How can child mortality be reduced

In , more than 12 million children in developing countries died before the age of 5 from diseases such as diarrhea, malnutrition, pneumonia, AIDS, malaria, and tuberculosis. By , that number had dropped to 6. Yet under-5 mortality rates remain unacceptably high, especially considering that most of these deaths are due to preventable or treatable causes.

The child mortality MDG is one of the goals lagging farthest behind: more than half of all countries are not on track to reduce the under-5 death rate by two-thirds by , and less than one third of IDA countries will meet the goal. Read More ». The 8 Goals: 1. These latter can be trained to assess, counsel, treat, refer and follow up children with pneumonia in the community[ 10 ]. Much of the work on community management of pneumonia was done in Nepal.

The model has been taken to scale through 54 female community health volunteers. At present, the programme covers infants and children over the age of two months, but there is concern that it should be expanded to cover younger infants. The Morang Innovative Neonatal Intervention MINI , implemented by the Ministry of Health and Population, with technical support from John Snow International and funding from The Bill and Melinda Gates Foundation through Saving Newborn Lives and Save the Children USA, trains existing Female Community Health Volunteers and peripheral government health workers to identify and manage neonatal infections [ 12 — 14 ] using oral antibiotics in the home cotrimoxazole and to refer rapidly to the nearest health facility for treatment of sepsis cases with injectable gentamicin.

This pilot study has shown good referral rates and reduction in case fatality rates, but there is no control group comparison, and it is uncertain whether these results could be reproduced at scale in the government system. The Warmi project, implemented in Bolivia in a poor, rural population of 15, with little health system infrastructure, worked with women's groups to encourage participatory planning for mother and infant care,[ 15 ] and documented a fall in perinatal mortality from to 44 per thousand births over three years.

Building on this example, we conducted the MIRA Makwanpur trial in a population of , in a middle hills rural district of Nepal. One woman facilitator per population cluster of facilitated monthly meetings with women's groups to address the issues of pregnancy, childbirth and newborn health. Each group moved through a participatory planning cycle to explore perinatal care strategies and solutions[ 16 ]. From a conservative viewpoint, the study at least demands replication and assessment of modifications that would make it scalable and institutionally sustainable within a national public health framework.

There is no doubt that improvements to women's diets are needed, particularly from a life-cycle perspective, and little doubt that behaviour change could improve the health of both women and their infants. However, programmatic effectiveness to achieve behaviour change remains unclear[ 19 , 20 ].

Nutrition is intimately linked with social development, and we propose that a community mobilisation intervention that has led to improvements in maternal and neonatal survival could also be a route into dietary behaviour change. The demand-side approach is a model that may sustain a range of issues.

It did not, however, include any discussions about diet and nutrition. There is ample scope for such discussions to be included in one or more action research cycles, and for local strategies to improve the nutritional status of women to be formulated.

We should like to examine the potential for including nutritional issues in the community group work. She is nominated by a mother's group, becomes its member secretary and is responsible for facilitating the group itself and for building linkages with the health system at village level. There are up to 54 FCHVs in Nepal: 48 in rural village development committees and in municipalities. Initial training on primary health care lasts 18 days.

Mother and child health and family planning are a particular focus. The FCHV has a number of specific responsibilities: facilitation of the mother's group, counselling on family planning and distribution of contraceptives, contribution to the community component of the integrated management of childhood illness, health education, safer motherhood referral services, immunization with an emphasis on oral polio vaccine and tetanus toxoid, distribution of vitamin A, anthelminthics and iron supplements, management of minor illnesses and injuries, and nutrition education [ 21 ].

FCHVs are not salaried, but receive support for attending training and incentives for particular activities. The SEARCH findings from rural India have shown that treatment of newborn infections in the community using paid workers to visit homes and provide injectable antibiotics can significantly reduce neonatal mortality [ 6 ].

The intervention was complex and scaling up presents difficulties for policymakers. Nepal's Acute Respiratory Infection programme, however, has been successful in achieving broad coverage by FCHVs to provide oral antibiotics and referral advice for children with signs of acute respiratory infection.

At present, the programme covers infants and children over the age of two months. We wish, therefore, to do two things: first, to build on and simplify the Indian model on a framework that targets scalability; second, to test the effectiveness of expanding the programme activities to cover the newborn period, a move supported by the Nepal Family Health Programme and others.

We have collaborated with and learnt from the MINI project, which has developed extensive training and monitoring packages for community-based management of newborn infections.

FCHVs are supported in convening monthly women's groups. Nine groups per cluster in total work through an action research cycle in which they i identify local issues around maternity, newborn health and nutrition, ii prioritise key problems, iii develop strategies to address them, iv implement the strategies, and v evaluate their success. They then move on to a second action cycle focused on nutrition, in which they follow the same steps i to v , but concentrate on maternal and infant nutrition and associated aspects of postpartum care.

