title: Strengthening Community-Based Vital Events Reporting for Real-Time Monitoring of Under-Five Mortality: Lessons Learned from the Balaka and Salima Districts in Malawi.
abstract: BACKGROUND
  Malawi ratified a compulsory birth and death registration system in 2009. Until it captures complete coverage of vital events, Malawi relies on other data sources to calculate mortality estimates. We tested a community-based method to estimate annual under-five mortality rates (U5MR) through the Real-Time Monitoring of Under-Five Mortality (RMM) project in Malawi. We implemented RMM in two phases, and conducted an independent evaluation of phase one after 21 months of implementation. We present results of the phase two validation that covers the full project time span, and compare the results to those of the phase one validation.
  
  
  RESULTS
  We assessed the completeness of the counts of births and deaths and the accuracy of disaggregated U5MR from the community-based method against a retrospective full pregnancy history for rolling twelve-month periods after the independent evaluation. We used full pregnancy histories collected through household interviews carried out between November 2013 and January 2014 as the validation data source. Health Surveillance Agents (HSAs) across the 160 catchment areas submitted routine reports on pregnancies, births, and deaths consistently. However, for the 15-month implementation period post-evaluation, average completeness of birth event reporting was 76%, whereas average completeness of death event reporting was 67% relative to that expected from a comparable pregnancy history. HSAs underestimated the U5MR by an average of 21% relative to that estimated from a comparable pregnancy history.
  
  
  CONCLUSIONS
  On a medium scale, the community-based RMM method in Malawi produced substantial underestimates of annualized U5MR relative to those obtained from a full pregnancy history, despite the additional incentives and quality-control activities. We were not able to achieve an optimum level of incentive and support to make the system work while ensuring sustainability. Lessons learned from the implementation of RMM can inform programs supporting community-based interventions through HSAs in Malawi.
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: Division of Policy and Practice, UNICEF, New York, New York, United States of America.
authors.forename: Agbessi
authors.initials: A
authors.lastname: Amouzou
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: Romesh
authors.initials: R
authors.lastname: Silva
authors.affiliation: World Food Program, Lilongwe, Malawi.
authors.forename: Benjamin
authors.initials: B
authors.lastname: Banda
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: Lois
authors.initials: L
authors.lastname: Park
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
authors.affiliation: Malawi National Statistical Office, Zomba, Malawi.
authors.forename: Mercy
authors.initials: M
authors.lastname: Kanyuka
mesh_terms: D002648:Child; D046688:Child Mortality / Q000639:trends*; D002675:Child, Preschool; D003153:Community Health Services / Q000706:statistics & numerical data*; D005191:Family Characteristics; D005260:Female; D006801:Humans; D007223:Infant; D007226:Infant Mortality / Q000639:trends*; D008295:Malawi; D008297:Male; D036801:Parturition; D011159:Population Surveillance; D011247:Pregnancy; D012189:Retrospective Studies