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2
DISEASE CONTROL PRIORITIES THIRD EDITION
Reproductive, Maternal,
Newborn, and Child Health
DISEASE CONTROL PRIORITIES THIRD EDITION
Series Editors
Dean T. Jamison
Rachel Nugent
Hellen Gelband
Susan Horton
Prabhat Jha
Ramanan Laxminarayan
Charles N. Mock
Dean T. Jamison
Rachel Nugent
Hellen Gelband
Susan Horton
Prabhat Jha
Ramanan Laxminarayan
Charles N. Mock
VOLUME
2
DISEASE CONTROL PRIORITIES THIRD EDITION
Reproductive, Maternal,
Newborn, and Child Health
EDITORS
Robert E. Black
Ramanan Laxminarayan
Marleen Temmerman
Neff Walker
2016 International Bank for Reconstruction and Development / The World Bank
1818 H Street NW, Washington, DC 20433
Telephone: 202-473-1000; Internet: www.worldbank.org
1 2 3 4 19 18 17 16
This work is a product of the staff of The World Bank with external contributions. The findings, interpretations, and
conclusions expressed in this work do not necessarily reflect the views of The World Bank, its Board of Executive Directors,
or the governments they represent. The World Bank does not guarantee the accuracy of the data included in this work. The
boundaries, colors, denominations, and other information shown on any map in this work do not imply any judgment on the
part of The World Bank concerning the legal status of any territory or the endorsement or acceptance of such boundaries.
Nothing herein shall constitute or be considered to be a limitation upon or waiver of the privileges and immunities of
The World Bank, all of which are specifically reserved.
Softcover: Hardcover:
ISBN: 978-1-4648-0348-2 ISBN: 978-1-4648-0347-5
ISBN (electronic): 978-1-4648-0368-0
DOI: 10.1596/978-1-4648-0348-2 DOI: 10.1596/978-1-4648-0347-5
Cover photo: Foune Kouyate waits to vaccinate her baby, Kadidia Goulibaly, at the Centre De Sante Communautaire De Banconi
(ASACOBA), a health clinic in Bamako, Mali, on November 4, 2013. Dominic Chavez/World Bank. Further permission required
for reuse.
Cover and interior design: Debra Naylor, Naylor Design, Washington, DC.
Foreword xi
Preface xiii
Abbreviations xv
1. Reproductive, Maternal, Newborn, and Child Health: Key Messages of This Volume 1
Robert E. Black, Neff Walker, Ramanan Laxminarayan, and Marleen Temmerman
PART 1 REPRODUCTIVE, MATERNAL, AND CHILD MORTALITY AND MORBIDITY AND THE
UNMET NEED FOR FAMILY PLANNING
ix
9. Diarrheal Diseases 163
Gerald T. Keusch, Christa Fischer Walker, Jai K. Das, Susan Horton, and Demissie Habte
14. Community-Based Care to Improve Maternal, Newborn, and Child Health 263
Zohra S. Lassi, Rohail Kumar, and Zulfiqar A. Bhutta
15. Innovations to Expand Access and Improve Quality of Health Services 285
Lori A. Bollinger and Margaret E. Kruk
16. Returns on Investment in the Continuum of Care for Reproductive, Maternal, Newborn,
and Child Health 299
Karin Stenberg, Kim Sweeny, Henrik Axelson, Marleen Temmerman, and Peter Sheehan
18. The Benefits of a Universal Home-Based Neonatal Care Package in Rural India:
An Extended Cost-Effectiveness Analysis 335
Ashvin Ashok, Arindam Nandi, and Ramanan Laxminarayan
19. Health Gains and Financial Risk Protection Afforded by Treatment and Prevention
of Diarrhea and Pneumonia in Ethiopia: An Extended Cost-Effectiveness Analysis 345
Stphane Verguet, Clint Pecenka, Kjell Arne Johansson, Solomon Tessema Memirie,
Ingrid K. Friberg, Julia R. Driessen, and Dean T. Jamison
x Contents
Foreword
When I became the Deputy Director of the Child Survival future where we reach the highest attainable standard
Partnership in 2004, I knew the task at hand was a chal- of health for all women, children, and adolescents. A
lenging one. We were only four years into the Millennium new funding mechanism, The Global Financing Facility
Development Goals (MDGs), but we already knew that in Support of Every Woman, Every Child, aims to bring
moving the needle on maternal and child survival would together existing and new sources of financing for
take more headway and greater advances. Since then, and smart, scaled, and sustainable financing to accelerate
particularly since 2010, we have accelerated progress in efforts to end preventable maternal, newborn, and child
an unprecedented manner, mobilized actors and part- deaths by 2030.
ners, and improved our way of working. Strategy, financing, and delivery of services need to
We have undergone an extraordinary transformation, be guided by the best available scientific knowledge on
halving maternal and child mortality under the MDGs. the efficacy of interventions and the effectiveness of pro-
As we transition to the Sustainable Development Goals grams. This volume of the Disease Control Priorities, third
(SDGs), we are in a much better position to achieve the edition (DCP3) series, Reproductive, Maternal, Newborn,
global and equitable progress we seek for all people. and Child Health, provides this rigorous knowledge base.
Goal 3 of the 17 SDGs is to ensure healthy lives and Readers now have at their fingertips the most relevant
promote well-being for all at all ages. This broad goal technical information on which interventions, pro-
embraces the unfinished agenda of the MDGs and goes grams, service delivery platforms, and policies can best
beyondto virtually end preventable maternal, new- help all to reach the ambitious Global Goal 3 targets
born, and child deaths and to improve access to sexual maternal mortality rates lower than 70 maternal deaths
and reproductive health, as well as access to medicines per 100,000 live births, neonatal mortality rates of 9
and vaccines. By moving toward this goal, we are work- per 1,000 live births, and stillbirth rates of 9 per 1,000
ing to protect the future and well-being of those closest total births. It is a source of great pride to know that my
to us: our mothers, children, and communities. WHO team, led by Professor Dr. Marleen Temmerman,
The 201015 Global Strategy for Womens and Director of the Department of Reproductive Health and
Childrens Health brought together hundreds of part- Research, contributed to this work. My team will con-
ners around the Every Woman Every Child movement tinue its efforts to end preventable mortality worldwide
to jointly achieve the ambitious goals for maternal and to achieve the three broad goals embraced by the
and child health. Building on this progress, the United new Global Strategysurvive, thrive, and transform.
Nations (UN) Secretary-General, in September 2015, We all have a role to play as we put this Global
launched a follow-up roadmap for 201630 at the UN Strategy into practice in every corner of the globe. We
General Assembly, The Global Strategy for Womens, need everyones continued engagement, support, and
Childrens, and Adolescents Health. The new strategy commitments. We have the knowledge, the tools, and
aligns fully with the SDGs, embracing the vision of a the will. A transformation by 2030 is within our reach.
xi
Preface
Reproductive, maternal, newborn, and child health of preventive and therapeutic interventions, as well
(RMNCH) encompasses health concerns spanning the as cost-effectiveness of these interventions and health
life course from adolescent girls to women before and system considerations for their implementation. The
during pregnancy to newborns and older children. In volume gives particular attention to the efficient and
recent years, it has been recognized that appropriately effective use of delivery platforms to provide pack-
addressing these concerns requires organizing services ages of interventionsa framing that supports country
in a continuum of care that encompasses these stages decision-making for universal health care. Despite our
in the life course. The rationale for the organization objective of covering a broad range of RMNCH topics
of the RMNCH volume is based on the link between in this volume, some topics of relevance to women and
interventions at each stage and health effects at that stage children were found to fit better in other volumes. These
and future stages, and consequently the need to deliver include surgical conditions, cancer, mental and develop-
integrated, preventive, and therapeutic interventions for mental disorders, HIV/AIDS and sexually transmitted
mothers and children. infections, malaria, injuries, and adolescent health and
In considering interventions that span the RMNCH development.
continuum, DCP3 has departed from the disease-specific RMNCH interventions have received significant
framing of interventions that was followed in previous attention in low- and middle-income countries and
editions. DCP1, published in 1993, largely focused on among international donors. The reasons for this include
individual diseases and conditions with those regarding the high burden of disease and the evidence that many
RNMCH. DCP1 referred to the unfinished agenda efficacious and cost-effective interventions are available
that included major diseases, such as acute respiratory to dramatically reduce the burden of ill health. The
infection, diarrhea, malaria, and poliomyelitis, as well promulgation of the Millennium Development Goals,
as malnutrition, HIV/AIDS and sexually transmitted with their strong focus on RMNCH concerns, gave fur-
infections, excess fertility, and maternal and perinatal ther impetus to implementation of the proven interven-
health, but it did not include the broader issue of neo- tions. It has been important that review of the evidence
natal health. In DCP2, published in 2006, nine of the 73 for new interventions and program approaches has con-
chapters were on RMNCH, reflecting the broader scope tinued through academic journals such as The Lancet,
of that edition including a greater emphasis on noncom- DCP, and other critical exercises that have identified
municable diseases, health system strengthening, and the needs and opportunities in RMNCH. Substantial
cross-cutting issues. success has been achieved with unprecedented declines
The unfinished agenda of RMNCH continues to in maternal and child mortality and fertility; however,
be as important today as it was in 1993. This volume problems remain, including large inequities among and
contains 19 chapters that range from descriptions of the within low- and middle-income countries in health ser-
current levels and causes of reproductive ill health, mater- vices and outcomes.
nal and child morbidity and mortality, undernutrition, We intend for this volume to provide an update of the
and compromised child development, to consideration evidence and help to shape what can be implemented
xiii
in integrated packages of services for reproductive We thank the following individuals who provided
health, maternal and newborn health, and child health valuable assistance and comments in the development
to achieve the new Sustainable Development Goals. of this volume: Brianne Adderley, Kristen Danforth, Alex
In addition, we hope that consideration of delivery of Ergo, Victoria Fan, Mary Fisk, Glenda Gray, Rajat Khosla,
interventions with greatest coverage and equity will pri- Nancy Lammers, Rachel Nugent, Rumit Pancholi, Helen
oritize strengthening of the three interlinked platforms: Pitchik, Carlos Rossel, Lale Say, Rachel Upton, Kelsey
communities, primary health centers, and hospitals. We Walters, and Gavin Yamey. We also thank the RMNCH
now have the knowledge and means to fully address the Authors Group for the preparation of the chapters and
unfinished agenda of RMNCH and must not miss the the reviewers organized by the National Academy of
opportunity and the obligation to act. Medicine (formerly the Institute of Medicine).
Robert E. Black
Ramanan Laxminarayan
Marleen Temmerman
Neff Walker
xiv Preface
Abbreviations
xv
EPI Expanded Program on Immunization
FBF fortified blended flour
FRP financial risk protection
GAM global acute malnutrition
Gavi Global Alliance for Vaccines and Immunization
GBS Group B streptococcus
GDP gross domestic product
GNI gross national income
HAZ height-for-age Z-score
HBNC home-based neonatal care
HEP health extension program
HEW health extension worker
HiB Haemophilus influenzae B
HICs high-income countries
HIV human immunodeficiency virus
HR hazard ratio
HSV-2 herpes simplex virus-2
IAP intrapartum antibiotic prophylaxis
iCCM Integrated Community Case Management
ICD International Classification of Diseases
ICPD International Conference on Population and Development
IDA iron deficiency anemia
IIV inactivated influenza vaccine
IMCI Integrated Management of Childhood Illness
IMNCI Integrated Management of Neonatal and Childhood Illness
IMPAC Integrated Management in Pregnancy and Childcare
IPT intermittent preventive treatment
ITN insecticide-treated bednet
IU international unit
IUD intrauterine device
IUGR intrauterine growth restriction
IYCF infant and young child feeding
JE Japanese encephalitis
LBW low birth weight
LHWs Lady Health Workers
LICs low-income countries
LiST Lives Saved Tool
LMICs low- and middle-income countries
LNS lipid-based nutrient supplement
LRI lower respiratory tract infections
LYS life-year saved
MAM moderate acute malnutrition
MD mean difference
MDG Millennium Development Goal
MgSO4 magnesium sulphate
MICs middle-income countries
MMR maternal mortality ratio
MNP multiple micronutrient powder
MUAC mid-upper arm circumference
NIMS Nutrition Impact Model Study
NMR newborn mortality rate
NPV net present value
OHT One Health Tool
xvi Abbreviations
OOP out-of-pocket
OPV oral polio vaccine
ORS oral rehydration solution
PBF performance-based financing
PCV pneumococcal conjugate vaccination
PPH postpartum hemorrhage
PUFA polyunsaturated fatty acids
QALY quality-adjusted life year
RCT randomized controlled trial
RDS respiratory distress syndrome
RDT rapid diagnostic test
RMNCH reproductive, maternal, newborn, and child health
RR relative risk
RUF ready-to-use food
RUSF ready-to-use supplementary food
RUTF ready-to-use therapeutic food
SAM severe acute malnutrition
SFP supplementary feeding program
SGA small for gestational age
STI sexually transmitted infection
TFC therapeutic feeding center
TFR total fertility rate
UCTs unconditional cash transfers
UHC universal health coverage
UMICs upper-middle-income countries
UN United Nations
UNICEF United Nations Childrens Fund
UPF universal public finance
USAID United States Agency for International Development
VLY value of a life-year saved
WASH Water, sanitation, and hygiene
WHO World Health Organization
WHZ weight-for-height z-score
YICSSG Young Infants Clinical Signs Study Group
Abbreviations xvii
Chapter
1
Reproductive, Maternal, Newborn, and Child
Health: Key Messages of This Volume
Robert E. Black, Neff Walker, Ramanan Laxminarayan, and
Marleen Temmerman
Corresponding author: Robert E. Black, Johns Hopkins Bloomberg School of Public Health, rblack1@jhu.edu.
