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

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

• Dr KANUPRIYA CHATURVEDI
• Dr S.K CHATURVEDI

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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)

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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)

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

• Pneumonia
• Diarrhoea
• Malaria
• Measles
• HIV/AIDS

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Malnutrition contributes to more than half of all
under-five deaths
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What are neonates dying of?

• Preterm births
• Severe infection
• Asphyxia
• Congenital anomalies
• Tetanus

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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

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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)

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Delivery strategies/tools exist
Community
IMCI Integrated Management of Childhood
Illness MPS Making Pregnancy Safer NUT -
Nutrition RBM Roll Back Malaria EPI Expanded
Programme on Immunization
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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
  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

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Indias share of the global burden of births
child deaths

• Live births 20
• Child deaths 20
• Infant deaths 24
• Neonatal deaths 30

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INDIAS SHARE OF GLOBAL BURDEN OF NEWBORN DEATHS
Est. N 4 millions
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About half of child deaths occur in the neonatal
period
Day U5 deaths
1st day 20
By 3rd day 25
By 7th day 37
By 28th day 50

• When do neonates die?

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Neonatal, post-neonatal and early child mortality
in Indian states
Source National Family Health Survey, 1998-9
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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

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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

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Essential components of IMNCI

• Improve health and nutrition workers skills
• Improve health systems
• Improve family and community practices

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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

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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

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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

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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.

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IMNCIColour Coded Case Management Strategy

• RED CLASSIFICATION Child needs Drugs inpatient
  care Mostly serious infections
• YELLOW CLASSIFICATION Child needs specific
  treatment, (e.g. antibiotics, anti-malarial, ORT)
  for Mild infections can be Provided at home /
  community level
• GREEN CLASSIFICATION Child needs no medicine,
  advise home care

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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

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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

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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

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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 HN 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

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Training Flow
Training of 6-8/district ToTs in Delhi
1 month
2 HNT training
District Doctors Trg
Implementation
2 wks
1 month
2 Facilitators from Delhi
1-2 months
State/Dist. HICDS TOT
Follow up training
Subsequent HNT/ Supervisors TOT/FTT
2 Facilitators from State Pool
2 Facilitators from Delhi
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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

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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

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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