Strengthening Community Networks for Vital Event Reporting: Community-Based Reporting of Vital Events in Rural Mali
Strengthening Community Networks for Vital Event Reporting: Community-Based Reporting of Vital Events in Rural Mali
Melinda K. Munos 0 1 2
Alain K. Koffi 0 1 2
Hamadoun Sangho 0 1 2
Mariam Guindo Traoré 0 1 2
Masseli Diakité 0 1 2
Romesh Silva 0 1 2
Mali RMM Working Group 0 1 2
Membership of the Mali RMM Working Group is listed in the Acknowledgments. 0 1 2
mmunos 0 1 2
@jhu.edu 0 1 2
0 Funding: This work and the Real-time Measurement of Under-five Mortality (RMM) study were part of the Real-time Results Tracking (RRT) Project. The Institute for International Programs at the Johns Hopkins Bloomberg School of Public Health led the RRT project with generous support from Canada's Department of Foreign Affairs, Trade, and Development , grant number 109947
1 Editor: Delmiro Fernandez-Reyes, University College London, UNITED KINGDOM
2 1 Department of International Health, Johns Hopkins Bloomberg School of Public Health , Baltimore , Maryland, United States of America, 2 Centre de Recherche, d'Etudes et de Documentation pour la Survie de l'Enfant , Bamako , Mali
Like many developing countries, Mali has few sources of mortality data. High quality mortality estimates are available from household surveys, such as the demographic and health surveys (DHS), approximately every five years, making it difficult to track progress in reducing mortality. The Rapid Mortality Monitoring (RMM) project in Mali aimed to address this issue by testing a community-based approach to measuring under-five mortality on a yearly basis. Seventy-eight community-based workers (relais) were identified in 20 villages comprising approximately 5,300 households. The relais reported pregnancies, births, and under-five deaths from July, 2012 to November, 2013. Data were double-entered, reconciled, cleaned, and analyzed monthly. In November-December 2013, we administered a full pregnancy history (FPH) to women of reproductive age in a census of the households in the project villages. We assessed the completeness of the counts of births and deaths, and the validity of under-five, infant, and neonatal mortality rates from the community-based method against the retrospective FPH for two rolling twelve-month periods. Monthly reporting by relais was high, with reports on pregnancies, births, and deaths consistently provided from all 78 relais catchment areas. Relais reported 1,660 live births and 276 under-five deaths from July, 2012 to November, 2013. The under-five mortality rate calculated from the relais data was similar to that estimated using the validation survey, where the overall ratios of the community-based to FPH-based mortality rates for the reporting periods were 100.4 (95% CI: 80.4, 120.5) and 100.8 (95% CI: 79.5, 122.0).
On a small scale, the community-based method in Mali produced estimates of annualized under-five mortality rates that were consistent with those obtained from a FPH. The
Competing Interests: The authors have declared
that no competing interests exist.
community-based method should be considered for scale-up in Mali, with appropriate
measures to ensure community engagement, data quality, and cross-validation with comparable
At international level, and within most developing countries, programs are being implemented
with the goal of reducing mortality in one of the most vulnerable population groups—children
under five. Understanding whether these programs are able to reduce under-five mortality
(and why) is of pressing concern for donors, countries, program implementers, and
researchers. Unfortunately, answering this question, particularly over short time periods, is complicated
by the challenges in measuring mortality change. In most developing countries, civil
registration is incomplete, and the main sources of mortality estimates are the health management
information system (HMIS) and household surveys such as the Demographic and Health
Surveys (DHS) program [
]. HMIS generally only take into account deaths in health facilities, and
do not include those at home (that is to say, in the community, where most deaths occur). DHS
take place approximately every five years, and between two surveys, it is not possible to know
whether or how mortality is changing. Furthermore, household surveys with full birth histories,
such as the DHS, report estimates for a five-year period before the survey, and do not have
sample sizes large enough to allow monitoring of mortality changes in “real time” (i.e., every 12
To address this problem, we sought to develop and test community-based approaches to
“real-time” (yearly) mortality measurement that could be built on a country’s existing health
system or civil registration system, in five countries in sub-Saharan Africa through the
Realtime Mortality Monitoring project (RMM).
