Download National Department of Health: Child Mortality in South Africa

National Department of Health
Child Mortality in South Africa
Presentation to the Select
Committee on Social Services
05 March 2013
Child Mortality Rates: definitions
Neonatal Mortality Rate (NNMR):
Number of deaths during the first 28 days of life per
1,000 live births
Infant Mortality Rate (IMR):
Number of deaths during the first year of life per
1,000 live births
Under-five mortality rates:
Number of deaths during the first five years of life
per 1,000 live births
2
Child Mortality in South Africa
• Child mortality is a global concern as reflected in the MDGs
adopted by the United Nations in 2000 (that all countries must
reduce by 2/3 the number of children who die before the age of
five, and this must be achieved by 2015)
• Rates remain unacceptably high for Sub-Saharan Africa a whole
• Mortality rates in Sub-Saharan Africa spiralled out of control in the
1990s due to rapidly escalating HIV and AIDS epidemic
• In South Africa, the rate started to decrease when we started
scaling up programmes especially our HIV programmes – this is
reflect in data reported by international bodies like the UNAIDS,
UNICEF and local research organisation like the MRC (as indicated
in the following table)
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Child Mortality in South Africa contd.
• The issue of child mortality was identified along
ago, even the UN has taken this up as part of
Millennium Development Goals (MDGs) 4 (2000)
as well as the AU as CARMMA (Campaign on
Accelerated Reduction of Maternal and Child
Mortality in Africa (2010)
• In South Africa our approach could not be based
on anectodal evidence or emotion by either
affected parents, health professionals or
communities at large – we needed empirical
evidence and scientific findings and solutions
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Ministerial Committees
• For these reasons three Ministerial
Committees were appointed:
– Confidential Enquiries into Maternal Mortality
(1996)
– National Committee on Perinatal Mortality (2007)
– National Committee on Child Mortality (2007)
• These committees report triennially on their
findings outlining the commonest causes of
mortality and make recommendations
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Child Mortality Rates, 2009-2011
Indicator
Under-5
Mortality Rate
(U5MR)
Infant Mortality
Rate (IMR)
Neonatal
Mortality Rate
(<28 days)
2009
56 per 1 000 live
births
40 per 1 000 live
births
14 per 1 000 live
births
2010
53 per 1 000 live
births
37 per 1 000 live
births
13 per 1 000 live
births
2011
42 per 1 000 live
births
30 per 1 000 live
births
14 per 1 000 live
births
Target 2014
50 per 1 000 live
births
(10% reduction)
of 2009 data)
36 per 1 000 live
births
(10% reduction)
of 2009 data)
12 per 1 000 live
births
(10% reduction)
of 2009 data)
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When do children die?
• 30% of deaths occur in the newborn
period
• 40% of deaths occur in children between
one month and one year of age
• 30% of deaths occur in children 1 – 5
years
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Why do children die?
• The majority of child deaths result from the following
5 conditions:
–
–
–
–
–
HIV infection
Newborn conditions – prematurity, asphyxia and infection
Pneumonia
Diarrhoea
Tuberculosis
• Malnutrition (predominantly mild and moderate) is an
important contributor in many deaths
• As can be seen these causes are mostly related to
socio-economic conditions
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Department of Health’s Responses
• NSDA: Strategic Output 2: Reduce maternal
and child mortality rates
• Maternal, Newborn, Child and Women’s
Health and Nutrition Strategic Plan, 2012 –
2016 launched in May 2012
– Outlines package of priority services to be
delivered to all women and children
– Key strategies for improved services and outcomes
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DOH Responses contd
• Campaign for the Accelerated Reduction in
Maternal and Child Mortality in Africa
(CARMMA) launched in May 2012
– Identifies priority activities to address maternal
and child survival
• PHC Re-engineering:
– District Clinical Specialist Teams (DCSTs)
– School Health Teams
– Municipal ward based outreach PHC teams
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CARMMA priorities
•
•
•
•
•
•
Contraception and family planning
Early booking and improve the quality of antenatal care
Prevention of Mother-to-child-transmission of HIV
Obstetric ambulances
Maternity Waiting Homes
Improving new born care and treatment of sick
children, including Kangaroo Mother Care
• Expanded Programme on Immunisation
• Exclusive breast-feeding
• Training (essential steps in the management of
obstetric emergencies, skilled birth attendants
including additional midwives)
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Priority Newborn Interventions
• Promotion of early and exclusive
breastfeeding
• Prevention of HIV infection through effective
PMTCT
• Resuscitation of newborns and care for
small/ill newborns according to standardised
• Post-natal visit within six days, which includes
newborn care and helping mothers to practice
exclusive breastfeeding.
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NEONATAL SURVIVAL STRATEGY: KEY INTERVENTIONS TO REDUCE MORTALITY
(NaPeMMCo, 2012)
KEY CAUSE OF
MORTALITY
Health system for
mothers and
babies:
INTERVENTIONS




