Causes of death and predictors of childhood mortality in Rwanda: A matched case-control study using verbal social autopsy

Background: Rwanda has dramatically reduced child mortality, but the causes and sociodemographic drivers for mortality are poorly understood. Methods: We conducted a matched case-control study of all children who died before 5 years of age in eastern Rwanda between 1st March 2013 and 28th February 2014 to identify causes and risk factors for death. We identified deaths at the facility level and via a community health worker reporting system. We used verbal social autopsy to interview caregivers of deceased children and controls matched by area and age. We used InterVA4 to determine probable causes of death and cause-specific mortality fractions, and utilized conditional logistic regression to identify clinical, family, and household risk factors for death. Results: We identified 618 deaths including 174 (28.2%) in neonates and 444 (71.8%) in non-neonates. The most commonly identified causes of death were pneumonia, birth asphyxia, and meningitis among neonates and malaria, acute respiratory infections, and HIV/AIDS-related death among non-neonates. Among neonates, 54 (31.0%) deaths occurred at home and for non-neonates 242 (54.5%) deaths occurred at home. Factors associated with neonatal death included home birth (aOR: 2.0; 95% CI: 1.4-2.8), multiple gestation (aOR: 2.1; 95% CI: 1.3-3.5), both parents deceased (aOR: 4.7; 95% CI: 1.5-15.3), mothers non-use of family planning (aOR: 0.8; 95% CI: 0.6-1.0), lack of accompanying person (aOR: 1.6; 95% CI: 1.1-2.1), and a caregiver who assessed the medical services they received as moderate to poor (aOR: 1.5; 95% CI: 1.2-1.9). Factors associated with non-neonatal deaths included multiple gestation (aOR: 2.8; 95% CI: 1.7-4.8), lack of adequate vaccinations (aOR: 1.7; 95% CI: 1.2-2.3), household size (aOR: 1.2; 95% CI: 1.0-1.4), maternal education levels (aOR: 1.9; 95% CI: 1.2-3.1), mothers non-use of family planning (aOR: 1.6; 95% CI: 1.4-1.8), and lack of household electricity (aOR: 1.4; 95% CI: 1.0-1.8). Conclusion: In the context of rapidly declining childhood mortality in Rwanda and increased access to health care, we found a large proportion of remaining deaths occur at home, with home deliveries still representing a significant risk factor for neonatal death. The major causes of death at a population level remain largely avoidable communicable diseases. Household characteristics associated with death included well-established socioeconomic and care-seeking risk factors.