Child Survival Programmes Research Articles

4 million neonatal deaths: When? Where? Why?

The proportion of child deaths that occurs in the neonatal period (38% in 2000) is increasing, and the Millennium Development Goal for child survival cannot be met without substantial reductions in neonatal mortality. Every year an estimated 4 million babies die in the first 4 weeks of life (the neonatal period). A similar number are stillborn, and 0.5 million mothers die from pregnancy-related causes. Three-quarters of neonatal deaths happen in the first week--the highest risk of death is on the first day of life. Almost all (99%) neonatal deaths arise in low-income and middle-income countries, yet most epidemiological and other research focuses on the 1% of deaths in rich countries. The highest numbers of neonatal deaths are in south-central Asian countries and the highest rates are generally in sub-Saharan Africa. The countries in these regions (with some exceptions) have made little progress in reducing such deaths in the past 10-15 years. Globally, the main direct causes of neonatal death are estimated to be preterm birth (28%), severe infections (26%), and asphyxia (23%). Neonatal tetanus accounts for a smaller proportion of deaths (7%), but is easily preventable. Low birthweight is an important indirect cause of death. Maternal complications in labour carry a high risk of neonatal death, and poverty is strongly associated with an increased risk. Preventing deaths in newborn babies has not been a focus of child survival or safe motherhood programmes. While we neglect these challenges, 450 newborn children die every hour, mainly from preventable causes, which is unconscionable in the 21st century.

Measuring the quality of child health care at first-level facilities

Sound policy and program decisions require timely information based on valid and relevant measures. Recent findings suggest that despite the availability of effective and affordable guidelines for the management of sick children in first-level health facilities in developing countries, the quality and coverage of these services remains low. We report on the development and evaluation of a set of summary indices reflecting the quality of care received by sick children in first-level facilities. The indices were first developed through a consultative process to achieve face validity by involving technical experts and policymakers. The definition of evaluation measures for many public health programs stops at this point. We added a second phase in which standard statistical techniques were used to evaluate the content and construct validity of the indices and their reliability, drawing on data sets from the multi-country evaluation of integrated management of childhood illness (MCE) in Brazil, Tanzania and Uganda. The statistical evaluation identified important conceptual errors in the indices arising from the theory-driven expert review. The experts had combined items into inappropriate indicators resulting in summary indices that were difficult to interpret and had limited validity for program decision making. We propose a revised set of summary indices for the measurement of child health care in developing countries that is supported by both expert and statistical reviews and that led to similar programmatic insights across the three countries. We advocate increased cross-disciplinary research within public health to improve measurement approaches. Child survival policymakers, program planners and implementers can use these tools to improve their monitoring and so increase the health impact of investments in health facility care.

Child Nutrition in Developing Countries

Malnutrition permeates all aspects of health, growth, cognition, motor and social development of young children in developing countries. More than 50% of deaths in these children can be attributed to malnutrition, most often in conjunction with serious infection. Irreversible and lifelong sequelae prevent children from reaching their full potential. Child survival initiatives and programs have accomplished much to save the lives of children from common and preventable illnesses, but the quality of the survivors' health needs to be improved, with much more attention paid to nutrition of the preschool and school child. Promotion of nutritional health must become an integral part of primary health services, especially for infants, preschoolers, schoolchildren, and women. Promotion of exclusive breastfeeding and appropriate complementary feeding and weaning are essential inputs. A daunting challenge is to improve diet quality through the raising and consumption of small animals by rural subsistence households to enhance maternal and child nutrition. School feeding from preschool onward must be an integral part of education so children are in a condition to learn. An excellent example of such programs is the WHO initiated Integrated Management of Childhood Illness, which integrates nutrition into the care of both sick and well children. The Early Child Development Program initiated by the World Bank and UNICEF has taken hold in many countries. Nutrition outcomes are closely linked with health and education activities starting in the preconception period through pregnancy, lactation, and childhood. Investment in human capital early in life will optimize the growth and social and economic development of children, families, and communities.

