Global Maternal, Newborn and Child Health: challenges and ... · (e.g., preeclampsia) Sepsis/infections maternal deaths These conditions also contribute to the three highest burden

Global Maternal, Newborn and Child

Health: challenges and opportunities

Zulfiqar A BhuttaFounding Chair

Women & Child Health Division

The Aga Khan University

Pakistan

Outline

• Global burden of Maternal & Child Mortality

• What works & how good are we at delivering?

• Innovations for scaling up: what’s new?

• Has anyone done this at scale? • Has anyone done this at scale?

• Challenges ahead

Maternal mortality ratios 1990-2008

400

500

600

700

800

900M

MR

0

100

200

300

400

1990 1995 2000 2005 2008

year

MM

R

Africa Asia CIS Developed Latin America Oceania World

Maternal mortality ratios at country level(~ 358,000 deaths annually in 2008)

8.1 million children under 5 years still die each year

The Good News

• Since 1990, the global under-five mortality rate has fallen by a third—from 89 deaths per 1,000 live births in 1990 to 60 in 2009.

• All regions except Sub-Saharan Africa, Southern Asia and Oceania have seen reductions of at least 50 percent.

The not so good news

• About 75% of all child deaths occur in Africa and South-East Asia,

• Around 50% in just five countries: India, Nigeria, DR Congo, Pakistan and China.

Top 10 countries for numbers of

stillbirths, neonatal and maternal deaths

Ranking for neonatal deaths

Ranking for

maternal deaths

Ranking for

stillbirths

India 1 1 1

Nigeria 2 2 3

Pakistan 3 8 2

China 4 13 8

2.4 million

neonatal 340,000

maternal 1.77

million China 4 13 8

DR Congo 5 3 6

Ethiopia 6 5 5

Bangladesh 7 6 4

Indonesia 8 7 7

Afghanistan 9 4 12

Tanzania 10 9 11

neonatal

deaths

Approx

67%

of global

total

maternal

deaths

Approx

65%

of global

total

Ref: Lawn JE et al BJOG sept 2009. Data sources: Estimates of maternal (2005) and neonatal (2008) deaths from WHO. Stillbirths from Cousens et al 2010 Updated Aug 2010

million

stillbirths

Approx

63%

of global

total

A limited number of related conditions account for the majority of neonatal

and maternal mortality

Maternal mortality by cause*

Total deaths per year ~0.38 million

26%Hemorrhage

Hypertensive

Account for:

• ~0.2 million

deaths

• 59% of

Obstructed labor

Unsafe abortion

Anemia

Other direct

causes

Other indirect

causes***

Unclassified

15%

9%

9%

8%

6%

7%

11%

8%

Hypertensive

disorders

(e.g., preeclampsia)

Sepsis/infections

• 59% of

maternal

deaths

27%Preterm birth

A limited number of related conditions account for the majority of neonatal

and maternal mortality

Maternal mortality by cause*


Neonatal mortality by cause*


Account for:

• ~2.8 million

deaths

26%Hemorrhage

Hypertensive

Account for:

• ~0.2 million

deaths

• 59% of

26%

23%

7%

7%

7%

3%

Severe infections

(e.g., sepsis,

pneumonia)

“Birth asphyxia”

Congenital

abnormalities

Tetanus

Other

Diarrhea

deaths

• 76% of

neonatal

deaths

In addition,

there are over

2.5 million

stillbirths

per year**

Obstructed labor

Unsafe abortion

Anemia

Other direct

causes

Other indirect

causes***

Unclassified

15%

9%

9%

8%

6%

7%

11%

8%

Hypertensive

disorders

(e.g., preeclampsia)

Sepsis/infections

• 59% of

maternal

deaths

These

conditions

also

contribute to

the three

highest

burden

newborn

conditions

Adapted from Gary Darmstadt & WHO

Malaria8%

AIDS2%

Pertrussis2%

Meningitis2% Other

infections9%

NCDs4%

Injury3%

Preterm 12%

Asphyxia 9%Neonatal

Causes of child deaths in 2008almost all due to preventable conditions

These causes

account for

81% of all

Diarrhea15%

Pneumonia14%

8%Asphyxia 9%

Sepsis 6%

Pneumonia 4%Diarrhea 1%

Tetanus 1%Congenital 3%

Other 5%

Neonatal41%

81% of all

neonatal

deaths3.6 million

Source CHERG/WHO 2010. Estimates for 193 countries for 2008. Black R et al Lancet 2010

What can be done?

