Reduction in child mortality in Niger: a Countdown to 2015 country case study

Challenges in reducing maternal and neonatal mortality in Niger: an in-depth case study

INTRODUCTION

Recent modelled estimates suggest that Niger made progress in maternal mortality since 2000. However, neonatal mortality has not declined since 2012 and maternal mortality estimates were based on limited data. We researched the drivers of progress and challenges.

METHODS

We reviewed two decades of health policies, analysed mortality trends from United Nations data and six national household surveys between 1998 and 2021 and assessed coverage and inequalities of maternal and newborn health indicators. Quality of care was evaluated from health facility surveys in 2015 and 2019 and emergency obstetric assessments in 2011 and 2017. We determined the impact of intervention coverage on maternal and neonatal lives saved between 2000 and 2020. We interviewed 31 key informants to understand the factors underpinning policy implementation.

RESULTS

Empirical maternal mortality ratio declined from 709 to 520 per 100 000 live births during 2000-2011, while neonatal mortality rate declined from 46 to 23 per 1000 live births during 2000-2012 then increased to 43 in 2018. Inequalities in neonatal mortality were reduced across socioeconomic and demographic strata. Key maternal and newborn health indicators improved over 2000-2012, except for caesarean sections, although the overall levels were low. Interventions delivered during childbirth saved most maternal and newborn lives. Progress came from health centre expansion, emergency care and the 2006 fee exemptions policy. During the past decade, challenges included expansion of emergency care, continued high fertility, security issues, financing and health workforce. Social determinants saw minimal change.

CONCLUSIONS

Niger reduced maternal and neonatal mortality during 2000-2012, but progress has stalled. Further reductions require strategies targeting comprehensive care, referrals, quality of care, fertility reduction, social determinants and improved security nationwide.

Spatial association and modelling of under-5 mortality in Thailand, 2020

Under-5 mortality rate (U5MR) is a key indicator of child health and overall development. In Thailand, despite significant steps made in child health, disparities in U5MR persist across different provinces. We examined various socio-economic variables, health service availability and environmental factors impacting U5MR in Thailand to model their influences through spatial analysis. Global and Local Moran's I statistics for spatial autocorrelation of U5MR and its related factors were used on secondary data from the Ministry of Public Health, National Centers for Environmental Information, National Statistical Office, and the Office of the National Economic and Social Development Council in Thailand. The relationships between U5MR and these factors were modelled using ordinary least squares (OLS) estimation, spatial lag model (SLM) and spatial error model (SEM). There were significant spatial disparities in U5MR across Thailand. Factors such as low birth weight, unemployment rate, and proportion of land use for agricultural purposes exhibited significant positive spatial autocorrelation, directly influencing U5MR, while average years of education, community organizations, number of beds for inpatients per 1,000 population, and exclusive breastfeeding practices acted as protective factors against U5MR (R2 of SEM = 0.588).The findings underscore the need for comprehensive, multi-sectoral strategies to address the U5MR disparities in Thailand. Policy interventions should consider improving socioeconomic conditions, healthcare quality, health accessibility, and environmental health in high U5M areas. Overall, this study provides valuable insights into the spatial distribution of U5MR and its associated factors, which highlights the need for tailored and localized health policies and interventions.

Cost-effectiveness of a direct to beneficiary mobile communication programme in improving reproductive and child health outcomes in India

INTRODUCTION

Kilkari is the largest maternal messaging programme of its kind globally. Between its initiation in 2012 in Bihar and its transition to the government in 2019, Kilkari was scaled to 13 states across India and reached over 10 million new and expectant mothers and their families. This study aims to determine the cost-effectiveness of exposure to Kilkari as compared with no exposure across 13 states in India.

METHODS

The study was conducted from a programme perspective using an analytic time horizon aligned with national scale-up efforts from December 2014 to April 2019. Economic costs were derived from the financial records of implementing partners. Data on incremental changes in the practice of reproductive maternal newborn and child health (RMNCH) outcomes were drawn from an individually randomised controlled trial in Madhya Pradesh and inputted into the Lives Saved Tool to yield estimates of maternal and child lives saved. One-way and probabilistic sensitivity analyses were carried out to assess uncertainty.

RESULTS

Inflation adjusted programme costs were US$8.4 million for the period of December 2014-April 2019, corresponding to an average cost of US$264 298 per year of implementation in each state. An estimated 13 842 lives were saved across 13 states, 96% among children and 4% among mothers. The cost per life saved ranged by year of implementation and with the addition of new states from US$392 ($385-$393) to US$953 ($889-$1092). Key drivers included call costs and incremental changes in coverage for key RMNCH practices.

CONCLUSION

Kilkari is highly cost-effective using a threshold of India's national gross domestic product of US$1998. Study findings provide important evidence on the cost-effectiveness of a national maternal messaging programme in India.

TRIAL REGISTRATION

NCT03576157.

Contribution of child health interventions to under-five mortality decline in Ghana: A modeling study using lives saved and missed opportunity tools

Background

Increased coverage of interventions have been advocated to reduce under-five mortality. However, Ghana failed to achieve the Millennium Development Goal on child survival in 2015 despite improved coverage levels of some child health interventions. Therefore, there is the need to determine which interventions contributed the most to mortality reduction and those that can further rapidly reduce mortality to inform the prioritization of the scale-up of interventions.

Materials and methods

Deterministic mathematical modeling was done using Lives Saved and Missed Opportunity Tools. Secondary data was used, and the period of the evaluation was between 2008 and 2014. Some of the interventions assessed were complementary feeding, skilled delivery, and rotavirus vaccine.

Results

A total of 48,084 lives were saved from changes in coverage of interventions and a reduction in the prevalence of stunting and wasting. Reduction in wasting prevalence saved 10,372(21.6%) lives, insecticide-treated net/indoor residual spraying 6,437(13.4%) lives saved, reduction in stunting 4,315(9%) lives saved and artemisinin-based combination therapy (ACTs) 4,325(9.0%) lives saved. If coverage levels of interventions in 2014 were scaled up to 90% in 2015, among neonates, full supportive care for prematurity (5,435 lives saved), full supportive care for neonatal sepsis/pneumonia (3,002 lives saved), and assisted vaginal delivery (2,163 lives saved), would have saved the most lives among neonates, while ACTs (4,925 lives saved), oral rehydration salts (ORS) (2,056 lives saved), and antibiotics for the treatment of pneumonia (1,805 lives saved) would have made the most impact on lives saved among children 1–59 months. Lastly, if all the interventions were at 100% coverage in 2014, the under-five mortality rate would have been 40.1 deaths per 1,000 live births in 2014.

Discussion

The state of the package of interventions will likely not lead to rapid mortality reduction. Coverage and quality of childbirth-related interventions should be increased. Additionally, avenues to further reduce stunting and wasting, including increased breastfeeding and complementary feeding, will be beneficial.

The correlation between food insecurity and infant mortality in North Carolina

OBJECTIVE

Food insecurity (FI) affects approximately 11·1 % of US households and is related to worsened infant outcomes. Evidence in lower income countries links FI and infant mortality rates (IMR), but there are limited data in the USA. This study examines the relationship between FI and IMR in North Carolina (NC).

DESIGN

NC county-level health data were used from the 2019 Robert Woods Johnson Foundation County Health Rankings. The dependent variable was county-level IMR. Eighteen county-level independent variables were selected and a multivariable linear regression was performed. The independent variable, FI, was based on the United States Department of Agriculture's Food Security Supplement to the Current Population Survey.

SETTING

NC counties.

PARTICIPANTS

Residents of NC, county-level data.

RESULTS

The mean NC county-level IMR was 7·9 per 1000 live births compared with 5·8 nationally. The average percentage of county population reporting FI was 15·4 % in the state v. 11·8 % nationally. Three variables statistically significantly predicted county IMR: percent of county population reporting FI; county population and percent population with diabetes (P values, respectively, < 0·04; < 0·05; < 0·03). These variables explained 42·4 % of the variance of county-level IMR. With the largest standardised coefficient (0·247), FI was the strongest predictor of IMR.

CONCLUSIONS

FI, low birth weight and diabetes are positively correlated with infant mortality. While correlation is not causation, addressing FI as part of multifaceted social determinants of health might improve county-level IMR in NC.

Stunting Prevention and Control Program to Reduce the Prevalence of Stunting: Systematic Review Study

BACKGROUND: Stunting is a condition in which the occurrence of failure to thrive in children as a result of chronic malnutrition so that the child is too short for his age. The prevalence of stunting in children under five in Indonesia is higher than the prevalence of stunting in the world. One of the impacts of stunting is the occurrence of developmental barriers, where if this is not prevented it will have an impact on the less than optimal performance of children in school and the long-term impact can be a decrease in the quality of human resources. AIM: This study aims to systematically identify stunting prevention and control programs to reduce the prevalence of stunting. METHODS: The method used in this study is the Systematic Review (SR). SR is a method that identifies, assesses, and interprets findings on a research topic to answer predetermined research questions. The keywords used to search for articles on electronic databases are ProQuest, Scinapse, PubMed, and Google Search. The keywords used are “stunting,” “parenting,” “parenting AND Stunting,” “stunting prevention,” “stunting prevention,” “stunting in lower and middle income countries,” “stunting and global programs,” and “stunting and Indonesia.” “Stunting and Asia Region” obtained from the ProQuest, Scinapse, PubMed, and Google Search database. RESULTS: Based on the identification results of this study, there are several forms of programs and interventions to prevent and control stunting that have been proven to be successful in reducing the prevalence of stunting, namely: CARING Trial, COWPEA, The Lulun Project, Rang-Din Nutrition Study, Tubaramure, NEO-MOM, Preparing for Life, Integrated Child Development Services, Early childhood caries, Small-Quantity, Lipid-Based Nutrient Supplements, Handwashing With Soap and Total Sanitation and Sanitation Marketing, PROCOMIDA, Community-Based Participatory Nutrition Promotion Program, Promote Children’s Growth and Development, Community-Based Growth Monitoring Including Nutritional Supplementation, Child Development Agents, Lady Health Worker program, ready-to-use supplementary foods, and Supporting Father Involvement, Positive Deviance/Hearth, JiVitA-3. CONCLUSION: From planning, conducting and reporting, it can be concluded that the intervention as an effort to prevent and control stunting had a significant effect between the intervention group and the treatment group and the control group which was only given normal treatment even without any treatment.

Optimising geographical accessibility to primary health care: a geospatial analysis of community health posts and community health workers in Niger

Background

Little is known about the contribution of community health posts and community health workers (CHWs) to geographical accessibility of primary healthcare (PHC) services at community level and strategies for optimising geographical accessibility to these services.

