSS kebeles than non-DSS kebeles of the Arba Minch Zuria District and urban kebeles. This may be due to effect of frequent contact of data collectors, supervisors and researchers with the community which is not true in non-DSS sites. This might create more concern and motivation of HEWs and other health cadres working in the kebeles, because they knew mortalities are continuously monitored by the Project. Or it might create awareness about service utilization and child care in the communities owing to frequent visiting and questioning of the households to fill the questionnaires by data collectors of the Project. Previous study in India, revealed that, health education by visiting homes of the mothers had positive maternal behavior change that may positively affect child survival [21]. Similarly, frequent home visit by lay volunteers was shown to improve treatment outcome of tuberculosis in Iraq [22]. However, as DSS sites are becoming sources of evidence for magnitude and cause of mortalities in areas where vital event registrations are lacking (in Africa, Asia and Oceania) [23, 24], we suggest further investigation of whether such variations exist in other sites or not and the reasons of such variations.

Finally, this study covered a large number of populations from urban and rural kebeles and kebeles of different climatic/agro-ecological zones and DSS and non-DSS sites. However, the followings should be taken into consideration in interpreting the findings. There may be recall bias in determining date of birth and date of death, as most of the data were collected retrospectively. However, in majority cases we used the child’s immunization card. In the absence of immunization card we applied local calendars with the help of HEWs. There may be under reporting of deaths (survivor selection bias) especially for early child deaths, which may underestimate the rates. Some of the associations reported in this analysis may be confounded by other factors.

The overall under-five mortality of the study area was found to be 43 per 1000 live births. The under-five mortality in the study area was lower than the national and regional reports. As significant numbers of children are dying during their early days of life in spite of high potential health coverage, investigation of quality of health services and strengthening of maternal and child health interventions during pregnancy, during and immediately after birth may help to avert majorities of neonatal mortalities. The mortality rates are significantly higher among rural communities than their urban counterparts. Therefore, child health interventions should give due attention, especially to those areas with low coverage of child and maternal health services. Finally, in order to address factors contributing for the continued risk of under-five mortality, study identifying the independent contributors of under-five mortality in the area need to be conducted. Besides, the actual reason for the relatively low rate of childhood mortality in DSS kebeles should be explored.