Rebecca Heidkamp

Malawi and Millennium Development Goal 4: a Countdown to 2015 country case study

BACKGROUND Several years in advance of the 2015 endpoint for the Millennium Development Goals (MDGs), Malawi was already thought to be one of the few countries in sub-Saharan Africa likely to meet the MDG 4 target of reducing under-5 mortality by two-thirds between 1990 and 2015. Countdown to 2015 therefore selected the Malawi National Statistical Office to lead an in-depth country case study, aimed mainly at explaining the countrys success in improving child survival. METHODS We estimated child and neonatal mortality for the years 2000-14 using five district-representative household surveys. The study included recalculation of coverage indicators for that period, and used the Lives Saved Tool (LiST) to attribute the child lives saved in the years from 2000 to 2013 to various interventions. We documented the adoption and implementation of policies and programmes affecting the health of women and children, and developed estimates of financing. FINDINGS The estimated mortality rate in children younger than 5 years declined substantially in the study period, from 247 deaths (90% CI 234-262) per 1000 livebirths in 1990 to 71 deaths (58-83) in 2013, with an annual rate of decline of 5·4%. The most rapid mortality decline occurred in the 1-59 months age group; neonatal mortality declined more slowly (from 50 to 23 deaths per 1000 livebirths), representing an annual rate of decline of 3·3%. Nearly half of the coverage indicators have increased by more than 20 percentage points between 2000 and 2014. Results from the LiST analysis show that about 280,000 childrens lives were saved between 2000 and 2013, attributable to interventions including treatment for diarrhoea, pneumonia, and malaria (23%), insecticide-treated bednets (20%), vaccines (17%), reductions in wasting (11%) and stunting (9%), facility birth care (7%), and prevention and treatment of HIV (7%). The amount of funding allocated to the health sector has increased substantially, particularly to child health and HIV and from external sources, but remains below internationally agreed targets. Key policies to address the major causes of child mortality and deliver high-impact interventions at scale throughout Malawi began in the late 1990s and intensified in the latter half of the 2000s and into the 2010s, backed by health-sector-wide policies to improve womens and childrens health. INTERPRETATION This case study confirmed that Malawi had achieved MDG 4 for child survival by 2013. Our findings suggest that this was achieved mainly through the scale-up of interventions that are effective against the major causes of child deaths (malaria, pneumonia, and diarrhoea), programmes to reduce child undernutrition and mother-to-child transmission of HIV, and some improvements in the quality of care provided around birth. The Government of Malawi was among the first in sub-Saharan Africa to adopt evidence-based policies and implement programmes at scale to prevent unnecessary child deaths. Much remains to be done, building on this success and extending it to higher proportions of the population and targeting continued high neonatal mortality rates. FUNDING Bill & Melinda Gates Foundation, WHO, The World Bank, Government of Australia, Government of Canada, Government of Norway, Government of Sweden, Government of the UK, and UNICEF.

Iron Supplementation of Young Children: Learning from the New Evidence:

High iron needs and low-iron diets combine to make early childhood one of the highest risk periods for iron deficiency. Recommendations for iron supplementation for this age group have been based on positive effects on anemia and child development. In contrast, the evidence regarding growth and morbidity outcomes has been equivocal, with some evidence of risk. The new evidence from Nepal and Zanzibar is reviewed, and possible interpretations are discussed. The Zanzibar trial found significant adverse effects in the overall population with poor malaria services and substantial benefit to iron-deficient children (the majority) in an area where access to treatments was provided. Cost-effectiveness analysis suggests that targeting supplements to iron-deficient children in Zanzibar may not increase costs (relative to universal supplementation) and would increase benefit. Operations research is needed to test this. We conclude with three options for maximizing the benefits and minimizing the risks of iron supplements.

