1. 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

2. 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)

3. 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)

4. 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

5. What are neonates dying of?
Preterm births
Severe infection
Asphyxia
Congenital anomalies
Tetanus }
~ 75%

6. 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

7. 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)

8. 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

9. Achievement of the MDG 4 & 5 constitutes a particular challenge
57 countries: likely to reduce child mortality by 2/3 ( ) 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

10. India’s share of the global burden of births & child deaths
Live births ~ 20%
Child deaths ~ 20%
Infant deaths ~ 24%
Neonatal deaths ~ 30%

11. INDIA’S SHARE OF GLOBAL BURDEN OF NEWBORN DEATHS Est. N = 4 millions

12. 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?

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

14. 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

15. 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

16. Essential components of IMNCI
Improve health and nutrition workers’ skills
Improve health systems
Improve family and community practices

17. 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

18. 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

19. 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

20. 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.

21. 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

22. 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

23. 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

24. 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

25. 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 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

26. 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

27. 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

28. 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

29. 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