Ou

tre

ach

/ou

tpa

tie

nt

Cli

nic

al

ANTENATAL CARE

- 4-visit focused

package

- IPTp and bednets for

malaria

POSTNATAL CARE

- Promotion of healthy

behaviours

- Early detection of and

referral for illness

- Extra care of LBW babies

CHILD HEALTH CARE- Immunisations, nutrition, e.g. Vitamin

A supplementation and growth

monitoring

- IPTp and bednets for malaria

- Care of children with HIV including

CHILDBIRTH CARE– Emergency obstetric care (including Ext

cephalic version, AMTSL, Partogram use, antenatal steroids, antibiotics as indicated

– Skilled obstetric care and immediate newborn care (hygiene, warmth, breastfeeding) and resuscitation, infection prevention

– PMTCT/ART for HIV

EMERGENCY NEWBORN AND CHILD CARE

- Hospital care of newborn and childhood illness including HIV

care

- Extra care of preterm babies including kangaroo mother care

- Emergency care of sick newborns

REPRO-

DUCTIVE

- Post-abortion

care, Safe

Abortion where

legal

- STI case

management

REPRODUCTIVE

HEALTH CARE

- Family planning

- Prevention and

management of STIs

and HIV including ART

Global Consensus MNCH interventions & Packages

ChildhoodNewborn/postnatalPre-pregnancy Pregnancy

Fam

ily

/co

mm

un

ity

Ou

tre

ach

/ou

tpa

tie

nt

malaria

- PMTCT/ART fro HIV

- Extra care of LBW babies

- PMTCT

- Counselling and

preparation for

newborn care,

breastfeeding, birth

and emergency

preparedness

Healthy home care including:

- Newborn care (hygiene, warmth)

- Nutrition including exclusive breastfeeding and appropriate

complementary feeding

- Seeking appropriate preventive care

- Danger sign recognition and careseeking for illness

- Oral rehydration salts for prevention of dehydration

- Where referral is not available, consider case management for

pneumonia, malaria, neonatal sepsis

- Where skilled care is not

available, consider clean

delivery and immediate

newborn care including

hygiene, warmth and early

initiation of breastfeeding

–Adolescent and

pre-pregnancy

nutrition

– Education

–Prevention of STIs

and HIV

- Care of children with HIV including

cotrimoxazole

- First level assessment and care of

childhood illness (IMCI)

and HIV including ART

- Peri-conceptual folic

acid

Intersectoral Improved living and working conditions – Housing, water and sanitation, and nutrition

Education and empowerment

Birth

FAMILY AND COMMUNITY

Moving in and out of care

Diarrhoea treatment

37

37

Sub-Saharan Africa

South Asia

Percentage of children under-five with diarrhoea receiving oral rehydration and continued feeding

39

55

39

Developing countries

East Asia and Pacific

Middle East and

North Africa

Source: UNICEF Global Databases, November 2010, based on Demographic and Health Surveys, Multiple

Indicator Cluster Surveys and other national surveys.

Pneumonia treatment – Care seeking

76

6664

58

Percentage of children under-five with suspected pneumonia taken to an appropriate health care provider

43

Middle East and North

Africa

East Asia and the Pacific

(Excluding China)

South Asia Sub-Saharan Africa Developing countries

(Excluding China)

Source: UNICEF, State of the World’s Children report 2010.

“The facts are always less than what really happened!”

Nadine Gordimer

50

60

70

Proportion of children aged 0-59 months with suspected pneumonia receiving antibiotics

Pneumonia treatment – antibiotics

0

10

20

30

40

DHS 2008 MICS 2008 DHS 2006-2007 DHS 2005-2006

Sierra Leone Mozambique Pakistan India

Poorest

Second

Middle

Fourth

Richest

Source: UNICEF Global Databases, November 2010, based on Demographic and Health Surveys, Multiple

Indicator Cluster Surveys and other national surveys.

