Lec 7

Maternal & Child Health (Undergraduate Global Health Module)

13 October, 2014 A/P Sri Chander

Saw Swee Hock School of Public Health National University of Singapore

an

Source: Invest in Girls and Women: Everybody Wins, Women Deliver, 2014

Chinchpada hospital encounter

• Play video link (2:50 – 7:10)

2

Session Outline Part one FOCUS: --What has worked? --What has not worked?

• New Focus on RMNCH + A • MDGs 4 & 5a: countdown • Under-5 mortality (deaths) • Under-5 child malnutrition • Neonatal mortality

(deaths) • Maternal mortality

Part two FOCUS: --What more can be done? • RMNCH continuum of care • Reducing preventable

deaths in under-5 children • Reducing preventable

neonatal deaths • Reducing preventable

maternal deaths • Focusing on adolescent

girls

Part one FOCUS:

--What has worked? --What has not worked?

• New Focus on RMNCH + A • MDGs 4 & 5a: countdown • Under-5 mortality (deaths) • Under-5 child malnutrition • Neonatal mortality (deaths) • Maternal mortality

New focus: Convergence of reproductive, maternal, newborn, child & adolescent health

MDGs 4 & 5a: countdown

MDG 4 Reduce Child Mortality

• Target 4.A: Reduce by two thirds, between 1990 and 2015, the under-five mortality rate

--The # of under-5 child deaths fell from 12.7 million in 1990 to 6.3 million in 2013 --Translates into about 17,000 fewer children dying daily -- Rate of decrease not enough to meet MDG 4 target; yet it is still remarkable progress --However, 44% of under-5 child deaths now among newborn babies

MDG 5 Improve Maternal Health

• Target 5.A: Reduce by three quarters, between 1990 and 2015, the maternal mortality ratio (MMR)

--The MMR fell by 45% between 1990 & 2013, from 380 to 210 deaths per 100,000 live births --Far off target • Target 5.B:

Achieve, by 2015, universal access to reproductive health

-- Substantial unmet need for family planning in low-income & middle-income countries --The large increase in contraceptive use in the 1990s was not matched in the 2000s

‘On track’ for MDG 5a only, not for MDG 4 (2) Eritrea and Equatorial Guinea

‘On track’ for MDG 4 only, not for MDG 5a (21) Bolivia, Botswana, Brazil, Ethiopia, Guatemala, Indonesia, Iraq, Korea DPR, Kyrgyz Republic, Liberia, Madagascar, Malawi, Mexico, Morocco, Niger, Peru, Philippines, Rwanda, Solomon Islands, Tanzania and Zambia

‘On track’ for both MDGs 4 and 5a (7) Bangladesh, Cambodia, China, Egypt, Lao PDR, Nepal and Vietnam

But, few countries on track to achieve their targets by 2015

‘On  track’  for  MDG  5a  only,   not for MDG 4 (2) Eritrea and Equatorial Guinea

‘On  track’  for  MDG  4  only,  not    for  MDG  5a  (21) Bolivia, Botswana, Brazil, Ethiopia, Guatemala, Indonesia, Iraq, Korea DPR, Kyrgyz Republic, Liberia, Madagascar, Malawi, Mexico, Morocco, Niger, Peru, Philippines, Rwanda, Solomon Islands, Tanzania and Zambia

‘On  track’  for  both   MDGs 4 and 5a (7) Bangladesh, Cambodia, China, Egipt, Lao PDR, Nepal and Vietnam

Under-5 mortality (deaths in the

first 5 years of life)

Mortality Definitions

Under-5 deaths: But Intra-country disparities remain: • By household wealth quintile

(poorest=highest U5MR)

• By gender

• By residence: urban, peri-urban, rural

• By educational level of the mother

• By other social stratifiers (e.g. caste, race, etc)

Children who live in poorer households, in rural

areas or whose mothers have less education are at higher risk of dying before age 5

Child Malnutrition

Through synergy with infectious diseases, malnutrition causes 35% of under-5 child deaths

Source: Countdown to 2015, 2010.