Methods

Using a complete georeferenced census of community health posts and CHWs in Niger and other high-resolution spatial datasets, we modelled travel times to community health posts and CHWs between 2000 and 2013, accounting for training, commodities and maximum population capacity. We estimated additional CHWs needed to optimise geographical accessibility of the population beyond the reach of the existing community health post network. We assessed the efficiency of geographical targeting of the existing community health post network compared with networks designed to optimise geographical targeting of the estimated population, under-5 deaths and Plasmodium falciparum malaria cases.

Results

The per cent of the population within 60-minute walking to the nearest community health post with a CHW increased from 0.0% to 17.5% between 2000 and 2013. An estimated 10.4 million people (58.5%) remained beyond a 60-minute catchment of community health posts. Optimal deployment of 7741 additional CHWs could increase geographical coverage from 41.5% to 82.9%. Geographical targeting of the existing community health post network was inefficient but optimised networks could improve efficiency by 32.3%–47.1%, depending on targeting metric.

Interpretations

We provide the first estimates of geographical accessibility to community health posts and CHWs at national scale in Niger, highlighting improvements between 2000 and 2013, geographies where gaps remained and approaches for optimising geographical accessibility to PHC services at community level.

A scoping review of research on policies to address child undernutrition in the Millennium Development Goals era

OBJECTIVE

The breadth of research on the impact of nutrition-specific policies to address child undernutrition is not well documented. This review maps the evidence base and identifies gaps on such policies.

DESIGN

We systematically searched Medline, Embase, PAIS Index for public policy, Scopus and Web of Science databases to identify eligible studies. Key study characteristics, including research design, type of policy, time span of policy before impact assessment, child age at outcome assessment and types of outcomes assessed, were abstracted in duplicate.

SETTING

Low-, middle- and high-income countries.

PARTICIPANTS

Studies were eligible for inclusion if they aimed to assess the impact of population-level nutrition-specific policies on undernutrition among children under 10 years of age.

RESULTS

Of the 5646 abstracts screened, eighty-three studies were included. A range of policies to address child undernutrition were evaluated; the majority were related to micronutrient fortification. Most studies were observational, reported on mandatory regional or sub-national polices, were conducted in high-income countries and evaluated policies within 1 year of implementation. A narrow set of health outcomes were evaluated, most commonly iodine deficiency disorders and neural tube defects.

CONCLUSIONS

Nutrition policies were commonly associated with improved child nutritional status and health. However, this evidence is primarily based on limited settings and on a limited number of outcomes. Further research is needed to assess the longer-term impact of a broader range of nutrition policies on child health, particularly in low- and middle-income countries.

Rapidly modifiable factors associated with full vaccination status among children in Niamey, Niger: A cross-sectional, random cluster household survey

Background and objectives

Vaccination status becomes more equitable when interventions are carried out to eliminate poverty or to improve levels in maternal education. Low-income countries need to identify interventions that would have a more immediate and equitable effect. The present study aimed to identify rapidly modifiable factors associated with full vaccination status among children in Niamey, Niger.

Methods

A cross-sectional, random cluster household survey was conducted in Niamey’s five health districts. Data on vaccination coverage and socioeconomic household characteristics were collected. Logistic regression analysis was conducted with data on 445 mothers and their children aged 12–23 months.

Results

Of 445 children, 38% were fully vaccinated. Mothers who were satisfied with their health worker’s attitude and had correct vaccination calendar knowledge (adjusted odds ratio [aOR] 5.32, 95% confidence interval [CI] 2.05–13.82) were more likely to have fully vaccinated children. Mothers who had completed secondary school (aOR 2.04, 95% CI 1.17–3.55) were also associated with having fully vaccinated children.

Conclusions

A higher rate of full vaccination among children could be achieved by relatively short-term modifiable factors. These modifiable factors are mothers’ satisfaction with health workers’ attitudes and knowledge of the vaccination calendar. Maternal satisfaction with health workers’ attitudes could be improved through better interpersonal communication between health workers and mothers. Specifically, mothers should be given specific information on time intervals between appointments. Strengthened communication interventions may be effective in improving both the acceptability of health services and low vaccination coverage.

Progress in reducing child mortality and stunting in India: an application of the Lives Saved Tool

The Lives Saved Tool (LiST) has been used to estimate the impact of scaling up intervention coverage on undernutrition and mortality. Evidence for the model is largely based on efficacy trials, raising concerns of applicability to large-scale contexts. We modelled the impact of scaling up health programs in India between 2006 and 2016 and compared estimates to observed changes. Demographics, intervention coverage and nutritional status were obtained from National Family and Health Survey 2005–6 (NFHS-3) for the base year and NHFS-4 2015–16 for the endline. We used the LiST to estimate the impact of changes in coverage of interventions over this decade on child mortality and undernutrition at national and subnational levels and calculated the gap between estimated and observed changes in 2016. At the national level, the LiST estimates are close to the actual values of mortality for children <1 year and <5 years in 2016 (at 41 vs 42.6 and 50 vs 56.4, respectively, per 1000 live births). National estimates for stunting, wasting and anaemia at are also close to the actual values of NFHS-4. At the state level, actual changes were higher than the changes from the LiST projections for both mortality and stunting. The predicted changes using the LiST ranged from 33% to 92% of the actual change. The LiST provided national projections close to, albeit slightly below, actual performance over a decade. Reasons for poorer performance of state-specific projections are unknown; further refinements to the LiST for subnational use would improve the usefulness of the tool.

Do nutrition and cash-based interventions and policies aimed at reducing stunting have an impact on economic development of low-and-middle-income countries? A systematic review

BACKGROUND

Childhood stunting is the most common manifestation of chronic malnutrition. A growing body of literature indicates that stunting can have negative repercussions on physical and cognitive development. There are increasing concerns that low- and middle-income countries (LMICs) are particularly susceptible to adverse consequences of stunting on economic development. The aim of this review is to synthesize current evidence on interventions and policies that have had success in reducing stunting and explore the impact of successes on economic indicators.

METHODS

This review adheres to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Articles were searched through MEDLINE via PubMed and Ovid, Cochrane Library, Web of Science and ProQuest. Only articles that addressed the effects of nutrition and cash-based interventions and/or policies on stunting and reported effects on childhood mortality and/or human capital indicators were included. Two reviewers independently abstracted data and assessed quality.

RESULTS

Seventeen studies from Africa (47%), South America (41%), and South Asia (12%) met the eligibility criteria: 8 cohort studies, 4 case studies, 4 Randomized Control Trials (RCTs) and 1 quasi-trial. Three types of interventions/policies were evaluated: multisectoral policies, nutritional supplementations and cash-based interventions (CCT). Overall, 76% of the included studies were successful in reducing stunting and 65% of interventions/policies reported successes on stunting reductions and economic successes. Five of the 11 successful studies reported on nutritional supplementation, 4 reported on multisectoral policies, and 2 reported on CCT interventions. Average Annual Rate of Reduction (AARR) was calculated to assess the impact of multisectoral policies on childhood mortality. AARR for under 5 mortality ranged from 5.2 to 6.2% and all countries aligned with the global target of 4.4% AARR. Quality assessment yielded positive results, with the biggest concerns being attrition bias for cohort studies, blinding for trials and generalizability of results for case studies.

CONCLUSIONS

Evidence suggests that investment in fighting chronic malnutrition through multisectoral policies, multi-year nutritional supplementation (protein or multiple micronutrient supplementation) and possibly CCTs can have a long-term impact on economic development of LMICs. More evidence is needed to inform practices in non-represented regions while prioritizing standardization of economic indicators in the literature.

Promoting progress in child survival across four African countries: the role of strong health governance and leadership in maternal, neonatal and child health

Despite numerous international and national efforts, only 12 countries in the World Health Organization's African Region met the Millennium Development Goal #4 (MDG#4) to reduce under-five mortality by two-thirds by 2015. Given the variability across sub-Saharan Africa, a four-country study was undertaken to examine barriers and facilitators of child survival prior to 2015. Liberia and Zambia were chosen to represent countries making substantial progress towards MDG#4, while Kenya and Zimbabwe represented countries making less progress. Our individual case studies suggested that strong health governance and leadership (HGL) was a significant driver of the greater success in Liberia and Zambia compared with Kenya and Zimbabwe. To elucidate specific components of national HGL that may have substantially influenced the pace of reductions in child mortality, we conducted a cross-country analysis of national policies and strategies pertaining to maternal, neonatal and child health (MNCH) and qualitative interviews with individuals working in MNCH in each of the four study countries. The three aspects of HGL identified in this study which most consistently contributed to the different progress towards MDG#4 among the four study countries were (1) establishing child survival as a top national priority backed by a comprehensive policy and strategy framework and sufficient human, financial and material resources; (2) bringing together donors, strategic partners, health and non-health stakeholders and beneficiaries to collaborate in strategic planning, decision-making, resource-allocation and coordination of services; and (3) maintaining accountability through a 'monitor-review-act' approach to improve MNCH. Although child mortality in sub-Saharan Africa remains high, this comparative study suggests key health leadership and governance factors that can facilitate reduction of child mortality and may prove useful in tackling current Sustainable Development Goals.

Are there decision support tools that might strengthen the health system for perinatal care in South African district hospitals? A review of the literature

Background

South Africa has a high burden of perinatal deaths in spite of the availability of evidence-based interventions. The majority of preventable perinatal deaths occur in district hospitals and are mainly related to the functioning of the health system. Particularly, leadership in district hospitals needs to be strengthened in order to decrease the burden of perinatal mortality. Decision-making is a key function of leaders, however leaders in district hospitals are not supported to make evidence-based decisions. The aim of this research was to identify health system decision support tools that can be applied at district hospital level to strengthen decision-making in the health system for perinatal care in South Africa.

Methods

A structured approach, the systematic quantitative literature review method, was conducted to find published articles that reported on decision support tools to strengthen decision-making in a health system for perinatal, maternal, neonatal and child health. Articles published in English between 2003 and 2017 were sought through the following search engines: Google Scholar, EBSCOhost and Science Direct. Furthermore, the electronic databases searched were: Academic Search Complete, Health Source – Consumer Edition, Health Source – Nursing/Academic Edition and MEDLINE.

Results

The search yielded 6366 articles of which 43 met the inclusion criteria for review. Four decision support tools identified in the articles that met the inclusion criteria were the Lives Saved Tool, Maternal and Neonatal Directed Assessment of Technology model, OneHealth Tool, and Discrete Event Simulation. The analysis reflected that none of the identified decision support tools could be adopted at district hospital level to strengthen decision-making in the health system for perinatal care in South Africa.