1
The three packages of reproductive, maternal and new- child health has increased from US$2.7 billion in 2003
born, and child health interventions have an annual to US$8.3 billion in 2012, when there was an additional
incremental cost of US$6.2 billion in low-income US$4.5 billion for reproductive health (Arregoces and
countries, US$12.4 billion in lower-middle-income others 2015). A continued focus on RMNCH is needed
countries, and US$8.0 billion in upper-middle- to address the remaining considerable burden of disease
income countries. The average per capita cost of in LMICs from unwanted pregnancies; high maternal,
these three packages is US$6.7, US$4.7, and US$3.9 newborn, and child mortality and stillbirths; high rates
in low-, lower-middle-, and upper-middle-income of undernutrition; frequent communicable and non-
countries, respectively. communicable diseases; and loss of human capacity.
These packages of interventions are delivered through Cost-effective interventions are available and can be
three key service platforms: community workers and implemented at high coverage in LMICs to greatly
health posts, primary health centers, and hospitals reduce these problems at an affordable cost.
(first level and referral). Community and primary RMNCH encompasses health problems across the
health center platforms could reduce 77 percent of life course from adolescent girls and women before
maternal, newborn, and child deaths and stillbirths and during pregnancy and delivery, to newborns and
that are preventable by these essential interventions children. An important conceptual framework is the
in the maternal and newborn health and child health continuum-of-care approach in two dimensions. One
packages. Hospitals contribute the remaining averted dimension recognizes the links from mother to child and
deaths through more advanced management of com- the need for health services across the stages of the life
plicated pregnancies and deliveries, severe infec- course. The other is the delivery of integrated preventive
tious diseases, and malnutrition in these calculations. and therapeutic health interventions through service
Contraceptive services are considered to be almost platforms ranging from the community to the primary
entirely delivered at primary health centers. health center and the hospital.
Weaknesses in RMNCH delivery platforms, includ- This volume presents the levels and trends of RMNCH
ing limited access to care, poor quality of services, indicators, proven interventions for prevention of mor-
and shortages of health workers or medicines, are tality, costs of these interventions and potential health
a major barrier to improving RMNCH outcomes. service delivery platforms, and system innovations.
To overcome these weaknesses and expand access to Other volumes in the third edition of Disease Control
RMNCH services, innovative delivery approaches Priorities also cover topics of importance to women and
are being deployed, such as task-shifting to other children that are related to the RMNCH health services
cadres of workers, household visitation, community packages (box 1.1). These topics include the following:
mobilization and service delivery, financial incentives
for households and health workers, and supervision Trauma care; obstetric surgery; obstetric fistula; sur-
and accreditation. gery for family planning, abortion, and postabortion
care; and surgery for congenital anomalies (Volume 1,
Essential Surgery)
INTRODUCTION
Breast cancer, cervical cancer and precancer, child-
Reproductive, maternal, newborn, and child health hood cancer, and cancer pain relief (Volume 3,
(RMNCH) has been a priority for both governments Cancer)
and civil society in low- and middle-income countries Childhood mental and developmental disorders
(LMICs). This priority was affirmed by world lead- (Volume 4, Mental, Neurological, and Substance Use
ers in the Millennium Development Goals (MDGs) Disorders)
that called for countries to reduce child mortality Cardiovascular and respiratory disorders (Volume 5,
by 67 percent and maternal mortality by 75 percent Cardiovascular, Respiratory, and Related Disorders)
between 1990 and 2015. Although substantial progress HIV/AIDS and other sexually transmitted infections,
on these targets has been made, few countries achieved tuberculosis, and malaria (Volume 6, HIV/AIDS,
the needed reductions. The United Nations (UN) STIs, Tuberculosis, and Malaria)
Secretary-Generals Global Strategy for Womens and Road traffic injury and interpersonal violence
Childrens Health, launched in 2010 and expanded in (Volume 7, Injury Prevention and Environmental
2015 to include adolescents, is an indication of the Health)
continued global commitment to the survival and well- Child (older than five years) and adolescent develop-
being of women and children (Ban 2010). Annual offi- ment (the subject of the entire Volume 8, Child and
cial development assistance for maternal, newborn, and Adolescent Development).
Budgets constrain choices. Policy analysis helps offers an approach that explicitly includes financial
decision makers achieve the greatest value from protection as well as the distribution across income
limited available resources. In 1993, the World Bank groups of financial and health outcomes resulting
published Disease Control Priorities in Developing from policies (for example, public finance) to increase
Countries (DCP1), an attempt to systematically intervention uptake (Verguet, Laxminarayan, and
assess the cost-effectiveness (value for money) of Jamison 2015). The task in all the volumes has been
interventions that would address the major sources to combine the available science about interventions
of disease burden in low- and middle-income coun- implemented in very specific locales and under very
tries (Jamison and others 1993). The World Banks specific conditions with informed judgment to reach
1993 World Development Report on health drew reasonable conclusions about the impact of interven-
heavily on DCP1s findings to conclude that specific tion mixes in diverse environments. DCP3s broad
interventions against noncommunicable diseases aim is to delineate essential intervention packages
were cost-effective, even in environments in which such as the essential packages in this volumeand
substantial burdens of infection and undernutrition their related delivery platforms. This information
persist (World Bank 1993). will assist decision makers in allocating often tightly
DCP2, published in 2006, updated and extended constrained budgets so that health system objectives
DCP1 in several respects, including explicit consid- are maximally achieved.
eration of the implications for health systems of DCP3s nine volumes are being published in 2015
expanded intervention coverage (Jamison and oth- and 2016 in an environment in which serious dis-
ers 2006). One way that health systems expand inter- cussion continues about quantifying the sustainable
vention coverage is through selected platforms that development goal (SDG) for health (United Nations
deliver interventions that require similar logistics 2015). DCP3s analyses are well placed to assist in
but address heterogeneous health problems. choosing the means to attain the health SDG and
Platforms often provide a more natural unit for assessing the related costs. Only when these volumes,
investment than do individual interventions, and and the analytic efforts on which they are based, are
conventional health economics has offered little completed will we be able to explore SDG-related
understanding of how to make choices across and other broad policy conclusions and generaliza-
platforms. Analysis of the costs of packages and tions. The final DCP3 volume will report those con-
platformsand of the health improvements clusions. Each individual volume will provide
they can generate in given epidemiological valuable specific policy analyses on the full range of
environmentscan help guide health system invest- interventions, packages, and policies relevant to its
ments and development. health topic.
The third edition is being completed. DCP3 differs
substantively from DCP1 and DCP2 by extending Dean T. Jamison
and consolidating the concepts of platforms and Rachel Nugent
packages and by offering explicit consideration of the
financial-risk-protection objective of health systems. Hellen Gelband
In populations lacking access to health insurance or Susan Horton
prepaid care, medical expenses that are high relative Prabhat Jha
to income can be impoverishing. Where incomes are
low, seemingly inexpensive medical procedures can Ramanan Laxminarayan
have catastrophic financial consequences. DCP3 Charles N. Mock
Reproductive, Maternal, Newborn, and Child Health: Key Messages of This Volume 3
LEVELS AND TRENDS IN RMNCH An estimated 74 million unintended pregnancies
INDICATORS occurred in LMICs in 2012 (Sedgh, Singh, and Hussain
2014). Some of these ended by unsafe abortion, a major
Reproductive Health cause of maternal morbidity and mortality (Singh,
Poor reproductive health outcomes for women and Sedgh, and Hussain 2010). About 8.5 million women
their children may result from a broad spectrum of worldwide suffer complications from unsafe abortions
morbid conditions and adverse circumstances and annually (Singh, Darroch, and Ashford 2014). Regardless
risk factors, such as unsafe sex leading to unwanted of legal status or policies on abortion, it can be fairly
pregnancies and sexually transmitted infections, as stated that preventing unsafe abortion is critical and
well as violence against women and girls. Because these that effective programming for reproductive health
are sensitive matters and are often related to gender needs should be uncoupled from laws on the legal sta-
inequality in a cultural and social context, measuring tus of abortion. The large effects of reducing unwanted
and quantifying the burden of these conditions and pregnancies on maternal, neonatal, and child deaths and
risk factors remains a challenge. This DCP3 volume stillbirths are estimated in a later section of this chapter.
focuses on four conditions and risk factors that have Another hidden burden of reproductive health is
significant impacts on reproductive health: unwanted infertility. In 2010, an estimated 48.5 million women
pregnancies, unsafe abortions, infertility, and violence were involuntarily childless as a result of male or female
against women. infertility, or both. This is especially concerning in
In 2015, 12 percent of married or in-union women LMICs, where infertility can lead to severe stigmatiza-
of reproductive age worldwide want to delay or tion, economic deprivation and denial of inheritance,
avoid pregnancy but are not using any method of divorce, and social isolation (Chachamovich and others
contraception. For example, women in Sub-Saharan 2010; Cui 2010).
Africa are twice as likely to have an unmet need for As an extreme manifestation of social and gender
family planning compared with the rest of the world inequality, violence against women and girls is often
(UN 2015). The total fertility rate remains very high a hidden problem, with serious health consequences.
in many countries in Sub-Saharan Africa (map 1.1, Women exposed to intimate partner violence are more
panel a). likely to have poor pregnancy outcomes; acquire HIV
Map 1.1 Total Fertility, Maternal Mortality Ratios, and Under-Five Mortality Rates by Country, 2015
a. Total Fertility (children per woman) 201015
IBRD 42133 | JANUARY 2016
11.9
22.9
33.9
44.9
55.9
>6
Data not available
or not applicable
Source: Based on UNPD 2015 (http://esa.un.org/unpd/wpp); map re-created based on WHO 2015.
119
2099
100299
300499
500999
>1,000
Data not available
or not applicable
14.9
514.9
1524.9
2554.9
>55
Data not available
or not applicable
(in some regions), syphilis, chlamydia, or gonorrhea; 30 percent of women age 1549 years in a relation-
experience depression; or have alcohol abuse disor- ship experience physical or sexual violence by their
ders (WHO, Department of Reproductive Health and intimate partner at some point in their lives (WHO,
Research, London School of Hygiene and Tropical Department of Reproductive Health and Research,
Medicine, and South African Medical Research London School of Hygiene and Tropical Medicine,
Council 2013). Studies have found between 3 percent and South African Medical Research Council 2013).
and 31 percent of women report partner violence dur- Tragically, many women do not seek help following
ing pregnancy (Devries and others 2010). Worldwide, these events.
