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Trends and social differentials in child mortality inRwanda 1990–2010: results from three demographicand health surveys
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH). (Internationell barnhälsa och nutrition)
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH). (Internationell kvinno- och mödrahälsovård och migration)
Maternal and Child Health, Pediatric HIV-AIDS, PMTCTRwanda Program of the Institute of Human Virology, School of Medicine, University of Maryland, Kigali, Rwanda.
Ministry of Health, Kigali, Rwanda.
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2015 (English)In: Journal of Epidemiology and Community Health, ISSN 0143-005X, E-ISSN 1470-2738, Vol. 69, no 9, 834-840 p.Article in journal (Refereed) Published
Abstract [en]

Background Rwanda has embarked on ambitious programmes to provide equitable health services and reduce mortality in childhood. Evidence from other countries indicates that advances in child survival often have come at the expense of increasing inequity. Our aims were to analyse trends and social differentials in mortality before the age of 5 years in Rwanda from 1990 to 2010. Methods We performed secondary analyses of data from three Demographic and Health Surveys conducted in 2000, 2005 and 2010 in Rwanda. These surveys included 34 790 children born between 1990 and 2010 to women aged 15-49 years. The main outcome measures were neonatal mortality rates (NMR) and under-5 mortality rates (U5MR) over time, and in relation to mother's educational level, urban or rural residence and household wealth. Generalised linear mixed effects models and a mixed effects Cox model (frailty model) were used, with adjustments for confounders and cluster sampling method. Results Mortality rates in Rwanda peaked in 1994 at the time of the genocide (NMR 60/1000 live births, 95% CI 51 to 65; U5MR 238/1000 live births, 95% CI 226 to 251). The 1990s and the first half of the 2000s were characterised by a marked rural/urban divide and inequity in child survival between maternal groups with different levels of education. Towards the end of the study period (2005-2010) NMR had been reduced to 26/1000 (95% CI 23 to 29) and U5MR to 65/1000 (95% CI 61 to 70), with little or no difference between urban and rural areas, and household wealth groups, while children of women with no education still had significantly higher U5MR. Conclusions Recent reductions in child mortality in Rwanda have concurred with improved social equity in child survival. Current challenges include the prevention of newborn deaths.

Place, publisher, year, edition, pages
2015. Vol. 69, no 9, 834-840 p.
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Identifiers
URN: urn:nbn:se:uu:diva-251290DOI: 10.1136/jech-2014-204657ISI: 000359388800004OAI: oai:DiVA.org:uu-251290DiVA: diva2:805152
Funder
Sida - Swedish International Development Cooperation Agency
Available from: 2015-04-14 Created: 2015-04-14 Last updated: 2017-12-04Bibliographically approved
In thesis
1. Child survival in Rwanda: Challenges and potential for improvement: Population- and hospital-based studies
Open this publication in new window or tab >>Child survival in Rwanda: Challenges and potential for improvement: Population- and hospital-based studies
2015 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

After the 1994 genocide and collapse of the health system, Rwanda initiated major social and health reforms in order to reduce child mortality and health inequities in accordance with the Millennium Development Goals. The aim of this thesis was to assess trends in under-five mortality (U5M) and equity in child survival, to study social barriers for improved perinatal and neonatal survival, and to evaluate Helping Babies Breathe (HBB), a newborn resuscitation program.

In paper I we analysed trends and social inequities in child mortality 1990−2010, using data from national Demographic and Health Surveys conducted in 2000, 2005, and 2010. The following papers were based on hospital studies in the capital of Rwanda. In paper II we explored social inequities in perinatal mortality. Using a perinatal audit approach, paper III assessed factors related to the three delays, which preceded perinatal deaths, and estimates were made of potentially avoidable deaths. Paper IV evaluated knowledge and skills gained and retained by health workers after training in HBB.

Under-five mortality declined from the peak of 238 deaths per 1000 live births (95% CI 226 to 251) in 1994 to 65 deaths per 1000 live births (95% CI 61 to 70) in 2010 and concurred with decreased social gaps in child and neonatal survival between rural and urban areas and household wealth groups. Children born to women with no education still had significantly higher under-five mortality. Neonatal mortality also decreased but at a slower rate as compared to infant and U5M. Maternal rural residence or having no health insurance were linked to increased risk of perinatal death. Neither maternal education nor household wealth was associated with perinatal mortality risks. Lack of recognition of pregnancy danger signs and intrapartum-related suboptimal care were major contributors to perinatal deaths, whereof one half was estimated to be potentially avoidable. Knowledge significantly improved after training in HBB. This knowledge was sustained for at least 3 months following training whereas practical skills had declined.

These results highlight the need for strengthening coverage of lifesaving interventions giving priority to underserved groups for improved child survival at community as well as at hospital levels.  

Place, publisher, year, edition, pages
Uppsala: Acta Universitatis Upsaliensis, 2015. 84 p.
Series
Digital Comprehensive Summaries of Uppsala Dissertations from the Faculty of Medicine, ISSN 1651-6206 ; 1122
Keyword
Trends, social differentials, child mortality, perinatal mortality, perinatal audit, three delays model, training healthcare workers, Helping Babies Breathe, urban hospitals, Kigali, Rwanda
National Category
Medical and Health Sciences
Research subject
Medical Science
Identifiers
urn:nbn:se:uu:diva-259476 (URN)978-91-554-9288-5 (ISBN)
Public defence
2015-09-23, Rosensalen, Barnsjukhuset Akademiska sjukhuset, Entrance 95/96, Uppsala, 09:15 (English)
Opponent
Supervisors
Available from: 2015-09-01 Created: 2015-08-05 Last updated: 2015-10-01

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Musafili, AimableEssén, BirgittaPersson, Lars-ÅkeEkholm Selling, Katarina

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