Main under-5 child infections Pneumonia

Diarrhea Malaria

Dengue Fever/ Dengue Hemorrhagic Fever

Tuberculosis

Breastfeeding Practices by UN Region During 2000-2010

0

10

20

30

40

50

60

70

80

90

Africa Latin America Asia Europe

(Per

cent

age)

Early initiation of breastfeeding

Exclusive breastfeeding (1-5 months)

Predominant breastfeeding (1-5 months)

Partial breastfeeding (1-5 months)

No breastfeeding (1-5 months)

Any breastfeeding (6-23 months)

28

Exclusive breastfeeding only about 30% or less in major UN regions  

Stunting Rate is Slowly Decreasing

• Figure 4

30

165 million children under five are stunted

(25.7%)   2.1% annual rate of reduction is

not fast enough to reach WHA

target

1960 1977 1982 1987 19961990 1992 2000 2009

Stunting 10-12%

Underwt,>50% Stunting, 40+% Wasting, 8-10%

VAD

IDA(preg)

IDD

Low stores,Pre& Sch 20%

Bitot’s  Spot  

Xeroph-thalmia,blindness

Rapid economic development& GlobalizationLow income country

IDA, >35%, highsevere anemia

Anemia 20%, mild

Low S. retinol,Lact, <0.5% Sch, 3%

Negligible Severe PEM

Anemia 20-25%, (Mild-mod.)

Thailand Nutrition Chronicles

I-salt, endemic

area

Resurvey, high TGR

high % & variablelow UIETGR< 5%

ZDDLow S.Zn Sch

30-50%Low S. Zn-Sch

30-50%

Play video: The Window of Opportunity (1:00 -3:00)

Why is good nutrition so important to

children under 2 years? • Stunting starts early and becomes permanent

by age 2 years • Child’s  brain:  80% developed by year 2: malnourished child has permanent brain

damage as early as 2 years • Prenatal malnutrition & low birth weightÆ

predisposition to obesity, high blood pressure, heart disease and diabetes later in life;

Growth Failure Begins Early in Life

-2

-1.75

-1.5

-1.25

-1

-0.75

-0.5

-0.25

0

0.25

0.5

0 3 6 9 12 15 18 21 24 27 30 33 36 39 42 45 48 51 54 57 60

Age (months)

Hei

ght f

or a

ge Z

-sco

re (N

CH

S)

Africa Latin America and Caribbean Asia

Intervene BEFORE Nutrition Declines

-2

-1.75

-1.5

-1.25

-1

-0.75

-0.5

-0.25

0

0.25

0.5

0 3 6 9 12 15 18 21 24 27 30 33 36 39 42 45 48 51 54 57 60

Age (months)

Und

erw

eigh

t Z-s

core

(NC

HS

)

Africa Asia Latin America and CaribbeanSource: DHS/IFPRI

Normal

Pregnancy

Focus on -9 to 24 months

-9 to +24 Window • Most malnutrition=between pregnancy and

the first 2 years of age. • Period just before pregnancy until about 2

years=special and cost-effective "window of opportunity" for impacting on nutrition

• Much of early damage is irreversible • Interventions after this age are too late, too

little, and too expensive.

Normal brain development

• Newborn brain weighs 400 grams • At one year of age the brain weighs

1,000 grams. • By 2 years of age the brain has reached

80 percent of its adult size. • By 18 years of age the brain has reached

its adult weight of 1400 grams

Child Brain Development (normal vs malnourished child)

Normal Malnourished

What is the Difference in Brain Scans of these two under-5 children?