Magnitude of inequities by intervention in 38 countries

Vitamin A administration (child)

Care seeking for pneumonia

ORT and continued feeding

Poorest Richest

0% 20% 40% 60% 80% 100%

Family planning needs satisfied

Antenatal care (4+ visits)

Skilled attendant at delivery

Postnatal visit

Insecticide-treated net use (child)

DPT3 vaccine

Measles vaccine

BCG vaccine

Coverage

Innovations

Community delivery platforms?Community delivery platforms?

What works in community settings?

What works in community settings?

Impact of Community-based Intervention Packages on

Neonatal Mortality (non categorized)

Source: Lassi ZS, Haider BA, Bhutta ZA. Community-based intervention packages for reducing maternal and neonatal morbidity and mortality and

improving neonatal. Cochrane Database of Systematic Reviews 2010

24% reduction in neonatal mortality!

Impact of Community-based Intervention

Packages on Stillbirths (non categorized)



26% reduction in Stillbirth rates!

Impact of Community-based Intervention

Packages on Maternal Morbidity



25% reduction in Maternal Morbidity!


Referrals to Health Facilities for Complications during

Pregnancy




Health Care Seeking for Neonatal Morbidities



Innovations

Using available human resources and

key technologies key technologies

Targeting Cord Care

• Maybe associated with

localizing signs

• Omphalitis rates may • Omphalitis rates may

approach 15-20%

• Rapid progress and

case fatality rates >

40%

Community Studies of Cord Chlorhexidine

application

Study Country Type of

study

Days of

Cleansing

with CHX

CHX

used

Comparis

on group

Outcomes available

Mullany et al.

2006

Nepal cRCT 1,2,3,4,6,8,10 4.0 %

solution

Dry Cord

care

Neonatal mortality,

Incidence of Omphalitis,

Cord separation time

(CST)(CST)

Arifeen et al.

2010

Bangladesh

(group 1)

cRCT 1,2,3,4,5,6,7 4.0 %

solution

Dry Cord

Care

Neonatal mortality,


Bangladesh

(group 1)

1 Neonatal mortality,


Bhutta et al.

2010

Pakistan cRCT 14 days 4.0 %

solution

Dry Cord

Care

Neonatal mortality,


Cord separation time

(CST)

Provision of Chlorhexidine in Clean Delivery

Kits for cord application

• Traditional Birth Attendants trained (2 day training program)

– To promote daily application of 4% CHX

for 14 days by family members. First

application after birth made by the TBA

– Promotion of practicing hand washing – Promotion of practicing hand washing

with antiseptic soap (esp; after toilet

use and before contact with naked

newborn) for at least two weeks in post

partum period.

• Provision & Replenishment of CDK (with or without 4 % CHX solution and / or soap) through TBAs in all clusters

Combined K-M curves for three community CHX trials from

Nepal, Bangladesh and Pakistan: All-cause neonatal mortality

Cord Chlorhexidine Working Group

Pooled analysis: Cleansing of umbilical cord with Any Chlorhexidine

vs. No Chlorhexidine: All-cause neonatal mortality

Study or Subgroup

Arifeen 2010

Bhutta 2010

Mullany 2006

log[Risk Ratio]

-0.1392

-0.478

-0.2744

SE

0.086

0.158

0.14

Weight

46.1%

24.9%

29.0%

IV, Random, 95% CI

0.87 [0.74, 1.03]

0.62 [0.45, 0.85]

0.76 [0.58, 1.00]

Risk Ratio Risk Ratio

IV, Random, 95% CI

Total (95% CI)

Heterogeneity: Tau² = 0.01; Chi² = 3.68, df = 2 (P = 0.16); I² = 46%

Test for overall effect: Z = 2.69 (P = 0.007)

100.0% 0.77 [0.64, 0.93]

0.01 0.1 1 10 100Favours experimental Favours control

Cord Chlorhexidine Working Group

Unpublished data (do not cite without permission)

23% reduction in all-cause neonatal mortality!

Innovations

Removing financial barriers through

conditional cash transfers?conditional cash transfers?