Conclusion

There is a need to either adapt an existing decision support tool or to develop a tool that will support decision-making at district hospital level towards strengthening the health system for perinatal care in South Africa.

A framework for medical power in two case studies of health policymaking in India and Niger

Medical professionals influence health policymaking but the power they exercise is not well understood in low- and middle-income countries. We explore medical power in national health policymaking for child survival in Niger (late 1990s-2012) and emergency medicine specialisation in India (early 1990s-2015). Both case studies used document review, in-depth interviews and non-participant observation; combined analysis traced policy processes and established theoretical categories around power to build a conceptual framework of medical power in health policymaking. Medical doctors, mainly specialists, utilised their power to shape policy differently in each case. In Niger, a small, connected group of paediatricians pursued a policy of task-shifting after a powerful non-medical actor, the country's president, shifted the debate by enacting broad health systems improvements. In India, a more fragmented group of specialists prioritised tertiary-level healthcare policies likely to benefit only a small subset of the population. Compared to high-income settings, medical power in these cases was channelled and expressed with greater variability in the profession's ability to organise and influence policymaking. Taken together, both cases provide evidence that a concentration of medical power in health policymaking can result in the medicalisation of public health issues.

Age distribution, trends, and forecasts of under-5 mortality in 31 sub-Saharan African countries: A modeling study

BACKGROUND

Despite the sharp decline in global under-5 deaths since 1990, uneven progress has been achieved across and within countries. In sub-Saharan Africa (SSA), the Millennium Development Goals (MDGs) for child mortality were met only by a few countries. Valid concerns exist as to whether the region would meet new Sustainable Development Goals (SDGs) for under-5 mortality. We therefore examine further sources of variation by assessing age patterns, trends, and forecasts of mortality rates.

METHODS AND FINDINGS

Data came from 106 nationally representative Demographic and Health Surveys (DHSs) with full birth histories from 31 SSA countries from 1990 to 2017 (a total of 524 country-years of data). We assessed the distribution of age at death through the following new demographic analyses. First, we used a direct method and full birth histories to estimate under-5 mortality rates (U5MRs) on a monthly basis. Second, we smoothed raw estimates of death rates by age and time by using a two-dimensional P-Spline approach. Third, a variant of the Lee-Carter (LC) model, designed for populations with limited data, was used to fit and forecast age profiles of mortality. We used mortality estimates from the United Nations Inter-agency Group for Child Mortality Estimation (UN IGME) to adjust, validate, and minimize the risk of bias in survival, truncation, and recall in mortality estimation. Our mortality model revealed substantive declines of death rates at every age in most countries but with notable differences in the age patterns over time. U5MRs declined from 3.3% (annual rate of reduction [ARR] 0.1%) in Lesotho to 76.4% (ARR 5.2%) in Malawi, and the pace of decline was faster on average (ARR 3.2%) than that observed for infant (IMRs) (ARR 2.7%) and neonatal (NMRs) (ARR 2.0%) mortality rates. We predict that 5 countries (Kenya, Rwanda, Senegal, Tanzania, and Uganda) are on track to achieve the under-5 sustainable development target by 2030 (25 deaths per 1,000 live births), but only Rwanda and Tanzania would meet both the neonatal (12 deaths per 1,000 live births) and under-5 targets simultaneously. Our predicted NMRs and U5MRs were in line with those estimated by the UN IGME by 2030 and 2050 (they overlapped in 27/31 countries for NMRs and 22 for U5MRs) and by the Institute for Health Metrics and Evaluation (IHME) by 2030 (26/31 and 23/31, respectively). This study has a number of limitations, including poor data quality issues that reflected bias in the report of births and deaths, preventing reliable estimates and predictions from a few countries.

CONCLUSIONS

To our knowledge, this study is the first to combine full birth histories and mortality estimates from external reliable sources to model age patterns of under-5 mortality across time in SSA. We demonstrate that countries with a rapid pace of mortality reduction (ARR ≥ 3.2%) across ages would be more likely to achieve the SDG mortality targets. However, the lower pace of neonatal mortality reduction would prevent most countries from achieving those targets: 2 countries would reach them by 2030, 13 between 2030 and 2050, and 13 after 2050.

Improving community health worker performance through supportive supervision: a randomised controlled implementation trial in Pakistan

AIM

To assess the effect of enhanced supportive supervision of lady health workers (LHWs) by lady health supervisors on integrated community case management of childhood pneumonia and diarrhoea.

METHODS

A total of thirty-four supervisors were randomly assigned to intervention and comparison arms. The intervention included enhanced training of supervisors on supervisory skills and written feedback to LHWs by supervisors. The performance of both cadres was assessed three times. Household surveys judged caregiver practices.

RESULTS

Intervention arm LHWs performed better than those in the comparison arm in assessing dehydration (92% [n = 25] vs 64% [n = 25]) and in classifying diarrhoea correctly (68% [n = 25] vs 40% [n = 25]). The two arms differed little in correct disease classification for pneumonia (44% [n = 25] vs 40% [n = 25]). Supervisory performance of intervention arm supervisors was better than that in the comparison arm in correcting the workers' clinical examination skills (64% [n = 25] vs 40% [n = 25]) and more frequent feedback. In the household survey, only 18% (n = 2182) intervention and 23% (n = 2197) comparison arm caregivers considered LHWs capable of providing diarrhoea and pneumonia care. Commodities for integrated community case management were not regularly available to workers.

CONCLUSION

Supportive supervision can improve community case management performance. Support through refresher training, logistics and commodities is essential.

Association between availability of children's book and the literacy-numeracy skills of children aged 36 to 59 months: secondary analysis of the UNICEF Multiple-Indicator Cluster Surveys covering 35 countries

Background

Stimulating home environments that have children's books, pictures and play toys facilitate caregiver-child interactions and enhance children's development. Although this has been demonstrated in small-scale intervention studies, it is important to document whether book ownership is beneficial at large scale in low and middle-income settings.

Methods

We conducted a secondary analysis using data from the multiple-indicator cluster survey, covering 100 012 children aged 36-59 months, from 35 countries. The outcome was children being on-track for a literacy-numeracy index (LNI) constructed from three questions assessing children's ability to identify/name at least 10 letters of the alphabet, read at least four simple popular words and know the names and symbols of all numbers from 1-10. The main exposure was availability of children's book to the child within household. Analysis considered the survey design, assessed and ranked risk ratios of being on track, adjusting for potential confounders such as child's age (in months), maternal education, household wealth index quintile and area of residence (rural/urban). Ecological analysis was performed using meta-regression after grouping countries by World Bank income groups (low- to high-income).

Results

Only half (51.8%) of children from all the countries analysed have at least one children's book at home and less than one-third (29.9%; 95% confidence interval (CI) = 23.5%, 36.3%) are on track for literacy-numeracy. After adjusting for confounders, the likelihood of being on track in literacy-numeracy almost doubled if at least one book was available at home compared to when there was none: RR = 1.89 (95% CI = 1.75, 2.03). There was an economic gradient showing that the likelihood of children being on track for LNI decreased with the country's income group: adjusted-RR ranged from 1.65 in upper middle income to 2.23 in LIC (F-test P-value <0.0001). Only three high-income countries were included, and children's books were universally available resulting in wide confidence intervals for the effect.

Conclusions

These findings are policy-relevant, as they corroborate the results from small scale experiments. Making children's book available to children is a cheap and feasible intervention that could change home dynamics to improve the future economic fortunes of children especially in the poorest countries.

Factors influencing rapid progress in child health in post-conflict Liberia: a mixed methods country case study on progress in child survival, 2000-2013

OBJECTIVES

Only 12 countries in the WHO's African region met Millennium Development Goal 4 (MDG 4) to reduce under-five mortality by two-thirds by 2015. Given the variability across the African region, a four-country mixed methods study was undertaken to examine barriers and facilitators of child survival prior to 2015. Liberia was selected for an in-depth case study due to its success in reducing under-five mortality by 73% and thus successfully meeting MDG 4. Liberia's success was particularly notable given the civil war that ended in 2003. We examined some factors contributing to their reductions in under-five mortality.

DESIGN

A case study mixed methods approach drawing on data from quantitative indicators, national documents and qualitative interviews was used to describe factors that enabled Liberia to rebuild their maternal, neonatal and child health (MNCH) programmes and reduce under-five mortality following the country's civil war.

SETTING

The interviews were conducted in Monrovia (Montserrado County) and the areas in and around Gbarnga, Liberia (Bong County, North Central region).

PARTICIPANTS

Key informant interviews were conducted with Ministry of Health officials, donor organisations, community-based organisations involved in MNCH and healthcare workers. Focus group discussions were conducted with women who have experience accessing MNCH services.

RESULTS

Three prominent factors contributed to the reduction in under-five mortality: national prioritisation of MNCH after the civil war; implementation of integrated packages of services that expanded access to key interventions and promoted intersectoral collaborations; and use of outreach campaigns, community health workers and trained traditional midwives to expand access to care and improve referrals.

CONCLUSIONS

Although Liberia experiences continued challenges related to limited resources, Liberia's effective strategies and rapid progress may provide insights for reducing under-five mortality in other post-conflict settings.

Safety of a heat-stable rotavirus vaccine among children in Niger: Data from a phase 3, randomized, double-blind, placebo-controlled trial

BACKGROUND

Rotavirus remains a major cause of diarrhea among children under 5 years of age. The efficacy of RotaSIIL, a pentavalent rotavirus vaccine, was shown in an event-driven trial in Niger. We describe the two-year safety follow-up of this trial.

METHODS

Follow-up of safety outcomes began upon administration of the first dose of RotaSIIL or placebo. Adverse events were followed until 28 days after the third dose, and serious adverse events were followed until 2 years of age. Suspected cases of intussusception were evaluated at first point of contact and then referred to hospital for surgical evaluation. Causes of death were obtained by chart review and verbal autopsy. Passive surveillance was carried out in health centers. Community health workers carried out active surveillance in villages. Between-group differences were evaluated using the chi-squared test and Fisher's exact test.

RESULTS

A total of 4092 children were randomized, and 4086 received at least one dose of RotaSIIL or placebo, constituting the intention-to-treat population, who accrued a total of 7385 child-years of follow-up time. At two years of follow-up, 58 (2.8%) participants who received RotaSIIL and 49 (2.4%) participants who received placebo had died (p = 0.38). Most deaths were due to infectious causes common to the study area. One participant had confirmed intussusception, 542 days after receiving the third dose of RotaSIIL. A total of 395 (19.3%) participants receiving RotaSIIL and 419 (20.5%) participants receiving placebo experienced any serious adverse event (p = 0.36). Most serious adverse events were hospitalizations due to infection (malaria, lower respiratory tract infection and gastroenteritis) or marasmus. Overall, 1474 (72.1%) participants receiving RotaSIIL and 1456 (71.1%) participants receiving placebo had at least one adverse event (p = 0.49) in the follow-up period.

