STATE OF WORLD AND PAKISTANI CHILDREN Compiled by: Prof M Akbar Nizamani Professor and Chairman Department of Paediatrics LUMHS Jamshoro

Learning Objectives To Know the definitions of mortality rates. To know the State of childhood deaths globally. To Know the common causes of deaths in children globally and in Pakistan. To know the causes of death in neonates. To know how malnutrition plays important role in childhood mortality. To know basic demographic Indicators of Pakistan To know that majority of causes of mortality and morbidity are preventable.

Definitions Infant mortality rate: Number of deaths in infants under one year of age per thousand live births per year. Neonatal mortality rate: Number of deaths in newborn under one month of age per thousand live births per year. Under 5 mortality rate: Number of deaths in infants under 5 years of age per thousand live births per year. Perinatal Mortality Rates: Number of total deaths after 28 weeks of gestation up to first week of life per thousand total births per year.

STATE OF WORLD AND PAKISTANI CHILDREN GLOBAL:6.6 MILLION UNDER 5Y DEATHS /YEAR (2010 Estimates R E Black et al) 0.63 MILLION /MONTH, 1.6 LACS/WEEK,23,000/DAY AND 16/MINUTE 0.35 MILLION PAKISTANI U5 CHILDREN DIE /YEAR,1-2 CHILD EVERY MINUTE. Abut 100,000 in Pneumonia and about 80,000 I diarrhea.

Two thirds of all neonatal deaths are in LBW infants 4 million newborn deaths – Why? almost all are due to preventable conditions Two thirds of all neonatal deaths are in LBW infants

Global Distribution of Causes of Child Deaths: 2008

Under Five Mortality 20-50% of the 8.5 million child deaths each year… 60.7% of diarrhea deaths 57.3% of malaria deaths 52.3% of pneumonia deaths 44.8% of measles deaths …are attributable to under nutrition Undernutrition is measured by weight-for-age Caulfield et al, 2004

Global Causes of Under-Five Deaths in 2010 Through synergy with infectious diseases undernutrition causes 35% of child deaths

Global distribution of deaths among children under five (2012) 6.6 million children died in 2012 More than half due to conditions that could be prevented or treated with access to simple, affordable interventions About 45% of all child deaths are linked to malnutrition TEXT: http://www.who.int/mediacentre/factsheets/fs178/en/ For conditions such as measles, polio, diphtheria, tetanus, pertussis, pneumonia due to Haemophilius influenzae type B and Streptococcus pneumonia and diarrhea due to rotavirus, vaccines are available and can protect children from illness and death Improvements in global child health led to 17,000 fewer children dying every day in 2012 than in 1990. Despite that progress, 18,000 children per day—6.6 million over the course of the year—still died in 2012 of easily preventable or treatable causes Nearly half of all under five deaths in 2012 were concentrated in Sub Saharan Africa IMAGE: http://www.childinfo.org/mortality_underfive.php Accelerating progress in child survival urgently requires greater attention to ending preventable child deaths in sub-Saharan Africa and South Asia, which together account for 4 out of 5 under-five deaths globally. South Asia has made strong progress on reducing preventable deaths, more than halving its number of deaths among children under 5 since 1990. Sub-Saharan Africa, however, continues to lag behind, having only decreased its under-five mortality by 45% since 1990. However, along with the Middle East and North Africa, it is one of only two regions that have experienced a consistent acceleration in the pace of reducing under-five mortality rates since 1990. References UNICEF analysis based on IGME 2013, drawing on provisional analyses by WHO and Child Health Epidemiology Reference Group (CHERG) 2013. References: Liu, Li, et al., ‘Global, Regional, and National Causes of Child Mortality: An updated systematic analysis for 2010 with time trends since 2000’, The Lancet, vol. 379, no. 9832, 9 June 2012, pp. 2151–2161. World Health Organization, ‘WHO-CHERG methods and data sources for child causes of death 2000-2011’, Global Health Estimates Technical Paper WHO/HIS/HSI/GHE/2013.2, WHO Geneva, available at . (CHERG 2013). The UN Inter-agency Group for Child Mortality Estimation (IGME), Levels and Trends in Child Mortality: Report 2013, UNICEF, New York, 2013. UNICEF, Committing to Child Survival: A Promise Renewed – Progress Report 2013, New York, 2013.

Summary of Global Estimates in 2010 7.6 million deaths in children < 5 years 64% (4.9 million) of deaths were from infectious diseases Pneumonia 18% 1.40 million Diarrhea 10% 0.80 million Malaria 7% 0.56 million 40% (3.1 million) of deaths occurred in neonates PTB Complications 14% 1.08 million Intrapartum-related complications 9% 0.72 million Sepsis or meningitis 5% 0.39 million 4% 0.33 million

Regional Causes of Deaths, 2010: Eastern Mediterranean and SE Asia

Estimated causes of mortality around the year 2010 for 194,000 neonatal deaths Almost all are due to preventable causes Source: Khan A et al. 2012. Newborn survival in Pakistan: a decade of change and future implications. Health Policy and Planning 27(Suppl. 3):iii72–iii87 Data source: Pakistan mortality estimates (Liu et al. 2012). Note: Severe infection includes sepsis, meningitis, pneumonia and tetanus.