Janani Suraksha Yojana – “Safe motherhood scheme”

• Launched in 2005; 100% centrally funded

• Goal: reduce maternal and neonatal mortality

• Works by incentivizing women to deliver in a health facility

• Implemented through Accredited Social Health Activists or ASHAs

• ASHAs also receive a cash benefit

• Budget allocation of US$342 million in 2009-10

• Some, mostly process evaluations, conducted in selected states

Accredited Social Health Activist (ASHA)

Madhya Pradesh, India

Photo: Department for International Development, UKAID

In-facility birth coverage, 2001 to 2003 Births receiving JSY, 2007/08

Lim et al (Lancet 2010)

State-level uptake by location of birth

Lim et al (2010)

0,00

0,05

0,10

0,15

0,20

0,25

0,30

0,35

0,40

0,45

0,50

% J

SY

JSY, out of facility

JSY, in-facility

Impact on mortality, national level

Perinatal mortality Stillbirth/neonatal mortality

OR P-value OR P-value

Matching 0.72 0.000 0.74 0.000

Before-after 0.70 0.000 0.75 0.000

Odds Ratios: JSY/no JSY

Whether or not knowledge is global, the use of knowledge is always local

Photo: UNICEF

… and innovations are not a substitute for national policies and implementation

Infant mortality by region, Brazil

Infant mortality rate, 2000

Cedeplar/UNDP, Brazil

Infant mortality is highest in the Northeast and North

Source: UNDP Brazil

Family health program, Brazil

Brazil MOH

Pro-poor dissemination strategy resulted in higher coverage in the most deprived areas of the country

Source: Ministry of Health, Brazil

43

0

10

20

30

40

50

60

70

80

1990

1991

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

Infa

nt m

ort

alit

y r

ate

x 1

00

0 liv

eb

irth

s

North Northeast Southeast South Central - West

Brazil: regional inequalities in infant mortality

Source: Barros et al, AJPH 2010 / MoH

Source: Monteiro et al, Bull WHO 2010.

Brazil: poor-rich gaps in stunting,1974-5 to 2006-7

0 20 40 60 80 100

1974-5

1989

1996

2006-7

Stunting gap between the poorest (red) and

richest (blue) quintiles (%)

Richest Poorest

Source: Monteiro et al, Bull WHO 2010

Source: New analyses

0% 20% 40% 60% 80% 100%

Contraceptive use

Skilled birth attendant

Antenatal care (4+)

Safe water

Poorest Richest

2006

1996

2006

1996

2006

1996

2006

1996

Brazil: poor-rich gaps in coverage1996 and 2006-7

Source: Barros et al, AJPH 2010 / DHS

…. Yet challenges remain!

Poorest 2nd 3rd 4th Richest

1 30 2

99 95

0

20

40

60

80

100

1995 2008

6130

4

94

83

0

20

40

60

80

100

1995 2008

17

320

4

83

64

0

20

40

60

80

100

1995 2008

44

75

0

556

20

0

20

40

60

80

100

1995 2008

94 94

0 46 2

0

20

40

60

80

100

1995 2008

India

Low coverage – Progress is highly inequitablePoorest 40% made little progress; large inequities

Special tabulation UNICEF, 2010 based on India NFHS 1993, 1999, 2006

1995-2008 trend analysis of sanitation practices by wealth quintiles, India, national

Improved and shared sanitation facilities Unimproved sanitation facilities Open defecation

Global contraceptive use

What proportion of undernutrition is attributable to LBW?

32.3

20.5

39.7

15.6

9.9

17.1

0

5

10

15

20

25

30

35

40

45

Stunting Wasting Underweight

LBW babies

Normal BW

32%

41%37%

69%

51%

58%

85%

73% 75%

49%53%

50%

0%

20%

40%

60%

80%

100%

Africa Asia Developing world

Exclusive breastfeeding (0-5 months)

Complementary feeding (6-9 months)

Continued breastfeeding (12-15 months)

Continued breastfeeding (20-23 months)

Infant and Young Child Feeding (IYCF) Practices in Africa, Asia and Developing World

Source: PFC 2010.

Disparities in Early Vocabulary Growth

Global Maternal, Newborn and Child Health: challenges and ... · (e.g., preeclampsia) Sepsis/infections maternal deaths These conditions also contribute to the three highest burden

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