CONCLUSIONS

At two years of follow-up, RotaSIIL was found to be safe.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT02145000.

Measles Vaccination Supports Millennium Development Goal 4: Increasing Coverage and Increasing Child Survival in Northern Ghana, 1996-2012

Background

Measles vaccine (MV) administered as the last vaccine after the third dose of diphtheria-tetanus-pertussis (DTP) may be associated with better child survival unrelated to prevention of measles infection. Other studies have shown that MV administered after DTP was more beneficial and was associated with lower mortality compared with DTP administered after MV or DTP administered simultaneously with MV. We compared the difference in mortality between measles vaccinated after DTP3 and measles-unvaccinated children in Navrongo, Ghana.

Methods

This was a follow-up study involving annual cohort of children aged 9–23 months from 1996 to 2012. We assessed survival in relation to the measles vaccination status within the first 12 months from interview date and until 5 years of age using Cox proportional hazards models.

Results

In all, 38,333 children were included in the study. The proportion of children vaccinated with MV-after-DTP3 increased from 45% in 1996 to 95% in 2012. The adjusted hazard ratio (HR) for measles unvaccinated compared with MV-after-DTP3 vaccinated children was 1.38 (1.15–1.66) in the first 12 months after assessment of vaccination status and 1.22 (1.05–1.41) with follow-up to 5 years of age. The national immunization days campaigns with oral polio vaccine or MV might have reduced the effect of being MV-after-DTP3 vaccinated vs MV-unvaccinated. For 12 months of follow-up, the HR before a campaign for MV-unvaccinated children was 1.63 (1.23–2.17) compared to those who received MV-after-DTP3. After the campaign, the HR reduced to 1.23 (0.97–1.54). Stratifying the analysis by sex, measles-unvaccinated boys had a HR of 1.69 (1.33–2.61) compared to measles-unvaccinated girls who had a HR 1.06 (0.79–1.40) during 1-year follow-up. In 1989, only 7% of children in the area had received MV-after-DTP3; the increase in MV-after-DTP3 coverage from 1989 to 2012 may have lowered mortality rate among children aged 9 months to 3 years by 24%.

Conclusion

Though an observational study, our findings suggest that measles vaccination, administered in the recommended sequence, is associated with improved child survival and may have contributed importantly to the mortality decline toward the achievement of Millennium Development Goal 4.

National Immunization Campaigns with Oral Polio Vaccine Reduce All-Cause Mortality: A Natural Experiment within Seven Randomized Trials

BACKGROUND

A recent WHO review concluded that live BCG and measles vaccine (MV) may have beneficial non-specific effects (NSEs) reducing mortality from non-targeted diseases. NSEs of oral polio vaccine (OPV) were not examined. If OPV vaccination campaigns reduce the mortality rate, it would suggest beneficial NSEs.

SETTING

Between 2002 and 2014, Guinea-Bissau had 15 general OPV campaigns and other campaigns with OPV plus vitamin A supplementation (VAS), VAS-only, MV, and H1N1 vaccine. In this period, we conducted seven randomized controlled trials (RCTs) with mortality as main outcome.

METHODS

Within these RCTs, we assessed whether the mortality rate was lower after-campaign than before-campaign. We used Cox models with age as underlying time and further adjusted for low birth-weight, season and time trend in mortality. We calculated the adjusted mortality rate ratio (MRR) for after-campaign vs before-campaign.

RESULTS

The mortality rate was lower after OPV-only campaigns than before, the MRR being 0.81 (95% CI = 0.68-0.95). With each additional dose of campaign-OPV the mortality rate declined further (MRR = 0.87 (95% CI: 0.79-0.96) per dose) (test for trend, p = 0.005). No other type of campaign had similar beneficial effects. Depending on initial age and with follow-up to 3 years of age, the number needed to treat with campaign-OPV-only to save one life was between 68 and 230 children.

CONCLUSION

Bissau had no case of polio infection so the results suggest that campaign-OPV has beneficial NSEs. Discontinuation of OPV-campaigns in low-income countries may affect general child mortality levels negatively.

Child health and nutrition in Peru within an antipoverty political agenda: a Countdown to 2015 country case study

BACKGROUND

Peru is an upper-middle-income country with wide social and regional disparities. In recent years, sustained multisectoral antipoverty programmes involving governments, political parties, and civil society have included explicit health and nutrition goals and spending increased sharply. We did a country case study with the aim of documenting Peru's progress in reproductive, maternal, neonatal, and child health from 2000-13, and explored the potential determinants.

METHODS

We examined the outcomes of health interventions coverage, under-5 mortality, neonatal mortality, and prevalence of under-5 stunting. We obtained data from interviews with key informants, a literature review of published and unpublished data, national censuses, and governmental reports. We obtained information on social determinants of health, including economic growth, poverty, unmet basic needs, urbanisation, women's education, water supply, fertility rates, and child nutrition from the annual national households surveys and the Peruvian Demographic and Health Surveys. We obtained national mortality data from the Interagency Group for Child Mortality Estimation, and calculated subnational rates from 11 surveys. Analyses were stratified by region, wealth quintiles, and urban or rural residence. We calculated coverage indicators for the years 2000-13, and we used the Lives Saved Tool (LiST) to estimate the effect of changes in intervention coverage and in nutritional status on mortality.

FINDINGS

From 2000 to 2013, under-5 mortality fell by 58% from 39·8 deaths per 1000 livebirths to 16·7. LiST, which was used to predict the decline in mortality arising from changes in fertility rates, water and sanitation, undernutrition, and coverage of indicators of reproductive, maternal, neonatal, and child health predicted that the under-5 mortality rate would fall from 39·8 to 28·4 per 1000 livebirths, accounting for 49·2% of the reported reduction. Neonatal mortality fell by 51% from 16·2 deaths per 1000 livebirths to 8·0. Stunting prevalence remained stable at around 30% until 2007, decreasing to 17·5% by 2013, and the composite coverage index for essential health interventions increased from 75·1% to 82·6%, with faster increases among the poor, in rural areas, and in the Andean region. Socioeconomic, urban-rural, and regional inequalities in coverage, mortality, and stunting were substantially reduced. The proportion of the population living below the poverty line reduced from 47·8% to 23·9%, women with fewer than 4 years of schooling reduced from 11·5% to 6·9%, urbanisation increased from 68·1% to 75·6%, and the total fertility rate decreased from 3·0 children per woman to 2·4. We interviewed 175 key informants and they raised the following issues: economic growth, improvement of social determinants, civil society empowerment and advocacy, out-of-health and within-health-sector changes, and sustained implementation of evidence-based, pro-poor reproductive, maternal, neonatal, and child health interventions.

INTERPRETATION

Peru has made substantial progress in reducing neonatal and under-5 mortality, and child stunting. This country is a good example of how a combination of political will, economic growth, broad societal participation, strategies focused on poor people, and increased spending in health and related sectors can achieve significant progress in reproductive, maternal, neonatal, and child health. The remaining challenges include continuing to address inequalities in wealth distribution, poverty, and access to basic services, especially in the Amazon and Andean rural areas.

FUNDING

Bill & Melinda Gates Foundation.

Improving access to child health services at the community level in Zambia: a country case study on progress in child survival, 2000-2013

Reductions in under-five mortality in Africa have not been sufficient to meet the Millennium Development Goal #4 (MDG#4) of reducing under-five mortality by two-thirds by 2015. Nevertheless, 12 African countries have met MDG#4. We undertook a four country study to examine barriers and facilitators of child survival prior to 2015, seeking to better understand variability in success across countries. The current analysis presents indicator, national document, and qualitative data from key informants and community women describing the factors that have enabled Zambia to successfully reduce under-five mortality over the last 15 years and achieve MDG#4. Results identified a Zambian national commitment to ongoing reform of national health strategic plans and efforts to ensure universal access to effective maternal, neonatal and child health (MNCH) interventions, creating an environment that has promoted child health. Zambia has also focused on bringing health services as close to the family as possible through specific community health strategies. This includes actively involving community health workers to provide health education, basic MNCH services, and linking women to health facilities, while supplementing community and health facility work with twice-yearly Child Health Weeks. External partners have contributed greatly to Zambia’s MNCH services, and their relationships with the government are generally positive. As government funding increases to sustain MNCH services, national health strategies/plans are being used to specify how partners can fill gaps in resources. Zambia’s continuing MNCH challenges include basic transportation, access-to-care, workforce shortages, and financing limitations. We highlight policies, programs, and implementation that facilitated reductions in under-five mortality in Zambia. These findings may inform how other countries in the African Region can increase progress in child survival in the post-MDG period.

How is the Lives Saved Tool (LiST) used in the global health community? Results of a mixed-methods LiST user study

BACKGROUND

The Lives Saved Tool (LiST) is a computer-based model that estimates the impact of scaling up key interventions to improve maternal, newborn and child health. Initially developed to inform the Lancet Child Survival Series of 2003, the functionality and scope of LiST have been expanded greatly over the past 10 years. This study sought to "take stock" of how LiST is now being used and for what purposes.

METHODS

We conducted a quantitative survey of LiST users, qualitative interviews with a smaller sample of LiST users and members of the LiST team at Johns Hopkins University, and a literature review of studies involving LiST analyses.

RESULTS

LiST is being used by donors, international organizations, governments, NGOs and academic institutions to assist program evaluation, inform strategic planning and evidenced-based decision-making, and advocate for high-impact interventions. Some organizations have integrated LiST into internal workflows and built in-house capacity for using LiST, while other organizations rely on the LiST team for support and to outsource analyses. In addition to being a popular stand-alone software, LiST is used as a calculation engine for other applications.

CONCLUSIONS

The Lives Saved Tool has been reported to be a useful model in maternal, newborn, and child health. With continued commitment, LiST should remain as a part of the international health toolkit used to assess maternal, newborn and child health programs.

Evidence-based approaches to childhood stunting in low and middle income countries: a systematic review

OBJECTIVE

We systematically evaluated health and nutrition programmes to identify context-specific interventional packages that might help to prioritise the implementation of programmes for reducing stunting in low and middle income countries (LMICs).