Independent Evaluation of the Integrated Community Case Management of Childhood Illness Strategy in Malawi Using a National Evaluation Platform Design

We evaluated the impact of integrated community case management of childhood illness (iCCM) on careseeking for childhood illness and child mortality in Malawi, using a National Evaluation Platform dose-response design with 27 districts as units of analysis. “Dose” variables included density of iCCM providers, drug availability, and supervision, measured through a cross-sectional cellular telephone survey of all iCCM-trained providers. “Response” variables were changes between 2010 and 2014 in careseeking and mortality in children aged 2–59 months, measured through household surveys. iCCM implementation strength was not associated with changes in careseeking or mortality. There were fewer than one iCCM-ready provider per 1,000 under-five children per district. About 70% of sick children were taken outside the home for care in both 2010 and 2014. Careseeking from iCCM providers increased over time from about 2% to 10%; careseeking from other providers fell by a similar amount. Likely contributors to the failure to find impact include low density of iCCM providers, geographic targeting of iCCM to “hard-to-reach” areas although women did not identify distance from a provider as a barrier to health care, and displacement of facility careseeking by iCCM careseeking. This suggests that targeting iCCM solely based on geographic barriers may need to be reconsidered.

Complementary feeding practices and child growth outcomes in Haiti: an analysis of data from Demographic and Health Surveys

The Haitian National Nutrition Policy identifies the promotion of optimal complementary feeding (CF) practices as a priority action to prevent childhood malnutrition. We analysed data from the nationally representative 2005-2006 Haiti Demographic Health Survey using the World Health Organization 2008 infant and young child feeding indicators to describe feeding practices among children aged 6-23 months and thus inform policy and programme planning. Multivariate regression analyses were used to identify the determinants of CF practices and to examine their association with child growth outcomes. Overall, 87.3% of 6-8-month-olds received soft, solid or semi-solid foods in the previous 24 h. Minimum dietary diversity (MDD), minimum meal frequency (MMF) and minimum acceptable diet (MAD) were achieved in 29.2%, 45.3% and 17.1% of children aged 6-23 months, respectively. Non-breastfed children were more likely to achieve MDD than breastfed children of the same age (37.3% vs. 25.8%; P < 0.001). The proportion of children achieving MMF varied significantly by age (P < 0.001). Children with overweight mothers were more likely to achieve MDD, MMF and MAD [odds ratio (OR) 2.08, P = 0.012; OR 1.81, P = 0.02; and OR 2.4, P = 0.01, respectively] than children of normal weight mothers. Odds of achieving MDD and MMF increased with household wealth. Among mothers with secondary or more education, achieving MDD or MAD was significantly associated with lower mean weight-for-age z-score and height-for-age z-score (P-value <0.05 for infants and young child feeding indicator × maternal education interaction). CF practices were mostly inadequate and contributed to growth faltering among Haitian children 6-23 months old.

Child malnutrition in Haiti: progress despite disasters

Despite a devastating earthquake and a major cholera outbreak in Haiti in 2010, surveys in 2006 and 2012 document marked reductions in child undernutrition. Intensive relief efforts in nutrition as well as synergies and improvements in various sectors before and after the earthquake were likely contributing factors. Despite a devastating earthquake and a major cholera outbreak in Haiti in 2010, surveys in 2006 and 2012 document marked reductions in child undernutrition. Intensive relief efforts in nutrition as well as synergies and improvements in various sectors before and after the earthquake were likely contributing factors. ABSTRACT Undernutrition, a chief child killer in developing countries, has been a major public health problem in Haiti. Following the 2010 disasters (earthquake and cholera) and the intensive relief efforts to address them, we sought to determine the trends of child undernutrition in Haiti using data from the 2005–06 Haiti Demographic and Health Survey (HDHS) and from a Standardized Monitoring and Assessment of Relief and Transitions (SMART) survey in 2012. Growth data analyses included 2,463 (HDHS) and 4,727 (SMART) children ages 0–59 months. We calculated the prevalence of stunting, wasting, and underweight for each survey using World Health Organization 2006 growth standards. To account for sampling design, probability weights were applied to all analyses. Statistical significance was determined by non-overlapping confidence intervals around estimates. Stunting prevalence declined from 28.5% (95% confidence interval [CI] = 25.9, 31.3) in 2005-06 to 22.2% (95% CI = 20.2, 24.3) in 2012; wasting, from 10.1% (95% CI = 8.2, 12.7) to 4.3% (95% CI = 3.6, 5.2); and underweight, from 17.7 % (95% CI = 15.6, 20.1) to 10.5% (95% CI = 9.3, 11.9). Additionally, stunting declined more in rural areas, from 33.6% (95% CI = 30.1, 37.2) in 2005–06 to 25% (95% CI = 23.4, 26.7) in 2012, than in urban areas, from 18.6% (95% CI = 15.3, 22.5) in 2005–06 to 18.4% (95% CI = 16.7, 20.1) in 2012, for reasons that remain unknown. Results of the 2012 HDHS confirmed the observed trends. Thus, undernutrition among Haitian children under 5 declined significantly between 2005–06 and 2012. Our results should be interpreted in view of investments and changes that occurred in different sectors (within and outside health and nutrition) before and after the earthquake.

