Circumstances of post-neonatal deaths in Ceara, Northeast Brazil: mothers’ health care-seeking behaviors during their infants’ fatal illness

Abstract

Promotion of oral rehydration therapy (ORT) for the treatment of diarrheal diseases and the WHO case management strategy for acute respiratory infections (ARI) have contributed to significant reductions in infant mortality, but these two conditions remain the leading causes of infant deaths in most developing countries. Identification of the factors contributing to these deaths may contribute to reduce infant mortality from preventable causes. To gain insight into the circumstances and maternal and health services factors that may contribute to infant deaths we used a verbal autopsy method to interview mothers of all infants who died during the previous 12 months (June 1995–May 1996) in 11 municipalities in the State of Ceara, Northeast Brazil. Our results revealed that one-third of the deaths occurred in a hospital and two-thirds at home. Almost all the infants who died at home, however, had been examined one or more times by a doctor, and 36% of them had been hospitalized during the disease episode that resulted in death. For most (85%) of these children the causes of death were diarrhea or acute respiratory infection, and it is likely that death could have been averted if appropriate treatment had been initiated promptly. Three major groups of factors that alone or in combination appeared to contribute to most deaths were delays in seeking medical care on behalf of the parents, medical interventions reported as ineffective by mothers and delays in providing medical care to children who arrived at the hospital too late in the day to be scheduled for consultation. Our findings suggest that government efforts to further reduce infant mortality in Ceara should focus on health education interventions that address quality of home care, recognition of signs of severity and danger and importance of seeking timely medical care; and on improving the quality of care provided at community health centers and hospitals. Measures likely to improve infants’ chance of survival include: ensuring prompt access to medical consultation for young children brought to health centers or hospitals with potentially life-threatening symptoms related to infections, health education to mothers on the need for continued home care after discharge and to return to the medical care facility if the child does not recover, and that they have access to medicine prescribed by hospital physicians. Further benefits could be obtained by using community health workers, now integrated into the Family Medicine Program (PSF) health teams, to provide health education, supervise home care, refer mothers to health centers and facilitate their access to hospitals.

Introduction

Although the promotion of oral rehydration therapy (ORT) for the treatment of diarrheal diseases and the WHO case management strategy for acute respiratory infections (ARI) have contributed to significant reductions in infant mortality, these two conditions remain the leading causes of infant deaths in most developing countries (World Health Organization, 1990a, World Health Organization, 1990b, UNICEF, 1994a). Little is known, however, about the circumstances in which these deaths occur and the maternal and health services factors that may contribute to them. Conceivably, some of these deaths occur at home among children who were never seen by a doctor during the illness episode that resulted in death, whereas others may have occurred despite prompt medical intervention. Although many cases will fall in between these two extremes, a classification of deaths according to the circumstances of death may provide a useful basis for public health intervention. For example, whether more emphasis should be given to maternal education on the recognition and early treatment of illnesses, increasing the accessibility of health care, or improving the quality of the care already provided in hospital and health centers.

Previous studies have reported excess mortality among children discharged from hospital after treatment for diarrhea, with increased risk for those aged less than six months, who were non-immunized, non-breast fed and whose mothers were illiterate (Roy et al., 1983, Snaton et al., 1986, Fauveau et al., 1992, Victora et al., 1992; Islam, Rahman, Mhalanabis & Mahmudur Rahman, 1996). Other studies have demonstrated that maternal health care-seeking behaviors were associated with several factors including socioeconomic conditions, mothers’ knowledge and beliefs of disease causation and severity, mother’s popular beliefs and characteristics of health services (Prajitno et al., 1979, Ulin and Ulin, 1981, De Zoysa et al., 1984, Green, 1985, Selwyn, 1987, Bentley et al., 1988, Mull and Mull, 1988, Nations et al., 1988, Nations and Rebhun, 1988a, Nations and Rebhun, 1988b, Kumar et al., 1989; Nougtara, Saverborn, Oepan & Diesfeld, 1989; Olango and Aboud, 1990, Fernandez et al., 1991, DeClerque et al., 1992, Aguila and Brown, 1993; Hounsa, Godin, Alihonov, Valois & Girard, 1993, 1994; Hudelson, 1993, Singh, 1993, Ricci et al., 1996). For example, choice of “traditional/lay providers” (e.g. traditional healers, drug vendors) and poor home treatment have been attributed to mothers’ low educational status, lack of knowledge about disease causation and lack of perception of disease severity (Selwyn, 1987, Kumar et al., 1989, Nougtara et al., 1989, Olango and Aboud, 1990, DeClerque et al., 1992, Hounsa et al., 1993, Hudelson, 1993, Hudelson, 1994; Stewart, Parker, Chakraboty & Begum, 1994; Ricci et al., 1996). Further studies have provided evidence that factors such as lack of child care, inaccessibility to health facilities and perceived poor quality of medical care hinder mothers’ prompt care seeking and utilization of biomedical services during their infants’ illnesses (Stewart et al., 1994, Hudelson, 1994).

In Ceara State, Brazil, a few studies have described the role of popular beliefs in influencing mothers’ choice of health care and treatment for their ill infants (Nations and Rebhun, 1988a, Nations and Rebhun, 1988b, Nations et al., 1988), but no study has examined the influence of health care system factors in influencing infant survival. To identify the factors associated with preventable post-neonatal deaths and to estimate their relative importance we conducted a survey among a sample of 127 women who had recently lost a child.