Reproductive, Maternal, Newborn, and Child Health: Key Messages of This Volume 5
Maternal Mortality and Morbidity Perinatal, Neonatal, and Child Mortality
Globally, the total number of maternal deaths The under-five mortality rate (U5MR), the probabil-
decreased by 43 percent, from 532,000 in 1990 to ity of dying between a live birth and the fifth birthday,
303,000 in 2015, and the global maternal mortality is one of the most important measures of the health
ratio declined by 44 percent, from 385 maternal of a population. Although MDG 4 was not achieved
deaths per 100,000 live births in 1990 to 216 in globally, some high-mortality countries in South Asia
2015 (Alkema and others 2015). LMICs continue to and Sub-Saharan Africa have achieved this target
account for 99 percent (302,000 out of 303,000) of (Afnan-Holmes and others 2015; Amouzou and oth-
global maternal deaths. The highest risks of maternal ers 2012). The U5MR remains very high, especially
death are in countries in South Asia and Sub-Saharan in many countries in Sub-Saharan Africa (map 1.1,
Africa (map 1.1, panel b). Thus, while considerable panel c).
progress has been made, particularly in recent years, The U5MR in 2015 is 42.5 per 1,000 live births, a
the goal of reducing maternal mortality by 75 percent decline from 90.6 per 1,000 live births in 1990 (You
by 2015 was not met. and others 2015). The U5MR fell by half or more from
The risk of maternal death has two components: the 1990 to 2015 in all world regions. The UN estimates
risk of getting pregnant, which is a risk related to fertility that only 24 of 82 low- or lower-middle-income coun-
and its control or lack of control; and the risk of devel- tries achieved the MDG 4 target (You and others 2015).
oping a complication and dying while pregnant, in labor, However, it is important to note that compared with
or postpartum. Chapter 3 of this volume, on maternal historical trends, the reduction of U5MR has accelerated
morbidity and mortality, focuses on the risk during since 2000, when the MDGs were approved (You and
pregnancy, delivery, and postpartum, which is highest at others 2015).
the time of delivery (Filippi and others 2016). The neonatal mortality rate is now widely followed as
The most important causes of maternal death are an important population health measure because a large
obstetric hemorrhage, hypertension, abortion, and proportion (45 percent in 2015) of the deaths in children
sepsis (figure 1.1, panel a). The overall proportion of under age five years occurs in the first month of life. In
HIV-related maternal deaths is highest in Sub-Saharan addition, the rate of stillbirths has received more atten-
Africa (Say and others 2014). Most maternal deaths tion with the recognition of the large number of viable
do not have well-defined medical causes, and given fetuses (2.6 million in 2015) who die after 28 weeks of
that many occur in the community rather than health gestation, often at the time of delivery (Blencowe and
facilities, determining the cause is challenging. Deaths others 2016).
due to abortive outcomes (for example, ectopic preg- Of the 5.9 million deaths occurring after a live birth
nancy, induced abortion, and miscarriage), obstructed before age five years, pneumonia, diarrhea, and neonatal
labor, and indirect causes are of considerable pro- sepsis or meningitis are the leading infectious causes
grammatic interest, but are particularly difficult to (figure 1.1, panel b). The leading single cause of child
capture because of poor reporting resulting from lack deaths was complications from preterm birth, followed
of knowledge and the sensitive nature of abortion and by pneumonia and intrapartum-related complications,
maternal deaths in facilities. Deaths due to abortion formerly known as birth asphyxia. In the next 15 years,
are often not reported to avoid stigma. Despite the with further implementation of proven health interven-
availability of proven interventions, the persistence of tions, it is anticipated that the infectious causes of death
deaths due to hemorrhage and hypertension are par- will decline more quickly than noninfectious causes (Liu
ticularly concerning. and others 2014).
The common causes of maternal morbidity in The proportion of global live births in Sub-Saharan
the community vary by region; these causes include Africa is projected to increase from 24.9 percent
anemia, preexisting hypertension or diabetes, depres- currently to 32.6 percent by 2030 because of the
sion, and other mental health conditions. Prolonged regions high fertility rate compared with other
and obstructed labor is associated with a high burden of regions. If the current regional trends in child mor-
morbidity and disability, including that due to obstetric tality are continued to 2030, global child deaths will
fistula. The true extent of maternal morbidity is not fall to 4.4 million (Liu and others 2014). However,
known because of difficulties in definition and mea- because of both the high number of births and high
surement. The World Health Organization (WHO) is U5MR, Sub-Saharan Africas share of global child
currently working with partners to develop standard deaths is expected to increase from 49.6 percent to
definitions and tools to close this gap. 59.8 percent by 2030.
Pneumonia 13%
Preterm birth
complications 16%
Sepsis
Intrapartum-related
11% Other disorders events 11%
Hemorrhage 11%
Hypertension 27% Sepsis 7%
14%
Neonatal 45% Congenital
abnormalities 5%
Embolism
Abortion 8% Other neonatal
3% Diarrhea disorders 3%
Other 9%
direct 4% Preexisting Pneumonia 3%
medical Injury 6%
Tetanus <1%
Obstructed conditions
labor 3% 15% Malaria 5% Diarrhea <1%
HIV-related Congenital abnormalities
Complications 5% 4%
of delivery Other indirect
3% causes 7% Preterm birth
Meningitis complications AIDS Measles Pertussis Intrapartum-related
2% 2% 1% 1% <1% events <1%
Source: Say and others 2014. Source: Liu and others 2016.
MATERNAL, FETAL, AND CHILD been published (Villar and others 2014). Compared with
MALNUTRITION AND EARLY CHILD this standard, the estimated global prevalence of small-
for-gestational-age births is about one-quarter lower
DEVELOPMENT (Kozuki and others 2015). As neonates and infants, these
Malnutrition includes both undernutrition and the babies have a higher risk of mortality than babies who
growing problem of overweight, both important prob- were appropriate weight for gestational age, and this risk
lems in women and children under age five years. In is similar using either the U.S. reference or the new inter-
women of reproductive age (age 2049 years), a body national standard (Kozuki and others 2015). They also
mass index (BMI) of less than 18.5 kilograms weight/ have an increased risk of stunted linear growth (Black
height in meters squared (kg/m2) is defined as under- and others 2013; Christian and others 2013). The risk of
nutrition or excessive thinness, and a BMI of greater mortality with small-for-gestational age birth increases
than or equal to 25 kg/m2 is considered overweight. if they are also premature.
The prevalence of maternal undernutrition has fallen Compared with an international growth standard, it
from almost 20 percent in Asia and Africa to about was estimated that in 2011 26 percent of children glob-
10 percent, which is still too high (Black and others ally had stunted linear growth (height-for-age of less
2013). The prevalence of overweight in women has than 2 standard deviations of the growth standard),
steadily increased during the same period in all world totaling 165 million children (Black and others 2013).
regions, reaching more than 50 percent in the Americas The prevalence of stunting has declined in LMICs since
and in Oceania, 30 percent in Africa, and 20 percent in 1990, more in Asia and Latin America than in Africa.
Asia (Black and others 2013). Deficiencies of iodine, Stunting prevalence has declined at similar rates in
calcium, zinc, iron, and other essential vitamins and rural and urban areas but remains higher in rural areas
minerals are also prevalent and have particular rele- (Stevens, Paciorek, and Finucane 2016). Severe wasting,
vance to maternal and fetal health. which was estimated to affect 3 percent, or 19 million,
Restriction of fetal growth, usually assessed by a low of the worlds children in 2011, requires urgent inter-
weight for gestational age at birth, is due to poor mater- vention with therapeutic feeding and treatment of con-
nal nutrition and other morbidity, infection, and toxic current infections (Lenters, Wazny, and Bhutta 2016).
in-utero exposures (Das and others 2016). Compared to Of the micronutrient deficiencies, vitamin A and zinc
a U.S. birthweight reference, more than a quarter of all deficiencies are associated with increased risk of mor-
live births in LMICs, or 32.4 million babies, were born tality and infectious disease morbidity (Black and others
small-for-gestational age (Black and others 2013). A new 2013; Das and others 2016). At the same time, over-
international birthweight standard has subsequently weight (greater than 2 standard deviations of the growth
Reproductive, Maternal, Newborn, and Child Health: Key Messages of This Volume 7
standard weight for height) has steadily increased since ESSENTIAL INTERVENTIONS ON
1990 to 7 percent, an increase of more than 50 percent, STILLBIRTHS AND MATERNAL, NEONATAL,
affecting 43 million children.
Fetal growth restriction, suboptimal breastfeeding,
AND CHILD DEATHS
stunting, wasting, and deficiencies of vitamin A and In this volume, we define three packages of interven-
zinc, usually in combination with infectious diseases, tions across the RMNCH continuum with the greatest
are important underlying causes of neonatal and child potential to reduce deaths and disability: reproductive
deaths. These conditions have been estimated to be the health, maternal and newborn health, and child (age
underlying causes of 45 percent of deaths in children 159 months) health.
under age five years (Black and others 2013). We report on estimated morbidity and mortality
Grantham-McGregor and International Child from 75 countries that include more than 95 percent of
Development Committee (2007) estimate that a high the worlds maternal and child deaths, the countries that
proportion of the worlds surviving children do had been monitored in the Countdown to 2015 initiative
not reach their developmental potential, based on (Requejo and others 2015). Estimates are derived using
rates of stunting and poverty. This poor devel- the Lives Saved Tool (LiST; box 1.2) by increasing the
opment outcome has numerous causes, including coverage of each intervention to 90 percent from the
antenatal and postnatal nutrition, exposure to vio- current level of coverage in each of these 75 countries
lence, brain injuries or infections, and environments (Requejo and others 2015).
with insufficient stimulation (Aboud and Yousafzai The deaths averted by individual interventions in
2016). Critical periods for brain development are the maternal and newborn health and the child health
during fetal growth and in the first two years of life. packages are shown in figure 1.2. The immediate (for
Micronutrient deficiencies in pregnancy have impor- 2015) impact on deaths of the individual interventions
tant consequences, such as compromised mental and their combined effects if implemented together was
development with iodine deficiency and neural tube estimated. For these estimates, the effects of folic acid
defects with folic acid deficiency (Black and others supplementation in the reproductive health package
2013). Inadequate diets and high rates of infectious are considered, and these effects are combined with the
diseases in the first two years of life lead to short maternal and newborn package for presentation.
stature (stunting) and permanent deficits in cogni- A separate analysis was undertaken for family plan-
tive and social development. Additional important ning services in the reproductive health package, in
determinants of development in children are the which the provision of contraception is scaled up to
amount and quality of household psychosocial stim- cover 90 percent of current unmet need (Walker, Tam,
ulation (Singla, Kumbakumba, and Aboud 2015) and and Friberg 2013). Because this reduces the number
the effects of maternal illness, including depression of pregnancies, we calculated the number of maternal,
(Walker and others 2007). neonatal, and child deaths and stillbirths that would be
prevented if the rates of mortality in 2015 had applied
to these pregnancies and births. Estimates of the effects
INTERVENTIONS TO REDUCE MATERNAL of other interventions such as human papillomavirus
vaccination or targeted health care approaches for ado-
AND CHILD MORBIDITY AND MORTALITY
lescents are considered in other volumes (for example,
The RMNCH volume identifies essential interventions, volume 3 Cancer and volume 8 Child and Adolescent
based on their efficacy and appropriateness, to address Development).
important health conditions. Tables 1.11.3 list these The impact is also considered for interventions pro-
interventions in the least advanced service platform at vided by each of three platforms for health services (see
which their delivery is possible. The three platforms tables 1.11.3). The community platform includes all
represent services that can be provided by (1) com- interventions that can be delivered by a community-
munity health workers or health posts; (2) primary based health worker with appropriate training and sup-
health centers; or (3) hospitals, both first-level and port or by outreach services, such as child health days,
referral. The interventions are grouped by the point immunizations, vitamin A, and other interventions. For
at which they are needed in the continuum of care. ill children, the integrated community case management
We also consider the nature of their delivery (urgent, (iCCM) approach is assumed to include diagnosis and
continuing care, or routine care), which has important treatment of pneumonia, diarrhea, and malaria cases
implications for the organization and responsibilities without danger signs that indicate the need for refer-
of the health system. ral (Hamer and others 2012; Young and others 2012).
The Lives Saved Tool (LiST) has been continually or size at birth) and cause-specific mortality
developing since 2003. The initial version of the (neonatal, child mortality for those age 159 months,
software was developed as part of the work for the maternal mortality, and stillbirths). The relation-
Child Survival Series in The Lancet in 2003 (Jones ship between an input (change in intervention
and others 2003). The original purpose of the coverage) and one or more outputs is specified as a
program was to estimate the impact that scaling measure of the effectiveness of the intervention in
up community-based interventions would have on reducing the probability of that outcome. The out-
under-five mortality (Jones and others 2003). The come can be cause-specific mortality or a risk factor.
