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

2. 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.

3. 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.

4. 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.

5. 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

6. Global Distribution of Causes of Child Deaths: 2008

7. 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

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

9. 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:
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:
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 Sub-Saharan Africa, however, continues to lag behind, having only decreased its under-five mortality by 45% since 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) 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 ’, 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.

10. 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

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

12. 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 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.

13. 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)

14. 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…

15. 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 ) 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!!

16. Trends in Childhood Mortality in Pakistan, 1990-2013

18. Neonatal and Under-Five Mortality Rates, 1990-2010

19. 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

20. 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.

21. 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%

22. 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

23. 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.

24. 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.

25. 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.

26. 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.