November 1998 Contents:
I. Why do Children Die? Hugo Diaz, SASHR
I. Why do children die? Hugo Diaz, SASHR
This seminar was conducted by Dr. Rene Salgado, Senior Technical Officer at the BASICS (Basic
Support for Institutionalizing Child Survival) Project, which has funding from the USAID's Child
Survival Project. Dr. Salgado presented a methodology for assessing why children die, using three
case studies for Bolivia, Guatemala and Kazakhstan. The population groups studied in Bolivia and
Guatemala consisted of American Indians with high rates of illiteracy and poverty. The Kazakhstan
population was less deprived, with high literacy rate.
"Why children die" refers not merely to the actual causes of death of children under 5 (in the case of
the Guatemala study, only deaths in the first seven days of life were included), such as pneumonia or
diarrhea, but also to certain characteristics in the chain of events from the onset of illness until the time
of death that explain why the death was not prevented. More specifically, the studies had the
-Identify causes of death of children less than five years old (perinatal period in the case of
-Identify the process (identification of illness, care seeking behavior, and quality of care) that
influenced the final result (death), and identify points of intervention that might, in the future, prevent
-Determine predictors of childhood mortality (in Kazakhstan only).
The studies use a framework referred to as the "Pathway to Survival". This is a diagram which
depicts various events, decisions and outcomes following onset of the disease. For example,
immediately following onset of the disease, the caretaker (usually the mother) may or may not
recognize that this is a serious problem requiring intervention. If she does recognize this fact, she may
either decide to provide care herself, or look for outside help. If she seeks outside help, she may
either go to a government clinic, a qualified private provider, or a traditional healer. The care
provided by either the caretaker or any outside source may or may not be of good quality, i.e.,
appropriate to the disease in question.
The investigators identify a number of recent deaths of children (e.g., 271 in the Bolivia study) and,
using the above framework, attempt to reconstruct the story of what happened in each case.
Identification of the deaths can be done from civil registries, from neighbors/relatives, from the
records of cemeteries, etc. A random sample is then drawn from the population of identified deaths,
for inclusion in the study. Once the set of deaths to be studied has been selected, the investigators
use several instruments to gather information:
-Ethnographic studies, to be able to understand the local terminology for various events, types of
providers, and other elements of the analysis [this information is used to adapt the instruments to local
-Verbal autopsy [uses questions for signs and symptoms during illness that lead to death; uses
algorithms and expert panel to determine most probable cause of death; it gives generally reliable
results for the major causes of childhood deaths, notably pneumonia and diarrhea].
-Social autopsy [reconstructs on a day-to-day basis all signs, symptoms, care seeking decisions and
actions, and treatments for the illness that caused death].
-Medical records abstraction forms.
Once the data/qualitative information have been gathered, it can be organized in many different ways
to throw light on the problem. Many of the conclusions thus reached are of direct relevance for the
design of interventions or projects.
In Bolivia, for example, it was found that of all cases of ARI & diarrhea deaths studied (N=146), in
only 43% of the cases did the caretaker recognize that there was a serious problem. All of those
caretakers who recognized that there was a serious problem sought outside help from various types
of providers. Appropriate care was provided in only about one-fifth of all the cases for which
outside help was sought, however.
In Kazakhstan the nature of the problem was found to be different from that in Bolivia. In
Kazakhstan, only in less than 10% of all the deaths from ARI & diarrhea did the caretaker fail to
seek outside help. In most cases in which outside help was sought, either formal sector providers, or
a combination of formal and informal sector providers, was used. The main problem here was the
abysmally poor quality of the medical care provided to these children. This problem was present in
Bolivia also, but in that country an even greater problem was the lack of awareness of the severity of
the problems on the part of the caretakers.
The above findings suggest different strategies for the two countries. In Bolivia, the results of the
study prompted the Government to emphasize community mobilization and IEC interventions (mainly
in the form of serialized, "soap opera" type radio programs, using material from the cases included in
the study). The Ministry of Health also introduced a Mortality Survey/ Surveillance Manual, in order
to keep track of childhood deaths on a systematic basis (hopefully as a first step to improving quality
of care). In the case of Kazakhstan there is obviously no need to increase awareness or motivation
of the population to seek care, but efforts should concentrate on improving the quality of care. Thus
the information collected and analyzed through studies of this nature can be very helpful in setting
priorities for various types of interventions to reduce under-5 deaths. The cost of the Bolivia study
was about US$50,000 and it took about four months to be completed. A manual for conducting
studies of this nature has been prepared by Johns Hopkins in cooperation with CDC. However,
expert assistance would almost certainly be required in order to conduct the studies.