title: Verbal/social autopsy study helps explain the lack of decrease in neonatal mortality in Niger, 2007-2010.
abstract: BACKGROUND
  This study was one of a set of verbal/social autopsy (VASA) investigations undertaken by the WHO/UNICEF-supported Child Health Epidemiology Reference Group to estimate the causes and determinants of neonatal and child deaths in high priority countries. The study objective was to help explain the lack of decrease in neonatal mortality in Niger from 2007 to 2010, a period during which child mortality was decreasing.
  
  
  METHODS
  VASA interviews were conducted of a random sample of 453 neonatal deaths identified by the 2010 Niger National Mortality Survey (NNMS). Causes of death were determined by expert algorithm analysis, and the prevalence of household, community and health system determinants were examined along the continuum of maternal and newborn care, the Pathway to Survival for newborn illnesses, and an extended pathway for maternal complications. The social autopsy findings were compared to available data for survivors from the same cohort collected by the NNMS and the 2012 Niger Demographic and Health Survey.
  
  
  RESULTS
  Severe neonatal infection and birth asphyxia were the leading causes of early neonatal death in the community and facilities. Death in the community after delayed careseeking for severe infection predominated during the late neonatal period. The levels of nearly all demographic, antenatal and delivery care factors were in the direction of risk for the VASA study decedents. They more often resided rurally (P < 0.001) and their mothers were less educated (P = 0.03) and gave birth when younger (P = 0.03) than survivors' mothers. Their mothers also were less likely to receive quality antenatal care (P < 0.001), skilled attendance at birth (P = 0.03) or to deliver in an institution (P < 0.001). Nearly half suffered an obstetric complication, with more maternal infection (17.9% vs 0.2%), antepartum hemorrhage (12.5% vs 0.5%) and eclampsia/preeclampsia (9.5% vs 1.6%) than for all births in Niger. Their mothers also were unlikely to seek health care for their own complications (37% to 42%) as well as for the newborn's illness (30.6%).
  
  
  CONCLUSIONS
  Niger should scale up its recently implemented package of high-impact interventions to additional integrated health facilities and expand the package to provide antenatal care and management of labor and delivery, with support to reach a higher level facility when required. Community interventions are needed to improve illness recognition and careseeking for severe neonatal infection.
authors.affiliation: Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
authors.forename: Henry D
authors.initials: HD
authors.lastname: Kalter
authors.affiliation: Ministry of Health, Niamey, Niger.
authors.forename: Asma Gali
authors.initials: AG
authors.lastname: Yaroh
authors.affiliation: Institute National des Statistics, Niamey, Niger.
authors.forename: Abdou
authors.initials: A
authors.lastname: Maina
authors.affiliation: Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
authors.forename: Alain K
authors.initials: AK
authors.lastname: Koffi
authors.affiliation: UNICEF, Niger country office, Niamey, Niger (retired staff).
authors.forename: Khaled
authors.initials: K
authors.lastname: Bensaïd
authors.affiliation: UNICEF, New York City, NY, USA.
authors.forename: Agbessi
authors.initials: A
authors.lastname: Amouzou
authors.affiliation: The Institute for International Programs, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
authors.forename: Robert E
authors.initials: RE
authors.lastname: Black
mesh_terms: D000293:Adolescent; D000328:Adult; D001238:Asphyxia Neonatorum / Q000401:mortality; D001344:Autopsy / Q000379:methods; D002423:Cause of Death; D003906:Developing Countries; D005260:Female; D006297:Health Services Accessibility; D006801:Humans; D007223:Infant; D007226:Infant Mortality / Q000639:trends*; D007231:Infant, Newborn; D007407:Interviews as Topic; D008297:Male; D009548:Niger; D007744:Obstetric Labor Complications / Q000401:mortality; D011247:Pregnancy; D011248:Pregnancy Complications / Q000401:mortality; D011295:Prenatal Care; D012424:Rural Population; D055815:Young Adult