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 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)

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 Community MPS IMCI NUT RBM HIV EPI Skilled care Infant feeding Vital vaccines Combating diarrhoea Combating malaria Antibiotics for pneumonia Combating HIV IMCI – Integrated Management of Childhood Illness MPS – Making Pregnancy Safer NUT - Nutrition RBM – Roll Back Malaria EPI – Expanded Programme on Immunization

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

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?

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

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