Estimating the Impact of Maternal, Neonatal and Child Survival Interventions

1. Estimating the Impact of Maternal, Neonatal and Child Survival Interventions Ingrid Friberg, PhD

2. The Lives Saved Tool - LiST • The Lives Saved Tool • A multi-cause model of mortality • Predict changes in • Under 5 and neonatal mortality rates and deaths • Maternal mortality ratios and deaths • Stillbirth rates and deaths • Causes of death • Using • Country specific health status • Changes in child and maternal health intervention coverage levels • i.e. ORS, facility delivery, etc. • Effect sizes of interventions based on the best available evidence

3. LiST Beginnings: Grew out of the “Bellagio” modeling exercise and the Lancet Child Survival Series (2003). Added in neonatal, nutrition, and updated information Goals: Promote evidence-based decision making Aid in planning expansion of maternal, neonatal and child health interventions Objectives: Estimate lives saved when introducing or scaling up key interventions

4. General Framework Demographic estimates and projections UN Pop/Spectrum Number of Child, Maternal and Fetal deaths Deaths by Cause WHO/UNICEF Country estimates Effectiveness Estimates Intervention Coverage Current Target/Goal/Endline *Change is critical* • Health Status • Stunted, wasted • Malaria prevalence • Vit A deficiency • Zinc deficiency Intervention Impact C1 C2 C3 C4 … Int1  Int2  Int3   • Deaths averted • By cause • By intervention Stunting, Wasting, Breastfeeding

5. Which interventions were included? • Proximate factors • Not distal • Work through health programs • Not included: income, education and crowding, etc. • Water and sanitation are the exceptions • Feasible in a low income country • 68 priority countries with highest MNCH mortality • Cause-specific evidence of effect • Research studies or systematic reviews • Delphi method if research is impossible (i.e. CEmOC) • Updated frequently • IJE April 2010, BMC Public Health April 2011

6. Intervention Types • Maternal, fetal, neonatal, child • Periconceptional, antenatal, birth, immediate postnatal, child • Preventive, curative • Nutritional, vaccination, water/sanitation, treatment • Risk factors: Cause-of-death specific • Immediate, time-lagged • External (family planning, AIDS), internal (all others)

7. Periconceptional InterventionsPregnancy Interventions • (Family planning) • Folic acid supplementation or fortification • Safe abortion services • Post abortion case management • Ectopic pregnancy case management • Tetanus toxoid vaccination • IPTp – malaria prevention in pregnancy • Syphilis detection and treatment • Calcium supplementation • Multiple micronutrient supplementation • Balanced energy supplementation • Diabetes case management • Maternal malaria case management • MgSO4 – management of pre-eclampsia • Fetal growth restriction and management • (PMTCT)

8. Childbirth Care Interventions • Clean birth practices • Immediate assessment and stimulation of the neonate • Labor and delivery management • SBA at home or facility, BEmONC and CEmONC • Neonatal resuscitation • At home or facility • Antenatal corticosteroids for preterm labor • Antibiotics for pPRoM • MgSO4 – for eclampsia • AMTSL – active management of the third stage of labor • Induction of labor for pregnancies 41+ weeks

9. Preventive Interventions • Thermal care • Clean postnatal practices • Breastfeeding • Promotion • Behavior • Complementary feeding • Education only • Education and supplementation • Vitamin A for prevention • Zinc for prevention • Insecticide treated materials • Improved water source • Water connection in the home • Improved sanitation • latrine, toilet • Hand washing with soap • Hygienic disposal of children’s stools • BCG vaccine • Polio vaccine • Pentavalent vaccine • DPT, Hib, HepB • Pneumococcal vaccine • Rotavirus vaccine • Measles vaccine

10. Curative Interventions • Maternal sepsis case management • Kangaroo mother care • Case management of serious neonatal illnesses • Oral antibiotics • Injectable antibiotics • Full supportive care: oxygen, IV fluids, IV antibiotics • ORS for diarrhea • Antibiotics for dysentery • Zinc for treatment of diarrhea • Oral antibiotics for management of pneumonia • Vitamin A for measles treatment • Therapeutic feeding • Antimalarials • (Cotrimoxazole for HIV+ children) • (ART for children)

11. What’s NOT in the model? • Education • Motivation • Gender issues • Economic status • Emergencies (i.e. famine, flooding) • Delivery mechanism • Only as relates to total population coverage • Quality of care • Effectiveness values, adjustments Assumption: Several of these factors are DISTAL factors which MAY work through COVERAGE changes…thus MAY already be in the model

12. Other things not in LiST • De-worming (yet) • IPTi (yet) • Breastfeeding initiation within 1 hour (yet) • Birth spacing benefit • Treatment of water in the home • Iron (or iron-folate) supplementation • Indoor air pollution • …