This paper reports on the implementation and validation of the community-based approach
to recording vital events in Mali—a large, land-locked country in West Africa with a relatively
small population (14.5 million in 2009) [
], and very high fertility (total fertility rate of 6.1 in
]. Although under-five mortality has decreased over the past two decades, almost 13%
of live-born children still die before their fifth birthday [
]. Like most countries, Mali relies
primarily on surveys such as DHS, which have taken place at intervals of six to seven years, to
track changes in under-five mortality.
The objectives of RMM in Mali were to implement a community-based RMM method that
builds on the existing structures of volunteers and health systems, and to assess the validity of
this method in measuring under-five mortality over 12-month periods.
Setting and selection of RMM area
The community-based RMM study in Mali was conducted in the health districts of Niono and
Barouéli, in the region of Ségou, located 240 km northeast of the capital, Bamako (Fig 1). The
region of Ségou is mainly rural, with higher mortality and approximately the same level of
fertility as the country as a whole [
The region of Ségou and the districts of Baraouéli and Niono were chosen in collaboration
with the National Directorate of Health (DNS), the Regional Directorate of Health (DRS), and
their partners. Initial selection criteria for the region and districts included the presence of
UNICEF and the implementation of community case management (CCM) of childhood illness
2 / 14
Fig 1. Map of Mali showing the two health districts selected for the RMM study in Ségou Region.
to permit the RMM results to contribute to an evaluation of the CCM program, although this
evaluation did not materialize. Additional selection criteria were accessibility during the rainy
season, and the judgment of the DNS and DRS with regards to whether the region and districts
had functional management teams and networks of relais in place.
In each health district chosen for the study, we established a list of health facility catchment
areas (19 for Niono, 23 for Barouéli). Two facility catchment areas were selected in each district
(Molodo and Nara IBT in Niono; Kalakè and Sanando in Barouéli). After excluding catchment
areas with populations of less than 5,000, we selected the RMM catchment areas based on the
district health team’s assessment of whether the health facility was functional, the level of
engagement by community organizations, and the existence of a functioning network of
The four selected facility catchment areas contained 49 villages (25 in Niono, 24 in
Barouéli). The villages in each catchment area were then stratified according to the distance
between the village and the first level health facility in the catchment area (<3 km, or 3 km).
Within each stratum, one to five villages were sampled by systematic random sampling with
probability proportional to the size of the village. In total, 20 villages were selected (S1 Table).
In the villages selected for the study, all of the households were eligible to participate, for a
total of approximately 5,300 households. A household was defined as the head of household,
all of his wives and their children residing in the compound, and the relatives living with them.
Female-headed households were defined as a woman and her children residing in the
compound, and any relatives living with them.
We conducted a cross-sectional qualitative assessment in May, 2010 in Niono and Barouéli
districts to explore the current practices for recording vital events, actors involved in the recording
3 / 14
of vital events, and barriers and local attitudes towards recording vital events data. The
methods and results of this research are described in a separate manuscript [
Implementation of community-based vital events reporting
Selection of cadre of community-based workers. Based on the results of the formative
research, the relais communautaires were selected as the best-placed cadre to collect vital events
data at the community level. Relais are an existing cadre of lay volunteer community workers
in Mali who are responsible for health sensitization activities, as well as recording births and
deaths in the community. Some relais have other leadership roles in the community, including
teachers and traditional birth attendants. Given these roles, relais were identified by
community members and health workers as a cadre that was both well-informed about pregnancies,
births, and deaths in the village, and authorized to report these events.
All 78 relais in the 20 RMM villages participated in this study. The characteristics of these
relais are provided in Table 1. No new relais were selected for the study, however, three relais
died during the course of the study and were replaced by their communities. Study personnel
played no role in choosing the replacements for these relais.
Training. Relais training was conducted from May to June, 2012. Seventy-eight relais were
trained for three days at the referral health facility in each district. Training was conducted by a
team of six trainers, including a study investigator, a field coordinator, a representative from
the regional health directorate, a representative from the district health office, and two medical
officers from first level facilities in the RMM area. The training focused on how to complete the
pregnancy, birth, and death registers, and the importance of ensuring the accuracy and
completeness of this information.
