Hitting the mark
Can under five mortality be cut by two thirds?

In 2000, the nations of the world pledged to achieve the Millennium Development Goals. These ambitious targets included a commitment over the period 1990 to 2015 to:

• eradicate extreme poverty and hunger (50% reduction in the numbers of people living on less than US$1/day)
• reduce under five mortality rate by two thirds
• reduce maternal mortality rates by 75%.

As the World Bank estimates and projections for progress show (see Figure 1 below), the goals for reduction in child mortality will be achieved in only a few countries.

Figure 1: click to enlarge

Indeed, in most sub-Saharan African (SSA) countries child mortality has increased, largely because of the effects of HIV infection and economic decline. In south Asia, the impressive declines in infant and child mortality over the past three decades have begun to falter.

Newborn care is a priority

In India the infant mortality rate has remained almost static since the mid-1990s. Perhaps the most important reason for this is that further declines in infant mortality will depend on reductions in newborn mortality, because two thirds of infant deaths now occur in the first month after birth. Most women in south Asia give birth at home. Indeed in all developing countries (DCs), World Bank analysis shows that more than 90% of women living in the poorest group for family income will deliver their baby at home.

This presents an enormous challenge for policy-makers: how to bring about immediate behaviour changes which will reduce the risks to mothers and their newborn infants after a home delivery, whilst, in the medium term, making institutional delivery more accessible, both physically and economically. World Health Organisation (WHO) estimates that about four million infants die each year in the newborn period, with an equal number lost as stillbirths.

The main causes of newborn death (see Figure 2 below) are infection, birth asphyxia and a low birth weight (LBW less than 2500 grammes) either because of growth retardation in the womb, or because of prematurity.

Figure 2: Direct causes of newborn deaths

Infections include neonatal tetanus, newborn septicaemia resulting from an unhygienic delivery or poor cord care, and pneumonia. Malaria exerts a more indirect effect in pregnancy by increasing the risk of low birth weight and stillbirth. Asphyxia most commonly results from a delayed or obstructed labour, or from a failure of a birth attendant to adequately resuscitate or assist breathing after birth. Prematurity, rather than growth retardation, is probably the biggest risk to a newborn infant. Being born one or two months before the due date hugely increases the risk of newborn death in communities where special nursing care for LBW babies is not available.

The problem in tackling newborn deaths is not that we don’t know what to do. There are many potential low cost and evidence-based interventions available to reduce newborn mortality:

The challenge is how to implement these interventions on a large scale and reach out to families most at risk, particularly where home delivery is the norm and access to obstetric and medical services is difficult. Dr Abhay Bang and colleagues developed a community-based newborn care programme in a poor rural district in India, and showed a large reduction in newborn mortality. The programme included traditional birth attendant training and the use of trained village women to diagnose and treat newborn infection with injectable antibiotics. Bang’s study shows the potential of low-cost newborn care, but faces problems with scaling up and sustainability. Their village workers were paid and therefore represent a new group of health worker; and many governments are reluctant to sanction the large scale use of injectable antibiotics by non-health professionals.

The Warmi programme in Bolivia made use of women’s groups to explore and tackle reproductive health problems at community level. Though a small study, the Warmi project appeared to reduce perinatal (period from the 20th week of gestation to 28 days after birth) mortality. This idea is now being tested in a much larger trial in Makwanpur, Nepal conducted by the Institute of Child Health in collaboration with Professor Dharma Manandhar and colleagues from MIRA, Nepal. The findings from this trial are expected in 2004.

Newborn care is an integral part of safer motherhood. The development of safer motherhood programmes has been slow worldwide, but may receive new impetus from the launch of a new Global Partnership for Safer Motherhood and Newborn Care in 2003. The partnership is led by the World Bank, WHO, UNICEF and the Saving Newborn Lives Initiative, along with a large network of international agencies, bilateral donors and Non-Governmental Organisations (NGOs). Let us hope that these combined forces will move the reduction of maternal and newborn mortality up the political agenda.

