The national tragedy of rising childhood mortality in Dominica: 15 years and counting

Although the world has celebrated accelerated mean annual reductions in child mortality over the past two decades, even in the most poorly resourced countries,1Lozano R Naghavi M Foreman K et al.Global and regional mortality from 235 causes of death for 20 age groups in 1990 and 2010: a systematic analysis for the Global Burden of Disease Study 2010.Lancet. 2012; 380: 2095-2128Summary Full Text Full Text PDF PubMed Scopus (8787) Google Scholar child survival trends in Dominica have remained in sharp contrast to the rest of the world since 2003. Dominica is the only country in recorded history where childhood mortality has been consistently and considerably on the rise for the past 15 years and counting. In this Correspondence piece, we used vital registration data, as well as the Global Burden of Disease Study 2017 and the UN Inter-agency group for child mortality estimates for the years 1960 to 2017 to generate an overall assessment of the rates and the distributions of causes of mortality in children aged 0–59 months in Dominica. The documented International Classification of Diseases (ICD) codes in the vital registration data were used to classify deaths during the perinatal period according to ICD-perinatal mortality.2WHOThe WHO application of ICD-10 to deaths during the perinatal period: ICD-PM. World Health Organization, Geneva2016http://www.who.int/reproductivehealth/publications/monitoring/icd-10-perinatal-deaths/en/Date accessed: January 3, 2019Google Scholar The mean annual increase in mortality in children aged less than 5 years in Dominica was 7·2% (95% CI 6·4–7·9) from 2002–16. Probability of dying in the first 28 days of life (neonatal mortality) increased 119% from 13·9 per 1000 livebirths to 30·4 in this same time period. Neonatal deaths make up a disproportionately high percentage of overall mortality in children aged less than 5 years in Dominica. This pattern is progressively worsening and reached an all-time-high value of 87·8% in 2016. From 2002–16, 52% of all neonatal deaths were classified as intrapartum, while antepartum constituted 9%, early neonatal (day 1–6) constituted 25%, and late neonatal (day 7–28) constituted 14%. Comparison of causes of death distribution among children aged less than 5 years in Dominica in 2000 and 2016 showed that intrapartum complications as a cause of death has more than tripled over this same time period. In 2016, more than 35% of all deaths in children aged less than 5 years in Dominica were caused by intrapartum complications. In no other country in the world, did intrapartum complications constitute more than 13% of deaths in children aged less than 5 years. Intrapartum complications are almost exclusively responsible for the rise in neonatal mortality, and hence the overall mortality, in children aged less than 5 years from 2000 to 2016 in Dominica. It is widely accepted, and supported by evidence, that the rate of deaths due to intrapartum-related complications is reflective of the quality of the health-care system.3Lawn J Kinney M Lee A et al.Reducing intrapartum-related deaths and disability: can the health system deliver?.Int J Gynaecol Obstet. 2009; 107: S123-S142Crossref PubMed Scopus (136) Google Scholar, 4Fauveau V New indicator of quality of emergency obstetric and newborn care.Lancet. 2007; 3701310Summary Full Text Full Text PDF PubMed Scopus (35) Google Scholar Unlike most countries with high neonatal mortality where a substantial percentage of births are happening outside standard facilities, in Dominica, almost all (99%) births in 2017 took place in a hospital.5UNICEF Office for the Eastern Caribbean AreaSituation Analysis of Children Commonwealth of Dominica. UNICEF, Barbados2017https://www.unicef.org/easterncaribbean/ECAO_Dominica_Sitan_2017.pdfDate accessed: February 19, 2019Google Scholar This finding emphasises the fact that a readily available and accessible birthing centre is not a proxy for good birthing care without also ensuring the presence of professionally trained providers and standardised protocols. The trends observed in mortality in children aged less than 5 years for Dominica could be a result of a poorly managed clinical practice environment; miscommunication among members of the perinatal team or inappropriate team response and prioritisation; shortage of relevant workforce; lack of standardised medical facilities and equipment; incompetency of providers because of insufficient training, experience, or complexity of complications; and an inability to translate evidence-based neonatal care information into practical outcomes.6Johnson D D'Agostino M Marti M et al.Knowledge management strategy for advancing the national health agenda in Dominica.Rev Panam Salud Publica. 2017; 41: e3PubMed Google Scholar In Dominica, only vital registration estimates of mortality in children aged less than 5 years are available, and the vital registration systems are considered biased. Although there is no evidence on the level of quality of data, both crude and adjusted estimates of mortality in children aged less than 5 years could be imperfect because of a lack of diagnostic accuracy and consistency of ICD coding, misclassification, and missing data. Incompleteness of data and under-registration might also vary over time and create fluctuations.7McCaw-Binns A Mullings J Holder Y The quality and completeness of 2008 perinatal and under-five mortality data from vital registration, Jamaica.West Indian Med J. 2015; 64: 3-16PubMed Google Scholar In 2010, WHO reported high variability in Caribbean mortality data quality, but Dominica was ranked as one of the five countries in the region with high quality data (>90% completeness and less than 10% ill-defined ICD codes).8WHOWorld health statistics 2012. World Health Organization, Geneva2012from:www.who.int/entity/ghoDate accessed: November 10, 2019Google Scholar Vital registration data analysis from all other regional small island developing states with similar economic, developmental, and political structures showed a trend towards decreased child mortality in the study period. This finding provides additional support that despite the limitation of the data, this report has essential policy implications. As outlined in the National Strategic Plan for Health report, the problem with the quality of the health services is not restricted to neonatal and birthing services; the country is also facing substantial challenges related to other health services and the wellbeing of its citizens.9Ministry of Health and EnvironmentNational strategic plan for health: investing in health—building a safer future. Volume 2: action plan 2010–2019, Roseau, Dominica.http://healthpromotion.gov.dm/multimedia/publications?download=29:strategic-health-plan-volume-2Date: 2010Date accessed: June 7, 2019Google Scholar The tragic national situation in Dominica did not take place overnight; rather, it is the cumulative result of well over a decade of rises in mortality being overlooked or perhaps minimised at the national and international level.10Pan American Health Organization/WHOEvidence and intelligence for action in health department/health analysis, metrics and evidence unit. PLISA Database. Health Situation in the Americas: Core Indicators 2018. Washington, DC, USA.https://www.paho.org/salud-en-las-americas-2017/?p=3988Date: 2018Date accessed: January 21, 2019Google Scholar The upward trend in neonatal mortality and mortality in children aged less than 5 years should cause alarm and prompt the authorities and multilateral agencies to invest and promote a high quality of care interventions. These interventions should be targeted to improve access and quality of obstetric and neonatal care, which in turn will decelerate and decrease neonatal mortality and mortality in children aged less than 5 years in Dominica. We declare no competing interests.

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