ESTIMATING THE IMPACT OF MATERNAL, NEONATAL AND CHILD SURVIVAL INTERVENTIONS

Ingrid Friberg, PhD

The Lives Saved Tool - LiST

The Lives Saved Tool A multi-cause model of mortality

Predict changes in Under 5 and neonatal mortality rates and deaths Maternal mortality ratios and deaths Stillbirth rates and deaths Causes of death

Using Country specific health status Changes in child and maternal health intervention

coverage levels i.e. ORS, facility delivery, etc.

Effect sizes of interventions based on the best available evidence

LiST

3

Beginnings:Grew out of the “Bellagio” modeling exercise and the Lancet Child Survival Series (2003). Added in neonatal, nutrition, and updated information

Goals: Promote evidence-based decision makingAid in planning expansion of maternal, neonatal and child health interventions

Objectives: Estimate lives saved when introducing or scaling up key interventions

Demographic estimates and

projections

UN Pop/Spectrum

Number of Child, Maternal and Fetal deaths

Deaths by CauseWHO/UNICEF Country estimates

Deaths averted -By cause-By intervention

General Framework

Intervention Coverage

CurrentTarget/Goal/Endline*Change is critical*

Health Status

•Stunted, wasted•Malaria prevalence•Vit A deficiency•Zinc deficiency

Stunting, Wasting, Breastfeeding

Effectiveness

EstimatesIntervention ImpactC1 C2 C3 C4 …

Int1 Int2 Int3

Which interventions were included? Proximate factors

Not distal Work through health programs

Not included: income, education and crowding, etc. Water and sanitation are the exceptions

Feasible in a low income country 68 priority countries with highest MNCH mortality

Cause-specific evidence of effect Research studies or systematic reviews Delphi method if research is impossible (i.e. CEmOC) Updated frequently IJE April 2010, BMC Public Health April 2011

Intervention Types

Maternal, fetal, neonatal, child

Periconceptional, antenatal, birth, immediate postnatal, child

Preventive, curative

Nutritional, vaccination, water/sanitation, treatment

Risk factors: Cause-of-death specific

Immediate, time-lagged

External (family planning, AIDS), internal (all others)

Periconceptional Interventions

Pregnancy Interventions

(Family planning) Folic acid supplementation or fortification Safe abortion services Post abortion case management Ectopic pregnancy case management

Tetanus toxoid vaccination IPTp – malaria prevention in pregnancy Syphilis detection and treatment Calcium supplementation Multiple micronutrient supplementation Balanced energy supplementation Diabetes case management Maternal malaria case management MgSO4 – management of pre-eclampsia Fetal growth restriction and management (PMTCT)

Childbirth Care Interventions

Clean birth practices Immediate assessment and stimulation of the neonate Labor and delivery management

SBA at home or facility, BEmONC and CEmONC Neonatal resuscitation

At home or facility Antenatal corticosteroids for preterm labor Antibiotics for pPRoM MgSO4 – for eclampsia AMTSL – active management of the third stage of labor Induction of labor for pregnancies 41+ weeks

Preventive Interventions Thermal care Clean postnatal practices

Breastfeeding• Promotion • Behavior

Complementary feeding • Education only• Education and supplementation

Vitamin A for prevention Zinc for prevention

Insecticide treated materials

Improved water source Water connection in the

home

Improved sanitation latrine, toilet

Hand washing with soap

Hygienic disposal of children’s stools

BCG vaccine Polio vaccine Pentavalent vaccine

DPT, Hib, HepB Pneumococcal vaccine Rotavirus vaccine Measles vaccine

Curative Interventions Maternal sepsis case management Kangaroo mother care Case management of serious neonatal illnesses

• Oral antibiotics• Injectable antibiotics• Full supportive care: oxygen, IV fluids, IV antibiotics

ORS for diarrhea Antibiotics for dysentery Zinc for treatment of diarrhea Oral antibiotics for management of pneumonia Vitamin A for measles treatment Therapeutic feeding Antimalarials (Cotrimoxazole for HIV+ children) (ART for children)

What’s NOT in the model?

Education Motivation Gender issues Economic status Emergencies (i.e. famine, flooding) Delivery mechanism

Only as relates to total population coverage Quality of care

Effectiveness values, adjustments

Assumption:

Several of these factors are DISTAL factors which MAY work through COVERAGE changes…

thus MAY already be in the model

Other things not in LiST

De-worming (yet) IPTi (yet) Breastfeeding initiation within 1 hour

(yet) Birth spacing benefit Treatment of water in the home Iron (or iron-folate) supplementation Indoor air pollution …

What LiST is, What LiST isn’t!

