Henry D Kalter, Alain K Koffi, M Abassy Kamwe, Jamie Perin, Robert E BlackTanzania VASA study – BMGF presentation

January 23, 2020

Biological Causes and Social Determinants of Under-5 Deaths in Tanzania

Results from the 2017-18 Tanzania Verbal/Social Autopsy (VASA) Study

Verbal autopsyEstimate:

♦ Proportions of antepartum and intrapartum stillbirths♦ Misclassification of stillbirths and neonatal deaths♦ Neonatal (0-27 days old) causes of death♦ Young child (1-59 months old) causes of death♦ Proportion of deaths, by cause, in health facilities and the

community

Social autopsyEstimate:

♦ Prevalence of household, community and health system determinants of the deaths

Tanzania VASA studyStudy objectives

2016 WHO verbal autopsy integrated with JHU/IIP social autopsy♦ VA: biological causes (neonatal and child illness signs/symptoms)♦ SA: social determinants (household, community, health system)

Preventive SA indicators♦ Neonates: cord care, thermal care, breastfeeding, PN check/counseling♦ 1-59 month olds: breastfeeding, diet, bed net use, indoor smoke

exposure, vaccinations, vitamin ACurative SA indicators

♦ Both age groups: Illness recognition, formal health careseeking, formal health careseeking constraints, referral and compliance

Maternal pregnancy and delivery SA indicators (stillbirths and NN deaths)♦ ANC♦ Pregnancy and delivery complications, and careseeking for these

Tanzania VASA studyStudy instrument

DHS and VASA Classification of Status at Birth 783 Stillbirths, Neonatal and Child Deaths,

Tanzania, 8/2011-2/2016

TDHS age-at-death

VASA age-at-death

Stillbirth

7+ months 0-27 days 1-59 months Total

Stillbirth 7+ months 184 13 0 197 (25.2%)

0-27 days 18 213 13 244 (31.2%)

1-59 mo. 2 2 338 342 (43.7%)

Total 204 (26.1%) 228 (29.1%) 351 (44.8%) 783 (100%)

Discrepancy between the DHS and VASA age classifications13/197 (6.6%) DHS stillbirths converted to VASA neonatal deaths20/586 (3.4%) DHS neonatal/child deaths converted to VASA stillbirthsOverall, 7 (20-13) deaths moved from a DHS neonatal/child death to a VASA stillbirth

TDHS age-at-death

VASA age-at-death

Stillbirth

7+ months 0-27 days 1-59 months Total

Stillbirth 7+ months 184 13 0 197 (25.2%)

0-27 days 18 213 13 244 (31.2%)

1-59 mo. 2 2 338 342 (43.7%)

Total 204 (26.1%) 228 (29.1%) 351 (44.8%) 783 (100%)

Age Distribution of DeathsStillbirths

Neonates

1-59 month olds

♦ Expert Algorithm (EAVA): Computerized algorithms of illness signs/symptoms arranged in a hierarchy

♦ Algorithms: e.g., Pneumonia: cough or difficult breathing AND fast breathing or lower chest wall indrawing

♦ Hierarchy: to identify the underlying cause of death

♦ Based on ICD-10 rules, temporality and specificity of CODs

♦ Identifies primary and co-morbid causes

♦ Kalter HD, Perin J, Black RE. Validating hierarchical verbal autopsy expert algorithms in a large data set with known causes of death. J Global Health, 2016;6(1).

♦ Other possible analysis methods: InSilicoVA, Tariff 2.0

♦ Compare findings of the methods

Tanzania VASA study Verbal autopsy analysis methods

WHO EAVA causes of death of 228 neonates and 351 1-59 month olds, Tanzania, 8/2010-2/2016 (Hierarchies► NN: Preterm below IP; Child: NN causes top / bottom)

NeonatesNeonatal tetanusCongenital malformation Intrapartum related eventsPreterm deliveryMeningitisDiarrheaPneumoniaSepsisOther (jaundice, hemorrhage, SUID)

1-59 month oldsIntrapartum related eventsCongenital malformation InjuryAIDSMalnutrition (underlying)Measles, Meningitis, Diarrhea, Pertussis,

Pneumonia, MalariaOther infectionsPossible malariaMalnutritionPreterm delivery

Causes of death of 228 neonates and 351 1-59 month olds, Tanzania, 8/2010-2/2016

(Hierarchies► NN: preterm below intrapartum / Child: intrapartum & congenital at top, preterm at bottom)

♦ Descriptive SA analysis: Determine the most common determinants of death

§ Tabulate the findings to identify the most common determinants of death

§ Examine the determinants within the Pathway to Survival conceptual framework

§ Extended pathway for neonatal deaths includes care of maternal pregnancy and delivery complications

♦ Predictive SA Analysis

§ Examine the time-to-event (death, care-seeking, etc)