METHODS

Electronic databases were used to systematically review the literature published between 1980 and 2015. Additional articles were identified from the reference lists and grey literature. Programmes were identified in which nutrition-specific and nutrition-sensitive interventions had been implemented for children under 5 years of age in LMICs. The primary outcome was a change in stunting prevalence, estimated as the average annual rate of reduction (AARR). A realist approach was applied to identify mechanisms underpinning programme success in particular contexts and settings.

FINDINGS

Fourteen programmes, which demonstrated reductions in stunting, were identified from 19 LMICs. The AARR varied from 0.6 to 8.4. The interventions most commonly implemented were nutrition education and counselling, growth monitoring and promotion, immunisation, water, sanitation and hygiene, and social safety nets. A programme was considered to have effectively reduced stunting when AARR≥3%. Successful interventions were characterised by a combination of political commitment, multi-sectoral collaboration, community engagement, community-based service delivery platform, and wider programme coverage and compliance. Even for similar interventions the outcome could be compromised if the context differed.

INTERPRETATION

For all settings, a combination of interventions was associated with success when they included health and nutrition outcomes and social safety nets. An effective programme for stunting reduction embraced country-level commitment together with community engagement and programme context, reflecting the complex nature of exposures of relevance.

PROSPERO REGISTRATION NUMBER

CRD42016043772.

The introduction of new policies and strategies to reduce inequities and improve child health in Kenya: A country case study on progress in child survival, 2000-2013

As of 2015, only 12 countries in the World Health Organization’s AFRO region had met Millennium Development Goal #4 (MDG#4) to reduce under-five mortality by two-thirds by 2015. Given the variability across the African region, a four-country study was undertaken to examine barriers and facilitators of child survival prior to 2015. Kenya was one of the countries selected for an in-depth case study due to its insufficient progress in reducing under-five mortality, with only a 28% reduction between 1990 and 2013. This paper presents indicators, national documents, and qualitative data describing the factors that have both facilitated and hindered Kenya’s efforts in reducing child mortality. Key barriers identified in the data were widespread socioeconomic and geographic inequities in access and utilization of maternal, neonatal, and child health (MNCH) care. To reduce these inequities, Kenya implemented three major policies/strategies during the study period: removal of user fees, the Kenya Essential Package for Health, and the Community Health Strategy. This paper uses qualitative data and a policy review to explore the early impacts of these efforts. The removal of user fees has been unevenly implemented as patients still face hidden expenses. The Kenya Essential Package for Health has enabled construction and/or expansion of healthcare facilities in many areas, but facilities struggle to provide Emergency Obstetric and Neonatal Care (EmONC), neonatal care, and many essential medicines and commodities. The Community Health Strategy appears to have had the most impact, improving referrals from the community and provision of immunizations, malaria prevention, and Prevention of Mother-to-Child Transmission of HIV. However, the Community Health Strategy is limited by resources and thus also unevenly implemented in many areas. Although insufficient progress was made pre-2015, with additional resources and further scale-up of new policies and strategies Kenya can make further progress in child survival.

Impact of a critical health workforce shortage on child health in Zimbabwe: a country case study on progress in child survival, 2000-2013

Despite notable progress reducing global under-five mortality rates, insufficient progress in most sub-Saharan African nations has prevented the achievement of Millennium Development Goal four (MDG#4) to reduce under-five mortality by two-thirds between 1990 and 2015. Country-level assessments of factors underlying why some African countries have not been able to achieve MDG#4 have not been published. Zimbabwe was included in a four-country study examining barriers and facilitators of under-five survival between 2000 and 2013 due to its comparatively slow progress towards MDG#4. A review of national health policy and strategy documents and analysis of qualitative data identified Zimbabwe's critical shortage of health workers and diminished opportunities for professional training and education as an overarching challenge. Moreover, this insufficient health workforce severely limited the availability, quality, and utilization of life-saving health services for pregnant women and children during the study period. The impact of these challenges was most evident in Zimbabwe's persistently high neonatal mortality rate, and was likely compounded by policy gaps failing to authorize midwives to deliver life-saving interventions and to ensure health staff make home post-natal care visits soon after birth. Similarly, the lack of a national policy authorizing lower-level cadres of health workers to provide community-based treatment of pneumonia contributed to low coverage of this effective intervention and high child mortality. Zimbabwe has recently begun to address these challenges through comprehensive policies and strategies targeting improved recruitment and retention of experienced senior providers and by shifting responsibility of basic maternal, neonatal and child health services to lower-level cadres and community health workers that require less training, are geographically broadly distributed, and are more cost-effective, however the impact of these interventions could not be assessed within the scope and timeframe of the current study.

Mortality among twins and singletons in sub-Saharan Africa between 1995 and 2014: a pooled analysis of data from 90 Demographic and Health Surveys in 30 countries

BACKGROUND

Sub-Saharan Africa has the world's highest under-5 and neonatal mortality rates as well as the highest naturally occurring twin rates. Twin pregnancies carry high risk for children and mothers. Under-5 mortality has declined in sub-Saharan Africa over the last decades. It is unknown whether twins have shared in this reduction.

METHODS

We pooled data from 90 Demographic and Health Surveys for 30 sub-Saharan Africa countries on births reported between 1995 and 2014. We used information on 1 685 110 singleton and 56 597 twin livebirths to compute trends in mortality rates for singletons and twins. We examined whether the twin-singleton rate ratio can be attributed to biological, socioeconomic, care-related factors, or birth size, and estimated the mortality burden among sub-Saharan African twins.

FINDINGS

Under-5 mortality among twins has declined from 327·7 (95% CI 312·0-343·5) per 1000 livebirths in 1995-2001 to 213·0 (196·7-229·2) in 2009-14. This decline of 35·0% was much less steep than the 50·6% reduction among singletons (from 128·6 [95% CI 126·4-130·8] per 1000 livebirths in 1995-2001 to 63·5 [61·6-65·3] in 2009-14). Twins account for an increasing share of under-5 deaths in sub-Saharan Africa: currently 10·7% of under-5 mortality and 15·1% of neonatal mortality. We estimated that about 315 000 twins (uncertainty interval 289 000-343 000) die in sub-Saharan African each year. Excess twin mortality cannot be explained by common risk factors for under-5 mortality, including birthweight. The difference with singletons was especially stark for neonatal mortality (rate ratio 5·0, 95% CI 4·5-5·6). 51·7% of women pregnant with twins reported receiving medical assistance at birth.

INTERPRETATION

The fate of twins in sub-Saharan Africa is lagging behind that of singletons. An alarming one-fifth of twins in the region dies before age 5 years, three times the mortality rate among singletons. Twins account for a substantial and growing share of under-5 and neonatal mortality, but they are largely neglected in the literature. Coordinated action is required to improve the situation of this extremely vulnerable group.

FUNDING

None.

Knowledge and power in policy-making for child survival in Niger

Calls to enhance the use of scientific evidence in international health and development policy have increased in recent years; however, analytic frameworks for understanding evidence use focus narrowly on scientific research and were created using data and observations nearly exclusively from Western countries. We examine processes of health policy development in a case study of Niger, a low-income West African country that adopted integrated community case management of childhood illness (iCCM) beginning in 2007, resulting in measurable declines in child mortality. Data collection included in-depth interviews with policy actors in Niger (N = 32), document review (N = 103) and direct observation of policy forums (N = 3). Data analysis used process tracing methodology and applied an Aristotelian definition of "knowledge" as 1) episteme (facts), 2) techne (skills) and 3) phronesis (practical wisdom), while also using a critical perspective to understand issues of power. We found sharp differentials in policy-makers' possession and use of codified forms of knowledge (episteme), with Nigerien policy officers' access highly mediated by actors at international agencies. Government policy-makers possessed skills and capacities (techne) to negotiate with donors and deliberate and weigh conflicting considerations; however they lacked capacity and resources to formally evaluate and document programs and thus reliably draw lessons from them. Practical wisdom (phronesis) emerged as key to the iCCM policy enterprise, particularly among Nigerien government actors, who used logical and ethical arguments to make decisions later found to be critical to iCCM's success. While codified knowledge confers power on members of policy discussions who can access it, this represents only one form of knowledge used in the policy process and perhaps not the most important. Future research on evidence-based policy should use broader definitions of evidence or knowledge, examine on how power conditions the use of knowledge, and examine challenges specific to low-resource policy environments.

Global, regional, and national causes of under-5 mortality in 2000-15: an updated systematic analysis with implications for the Sustainable Development Goals

BACKGROUND

Despite remarkable progress in the improvement of child survival between 1990 and 2015, the Millennium Development Goal (MDG) 4 target of a two-thirds reduction of under-5 mortality rate (U5MR) was not achieved globally. In this paper, we updated our annual estimates of child mortality by cause to 2000-15 to reflect on progress toward the MDG 4 and consider implications for the Sustainable Development Goals (SDG) target for child survival.

METHODS

We increased the estimation input data for causes of deaths by 43% among neonates and 23% among 1-59-month-olds, respectively. We used adequate vital registration (VR) data where available, and modelled cause-specific mortality fractions applying multinomial logistic regressions using adequate VR for low U5MR countries and verbal autopsy data for high U5MR countries. We updated the estimation to use Plasmodium falciparum parasite rate in place of malaria index in the modelling of malaria deaths; to use adjusted empirical estimates instead of modelled estimates for China; and to consider the effects of pneumococcal conjugate vaccine and rotavirus vaccine in the estimation.

FINDINGS

In 2015, among the 5·9 million under-5 deaths, 2·7 million occurred in the neonatal period. The leading under-5 causes were preterm birth complications (1·055 million [95% uncertainty range (UR) 0·935-1·179]), pneumonia (0·921 million [0·812 -1·117]), and intrapartum-related events (0·691 million [0·598 -0·778]). In the two MDG regions with the most under-5 deaths, the leading cause was pneumonia in sub-Saharan Africa and preterm birth complications in southern Asia. Reductions in mortality rates for pneumonia, diarrhoea, neonatal intrapartum-related events, malaria, and measles were responsible for 61% of the total reduction of 35 per 1000 livebirths in U5MR in 2000-15. Stratified by U5MR, pneumonia was the leading cause in countries with very high U5MR. Preterm birth complications and pneumonia were both important in high, medium high, and medium child mortality countries; whereas congenital abnormalities was the most important cause in countries with low and very low U5MR.

INTERPRETATION

In the SDG era, countries are advised to prioritise child survival policy and programmes based on their child cause-of-death composition. Continued and enhanced efforts to scale up proven life-saving interventions are needed to achieve the SDG child survival target.

FUNDING

Bill & Melinda Gates Foundation, WHO.