Bill & Melinda Gates Foundation provided support The overarching assumption in LiST is that mortal-
for the further development and maintenance of ity rates and cause-of-death structure will not
the software as part of the work of the Child Health change except in response to changes in coverage of
Epidemiology Reference Group (CHERG). At that interventions.
point, the software was shifted into the free and pub- The roughly 70 separate interventions within LiST
licly available Spectrum software package, to take (see tables 1.11.3) target stillbirths, neonatal mor-
advantage of the demographic capabilities in that tality, mortality in children age 159 months,
software and to provide links to other models for maternal mortality, or risk factors such as stunting
family planning and AIDS (Stover, McKinnon, and and wasting, within the model. In LiST, interven-
Winfrey 2010). Since that time, LiST has expanded tions can be linked to multiple outcomes, with some
its scope to examine the impact of interventions interventions linked to multiple causes of death and
on birth outcomes and stillbirths (Pattinson and risk factors. LiST allows the impact of scaling up
others 2011), maternal mortality, and incidence of coverage of multiple interventions to be examined
pneumonia and diarrhea (Bhutta and others 2013), simultaneously.
as well as neonatal and child mortality.
CHERG, along with its institutional sponsors, the
LiST has been characterized as a linear, mathemati- WHO and UNICEF, developed rules of evidence to
cal model that is deterministic (Garnett and others decide what interventions should be included in the
2011). It describes fixed relationships between model as well as how to develop the estimates of
inputs and outputs that will produce the same out- effectiveness (Walker and others 2010). The assump-
puts each time one runs the model. The primary tions used within LiST are drawn from various
inputs in LiST are coverage of interventions with sources, but most of the evidence about effectiveness
the condition that the quality of that intervention is of interventions is presented in three journal supple-
sufficient to be effective, what is commonly referred ments (Fox and others 2011; Sachdev, Hall, and
to as effective coverage. The outputs are changes in Walker 2010; Walker 2013). The set of assumptions
population-level risk factors (such as wasting or and their sources can be found at the LiST website
stunting rates, birth outcomes such as prematurity, (http://www.livessavedtool.org).
The primary health center (PHC) platform is a facility training and supervision of community-based workers.
with a doctor or a nurse midwife (or both), nurses and For LiST modeling, the effects of meeting the unmet
support staff, as well as basic diagnostic and treatment need for contraceptives are considered to be delivered by
capabilities. The PHC provides facility-based contracep- the PHC platform. For young infants and children, the
tive services, including long-acting reversible contracep- Integrated Management of Childhood Illness approach
tives (implants, intrauterine devices); surgical sterilization is assumed to be used at the PHC level (Bryce and others
(vasectomy, tubal ligation); care during pregnancy and 2004). The hospital platform, consisting of both first-
delivery for uncomplicated pregnancies; provision of level and referral hospitals, includes more advanced ser-
medical care for adults and children, such as injectable vices for management of labor and delivery in high-risk
antibiotics, that cannot be done in the community; and women or those with complications, including operative
Reproductive, Maternal, Newborn, and Child Health: Key Messages of This Volume 9
Figure 1.2 Deaths Averted by Individual Interventions in the Maternal and Newborn Health and Child Health Packages
Neonatal deaths averted Child (age 159 months) deaths averted Maternal deaths averted Stillbirth deaths averted
Note: ART = antiretroviral therapy; DPT = diphtheria, pertussis, tetanus; HIV = human immunodeficiency virus; IPTp = intermittent preventive treatment in pregnancy; ITN/IRS = insecticide-treated
net/indoor residual spraying; MgSO4 = magnesium sulfate; PMTCT = prevention of mother-to-child transmission; pPRoM = preterm premature rupture of membranes.
delivery, full supportive care for preterm newborns, and Some deaths are averted through provision of folic acid
children with severe infection or severe acute malnutri- before conception and in early pregnancy, reducing both
tion with infection. stillbirths and neonatal deaths by preventing fetal neural
The reproductive health package, other than pro- tube defects, resulting in a reduction of stillbirths of
vision of contraceptive services, consists primarily of 26,000 and neonatal deaths of 48,000 at the current rates
educational interventions that are not expected to have a of fertility. These deaths are included in the maternal
direct impact on deaths, but are important to encourage and newborn package for presentation in this chapter.
behaviors to prevent infections, ensure proper nutrition The largest effect of the reproductive health package is
of girls before pregnancy, or to seek care for antenatal or from the contraceptive services that prevent unintended
delivery services at other levels. The effects of these prac- pregnancies. It is estimated that if 90 percent of current
tices or treatments are included in LiST and are assigned unmet need for contraceptives had been met, 28 million
to the level at which the practice or treatment occurs. births would have been prevented in 2015. This level of
Delivery platforma
Community worker or health First-level and referral
post Primary health center hospitals
Pregnancy 1. Preparation for safe birth and
newborn care; emergency
planning
2. Micronutrient
supplementationb
3. Nutrition educationb
table continues next page
Reproductive, Maternal, Newborn, and Child Health: Key Messages of This Volume 11
Table 1.2 Essential Interventions for Maternal and Newborn Health (continued)
Delivery platforma
Community worker or health First-level and referral
post Primary health center hospitals
4. IPTpb
5. Food supplementationb
6. Education on family planning 1. Management of unwanted pregnancyb
7. Promotion of HIV testing 2. Screening and treatment for HIV and syphilisb
3. Management of miscarriage or incomplete
abortion and postabortion careb
4. Antibiotics for pPRoMb
5. Management of chronic medical conditions
(hypertension, diabetes mellitus, and others)
6. Tetanus toxoidb
7. Screening for complications of pregnancyb
8. Initiate antenatal steroids (as long as clinical 1. Antenatal steroidsb
criteria and standards are met)b
9. Initiate magnesium sulfate (loading dose)b 2. Magnesium sulfateb
10. Detection of sepsisb 3. Treatment of sepsisb
4. Induction of labor posttermb
5. Ectopic pregnancy case
managementb
6. Detection and management of
fetal growth restrictionb
Delivery 8. Management of labor and 11. Management of labor and delivery in low-risk 7. Management of labor and
(woman) delivery in low-risk women women (BEmNOC) including initial treatment delivery in high-risk women,
by skilled attendantb of obstetric and delivery complications prior to including operative delivery
transferb (CEmNOC)b
Postpartum 9. Promotion of breastfeedingb
(woman)
Postnatal 10. Thermal care for preterm 12. Kangaroo mother careb 8. Full supportive care for preterm
(newborn) newbornsb newbornsb
11. Neonatal resuscitationb
12. Oral antibiotics for 13. Injectable and oral antibiotics for sepsis, 9. Treatment of newborn
pneumoniab pneumonia, and meningitisb complications, meningitis, and
other very serious infectionsb
14. Jaundice managementb
Note: Red type denotes urgent care, blue type denotes continuing care, black type denotes routine care. In this table, the community worker or health post consists of a trained and
supported health worker based in or near communities working from home or a fixed health post. A primary health center is a health facility staffed by a physician or clinical officer
and often a midwife to provide basic medical care, minor surgery, family planning and pregnancy services, and safe childbirth for uncomplicated deliveries. First-level and referral
hospitals provide full supportive care for complicated neonatal and medical conditions, deliveries, and surgeries.
BEmNOC = basic emergency newborn and obstetric care; CEmNOC = comprehensive emergency newborn and obstetric care; HIV = human immunodeficiency virus;
IPTp = intermittent preventive treatment in pregnancy; pPRoM = preterm premature rupture of membranes.
a. All interventions listed for lower-level platforms can be provided at higher levels. Similarly, each facility level represents a spectrum and diversity of capabilities. The column in
which an intervention is listed is the lowest level of the health system in which it would usually be provided.
b. The intervention effect was included in the Lives Saved Tool (LiST).
contraception, in turn, would reduce maternal deaths For stillbirths, 19 percent could be averted with the com-
by 67,000, neonatal deaths by 440,000, child deaths by munity platform, 46 percent with the PHC platform,
473,000, and stillbirths by 564,000. Because about half and an additional 35 percent in hospitals. For maternal
of unwanted pregnancies are ended in abortion, pre- deaths, 13 percent could be averted with the community
venting these pregnancies would also reduce millions platform, 71 percent with the PHC platform, and the
of abortions, more than half of which would have been remaining 16 percent with hospital care. For neonatal
unsafe (Singh and others 2009). In addition, delayed deaths, the relative effects on level of services are differ-
age of first pregnancy and avoidance of short interpreg- ent from maternal deaths, with a possible 48 percent of
nancy intervals would reduce adverse birth outcomes newborn deaths averted with the community platform,
such as preterm delivery. It is important to note that an additional 12 percent with the PHC platform, and a
these potential deaths averted by preventing unplanned further 40 percent with hospital care. The interventions
pregnancies cannot be added to the potential lives saved with the largest effects are labor and delivery manage-
by the maternal and newborn and child health packages ment, care of preterm births, and treatment of neonatal
(plus folic acid supplementation), which are estimated at sepsis and pneumonia (figure 1.2).
the current rates of fertility and mortality. The child health package includes essential interven-
The maternal and newborn package provides many tions across all three service platforms and together these
interventions resulting in large effects on all of the mor- could avert 1,437,000 child deaths. The largest impact
tality outcomes in the current year (figure 1.3). We esti- (93 percent of avertable child deaths) can be realized by
mate that 2,574,000 deaths would be averted, including interventions in the community platform (figure 1.3),
149,000 maternal deaths, 849,000 stillbirths, 1,498,000 especially through immunizations and treatment of
neonatal deaths, and 78,000 child deaths (figure 1.2). infectious diseases (figure 1.2). The PHC platform
Reproductive, Maternal, Newborn, and Child Health: Key Messages of This Volume 13
Figure 1.3 Deaths Averted by Health Care Packages through Three Service Platforms
1,600,000
1,400,000
1,200,000
1,000,000
800,000
600,000
400,000
200,000
0
MN CH MN CH MN CH
Community Primary health center Hospital
Maternal deaths averted Stillbirths averted Neonatal deaths averted Child (age 159 months) deaths averted
Source: Analyses using the Lives Saved Tool (LiST).
Note: CH = child health package; MN = maternal and newborn package.
results in additional effects on child deaths primarily tables 1.11.3); provided as continuing care such as for
through treatment of severe infectious diseases and of chronic conditions (shown in blue in tables 1.11.3); or
severe acute malnutrition (SAM). SAM can be managed if the service has to be available at all times and offered
on an outpatient basis with therapeutic feeding but is as urgent care (shown in red in tables 1.11.3). Because
placed in the PHC platform because of the need for ini- of the unpredictable nature of most life-threatening
tial assessment and stabilization. The hospital platform conditions in maternal, newborn, and child health, such
averts some additional deaths with full supportive care as complications of labor and delivery or acute illnesses,
for very severe infectious diseases and malnutrition. most of the essential interventions must be available for
Scaling up all interventions in the maternal and urgent care at all times of the day.
newborn health and child health packages in 2015
would avert 149,000 maternal deaths, 849,000 stillbirths,
1,498,000 neonatal deaths, and 1,515,000 child deaths,
a total of 4,011,000 deaths averted. Then, interven-
COST-EFFECTIVENESS
tions would result in a reduction in about half of the Individual RMNCH interventions, summarized
estimated global 303,000 maternal deaths in 2015 and in figure 1.4, have been shown to be cost-effective
also about half of the 5,900,000 global newborn and (Horton and Levin 2016). This volume explores the cost-
child deaths (Alkema and others 2015; You and others effectiveness of packages of interventions that have not
2015). However, they would result in a reduction of only yet been scaled up across LMICs. It also reports on new
about one-third of the 2,600,000 stillbirths (Blencowe results from extended cost-effectiveness analyses that
and others, forthcoming). Well-functioning community look at financial-risk-protection outcomes in addition
and PHC platforms could avert 77 percent of maternal, to the health outcomes that are part of traditional cost-
newborn, and child deaths and stillbirths that are pre- effectiveness analyses.
ventable by these essential interventions, with hospitals Expansion of coverage of the traditional Expanded
contributing the remaining averted deaths through more Program on Immunization package of bacillus Calmette-
advanced management of complicated pregnancies and Guerin; diphtheria, pertussis, and tetanus; measles; polio;
deliveries and newborn and child conditions. and hepatitis B vaccines remains highly cost-effective,
An additional consideration for the organization regardless of delivery modality. Introduction of pneu-
of health services is whether the interventions can be mococcal and rotavirus vaccines at Gavi (the Global
provided as scheduled routine care (shown in black in Vaccine Alliance) prices can avert deaths at a cost of less
Nutrition in pregnancy
Cesarean section for obstructed labor
IYCF (food and education)
Vitamin A and zinc
Pneumonia and diarrhea, multiple interventions
Community management of severe acute malnutrition
Safe abortion, LIC
Womens groups - prenatal and newborn care
HiB vaccine lower-middle-income countries
Home-based and community-based neonatal care
HiB vaccine LIC
Train TBAs for safer births
Rotavirus vaccine lower-middle-income countriesa
Treatment of severe malaria with artesunate
Train GPs to do cesarean sections LIC
Rotavirus vaccine LICa
Pneumococcus vaccine LICa
1 10 100 1,000 10,000 100,000
Note: Some vaccine results are for lower-middle-income countries. If country group is not specified, results refer to low and lower-middle-income countries combined.