§ Examine the drivers of Care seeking using ML algorithms (Ongoing)

Tanzania VASA studySA Data Analysis

59.8 54.1

79.4

50.9 51.5

19.9

78.267.7

89.8

67.258.9

35.0

40.2 45.9

20.6

49.1 48.5

80.1

21.8

32.3

10.2

32.841.1

65.0

Bloodpressure

measured

Urinesample

collected

Bloodsampletaken

Nutritioncounselingprovided

Counselledabout

pregnancydanger signs

Bloodpressure

measured

Urinesample

collected

Bloodsampletaken

Nutritioncounselingprovided

Counselledabout

pregnancydanger signs

Quality ANC Quality ANC

Stillbirth (N=191) Neonatal deaths (N=220)

Missed opportunities Proportion covered

MATERNAL HEALTH DURING PREGNANCY :Quality of 1 and more ANC visit (s) –

191 Stillbirths and 220 Neonatal deaths

PREVENTIVE CARE:Quality ANC by Number of visits

PREVENTIVE CARE:Quality ANC by Number of visits

MATERNAL HEALTH DURING PREGNANCY :Maternal Complications and Careseeking During the Pregnancy

and Delivery for Stillbirth and Neonatal deaths

ITEMS STILLBIRTHS NEONATAL DEATHS

X2 (P-value)

# Mothers N=204 N=208 -# Mothers with at least one maternal complication during pregnancy or labor/delivery

128 /204 (62.9%) 125/228 (54.7 %) 2.2364 (0.1359)

# Mothers with at least one pregnancy complication before labor

61/204 (29.8%) 47/228 (20.8%) 2.966 (0.0861)

#Sought some formal health care for any pregnancy complication

36/61 (58.4%) 43/47 (91.6%) 14.4040 (0.0003)

#Mothers with at least one labor and delivery(L/D) complication that began at home

84/204 (41.0%) 89/228 (38.9%) 0.1599 (0.6895)

#Sought some formal care for any L/D complication that started at home

48/84 (57.7%) 66/89 (74.7%) 3.8120 (0.0529)

#Mothers with at least one pregnancy complication before labor AND at least one labor and delivery complication that began at home

29/204 (14.3%) 22/228 (9.7%) 1.7162 (0.1912)

MATERNAL HEALTH DURING PREGNANCY :Main Maternal Complications and Careseeking During the Pregnancy and Delivery for Stillbirth and Neonatal deaths

ITEMS STILLBIRTHS NEONATAL DEATHS X2 (P-value)

Main pregnancy complications before labor

n=61 n=47 -

#Maternal Sepsis 19 /61 (31.5%) 10/47 (20.6%) 1.6768 (0.1988)

#Sought formal health 14/19 (75.3%) 8/10 (79.8%) 0.0653 (0.8009)

#Ante-partum Hemorrhage 27 /61 (43.6%) 19/47 (40.3)) 0.0674 (0.7958)

#Sought formal health 18/27 (69.0%) 18/19 (99.2%) 34.4346 (0.000)Main L/D complication that started at home

n=84 n=89 -

#Intrapartum hemorrhage that started at home

37/84 (43.6%) 34/89 (38.8%) 0.2629 (0.6090)

#Sought any formal health 15/37 (42.1%) 23/34 (66.5%) 2.2343 (0.1397)#Prolonged Labor 62/84 (74.0%) 63/89 (70.5%) 0.1481 (0.7010)

#Sought any formal care 40/62 (63.9%) 47/63 (75.6%) 1.0669 (0.3041)

Pathway to formal care seeking for 228 Neonatal deaths

a. 228 newborns

b1. Born at a health facility N=156/228 (68.5%)

b2. Born at Home N=71/228 (31.5%)

c1. Illness began at the delivery facility

N=102/228 (44.7%)

c2. Illness did NOT begin at the delivery facility

N=54/228 (23.8%)

d2. Left the delivery facility alive

N=38/228 (16.5%)

e. Illness started at home could later trigger care-seeking process

N=109/228 (48.0%)

f. Child “died immediately”

N=23/109 (21.4%)

g. No care given or sought

N=34/109 (30.0%)

i. Outside of Home Care as first or later Action

N=45/109 (41.4%)

h. Home care Only

N=6/109 (5.3%)

j. Child died while setting out, or died on

route N=3/109 (2.9%)

k. Only Informal care given or sought N=2/109 (2.1%)

l. Child reached the first health provider

and died at the facility N=23/109 (21.1%)

m. Child reached the first health provider and left the

facility alive N=17/109 (15.3%)

d1. Died at the delivery facility

N=106/228 (46.4%)

n=89

n=16

n=12, Left the facility alive

n=38

n=1, Don’t know

Comparison of cause of deaths by place of birth-Neonatal deaths

19.1

3.7

0.5

3.3

8.4

20.3

14.1 14.6

0.1

16.0

33.3

5.9

0.0 0.0

3.1

21.1

13.6

9.6

0.4

12.9

Intrapart

um related eve

nts

Malform

ation

Diarrhea

Meningitis

other

Pneumonia

PretermSep

sis

Tetanus

Unspecif

ied

Born at and left the health facility alive or born athome (N=109)Born and died at a health facility (N=119)