Community sensitization. In preparation for the RMM study, study investigators
conducted sensitization activities with local authorities and local communities. In March, 2012,
newsletters were sent to administrative and socio-health authorities (Regional Directorates of
Health, Social Development, and Statistics) for the region of Ségou, the medical officers for the
n (N = 78)
health districts of Niono and Barouéli, and the four technical directors of the health centers
(Directeur Technique du Centre, or DTC) in the health catchment areas of the study. Study
staff also visited the two districts to meet with officials from the Regional Directorate of Health
and Social Development, Regional Directorate of Planning, Statistics, Information Technology
and Land Use, the association of community health workers, and the chief medical officers and
prefects of the two districts involved, to inform them about the RMM study.
At the community level, in June, 2012 study staff and local health officers held half day
meetings in each RMM village to explain the study objectives and procedures, and the rationale
for and importance of collecting information on vital events. These meetings were attended by
village leaders, relais, and the leaders of women’s groups.
Data collection. Relais collected data on pregnancies, births, and deaths in the 20 RMM
communities from June, 2012 to November, 2013. The pregnancy register also collected
information on pregnancy outcomes, which were classified as live births, miscarriages and
stillbirths. The month of June 2012 was a pilot period, and data from that month were discarded.
Each relais was given three carbon paper registries—one each for births, deaths, and
pregnancies—in either French or Bamanan (the local language) to record vital events (S1 Text). All but
two study relais read and wrote French and/or Bamanan to some extent; the one relais who
could not read or write was paired with another relais who helped him complete his registries.
Although relais are normally volunteers in Mali, we paid them 15,000 FCFA (approximately
30 USD) every three months, gave them phone cards to allow them to call their supervisor, and
reimbursed them for travel to quarterly meetings.
Supervision and data quality assurance. The RMM project reinforced the supervision
model of the Mali health system. RMM district coordinators established a field visit calendar
with all RMM relais and with the community health worker (agent de santé communautaire or
ASC) charged by the health system with supervising that relais. Field coordinators (hired for
this study) supervised the relais every 15 days during the first two months of data collection,
and monthly thereafter, often accompanied by ASCs.
The RMM research coordinator, RMM district coordinators, and representatives of the
local health system supervised RMM relais quarterly. These supervision visits included a
meeting in each district with all RMM relais in that district, in order to share experiences, examine
registers to assess data quality, and address any problems. The visits also offered the
opportunity to sensitize the relais on data quality issues and the importance of recording all events.
Finally, study staff, medical officers from first-level and referral facilities, and representatives
from the regional health directorate organized bi-annual supervision visits.
The RMM team put in place a number of procedures to ensure data quality, including
verification of a 10% sample of reported births and deaths in randomly selected RMM villages
during quarterly supervision visits, confirmation of the classification of all reported stillbirths with
the health worker or traditional birth attendant who assisted the delivery or with the mother,
and the provision of a list of pregnant women with estimated delivery dates in the next month
(taken from the pregnancy register) to each relais on a monthly basis. The lists of women with
an upcoming due date were shared with the relais starting in December, 2012, and were aimed
at helping relais to monitor pregnancy outcomes and improve completeness of recording for
births and early neonatal deaths.
Data management. The carbon copy sheets from the relais’ registers were double-entered
each month. The resulting databases were compared and reconciled, and logic checks were
conducted. Key variables were tabulated and the tables used to identify potential data quality
issues monthly so that these could be addressed promptly. The results of these tabulations were
fed back to relais during the quarterly supervision visits, and any data quality concerns were
addressed with them.
5 / 14
Validation of community-based vital events reporting
Design. We assessed the accuracy and completeness of the relais-reported data on births
and under-five deaths by comparing these data to the results of a full pregnancy history for two
rolling 12-month periods (July, 2012 to June, 2013 and October, 2012 to September, 2013).
The full pregnancy history (hereafter referred to as the “validation survey”) was administered
to women aged 15 to 49 years in a census of the households in RMM communities in
November and December, 2013 (survey questionnaire available in S2 Text).
Training. Fifty-five interviewers and team leaders with at least a high school diploma, who
were minimally computer literate and who spoke the local language (Bamanan) were selected
for an eight-day training workshop. The workshop included training on study procedures,
paper and electronic questionnaires in French and Bamanan, and human subjects research
protections. In addition, interviewers and supervisors had two days of field practice in villages
near Bamako. Team leaders received two days of additional training on supervision and data
management procedures. Training was conducted by study investigators and staff, including
the principal investigator. At the conclusion of the training, forty interviewers and eight team
leaders were selected for the validation survey based on their performance and language skills.