Reproductive, maternal, newborn, and child health: key messages from Disease Control Priorities 3rd Edition

As part of Disease Control Priorities 3rd Edition, the World Bank will publish a volume on Reproductive, Maternal, Newborn, and Child Health that identifies essential cost-effective health interventions that can be scaled up to reduce maternal, newborn, and child deaths, and stillbirths. This Review summarises the volume's key findings and estimates the effect and cost of expanded implementation of these interventions. Recognising that a continuum of care from the adolescent girl, woman, or mother to child is needed, the volume includes details of preventive and therapeutic health interventions in integrated packages: Maternal and Newborn Health and Child Health (along with folic acid supplementation, a key reproductive health intervention). Scaling up all interventions in these packages from coverage in 2015 to hypothetically immediately achieve 90% coverage would avert 149 000 maternal deaths, 849 000 stillbirths, 1 498 000 neonatal deaths, and 1 515 000 additional child deaths. In alternative calculations that consider only the effects of reducing the number of pregnancies by provision of contraceptive services as part of a Reproductive Health package, meeting 90% of the unmet need for contraception would reduce global births by almost 28 million and consequently avert deaths that could have occurred at 2015 rates of fertility and mortality. Thus, 67 000 maternal deaths, 440 000 neonatal deaths, 473 000 child deaths, and 564 000 stillbirths could be averted from avoided pregnancies. Particularly effective interventions in the Maternal and Newborn Health and Child Health packages would be management of labour and delivery, care of preterm births, and treatment of serious infectious diseases and acute malnutrition. Nearly all of these essential interventions can be delivered by health workers in the community or in primary health centres, which can increase population access to needed services. The annual incremental cost of immediately scaling up these essential interventions would be US$6·2 billion in low-income countries, $12·4 billion in lower-middle-income countries, and $8·0 billion in upper-middle-income countries. With the additional funding, greater focus on high-effect integrated interventions and innovations in service delivery, such as task shifting to other groups of health workers and supply and demand incentives, can help rectify major gaps in accessibility and quality of care. In recent decades, reduction of avoidable maternal and child deaths has been a global priority. With continued priority and expansion of essential reproductive, maternal, newborn, and child health interventions to high coverage, equity, and quality, as well as interventions to address underlying problems such as women's low status in society and violence against women, these deaths and substantial morbidity can be largely eliminated in another generation.

Global, regional, national, and selected subnational levels of stillbirths, neonatal, infant, and under-5 mortality, 1980-2015: a systematic analysis for the Global Burden of Disease Study 2015

BACKGROUND

Established in 2000, Millennium Development Goal 4 (MDG4) catalysed extraordinary political, financial, and social commitments to reduce under-5 mortality by two-thirds between 1990 and 2015. At the country level, the pace of progress in improving child survival has varied markedly, highlighting a crucial need to further examine potential drivers of accelerated or slowed decreases in child mortality. The Global Burden of Disease 2015 Study (GBD 2015) provides an analytical framework to comprehensively assess these trends for under-5 mortality, age-specific and cause-specific mortality among children under 5 years, and stillbirths by geography over time.

METHODS

Drawing from analytical approaches developed and refined in previous iterations of the GBD study, we generated updated estimates of child mortality by age group (neonatal, post-neonatal, ages 1-4 years, and under 5) for 195 countries and territories and selected subnational geographies, from 1980-2015. We also estimated numbers and rates of stillbirths for these geographies and years. Gaussian process regression with data source adjustments for sampling and non-sampling bias was applied to synthesise input data for under-5 mortality for each geography. Age-specific mortality estimates were generated through a two-stage age-sex splitting process, and stillbirth estimates were produced with a mixed-effects model, which accounted for variable stillbirth definitions and data source-specific biases. For GBD 2015, we did a series of novel analyses to systematically quantify the drivers of trends in child mortality across geographies. First, we assessed observed and expected levels and annualised rates of decrease for under-5 mortality and stillbirths as they related to the Soci-demographic Index (SDI). Second, we examined the ratio of recorded and expected levels of child mortality, on the basis of SDI, across geographies, as well as differences in recorded and expected annualised rates of change for under-5 mortality. Third, we analysed levels and cause compositions of under-5 mortality, across time and geographies, as they related to rising SDI. Finally, we decomposed the changes in under-5 mortality to changes in SDI at the global level, as well as changes in leading causes of under-5 deaths for countries and territories. We documented each step of the GBD 2015 child mortality estimation process, as well as data sources, in accordance with the Guidelines for Accurate and Transparent Health Estimates Reporting (GATHER).

FINDINGS

Globally, 5·8 million (95% uncertainty interval [UI] 5·7-6·0) children younger than 5 years died in 2015, representing a 52·0% (95% UI 50·7-53·3) decrease in the number of under-5 deaths since 1990. Neonatal deaths and stillbirths fell at a slower pace since 1990, decreasing by 42·4% (41·3-43·6) to 2·6 million (2·6-2·7) neonatal deaths and 47·0% (35·1-57·0) to 2·1 million (1·8-2·5) stillbirths in 2015. Between 1990 and 2015, global under-5 mortality decreased at an annualised rate of decrease of 3·0% (2·6-3·3), falling short of the 4·4% annualised rate of decrease required to achieve MDG4. During this time, 58 countries met or exceeded the pace of progress required to meet MDG4. Between 2000, the year MDG4 was formally enacted, and 2015, 28 additional countries that did not achieve the 4·4% rate of decrease from 1990 met the MDG4 pace of decrease. However, absolute levels of under-5 mortality remained high in many countries, with 11 countries still recording rates exceeding 100 per 1000 livebirths in 2015. Marked decreases in under-5 deaths due to a number of communicable diseases, including lower respiratory infections, diarrhoeal diseases, measles, and malaria, accounted for much of the progress in lowering overall under-5 mortality in low-income countries. Compared with gains achieved for infectious diseases and nutritional deficiencies, the persisting toll of neonatal conditions and congenital anomalies on child survival became evident, especially in low-income and low-middle-income countries. We found sizeable heterogeneities in comparing observed and expected rates of under-5 mortality, as well as differences in observed and expected rates of change for under-5 mortality. At the global level, we recorded a divergence in observed and expected levels of under-5 mortality starting in 2000, with the observed trend falling much faster than what was expected based on SDI through 2015. Between 2000 and 2015, the world recorded 10·3 million fewer under-5 deaths than expected on the basis of improving SDI alone.

INTERPRETATION

Gains in child survival have been large, widespread, and in many places in the world, faster than what was anticipated based on improving levels of development. Yet some countries, particularly in sub-Saharan Africa, still had high rates of under-5 mortality in 2015. Unless these countries are able to accelerate reductions in child deaths at an extraordinary pace, their achievement of proposed SDG targets is unlikely. Improving the evidence base on drivers that might hasten the pace of progress for child survival, ranging from cost-effective intervention packages to innovative financing mechanisms, is vital to charting the pathways for ultimately ending preventable child deaths by 2030.

FUNDING

Bill & Melinda Gates Foundation.

Remaining missed opportunities of child survival in Peru: modelling mortality impact of universal and equitable coverage of proven interventions

BACKGROUND

Peru has made great improvements in reducing stunting and child mortality in the past decade, and has reached the Millennium Development Goals 1 and 4. The remaining challenges or missed opportunities for child survival needs to be identified and quantified, in order to guide the next steps to further improve child survival in Peru.

METHODS

We used the Lives Saved Tool (LiST) to project the mortality impact of proven interventions reaching every women and child in need, and the mortality impact of eliminating inequalities in coverage distribution between wealth quintiles and urban-rural residence.

RESULTS

Our analyses quantified the remaining missed opportunities in Peru, where prioritizing scale-up of facility-based case management for all small and sick babies will be most effective in mortality reduction, compared to other evidenced-based interventions that prevent maternal and child deaths. Eliminating coverage disparities between the poorest quintiles and the richest will reduce under-five and neonatal mortality by 22.0 and 40.6 %, while eliminating coverage disparities between those living in rural and urban areas will reduce under-five and neonatal mortality by 29.3 and 45.2 %. This projected neonatal mortality reduction achieved by eliminating coverage disparities is almost comparable to that already achieved by Peru over the past decade.

CONCLUSIONS

Although Peru has made great strides in improving child survival, further improvement in child health, especially in newborn health can be achieved if there is universal and equitable coverage of proven, quality health facility-based interventions. The magnitude of reduction in mortality will be similar to what has been achieved in the past decade. Strengthening health system to identify, understand, and direct resources to the poor and rural areas will ensure that Peru achieve the Sustainable Development Goals by 2030.

Creating the next steps to care: Maternal heath, improvisation, and Fulani women in Niamey, Niger

On paper, Niger's maternal healthcare system is extensively outlined by policies which assure access to certain services and create hierarchical referral chains. In practice it remains intensely improvisational: actors in the system must frequently make up the next steps to giving and receiving care, often outside the existing policies and procedures. Although population health in Niger has improved since the recently enacted gratuité des soins policy (which guarantees free access to certain material and child health services), care on the ground is still dictated by difficult circumstances and scarce resources. Health workers often lack the required medications and supplies; nevertheless, they must find ways to deliver services. Patients seeking maternal health services are frequently dissatisfied with the care they receive and so move forward of their own volition, by negotiating with health workers or by looking for services elsewhere. This research builds on recent scholarly work on improvisation, and asks us to further look at the ways that improvisation can be informed by the identity of the actors. Examining case studies of women from the Fulani ethnic group illustrates how particular cultural differences can inform improvisation. Analysing improvisation can also have policy implications; identifying typical points of departure from the official maternal health care system can reveal points where Niger can bolster its commitment to a universally high quality of care.

Countdown to 2015 country case studies: what have we learned about processes and progress towards MDGs 4 and 5?

Background

Countdown to 2015 was a multi-institution consortium tracking progress towards Millennium Development Goals (MDGs) 4 and 5. Case studies to explore factors contributing to progress (or lack of progress) in reproductive, maternal, newborn and child health (RMNCH) were undertaken in: Afghanistan, Bangladesh, China, Ethiopia, Kenya, Malawi, Niger, Pakistan, Peru, and Tanzania. This paper aims to identify cross-cutting themes on how and why these countries achieved or did not achieve MDG progress.

Methods

Applying a standard evaluation framework, analyses of impact, coverage and equity were undertaken, including a mixed methods analysis of how these were influenced by national context and coverage determinants (including health systems, policies and financing).

