Child Mortality Rates: definitions

1. National Department of HealthChild Mortality in South AfricaPresentation to the Select Committee on Social Services05 March 2013

2. 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

3. 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)

4. 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

5. 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

6. Child Mortality Rates, 2009-2011

7. 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

8. 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

9. 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

10. 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

11. 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)

12. 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.

13. NEONATAL SURVIVAL STRATEGY: KEY INTERVENTIONS TO REDUCE MORTALITY (NaPeMMCo, 2012)

16. 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.

17. 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)

18. 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.

19. 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

20. 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

21. 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

22. 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.

23. Management of common illnesses at PHC facilities Guidelines for managing common conditions Includes: provision of preventive services screening for TB early identification of HIV-infected children initiation of ART where indicated

24. 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

25. CHILD SURVIVAL INTERVENTIONS (CoMMiC, 2012)

28. 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

29. 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

32. Package of services offered.

36. DENTAL CLINIC

38. Monitoring and Evaluation • Child Mortality Rates: both institutional and community mortality • Routine data collected through the District Health Information System • CARMMA Dashboard

39. 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.

40. THANK YOU