Brian Houle and colleagues examine the temporal relationship between mother and child death by using 15 years of data (1994–2008) from household surveys conducted in the Agincourt sub-district of South Africa.
There is evidence that a young child's risk of dying increases following the mother's death, but little is known about the risk when the mother becomes very ill prior to her death. We hypothesized that children would be more likely to die during the period several months before their mother's death, as well as for several months after her death. Therefore we investigated the relationship between young children's likelihood of dying and the timing of their mother's death and, in particular, the existence of a critical period of increased risk.
Methods and Findings
Data from a health and socio-demographic surveillance system in rural South Africa were collected on children 0–5 y of age from 1 January 1994 to 31 December 2008. Discrete time survival analysis was used to estimate children's probability of dying before and after their mother's death, accounting for moderators. 1,244 children (3% of sample) died from 1994 to 2008. The probability of child death began to rise 6–11 mo prior to the mother's death and increased markedly during the 2 mo immediately before the month of her death (odds ratio [OR] 7.1 [95% CI 3.9–12.7]), in the month of her death (OR 12.6 [6.2–25.3]), and during the 2 mo following her death (OR 7.0 [3.2–15.6]). This increase in the probability of dying was more pronounced for children whose mothers died of AIDS or tuberculosis compared to other causes of death, but the pattern remained for causes unrelated to AIDS/tuberculosis. Infants aged 0–6 mo at the time of their mother's death were nine times more likely to die than children aged 2–5 y. The limitations of the study included the lack of knowledge about precisely when a very ill mother will die, a lack of information about child nutrition and care, and the diagnosis of AIDS deaths by verbal autopsy rather than serostatus.
Young children in lower income settings are more likely to die not only after their mother's death but also in the months before, when she is seriously ill. Interventions are urgently needed to support families both when the mother becomes very ill and after her death.
Please see later in the article for the Editors' Summary
Over the past few years, there has been enormous international effort to meet the target set by Millennium Development Goal 4—to reduce the under-five child mortality rate by two-thirds from the 1990 level by 2015. There has been some encouraging progress, and according to the latest figures from the World Health Organization, in 2011, just under 7 million children less than five years died, a fall of almost 3 million from a decade ago. However, such efforts must also consider the health of the mother, as it is now also well established that the health of children is intrinsically linked to their mother's health: there is strong evidence from low- and middle-income countries that children's risk of dying increases around the time of their mother's death, particularly relating to the HIV pandemic in Africa.
Why Was This Study Done?
Previous studies examining the timing of a child's death relative to that of their mother have mainly focused on the period after the mother's death. So far, there have been few studies examining the link between a child's death and the period when his/her mother becomes ill and unable to care for and feed her child. In this study from the Agincourt sub-district in northeast South Africa, the researchers investigated the relationship between young children's chance (odds) of dying and the timing of their mother's death, particularly to examine whether there were critical periods of risk for children before their mother's death.
What Did the Researchers Do and Find?
The researchers used the health and socio-demographic surveillance system in the area, which had 15 years (1994–2008) of information from yearly household surveys. The researchers focused on young children (0–6 months, 7–23 months, and 24–59 months) whose mothers had died, and through a statistical model, analysed the changes in the child's chance (odds) of dying from a year before the mother's death through to any time after her death during the study period. The cause of the mother's death was identified from verbal autopsy and categorized as being related to AIDS or tuberculosis (chronic) or other (mostly acute) causes not related to these infections. The researchers took other factors into account in their analysis and compared the odds of dying for children whose mothers died with those whose mothers were alive.
Using these methods, the researchers found that a total of 1,244 children (3% of the total sample) died between 1994 and 2008. Importantly, the researchers found that although the period when children are more likely to die began to increase in the period 6–11 months before their mother's death, there were three distinct periods of a much higher chance (odds) of death: the period 1–2 months before the month in which their mother died (odds ratio 7.1), the month of her death (odds ratio 12.6), and the period 1–2 months following her death (odds ratio 7.0). Furthermore, during the five-month period around the time of their mother's death, children (both boys and girls) aged 0–6 months were about nine times more likely to die than children aged 24–59 months. Finally, children were about 1.5 times more likely to die if their mother died of an AIDS/tuberculosis-related cause.
What Do These Findings Mean?
These finding suggest that in low-income settings, young children are more likely to die in the months before their mother's death, when she is seriously ill, not just in the period after her death. The chance of dying is particularly increased in very young children (0–6 months) and in children whose mother died of HIV/tuberculosis-related causes. Although this study had several limitations, such as limited information on the child's cause of death, this study highlights the urgent need for proactive and coordinated community-based interventions to support families, especially vulnerable children, when a mother becomes seriously ill, in addition to the period following her death.
Please access these websites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001409.
The Countdown to 2015 initiative has the latest country information on progress in reducing maternal, neonatal, and child deaths
The World Health Organization has more information on Millennium Development Goal 4
The Joint United Nations Joint Programme on HIV/AIDS has information about the number of deaths from HIV-related causes
MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt) has more information on the research platform that made this study possible