Data collection. Data were collected by eight teams comprised of five interviewers and
one supervisor. Data collection teams attempted to interview all households in the RMM
communities. The study team had enumerated households in June, 2012, and in November
and December, 2012, the list of households was updated and the compounds were mapped.
For the validation survey, the household lists and maps from 2012 were used to locate
households, and the relais in each village guided data collection teams to any compounds or
households that had been established since December, 2012. Interviewers made up to three
attempts to interview each household.
In each household, interviewers first listed the household members along with their age and
sex in order to identify women aged 15 to 49 years who were eligible for the full pregnancy
history (FPH) questionnaire. After providing consent, these women were asked about all of the
pregnancies that they had had in their lifetime, including: the outcome of the pregnancy (live
birth, stillbirth, or miscarriage); whether it was a multiple birth; sex, month and year of birth,
and vital status of the child (for live births); and age at death (for live births that had died). Up
to three attempts were made to interview each eligible woman.
Supervision. Data collection teams were supervised by two staff members from the National
Statistics Institute in Ségou (DRPSIAP-Ségou) as well as the study data manager, all of whom had
participated in the interviewer training and were present in the field for the entire survey period.
In addition, study investigators conducted two, two-week supervision visits during data collection.
Data management. Data were collected on netbooks using CSPro software [
were downloaded and checked by team leaders each night. Data were compiled and checked by
supervisors and central study staff weekly. Data were cleaned in CSPro and Stata, version 13 .
Ethical clearance for the RMM study was obtained from the Johns Hopkins School of Public
Health’s Institutional Review Board (IRB 3909) and the Ethical Review Committee, Faculty of
Medicine, University of Bamako. Oral consent was obtained from study participants. We
obtained a waiver of written consent from the IRB because much of the study population is
illiterate. Oral consent was documented by study interviewers, who signed and dated the
consent form after a study respondent provided their consent to participate. This procedure was
approved by the Johns Hopkins School of Public Health IRB and the Ethical Review
Committee, Faculty of Medicine, University of Bamako.
6 / 14
The anonymized datasets for this study are available at: DOI 10.7281/T1F769G3
Data on births and under-five deaths reported by relais in the period of July, 2012 to
September, 2013 were included in the validation analysis. The data were analyzed for two rolling
12-month periods: July, 2012 to June, 2013, and October, 2012 to September, 2013. Data
analysis was conducted in R version 3.0.2 (2013-09-25) [
We calculated the number of births and neonatal, infant, and under-five deaths reported by
relais for each 12-month period. Because all relais submitted their vital event reporting forms
for all 15 months of the RMM implementation period, we did not need to adjust the relais data
for missing reports. We calculated neonatal, infant and under-five mortality rates for each
period by dividing the number of these deaths documented by relais in a given period by the
total births documented by relais in that same period.
The validation analysis involved two components: (1) an evaluation of the completeness of
births and deaths reporting by relais; and (2) a comparison of under-five, infant, and neonatal
mortality rates calculated from the relais data with those estimated from the validation survey
for each 12-month period.
To evaluate the completeness of births and under-five deaths documented by the relais, we
estimated the expected number of births and under-five deaths that should have been collected
by relais for each 12-month period. We estimated the crude birth rate and the under-five
mortality rate in each period directly from the validation survey. To estimate the expected number
of births that should have been reported by relais, we multiplied the crude birth rate for each
12-month period by the total population size of the RMM catchment area in each district. The
expected number of under-five deaths was calculated similarly, by multiplying the under-five
mortality rate estimated from the validation survey by the expected number of births
(calculated as described above). We examined the completeness of relais-based births and under-five
deaths data by calculating the ratio of the total numbers of births and under-five deaths
documented by relais to the expected numbers estimated as described above.
To compare under-five, infant, and neonatal mortality rates calculated from the relais data
with those estimated from the validation survey, we calculated mortality rates from the relais
data and the validation survey data by dividing the reported number of under-five deaths that
occurred in each 12 month validation period by the number of live births that occurred during
the same period. The mortality calculation was done in the same way for each data source to
ensure direct comparability. Standard errors and confidence intervals were estimated using the
jackknife resampling technique [
]. The Delta method  was used to examine the
equivalence of the mortality rates based on the relais data with the rates from the validation survey.