Perinatal health in Pakistan: a review of the current situation

The perinatal mortality rate of 63-92/1000 births as reported from two provinces of Pakistan is unacceptably high. A vast majority of births and neonatal deaths occur at home and remain unregistered. In spite of a number of child survival programmes of proven efficacy in place, the impact on perinatal health is poor. Initiatives such as behaviour change communication, skill-based training of birth attendants and reaching the un-reached may be the key future strategies to reduce perinatal losses.

Perinatal health in Pakistan: a review of the current situation*

The perinatal mortality rate of 63–92/1000 births as reported from two provinces of Pakistan is unacceptably high. A vast majority of births and neonatal deaths occur at home and remain unregistered. In spite of a number of child survival programmes of proven efficacy in place, the impact on perinatal health is poor. Conclusion: Initiatives such as behaviour change communication, skill‐based training of birth attendants and reaching the un‐reached may be the key future strategies to reduce perinatal losses.

Why are 4 million newborn babies dying each year?

In the summer of 2003 The Lancet published five articles on child survival written by the Bellagio Child Survival Group. These publications have had tangible effects. A Global Partnership for Child Survival secretariat is being established to assist the development and implementation of plans to reduce child deaths in 42 countries that account for 90% of deaths in those younger than 5 years of age. Two national meetings in Ethiopia and Cambodia have been held to discuss strategies for implementing the interventions outlined in the Bellagio child-survival series. Other countries are revising their child health and survival programmes. Although the Bellagio series has had an important effect in the child-survival arena a major gap in information and action remains about deaths in the first 4 weeks of life—the neonatal period. The second half of the 20th century witnessed a remarkable reduction in child mortality with a halving of the risk of death before the age of 5 years. Most of this reduction however has been because of lives saved after the first 4 weeks of life with little reduction in the risk of death in the neonatal period for most babies worldwide. Neonatal deaths estimated at nearly 4 million annually now account for 36% of deaths worldwide in children aged under 5 years. Millenium Development Goal 4 (MDG-4) regarding child survival stipulates a reduction of two-thirds in deaths in children aged under 5 years from 95 per 1000 in 1990 to 31 per 1000 in 2015. Given that the current global neonatal mortality rate is estimated to be 31 per 1000 live-births8 a substantial reduction in neonatal deaths will be required to meet MDG-4. Reduction of neonatal deaths should become a major public-health priority. (excerpt)

Qualitative research to make practical sense of sustainability in primary health care projects implemented by non-governmental organizations.

Sustainability continues to be a serious concern for Primary Health Care (PHC) interventions targeting the death of millions of children in developing countries each year. Our work with over 30 Non-Governmental Organizations (NGOs) implementing USAID's Child Survival and Health Grants Program (CSHGP)-funded projects revealed the need for a study to develop a framework for sustainability assessment in these projects. We surveyed NGO informants and project managers through semi-structured interviews and questionnaires. This paper summarizes our study findings. The NGOs share key values about sustainability, but are skeptical about approaches perceived as disconnected from field reality. In their experience, sustainable achievements occur through the interaction of capable local stakeholders and communities. This depends strongly on enabling conditions, which NGO projects should advance. Sustainability assessment is multidimensional, value-based and embeds health within a larger sustainable development perspective. It reduces, but does not eliminate, the unpredictability of long-term outcomes. It should start with the consideration of the 'local systems' which need to develop a common purpose. Our ability to address the complexity inherent to sustainability thinking rests with the validity of the models used to design interventions. A participant, qualitative research approach helped us make sense of sustainability in NGO field practice.

Advancing newborn health and survival in developing countries: a conceptual framework.

Four million newborns die every year at home, often without skilled care at delivery or any other contact with the formal health system. Improved household practices and use of services, often in the community, should improve survival. We developed a conceptual framework for household and community newborn and maternal care that acknowledges the inseparability of the mother and neonate, yet stresses elements relating to the newborn, heretofore underemphasized in safe motherhood and child-survival programs. The framework identifies five paths that, if implemented well, would generally improve newborn outcomes: (1) use of routine maternal and newborn care and good-quality services; (2) response to maternal danger signs; (3) response to the nonbreathing newborn; (4) care for the low birth weight baby; and (5) response to newborn danger signs, particularly those of infection. This model, balancing preventive (19 routine behaviors) and curative care (14 special behaviors), is rooted in the community, bridges safe motherhood and child survival, and provides a framework for newborn health research, programmatic, and advocacy agendas for developing countries.