Multi-cause mortality model

Mathematic model Models coverage impacts Potential impact

assessment National or sub-national

prioritization tool Discussion points Evidence-based

Truth Probabilistic model Natural history

model Detailed costing or

planning tool Bottlenecks,

budgeting Exhaustive

Is Isn’t

DATA AND MODELING

Data Needs Country-Specific

Population data and trends Default: UN Population Division 1950-2050 (DemProj) User entered (district) data

Cause of death structure Default: WHO/UNICEF/CHERG (2008) User entered data

Intervention coverage Population based data Default: DHS/MICS/JMP/WHO-UNICEF (closest to 2008) User entered data

Global Intervention Effectiveness data

User entered data

Stunting

Zinc

Diarrhea incidence

IUGRAppropriate Complementary Feeding

Complementary feeding education and/or supplementation

Previous Stunting

Malaria Mortality

DiseaseSpecificTreatments

DiseaseSpecific Preventions

Risk factors

ITN/IRS

Antimalarials

Stunting

Wasting

PneumoniaMortality

Hib vaccineBreast Feeding Promotion

Pneumococcal vaccine

Oral antibiotics for pneumonia

Zinc for prevention

Diarrhea incidence

Improved H2O source within 30 minutes

Hand washing with soap

Water connection in the home

Improved sanitation

Hygienic disposal of children’s stools

Stunting

IUGR

Pregnant women protected via IPT or sleeping under an ITN

Balanced energy supplementation

Multiple micronutrient supplementation

Breast Feeding

Wasting Therapeutic feeding

Complementary feeding education/supplementation

How are the models built?

Preventions Treatments Risk factors Multiple interventions?

Two Preventions (or Risk Factors): Proportional impact by coverage/effect size

Calculated on residual deaths No double counting

Preventions and Treatments: Enter prevention(s), then treatment(s) Deaths not already averted

Some Limitations

Data availability• If no baseline, can’t evaluate impact accurately

Data quality Sensible scale up targets

• Feasible, acceptable, funds available Interventions included in software

Some evaluated for one outcome, not others Maternal

• No country specific cause of death yet; regional causes

• No risk factors yet• Not yet vetted intervention impacts through CHERG

and other groups

LIST“VALIDATION”USES

Neonatal Package Modeling

ACSD Results

Modeling Mortality Rates and Equity

ITN studies

How can LiST be used?

Planning, Evaluation, Research, Advocacy Strategic planning

Which interventions are necessary to reduce mortality? (maternal, neonatal, under-5)

Will the targets reduce mortality as much as needed? Evaluation and intermediate-term follow-up

What is the impact of observed coverage changes? Evaluation of historic trends (i.e. multiple DHS/MICS

surveys) Predict lives saved (past and future)

How many lives could be saved with full scale-up of proven interventions in priority countries?

How many deaths remain left after vaccination scale ups?

How has LiST been used?

Globally Global Action Plan for Pneumonia ‘Impatient Optimist’ speech by Bill Gates

Regionally ASADI, by Saving Newborn Lives

Country level Catalytic initiative: to guide planning and

priority setting (Malawi, Ghana, Niger) Ethiopia

Sub-nationally CSHGP DFID in Nigeria (PRRINN-MNCH)

Who has used LiST?

Gates Foundation, GAVI USAID, DFID, CIFF MCHIP Save the Children, Saving Newborn

Lives, MSH WHO (GAPP), UNICEF CHAI

How NOT to use LiST As the correct answer

It depends on what you put in and what your goals are Also must consider cost, feasibility, accepability

To suggest decreasing coverage of any interventions Mortality has declined BECAUSE of those interventions

To suggest taking funds away from interventions To suggest that things in LiST are “GOOD” while

everything else is “BAD” It is based upon data availability unless otherwise stated

To decide HOW to do anything!!! That is for the programmers to decide!

What can I get out of LiST?

Number of deaths Total, by cause, by age group

Mortality rates/ratios (NMR, U5MR, MMR, SBR) Deaths averted,

Total, by cause, by intervention, by age group Intermediate outcomes

Stunting, wasting, breastfeeding

Displays Tables, graphs, pie charts Single country, multiple scenarios within one

country Multiple countries, single or multiple scenarios

Future Directions for LiST

Costing tie-ins Both a CHOICE based costing tool and MBB Part of the new One Health Model

Yes, we will be adding in uncertainty Improve the maternal model A new tool for multi-country analyses

LiST Resources

FREE Web Links

www.futuresinstitute.org www.healthpolicyinitiative.com/index.cfm?

id=software&get=Spectrum www.jhsph.edu/iip/list (join the listserv there) list.cherg.org

Software + Manual Languages English, French, Spanish, Portuguese

Contact Ingrid Friberg - ifriberg@jhsph.edu