Our main objective is to test the replicability and scalability of the women's group interventions focused on maternal and newborn health described above from Makwanpur, Nepal and Jharkhand and Orissa, India in reducing neonatal mortality and, in the second action cycle, to explore the potential for this approach to improve maternal and infant nutrition.

FCHVs are trained to care for vulnerable newborn infants. They i identify local births, ii identify low birth weight infants, iii identify possible newborn infection, iv manage the process of treatment with oral antibiotics Amoxicillin and referral to a health facility to receive parenteral gentamicin, and v follow up infants and support families.

We aim to build on operational research studies in Nepal that have shown that the approach is feasible, by testing the effect on mortality at population level. The methodology is a cluster randomized controlled trial. A cluster design has been chosen because the unit of randomisation is the village development committee rather than the individual mother and child. The study has a factorial design, summarized in Figure 1. Each cluster has a population of about From each of these two arms, 15 clusters are randomly allocated to receive the community health volunteer training intervention.

Design of the study. Essential Newborn Care training was provided throughout the district, followed by exclusion of small and conflict-affected clusters and stratified block randomisation on the basis of cluster size to women's groups intervention and control. A second block randomisation allocated equal numbers of clusters to sepsis management intervention within each women's group study arm. What is the impact on neonatal mortality of training community health volunteers on the recognition and management of neonatal sepsis?

What is the impact of a participatory women's group intervention that focuses on nutrition and feeding practices on the nutritional status of women and their young children? What is the impact of a participatory intervention with women's groups on infant and under-2 mortality? What is the impact on early infant mortality of training community health volunteers on the recognition and management of neonatal sepsis?

A participatory intervention with women's groups will be associated with reductions in neonatal mortality. Training of community volunteers in the recognition and management of neonatal sepsis will be associated with increases in identification and treatment of neonatal sepsis, and improvements in neonatal mortality.

A participatory intervention in which women's groups discuss diet and nutrition will be associated with positive changes in maternal diet and infant feeding, and in anthropometric status of women and their young children.

The administrative centre in Janakpur municipality - which is excluded from the trial - manages a local team of researchers, health workers and field workers, as well as maintaining excellent relations with both hospital collaborators and the District Public Health Office. Dhanusha is a terai lowland district of km 2. According to the census, it had a population of about 20 per doctor and was the fifth most populous district in Nepal.

The average household size was 5. Dhanusha's human development index, a composite measure of three dimensions of human development--a long and healthy life, access to education and a decent standard of living [ 23 ] was 0.

The commonest language spoken is Maithili and the majority religion Hinduism The main beneficiaries of the study are women of reproductive age years , of whom there were , according to Dhanusha District Public Health Office data for , and infants under one year of age, of whom there were 19 Key participants are women who either join community groups or have a pregnancy.

The women's group intervention involves social mobilisation and group membership and activities are not restricted to women of reproductive age. Since the aim is to improve the situation of pregnant women and their newborn infants, any participant who may affect this may be involved. Particular stakeholders may be older women, male community members, health workers and local opinion formers. Experience from other sites has shown that women form the core membership of groups and that both women of reproductive age and older women get involved.

All women and their newborn infants are eligible to participate in the data collection exercise, for which enrolment occurs in the postnatal period. Each FCHV is already tasked with women's group activities under current government guidelines, although most groups were not meeting regularly before the study began.

FCHVs are trained and supported in acting as facilitators for women's groups, according to guidelines developed by the intervention team. Groups are strengthened where they already exist, and initiated where they do not. In general, there is one women's group per ward, corresponding with nine per cluster and over the whole intervention area. FCHVs convene women's groups monthly. The primary newborn and maternal health cycle, following a similar agenda to that used in the MIRA Makwanpur trial,[ 16 ] but with additional nutritional content, comprises nine pre-implementation meetings, a community meeting to share problems, plans and enlist community support, an implementation phase and an evaluation summarized in Figure 2.

The monthly meetings proceed from discussions of illness, mortality and poor nutrition in mothers and babies, via discussions of common problems in the community and the collection of local information by group members, to prioritisation of the most important problems.

Following this, strategies to address these problems are formulated, shared with the wider community and implemented. Finally, the groups themselves evaluate the effects of the strategies and then move on to further activities and discussions.

The FCHVs assist the women's groups in devising local strategies to realistically tackle the issues in a resource-constrained context. The sequence of women's group activities. Meetings conducted on a monthly basis between May and April by groups in 30 study clusters.