Integrating quantitative and qualitative methods to assess the impact of child survival programs in developing countries: the case of a program evaluation in Ceara, Northeast Brazil.

In evaluating public health programs, the tradition has been to design quantitative approaches, relying on epidemiological and statistical techniques to determine if and to what extent a program has an effect on a predetermined targeted population. More recently, however, qualitative methods such as rapid ethnographic assessments and focus groups have been implemented more frequently. This article describes an outcome evaluation of a community health workers program that integrated quantitative and qualitative methods to assess the impact of child survival interventions in reducing infant mortality and inadequate weight gain in children among municipalities in the state of Ceara, Northeast Brazil. By using multiple methods that combine quantitative and qualitative components, researchers can broaden their understanding of complex public health issues and direct use of data for decision making.

Vaginal disinfection during labour for reducing the risk of mother-to-child transmission of HIV infection.

Mother-to-child transmission (MTCT) of HIV infection is one of the most tragic consequences of the HIV epidemic, especially in resource-limited countries, resulting in about 650 000 new paediatric HIV infections each year world-wide. The paediatric HIV epidemic threatens to seriously undermine decade-old child survival programmes. This is one of several reviews assessing the available evidence for preventing HIV transmission from an HIV-infected woman to her child. The other reviews assess the effects of antiretroviral therapy, Caesarean section delivery, breast feeding, and vitamin A supplementation. To estimate the effect of vaginal lavage on the risk of MTCT of HIV and infant and maternal mortality and morbidity, as well as tolerability of vaginal lavage in HIV infected women. We searched the Cochrane Controlled Trials Register, Cochrane Pregnancy and Childbirth Register, PubMed, EMBASE, AIDSLINE, LILACS, AIDSTRIALS, and AIDSDRUGS, using standardised methodological filters for identifying trials. We also searched reference lists of identified articles, relevant editorials, expert opinions and letters to journal editors, and abstracts and proceedings of relevant conferences, and contacted subject experts and pharmaceutical companies. There were no language restrictions. Randomised trials or clinical trials comparing vaginal disinfection during labour with placebo or no treatment, in known HIV infected pregnant women. Trials had to include an estimate of the effect of vaginal disinfection on MTCT of HIV and/or any other pre-specified adverse pregnancy outcome to be included. Two reviewers independently assessed trial eligibility and quality, and extracted data. Only one low quality trial included an estimate of the effect of vaginal disinfection on at least one pre-specified outcome. There was no evidence of an effect of vaginal disinfection on MTCT of HIV (odds ratio 0.93, 95% confidence interval 0.63 to 1.38), and no information was available on the other pre-specified outcomes. There is a need for well-designed randomised controlled trials to estimate the effects of vaginal disinfection on MTCT of HIV.

Time to focus child survival programmes on the newborn: assessment of levels and causes of infant mortality in rural Pakistan.

Population-based surveys were conducted in selected clusters of Pakistan's least developed provinces, Balochistan and North-West Frontier Province (NWFP), including the Federally Administered Tribal Areas (FATA), to assess levels and causes of neonatal and postneonatal mortality. Interviews were conducted in a total of 54 834 households: Balochistan, 20 486; NWFP, 26 175; and FATA, 8173. Trained interviewers administered questionnaires after obtaining verbal informed consent from the respondents. Verbal autopsy interviews were conducted for infant deaths reported for the previous year. The infant mortality rate based on combined data from the different sites was 99.7 per 1000 live births (range 129.0-70.1). The contribution of neonatal deaths to all infant deaths was much higher for NWFP (67.2%), where the overall rate was lowest, than for Balochistan (50.8%) and FATA (56.8%). Around 70% of all neonatal deaths occurred in the early neonatal period. The three main clinical causes of infant deaths were diarrhoea syndrome (21.6%), tetanus (11.7%) and acute respiratory infections (11.6%). In the neonatal period, however, tetanus (18.3%), small size for gestational age or low birth weight (15.3%), and birth injury (12.0%) accounted for nearly half (45.6%) of all deaths, while the contributions of diarrhoea syndrome (5.1%) and acute respiratory infections (6.0%) were less significant (11.1%). Tetanus was the cause of death for 21.7% and 17.1% of all infant deaths in FATA and NWFP respectively. The results suggest that there should be a shift in child survival programmes to give greater emphasis to maternal and neonatal health, in particular to maternal tetanus immunization, safe delivery and cord care.

