ESTIMATING THE IMPACT OF MATERNAL NEONATAL AND CHILD

ESTIMATING THE IMPACT OF MATERNAL, NEONATAL AND CHILD SURVIVAL INTERVENTIONS Ingrid Friberg, Ph. D

The Lives Saved Tool - Li. ST 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

Li. ST 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 3

General Framework Demographic estimates and projections Number of Child, Maternal and Fetal deaths UN Pop/Spectrum Health Status • Stunted, wasted • Malaria prevalence • Vit A deficiency • Zinc deficiency Intervention Coverage Current Target/Goal/Endline *Change is critical* Deaths averted -By cause -By intervention Deaths by Cause WHO/UNICEF Country estimates Effectivenes s Estimates Intervention Impact C 1 C 2 C 3 C 4 … Int 1 Int 2 Int 3 Stunting, Wasting, Breastfeeding

Which interventions were included? Proximate factors Work through health programs Not included: income, education and crowding, etc. Water and sanitation are the exceptions Feasible in a low income country Not distal 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. CEm. OC) Updated frequently IJE April 2010, BMC Public Health April 2011

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)

Periconceptional Interventions q q (Family planning) Folic acid supplementation or fortification Safe abortion services Post abortion case management Ectopic pregnancy case management Pregnancy Interventions q q q 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 Mg. SO 4 – management of pre-eclampsia Fetal growth restriction and management (PMTCT)

Childbirth Care Interventions Clean birth practices Immediate assessment and stimulation of the neonate Labor and delivery management Neonatal resuscitation SBA at home or facility, BEm. ONC and CEm. ONC At home or facility Antenatal corticosteroids for preterm labor Antibiotics for p. PRo. M Mg. SO 4 – for eclampsia AMTSL – active management of the third stage of labor

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

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)

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

Other things not in Li. ST 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 …

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

DATA AND MODELING

Data Needs Country-Specific Population data and trends Default: UN Population Division 1950 -2050 (Dem. Proj) 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 User Effectiveness data entered data

Stunting Appropriate Complementary Feeding IUGR Zinc Diarrhea incidence Complementary feeding education and/or supplementation Previous Stunting

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

Improved H 2 O source within 30 minutes Breast Feeding Promotion Pneumococcal vaccine Hib vaccine Hand washing with soap Breast Feeding Improved sanitation Diarrhea incidence Water connection in the home 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 Pneumonia Mortality

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

Some Limitations Data availability • Data quality Sensible scale up targets • Feasible, acceptable, funds available Interventions included in software If no baseline, can’t evaluate impact accurately 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

LIST “VALIDATION” USES

Neonatal Package Modeling

ACSD Results

Modeling Mortality Rates and Equity

ITN studies

How can Li. ST 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

How has Li. ST 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)

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

How NOT to use Li. ST 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 Li. ST are “GOOD”

What can I get out of Li. ST? Number of deaths Mortality rates/ratios (NMR, U 5 MR, MMR, SBR) Deaths averted, Total, by cause, by intervention, by age group Intermediate outcomes Total, by cause, by age group Stunting, wasting, breastfeeding Displays Tables, graphs, pie charts Single country, multiple scenarios within one country Multiple countries, single or multiple scenarios

Future Directions for Li. ST 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

Li. ST Resources FREE Web Links www. futuresinstitute. org www. healthpolicyinitiative. com/index. cfm? id=softwar e&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