Statistical equivalence of the community-based and survey-based methods was assessed by
calculating the ratio of the relais-based mortality rate to the validation survey-based mortality rate
and the corresponding 95% confidence interval (CI), with a ratio of 1.0 indicating perfect
statistical equivalence. If the upper bound of the 95% CI was less than 0.80, or the lower bound
was greater than 1.20, we rejected the hypothesis of equivalence between the mortality rates
produced by the two methods. These rejection criteria were defined a priori.
Community-based vital events data
In the two RMM districts, 78 relais in 20 villages conducted vital event reporting for the RMM
project. These relais covered a total population of approximately 32,128 individuals, or 5,355
7 / 14
Fig 2. Number of relais catchment areas reporting data, by district.
households. Monthly data on pregnancies, births, and deaths were consistently reported from
100% of the relais catchment areas (Fig 2).
In total, the relais reported 1,660 live births in the 17 months of RMM data collection—785
in Barouéli and 875 in Niono—and 37 stillbirths. The overall sex ratios at birth were 111 male
births for every 100 female births in Barouéli and 128 in Niono. Relais reported a total of 276
deaths in the 17 months of data collection—127 in Barouéli and 149 in Niono. The age
distribution of neonatal deaths and children who died between the ages of one and twenty-three
months is reported in S1 and S2 Figs.
Validation survey data
All 5,413 households in the RMM relais catchment areas were eligible to participate in the
validation survey, and a total of 5,064 households (93.6%) were successfully interviewed. These
interviews identified 6,533 eligible women (women aged 15–49 years), of whom 6,304 (96.5%)
were interviewed. The main reason for household and women non-response was households
or individuals who were absent; interviewers reported that most absences were due to the
harvest or other work, as the survey was conducted during the harvest.
Interviewed women reported 26,165 pregnancies over the course of their lives, of which 904
(3.5%) ended in a stillbirth, 1,575 (6%) in a miscarriage, and 23,686 in a live birth. The average
sex ratio in the validation survey was 109 male births for every 100 female births in Barouéli,
and 114 in Niono. The age distribution of neonatal deaths and children who died between the
ages of one and twenty-three months in the validation survey is reported in S3 and S4 Figs.
PLOS ONE | DOI:10.1371/journal.pone.0132164
Neonatal Mortality Rate (per 1,000)
Infant Mortality Rate (per 1,000)
Under-Five Mortality Rate (per 1,000)
validation survey. The under-five mortality rates from the community-based method and
survey-based method differed by one death per 1000 or less, and the ratios of the
communitybased to the survey-based mortality rates were 1.00 (95% CI: 0.80, 1.201) and 1.01 (95% CI:
0.80, 1.22) for the reporting periods, indicating statistical equivalence of the methods. However,
the relais-reported infant mortality rate (IMR) and neonatal mortality rate (NMR) were greater
than the IMR and NMR estimated from the validation survey.
Summary and interpretation of key findings
This study sought to assess the ability of community-based workers in Mali to record vital
events data (births and under-five deaths) accurately and completely. The study strengthened
the supports available to the relais by: hiring two full-time field coordinators (one for every 10
villages) who conducted monthly supervision, data verification, and data entry activities;
analyzing data on an ongoing basis and providing feedback to relais at quarterly meetings; and
providing compensation to relais in the form of quarterly stipends and airtime. In addition, the
study included strong community sensitization regarding the importance of vital events
reporting, and was conducted in a relatively small population over a relatively short time period. The
results of this study therefore provide information about the ability of a community-based
system to provide accurate mortality information in a small population given relatively strong
supports. This study was not a test of the scalability of this method and does not provide an
indication of how such a method would perform at scale.
We found that both the community-based method and the validation survey produced
relatively high quality data. The sex ratios at birth, however, which are expected to fall between 102
and 107 male births per 100 female births in most populations [
], suggested some
underreporting of female births relative to male births, particularly in Niono district, for the
community-based data and the validation data. We also saw indications of age heaping, where
respondents round the reported age to the nearest 6 or 12 months, for age at death in the
validation study, especially at 12 months of age. This finding is not surprising for a retrospective
mortality survey, where the mother may not be able to recall the child’s exact age at death with
precision. Notwithstanding these issues, we believe that the quality of the data is sufficiently
high to allow for a valid test of the performance of the community-based method in estimating
mortality over 12-month periods.