Family home care providers

Notwithstanding several child survival and safe motherhood programmes, maternal expenditures including antenatal care (ANC) and postnatal care (PNC) are gaining new heights every day. This study examines the extent of healthcare expenditure incurred for seeking delivery care including ANC and PNC across the socio-economic characteristics. Further, this study examines the extent of catastrophic delivery expenditure and its impoverishing effect on Indian women. The present study used unit level records of the 71st round of the National Sample Survey Office (NSSO) which was surveyed during January to June in 2014 on the theme ‘Social Consumption: Health.’ Results reveal that women who gave births to their babies in public hospitals spend rupees 1587 for the childbirth whereas the women who gave births to their babies in private hospitals spend more than nine times higher money for the delivery in rural areas (rupees 14,777.2). What's worse is that any additional burden on the already facing high maternal healthcare expenditure tips 46.6% women (among those who delivered) below the poverty line. In conclusion, there is a dire need of strengthening maternal health services which should be readily available, accessible and affordable to all irrespective of class-caste-region.

Assessing a computerized routine health information system in Mali using LQAS.

Between 1987 and 1998 Save the Children conducted a child survival programme in Mali with the goal of reducing maternal and child morbidity and mortality. An integral part of this programme was a computerized demographic surveillance and health information system (HIS) that gathered data on individuals on an on-going basis. To assess the overall coverage and quality of the data in the HIS, to identify specific health districts that needed improvements in data collection methods, and to determine particular areas of weakness in data collection. Random samples of 20 mothers with children <5 years were selected in each of 14 health districts. Mothers were interviewed about pregnancies, live births, deaths of children <5, and children's growth monitoring and immunization status. The Lot Quality Assurance Method (LQAS) was used to identify districts in which records and interview results did not meet predetermined levels of acceptability. Data collected in the interviews were combined to estimate overall coverage and quality. When all variables were analyzed, all 14 lots were rejected, and it was estimated that 52% of all events occurring in the community were registered in ProMIS. Much of this poor performance was due to immunization and growth monitoring data, which were not updated due to printer problems. Coverage of events increased (92%) when immunizations and growth monitoring were excluded, and no lots were rejected. When all variables were analyzed for quality of data recorded, six lots were rejected and the overall estimation was 83%. With immunizations and growth monitoring excluded, overall quality was 86% and no lots were rejected. The comprehensive computerized HIS did not meet expectations. This may be due, in part, to the ambitious objective of complete and intensive monitoring of a large population without adequate staff and equipment. Future efforts should consider employing a more targeted and streamlined HIS so that data can be more complete and useful.

Malnutrition as an underlying cause of childhood deaths associated with infectious diseases in developing countries.

Recent estimates suggest that malnutrition (measured as poor anthropometric status) is associated with about 50% of all deaths among children. Although the association between malnutrition and all-cause mortality is well documented, the malnutrition-related risk of death associated with specific diseases is less well described. We reviewed published literature to examine the evidence for a relation between malnutrition and child mortality from diarrhoea, acute respiratory illness, malaria and measles, conditions that account for over 50% of deaths in children worldwide. MEDLINE was searched for suitable review articles and original reports of community-based and hospital-based studies. Findings from cohort studies and case-control studies were reviewed and summarized. The strongest and most consistent relation between malnutrition and an increased risk of death was observed for diarrhoea and acute respiratory infection. The evidence, although limited, also suggests a potentially increased risk for death from malaria. A less consistent association was observed between nutritional status and death from measles. Although some hospital-based studies and case-control studies reported an increased risk of mortality from measles, few community-based studies reported any association. The risk of malnutrition-related mortality seems to vary for different diseases. These findings have important implications for the evaluation of nutritional intervention programmes and child survival programmes being implemented in settings with different disease profiles.

Reducing deaths from diarrhoea through oral rehydration therapy.

