Measuring child mortality in resource limited settings using alternative approaches: South African case study

Post the Millennium Development Goal project a significant number of countries are still faced with the challenge of monitoring child mortality. Despite numerous enquiries since 1996 to provide this basic health indicator, South Africa has experienced prolonged periods of uncertainty regarding the level and trend of infant and under-5 mortality. The thesis develops an analytical framework to review all available data sources and methods of analysis and presents the results of the four approaches adopted to measure child mortality trends. Reviewing the demographic indicators produced from seven census and survey enquiries, the overall performance and the strengths and limitations of each approach is evaluated. Poor and extremely poor quality of data for child mortality emerges as a pervasive challenge to census and survey data. The thesis presents the remarkable improvement in the completeness of birth and death registration through South Africa's CRVS system, particularly since 2000, illustrating the possibility of using CRVS data to monitor provincial child mortality in the future and highlighting statistical challenges arising from the movement of children. In conclusion, South Africa should focus on improving CRVS for purposes of monitoring childhood mortality provincially and the comprehensive evaluation of available data is a useful lesson for other upper-middle-income countries

What is the infant mortality rate in South Africa? The need for improved data

Objectives. To review recent infant mortality and birth registration data in South Africa and to investigate geographical differences.Outcome measures. Estimates of infant mortality rates, proportion of births not registered, and proportion of births recorded in health services.Methods. 1. Published infant mortality data for South Africa were collated. Demographic data from national household surveys (1993 and 1994 October Household Surveys and the 1993 Poverty Survey by the Southern African Labour and Development Research Unit (SALDRU) at Ucr) were analysed using the indirect method developed by Brass. 2. Birth registration data were analysed and compared with the estimated number of births to identify regions with greater under-registration. The number of births recorded in the health services was analysed by province in order to assess and explore alternatives within health authorities that could complement the existing system.Results. 1. Published estimates of infant mortality for the period from 1990 range from 40 to 71 / 1 000 births and estimates based on national household surveys conducted in this period from 11 to 81/1000 births. 2. Completeness of birth registration in the nine provinces ranges from less than 10"10 in the Eastern Cape, North West and Northern Province to 60% in the Western Cape. An overall improvement from 19% to 60% could be achieved if births recorded through the health services were included in the vital registration system.Conclusions. The infant mortality rate in South Africa is not known with any certainty. The extent of completeness of the birth registration system was 19%, which indicates a need for urgent improvement in order to provide key health status indicators. This study indicates that there is some potential for improving the extent of birth registration if it could be facilitated through the health service. However, this alone would not achieve complete registration.Recommendations. Surveys will have to be relied upon until such time as routinely available statistics are accurate. The October Household Survey conducted annually by the Central Statistical Service is potentially an important Source of health status information. It is imperative that either the design of the birth history questionnaire be improved or that it be replaced by a less frequent but more specialised demographic and health survey