Results

The majority (7/10) of case study countries met MDG-4 with over two-thirds reduction in child mortality, but none met MDG-5a for 75 % reduction in maternal mortality, although six countries achieved >75 % of this target. None achieved MDG-5b regarding reproductive health. Rates of reduction in neonatal mortality were half or less that for post-neonatal child mortality. Coverage increased most for interventions administered at lower levels of the health system (e.g., immunisation, insecticide treated nets), and these experienced substantial political and financial support. These interventions were associated with ~30–40 % of child lives saved in 2012 compared to 2000, in Ethiopia, Malawi, Peru and Tanzania. Intrapartum care for mothers and newborns -- which require higher-level health workers, more infrastructure, and increased community engagement -- showed variable increases in coverage, and persistent equity gaps. Countries have explored different approaches to address these problems, including shifting interventions to the community setting and tasks to lower-level health workers.

Conclusions

These Countdown case studies underline the importance of consistent national investment and global attention for achieving improvements in RMNCH. Interventions with major global investments achieved higher levels of coverage, reduced equity gaps and improvements in associated health outcomes. Given many competing priorities for the Sustainable Development Goals era, it is essential to maintain attention to the unfinished RMNCH agenda, particularly health systems improvements for maternal and neonatal outcomes where progress has been slower, and to invest in data collection for monitoring progress and for rigorous analyses of how progress is achieved in different contexts.

Electronic supplementary material

The online version of this article (doi:10.1186/s12889-016-3401-6) contains supplementary material, which is available to authorized users.

Revaccination with Live Attenuated Vaccines Confer Additional Beneficial Nonspecific Effects on Overall Survival: A Review

BACKGROUND

Live vaccines against measles (MV), tuberculosis (BCG), polio (OPV) and smallpox reduce mortality more than explained by target-disease prevention. The beneficial nonspecific effects (NSEs) of MV are strongest when MV is given in presence of maternal antibodies. We therefore hypothesised that revaccination in presence of prior immunity enhances beneficial NSEs.

METHODS

Literature search for studies of revaccination and mortality.

FINDINGS

In two randomised trials (RCTs), two doses versus one dose of MV reduced all-cause mortality by 63% (95% CI: 23-83%) from 9 to 18months of age. In a quasi-experimental study two doses before and after 9months compared with one dose of MV after 9months of age reduced mortality by 59% (25-81%). BCG-revaccination significantly enhanced BCG's effect against overall child mortality in two RCTs. In a natural experiment study of OPV campaigns over a 13-year-period in Guinea-Bissau, each additional dose of OPV was associated with a 13% (4-21%) reduction in mortality rate. The beneficial NSEs of smallpox vaccination for survival increased significantly with the number of smallpox vaccination scars.

INTERPRETATION

Revaccination with live vaccines led to substantial reductions in overall mortality. These findings challenge current understanding of vaccines and may explain the beneficial effects of campaigns with live vaccines.

Women's Education and Health Inequalities in Under-Five Mortality in Selected Sub-Saharan African Countries, 1990-2015

Background

The aim of the study was to analyse trends in the relationship between mother’s educational level and mortality of children under the year of five in Sub-Saharan Africa, from 1990 to 2015.

Data and Methods

Data used in this study came from different waves of Demographic and Health Surveys (DHS) of Sub-Saharan countries. Logistic regression and Buis’s decomposition method were used to explore the effect of mother’s educational level on the mortality of children under five years.

Results

Although the results of our study in the selected countries show that under-five mortality rates of children born to mothers without formal education are higher than the mortality rates of children of educated mothers, it appears that differences in mortality were reduced over the past two decades. In selected countries for our study, we noticed a significant decline in mortality among children of non-educated mothers compared to the decrease in mortality rates among children of educated mothers during the period of 1990–2010. The results show that the decline in mortality of children under five years was much higher among the children born to mothers who have never received formal education—112 points drop in Malawi, over 80 in Zambia and Zimbabwe, 65 points in Burkina Faso, 56 in Congo, 43 in Namibia, 27 in Guinea, Cameroon, and 22 to 15 in Niger. However, we noted a variation in results among the countries selected for the study—in Burkina Faso (OR = 0.7), in Cameroon (OR = 0.8), in Guinea (OR = 0.8) and Niger (OR = 0.8). It is normally observed that children of mothers with 0–6 years of education are about 20% more likely to survive until their fifth year compared to children of mothers who have not been to school. Conversely, the results did not reveal significant differences between the under-five deaths of children born to non-educated mothers and children of low-level educated mothers in Congo, Malawi and Namibia.

Conclusion

The decline in under-five mortality rates, during last two decades, can be partly due to the government policies on women’s education. It is evident that women’s educational level has resulted in increased maternal awareness about infant health and hygiene, thereby bringing about a decline in the under-five mortality rates. This reduction is due to improved supply of health care programmes and health policies in reducing economic inequalities and increasing access to health care.

Social determinants of child mortality in Niger: Results from the 2012 National Verbal and Social Autopsy Study

Background

Understanding the determinants of preventable deaths of children under the age of five is important for accelerated annual declines – even as countries achieve the UN’s Millennium Development Goals and the target date of 2015 has been reached. While research has documented the extent and nature of the overall rapid decline in child mortality in Niger, there is less clear evidence to provide insight into the contributors to such deaths. This issue is the central focus of this paper.

Methods

We analyzed a nationally representative cross–sectional sample of 620 child deaths from the 2012 Niger Verbal Autopsy/Social Autopsy (VASA) Survey. We conducted a descriptive analysis of the data on preventive and curative care, guided by the coverage of proven indicators along the continuum of well child care and illness recognition and care–seeking for child illnesses encompassed by the BASICS/CDC Pathway to Survival model.

Results

Six hundred twenty deaths of children (1–59 months of age) were confirmed from the VASA survey. The majority of these children lived in households with precarious socio–economic conditions. Among the 414 children whose fatal illnesses began at age 0–23 months, just 24.4% were appropriately fed. About 24% of children aged 12–59 months were fully immunized. Of 601 children tracked through the Pathway to Survival, 62.4% could reach the first health care provider after about 67 minutes travel time. Of the 306 children who left the first health care provider alive, 161 (52.6%) were not referred for further care nor received any home care recommendations, and just 19% were referred to a second provider. About 113 of the caregivers reported cost (35%), distance (35%) and lack of transport (30%) as constraints to care–seeking at a health facility.

Conclusion

Despite Niger’s recent major achievements in reducing child mortality, the following determinants are crucial to continue building on the gains the country has made: improved socio–economic state of the poor in the country, investment in women’s education, adoption of the a law to prevent marriage of young girls before 18 years of age, and implementation of health programs that encourage breastfeeding and complementary feeding, immunization, illness recognition, prompt and appropriate care–seeking, and improved referral rates.

Verbal/Social Autopsy in Niger 2012-2013: A new tool for a better understanding of the neonatal and child mortality situation

Niger, one of the poorest countries in the world, recently used for the first time the integrated verbal and social autopsy (VASA) tool to assess the biological causes and social and health system determinants of neonatal and child deaths. These notes summarize the Nigerien experience in the use of this new tool, the steps taken for high level engagement of the Niger government and stakeholders for the wide dissemination of the study results and their use to support policy development and maternal, neonatal and child health programming in the country. The experience in Niger reflects lessons learned by other developing countries in strengthening the use of data for evidence–based decision making, and highlights the need for the global health community to provide continued support to country data initiatives, including the collection, analysis, interpretation and utilization of high quality data for the development of targeted, highly effective interventions. In Niger, this is supporting the country’s progress toward achieving Millennium Development Goal 4. A follow–up VASA study is being planned and the tool is being integrated into the National Health Management Information System. VASA studies have now been completed or are under way in additional sub–Saharan African countries, in each through the same collaborative process used in Niger to bring together health policy makers, program planners and development partners.

Assessment of Malawi's success in child mortality reduction through the lens of the Catalytic Initiative Integrated Health Systems Strengthening programme: Retrospective evaluation

Background

Malawi is estimated to have achieved its Millennium Development Goal (MDG) 4 target. This paper explores factors influencing progress in child survival in Malawi including coverage of interventions and the role of key national policies.

Methods

We performed a retrospective evaluation of the Catalytic Initiative (CI) programme of support (2007–2013). We developed estimates of child mortality using four population household surveys undertaken between 2000 and 2010. We recalculated coverage indicators for high impact child health interventions and documented child health programmes and policies. The Lives Saved Tool (LiST) was used to estimate child lives saved in 2013.

Results

The mortality rate in children under 5 years decreased rapidly in the 10 CI districts from 219 deaths per 1000 live births (95% confidence interval (CI) 189 to 249) in the period 1991–1995 to 119 deaths (95% CI 105 to 132) in the period 2006–2010. Coverage for all indicators except vitamin A supplementation increased in the 10 CI districts across the time period 2000 to 2013. The LiST analysis estimates that there were 10 800 child deaths averted in the 10 CI districts in 2013, primarily attributable to the introduction of the pneumococcal vaccine (24%) and increased household coverage of insecticide–treated bednets (19%). These improvements have taken place within a context of investment in child health policies and scale up of integrated community case management of childhood illnesses.

Conclusions

Malawi provides a strong example for countries in sub–Saharan Africa of how high impact child health interventions implemented within a decentralised health system with an established community–based delivery platform, can lead to significant reductions in child mortality.

Verbal/social autopsy study helps explain the lack of decrease in neonatal mortality in Niger, 2007-2010

BACKGROUND

This study was one of a set of verbal/social autopsy (VASA) investigations undertaken by the WHO/UNICEF-supported Child Health Epidemiology Reference Group to estimate the causes and determinants of neonatal and child deaths in high priority countries. The study objective was to help explain the lack of decrease in neonatal mortality in Niger from 2007 to 2010, a period during which child mortality was decreasing.

METHODS

VASA interviews were conducted of a random sample of 453 neonatal deaths identified by the 2010 Niger National Mortality Survey (NNMS). Causes of death were determined by expert algorithm analysis, and the prevalence of household, community and health system determinants were examined along the continuum of maternal and newborn care, the Pathway to Survival for newborn illnesses, and an extended pathway for maternal complications. The social autopsy findings were compared to available data for survivors from the same cohort collected by the NNMS and the 2012 Niger Demographic and Health Survey.

FINDINGS

Severe neonatal infection and birth asphyxia were the leading causes of early neonatal death in the community and facilities. Death in the community after delayed careseeking for severe infection predominated during the late neonatal period. The levels of nearly all demographic, antenatal and delivery care factors were in the direction of risk for the VASA study decedents. They more often resided rurally (P < 0.001) and their mothers were less educated (P = 0.03) and gave birth when younger (P = 0.03) than survivors' mothers. Their mothers also were less likely to receive quality antenatal care (P < 0.001), skilled attendance at birth (P = 0.03) or to deliver in an institution (P < 0.001). Nearly half suffered an obstetric complication, with more maternal infection (17.9% vs 0.2%), antepartum hemorrhage (12.5% vs 0.5%) and eclampsia/preeclampsia (9.5% vs 1.6%) than for all births in Niger. Their mothers also were unlikely to seek health care for their own complications (37% to 42%) as well as for the newborn's illness (30.6%).