Malnutrition & infection

“Otak Kosong”  or  Empty  Brain  is  permanent “Irreversible  loss  of  opportunity”

LOST GENERATION (Labor)

Well nourished & healthy

Smart child—Life in all its Fullness Quality Human Resource

Higher Income (>7% more)

Burden Resource

Impact of Nutrition and Health towards Brain’s  Growth  and  Development

By: Prof. Ascobat Gani

Early life programming in pregnancy • Extensive studies in last 20 years: Æ low birth weight (esp when followed by accelerated postnatal growth) Æobesity, diabetes, heart disease & hypertension

• Environmental stresses (esp in utero) Æchange regulatory gene expression (DNA methylation) Æincreased risk of chronic disease later in life

• Poor prenatal dietÆdouble negative effect: Ælow birth weight Æhigher risk of NCDs (non-communicable diseases) later in life

Fetus already being programmed for obesity, diabetes & heart disease in the uterus

• Fetus and young child very sensitive to extra fat Ædeposited rapidly in the heart, liver Æand abdomen (retroperitoneal fat): main site of insulin resistance • Maternal diet & metabolism tells various genes

how to function & behaveÆremains with the child rest of his life

• ThereforeÆneed to focus on first 1,000 days (pregnant women & children under 2 years)

Neonatal mortality (deaths in 1st month [28 days] of life)

“Asphyxia”  anecdote

SOURCE: DR HOWARD SOBEL, WHO WPRO, 2012

Figure 2

Source: The Lancet 2014; 384:189-205 (DOI:10.1016/S0140-6736(14)60496-7)

Terms and Conditions

Maternal mortality

Where do we stand?

MDG 4 - Reduce child mortality – Under 5 mortality fell 41% from 1990 – Sub-Saharan Africa doubled its average rate of reduction : 1.2 % in 1990-2000 to 2.4

per cent during 2000-2010

MDG 5a - Improve maternal health Maternal mortality fell 47% from 1990

MDG 5b - Universal access to reproductive health

By 2008, more than 50%women aged 15 -49yrs were using contraception

MDG 6 - HIV/AIDS, malaria and other diseases

New HIV infections declined; Proportion of women living with HIV remains stable at 50%

Source: Trends in Maternal Mortality: 1990 t0 2013; WHO, UNICEF, UNFPA, The World Bank, United Nations Population Division, 2014

Source: Invest in Girls & Women: Everybody Wins, Women Deliver, 2014

Source: Trends in Maternal Mortality: 1990 t0 2013; WHO, UNICEF, UNFPA, The World Bank, United Nations Population Division, 2014

Nepal: my first visit in early 1990s: Training TBAs: useful to reduce maternal deaths?

NEPAL

NEPAL

NEPAL

Question: What is the best and cheapest way to reduce maternal

deaths in Nepal?

Source: Invest in Girls & Women: Everybody Wins, Women Deliver, 2014

Source: Invest in Girls & Women: Everybody Wins, Women Deliver, 2014

Source: Invest in Girls & Women: Everybody Wins, Women Deliver, 2014

Timor Leste: Phase 2 delay Topography, distance, communications, roads

Inequalities in Reproductive, maternal, neonatal & child health

Play video: Why did Mrs X die? Retold

(0:00 to 4:45)

Gender inequalities in mortality & birth rates in some South Asian countries like India

• Differential allocation of care to girls and boys, prenatal sex selection, female feticide (UNICEF, Mumbai study)

• Infanticide, neglect, and gender-based violence • Skewed sex ratios at birth/later years: girls= disadvantaged • Wide gender disparities in child immunization, care/

treatment for diarrhea & pneumonia, & nutrition including breast feeding. • Young women and girls = victims of neglect, poor

healthcare, violence during adolescence & maternity. • Gender inequalities in India surpass inequalities in

geographies (urban or rural), class, caste, religion, and literacy levels

Source: USAID/India, 2013

Need to achieve gender-equitable RMNCH + A outcomes

• Need to improve gender differentials in: --sex ratios at birth --infant and child mortality among girls --breastfeeding, immunization, & treatment seeking behavior for childhood illnesses among girls.

• Need to reduce: --anemia among adolescent girls & young married women --gender-based violence, violence during pregnancy and in the postpartum period.

