Download - ESTIMATING THE IMPACT OF MATERNAL, NEONATAL AND CHILD SURVIVAL INTERVENTIONS Ingrid Friberg, PhD
ESTIMATING THE IMPACT OF MATERNAL, NEONATAL AND CHILD SURVIVAL INTERVENTIONS
Ingrid Friberg, PhD
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
LiST
3
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 makingAid in planning expansion of maternal, neonatal and child health interventions
Objectives: Estimate lives saved when introducing or scaling up key interventions
Demographic estimates and
projections
UN Pop/Spectrum
Number of Child, Maternal and Fetal deaths
Deaths by CauseWHO/UNICEF Country estimates
Deaths averted -By cause-By intervention
General Framework
Intervention Coverage
CurrentTarget/Goal/Endline*Change is critical*
Health Status
•Stunted, wasted•Malaria prevalence•Vit A deficiency•Zinc deficiency
Stunting, Wasting, Breastfeeding
Effectiveness
EstimatesIntervention ImpactC1 C2 C3 C4 …
Int1 Int2 Int3
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
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
Pregnancy 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)
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
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
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 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
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 …
What LiST is, What LiST 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
Is Isn’t
DATA AND MODELING
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
Stunting
Zinc
Diarrhea incidence
IUGRAppropriate Complementary Feeding
Complementary feeding education and/or supplementation
Previous Stunting
Malaria Mortality
DiseaseSpecificTreatments
DiseaseSpecific Preventions
Risk factors
ITN/IRS
Antimalarials
Stunting
Wasting
PneumoniaMortality
Hib vaccineBreast Feeding Promotion
Pneumococcal vaccine
Oral antibiotics for pneumonia
Zinc for prevention
Diarrhea incidence
Improved H2O source within 30 minutes
Hand washing with soap
Water connection in the home
Improved sanitation
Hygienic disposal of children’s stools
Stunting
IUGR
Pregnant women protected via IPT or sleeping under an ITN
Balanced energy supplementation
Multiple micronutrient supplementation
Breast Feeding
Wasting Therapeutic feeding
Complementary feeding education/supplementation
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• 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
LIST“VALIDATION”USES
Neonatal Package Modeling
ACSD Results
Modeling Mortality Rates and Equity
ITN studies
How can LiST 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?
How has LiST 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 LiST?
Gates Foundation, GAVI USAID, DFID, CIFF MCHIP Save the Children, Saving Newborn
Lives, MSH WHO (GAPP), UNICEF CHAI
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!
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
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
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 - [email protected]