Strategies initiated after meeting 10 in both cycles may be implemented continually while meetings on other topics are ongoing and also after the end of the intervention period. Community commitment and ownership are essential to ensure implementation. The FCHV's brief is to activate and strengthen women's groups, support them in identifying and prioritising maternal and neonatal problems, help to identify possible solutions and support the planning, implementation and monitoring of the solution strategies in the community.

Formative research on beliefs and practices in pregnancy and postpartum informed the design of a second cycle of monthly meetings focused on nutrition. The meetings cover socio-cultural problems or barriers associated with the following: nutrition in pregnancy; high prevalence of low birth weight; nutrition, hygiene and postpartum care of the mother; early and exclusive breastfeeding; and complementary feeding of the infant at six months see Figure 2 for sequence of meetings.

The pattern of the second action research cycle is the same as cycle one: after a pre-implementation phase covering the topics outlined, a community meeting is held to enlist support and share ideas. Strategies initiated during the first action cycle may continue to be implemented by the groups during the second cycle and also after the implementation period. Process evaluation is used to document each group's progress through the monthly meeting cycles, recording group attendance, outcomes or decisions from individual meetings, problems prioritised, strategies implemented, progress with strategies and findings from the participatory evaluations.

Our focus is on training FCHVs in the recognition and management of neonatal sepsis. MIRA has programmatic experience in health service strengthening at all levels. This relates mainly to the training of cadres from FCHVs to doctors in essential newborn care. We are building on this experience to devise and implement a new training and support programme for FCHVs. Birth defects are currently the leading cause of infant mortality in the United States.

There are several things pregnant women can do to help reduce the risk of certain birth defects, such as getting enough folic acid before and during pregnancy to prevent neural tube defects.

Learn more about some risk factors for birth defects. There is currently no definitive way to prevent preterm birth , the second most-common cause of infant mortality in the United States.

Preterm infants commonly have a low birth weight, but sometimes full-term infants are also born underweight. Adequate prenatal care is essential to ensuring that full-term infants are born at a healthy weight. There are some known risk factors for preterm birth—including having had a preterm birth with a previous pregnancy—and women with known risk factors may receive treatments to help reduce those risks.

But in most cases, the cause for preterm birth is not known, so there are not always effective treatments or actions that can prevent a preterm delivery. Researchers and healthcare providers are also working to understand the health challenges faced by infants born preterm or at a low birth weight as a way to develop treatments for these challenges.

For instance, preterm infants are at high risk for serious breathing problems as a result of their underdeveloped lungs. Treatments such as ventilators and steroids can help stabilize breathing to allow the lungs to develop more fully. In addition, studies suggest that infants born at low birth weight are at increased risk of certain adult health problems, such as diabetes, high blood pressure, and heart disease.

Health-care providers -- mainly doctors, clinical officers, midwives, nurses, and laboratory and support staff -- are only able to provide quality care in rural areas if they are supported with functional equipment, sufficient essential supplies, including drugs, regular supervision and opportunities for career development. Availability of other social services for the family, such as schooling and markets for essential supplies, is equally important.

These basic conditions cannot be met by the health sector alone, but require inputs from others concerned with rural development. These are issues that the Government can take up with the private sector, faith-based organizations and development partners. Experience shows that it is relatively easy to fix the missing functions of a hospital or health centre. Especially where skilled health-care providers are readily available, well-functioning health facilities can be upgraded through training and provision of essential supplies and equipment.

Our assessments in 20 countries indicate that this is the most frequently occurring problem in Africa. In contrast, upgrading inferior health facilities involves far more extensive changes, such as connecting running water and electricity, adding new cadres of skilled attendants, Government authorization to mid-level health-care providers to perform live-saving functions, and provision of staff quarters to ensure they are available to provide hour service. In many African countries, AIDS is becoming an increasingly significant contributor to child mortality.

A significant expansion of children's access to antiretroviral treatment and PMTCT services for mothers is therefore essential, in order to have significant impact on infant and child mortality, which has shown to be the case in Botswana.

In conclusion, opportunities exist to scale up child survival interventions through capitalizing on well-functioning and successful programmes, such as the Expanded Programmes of Immunization, relatively high antenatal care attendance and the Integrated Child Health campaigns.

Other community-based interventions, including Community Integrated Management of Childhood Illnesses, have high coverage and are proven to be effective. It is also critical to ensure that Governments adopt policies to reach poor and marginalized communities. To achieve this goal, both the public and private sectors have a crucial role to play. In at least eight countries where these principles and policies have been adopted, recent demographic health surveys have indicated an over per-cent reduction in mortality within five years.

Although the challenges of achieving the goal of reducing child mortality are daunting, some African countries are leading the way in overcoming these challenges and thus becoming a beacon of hope for others. Notes 1. Jones et al. Lucas, J.