Short Break

Part two FOCUS: --What can be done? • RMNCH continuum of care • Reducing preventable deaths in under-5

children • Reducing preventable neonatal deaths • Reducing preventable maternal deaths • Focusing on adolescent girls

RMNCH + A: Places of Care Giving Continuum

Improving home & community management: key cornerstone of RMNCH

RMNCH continuum of care: proven interventions

Coverage is

patchy

* Coverage indicators from Recommendation 2 of the Commission on Information and Accountability for Women’s and Children’s Health (2011).

Adapted from: Countdown to 2015, Building a Future for Women and Children, The 2012 Report (2012).

§ Global HIV/AIDS Response: Epidemic update and health sector

progress towards Universal Access, Progress Report 2011. WHO, UNICEF and UNAIDS (2011).

Reducing preventable deaths in under-5 children

Need for appropriate targeting

Focus on the first 1,000 days: • Pregnant women • Children under two years

Nutrition-Specific Interventions and Programs: How can they Help Accelerate Progress in Improving

Maternal and Child Nutrition?

97

Reducing preventable neonatal deaths

We have the knowledge and tools to reduce the main causes of death

Preterm birth

• Preterm labor management including antenatal corticosteroids*

• Care including Kangaroo mother care, essential newborn care

Birth complications

(and intrapartum stillbirths)

• Prevention with obstetric care * • Essential newborn care, and resuscitation*

Neonatal infections

• Prevention, essential newborn care especially breastfeeding, Chlorhexidine where appropriate*

• Case management of neonatal sepsis *

1

2

* Prioritised by the UN Commission on Life Saving Commodities for Women and Children

Over two-thirds of newborn deaths preventable – actionable now without intensive care

3

SOURCE: DR HOWARD SOBEL, WHO WPRO, 2012

PLAY Video: The First Embrace: A touching

Solution to save lives WHO, WPRO, 2014

0.00 – 5:30

Play  video:  “4 Breast  Crawl” (0:00 – 3:50)

Preventing neonatal sepsis – evidence for Chlorhexidine for cord care

http://www.healthynewbornnetwork.org/topic/chlorhexidine-umbilical-cord-care?utm_source=February+2013+Update&utm_campaign=February+Update&utm_medium=email

Reducing preventable maternal deaths

Trends in Maternal Mortality: 1990 t0 2013; WHO, UNICEF, UNFPA, The World Bank, United Nations Population Division, 2014

Source: Invest in Girls & Women: Everybody Wins, Women Deliver, 2014

What are the 13 Life Saving Commodities for MNCH?

Misoprostol for prevention of PPH at homebirths or facilities

What? • Misoprostol is a utero-

tonic that prevents and treats postpartum haemorrhage (PPH)

• It is available in oral tablet form (3 tablets of 200mcg) to be taken immediately after birth & aimed at preventing a PPH

• WHO now recommends it for prevention of PPH where oxytocin is not available or cannot be safely used (no SBA)

• It is less heat sensitive than oxytocin which makes it an ideal medicine for use during home births or in low resource facilities

Community Distribution of Misoprostol to prevent PPH

• CHWs/TBAs, trained in its use, can distribute it in advance for prevention of PPH & self administration is safe and effective

Invest in adolescent girls

Behavior change communications program for girl children/adolescent girls

• UNIQUE IN TWO WAYS: --GROWTH HORMONE SPURT **18-24 MTHS BEFORE ONSET OF MENARCHE **GOD-GIVEN 2NDCHANCE FOR CATCH-UP GROWTHÆ INCREASED STATURE & BIGGER PELVISÆINCREASED BIRTH WEIGHT --OPEN/TEACHABLE: NUTRITION, LITERACY, PREGNANCY & FAMILY SPACING EDUCATION

• GIVE PROTEIN/CALCIUM-RICH FOOD SUPPLEMENT TO ALL GIRL CHILDREN

(9-11 YEARS) • ENSURE GIRL CHILD GOES TO SCHOOL (build

more toilets in schools for girls) • TRACK GENDER-DISAGGREGATED DATA ON

STUNTING INDICATOR (HEIGHT/AGE)

Source: Invest in Girls and Women: Everybody Wins, Women Deliver, 2014