Child Mortality Rates: definitions

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 birthsInfant Mortality Rate (IMR): Number of deaths during the first year of life per

1,000 live birthsUnder-five mortality rates: Number of deaths during the first five years of life

per 1,000 live births

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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, 2009-2011Indicator 2009 2010 2011 Target 2014

Under-5 Mortality Rate (U5MR)

56 per 1 000 live births




(10% reduction) of 2009 data)

Infant Mortality Rate (IMR)






Neonatal Mortality Rate (<28 days)






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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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KEY CAUSE OF MORTALITY

INTERVENTIONS

Health system for mothers and babies:

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

Knowledge and skills of health care providers:Hypoxic deaths maybe a result of inadequate intrapartum care provided by health care providers.

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)

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

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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%.

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

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%.

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 1000g-2000g group (these are low weight babies, normal is between 2.5-3.5 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.

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Care of small/sick newborns

Intervention must address the major causes of mortalityPrematurityIncludes provision of Kangaroo Mother Care (KMC) for

stable low-birth weight babiesAsphyxiaReducing deaths from asphyxia are primarily depend on

improved maternal care and better newborn resuscitation

InfectionInfection control, especially hand-washing, and

promotion of breastfeeding.

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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 careImportant gap in care for mothers and childrenPHC outreach teams play an important role in post-natal care: especially with

regards to supporting breastfeeding

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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.

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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

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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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KEY CAUSE OF MORTALITY INTERVENTION

HIV50% of under-5 deaths are associated with HIV

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.

NUTRITION32% of under-5 deaths are associated with severe acute malnutrition

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.

CARE IN OUTPATIENTS AND CASUALTY

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.

CHILD SURVIVAL INTERVENTIONS (CoMMiC, 2012)

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IN-PATIENT CARE 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.

STRENGTHEN CHILD SURVIVAL PROGRAMMESIn-hospital case fatality rates are high:Severe acute malnutrition 19.6%Diarrhoeal disease 9.2%Acute respiratory infection 9.3%

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

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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Documents

Child Mortality Rates: definitions