BackgroundThe rate of decline in child mortality is too slow in most African countries to achieve the Millennium Development Goal of reducing under-five mortality by two-thirds between 1990 and 2015. Effective strategies to monitor child mortality are needed where accurate vital registration data are lacking to help governments assess and report on progress in child survival. We present results from a test of a mortality monitoring approach based on recording of births and deaths by specially trained community health workers (CHWs) in Malawi.Methods and FindingsGovernment-employed community health workers in Malawi are responsible for maintaining a Village Health Register, in which they record births and deaths that occur in their catchment area. We expanded on this system to provide additional training, supervision and incentives. We tested the equivalence between child mortality rates obtained from data on births and deaths collected by 160 randomly-selected and trained CHWs over twenty months in two districts to those computed through a standard household mortality survey. CHW reports produced an under-five mortality rate that was 84% (95%CI: [0.71,1.00]) of the household survey mortality rate and statistically equivalent to it. However, CHW data consistently underestimated under-five mortality, with levels of under-estimation increasing over time. Under-five deaths were more likely to be missed than births. Neonatal and infant deaths were more likely to be missed than older deaths.ConclusionThis first test of the accuracy and completeness of vital events data reported by CHWs in Malawi as a strategy for monitoring child mortality shows promising results but underestimated child mortality and was not stable over the four periods assessed. Given the Malawi government's commitment to strengthen its vital registration system, we are working with the Ministry of Health to implement a revised version of the approach that provides increased support to CHWs.

ObjectivesFew developing countries have the accurate civil registration systems needed to track progress in child survival. However, the health information systems in most of these countries do record facility births and deaths, at least in principle. We used data from two districts of Malawi to test a method for monitoring child mortality based on adjusting health facility records for incomplete coverage.MethodsTrained researchers collected reports of monthly births and deaths among children younger than 5 years from all health facilities in Balaka and Salima districts of Malawi in 2010–2011. We estimated the proportion of births and deaths occurring in health facilities, respectively, from the 2010 Demographic and Health Survey and a household mortality survey conducted between October 2011 and February 2012. We used these proportions to adjust the health facility data to estimate the actual numbers of births and deaths. The survey also provided ‘gold-standard’ measures of under-five mortality.ResultsAnnual under-five mortality rates generated by adjusting health facility data were between 35% and 65% of those estimated by the gold-standard survey in Balaka, and 46% and 50% in Salima for four overlapping 12-month periods in 2010–2011. The ratios of adjusted health facility rates to gold-standard rates increased sharply over the four periods in Balaka, but remained relatively stable in Salima.ConclusionsEven in Malawi, where high proportions of births and deaths occur in health facilities compared with other countries in sub-Saharan Africa, routine Health Management Information Systems data on births and deaths cannot be used at present to estimate annual trends in under-five mortality.