title: Monitoring child mortality through community health worker reporting of births and deaths in Malawi: validation against a household mortality survey.
abstract: BACKGROUND
  The rate of decline in child mortality is too slow in most African countries to achieve the Millennium Development Goal of reducing under-five mortality by two-thirds between 1990 and 2015. Effective strategies to monitor child mortality are needed where accurate vital registration data are lacking to help governments assess and report on progress in child survival. We present results from a test of a mortality monitoring approach based on recording of births and deaths by specially trained community health workers (CHWs) in Malawi.
  
  
  RESULTS
  Government-employed community health workers in Malawi are responsible for maintaining a Village Health Register, in which they record births and deaths that occur in their catchment area. We expanded on this system to provide additional training, supervision and incentives. We tested the equivalence between child mortality rates obtained from data on births and deaths collected by 160 randomly-selected and trained CHWs over twenty months in two districts to those computed through a standard household mortality survey. CHW reports produced an under-five mortality rate that was 84% (95%CI: [0.71,1.00]) of the household survey mortality rate and statistically equivalent to it. However, CHW data consistently underestimated under-five mortality, with levels of under-estimation increasing over time. Under-five deaths were more likely to be missed than births. Neonatal and infant deaths were more likely to be missed than older deaths.
  
  
  CONCLUSIONS
  This first test of the accuracy and completeness of vital events data reported by CHWs in Malawi as a strategy for monitoring child mortality shows promising results but underestimated child mortality and was not stable over the four periods assessed. Given the Malawi government's commitment to strengthen its vital registration system, we are working with the Ministry of Health to implement a revised version of the approach that provides increased support to CHWs.
authors.affiliation: Institute for International Programs, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America.
authors.forename: Agbessi
authors.initials: A
authors.lastname: Amouzou
authors.affiliation: Malawi National Statistical Office, Zomba, Malawi.
authors.forename: Benjamin
authors.initials: B
authors.lastname: Banda
authors.affiliation: Malawi National Statistical Office, Zomba, Malawi.
authors.forename: Willie
authors.initials: W
authors.lastname: Kachaka
authors.affiliation: Institute for International Programs, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America.
authors.forename: Olga
authors.initials: O
authors.lastname: Joos
authors.affiliation: Malawi National Statistical Office, Zomba, Malawi.
authors.forename: Mercy
authors.initials: M
authors.lastname: Kanyuka
authors.affiliation: Institute for International Programs, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America.
authors.forename: Kenneth
authors.initials: K
authors.lastname: Hill
authors.affiliation: Institute for International Programs, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America.
authors.forename: Jennifer
authors.initials: J
authors.lastname: Bryce
mesh_terms: D002648:Child; D046688:Child Mortality; D003150:Community Health Workers; D005191:Family Characteristics; D005260:Female; D006801:Humans; D007223:Infant; D007226:Infant Mortality; D008295:Malawi; D008297:Male; D036801:Parturition; D015203:Reproducibility of Results; D012107:Research Design