Birth Asphyxia Burden Pakistan About 80,000 newborns die Equal number die as fresh still births Un specified number develop impairement Services for physical and mental impairement poorly developed (Bhutta et al, 2008)

Pakistan is not on track to achieve MDG 4 and 5 U5MR – 89 per 1,000 live births (slow decrease) IMR – 74 per 1,000 live births (slow decrease; target is to reduce IMR to 40). NMR – 55 per 1,000 live births (stagnant) Two-thirds of children under one year die during first 28 days of life Pneumonia and diarrhea are major killers of children under five. Every hour in Pakistan: Three women die due to maternal causes Only 52% delivered assisted by a skilled provider (13 percent point increase) Only 48% delivered at Health facilities (14 percent point increase) Let me start with existing evidence…

40-Year Trend in Infant and Neonatal Mortality in Pakistan IMR has considerably declined NMR remained constant in last three decades IMR NMR NMR reducing at 0.9% per year, less than half of the regional annual average (1.8%). Neonatal mortality contributes to two-thirds of all deaths under the age of five years Actually, the latest data (PDHS 2012-13) show further decrease of IMR (74/ 1000 LB) with same and even slight increase of the NMR (55/ 1000 LB). Proportion of neonatal deaths among infant deaths is going up!!

Trends in Childhood Mortality in Pakistan, 1990-2013

Neonatal and Under-Five Mortality Rates, 1990-2010

PDHS 2013- Data (Sindh-Pakistan) Indicator Pakistan Sindh NMR (per 1000 live births) 55 54 IMR (per 1000 live births) 74 U5MR (per 1000 live births) 89 93 CPR % 35 30 TFR % 3.8 3.9 SBA % 73 78 (U 90 % R 65 %) ANC (4 visits) 37 Place of delivery % HF 49 (15 public+34 Pvt) Home 51 HF 59 (14P+45 Pvt) Home 41 MMR (PDHS 2006) 276 314

Morbidity Problems in Neonates: HIE Disability Fresh Stillbirths Problems in children: Post CNS infections sequelae Post vaccine preventable diseases sequelae Diarrhoea, infections, malnutrition cycle. Micronutritient deficiency, hidden hunger, low IQ , poor output. Discrimination against girl child. Unhealthy un educated mother. Poor quality of life.

SINDH: child malnutrition rates very high NNS (2002) reveals 13% global acute malnutrition (GAM) Pakistan; 18-23% in Sindh post flood. Stunting : 50 %: Highest in south Asia (Only 17% in Srilanka) Underweight : 50% Wasting: 18%

PAKISTAN :DEMOGRAPHIC AND HEALTH INDICATORS POPULATION:180 MILLION(6th most populous country in the world). 146th on human development index out of 190 countries. Decline in U5(95) and IMR(67:Thousand live births). PMR static at 54 : thousand total births High fertility rate at 4 and Birth rate remained unchanged at 2.2% highest in Asia. Hence under 15 population at 43%. Massive addition of about 3million /year

PAKISTAN DEMOGRAPHIC AND HEALTH INDICATORS High fertility rate(4.8) : Population explosion Low contraceptive prevalence(<30%) Anemia in pregnancy 40%(3-4% maternal deaths) Tetanus immunisation58%(Unicef,2002) Antenatal care received 28% and delivered at home76% (GOP 2002) and attended by a trained birth attendant 20%. Maternal mortality ratio:350/100,000 live births,25-30 thousand women die each year, one mother every 20 minutes.

PAKISTAN :HEALTH and DEMOGRAPHIC INDICATORS High U5,IMR,Perinatal and Neonatal mortality rates. LOW BIRTH WEIGHT :25-33% Exclusive breast feeding:25% Severe and moderate malnutrition in U5 children 40% Per capita food production and calories100% Safe drinking water ?,Sanitation rural 20%. Immunization coverage 12-23months <58% TT Vaccination of pregnant women31% Adult literacy rate35% Federal expenditure on health increasing but still only 0.7% of GNP. Little on women and children; More on security and debt servicing.

ALL IS NOT BLEAK Mortality rates declining except PMR Polio being eradicated ORS saving 1 million lives /year Vitamin A and Iodine supplements Television coverage very high Maternal and child health strategies in pre service curricula. Training programs for LHW covering about 40% of rural community and midwives. Child survival and health promotion strategies in -corpora ting: IMNCI,ARI,CDD,EPI and Nutrition projects.

Summary Children, infants and neonates are dying in large number in developing countries including Pakistan. Malnutrition is the most important risk factor causing deaths in children. Neonatal and peri natal mortality rates are not declining. Demographic indicators of Pakistan are not good. Majority of problems are easily preventable.