Alarming findings from SA child death forensic review

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childhomicidebannerwebHomicide is the second-biggest cause of death among SA children whose bodies end up at a morgue, a pilot study published in the SA Medical Journal has found. And among babies who die, 70% do so at home, mainly from respiratory tract infections like pneumonia, with parents unaware that something is wrong.

A Sunday Times report says among the alarming findings in this study and an earlier one are that: three children are murdered every day; nearly half of child homicides are linked to abuse and neglect; physical punishment under the guise of discipline is a contributing factor; nearly half of murdered children have single moms; more than a third are killed by an acquaintance and a third are killed by their mothers; and murder is the biggest cause of death among 15 to 17-year-olds.

The new study was based on the international ‘child death review’ model, where every death deemed ‘unnatural’ is discussed by a team of experts including a senior state advocate, medical specialists, pathologists, social workers and police. These include murders, suicides, accidents, sudden and unexplained deaths and cases where someone may be liable.

The report says another alarming finding was that among babies who die, 70% do so at home, mainly from respiratory tract infections like pneumonia, with parents unaware that something is wrong. “People don’t realise the enormity of what is happening,” said Professor Lorna Martin, head of forensics and toxicology at the University of Cape Town and Salt River mortuary.

According to the report, Health Minister Aaron Motsoaledi sees an increase in the number of trained community health workers as the answer to these tragedies, and was in New York recently at the UN General Assembly lobbying for just that. He said: “The idea that most newborn babies who die, die at home, means we have no control. That is why I believe the new approach to healthcare should be about strengthening the primary healthcare system. Community health workers can pick up problems – and it is an affordable system. We can’t just rely on clinics and hospitals – it is not viable.

“These community health workers are not medical professionals, but they are trained to pick up problems early in ways that parents aren’t. The review also corroborated earlier research that South Africa has one of the highest global rates of neonaticide — the killing or abandonment of a baby under six days old.”

Of all child homicides, 16% were due to abandonment in the first week of life. According to the researchers, this was “shown to be a period of increased risk of deaths resulting from abandonment and injury”.

Also of concern, the report says, is infanticide, the killing of a child – deliberately or through abandonment – before their first birthday. A worrying gender component is that girls were much more likely to be abandoned than boys.

Neonaticide and infanticide are “far more common than the child death review pilot suggests”, say the researchers, “as many infants are ‘dumped’ in sewers, refuse dumps and dirt bins, and the pilot only identified remains brought to a mortuary”.

They say that despite liberal legislation on the termination of pregnancy and the availability of community-based contraception services, “it would appear that we are not meeting the needs of large numbers of women. We need to examine maternal and mental health services for pregnant women and determine the appropriate support services required by women in communities to decrease infanticide.”

Abstract
Background: Child mortality trends in South Africa (SA) show a decrease, but remain high and appear to have plateaued. To attain the new sustainable development goals, we need a better understanding of causes of death and the associated factors.
Objectives: To describe the SA child death review (CDR) pilot, the pattern of child deaths reviewed and the factors associated with these deaths.
Methods: CDR teams were established at two pilot sites, Salt River mortuary (Western Cape Province) and Phoenix mortuary (KwaZulu-Natal Province). All child deaths were reviewed by a multidisciplinary team at the pilot sites for the period 1 January 2014 – 31 December 2014.
Results: The CDR pilot reviewed 711 cases. Over half (53.3%) were natural deaths, as opposed to 42.6% non-natural deaths. Most infant deaths (83.9%) were due to natural causes, while 91.7% of deaths in the 15 – 17-year-old age group were due to injuries. The leading cause of deaths reviewed (30.8%) was respiratory tract infection (RTI), mainly among infants (51.6%). Homicide was the second most common cause of death and affected children of all ages, with the highest burden (52.8%) in the 15 – 17-year age group. Child abuse and neglect accounted for 11.3% of deaths. RTI was shown to be more likely after the neonatal period (odds ratio (OR) 2.92; p<0.000) and in preterm infants (OR 1.98; p=0.005).
Conclusions: CDR teams have been effective in improving identification of the causes of out-of-hospital deaths, as well as by identifying remediable factors critical to reducing child deaths further.

Authors
Shanaaz Mathews, Lorna J Martin, David Coetzee, Chris Scott, Threnesan Naidoo, Yasheen Brijmohun, Karisha Quarrie

Sunday Times report
SAMJ abstract
SAMJ editorial


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