Reversal in childhood mortality trend in rural KwaZulu-Natal, South Africa

Abstract This study uses pregnancy history information from a demographic surveillance site in rural KwaZulu-Natal, along the eastern coastal board of South Africa, to investigate the mortality levels, trends and selected factors associated with childhood mortality. Life table analysis of the data reveals a reversal of the downward trend in mortality rates over time that began around 1990 in this population. Between 1990 and 2000 infant mortality increased from 43 to 65 per 1000 live births and under-five mortality from 65 to 116 per 1 000 live births which translates into a RR of 1.85 over the 10 year period (p-value <0.001). Maternal HIV prevalence in this area is among the highest in South Africa and rose from 4.2% to 26.0% during this period, making it probable that much of the increase in child deaths is attributable to mother to child transmission of HIV. Negative binomial regression identified the source of water, level of maternal education at the time of the survey and being a recipient of the child support grant as important factors associated with child mortality. However, their joint effect is attenuated by the overwhelming impact of HIV which also appears to have swamped the anticipated health benefit expected from various health care reforms.Keywords: Child mortality; rural South Africa; factors associated with child mortality; HIV prevalence; Demographic Surveillance SiteResume Renversement de tendance du taux de mortalite infantile dans la zone rurale du Kwazulu Natal en Afrique du Sud. Cette étude utilise des informations historiques sur les naissances dans un site rural de surveillance démographique au KwaZulu-Natal sur la cote orientale de l'Afrique du Sud pour evaluer le taux de mortalité et leurs tendances et identifier les facteurs associés à la mortalité infantile. L’analyse des table de vie révèle une inversion de la tendance à la baisse du taux de mortalité entre 1990 et 2000 ., Pendant cette periode, la mortalité infantile a augmenté de 43 à 65 par 1000 naissances et celle des moins de 5 ans de 65 à 116 pour 1 000 naissances, ce qui se traduit par un RR de 1,85 pour la periode etudiee. (p-valeur < 0,001). La prévalence du VIH dans cette region est parmi les plus élevées en Afrique du Sud et a augmenté de 4,2 % à 26,0 % pendant cette période, il est donc probable que l'augmentation des décès d'enfants est en grande partie attribuable à la transmission du VIH de la mere a l’enfant. Une régression binomiale négative a identifie l’acces a léau potable , le niveau d'éducation de la mere au moment de l'enquête et à si la mere est bénéficiaire d’ allocation sociale pour lénfant comme des facteurs importants associés à la mortalité infantile. Cependant leur effet meme combine, est atténué par l'immense impact du VIH qui semble avoir submerge les bénéfices attendus des diverses réformes de la santé.Mot clefs: Mortalite infantile, L’Afrique Du Sud rurale, facteurs associes a la mortalite infantile, prevalence du SIDA, Site de Surveillance Demographique

Provincial mortality in South Africa, 2000 - Priority-setting for now and a benchmark for the future

Background. Cause-of-death statistics are an essential component of health information. Despite improvements, underregistration and misclassification of causes make it difficult to interpret the official death statistics. Objective. To estimate consistent cause-specific death rates for the year 2000 and to identify the leading causes of death and premature mortality in the provinces. Methods. Total number of deaths and population size were estimated using the Actuarial Society of South Africa ASSA2000 AIDS and demographic model. Cause-of-death profiles based on Statistics South Africa's 15% sample, adjusted for misclassification of deaths due to ill-defined causes and AIDS deaths due to indicator conditions, were applied to the total deaths by age and sex. Age-standardised rates and years of life lost were calculated using age weighting and discounting. Results. Life expectancy in KwaZulu-Natal and Mpumalanga is about 10 years lower than that in the Western Cape, the province with the lowest mortality rate. HIV/AIDS is the leading cause of premature mortality for all provinces. Mortality due to pre-transitional causes, such as diarrhoea, is more pronounced in the poorer and more rural provinces. In contrast, non-communicable disease mortality is similar across all provinces, although the cause profiles differ. Injury mortality rates are particularly high in provinces with large metropolitan areas and in Mpumalanga. Conclusion. The quadruple burden experienced in all provinces requires a broad range of interventions, including improved access to health care; ensuring that basic needs such as those related to water and sanitation are met; disease and injury prevention; and promotion of a healthy lifestyle. High death rates as a result of HIV/AIDS highlight the urgent need to accelerate the implementation of the treatment and prevention plan. In addition, there is an urgent need to improve the cause-of-death data system to provide reliable cause-of-death statistics at health district level

Strengthening public health in South Africa: building a stronger evidence base for improving the health of the nation

An assessment of the relative burden attributable to selected risk factors provides an important evidence base for prioritising risk factors that should be targeted for public health interventions. Selecting interventions should be based on a robust and transparent process of scientific evaluations of their effectiveness, as well as assessment of their cost effectiveness, local applicability and appropriateness, and likely effects on health inequalities. Establishing such an evidence base is an ongoing process that is still at an early stage in South Africa. A recent review of disease control priorities for developing countries (DCPP) examined the global evidence regarding the effectiveness of interventions for major health burdens. Despite acknowledging the lack of intervention trials in developing countries, this DCPP review provides a unique resource for identifying interventions that might be useful in South Africa