GP = general practitioner; HiB = Haemophilus influenzae B; IYCF = infant and young child feeding interventions (education combined with food distribution to poorest); LIC = low-income country;
TBA = traditional birth attendant.
a. Cost-effectiveness of vaccines is sensitive to vaccine price. Rotavirus and pneumococcus vaccine costs to LICs are a fraction (for example, 5 percent) of the price paid by Gavi, the Vaccine
Alliance to procure the vaccines; Gavi, in turn, receives prices that are more favorable than what upper-middle-income countries pay as a result of volume discounts and other factors.
than US$100 per death (Horton and Levin 2016), but pneumococcal conjugate vaccine provides substan-
these estimates do not include reduced out-of-pocket tially higher financial risk protection and saves more
expenditures, improved financial risk protection for lives for the poor in Ethiopia than the current situ-
households, or long-term benefits of improved cogni- ation. Financial risk protection associated with an
tion and lifetime productivity (Barnighausen and others intervention is measured using the money-metric-
2014). Megiddo and others (2014) find that introduction equivalent value of insurance, which is simply what
of a rotavirus vaccine in India was cost-saving and was an individual would pay as an insurance premium to
estimated to avert 34.7 (95 percent uncertainty range ensure that they are fully protected against the disease
[UR], 31.737.7) deaths and US$215,569 (95 percent or adverse health condition.
UR, US$207,846US$223,292) out-of-pocket expendi- India alone accounts for 28 percent of neonatal
ture per 100,000 children under age five years. deaths globally. In 2011, India introduced a home-
Chapters in this volume have calculated that home- based newborn care (HBNC) package to be delivered
based management of maternal and neonatal care, by community health workers across rural areas of the
including interventions to train traditional birth atten- country. Nandi and others (2015) estimate the disease
dants for safer births (Sabin and others 2012), can and economic burdens averted by scaling up the HBNC
be cost-effective with lower-end estimates of cost- among households in rural India. Compared with a
effectiveness of less than US$1,000 per death averted. baseline of no coverage, providing the care package
Scaling up midwifery services with referral when needed through the existing network of community health
and family planning would cost US$2,200 per death workers could avert 48 (95 percent uncertainty range
averted (Bartlett and others 2014). [UR] 3463) incident cases of severe neonatal morbidity
Using extended cost-effectiveness analysis (Verguet and 5 (95 percent UR 47) related deaths, save US$4,411
and others 2015), it was shown that investing in (95 percent UR US$3,088US$5,735) in out-of-pocket
the provision of universal public finance for pneu- treatment expenditure, and provide US$285 (95 percent
monia treatment and for combined treatment with UR US$200US$371) in insurance value per 1,000 live
Reproductive, Maternal, Newborn, and Child Health: Key Messages of This Volume 15
births in rural India. Intervention benefits were greater COST OF SCALING UP ESSENTIAL
for lower socioeconomic groups. INTERVENTIONS FOR REPRODUCTIVE,
Investments that increase the supply and demand for
RMNCH interventions can have long-lasting effects
MATERNAL, NEWBORN, AND CHILD HEALTH
for example, the benefits of investments in nutrition can This volume estimates the annual cost of scaling up
go beyond the immediate improvement in nutritional three service packages for reproductive health (family
status by also improving cognitive development, school planning costs only), maternal and newborn health,
performance, and future earnings (Victora and others and child health in 74 of the 75 Countdown coun-
2008; Walker and others 2007). tries (Sudan is not included because of lack of data).
The economic and social benefits of a set of inte- These countries account for more than 95 percent
grated RMNCH interventions include health and of the worlds maternal and child deaths. We estimate
fertility impacts (Stenberg and others 2014). Some of the annual incremental costs of scaling up the three
these benefits are strictly economic, reflected in higher packages described in table 1.1, based on per capita
gross domestic product (GDP) from increased work- cost estimates from a global reproductive, maternal,
force participation and higher productivity. Other newborn, and child health investment case (Stenberg
benefits, denoted as social benefits, are not reflected in and others 2014). Using population estimates for
conventional GDP measures. For example, the value of 2015 associated with the health impact shown in
a childs life saved does not depend only on his or her figure 1.3, the annual incremental cost is US$6.2
participation in the labor force when an adult. When billion in low-income countries, US$12.4 billion in
taking into consideration the full-income approach lower-middle-income countries, and US$7.9 billion
that goes beyond GDP to also capture these social in upper-middle-countries (table 1.4). Considering
benefits, including from reducing morbidity and con- a longer time horizon of 2013 to 2035, the annual
trolling fertility, the benefit-cost ratios indicate high incremental costs of scaling up the three packages
returns on increased investment in RMNCH in most increases slightly depending on the country income
countries, especially when benefits beyond the inter- groups, reflecting a larger target population, consistent
vention period are included. For all LMICs considered with Stenberg and others (2014) and chapter 16 in this
as a group, the benefit-cost ratio is 8.7 for the inter- volume (Stenberg and others 2016). These estimates
vention period to 2035 at a 3 percent discount rate include health system strengthening costs, such as
(Stenberg and others 2014; Stenberg and others 2016). program management, infrastructure needs, improved
Table 1.4 Cost of Essential Reproductive Health (family planning only), Maternal and Newborn Health, and Child
Health Packages by Country Income Group for 2015 and 2035 (million 2012 U.S. dollars, except per capita costs)
Low-income Lower-middle-income Upper-middle-income Total cost per
countries countries countries package
Package 2015 2035 2015 2035 2015 2035 2015 2035
Reproductive health package costsa $562 $603 $520 $630 $151 $164 $1,233 $1,397
Cost per capita $0.6 $0.5 $0.2 $0.2 $0.1 $0.1 $0.2 $0.2
Maternal and newborn health $1,183 $1,268 $2,922 $3,542 $1,768 $1,923 $5,872 $6,733
package costsa
Cost per capita $1.3 $1.0 $1.1 $1.1 $0.9 $0.9 $1.0 $1.0
Child health package costsa $4,484 $4,810 $8,838 $10,712 $6,060 $6,591 $19,382 $22,113
Cost per capita $4.8 $3.9 $3.4 $3.3 $2.9 $2.9 $3.5 $3.3
Total costs $6,229 $6,681 $12,406 $14,884 $7,979 $8,679 $26,614 $30,243
Total per capita costs $6.7 $5.4 $4.7 $4.6 $3.9 $3.9 $4.7 $4.5
Note: Estimates have been inflated to 2012 U.S. dollars using U.S. consumer price index data (World Bank World Development Indicators).
a. Package costs include commodities, front-line health workers, and additional health system strengthening costs for scaling up services.
Reproductive, Maternal, Newborn, and Child Health: Key Messages of This Volume 17
care visits, and normal deliveries at home or health chosen physicians every six months during a three-year
centers with trained birth attendants. Costs per benefi- period to assess physicians quality indicators. Bonus
ciary tend to increase with the complexity of the service payments were awarded if qualifying scores were met.
(that is, treatment of obstetric or abortion complica- Outcomes of interestincluding age-adjusted wasting,
tions, treatment of severe acute child malnutrition, and C-reactive protein, hemoglobin level, parental self-
a range of community-based nutrition interventions). reported health of children, and children under age five
For example, breastfeeding support and prevention years hospitalized for diarrhea or pneumoniawere
of micronutrient deficiencies are inexpensive com- not improved in intervention sites. Only two indicators
pared with facility-based treatment of severe acute improved. Parental self-reported health of children
malnutrition. Within packages, costs are also likely to increased by 7 percentage points and wasting declined
vary depending on the context and conditionthe by 9 percentage points. A Cochrane review suggests that
prevention and treatment of malaria and diarrheal the quality of evidence is too poor to draw general con-
disease are less expensive per child (US$20 to US$100) clusions about the effectiveness of pay for performance
than treating pneumonia and meningitis, which more and notes that several studies arrive at contradictory
often require inpatient admission (US$150 per visit, results (Witter and others 2012).
or US$800 per child treated for pneumonia; US$300 Safe childbirth (intrapartum care) checklists have
to US$500 for inpatient care treatment of meningitis been proposed as a way of reducing newborn deaths,
and pneumonia). but there are gaps in the evidence base. The WHO
childbirth safety checklist was developed to help reduce
the major causes of these deaths (hemorrhage, infec-
IMPROVING INTERVENTION UPTAKE AND tion, obstructed labor, and others) (Spector and oth-
QUALITY ers 2013; Temmerman, Khosla, Bhutta, and Bustreo
2015; Temmerman, Khosla, Laski, and others 2015).
Supply- and demand-side interventions to improve Since most deaths associated with childbirth occur
intervention uptake and quality are increasingly used to within a 24-hour window and the major causes are
ensure that essential RMNCH services are delivered with well described, checklists have promise for improv-
quality and used appropriately. ing healthy delivery. Follow-up studies are currently
underway that focus directly on health outcomes attrib-
utable to the increase in these practices. The qual-
Supply-Side Interventions ity of RMNCH services can also be improved using
On the supply side, interest has been growing in the supportive supervision for front-line health workers,
use of pay-for-performance, which rewards providers which is associated with small benefits for provider
or health care organizations for achieving coverage or practice and knowledge (Bosch-Capblanch, Liaqat, and
quality targets. One study in Rwanda shows a 23 percent Garner 2011).
increase in facility delivery and larger increases in pre- Recent efforts have been made in task-shiftingan
ventive care visits by young children in facilities enrolled innovative approach to increase the delivery of RMNCH
in a payment plan compared with randomly selected services by reassigning certain tasks to community
controls (Basinga and others 2011). workers. Lay community health workers are increasingly
A study of performance-based financing in Rwanda being deployed to classify and treat childhood infectious
in which the government implemented an incentive diseases, such as pneumonia, diarrhea, and malaria, and
program in several districts to motivate providers to approaches such as iCCM for their management are
improve the quality of care and increase service output expanding widely (Young and others 2012). A recent
found no significant differences in the use of mater- WHO Guidance Panel on Task Shifting suggested that
nal health services between intervention and control health workers could carry out many tasks related to
sites (Priedeman Skiles and others 2013). Only facility maternal and newborn health, provided they received
birth deliveries (p = 0.014) were 10 percentage points adequate training and support (WHO 2012). These per-
higher for the intervention sites compared with con- sonnel include lay workers (for example, for promotion
trols. Performance-based financing may be useful if of appropriate care-seeking behavior and antenatal care
targeted at specific services, such as facility deliveries, during pregnancy, administration of misoprostol to pre-
but only if service use was consistently low. Peabody vent postpartum hemorrhage, and promotion and sup-
and others (2014) considered payment-for-performance port of breastfeeding), auxiliary nurses (for example, for
incentives and child health outcomes in the Philippines administration of injectable contraceptives), auxiliary
using clinical performance vignettes among randomly nurse midwives (for example, for neonatal resuscitation
Reproductive, Maternal, Newborn, and Child Health: Key Messages of This Volume 19
individuals provided valuable assistance and comments N. Walker, and M. Temmerman. Washington, DC:
on this chapter: Brianne Adderley, Rachel Nugent, World Bank.
Lale Say, and Gavin Yamey. Members of the RMNCH Afnan-Holmes, H., M. Magoma, T. John, F. Levira, G. Msemo,
Authors Group wrote chapters on which this initial and others. 2015. Tanzanias Countdown to 2015:
An Analysis of Two Decades of Progress and Gaps for
chapter draws. The group includes Frances Aboud,
Reproductive, Maternal, Newborn, and Child Health, to
Fernando Althabe, Ashvin Ashok, Henrik Axelson,
Inform Priorities for post-2015. The Lancet Global Health
Rajiv Bahl, Akinrinola Bankole, Zulfiqar Bhutta, Lori 3 (7): e396409. doi:10.1016/S2214-109X(15)00059-5.
