Global trends of neonatal, infant and child mortality: implications for

child survival

Dr KANUPRIYA CHATURVEDI

Dr S.K CHATURVEDI

When are child deaths occurring?

• The 10.6 million annual child deaths are not distributed evenly over the 0-4 year age period

• More than 70% of all child deaths occur in the first year of life

• And of these … nearly 40% occur in the first month of life (the neonatal period)

Where are child deaths occurring?

• Only 2 WHO regions account for more than 70% of all under-five deaths:

42% in the African region 29% in South-east Asia region

• Only 6 countries account for 50% of all child deaths (2002 data):

India (Sear)Nigeria (Afr)China (Wpr)Pakistan (Emr)Ethiopia (Afr)DR Congo (Afr)

What are under-fives dying of?(excluding neonatal causes of death)

• Pneumonia

• Diarrhoea

• Malaria

• Measles

• HIV/AIDS} ~ 50%

Malnutrition contributes to more than half of all under-five deaths

What are neonates dying of?

• Preterm births

• Severe infection

• Asphyxia

• Congenital anomalies

• Tetanus

} ~ 75%

Progress has been variable

• Neonatal mortality has fallen at a lower rate than post-neonatal or early child mortality

• Relatively greater progress has been made in some regions and countries

e.g. neonatal mortality is now 58% lower in high income countries than in 1983, compared to 14% reduction in low/ middle income countries

• Large variations in mortality rates exist even within the same country

Solutions exist ….• Skilled care: skilled care during pregnancy, childbirth

and in the post-natal period

• Infant feeding: exclusive breastfeeding, complementary feeding and micronutrients

• Vital vaccines: measles and tetanus immunization and other conventional and new vaccines

• Combating diarrhoea: low osmolarity ORS and zinc in case management of diarrhoea, antibiotics for dysentery

• Treating pneumonia and newborn sepsis: prompt treatment with appropriate antibiotics

Where appropriate: • Combating malaria • Preventing and caring for HIV (mother and child)

Delivery strategies/tools exist

MPS

IMCINUT

RBM HIV

EPI

Skilled care

Infant feeding Vital vaccines

Combating diarrhoea

Combating malaria

Antibiotics for pneumonia

Combating HIV

IMCI – Integrated Management of Childhood Illness

MPS – Making Pregnancy Safer

NUT - Nutrition

RBM – Roll Back Malaria

EPI – Expanded Programme on Immunization

Achievement of the MDG 4 & 5constitutes a particular challenge

– 57 countries: likely to reduce child mortality by 2/3 (1990-2015) but still intra-country disparities

– 16 countries: retrogression/significant increase in child mortality

– Progress slow/stagnating in Sub-Saharan Africa Progress slow/stagnating in Sub-Saharan Africa and South Asia

– 42 countries account for 90% of all child deaths– Over 1 billion children severely deprived of basic Over 1 billion children severely deprived of basic

health & other social services health & other social services Linked to Poverty, Linked to Poverty, Conflict and HIVConflict and HIV

India’s share of the global India’s share of the global burden of births & child deathsburden of births & child deaths

• Live birthsLive births ~ 20%~ 20%

• Child deathsChild deaths ~ 20%~ 20%

• Infant deathsInfant deaths ~ 24%~ 24%

• Neonatal deathsNeonatal deaths ~ 30%~ 30%

INDIA’S SHARE OF GLOBAL BURDEN OF NEWBORN DEATHS Est. N = 4 millions

India27%

China10%

Pakistan7%

Nigeria6%Bangladesh

4%

Ethiopia4%

others42%

About half of child deaths occur About half of child deaths occur in the neonatal periodin the neonatal period

DayDay % U5 % U5 deathsdeaths

1st day 20

By 3rd day 25

By 7th day 37

By 28th day 503.1

10

12.6

2.8

2.8

5.5

6.2

10.2

7.3

39.3

74.1

0 10 20 30 40 50 60 70 80

Week 4

Week 3

Week 2

D7

D6

D5

D4

D3

D2

D1

Week 1

Percent (%)

When do neonates die?When do neonates die?

Neonatal, post-neonatal and early child mortality in Indian states

0

20

40

60

80

100

120

140

160

Un

der-

five m

ort

ali

ty

1-4 year

Post-neonatal

Neonatal

Source: National Family Health Survey, 1998-9

SOLUTIONS EXIST

• A mix of community and facility-based A mix of community and facility-based interventionsinterventions

• A mix of integrated child health A mix of integrated child health approachesapproaches

• Integrated management of neonatal and Integrated management of neonatal and child hood illnesses is proven toolchild hood illnesses is proven tool

Goals of IMNCI

• Standardized case management of sick newborns and children

• Focus on the most common causes of mortality

• Nutrition assessment and counselling for all sick infants and children

• Home care for newborns to – promote exclusive breastfeeding– prevent hypothermia– improve illness recognition & timely care seeking

Essential components of IMNCI

• Improve health and nutrition workers’ skills

• Improve health systems

• Improve family and community practices

IMNCI-INDIA-Major Adaptations

• The entire 0-5 year period covered including the first week of life

• 50% of training time for management of young infants (0-2 months)