Knowledge and

skills of health care
providers:
Hypoxic deaths maybe a 
result of inadequate
intrapartum care provided
by health care providers.

Contraception, including for post miscarriage and
postpartum
24 hour access to functioning emergency obstetric and
neonatal care including clear referrals routes with
dedicated obstetric and neonatal ambulances
Maternal waiting homes, KMC sites in all hospitals
CEOs to ensure that there is no rotation of nursing
staff providing neonatal care
Train all health care workers providing maternity and
neonatal care in the ESMOE-EOST programme and in
managing the immature infant using the SA INC toolkit
Train all health care workers who deal with pregnant
women in HIV advice, counselling, testing and support
, initiation of HAART, monitoring of HAART
Train all health care workers in correct management of
intrapartum care (use of the Partogram, 3rd stage of
labour)
13
Deaths due to asphyxia:
Asphyxia was the leading
cause of neonatal deaths in
the birth category >1000g.
70% of death in the >2,5kg
group were classified as
hypoxia related.
A birth attendant skilled in
neonatal resuscitation can
reduce deaths to hypoxia by
up to 40%.





Deaths due to
prematurity:

The use and application of
nasal CPAP at a district
hospital can reduce mortality 
of this group by up to 40%.

Every women in labour must be monitored
appropriately by a skilled birth attendant
All birth attendants must skilled in at least bag and mask
ventilation of the neonate
The partogram must be used to monitor labour
according to prescribed norms
All complicated and obstructed labours must have access
to Caesarean section when indicated
Corticosteroids must be given where possible to every
women in preterm labour
Antibiotics must be given to every women with preterm
premature rupture of membranes
All hospitals (especially district hospitals)must have staff
skilled in the use of nasal CPAP
All mothers of immature infants must have easy access
to Kangaroo Mother Care
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Deaths due to
infection:
Infection is the third
largest cause of
neonatal deaths in all
weight categories, but
highest in the 1000g2000g group (these
are low weight babies,
normal is between 2.53.5 kgs) requiring high
level care