Bollinger, Deborah Hay Burgess, Doris Chou, John Alkema, L., D. Chou, D. Hogan, S. Zhang, A. B. Moller, and
Cleland, Daniela Colaci, Simon Cousens, Valrie others. 2015. Global, Regional, and National Levels and
DAcremont, Jai Das, Julia Driessen, Alex Ezeh, Daniel Trends in Maternal Mortality between 1990 and 2015, with
Feikin, Veronique Filippi, Mariel Finucane, Christa Scenario-Based Projections to 2030: A Systematic Analysis
Fischer Walker, Brendan Flannery, Ingrid Friberg, Bela by the UN Maternal Mortality Estimation Inter-Agency
Ganatra, Claudia Garca-Moreno, Marijke Gielen, Group. The Lancet. doi:10.1016/S0140-6736(15)00838-7.
Wendy Graham, Metin Gulmezoglu, Demissie Habte, Amouzou, A., O. Habi, K. Bensaid, and Niger Countdown
Mary J. Hamel, Davidson H. Hamer, Peter Hansen, Case Study Working Group. 2012. Reduction in Child
Mortality in Niger: A Countdown to 2015 Country Case
Karen Hardee, Julie M. Herlihy, Natasha Hezelgrave,
Study. The Lancet 380 (9848): 116978. doi:10.1016
Justus Hofmeyr, Dan Hogan, Susan Horton, Aamer
/S0140-6736(12)61376-2.
Imdad, Dean Jamison, Kjell Arne Johansson, Jerry Arregoces, L., F. Daly, C. Pitt, J. Hsu, M. Martinez-Alvarez, and
Keusch, Margaret Kruk, Rohail Kumar, Zohra Lassi, Joy others. 2015. Countdown to 2015: Changes in Official
Lawn, Theresa Lawrie, Ramanan Laxminarayan, Lindsey Development Assistance to Reproductive, Maternal,
Lenters, Colin Mathers, Solomon Tessema Memirie, Newborn, and Child Health, and Assessment of Progress
Arindam Nandi, Olufemi T. Oladapo, Shefali Oza, Clint between 2003 and 2012. The Lancet Global Health 3 (7):
Pecenka, Carine Ronsmans, Rehana Salam, Lale Say, e41021. doi:10.1016/S2214-109X(15)00057-1.
Peter Sheehan, Joao Paulo Souza, Meghan Stack, Karin Ban, K. 2010. Global Strategy for Womens and Childrens
Stenberg, Gretchen Stevens, John Stover, Kim Sweeny, Health. Partnership for Maternal, Newborn and Child
Stphane Verguet, Kerri Wazny, Aisha Yousafzai, and Health, New York, NY.
Barnighausen, T., S. Berkley, Z. A. Bhutta, D. M. Bishai,
Abdhalah Ziraba.
M. M. Black, and others. 2014. Reassessing the Value of
Vaccines. The Lancet Global Health 2 (5): e25152.
Bartlett, L., E. Weissman, R. Gubin, R. Patton-Molitors, and
NOTES I. K. Friberg. 2014. The Impact and Cost of Scaling up
Midwifery and Obstetrics in 58 Low- and Middle-Income
World Bank Income Classifications as of July 2014 are as fol-
Countries. PLoS One 9 (6): e98550. doi:10.1371/journal.
lows, based on estimates of gross national income (GNI) per
pone.0098550.
capita for 2013:
Basinga, P., P. J. Gertler, A. Binagwaho, A. L. Soucat, J. Sturdy,
Low-income countries (LICs) = US$1,045 or less and C. M. Vermeersch. 2011. Effect on Maternal and
Middle-income countries (MICs) are subdivided: Child Health Services in Rwanda of Payment to Primary
Lower-middle-income = US$1,046 to US$4,125 Health-Care Providers for Performance: An Impact
Upper-middle-income (UMICs) = US$4,126 to US$12,745 Evaluation. The Lancet 377 (9775): 142128. doi:10.1016
High-income countries (HICs) = US$12,746 or more. /S0140-6736(11)60177-3.
Bellows, B., C. Kyobutungi, M. K. Mutua, C. Warren, and
1. For the maternal and newborn health package, health sys- A. Ezeh. 2013. Increase in Facility-Based Deliveries
tem costs are assumed to constitute 19 percent, 23 percent, Associated with a Maternal Health Voucher Programme in
and 22 percent of the total package for low-, lower-middle, Informal Settlements in Nairobi, Kenya.[Research Support,
and upper-middle-income groups, respectively. For the Non-U.S. Govt]. Health Policy and Planning 28 (2): 13442.
child health package, they are 72 percent, 71 percent, doi:10.1093/heapol/czs030.
and 76 percent of the total for low-, lower-middle, and Bellows, N. M., B. W. Bellows, and C. Warren. 2011. Systematic
upper-middle-income groups, respectively. Review: The Use of Vouchers for Reproductive Health
Services in Developing Countries: Systematic Review.
Tropical Medicine and International Health 16 (1): 8496.
Bhutta, Z. A., J. K. Das, N. Walker, A. Rizvi, H. Campbell,
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Reproductive, Maternal, Newborn, and Child Health: Key Messages of This Volume 23
Chapter
2
Burden of Reproductive Ill Health
Alex Ezeh, Akinrinola Bankole, John Cleland,
Claudia Garca-Moreno, Marleen Temmerman,
and Abdhalah Kasiira Ziraba
Corresponding author: Alex Ezeh, African Population and Health Research Center, Nairobi, Kenya, and School of Public Health, University of the Witwatersrand,
Johannesburg, South Africa, aezeh@aphrc.org.
25
falling fertility and population growth rates in the past the lack of studies. This method has been adapted to
half century. Because of its direct link to family sizes single and successive cross-sectional surveys to provide
and population change, contraception has a wide range aggregate estimates of unwanted fertility (Casterline
of social, economic, and environmental benefits, in and El-Zeini 2007). As with the first approach, mistimed
addition to its well-documented health advantages for births are ignored.
women and children. It enables women to escape the The third approach uses retrospective questions con-
incessant cycle of pregnancies and infant care and rep- cerning the wantedness and preferred timing of recent
resents progress toward gender equality and enhanced births. It has the advantage of incorporating mistimed
opportunities for women. At the national level, a fall in as well as unwanted births, but estimates are vulnerable
birth rates brings about declines in dependency ratios to post factum rationalization due to an understandable
and increases potential opportunities for economic reluctance of mothers to report children as unwanted or
growth. mistimed. Prospective studies in India, Malawi, Morocco,
Contraception has wider social and economic ben- and Pakistan indicate that a large proportions of births
efits, but its immediate purpose is to avoid unintended to women who reported at baseline a desire to have no
pregnancies. The majority of these pregnancies stem more children were subsequently classified by mothers
from the non-use of contraceptive methods among as wanted or mistimed (Baschieri and others 2013; Jain
women wishing to avoid or postpone childbearing. and others 2014; Speizer and others 2013; Westoff and
This section discusses the measurement of unintended Bankole 1998). Similarly, an appreciable fraction of
pregnancies, both levels and trends, and reasons for and births that occur as the result of accidental pregnancy
consequences of unintended births. while using a contraceptive method or after abandoning
a method are reported as wanted. (Ali, Cleland, and
Shaw 2012; Curtis, Evens, and Sambisa 2011; Trussell,
Measurement
Vaughan, and Stanford 1999). These inconsistencies are
Measurement of unintended pregnancies is complicated usually interpreted as the consequence of rationaliza-
because many are terminated, and these terminations tion, but they may reflect a genuine difference between
are underreported. Because most induced abortions are a more abstract preference before childbirth and a more
from unintended pregnancies, the solution is to combine emotional reaction after the event.
survey data on unintended births with indirect estimates The three approaches to measurement yield very
of abortion incidence available for all subregions and different results. No consensus exists on how best to
many countries. obtain valid estimates of unintended births, even in the
Demographic and Health Surveys (DHS) are the United States, where the topic has attracted considerable
main source of data on unintended births. The measure- attention (Campbell and Mosher 2000; Santelli and
ment of unintended births or current pregnancies from others 2003). This section presents results based on the
this source has been approached in three ways: retrospective method because studies using this method
are the sole source of global and regional estimates, but
Answers to questions on total desired family size the results are presented with the caveat that they may
Prospective questions on whether another child is be downwardly biased. Another approach that has been
wanted tried, but on a limited scale, is the London Measure of
Retrospective questions on each recent birth to ascer- Unplanned Pregnancy (Morof and others 2012; Wellings
tain whether the child was wanted, unwanted, or and others 2013).
mistimed by two or more years.
In the first approach, births that exceed total desired Prevalence and Incidence
family size are defined as unwanted; if they are equal to By combining regional estimates on induced abor-
or less than total desired family size, they are considered tion and retrospective survey data on mistimed and
wanted. This classification can be expressed as unwanted unwanted births with allowances for miscarriages,
or wanted fertility rates. No account is taken of mistimed Sedgh, Singh, and Hussain (2014) derive global and
births. A more serious problem stems from the likeli- regional estimates on the incidence of unintended preg-
hood that desired total family sizes are, in part, a ratio- nancies and the proportion of all pregnancies that are
nalization of actual family sizes, with the consequence unintended (table 2.1). Globally, their prevalence data
that unwanted births are likely to be underestimated. indicate that 40 percent of all pregnancies in 2012 were
The second approach is straightforward in prospec- unintended. The prevalence of unintended pregnancies
tive studies, but its application is severely limited by is higher, and such pregnancies are more likely to be
terminated, in high-income countries (HICs) than in risk of an unintended pregnancy spans 20 years or more.
LMICs. However, when expressed as annual rates per The use of effective contraception for so many years is a
1,000 women of reproductive age, unintended pregnan- daunting prospect. In societies in which the preference
cies are more common in LMICs. for larger families remains high, as in much of Sub-
There is little relationship between the prevalence or Saharan Africa, the risk span is shorter. Despite this
incidence of unintended pregnancy and the level of con- upward pressure from increasing exposure to risk, unin-
traceptive use or unmet need. The reason for this appar- tended pregnancy rates per 1,000 women of reproduc-
ently counterintuitive observation is that exposure to tive age fell by an estimated 4.8 percent and 5.3 percent
risk of unintended pregnancy increases as desired family in HICs and LMICs, respectively, between 2008 and
size and fertility fall. In societies in which sexual activity 2012 (Sedgh, Singh, and Hussain 2014). There was a
starts early and couples want two or fewer children, the 5.6 percent decline in Latin America and the Caribbean,
Table 2.3 Incidence of Abortion and Complications from Unsafe Abortion in Low- and Middle-Income Countries
Number of women with Annual rate of
Annual number Abortion complications from unsafe complications treated
of women who rates per 1,000 abortion treated in health in health facilities
Country, date had abortions (a) women (b) facilities (c) per 1,000 women (d)
Africa
Burkina Faso, 2008 (a) 87,200 25.0 22,900 6.6*
Egypt, Arab Rep. 1996 (b) 324,000 23.0 216,000 15.3
Ethiopia, 2008 (c) 382,450 23.1 52,600 3.2
Kenya, 2013 (d) 464,700 48.0 119,900 12.4*
Malawi, 2009 (e) 67,300 23.0 18,700 6.4*
Nigeria, 1996 (f) 610,000 25.0 142,200 6.1
Rwanda, 2009 (g) 60,000 25.0 16,700 7.0
Uganda, 2002 (h) 296,700 54.0 85,000 16.4
Asia
Bangladesh, 2010 (i) 647,000 18.2 231,400 6.5
Pakistan, 2002 (j) 890,000 29.0 197,000 7.0
Philippines, 2000 (k) 78,900 27.0 78,150 4.4
8 percent and 18 percent, excluding late maternal death Table 2.4 Prevalence of Severe Symptoms from
(Kassebaum and others 2014; Say and others 2014). Unsafe Abortion in Low- and Middle-Income Countries
Percentage of women with severe
Abortion-Related Morbidity
symptoms among those presenting with
Each year, 7 million women receive treatment for
Country, date unsafe abortion complications
complications from unsafe abortions in the develop-
ing world (Singh 2006, 2010; Singh and others 2009). South Africa, 2000 (a) 10
The annual rate of treatment after unsafe abortions is Malawi, 2009 (b) 21
6.9 per 1,000 women of reproductive age, which means Ethiopia, 2008 (c) 27
4.6 million women receive needed treatment in Asia,
Kenya, 2012 (d) 37
as do 1.6 million in Sub-Saharan Africa and 757,000
in Latin America and the Caribbean (Singh 2006). The Cambodia, 2005 (e) 42
incidence and severity of unsafe abortion complications Sources: (a) = Jewkes and others 2005; (b) = Kalilani-Phiri and others 2015;
(c) = Gebreselassie and others 2010; (d) = African Population and Health Research
are closely related to the training of the providers and Center and Ministry of Health Kenya 2013; (e) = Fetters and others 2008.
the abortion methods used. A substantial proportion
of the procedures are performed by untrained pro-
viders, including by pregnant women. In each coun- Studies report that among women presenting with
try in which the AICM has been applied to estimate unsafe abortion complications in health facilities, the
abortion incidence, a substantial number of women proportion diagnosed with severe symptoms varies
are admitted annually for treatment of complications widely (table 2.4).
resulting from unsafe abortions. These estimates are Severe complications, if not well managed, may result
approximations based on the best guesses of health care in anemia, RTIs, elevated risk of ectopic pregnancy,
providers and professionals, as well as on a number of premature delivery or miscarriage in subsequent preg-
assumptions. Table 2.3 shows abortion rate and abor- nancies, and infertility (WHO 2004). Almost 5 million
tion complication rate. women are living with temporary or permanent dis-
Health complications typically associated with abilities associated with unsafe abortion; more than
unsafe abortion include hemorrhage; sepsis; perito- 3 million of these women suffer from the effects of RTIs,
nitis; RTIs; and trauma to the cervix, vagina, uterus, and close to 1.7 million experience secondary infertility
and abdominal organs (Grimes and others 2006; (WHO 2007).
