Centre for Maternal, Adolescent, Reproductive, and Child Health

Can reviews of in-hospital child deaths help reduce mortality rates?

Andy Young, MARCH Child Theme Student Liaison

In 40 countries, more than 1 in 20 children died before their 5th birthday in 2015. In the UK and other high income countries, this rate is less than 1 in 200.1 The underlying causes of this tenfold difference in childrens’ chances of survival are almost entirely preventable. Impressive reductions have been made in under 5 mortality during the Millennium Development Goal era through economic development and subsequent improvements in hygiene and sanitation.2,3 Some progress can also be attributed to health care services and the provision of neonatal care, immunisations, and case management of common childhood conditions.4 This should be celebrated, but it should not be cause for complacency. To achieve ongoing reductions in child mortality, improvements to health services will continue to be an important part of the puzzle.


Countries where 50 children died before their 5th birthday per 1000 live births in 2017.1

Many of the interventions used to improve child survival through health service strengthening have been standardised packages such as Integrated Management of Childhood Illness, which aside from some minor tweaks, is implemented almost identically in every country. As we move towards the Sustainable Development Goal target of ensuring less than 1 in 40 children die before their fifth birthday5, there will be fewer and fewer easy wins that can be solved with this type of one-size-fits-all programme. Robust, decentralised processes which empower local actors to identify problems and implement solutions will be essential to achieving this goal.

A sensible place to start would be to look at the child deaths that are already occurring at a local level and identify the common themes that are leading to these deaths. In high-income, low-mortality settings, this is achieved through statutory review of all child deaths. However, this process requires significant resources and is likely to be unachievable in low-income, high-mortality settings. The World Health Organisation (WHO) suggests that reviewing in-hospital child deaths may be a more efficient method to achieve a similar result6. Although not all child deaths occur in hospital, those that do often have some contemporaneously recorded written information about the likely cause of death and the events leading up to it within the hospital. The WHO argues that this information could be used to help guide improvements to facility-based care. Understanding the societal and health systems factors requires conversations with bereaved families, the wider community and primary care providers. This is equally important but does require additional allocation of resources.

To support facilities in utilising this information, the WHO has released the “Operational guide for facility-based audit and review of paediatric mortality”7 with a supporting editorial in the Archives of Disease in Childhood6. The operational guide outlines a six-step process outlined below. This process would be completed by a working group, using regular mortality review meetings as the forum for discussing cases, identifying modifiable factors and recommending solutions.

The WHO 6 step process for Child Mortality Review.7

Although this process utilises inpatient child deaths, the guide suggests exploring the potentially modifiable factors leading to the death from the beginning of the patient’s journey from their community, through the primary care and referral systems, to their admission and care in hospital. This patient journey highlights the important and complex relationships between social, environmental, and health systems causes of child mortality.

For example, the child who presents moribund to a hospital with a vaccine preventable illness because of delays in recognition and referral of their illness by their primary care provider may be too sick to survive despite the best use of the resources available to that hospital. Taking a holistic view of this patient journey extends the possibility of including stakeholders outside of the department where the child died. The involvement of these stakeholders will enable the utilisation of lessons learned from each death to effect change in the wider health system and community.

The process is attractively simple and holds promise, however, its full implementation is less than straightforward. A recent systematic review of child mortality audits identified 22 studies which described teams which were able to complete steps 1-4 (identifying cases to recommending solutions), but only 4 who carried this through to steps 5 or 6 (implementing changes and evaluating their impact).8 There are many barriers to successfully implementing solutions to the problems identified through mortality review: lack of involvement or support from senior staff, a small or under-resourced quality improvement team, lack of follow up and accountability for actions, poor engagement with clinical and non-clinical stakeholders outside the department conducting the review. If these barriers are not overcome to reach these final steps, the process of mortality review will not be optimally effective, draining resources from under-resourced departments without providing any meaningful change.

The key to the success of the paediatric mortality review as a driver for positive change for children in high-mortality settings will be the ability to overcome these barriers and to implement and evaluate the actions the process generates. Whether this is achievable at scale remains to be seen, and will only become apparent with rigorous evaluation of attempts to put this operational guide into practice.

A case example from the operational guide, reviewing the death from pneumonia of a 4-year-old boy with cerebral palsy.7


  1. UNICEF IGME Under-5 Mortality Estimates 2017. https://data.unicef.org/topic/child-survival/under-five-mortality/.
  2. O’Hare B, Makuta I, Chiwaula L, Bar-Zeev N. Income and child mortality in developing countries: a systematic review and meta-analysis. J R Soc Med. 2013;106(10):408-414. doi:10.1177/0141076813489680
  3. Fink G, Günther I, Hill K. The effect of water and sanitation on child health: evidence from the demographic and health surveys 1986–2007. Int J Epidemiol. 2011;40(5):1196-1204. doi:10.1093/ije/dyr102
  4. Liu L, Oza S, Hogan D, et al. Global, regional, and national causes of under-5 mortality in 2000-15: an updated systematic analysis with implications for the Sustainable Development Goals. Lancet (London, England). 2016;388(10063):3027-3035. doi:10.1016/S0140-6736(16)31593-8
  5. Sustainable Development Goal 3. https://sustainabledevelopment.un.org/sdg3.
  6. Duke T, Irimu G, Were W. New WHO guidelines on paediatric mortality and morbidity auditing. Arch Dis Child. March 2019:archdischild-2019-316956. doi:10.1136/archdischild-2019-316956
  7. WHO | Improving the quality of paediatric care: an operational guide for facility-based audit and review of paediatric mortality. WHO. 2019. https://www.who.int/maternal_child_adolescent/documents/improving-quality-paediatric-care/en/. Accessed March 13, 2019.
  8. Personal correspondence: T Duke.


Comments are closed.