Infant and child mortality, measured by the rate of deaths of children aged less than five years, has undergone a dramatic decline in most countries in the world since 1950. Following the Alma Ata declaration in 1978, the emphasis shifted to the ‘community approach’ and to ‘primary health care’, with a focus on rural areas in developing countries.
This decline in mortality is usually attributed to increasing income, improvements in living standards and nutrition, and progress in preventive and curative medicine and to national health programmes. A series of large-scale programs were launched in the 1980s and 1990s aimed at reducing child mortality.
Child Mortality Rates in Africa
In particular, the so-called ‘Child Survival Programs’, sponsored by the United States Agency for International Development and international organizations, launched around 1985, were very influential in numerous countries. These were based on a ‘selective primary health care approach’ and targeted a short list of diseases. In typical Child Survival Programs, the main focus was on childhood diseases, and the main actions promoted were:
- Comprehensive vaccinations to prevent some leading causes of death, such as measles, whooping cough, tetanus, diphtheria, poliomyelitis, and tuberculosis.
- The promotion of oral rehydration therapy (ORT) at the community level to prevent deaths from acute watery diarrhoea.
- Nutritional programmes, particularly supplementation of vitamin A.
Since 1995, a new wave of health programmes emerged, with emphasis on ‘Integrated Management of Childhood Illnesses’ within the health system. For communicable diseases, the main focus was on the diagnosis and treatment of acute lower respiratory infections (ALRIs) and other childhood infections, and in particular the proper use of antibiotics.
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The effects of these programmes could be monitored by analyzing the mortality trends in population-based surveys, such as demographic and health surveys (DHSs). Morocco is a good example of such health programmes over the past 25 years.
Morocco's Experience with Child Mortality Reduction
Morocco underwent a dramatic mortality decline since independence. The decline in mortality among children aged less than five years was particularly rapid over the 1988-1997 period, at an average rate of −6% a year, and faster for children (aged 1-4 year(s)) than for infants.
The National Program on Immunization started in 1981 (PEV) and was reinforced in 1987 (PNI). Vaccinations were provided, free of charge, to the whole population. A program of combating diarrhoeal diseases (PLMD) was initiated in 1979, took off within a few years, and was further extended in 1990. As a result, the proportion of diarrhoea episodes treated with ORT increased from 14% in 1992 to 30% in 1997 and continued to increase ever since. The nutrition programme has been running for many years and included the promotion of exclusive breastfeeding for 4-5 months, child growth monitoring, prevention of vitamin D, vitamin A and iron deficiencies, and by improving the detection and treatment of severe malnutrition.
On the maternal and delivery side, women were asked to make three visits to antenatal clinics during their pregnancy. Tetanus toxoid injections and iron supplementation were provided. However, the coverage of antenatal care remained limited, and deliveries often occurred at home, primarily because a large proportion of the population lives in remote areas, far from the nearest clinic, and lack safe transportation for pregnant women.
The aim of this study was to document the changing profile in cause-specific mortality in Morocco over a nine-year period and to provide evidence for assessing the impact of child-survival programmes conducted in the 1980s and 1990s. The method used for evaluating the impact of child-survival programmes focuses on changing cause-specific mortality rates.
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Data Collection and Methodology
Two surveys on causes and circumstances of child deaths were conducted in Morocco. The first survey-ECCD-1 (Enquête sur les Causes et Circonstances de Décès)-was conducted in 1988-1989 on a representative sample of deaths of children aged less than five years. The second survey-ECCD-2-was conducted in 1997-1998 on a sample of deaths recorded by the PapChild Survey.
A verbal autopsy questionnaire was developed for Morocco in 1988 on the model of that developed in Senegal. The surveys were conducted by trained paramedics, who underwent a two-week training workshop. Two independent physicians reviewed the filled questionnaires, and in the case of disagreement, a third person reviewed until a final diagnosis was made.