Henshaw and others 2008). Beginning with an effort
sparked by a seminal WHO-led study in 1986, a Economic and Social Consequences
fairly standard method has been developed and used Unsafe abortion has direct and indirect costs. Direct
to measure the nature and severity of unsafe abor- costs include expenses related to the provision of med-
tion complications based on nationally representative ical care to women presenting with abortion-related
surveys (Benson and Crane 2005; Fetters 2010; Figa- complications, such as cost of medicine, providers
Talamanca and others 1986). time, and hospital stays. Indirect costs are opportunity
Table 2.5 Prevalence of Candida Species and Vulvovaginal Candidiasis from Community-Based Studies
Prevalence Prevalence of
of candida vulvovaginal
Study species (%) candidiasis* (%)
Epidemiologic features of vulvovaginal candidiasis among reproductive-age women in India (a) 35.0 7.1
Reproductive tract infections among young married women in Tamil Nadu, India (b) 10.0 10.0
Sexually transmitted infections, bacterial vaginosis, and candidiasis in women of reproductive age in rural Northeast 12.5
Brazil: a population-based study (c)
Prevalence and risk factors for bacterial vaginosis and other vulvovaginitis in a population of sexually active 22.0
adolescents from Salvador, Bahia, Brazil (d)
Sexually transmitted infections in a female population in rural Northeast Brazil: prevalence, morbidity, and risk factors (e) 5.8
Community-based study of reproductive tract infections among women of the reproductive age group in the Urban 16.1
Training Centre Area in Hubli Kamataka, India (f)
Prevalence of and factors associated with reproductive tract infections among pregnant women in 10 communes in 17.0
Nghe An Province, Vietnam (g)
Prevalence and risk factors for vaginal candidiasis among women seeking primary care for genital infections in Dar es 45.0
Salaam, Tanzania (h)
Sources: (a) = Rathod and others 2012; (b) = Prasad and others 2005; (c) = Oliveira and others 2007; (d) = Mascarenhas, Machado, and others 2012; (e) = de Lima Soares and others
2003; (f) = Balamurugan and Bendigeri 2012; (g) = Goto and others 2005; (h) = Namkinga and others 2005.
*According to Centers for Disease Control and Prevention criteriaone or more symptoms and signs and positive lab test or culture.
North America
United States, NHANES, 200104 (f) Random sample of 3,739 women 29.2
Western Europe
Finland, Aland Islands, 19932008 (g) Random sample of 819 women in 1993 and 771 15.6 (1993)
women in 2008 8.6 (2008)
Sub-Saharan Africa
The Gambia, Farafenni, 1999 (j) Random sample of 1,348 women 37.0
Burkina Faso, Ouagadougou, 2003 (k) Random sample of 883 women 7.9
Sources: (a) = de Lima Soares and others 2003; (b) = Miranda and others 2009; (c) = Oliveira and others 2007; (d) = Garcia and others 2004; (e) = Jones and others 2007;
(f) = Koumans and others 2007; (g) = Eriksson and others 2010; (h) = Lan and others 2008; (i) = Go and others 2006; (j) = Walraven and others 2001; (k) = Kirakoya-Samadoulougou
and others 2011.
Note: NHANES = National Health and Nutrition Examination Survey.
*Based on the Nugent Scoring System.
Table 2.7 Global and Regional Prevalence Estimates for Trend Analysis of Primary Infertility in Women Exposed
to the Risk of Pregnancy
Percent
or does not cover fertility treatment. As a result, cost of The declaration describes the many forms this violence
treatment of infertility is almost always borne by those can take, including the following:
affected; in many cases, the available treatment is basic
and ineffective (Dyer and Patel 2012). Intimate partner violence (IPV), sexual violence,
including abuse of female children, dowry-related
violence, killings in the name of honor, forced mar-
VIOLENCE AGAINST WOMEN riages, FGM and other traditional practices harmful to
women, violence related to exploitation, sexual harass-
Violence against women is a serious health problem and ment and intimidation in workplaces, educational
a violation of human rights. It has significant impacts on institutions, and elsewhere, trafficking, forced prostitu-
womens health and development, and its consequences tion, and violence perpetrated or condoned by the state.
are individual as well as intergenerational and societal.
Violence affects womens health and well-being, produc- According to Heise and Garca-Moreno (2002), IPV
tivity, and ability to bond with and care for their children. is behavior by an intimate partner or ex-partner that
Although violence against women has been accepted as an causes physical, sexual, or psychological harm, includ-
important public health and clinical care issue, it remains ing physical aggression, sexual coercion, psychological
unaddressed in the health care policies of many countries. abuse, and controlling behaviors.
This section focuses on violence against women and, Sexual violence is any sexual act, attempt to obtain a
in particular, on intimate partner violence (IPV) and sexual act, or other act directed against a persons sexu-
sexual violence because these are the most common ality, using coercion, by any person, regardless of their
forms of violence experienced globally, and they have relationship to the victim, in any setting. It includes rape,
important sexual and reproductive health consequences. defined as the physically forced or otherwise coerced
penetration of the vulva or anus with a penis, other body
part, or object (Jewkes and others 2002).
Definitions and Measurements There are many challenges to measuring violence against
The United Nations Declaration on the Elimination women; studies are often not comparable because they
of Violence against Women (1993) defines violence use different samples (all women, married women, ever-
against women1 as any act of gender-based violence partnered women, currently partnered), different measures
that results in, or is likely to result in, physical, sexual, of violence, different time frames (ever, last 12 months, last
or mental harm or suffering to women, including month). There are also specific ethical and safety concerns
threats of such acts, coercion, or arbitrary deprivation related to asking women about partner violence. However,
of liberty, whether occurring in public or in private life. a consensus exists that the best way to measure violence
Map 2.1 Rates of Intimate Partner Violence, by World Health Organization Region, 2010
IBRD 41895 | OCTOBER 2015
25.4%
WHO European Region
23.2%
High Income
37.0%
WHO Eastern
Mediterranean Region 24.6%
WHO Western
29.8% 37.7% Pacific Region
WHO South-East
WHO Region of the Americas
Asia Region
36.6%
WHO African Region
WHO, Global and regional estimates of violence against women: prevalence and
health effects of intimate partner violence and non-partner sexual violence, 2013.
Corresponding author: Vronique Filippi, London School of Hygiene & Tropical Medicine, Veronique.Filippi@lshtm.ac.uk.
51
nature and incidence of many indirect complications
Box 3.1 that are aggravated by pregnancy. For example, reliable
population-based estimates of the occurrence of asthma
Underlying Causes of Maternal Deaths during pregnancy do not exist in LICs.
This chapter addresses the extent and nature of mater-
Pregnancies with abortive outcome nal mortality and morbidity and serves as a backdrop to
Hypertensive disorders subsequent chapters on obstetric interventions in LICs.
Obstetric hemorrhage It introduces the determinants of maternal mortality
Pregnancy-related infection and morbidity and their strategic implications. The next
Other obstetric complications section uses the most recent estimates from the World
Unanticipated complications of management Health Organization (WHO) to show that women face
Nonobstetric complications a higher risk of maternal death in Sub-Saharan Africa.
Unknown or undetermined It discusses the recent findings of a WHO meta-analysis
Coincidental causes that show that the most important direct causes are hem-
orrhage, hypertension, abortion, and sepsis; however, the
Source: WHO 2012.
proportion of deaths due to indirect causes is increasing
in most parts of the world. The chapter then focuses
on pregnancy-related complications, including nonfatal
Maternal death studies require large sample sizes;
illnesses such as antenatal and postpartum depression,
recent national-level data are often nonexistent, and
using the findings from systematic reviews conducted by
maternal mortality tracking relies principally on mathe-
the Child Health Epidemiology Reference Group. The
matical models. This lack of data has led to a repeated call
most common contributors to maternal morbidity are
for countries to improve their vital registration systems
probably anemia and depression at the community level,
and to strengthen other mechanisms for informing inter-
but prolonged and obstructed labor results in the highest
vention strategies, such as the maternal death surveillance
burden of disease because of fistulas (IHME 2013). The
and response system proposed within the new account-
chapter discusses the broader determinants of maternal
ability framework (WHO 2013). Accountability remains
morbidity and mortality, and then concludes by making
a central part of United Nations Secretary General Ban
the links with the interventions highlighted in chapter 7
Ki-Moons updated global strategy to accelerate progress
in this volume (Glmezoglu and others 2016).
for womens, childrens, and adolescents health (http://
www.everywomaneverychild.org/global-strategy-2). The
accountability framework, developed under the 2010 MATERNAL MORTALITY LEVELS
global strategy to accelerate womens and childrens AND TRENDS
health, included recommendations for improvements
in resource tracking; international and national over- The WHO, in collaboration with the United Nations
sight; and data monitoring, including maternal mortality Childrens Fund, the United Nations Population
Fund, the World Bank Group, and the United Nations
(Commission on Information and Accountability for
Population Division, publishes global estimates of
Womens and Childrens Health 2011).
maternal mortality, which are excerpted in this chapter
Information on maternal morbidity is frequently col-
lected in hospital studies, which are only representative (WHO 2015). A complete description of the method-
of patients who seek care. Community-based studies are ology and underlying data and statistical model can be
rare in LICs and suffer from methodological limitations, found in the publication and online.3 In this chapter,
particularly when they rely on self-reporting of obstetric the latest estimate is for 2015. Whenever an estimate
complications. Self-reporting is known not to agree suf- includes trend data between two points, updates of
ficiently with medical diagnoses to estimate prevalence. those estimates typically supersede previously published
In particular, studies validating retrospective interview figures. Readers are directed to the WHOs Reproductive
Health and Research web page on maternal mortality to
surveys find that women without medical diagno-
access the latest published data.4
ses of complications during labor frequently reported
symptoms of morbidity during surveys, a phenome-
non that can lead to an overestimation of prevalence Maternal Mortality Ratio Levels and Trends, 19902015
(Ronsmans and others 1997; Souza and others 2008). Globally, the total number of maternal deaths
In addition, community-based studies have focused on decreased by 43 percent from 532,000 in 1990 to 303,000
direct obstetric complications; little is known about the in 2015. The global maternal mortality ratio (MMR)
Assessing maternal deaths among human immuno- (18 percent), Lesotho (13 percent), and Mozambique
deficiency virus (HIV)infected women is a separate (11 percent).
but related estimation process. Worldwide in 2015, AIDS-related indirect maternal deaths accounted
4,700 maternal deaths were attributed to HIV (an for 1.6 percent of global maternal deaths.
indirect cause of maternal deaths because the con- Underreporting and misclassification of indirect
dition usually preexists pregnancy, and this cause maternal deaths due to HIV/AIDS are a particular
of death is not specific to pregnant women); 4,000 issue in death certificate coding and when coun-
(85 percent) of these deaths were in Sub-Saharan tries rely on verbal autopsies to ascertain cause of
Africa. The MDG region of Southern Asia was a death. This imprecision highlights the need for
distant second, with 310 deaths. The proportion of review of deaths of HIV-infected women tempo-
maternal deaths attributed to HIV was highest in ral to pregnancy; the women may die from HIV or
Sub-Saharan Africa (2.0 percent) and Latin America with HIV while pregnant. As methods for global
and the Caribbean (1.5 percent). Without HIV, the maternal death estimation evolve, the evidence
MMR for Sub-Saharan Africa would be 535 mater- for the parameters needed to estimate indirect
nal deaths per 100,000 live births, rather than 510. maternal HIV deaths and further clarification on
The proportion of HIV-attributable maternal deaths the use of ICD-10 codes will standardize and
is 10 percent or more in five countries: South Africa improve our understanding of maternal and HIV
(32 percent), Swaziland (19 percent), Botswana death tallies.
causes, point estimates show substantial differences confidence interval 3.2 percent to 33.4 percent)
across regions. Hemorrhage accounted for 36.9 percent and 11.5 percent (95 percent confidence interval
(95 percent confidence interval 24.1 percent to 1.6 percent to 40.6 percent), respectively.