Strict adherence to basic hygiene in labour wards
and nurseries. D-germ alcohol sprays, soap, clean
water and paper towels must be available in all
nurseries as essential consumables
Case management of neonatal sepsis, meningitis
and pneumonia
As breast milk provides the best nutrition and
protection for the preterm baby, districts should
provide breast milk (not preterm formulas) to all
preterm babies by the establishment of human milk
banks.
Infection dashboard introduced in all neonatal
nurseries to reduce infections by heightening
awareness and surveillance of infection rates.
15
Care of small/sick newborns
Intervention must address the major causes of mortality
Prematurity
Includes provision of Kangaroo Mother Care (KMC) for
stable low-birth weight babies
Asphyxia
Reducing deaths from asphyxia are primarily depend on
improved maternal care and better newborn
resuscitation
Infection
Infection control, especially hand-washing, and
promotion of breastfeeding.
16
Promotion of Breastfeeding (SA is regarded as
having the lowest rate of Breastfeeding)
• Breastfeeding (especially exclusive breastfeeding) rates remain
extremely low, even though Exclusive Breastfeeding is a key child
survival intervention
• The reason that Breastfeeding rates fell in the 1990s and early 21st
century is HIV and the concern about HIV transmission however, not
breastfeeding has a number of negative consequences including:
– Poor bonding with the mother
– Lower levels of immunity of babies (that increases the chances of infections in
the baby)
– Higher rates of diarhoea (given lack of clean water in some areas)
• Experts (including UNICEF) told us at the breastfeeding consultation
that breastfeeding even in the context of HIV is what needs to be
done (provided that there is no mixed feeding)
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Tshwane Declaration on Promotion of Breastfeeding
– Finalisation and implementation of the National Regulations on the
International Code on Marketing of Breast Milk
– Ensuring that all workers, including domestic and farm workers, benefit from
maternity protection.
– All mothers to be supported to breastfeed their infants exclusively for six
months and, thereafter, to give appropriate complementary foods and
continue breastfeeding up to two years of age and beyond.
– Establishment of human milk banks
– Implementation of the Mother and Baby Friendly Health Initiative (MBFHI)
and KMC in all hospitals
– Services to promote, protect and support breastfeeding should be
implemented at community and facility levels.
– Continued research, monitoring and evaluation should inform policy
development and strengthen implementation.
– Formula feeds will no longer be provided at public health facilities, except on
prescription by appropriate healthcare professional.
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Prevention of Mother to Child
Transmission of HIV (PMTCT)
• Improvements in PMTCT is the single most important
reason for declining mortality rates
• MTCT transmission rate among HIV-exposed infants at six
weeks
– 2008: 8.0%
– 2010: 3.5%
– 2011: 2.7%
• New guidelines will be implemented in April 2013 –
should lead to further reductions (< 1%)
– ARVs for all pregnant HIV women regardless of CD4 count for
the duration of Breastfeeding
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Post-natal care
Important gap in care for mothers and children
PHC outreach teams play an important role in post-natal care: especially with
regards to supporting breastfeeding
South Africa: Postnatal Care mother visits within 6
days rate
70.0
60.9
60.0
Percentage
51.8
50.0
40.0
30.0
17.1
20.0
10.0
4.8
0.0
2008
2009
2010
2011
2012 (Jan-Oct)
Postnatal Care mother visits within 6 days rate
Linear (Postnatal Care mother visits within 6 days rate)
20
Preventative and Promotive Services
• Package of Early Childhood
Development interventions
• Better nutrition – highlighted in
Early Childhood Development
Diagnostic Review
– infant and young child feeding
– growth monitoring and
promotion
– Vitamin A supplementation
– regular deworming
• Immunisations
– New vaccines against some
forms of diarrhoea and
pneumonia introduced in 2008
– 5% reduction in deaths due to
pneumonia and diarrhoea
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Other child health services
•
•
•
•
Correct management of common childhood illnesses at
Primary Health Care facilities (includes early
identification and management of children with HIV
and TB); TB in children is difficult to diagnose globally
(lack of sputum) – therefore prevention very important
Improved hospital care for ill children, especially for
those with common conditions (pneumonia, diarrhoea
and severe malnutrition)
Expansion and strengthening of school health services;
and
Developing services for children with long-term health
conditions.
22
Management of common illnesses at
PHC facilities
• Guidelines for managing
common conditions
• Includes:
 provision of preventive
services
 screening for TB
 early identification of HIVinfected children
 initiation of ART where
indicated
23
Care in Hospitals
• Mortality audits have been used in many hospitals to
improve the quality of care
• Mortality targets for each hospital have been set for
maternal, neonatal and child deaths
• District Clinical Specialist Teams have a key role to play
in improving clinical governance
• Need guidelines, protocols at facilities that are used –
these teams have started to ensure that facilities use
guidelines
• The teams will also provide technical inputs (training)
• We will want hospitals and the teams to be accountable
for all deaths
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CHILD SURVIVAL INTERVENTIONS (CoMMiC, 2012)
KEY CAUSE OF MORTALITY
INTERVENTION
HIV
50% of under-5 deaths are
associated with HIV