HIV and breastfeeding

The problem of mother-to-child transmission (MTCT) of HIV through breastfeeding creates a seemingly impossible dilemma for policy-makers. On the one hand exclusive breast-feeding confers nutritional benefit, protects infants against many common infections and reduces infant mortality. On the other hand, for HIV-positive mothers, replacement feeding (for more educated and affluent mothers) or early weaning will reduce the risk of HIV transmission. In this issue of insights health, Coulter and Ogundele discuss the options available to mothers and the problems facing health planners. Bunn describes a study in Zambia which examined the actual feeding practices of mothers who knew they were HIV positive. Many HIV-positive mothers did not persist with exclusive breast-feeding nor did they dilute cow’s milk with water as recommended when they decided to use modified cow’s milk as a breast milk substitute. These findings strongly support the need for better community-based lactation and feeding counselling in communities where HIV is prevalent.

Malaria and fits

In SSA both malaria and convulsions are common clinical problems amongst under fives. The incidence of epilepsy is also higher than in other parts of the world. Newton examines the links between malaria and epilepsy in Kilifi, Kenya. He finds that children with a history of cerebral malaria have a significantly greater chance of developing epilepsy. The reasons for the link are not clear, but it raises the possibility that more effective control of malaria in children will also lead to a reduction in epilepsy, a common and disabling condition.

Adolescent obesity

In DCs which have undergone fairly rapid economic and demographic transition, obesity is beginning to emerge as a new form of malnutrition. In China, Hesketh studied the nutritional status of adolescents in both urban and rural areas. Whilst the problems of anaemia and low weight persist in both areas, the risk of obesity has dramatically increased in the urban setting (ten times greater than in rural areas), particularly among boys and those children with a sedentary lifestyle. The next decade presents a new challenge for health and nutrition promotion if an obesity epidemic is to be stopped.

Vaccines and female mortality

In 1992 a new high-titre measles vaccine (HTMV), given at an earlier age than the standard vaccine, was withdrawn after studies in Senegal and Haiti showed higher child mortality among females. Aaby re-analysed the West African studies and suggests that a change in the sequence of vaccinations, rather than the HTMV itself, may have been the cause of increased female mortality. The higher female mortality rate was only observed in those who received an additional diphtheria-tetanus-pertussis or an inactivated polio vaccination administered after the HTMV was given. There is much we still do not know about the effects of childhood vaccinations in different populations and these findings highlight the importance of long term epidemiological surveillance in immunisation research.

Integrated Management of Childhood Illness (IMCI)

The IMCI programme introduced by WHO and UNICEF in the mid-1990s has been one of the most important new policy developments in international child health. Improving the skills of health workers in diagnosing common childhood illnesses has been the most successful part of the programme, but Hill points out the care-seeking barriers in traditional communities where families use a local illness classification system rather than one based on biomedical criteria. This means that IMCI programmes must carefully adapt to local language and culture if families are to bring sick children for treatment more promptly.

Overall, the gains in international child health over the past 20 years are seriously threatened by AIDS, economic decline, a lack of political commitment and new challenges from emerging infections, low birth weight and obesity. Policy-makers must keep child health at the top of the international health agenda. Supply-side issues such as availability of drugs and vaccines, skills of health workers, algorithms for the diagnosis of sick children and referral systems pose many challenges. But demand-side issues such as how to improve community awareness of newborn and child health problems and how to promote rapid care-seeking behaviour for sick infants and children remains the biggest challenge in the poorest countries.

Anthony Costello
International Perinatal Care Unit
Institute of Child Health
30 Guilford Street
London WC1N 3JH
UK

A.Costello@ich.ucl.ac.uk

Anthony Costello is Professor of International Child Health (ICH) at the Institute of Child Health and Great Ormond Street Hospital, London. He is Director of the International Perinatal Care Unit at ICH. He is also founder of Women and Children First, an NGO set up to promote the health of mothers and infants.

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