• The order of training reversed; now begins with management of young infants

• Reduced training duration (8 days), separate training materials for physicians & health workers

• Management now consistent with current policies of MoHFW, DWCD,IYCF,PD & NAMP

• Home-based care of young infants by health workers added

Potential of the adapted IMNCI Package

• Accelerating the reduction in infant and child mortality in both rural and urban areas, particularly by its impact on neonatal mortality through home and facility based care

• Lower burden on hospitals, particularly in urban areas where access to care is not a limiting factor

• The package has been organized in a way that states with low post-neonatal infant mortality can use 0-2 month training material only

Home visits for young infants: Objectives

– Promote & support exclusive breastfeeding– Teach the mother how to keep the young

infant warm– Teach the mother to recognize signs of

illness for which to seek care– Identify illness at visit and facilitate referral– Give advise on cord care and hand washing

Home visits for young infants: Schedule

• All newborns: 3 visits (within 24 hours of birth, day 3-4 and day 7-10)

• Newborns with low birth weight: 3 more visits on day 14, 21 and 28.

IMNCIIMNCIColour Coded Case Management StrategyColour Coded Case Management Strategy

• RED CLASSIFICATIONRED CLASSIFICATION: Child needs Drugs & : Child needs Drugs & inpatient care –Mostly serious infectionsinpatient care –Mostly serious infections

• YELLOW CLASSIFICATIONYELLOW CLASSIFICATION: Child needs : Child needs specific treatment, (e.g. antibiotics, anti-specific treatment, (e.g. antibiotics, anti-malarial, ORT) for Mild infections can be malarial, ORT) for Mild infections can be Provided at homeProvided at home / community levelcommunity level

• GREEN CLASSIFICATIONGREEN CLASSIFICATION: Child needs no : Child needs no medicine, advise home caremedicine, advise home care

Other innovations in case assessment

• Visible severe wasting as indicator for hospital admission rather than weight for age

• Palmar pallor to detect anaemia

• Breast feeding assessment: attachment and suckling

Innovations in therapy

• Single daily dose gentamycin Single daily dose gentamycin

• How to treat at home when hospital How to treat at home when hospital admission is not feasibleadmission is not feasible

• Counselling the mother to give oral Counselling the mother to give oral drugs at homedrugs at home

• Clear recommendations for follow upClear recommendations for follow up

• Negotiated feeding counselling Negotiated feeding counselling

What does IMNCI not provide at all or fully

• Antenatal care

• Skilled birth attendance

• Birth asphyxia management

• Improved health system management

• What can be rapidly added to IMNCI

• Inpatient care modules for first level referral hospitals

IMNCI Experience--Milestones• Early 2002, GOI constituted an Adaptation Group • In joint GOI-UNICEF review meeting in April 2002 GOI

requested to experiment IMNCI in BDCS districts• July 2002, First national 2 days planning meeting• December 2002, pre-tested 8-days physician course material• Early 2003 - adaptation of H&N workers module • May 2003 – First field testing in Osmanabad followed by one in

Shivpuri & content & methodology frozen • Implementation started in Andoor PHC, Osmanabad in June 03

followed by Valsad district• Follow-up training of supervisors in April 04 in Osmanabad • Field trial for case registers initiated in late 2004• Physicians courses from 2005 included community visit,

facilitation technique and briefing on Health workers’ course• First Facilitation technique course in Orissa in June 2005

Training Flow

Training of 6-8/district ToTs in Delhi

2 HNT training

State/Dist. H&ICDS TOT

Subsequent HNT/ Supervisors TOT/FTT

Implementation

Follow up training

2 Facilitators from Delhi

2 Facilitators from State Pool

2 Facilitators from Delhi

1 month

1 month

District Doctors Trg

1-2 months

2 wks

Training: Strengths -- Contents Doable

50% of training time for management of young infants (0-2 months)

Visible severe wasting as indicator for hospital admission rather than weight for age

Palmar pallor to detect anaemia Breast feeding assessment: attachment and suckling Immunization and micronutrient assessment & referring How to treat at home when hospitalization not feasible Counselling the mother to give oral drugs at home Clear recommendations for follow up Negotiated feeding counselling Specific advices for home care including identification of

danger signs Management consistent with current policies of the MoHFW,

DWCD and NVBDCP

Training Limitations: Contents

• Does not provide MNC through– Antenatal care– Skilled birth attendance – Birth Asphyxia Management

• Inpatient care modules for first level referral hospitals to be developed

• No specific inputs for Improved health system management

• Drug logistic- specially formulations dependant on SC/PHC RCH supplies

Key messages

• Maternal and newborn care and support is essential to achieve a substantial reduction in neonatal mortality

• Improving child survival requires coordinated action between maternal and child health, and other programme areas (e.g. EPI, NUT, RBM, HIV)

• IMCI is an effective delivery strategy for multiple child survival interventions (India has already incorporated newborn care)

• For substantive impact, strong community component must accompany the health system strengthening