13. What LiST is, What LiST isn’t! Is Isn’t • Multi-cause mortality model • Mathematic model • Models coverage impacts • Potential impact assessment • National or sub-national prioritization tool • Discussion points • Evidence-based • Truth • Probabilistic model • Natural history model • Detailed costing or planning tool • Bottlenecks, budgeting • Exhaustive

14. DATA AND MODELING

15. Data Needs • Country-Specific • Population data and trends • Default: UN Population Division 1950-2050 (DemProj) • User entered (district) data • Cause of death structure • Default: WHO/UNICEF/CHERG (2008) • User entered data • Intervention coverage • Population based data • Default: DHS/MICS/JMP/WHO-UNICEF (closest to 2008) • User entered data • Global • Intervention Effectiveness data • User entered data

16. Stunting Appropriate ComplementaryFeeding IUGR Zinc Diarrhea incidence Previous Stunting Complementary feeding education and/or supplementation

17. Malaria Mortality Antimalarials Wasting Stunting ITN/IRS Disease Specific Treatments Disease Specific Preventions Risk factors

18. Breast Feeding Promotion Pneumococcal vaccine Hib vaccine Improved H2O source within 30 minutes Hand washing with soap Breast Feeding Improved sanitation Diarrhea incidence Water connection in the home Pneumonia Mortality Hygienic disposal of children’s stools Stunting Complementary feeding education/supplementation Pregnant women protected via IPT or sleeping under an ITN IUGR Multiple micronutrient supplementation Balanced energy supplementation Zinc for prevention Wasting Therapeutic feeding Oral antibiotics for pneumonia

20. How are the models built? • Preventions • Treatments • Risk factors • Multiple interventions? • Two Preventions (or Risk Factors): • Proportional impact by coverage/effect size • Calculated on residual deaths • No double counting • Preventions and Treatments: • Enter prevention(s), then treatment(s) • Deaths not already averted

21. Some Limitations • Data availability • If no baseline, can’t evaluate impact accurately • Data quality • Sensible scale up targets • Feasible, acceptable, funds available • Interventions included in software • Some evaluated for one outcome, not others • Maternal • No country specific cause of death yet; regional causes • No risk factors yet • Not yet vetted intervention impacts through CHERG and other groups

22. LIST“VALIDATION”USES

23. Neonatal Package Modeling

24. ACSD Results

25. Modeling Mortality Rates and Equity

26. ITN studies

27. How canLiST be used? • Planning, Evaluation, Research, Advocacy • Strategic planning • Which interventions are necessary to reduce mortality? (maternal, neonatal, under-5) • Will the targets reduce mortality as much as needed? • Evaluation and intermediate-term follow-up • What is the impact of observed coverage changes? • Evaluation of historic trends (i.e. multiple DHS/MICS surveys) • Predict lives saved (past and future) • How many lives could be saved with full scale-up of proven interventions in priority countries? • How many deaths remain left after vaccination scale ups?

28. How hasLiST been used? • Globally • Global Action Plan for Pneumonia • ‘Impatient Optimist’ speech by Bill Gates • Regionally • ASADI, by Saving Newborn Lives • Country level • Catalytic initiative: to guide planning and priority setting (Malawi, Ghana, Niger) • Ethiopia • Sub-nationally • CSHGP • DFID in Nigeria (PRRINN-MNCH)

29. Who has used LiST? • Gates Foundation, GAVI • USAID, DFID, CIFF • MCHIP • Save the Children, Saving Newborn Lives, MSH • WHO (GAPP), UNICEF • CHAI

30. How NOT to use LiST • As the correct answer • It depends on what you put in and what your goals are • Also must consider cost, feasibility, accepability • To suggest decreasing coverage of any interventions • Mortality has declined BECAUSE of those interventions • To suggest taking funds away from interventions • To suggest that things in LiST are “GOOD” while everything else is “BAD” • It is based upon data availability unless otherwise stated • To decide HOW to do anything!!! • That is for the programmers to decide!

31. What can I get out of LiST? • Number of deaths • Total, by cause, by age group • Mortality rates/ratios (NMR, U5MR, MMR, SBR) • Deaths averted, • Total, by cause, by intervention, by age group • Intermediate outcomes • Stunting, wasting, breastfeeding • Displays • Tables, graphs, pie charts • Single country, multiple scenarios within one country • Multiple countries, single or multiple scenarios

32. Future Directions for LiST • Costing tie-ins • Both a CHOICE based costing tool and MBB • Part of the new One Health Model • Yes, we will be adding in uncertainty • Improve the maternal model • A new tool for multi-country analyses

33. LiST Resources • FREE • Web Links • www.futuresinstitute.org • www.healthpolicyinitiative.com/index.cfm?id=software&get=Spectrum • www.jhsph.edu/iip/list (join the listserv there) • list.cherg.org • Software + Manual Languages • English, French, Spanish, Portuguese • Contact • Ingrid Friberg - ifriberg@jhsph.edu