The community-based method in Mali produced estimates of the under-five mortality rate
that were statistically and practically equivalent to those produced by the full pregnancy history
in the validation survey. By practical equivalence we mean that the estimates produced by both
methods were very close (a difference of one death per 1000 live births) and therefore
interchangeable for the purposes of tracking progress in reducing under-five mortality. At small
scale, this method therefore performed as well as a standard retrospective mortality survey
with full pregnancy history in producing estimates of under-five mortality. This finding
suggests that, with relatively strong supervision and incentives, community-based workers are
capable of collecting data that would allow governments and programs to track changes in
under-five mortality on an annual basis. It is not clear, however, whether the quality of the data
collected by these workers could be maintained if the program were scaled up, nor whether
such a large-scale program would be cost effective.
Although surveys with full birth histories or full pregnancy histories are generally
considered to be the best available approach for producing estimates of mortality rates in developing
countries, we found that the community-based method produced higher estimates of early
mortality, particularly neonatal mortality, relative to the retrospective validation survey. As it is
10 / 14
unlikely that women would report deaths that did not occur, these higher rates could be due to
lower reporting of births in the community-based method than in the validation survey, higher
reporting of early deaths in the community-based method than the validation survey, or
misclassification of stillbirths or early neonatal deaths in the community-based method or
validation survey. Births do not seem to have been under-reported by the community-based method
in comparison to the validation survey. A comparison of the patterns of neonatal deaths by age
at death (in days) in the community-based and survey-based methods, relative to the expected
daily risk of death [
] reveals some misclassification of day zero deaths as day one deaths in
the validation survey, and a slightly higher than expected proportion of neonatal deaths in the
first day of life for the community-based method in the second 12-month validation period (S5
and S6 Figs). This could indicate misclassification of some stillbirths as early neonatal deaths in
the second validation period, which would account in part for the higher neonatal mortality
rate observed with the community-based method.
There are plausible explanations for the increased reporting of early deaths in the
community-based method in Mali. This method was prospective and included reporting pregnancies,
which could then be followed to obtain pregnancy outcomes. District coordinators and central
study staff emphasized to relais the importance of having an outcome for each pregnancy, and
the importance of reporting all deaths, even those that occurred very early. Finally, the
community-based method used relais, who are well-known members of the community, to report
births and deaths. Their status as respected community members who conduct some health
sensitization activities may have given them an advantage in learning about births and deaths,
relative to the interviewers used in the validation survey, who were not from the community.
There is some qualitative evidence suggesting that in developing countries, perinatal events
(stillbirths and early neonatal deaths) are highly sensitive and are not publicly discussed or
]. Further, there may be confusion as to the classification of early events; the medical
terms “miscarriage,” “stillbirth,” and “neonatal death” do not always have equivalents in local
languages, and perinatal losses may be categorized more in terms of the baby’s size or
appearance (large, “mature”, or “immature”) than whether the event happened before, during, or after
]. A few studies have attempted to assess the validity of retrospective survey-based data
on neonatal and child deaths, either through an internal data quality assessment or by
comparison with demographic surveillance-type data. The results have been mixed, with several studies
showing slightly higher infant mortality estimates from surveillance compared to retrospective
surveys, but no difference for neonatal deaths [
14, 15, 16
]. Haws et al. also cited unpublished
findings from Uttar Pradesh, India, showing a much higher neonatal mortality rate measured
through prospective surveillance than through a retrospective mortality survey [
Our study has several limitations. Although ideally we would have validated the
communitybased method against a method that recorded all births and deaths, no such method exists.
Although surveys with retrospective pregnancy histories are considered the best available
method for collecting data, particularly in large populations, they do not capture all births and
deaths due to recall error, misreporting, and interviewer error. Thus, our validation of the
community-based method was closer to an equivalence test against the current standard for
collecting mortality data for children under five years.
Second, the community-based method was implemented over a relatively short period of
time (17 months). It is possible that when implemented over a longer period of time, the
completeness of reporting would deteriorate. Routine quality control and continuous field
supervision may be difficult to sustain over longer periods of time.