In 1980, diarrhoea was the leading cause of child mortality, accounting for 4.6 million deaths annually. Efforts to control diarrhoea over the past decade have been based on multiple, potentially powerful interventions implemented more or less simultaneously. Oral rehydration therapy (ORT) was introduced in 1979 and rapidly became the cornerstone of programmes for the control of diarrhoeal diseases. We report on the strategy for controlling diarrhoea through case management, with special reference to ORT, and on the relationship between its implementation and reduced mortality. Population-based data on the coverage and quality of facility-based use of ORT are scarce, despite its potential importance in reducing mortality, especially for severe cases. ORT use rates during the 1980s are available for only a few countries. An improvement in the availability of data occurred in the mid-1990s. The study of time trends is hampered by the use of several different definitions of ORT. Nevertheless, the data show positive trends in diarrhoea management in most parts of the world. ORT is now given to the majority of children with diarrhoea. The annual number of deaths attributable to diarrhoea among children aged under 5 years fell from the estimated 4.6 million in 1980 to about 1.5 million today. Case studies in Brazil, Egypt, Mexico, and the Philippines confirm increases in the use of ORT which are concomitant with marked falls in mortality. In some countries, possible alternative explanations for the observed decline in mortality have been fairly confidently ruled out. Experience with ORT can provide useful guidance for child survival programmes. With adequate political will and financial support, cost-effective interventions other than that of immunization can be successfully delivered by national programmes. Furthermore, there are important lessons for evaluators. The population-based data needed to establish trends in health service delivery, outcomes and impact are not available in respect of diarrhoea, as is true for malaria, pneumonia and other major childhood conditions. Standard indicators and measurement methods should be established. Efforts to change existing global indicators should be firmly resisted. Support should be given for the continuing evaluation and documentation activities needed to guide future public health policies and programmes.

National Vitamin A Prophylaxis Programme: need for change in current age strategy.

Child survival and Safe Motherhood Programme emphasises on giving vitamin A prophylaxis upto three years of age only, contrary to earlier practice of its administration upto six years of age, based on the assumption of reduction of serious manifestations of vitamin A deficiency three years of age onwards. A cross-sectional study enrolling 1094 children was done to investigate vitamin A deficiency in under six children in urban slums of Nagpur city in Central India in post CSSM scenario. Clinical as well as subclinical (detected by abnormal conjunctival impression cytology) assessment of vitamin A status was performed according to standard procedures, as per WHO recommendations. The overall prevalence of xerophthalmia was 8.7%. Only milder manifestations of xerophthalmia were observed. Significantly higher prevalence of xerophthalmia was observed in more than three years of age. Although nonsignificant, higher prevalence of subclinical vitamin A deficiency was observed in above three years of age group. In view of current age strategy for vitamin A supplementation (< or = 3 years) and observed higher prevalence of clinical and subclinical vitamin A deficiency above three years of age in this study (also endorsed by earlier studies) a call for review of current age strategy for vitamin A supplementation is warranted.

Recent developments for neonatal health in developing countries

Interventions to reduce neonatal mortality are at the cutting edge of child survival programmes. Neonatal deaths account for up to two-thirds of infant deaths in developing countries. The common causes of death are preterm birth, intrauterine growth retardation, perinatal infection, impaired metabolic adaptation, and asphyxia. Effective interventions before delivery include food and micronutrient supplementation, malaria protection, and immunization against tetanus and perhaps pneumococcal infection in future. Many cost-effective intrapartum interventions, such as partography and magnesium sulphate for eclampsia, are not routinely implemented. Likewise, resuscitation, prevention and treatment of hypothermia, promotion of early and exclusive breastfeeding, and rapid treatment of neonatal infection with injectable antibiotics given by primary care workers are cost-effective postnatal interventions. The challenge is to get these interventions into policy and practice. Going to scale must involve partnerships between government, international agencies and non-government organizations. Interventions to reduce neonatal mortality are at the cutting edge of child survival programmes. Neonatal deaths account for up to two-thirds of infant deaths in developing countries. The common causes of death are preterm birth, intrauterine growth retardation, perinatal infection, impaired metabolic adaptation, and asphyxia. Effective interventions before delivery include food and micronutrient supplementation, malaria protection, and immunization against tetanus and perhaps pneumococcal infection in future. Many cost-effective intrapartum interventions, such as partography and magnesium sulphate for eclampsia, are not routinely implemented. Likewise, resuscitation, prevention and treatment of hypothermia, promotion of early and exclusive breastfeeding, and rapid treatment of neonatal infection with injectable antibiotics given by primary care workers are cost-effective postnatal interventions. The challenge is to get these interventions into policy and practice. Going to scale must involve partnerships between government, international agencies and non-government organizations.