Validation of the verbal autopsy technique was done by comparing verbal autopsy diagnosis with hospital diagnosis for those deaths that occurred in a hospital. Investigators of the verbal autopsies were blind to hospital diagnosis, and conversely persons who recorded the hospital diagnosis ignored the findings of verbal autopsy.
Death rates were estimated from the demographic sample surveys for the periods covered by the verbal autopsy surveys: in the first case from the ENDPR, and in the second case from the DHS 2003-2004. The distribution of deaths by cause was used for computing rates of cause-specific mortality for three age-groups: neonatal (<28 days), postneonatal (28 days-11 months), and childhood (12-59 months).
Key Findings and Trends
Mortality of children aged less than five years was estimated at 234 per 1,000 in 1955-1959 (WFS) and at 47 per 1,000 in 1999-2003 (DHS 2003-2004). Data indicated a steady decline, although the speed was somewhat slower between 1956 and 1975 and somewhat faster after 1985.
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Mortality of children aged less than five years was estimated at 103 per 1,000 at the ECCD-1 survey (data from ENDPR for 1987-1988) and at 59 per 1,000 at the ECCD-2 survey (data from the DHS 2003-2004 for the 5-9 years before, i.e. 1994-1998). The decline in mortality between the two surveys was already rapid for neonatal deaths (-4.8% per year), very rapid for postneonatal deaths (−6.4% per year), and extremely rapid for children deaths (-9.9% per year).
The decline in mortality between the two surveys was not homogenous by causes of death. For neonates, three causes of death underwent a statistically significant mortality decline: neonatal tetanus (-95%), pneumonia of the newborn (-57%), and low birth-weight (-57%), all declining faster than the others.
Postneonatal mortality declined for most causes and was significant for seven of them: diarrhoeal diseases (acute diarrhoea, chronic diarrhoea, dysentery being only borderline), tuberculosis, selected infectious diseases (meningitis, laryngitis, septicaemia), and malnutrition. Mortality from accidents, congenital defect, and other and unknown changed little, and the differences were not significant.
Child mortality revealed a similar pattern, with an even faster decline. Causes of death that showed a significant decline were basically the same as for postneonatal deaths: diarrhoeal diseases (in this case acute diarrhoea and dysentery), malnutrition, tuberculosis, and selected infectious diseases (in this case typhoid, meningitis, and septicaemia).
The decline in cause-specific mortality could be attributed to the success of public-health programmes: the Expanded Programme on Immunization, the management of diarrhoeal diseases and malnutrition, and the use of antibiotics for selected infectious diseases. It is likely that improvements in living conditions, child-feeding practices, hygiene, and sanitation also contributed to the decline in mortality, although these could not explain the magnitude of the changes for target diseases.
Here is a summary of the mortality decline rates for different age groups:
Developing Countries Tackle Mother and Infant Mortality
Table: Mortality Decline Rates in Morocco
| Age Group | Decline Rate (% per year) |
|---|---|
| Neonatal (<28 days) | -4.8% |
| Postneonatal (28 days-11 months) | -6.4% |
| Childhood (12-59 months) | -9.9% |
For neonates, the decline in the number of tetanus cases was of similar magnitude (92% in national causes of death statistics versus 95% in the ECCD surveys) and, likewise, for neonatal diarrhoea (67% vs 54%), for neonatal pneumonia (66% vs 57%), for prematurity (9% against 1% in the surveys), birth trauma (13% against 8% in the surveys), and for the total of all causes combined (35% in both cases).
For postneonatal and childhood deaths, the agreement between the two sources was also good for several causes. The decline in the number of deaths was similar for all causes combined (44% in both cases) and for selected causes: diarrhoea (74% and 55% respectively in the two age-groups), tuberculosis (58% vs 84%), and measles (96% vs 88%).
Causes of death could be classified according to the health programmes targeting them. Four major programmes were selected: the vaccination (EPI) programme targeting measles, whooping cough, tetanus, tuberculosis, diphtheria, and poliomyelitis; case management for diarrhoeal diseases and malnutrition; case management for bacterial infections, such as pneumonia, typhoid, meningitis, septicaemia; and care of the newborn.
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