Initial burden of disease estimates for South Africa, 2000

BACKGROUND This paper describes the first national burden of disease study for South Africa. The main focus is the burden due to premature mortality, i.e. years of life lost (YLLs). In addition, estimates of the burden contributed by morbidity, i.e. the years lived with disability (YLDs), are obtained to calculate disability-adjusted life years (DALYs); and the impact of AIDS on premature mortality in the year 2010 is assessed. METHOD Owing to the rapid mortality transition and the lack of timely data, a modelling approach has been adopted. The total mortality for the year 2000 is estimated using a demographic and AIDS model. The non-AIDS cause-of-death profile is estimated using three sources of data: Statistics South Africa, the National Department of Home Affairs, and the National Injury Mortality Surveillance System. A ratio method is used to estimate the YLDs from the YLL estimates. RESULTS The top single cause of mortality burden was HIV/AIDS followed by homicide, tuberculosis, road traffic accidents and diarrhoea. HIV/AIDS accounted for 38% of total YLLs, which is proportionately higher for females (47%) than for males (33%). Pre-transitional diseases, usually associated with poverty and underdevelopment, accounted for 25%, non-communicable diseases 21% and injuries 16% of YLLs. The DALY estimates highlight the fact that mortality alone underestimates the burden of disease, especially with regard to unintentional injuries, respiratory disease, and nervous system, mental and sense organ disorders. The impact of HIV/AIDS is expected to more than double the burden of premature mortality by the year 2010. CONCLUSION This study has drawn together data from a range of sources to develop coherent estimates of premature mortality by cause. South Africa is experiencing a quadruple burden of disease comprising the pre-transitional diseases, the emerging chronic diseases, injuries, and HIV/AIDS. Unless interventions that reduce morbidity and delay morbidity become widely available, the burden due to HIV/AIDS can be expected to grow very rapidly in the next few years. An improved base of information is needed to assess the morbidity impact more accurately

Mortality trends and diff erentials in South Africa from 1997 to 2012: second National Burden of Disease Study

Background The poor health of South Africans is known to be associated with a quadruple disease burden. In the second National Burden of Disease (NBD) study, we aimed to analyse cause of death data for 1997–2012 and develop national, population group, and provincial estimates of the levels and causes of mortality. Method We used underlying cause of death data from death notifi cations for 1997–2012 obtained from Statistics South Africa. These data were adjusted for completeness using indirect demographic techniques for adults and comparison with survey and census estimates for child mortality. A regression approach was used to estimate misclassifi ed HIV/AIDS deaths and so-called garbage codes were proportionally redistributed by age, sex, and population group population group (black African, Indian or Asian descent, white [European descent], and coloured [of mixed ancestry according to the preceding categories]). Injury deaths were estimated from additional data sources. Age-standardised death rates were calculated with mid-year population estimates and the WHO age standard. Institute of Health Metrics and Evaluation Global Burden of Disease (IHME GBD) estimates for South Africa were obtained from the IHME GHDx website for comparison. Findings All-cause age-standardised death rates increased rapidly since 1997, peaked in 2006 and then declined, driven by changes in HIV/AIDS. Mortality from tuberculosis, non-communicable diseases, and injuries decreased slightly. In 2012, HIV/AIDS caused the most deaths (29·1%) followed by cerebrovascular disease (7·5%) and lower respiratory infections (4·9%). All-cause age-standardised death rates were 1·7 times higher in the province with the highest death rate compared to the province with the lowest death rate, 2·2 times higher in black Africans compared to whites, and 1·4 times higher in males compared with females. Comparison with the IHME GBD estimates for South Africa revealed substantial diff erences for estimated deaths from all causes, particularly HIV/AIDS and interpersonal violence. Interpretation This study shows the reversal of HIV/AIDS, non-communicable disease, and injury mortality trends in South Africa during the study period. Mortality diff erentials show the importance of social determinants, raise concerns about the quality of health services, and provide relevant information to policy makers for addressing inequalities. Diff erences between GBD estimates for South Africa and this study emphasise the need for more careful calibration of global models with local data