11 / 14
Third, our validation analysis assumes that migration in and out of the study area is
negligible during the 17-month reference period. One of the villages in the RMM area had a large
population of Fulani (a nomadic ethnic group), and relais in this village reported difficulty in
tracking births and deaths, which were often reported months after the fact if they occurred
while a household was away from the village. This village represented approximately 6% of the
population of the RMM area, and the other villages within the study area had very little
migration. Hence, community-based vital events reporting might not work as well for areas with
non-negligible levels of migration. For urban areas and for the northern regions of Mali, which
have large nomadic populations and have been experiencing considerable conflict-related
migration, there may be inconsistencies between the vital events that are observable by relais
and those that can be reported retrospectively by a sample of households.
Fourth, this study did not involve systematic active surveillance of pregnancies. Rather,
relais reported pregnancies when women shared that information with community members
and reported on the outcome when women informed them of the birth, stillbirth, or
miscarriage. We encouraged relais to follow up with women with approaching due dates to learn
about the outcome of the pregnancy, but this was not done in a systematic way, which may
have resulted in underreporting of pregnancy losses. A potential refinement of the RMM
community-based method might involve more proactive and detailed pregnancy status tracking so
as to reduce potential misclassification errors, although this would likely require increased
supervision of relais.
Finally, the validation analysis we present in this paper evaluates the consistency of annualized
birth counts, death counts, and under-five mortality rates between two data collection systems as
opposed to assessing the consistency of record-level reporting of vital events information
between the two systems. In a separate analysis within this collection, Silva et al. report on a
record-linkage study that evaluates the consistency of reporting between both data collection
methods and the level of under-reporting of birth events and death events by both systems.
This assessment suggests that community-based methods for vital events reporting built on the
existing system for reporting these events holds promise for obtaining data on mortality at
12-month intervals on a small scale, and potentially on a larger scale, if adequate supports are
put into place. The community-based method tested in Mali performed well when
implemented in 20 villages with strong supports, and should be considered for gradual scale-up in
Mali, with appropriate measures to ensure community and relais engagement, close
supervision of relais, ongoing data analysis and data quality assessment, and cross-validation with
S1 Fig. Distribution of neonatal deaths by age at death in days, Mali community-based
data, July 2012-November 2013.
S2 Fig. Distribution of deaths from 1 to 23 months by age at death in months, Mali
community-based data, July 2012-November 2013.
S3 Fig. Distribution of neonatal deaths by age at death in days, Mali RMM validation
survey, November-December 2013.
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S4 Fig. Distribution of deaths from 1 to 23 months by age at death in months, Mali RMM
validation survey, November-December 2013.
S5 Fig. Cumulative percentage of neonatal deaths by day of death, July 2012-June 2013.
S6 Fig. Cumulative percentage of neonatal deaths by day of death, October 2012-September
S1 Table. List of RMM villages.
S1 Text. Relais vital event reporting forms.
S2 Text. Validation survey questionnaire.
We would like to acknowledge Kate Gilroy (Intrahealth) for overseeing the formative research
and developing the initial study design, Samba Keita (Mali Ministry of Health—CPS) for his
technical assistance with CSPro for the validation study, and Abdoulaye Ongoiba (CREDOS)
for his administrative support. We thank the Mali RMM Steering Committee and the Mali
Ministry of Health for their guidance throughout the study. The Ségou Regional Health
Directorate, district health officers, and local health personnel provided invaluable assistance in
sensitizing local communities and supervising relais. Finally, we thank the field coordinators and
relais for their efforts in implementing this study, and the RMM communities for sharing
information about vital events with the relais.
Members of the Mali RMM Working Group are: Country collaborators Seydou Doumbia,
Masseli Diakité, Assa Keita, Haoua Keita, Hamadoun Sangho, Ibrahim Terera, and Mariam
Guindo Traoré; current and former Johns Hopkins University faculty and students Agbessi
Amouzou, Robert Black, Jennifer Bryce, Olga Joos, Alain Koffi, Melinda Munos, Romesh Silva,
and Emily Wilson; and RMM Technical Advisor Kenneth Hill and Gareth Jones. All
contributed to the design and implementation of the RMM project in Mali.
Conceived and designed the experiments: MM AK HS AA KH RB JB GJ SD. Performed the
experiments: MGT MD IT AK HK OJ. Analyzed the data: RS MM AK MGT MD IT EW.
Wrote the paper: MM AK RS HS MGT MD JB RB.
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