Predictors of Anemia among Haitian Children Aged 6 to 59 Months and Women of Childbearing Age and Their Implications for Programming

Background The Haitian National Nutrition Policy prioritizes prevention and treatment of anemia among mothers and young children, but there are few available data to support planning for scale-up of anemia interventions. Objective To describe the prevalence and predictors of anemia among Haitian women (15 to 49 years) and children (6 to 59 months) and to draw implications for national nutrition programming. Methods Descriptive and univariate analyses and multivariate logistic regression models were performed using data from the nationally representative Haitian Demographic Health Survey 2005/06. Results The prevalence of mild (hemoglobin 11.0 to 11.9 g/dL), moderate (hemoglobin 8.0 to 10.9 g/dL), and severe (hemoglobin < 8.0 g/dL) anemia was 19.2%, 21.7%, and 4.4%, respectively, among women aged 15 to 49 years and 22.9%, 33.9%. and 2.2% among children aged 6 to 59 months. Unexpectedly, anemia was more prevalent in urban women (54.4 %) and children (65.1%) than in rural women (43.1%, p < .001) and children (55.7%, p = .004). In multivariate regression models, factors associated with anemia among urban women (birth spacing, p = .027; overweight BMI, p < .001; education level, p = .022) were different from those in rural women (wealth quintile, p < .05; employment, p = .003). Anemia in urban and rural children aged 6 to 59 months increased with child age (p < .05) and maternal anemia status (p = .004; p < .001). Female sex (p = .007) and maternal overweight (p = .009) were associated with reduced risk of anemia in rural children only. Conclusions Anemia among Haitian young children and women of childbearing age is a severe public health problem. The findings suggest the need for context-specific rural and urban strategies, reinforcement of anemia prevention in health services reaching women of childbearing age, and targeted interventions for young children.

Measuring Implementation Strength for Integrated Community Case Management in Malawi: Results from a National Cell Phone Census

Program managers, investors, and evaluators need real-time information on how program strategies are being scaled up and implemented. Integrated Community Case Management (iCCM) of childhood illnesses is a strategy for increasing access to diagnosis and treatment of malaria, pneumonia, and diarrhea through community-based health workers. We collected real-time data on iCCM implementation strength through cell phone interviews with community-based health workers in Malawi and calculated indicators of implementation strength and utilization at district level using consensus definitions from the Ministry of Health (MOH) and iCCM partners. All of the iCCM implementation strength indicators varied widely within and across districts. Results show that Malawi has made substantial progress in the scale-up of iCCM since the 2008 program launch. However, there are wide differences in iCCM implementation strength by district. Districts that performed well according to the survey measures demonstrate that MOH implementation strength targets are achievable with the right combination of supportive structures. Using the survey results, specific districts can now be targeted with additional support.

