Transcript Global trends of neonatal, infant and child mortality: implications for child survival Dr KANUPRIYA CHATURVEDI Dr S.K CHATURVEDI.

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 04 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
Skilled care
NUT
Infant feeding
IMCI
Combating diarrhoea
RBM
Vital vaccines
Antibiotics for
pneumonia
Combating malaria
IMCI – Integrated Management of Childhood Illness
MPS – Making Pregnancy Safer
NUT - Nutrition
RBM – Roll Back Malaria
EPI – Expanded Programme on Immunization
EPI
Combating HIV
HIV
Achievement of the MDG 4 & 5
constitutes 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 and
South Asia
– 42 countries account for 90% of all child deaths
– Over 1 billion children severely deprived of basic
health & other social services  Linked to Poverty,
Conflict and HIV
India’s share of the global
burden of births & child deaths
• Live births
~ 20%
• Child deaths
~ 20%
• Infant deaths
~ 24%
• Neonatal deaths
~ 30%
INDIA’S SHARE OF GLOBAL BURDEN
OF NEWBORN DEATHS Est. N = 4 millions
India
27%
others
42%
Ethiopia
4%
Bangladesh
4%
China
10%
Nigeria
6%
Pakistan
7%
About half of child deaths occur
in the neonatal period
Day
When do neonates
die?
Week 1
74.1
D1
1st day
20
By 3rd day
25
By 7th day
37
By 28th day
50
39.3
D2
% U5
deaths
7.3
D3
10.2
D4
6.2
D5
5.5
D6
2.8
D7
2.8
Week 2
12.6
Week 3
10
Week 4
3.1
0
10
20
30
40
Percent (%)
50
60
70
80
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Source: National Family Health Survey, 1998-9
H
Under-five mortality
Neonatal, post-neonatal and early child mortality in
Indian states
160
140
120
100
1-4 year
80
Post-neonatal
Neonatal
60
40
20
0
SOLUTIONS EXIST
• A mix of community and facility-based
interventions
• A mix of integrated child health
approaches
• Integrated management of neonatal and
child 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.
IMNCI
Colour Coded Case Management Strategy
• RED CLASSIFICATION: Child needs Drugs &
inpatient care –Mostly serious infections
• YELLOW CLASSIFICATION: Child needs
specific treatment, (e.g. antibiotics, antimalarial, ORT) for Mild infections can be
Provided at home / community level
• GREEN CLASSIFICATION: Child needs no
medicine, 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
• How to treat at home when hospital
admission is not feasible
• Counselling the mother to give oral
drugs at home
• Clear recommendations for follow up
• 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
1 month
District Doctors Trg
2 HNT training
2 wks Implementation
1 month
2 Facilitators
from Delhi
2 Facilitators
from State Pool
State/Dist. H&ICDS TOT
Subsequent HNT/
Supervisors TOT/FTT
1-2 months
Follow up training
2 Facilitators
from Delhi
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