Training nurses to reduce child mortality.

After a shaky start, South Africa is finally making progress towards achieving the fourth of the eight Millennium Development Goals (MDGs), namely to reduce under-five mortality by two-thirds between 1990 and 2015 (UNDP 2003). However, whilst there has been a sustained decline in the country's under-five mortality rate (U5MR), this has only occurred since 2007 and the MDG target of 20 is unlikely to be realised within the final 500 days. The latest vital registration data for 2011 (Statistics South Africa 2014) suggests a national U5MR of 38.5 per 1000 live births, which is down from both the estimated 1990 baseline of 62 and the 2007 figure of 62.1 (NDoH 2011). Almost a third of these deaths occur during the first month of life, producing a neonatal mortality rate (NNMR) of 11.2, and three-quarters occur within a year of birth, resulting in an infant mortality rate (IMR) of 28.4. Since 2007 most of the gains in under-five survival have occurred in the postneonatal period, with the NNMR remaining in a narrow range between 12 and 14 deaths per 1000 live births. These national figures conceal a marked interprovincial inequity, with a threefold variation between the Western Cape (with the lowest U5MR at 24.1) and the Free State, where the U5MR is 71.2. Prematurity, birth asphyxia and sepsis account for most deaths during the neonatal period and, collectively, neonatal illnesses are the most common cause of death in infancy and early childhood. In the postneonatal period, gastroenteritis and acute respiratory illnesses come to the fore, and from one year of age non–natural deaths and tuberculosis play an increasing role in child mortality (Statistics South Africa 2014). Two conditions underlie many of these deaths: 34% of children dying in public sector hospitals are severely malnourished, whilst just over half are infected with or exposed to the human immunodeficiency virus (HIV) (eds. Stephen et al. 2011). Almost half (45.5%) of all deaths amongst children below five years of age occur outside the health services (Statistics South Africa 2014), and of those deaths in the public health sector more than a quarter occur within the first 24 hours of admission (eds. Stephen et al. 2011). Audits of childhood deaths in public hospitals suggest that approximately a quarter of these deaths are avoidable (Stephen et al. 2011). Avoidable factors, which are amenable to the intervention of nursing professionals, occur at both the household and primary …