Home deaths of children under 5 years in rural South Africa: a population-based longitudinal study

Objectives: To determine the proportion of under-5 deaths that occurred at home in rural South Africa, whether care was sought prior to death, and determinants of home deaths amongst those who sought care. Methods: Verbal autopsy data were used for all under-5 deaths, 2000–2015, in two health and demographic surveillance system sites. Trends in place of death and care-seeking were assessed. Associations between sociodemographic factors and home death despite seeking care were assessed by multivariate logistic regressions. Results: There were 3760 under-5 deaths; 1954 (53%) at home and 1510 (41%) in health facilities. Eighty-four per cent of children who died at home accessed healthcare during their final illness. Amongst neonates for whom care was sought, those who were 8–27 days old were more likely to die at home than those who were 0–7 days old (OR = 5.56, 95%CI 2.69–11.55, P < 0.001). Factors associated with home death of infants and young children despite seeking care included low maternal education (OR = 1.71, 95%CI 1.31–2.24, P < 0.001), larger household size (OR = 1.56, 95%CI 1.17–2.06, P = 0.002), traditional medicine use (OR = 2.33, 95%CI 1.75–3.12, P < 0.001) and Mozambican descent (OR = 1.47, 95%CI 1.06–2.03, P = 0.020). The proportion of HIV-related deaths that occurred at home fell from 60% in 2008–2011 to 39% in 2012–2015 (χ2 = 13.86, P < 0.001). Conclusion: More than half of under-5 deaths in rural South Africa occurred at home although healthcare was sought for most children, highlighting that home deaths are not simply a function of poor care-seeking. Interventions should target high-risk sociodemographic groups.