NUTRITION
32% of under-5 deaths are
associated with severe acute
malnutrition






CARE IN OUTPATIENTS AND CASUALTY



Functional PMTCT programme (100% HIV status known for
mothers at the time of delivery/before discharge post delivery).
Improved 6-12 week PCR coverage – (aim for 10% increase).
Every child who is eligible for ARVs receives these.
Ensure that the HIV status of every child admitted to hospital is
established before discharge.
Ensure that all children’s wards are mother baby hospital initiative
compliant.
Achieve fully effective implementation of WHO 10 Steps for the
Management of Severe Acute Malnutrition.
Ensure hospital mealtime and snack schedules are child friendly.
Develop a functional dedicated paediatric “area” in casualty / OPD
– this includes appropriate facility, equipment & staff.
Ensure 24 hour access to effective triage & resuscitation for
children in the hospital
Ensure that immunisations are available 24 hours a day.
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IN-PATIENT CARE





STRENGTHEN CHILD SURVIVAL

PROGRAMMES
In-hospital case fatality rates are 
high:
Severe acute malnutrition 19.6% 
Diarrhoeal disease
9.2%
Acute respiratory infection 9.3%

Appoint a dedicated, full time doctor to run the children’s ward.
Ensure 50% of nursing staff in the children’s ward are
permanently based in the ward & DO NOT rotate.
Establish at least 2 functional high care beds in each children’s
ward.
All children in hospital must be seen by a doctor every day,
including weekends, & the sicker ones more frequently
Children with dehydrating diarrhoea must have a 4 hourly
hydration check.
The Paediatric EDL must be available in all children’s wards &
OPDs & issued to all doctors working with children.
The EDL standard treatment guidelines must be followed as the
minimum standard of care.
Ensure that nurses & doctors are trained in the assessment &
resuscitation of critically ill children & the care of common
paediatric emergencies.
Provide facilities to allow the primary caregiver to remain in
hospital with each sick child.
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STRENGTHEN DATA SYSTEMS
 Implement a standardised children’s ward
admission register (ADD Triplet)
 Ensure that every childhood death is audited
using the Child Healthcare Problem Identification
Programme (Child PIP)
STRENGTHEN HEALTH SYSTEMS  Ensure a functional referral pathway
 Implement an outreach programme to support
referring facilities
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Role of Hospital CEOs
• Ensure norms and standards adhered to, including
equipment and drugs
• Ensure SOPs in place for all aspects of service delivery –
especially staffing and rosters
• Review indicators (dashboard for MCH) monthly and act
• Ensure staff trained (e.g., ESMOE)
• Review the minutes of M&M meetings including checking
attendance of senior managers, & corrective steps taken
• Review admissions refusals; ensure admission/referral
policies are known and adhered to.
• National workshop with newly appointed hospital CEOs
held in February
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Strengthening of school health
services
The revised School Health Policy includes:
• Five areas to be covered: screening (eyes, ears, dental), immunisation, alcohol and
substance use, sexual and reproductive health, HIV counselling and testing)
• Most important are immunisation and reproductive health (teenage pregnancies
account for 8% of all pregnancies but contribute to 36% of maternal mortality;
teen pregnancies also related premature and low weight babies)
• a commitment to close collaboration amongst all role players especially
Departments of Health, Basic Education and Social Development;
• provision of services to learners in all educational phases;
• provision of a more comprehensive service, which addresses not only barriers to
learning but also other conditions that contribute to morbidity and mortality
among learners during both child- and adulthood;
• more emphasis on provision of health services in schools, with a commitment to
expanding the range of services over time; and
• a more systematic approach to implementation.
• Since the launch of the School Health Programme by the President in October
2012, 77 250 grade 1 children have been screened
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Package of services offered.
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DENTAL CLINIC
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Monitoring and Evaluation
• Child Mortality Rates: both institutional and
community mortality
• Routine data collected through the District
Health Information System
• CARMMA Dashboard
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Conclusions
• Child mortality rates are falling – further
strengthening of services at community, PHC and
hospital levels will result in further declines
• This provides an opportunity to focus on ensuring
optimal nutrition and development of children
• Neonatal Mortality Rates are static, and
interventions to improve newborn care are being
implemented.
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THANK YOU
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