The mortality rate for neonates and children under the age of 5 has been declining across the globe for more than 30 years, marking one of the greatest achievements in global health in the 21st century. Nonetheless, millions of children under the age of 5 die every year, with many of the deaths resulting from avoidable causes. Furthermore, these deaths are not equally distributed, but rather have been shown to be concentrated in low-income and otherwise marginalized communities. For these reasons, further reductions in under-5 mortality remains a key priority in the global health arena, as evidenced by its inclusion as an indicator in the Sustainable Development Goals (SDGs).

The Under-5 child health and mortality statistics project, a collaboration between IHME and UADY funded by the W.K. Kellogg Foundation, seeks to contribute to this goal by strengthening the evidence and understanding of key factors related to under-5 mortality in Yucatán, Mexico. Specifically, the project focuses on two themes:

  • the decision to, and ensuing process of, seeking medical care for children under the age of 5 suffering from illness or disease, and
  • the reliability and accuracy of cause of death certification and other medical record systems.

Search for care

The decision to seek care, and subsequent timing of obtaining medical attention, can have profound implications for children under the age of 5 experiencing serious illness and disease. A broad range of factors often plays an important role in the process of obtaining timely medical attention, including the recognition of alarm signs for serious illnesses, access to childcare and transportation, sufficient financial resources to cover the cost of care or transportation, and wait times at health facilities.

IHME and UADY therefore sought to more fully understand the effect of the various bottlenecks in the search for care process which might significantly delay the provision of medical care and worsen health outcomes for seriously ill children under the age of 5. To this end, questions regarding care seeking behavior were included in verbal autopsy interviews which were conducted in 2017. Among the important findings resulting from this research was that once the decision to seek care was made, children typically received appropriate medical attention in a timely manner. The most significant delays appear to arise from caretakers’ decision to seek medical care.

In order to address this bottleneck, IHME and UADY are collaborating with community members to design materials aimed primarily at improving the recognition of alarm signs for common causes of mortality among children under the age of 5 in Yucatán, Mexico. The materials will also seek to build strategies within the community for preventing common causes of mortality and morbidity in children. Originally, these materials were intended to be presented in a series of workshops attended by mothers and primary caretakers of children under the age of 5 in select communities. Furthermore, the effect of these measures was to be evaluated using a household survey designed to capture respondents’ ability to identify key signs that a child requires medical attention.

Due to the COVID-19 epidemic in Yucatán and the enactment of social distancing and other measures aimed at reducing the spread of the disease, alternative methods for the remote implementation and evaluation of community interventions are being explored.

Cause of death certification

Accurate information on mortality and causes of death is a vital component for a well-functioning health system. However, obtaining accurate and reliable cause of death records remains a challenge in a variety of settings around the world. While the state of Yucatán, and more broadly Mexico as a whole, enjoys a relatively robust vital registration system, improving the consistency and reliability of cause of death certification, particularly for children under the age of 5, can provide valuable information for health system planners, policymakers, and researchers working to reduce under-5 mortality.

To better understand the functioning of vital registration and other important medical record systems, in 2017, IHME and UADY collected and aggregated data on deaths of children under 5 using a variety of sources and modes, including electronic medical record review and verbal autopsies. (More details regarding instruments and methods of data collection are available on the “Data collection tools and methods” section of this website.) Triangulation and subsequent analysis of these records, both at a population and an individual level, identified weaknesses in the process of certification of causes of death for children under 5.

In 2019 and 2020, IHME and UADY, are developing training materials aimed at standardizing the process for cause of death certification, with a specific focus on under-5 deaths in Yucatán. With cooperation from Agustín O’Horan Hospital and the Ministry of Health in Yucatán, a workshop will be conducted using these materials with clinical providers responsible for certifying causes of death at O’Horan Hospital. Finally, IHME and UADY originally intended to conduct an evaluation of this intervention, based primarily on the collection and analysis of medical record data for deaths which occurred prior to the intervention compared to deaths which occurred after the intervention. As in the case of the community intervention, remote platforms may be used to deliver and evaluate the health facility intervention in order to comply with social distancing guidelines to prevent the spread of COVID-19.