Complementary Feeding Interventions Have a Small but Significant Impact on Linear and Ponderal Growth of Children in Low- and Middle-Income Countries: A Systematic Review and Meta-Analysis

Background: World Health Assembly member states have committed to ambitious global targets for reductions in stunting and wasting by 2025. Improving complementary diets of children aged 6-23 mo is a recommended approach for reducing stunting in children <5 y old. Less is known about the potential of these interventions to prevent wasting.Objective: The aim of this article was to review and synthesize the current literature for the impact of complementary feeding interventions on linear [length-for-age z score (LAZ)] and ponderal [weight-for-length z score (WLZ)] growth of children aged 6-23 mo, with the specific goal of updating intervention-outcome linkages in the Lives Saved Tool (LiST).Methods: We started our review with studies included in the previous LiST review and searched for articles published since January 2012. We identified longitudinal trials that compared children aged 6-23 mo who received 1 of 2 types of complementary feeding interventions (nutrition education or counseling alone or complementary food supplementation with or without nutrition education or counseling) with a no-intervention control. We assessed study quality and generated pooled estimates of LAZ and WLZ change, as well as length and weight gain, for each category of intervention.Results: Interventions that provided nutrition education or counseling had a small but significant impact on linear growth in food-secure populations [LAZ standardized mean difference (SMD): 0.11; 95% CI: 0.01, 0.22] but not on ponderal growth. Complementary food supplementation interventions with or without nutrition education also had a small, significant effect in food-insecure settings on both LAZ (SMD: 0.08; 95% CI: 0.04, 0.13) and WLZ (SMD: 0.05; 95% CI: 0.01, 0.08).Conclusions: Nutrition education and complementary feeding interventions both had a small but significant impact on linear growth, and complementary feeding interventions also had an impact on ponderal growth of children aged 6-23 mo in low- and middle-income countries. The updated LiST model will support nutrition program planning and evaluation efforts by allowing users to model changes in intervention coverage on both stunting and wasting.

Pre-earthquake non-epidemic Vibrio cholerae in Haiti.

Introduction To our knowledge, there was no record of Vibrio cholerae in Haiti until the 2010 post earthquake outbreak. Methodology This study describes the analysis of 301 stool samples from 117 infants in Port-au-Prince, Haiti, who participated in a pediatric nutrition study between July 2008 and October 2009. Results Nine samples were identified positive with both SYBR Green and Taqman-MGB probe based molecular assays targeting V. cholerae hlyA and toxR, respectively (Ct = 33 – 40), but none were O1 or O139. Conclusions Our results from multiple molecular assays demonstrate the presence of non-O1/O139 V. cholerae DNA in stools collected from nine asymptomatic Haitian infants two years prior to the 2010 earthquake.

Modeling the Impact of Nutrition Interventions on Birth Outcomes in the Lives Saved Tool (LiST)

Background: Negative birth outcomes [small-for-gestational age (SGA) and preterm birth (PTB)] are common in low- and middle-income countries and have important subsequent health and developmental impacts on children. There are numerous nutritional and non-nutritional interventions that can decrease the risk of negative birth outcomes and reduce subsequent risk of mortality and growth faltering.Objective: The objective of this article was to review the current evidence for the impact of nutritional interventions in pregnancy [calcium supplementation, iron and folic acid supplementation, multiple micronutrient (MMN) supplementation, and balanced energy supplementation (BES)] and risk factors (maternal anemia) on birth outcomes, with the specific goal of determining which intervention-outcome linkages should be included in the Lives Saved Tool (LiST) software.Methods: A literature search was conducted by using the WHO e-Library of Evidence for Nutrition Actions as the starting point. Recent studies, meta-analyses, and systematic reviews were reviewed for inclusion on the basis of their relevance to LiST.Results: On the basis of the available scientific evidence, the following linkages were found to be supported for inclusion in LiST: calcium supplementation on PTB (12% reduction), MMN supplementation on SGA (9% reduction), and BES on SGA (21% reduction among food-insecure women).Conclusions: The inclusion of these linkages in LiST will improve the utility of the model for users who seek to estimate the impact of antenatal nutrition interventions on birth outcomes. Scaling up these interventions should lead to downstream impacts in reducing stunting and child mortality.