Pathway to Survival Component and Indicators of under-five deaths

Pathway to SurvivalComponent and Indicators

Neonatal deaths (0-27 days)

N=109

Child deaths (1-59 months)

N=351

X2

(P-Value)

Illness recognition at home1. Caregiver recognized any illness

Caregiver recognized sign(s) of possibly severe or severe illness

99 (91.3%) 340 (96.8%) 4.87 (0.028)

Care-seeking patterns2. Child “died immediately” 23 (21.4%) 16 (4.6%) 14.97 (0.000)3. No care given or sought for child 34 (31.0%) 8 (2.3%) 60.21 (0.000)4.1 Home care only 6 (5.3%) 4 (1.2%) 3.74 (0.054)

4.2 Sought or tried to seek outside care as first action

40 (36.9%) 260 (74.1%) 29.66 (0.000)

4.3 Sought or tried to seek outside care as second action

5 (4.5%) 62 (17.8%) 7.16 (0.008)

Choice of outside care5.1 Formal care only 42 (38.6%) 235 (67.0%) 14.72 (0.000)

5.2 Informal and formal care 1 (0.7%) 68 (19.3%) 31.1 (0.000)5.3 Informal care only 2 (2.1%) 19 (5.5%) 0.98 (0.324)

Choice of any formal care n=43 n=303

6.1 Child died before setting out, or died on route, or could not reach the health care provider

3 (7.3%) 11 (3.8%) 0.83 (0.365)

7.1 Child reached the first health care provider and died at the facility

23 (53.6%) 77 (25.3%) 9.82 (0.002)

7.2 Child reached the first health provider and left the facility alive

17 (39.1%) 215 (70.9%) 11.88 (0.001)

Action of health provider at discharge (ofthe children who left the health facilityalive)

n=17 n=215

8.1 child was not referred, nor received any home care recommendations

3 (18.1%) 65 (30.4%) 1.33 (0.250)

8.2 Child received home care recommendations only

10 (53.4%) 83 (38.4%) 1.23 (0.274)

8.3 Child was referred to another health care provider and received home care recommendations

1 (5.0%) 38 (17.6%) 2.03 (0.156)

8.4 Child was referred to anotherhealth care provider only

4 (23.5%) 29 (13.6%) 1.87 (0.171)

Pathway to SurvivalComponent and Indicators

Neonatal deaths (0-27

days)

Child deaths (1-59

months)

X2

(P-Value)

Pathway to Survival Component and Indicators of under-five deaths, cont’d

On Average, how many actions were taken when care was sought, and what was the proportion of “Any formal care” for each action?

Actions

464 464 1 1 Total 1.407328 .6918103 407 407 1 1 Child death 1.439803 .6707617 57 57 1 1Neonatal death 1.175439 .8421053 category fnum formal~e

by categories of: category (Death category)Summary statistics: mean, p50, N

. tabstat fnum formalcare, by(category) s(mean median n)

How fast did the first Formal Care occur among Deceased Newborns who sought or tried to seek any care?

total 59 .7457627 53 1 1 1 Other ca 17 .8235294 17 1 1 1NN Infec 33 .7272727 29 1 1 1 IPRE 9 .6666667 7 1 1 3 codnn time at risk rate subjects 25% 50% 75% incidence no. of Survival time

id: ID analysis time _t: saq605j_ failure _d: formalcare == 1

. stsum, by(codnn)

(Illness day the action was taken)

(Child ID)

How fast did the first Formal Care occur Deceased Children (1-59mo) who sought or tried to seek any care?

total 572 .3479021 319 1 2 3 Other 266 .3120301 121 1 2 2 Injury 17 .5882353 16 1 1 2Infectio 289 .366782 182 1 2 3 codch time at risk rate subjects 25% 50% 75% incidence no. of Survival time

id: ID analysis time _t: saq605j_ failure _d: formalcare == 1

. stsum, by(codch)

(Illness day the action was taken)(Child ID)

What are the determinants of the earliest formal care seeking among newborn during the fatal illness?

What are the determinants of the earliest formal care seeking among newborn during the fatal illness?

What are the determinants of the earliest formal care seeking among children during the fatal illness? (from 5 VASA countries)

♦ Large and rich dataset:

§ Describe the pathways through which social factors ultimately contributed to child mortality in Tanzania.

§ Provide Insight into modifiable social factors that will be vital to health policymakers in both government and non—governmental organizations

§ Use of analytics to examine the drivers of Care seeking using ML algorithms

CONCLUSIONS

Thank youAsante