Global trends of neonatal, infant and child mortality: implications for child survival Dr KANUPRIYA CHATURVEDI Dr S.K CHATURVEDI.
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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
IN
D
IA
ha
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de a
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M M el
ah a hi
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il ht ra
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es ga du
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ar g
na a
t l
S aka
ik
Ja
ki
m
P
m H un m
u a ja
& ry b
K an
A
nd ash a
hr G m
a u ir
A
ru
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ra a
na
de t
ch
al As sh
P sa
ra m
de
O sh
ris
R B sa
aj ih
as a
M
r
U
M tt a egh t ha
ad r a n
hy Pr lay
a ad a
P es
ra h
de
sh
im
ac
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