CONCLUSIONS

Niger should scale up its recently implemented package of high-impact interventions to additional integrated health facilities and expand the package to provide antenatal care and management of labor and delivery, with support to reach a higher level facility when required. Community interventions are needed to improve illness recognition and careseeking for severe neonatal infection.

Geographical Inequalities and Social and Environmental Risk Factors for Under-Five Mortality in Ghana in 2000 and 2010: Bayesian Spatial Analysis of Census Data

BACKGROUND

Under-five mortality is declining in Ghana and many other countries. Very few studies have measured under-five mortality-and its social and environmental risk factors-at fine spatial resolutions, which is relevant for policy purposes. Our aim was to estimate under-five mortality and its social and environmental risk factors at the district level in Ghana.

METHODS AND FINDINGS

We used 10% random samples of Ghana's 2000 and 2010 National Population and Housing Censuses. We applied indirect demographic methods and a Bayesian spatial model to the information on total number of children ever born and children surviving to estimate under-five mortality (probability of dying by 5 y of age, 5q0) for each of Ghana's 110 districts. We also used the census data to estimate the distributions of households or persons in each district in terms of fuel used for cooking, sanitation facility, drinking water source, and parental education. Median district 5q0 declined from 99 deaths per 1,000 live births in 2000 to 70 in 2010. The decline ranged from <5% in some northern districts, where 5q0 had been higher in 2000, to >40% in southern districts, where it had been lower in 2000, exacerbating existing inequalities. Primary education increased in men and women, and more households had access to improved water and sanitation and cleaner cooking fuels. Higher use of liquefied petroleum gas for cooking was associated with lower 5q0 in multivariate analysis.

CONCLUSIONS

Under-five mortality has declined in all of Ghana's districts, but the cross-district inequality in mortality has increased. There is a need for additional data, including on healthcare, and additional environmental and socioeconomic measurements, to understand the reasons for the variations in mortality levels and trends.

Trends and risk factors for childhood diarrhea in sub-Saharan countries (1990-2013): assessing the neighborhood inequalities

BACKGROUND

Diarrheal diseases are a major cause of child mortality and one of the main causes of medical consultation for children in sub-Saharan countries. This paper attempts to determine the risk factors and neighborhood inequalities of diarrheal morbidity among under-5 children in selected countries in sub-Saharan Africa over the period 1990-2013.

DESIGN

Data used come from the Demographic and Health Survey (DHS) waves conducted in Burkina Faso (1992-93, 1998-99, 2003, and 2010), Mali (1995, 2001, 2016, and 2012), Nigeria (1990, 1999, 2003, 2008, and 2013), and Niger (1992, 1998, 2006, and 2012). Bivariate analysis was performed to assess the association between the dependent variable and each of the independent variables. Multilevel logistic regression modelling was used to determine the fixed and random effects of the risk factors associated with diarrheal morbidity.

RESULTS

The findings showed that the proportion of diarrheal morbidity among under-5 children varied considerably across the cohorts of birth from 10 to 35%. There were large variations in the proportion of diarrheal morbidity across countries. The proportions of diarrheal morbidity were higher in Niger compared with Burkina Faso, Mali, and Nigeria. The risk factors of diarrheal morbidity varied from one country to another, but the main factors included the child's age, size of the child at birth, the quality of the main floor material, mother's education and her occupation, type of toilet, and place of residence. The analysis shows an increasing trend of diarrheal inequalities according to DHS rounds. In Burkina Faso, the value of the intraclass correlation coefficient (ICC) was 0.04 for 1993 DHS and 0.09 in 2010 DHS; in Mali, the ICC increased from 0.04 in 1995 to 0.16 in 2012; in Nigeria, the ICC increased from 0.13 in 1990 to 0.19 in 2013; and in Niger, the ICC increased from 0.07 in 1992 to 0.11 in 2012.

CONCLUSIONS

This suggests the need to fight against diarrheal diseases on both the local and community levels across villages.

Neonatal pneumonia in sub-Saharan Africa

Neonatal pneumonia is a devastating condition. Most deaths in sub-Saharan Africa can be attributed to preventable diseases, including pneumonia, diarrhoea and malaria, which together killed an estimated 2.2 million children under the age of 5 years in 2012, accounting for a third of all under-five deaths in this region. Some countries are making progress in reducing mortality through community-based health schemes; however, most countries in this region are far from achieving the World Health Organization Sustainable Development Goals for reducing childhood morbidity and mortality. The microorganisms causing neonatal pneumonia are well known. Both bacteria and viruses are commonly responsible, while fungal organisms occur in the context of nosocomial disease, and parasites occur in HIV-infected children. The common bacterial pathogens are group B streptococci (and other streptococcal species) and Gram-negative organisms, most notably Escherichia coli and Klebsiella spp. The viruses that predominate are the common respiratory pathogens, namely respiratory syncytial virus, human rhinovirus, and influenza virus. Viral disease is often nosocomial and transmitted to infected neonates in the neonatal intensive care unit or other neonatal facilities by infected parents and staff. Neonatal pneumonia often presents with non-specific respiratory distress in newborns. In the premature infant it is often indistinguishable from surfactant deficiency-associated respiratory distress syndrome. Therefore, diagnostic testing that is cheap and reliable is urgently sought in this region. All neonates with pneumonia must receive broad-spectrum antibiotic cover. This usually entails the combination of penicillin and an aminoglycoside. A lack of appropriate drugs and neonatal intensive care unit facilities are hampering progress in managing neonatal pneumonia.

Maternal anemia and risk of adverse birth and health outcomes in low- and middle-income countries: systematic review and meta-analysis

BACKGROUND

Anemia is a leading cause of maternal deaths and adverse pregnancy outcomes in developing countries.

OBJECTIVES

We conducted a systematic review and meta-analysis to estimate the pooled prevalence of anemia, the association between maternal anemia and pregnancy outcomes, and the population-attributable fraction (PAF) of these outcomes that are due to anemia in low- and middle-income countries.

DESIGN

PubMed, EMBASE, CINAHL, and the British Nursing Index were searched from inception to May 2015 to identify cohort studies of the association between maternal anemia and pregnancy outcomes. The anemic group was defined as having hemoglobin concentrations <10 or <11 g/dL or hematocrit values <33% or <34% depending on the study. A metaregression and stratified analysis were performed to assess the effects of study and participant characteristics on adverse pregnancy risk. The pooled prevalence of anemia in pregnant women by region and country-income category was calculated with the use of a random-effects meta-analysis.

RESULTS

Of 8182 articles reviewed, 29 studies were included in the systematic review, and 26 studies were included in the meta-analysis. Overall, 42.7% (95% CI: 37.0%, 48.4%) of women experienced anemia during pregnancy in low- and middle-income countries. There were significantly higher risks of low birth weight (RR: 1.31; 95% CI: 1.13, 1.51), preterm birth (RR: 1.63; 95% CI: 1.33, 2.01), perinatal mortality (RR: 1.51; 95% CI: 1.30, 1.76), and neonatal mortality (RR: 2.72; 95% CI: 1.19, 6.25) in pregnant women with anemia. South Asian, African, and low-income countries had a higher pooled anemia prevalence than did other Asian and upper-middle-income countries. Overall, in low- and middle-income countries, 12% of low birth weight, 19% of preterm births, and 18% of perinatal mortality were attributable to maternal anemia. The proportion of adverse pregnancy outcomes attributable to anemia was higher in low-income countries and in the South Asian region.

CONCLUSION

Maternal anemia remains a significant health problem in low- and middle-income countries.

Malawi and Millennium Development Goal 4: a Countdown to 2015 country case study

BACKGROUND

Several years in advance of the 2015 endpoint for the Millennium Development Goals (MDGs), Malawi was already thought to be one of the few countries in sub-Saharan Africa likely to meet the MDG 4 target of reducing under-5 mortality by two-thirds between 1990 and 2015. Countdown to 2015 therefore selected the Malawi National Statistical Office to lead an in-depth country case study, aimed mainly at explaining the country's success in improving child survival.

METHODS

We estimated child and neonatal mortality for the years 2000-14 using five district-representative household surveys. The study included recalculation of coverage indicators for that period, and used the Lives Saved Tool (LiST) to attribute the child lives saved in the years from 2000 to 2013 to various interventions. We documented the adoption and implementation of policies and programmes affecting the health of women and children, and developed estimates of financing.

FINDINGS

The estimated mortality rate in children younger than 5 years declined substantially in the study period, from 247 deaths (90% CI 234-262) per 1000 livebirths in 1990 to 71 deaths (58-83) in 2013, with an annual rate of decline of 5·4%. The most rapid mortality decline occurred in the 1-59 months age group; neonatal mortality declined more slowly (from 50 to 23 deaths per 1000 livebirths), representing an annual rate of decline of 3·3%. Nearly half of the coverage indicators have increased by more than 20 percentage points between 2000 and 2014. Results from the LiST analysis show that about 280,000 children's lives were saved between 2000 and 2013, attributable to interventions including treatment for diarrhoea, pneumonia, and malaria (23%), insecticide-treated bednets (20%), vaccines (17%), reductions in wasting (11%) and stunting (9%), facility birth care (7%), and prevention and treatment of HIV (7%). The amount of funding allocated to the health sector has increased substantially, particularly to child health and HIV and from external sources, but remains below internationally agreed targets. Key policies to address the major causes of child mortality and deliver high-impact interventions at scale throughout Malawi began in the late 1990s and intensified in the latter half of the 2000s and into the 2010s, backed by health-sector-wide policies to improve women's and children's health.

INTERPRETATION

This case study confirmed that Malawi had achieved MDG 4 for child survival by 2013. Our findings suggest that this was achieved mainly through the scale-up of interventions that are effective against the major causes of child deaths (malaria, pneumonia, and diarrhoea), programmes to reduce child undernutrition and mother-to-child transmission of HIV, and some improvements in the quality of care provided around birth. The Government of Malawi was among the first in sub-Saharan Africa to adopt evidence-based policies and implement programmes at scale to prevent unnecessary child deaths. Much remains to be done, building on this success and extending it to higher proportions of the population and targeting continued high neonatal mortality rates.

FUNDING

Bill & Melinda Gates Foundation, WHO, The World Bank, Government of Australia, Government of Canada, Government of Norway, Government of Sweden, Government of the UK, and UNICEF.