Special care for newborns at a community hospital: a 5-year experience.

A workable model for the special care of newborns has been developed at a community hospital in a predominantly tribal block. Adequate warmth, prompt resuscitation, proper feeding and oxygen administration, when necessary, formed the key interventions. This facility was developed with existing staff and infrastructure and with minimal material inputs. Neonatal survivals were 61.5% in the 1000-1500 g category and 92.5% in the 1520-2000 g category during a five year period. We believe that this model is both replicable and affordable. It has the potential for developing horizontal links with perinatal care and child survival programmes.

“Feeding the gut”: The scientific basis for continued enteral nutrition during acute diarrhea

The development of oral rehydration solutions for the treatment of diarrheal diseases stands as a monumental scientific achievement and perhaps the finest broadly applicable example of collaboration between basic and applied biomedical research. 1 Anonymous Water with sugar and salt [editorial]. Lancet. 1978; 2: 300-301 PubMed Google Scholar Laboratory and animal models in the 1950s and 1960s delineated the process of molecular cotransport across the gastrointestinal epithelia and paved the way for clinical studies that documented the persistence of this mechanism in diarrhea. 2 Hirschhorn N The treatment of acute diarrhea in children: an historical and physiological perspective. Am J Clin Nutr. 1980; 33: 637-663 PubMed Google Scholar After landmark studies in Dhaka and Calcutta demonstrated the efficacy of ORS in severe diarrhea such as cholera, 3 Nalin D Cash R Islam R et al. Oral maintenance therapy for cholera in adults. Lancet. 1968; 2: 370-372 Abstract PubMed Google Scholar , 4 Pierce N Banwell J Mitra R et al. Effect of intragastric glucose-electrolyte infusion upon water and electrolyte balance in Asiatic cholera. Gastroenterology. 1968; 55: 333-342 Abstract Full Text PDF PubMed Google Scholar trials confirming its efficacy in non-cholera diarrhea and in pediatric patients quickly followed. ORS was soon adopted by the World Health Organization and the United Nations Children's Fund as a major weapon in child survival programs, and, although recent attempts to improve the composition of ORS have been made, 5 Gore SM Fontaine O Pierce NF Impact of rice based oral rehydration solution on stool output and duration of diarrhoea: meta-analysis of 13 clinical trials. BMJ. 1992; 304: 287-291 Crossref PubMed Scopus (169) Google Scholar , 6 Anonymous Multicentre evaluation of reduced-osmolarity oral rehydration salts solution. International Study Group on Reduced-osmolarity ORS solutions. Lancet. 1995; 345: 282-285 Crossref PubMed Scopus (120) Google Scholar ORS continues to be the cornerstone for successful case management of diarrheal diseases.

Reproductive health in India.

While Indias National Family Welfare Programme has averted about 168 million births since its inception in 1951 Indias population has more than doubled since 1961. Simply meeting unmet demand for family planning (FP) will help India achieve its goal of replacement-level fertility however by increasing contraceptive prevalence from 41% to 60% of married women. In 1992 India began to incorporate a reproductive health perspective into its FP efforts. India must improve the accessibility and quality of FP and abortion services take steps to ensure safe deliveries and improve maternal health. Data on prevalence of reproductive tract infections and sexually transmitted diseases are scarce but knowledge about HIV/AIDS prevention has been shown to be poor. Reproductive health research in India has focused on continuation rates of various IUDs improving the counseling and technical skills of health staff at postpartum centers continuation rates of Norplant under field conditions and promoting the concept of informed choice of contraception. The government is implementing the following steps to improve reproductive health: 1) exploring a client-centered instead of target and incentive driven approach to FP 2) expanding the use of male methods and spacing methods and 3) adding other components of reproductive health into ongoing child survival and safe motherhood programs. Improving the National Family Welfare Program will require an increase in funding and enhanced collaborative research.