51.6 percent) of deaths in northern Africa, compared The proportion of deaths due to indirect causes was
with 16.3 percent (95 percent confidence interval highest in Southern Asia, 29.3 percent (95 percent confi-
11.1 percent to 24.6 percent) in developed regions. dence interval 12.2 percent to 55.1 percent), followed by
Hypertensive disorders were a significant cause of death Sub-Saharan Africa, 28.6 percent (95 percent confidence
in Latin American and the Caribbean, accounting for interval 19.9 percent to 40.3 percent); indirect causes
22.1 percent (95 percent confidence interval 19.9 percent also accounted for nearly 25.0 percent of the deaths in
to 24.6 percent) of all maternal deaths in the region. the developed regions. The overall proportion of HIV/
Almost all sepsis deaths occurred in developing AIDS maternal deaths is highest in Sub-Saharan Africa,
regions, and the percentage of deaths was high- 6.4 percent (95 percent confidence interval 4.6 percent
est at 13.7 percent (95 percent confidence interval to 8.8 percent).
3.3 percent to 35.9 percent) in Southern Asia. Only a
small proportion of deaths are estimated to result from
abortion in Eastern Asia, 0.8 percent (95 percent confi- Trends in Maternal Death Causes
dence interval 0.2 percent to 2.0 percent), where access The continued dearth of basic information in most
to abortion is generally less restricted. Latin America countries of the developing region, where most of the
and the Caribbean and Sub-Saharan Africa have higher deaths occur, impedes the ability to address the question
proportions of deaths in this category than the global of changes in causes of maternal deaths over time. In
average, 9.9 percent (95 percent confidence interval determining trends in causes of maternal deaths, it is
8.1 percent to 13.0 percent) and 9.6 percent (95 percent reasonable to conclude that the proportion of indirect
confidence interval 5.1 percent to 17.2 percent), respec- deaths is increasing in all regions. The actual indirect
tively. Another direct cause, embolism, accounted causes differ in that HIV/AIDS deaths are highest in
for more deaths than the global average in South- Sub-Saharan Africa; other medical causes are highest in
Eastern Asia and Eastern Asia, 12.1 percent (95 percent developed regions and Eastern Asia.
Perceived Morbidity
Where women are not able to access services eas- Principal Morbidity Diagnoses
ily, surveys are conducted to measure their health The principal medical causes of mortality are also impor-
status. Accurate diagnoses are difficult to make in tant morbidity diagnoses, but they are not the only ones
survey conditions without confirmation from a clinical to consider. To this list must be added other contributing
examination, laboratory reports, or medical records factors, such as depression and anemia, because of their
(Ronsmans and others 1997). However, surveys provide frequency or severity. We must also add the sequelae of
evidence of womens experience of health and morbid- difficult labor, such as incontinence, fistulas, and prolapse.
ity during pregnancy. Overall, many women complain A further consideration is the presence of comorbidities,
about ill health in pregnancy and the puerperium. such as obstructed labor followed by infection, that com-
Studies of self-reports in low-income settings typically plicate management, diagnosis, and classification.
find that more than 70 percent of women report signs or Figure 3.1 illustrates a conceptual framework of the
symptoms of pregnancy-related complications (Lagro ways in which different maternal conditions interact.
and others 2003). In a Nepal study, women reported, on Long-term health sequelae are associated with cer-
average, three to four days per week with symptoms of tain diagnoses in pregnancy. For example, neglected
illness during pregnancy (Christian and others 2000). obstructed and prolonged labors are associated with
The type of symptoms reported varied according to obstetric fistulas. The conceptual framework also
gestational age, with nausea and vomiting more com- includes medical risk factors. One of these, obesity, has
mon in early pregnancy, and swelling of the hands become a global epidemic and has been linked with
and face more common toward the end of pregnancy. increasing levels of hypertension and diabetes. The
Counterintuitive changes in self-reported ill health have management of pregnancy and childbirth, including
been described for the postpartum period, with antic- cesarean section, is also a risk factor for future problems,
ipated declines in symptoms over time sometimes for example, placenta previa. Female genital mutila-
followed by increases (Filippi and others 2007; Saurel- tion, particularly in its most severe form, is associated
Cubizolles and others 2000); self-perceived ill health with adverse maternal and perinatal outcomes, includ-
is not simply a result of biological changes but also of ing postpartum hemorrhage and emergency cesarean
social support and influences. (WHO 2006).
Main
complications
Obstetric Sequelae
Hemorrhage Infertility
Hypertension Incontinence
Sepsis Prolapse
Abortion Anemia
Obstructed labor
Anemia
Prolonged labor
HIV
Obesity
Unsafe sex
Management of delivery
Female genital mutilation
This section focuses on 11 groups of diagnoses that worldwide (WHO 2011b); of these, 5 million women are
can lead to direct obstetric deaths or associated long- subsequently hospitalized (Singh 2006), most because of
term ill health: abortion, hypertensive disease, obstetric hemorrhage (44 percent of admitted cases) or infections
hemorrhage, infection, prolonged and obstructed (24 percent) (Adler and others 2012a). On average, 237
labor, anemia, postpartum depression, postpartum women experience a severe maternal morbidity associ-
incontinence, fistula, postpartum prolapse, and HIV/ ated with induced abortion for every 100,000 live births
AIDS. Other important indirect conditions that we in countries where abortion is unsafe (Adler and others
do not consider are discussed in other DCP3 volumes, 2012b). Evidence indicates that the morbidity patterns
including volume 6 on HIV/AIDS, STIs, Tuberculosis, associated with unsafe abortion are being transformed
and Malaria. Figures 3.2 and 3.3 summarize the preva- by the rapid growth of the medical abortion market,
lence of the considered conditions. with the incidence of severe morbidity episodes declining
more rapidly than the incidence of less severe episodes
Abortion (Singh, Monteiro, and Levin 2012).
Morbidity with abortive outcomes comprises several
diagnoses, including ectopic pregnancy, abortion, and Hypertensive Disease
miscarriage, as well as other abortive conditions (WHO Women in pregnancy or the puerperium can suffer from
2013) (box 3.3). preeclampsia, eclampsia, and chronic hypertension.
Induced abortion is a safe procedure, safer than Eclampsia and preeclampsia tend to occur more fre-
childbirth when performed in a suitable environment quently in the second half of pregnancy; less commonly,
and with the right method. Among unsafe abortions, they can occur up to six weeks after delivery. Medication
the morbidity burden is large. Information on the can alleviate the symptoms and their negative effects, but
incidence of unsafe abortion and subsequent outcomes the only cure is expedited delivery. The etiology of the
at the population level is particularly challenging to condition remains unclear.
obtain because of fear of disclosure. On the basis of One systematic review reported that the global
estimates derived from hospital data (adjusted for bias), prevalence of preeclampsia is 4.6 percent (95 percent
an estimated 22 million unsafe abortions occur each year confidence interval 2.7 percent to 8.2 percent), and
via
sia
ia
n
ab d
or ed
tio
lence of 1 percent (Ananth and others 1999).
ps
dl n
re
mp
te d a
ab iat
Pla age
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ec
or
n
lam
ap
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uc ge
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ee
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ps
id
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e
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ag
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Ut
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ve
Pregnancy-Related Infection
Ob
so ar
Se
as Ne
definitions and followed women for only 28 days (Bang Its main symptoms include excessive fatigue; it can
and others 2004). Risk factors for infections include contribute to or lead directly to a maternal death when
HIV/AIDS and cesarean section. Hb concentration has reached particularly low levels.
Anemia has many different causes, including blood loss;
Prolonged and Obstructed Labor infection-related blood cell destruction; and deficient
An unpublished systematic review by Adler and others red blood cell production because of sickle cell disease,
located only 16 published population-based studies parasitic diseases such as hookworm or malaria, or
of obstructed and prolonged labor worldwide since nutritional deficiency, including iron deficiency.
2000. The studies could not be combined through During pregnancy, anemia is diagnosed when Hb levels
meta-analysis to obtain a global prevalence because are below the threshold of 11 grams/deciliter. Anemia
of high heterogeneity, which was largely attributed to is classified as severe when the levels reach 7 grams/
differences in case definitions. However, the median deciliter. Anemia is well-documented in low-income
prevalence was estimated to be 1.9 per 100 deliveries for settings thanks to the ease with which lay fieldworkers
obstructed labor, and 8.7 per 100 deliveries for combined can collect hemoglobin levels in survey conditions.
obstructed and prolonged labor. A systematic review of Using 257 population-based data sets for 107 coun-
articles from 1997 to 2002 reporting on uterine rup- tries, Stevens and others (2013) estimate that globally
ture finds extremely low prevalence in the community 38.0 percent (95 percent confidence interval 34 percent
setting (median 0.053, range 0.016 to 0.30 per hundred to 43 percent) of pregnant women have anemia, and
pregnant women), but it included a study with self- 0.9 percent (95 percent confidence interval 0.6 percent
reporting, which tends to overestimate the prevalence of to 1.3 percent) have severe anemia. Pregnant women
rare conditions (Hofmeyr, Say, and Glmezoglu 2005). in Central and West Africa appear particularly affected
(56.0 percent are anemic, and 1.8 percent are severely so).
Anemia However, global prevalence trends have improved since
Anemiawhich occurs when the number of red cells 1995 (Stevens and others 2013). The review by Wagner
or hemoglobin (Hb) concentration has reached too and others (2012) demonstrates that women who suffer
low a level in the bloodis a commonly diagnosed severe blood loss during childbirth may remain anemic
condition during pregnancy or the postpartum period. for several months during the postpartum period.
Corresponding author: Li Liu, The Institute for International Programs, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA; lliu26@jhu.edu.
71
mortality rates. We also present estimates of the broadest only by possible differences in stillbirth rates, which are
measure of child mortality risk, the TU5MR. likely to be minor, given the close overlap of the regions.
As a result of using this new conceptualization, we
have to combine information from two sources, one
for stillbirths and the other for mortality following a Results
live birth, and make some approximations along the Table 4.1 shows probabilities of dying for the four
way. However, the approximations are relatively minor age ranges and for the TU5MR. Globally, the TU5MR
and do not affect the overall picture of recent levels and declined from 95.4 per 1,000 viable fetuses in 2000 to
trends in TU5MR. 59.1 in 2015, an annual average rate of reduction (ARR)
of 3.2 percent (table 4.2). For LMICs, the TU5MR
declined from 105.9 in 2000 to 65.2 in 2015, and the
Sources decline for high-income countries (HICs) was from
The estimates presented in this section are based on sepa- 14.3 to 9.7. The ARR was somewhat faster in the LMICs
rate estimation exercises, one for the stillbirth rate and one (3.2 percent) than in the HICs (2.6 percent), so the risk
for mortality of live-born children to age five years. For ratio for LMICs to HICs declined from 7.4 to 6.7 over
mortality of live-born children, we use the estimates by the period; the absolute difference narrowed much more
the IGME (You and others 2015); the methodology used sharply, from 92 to 56 per 1,000 viable fetuses. In both
by the IGME to arrive at estimates is described elsewhere years, there is large variation across regions. HICs had
(Alkema and others 2014). We present the probabilities of the lowest risks, about one-third that of the next best
dying from live birth and the ratio of numbers of deaths region, Latin America and the Caribbean. Sub-Saharan
to live births for World Bank regions for 2000 and 2015. Africa had the highest risk, with the TU5MR remaining
The derivation of stillbirth rates and numbers of still- substantially greater than 100 per 1,000 in both years,
births is less direct. The most recent systematic analysis more than 10 times the risk in HICs. The region with
of stillbirth rates provides estimates for MDG regions the second-highest risk in both years was South Asia,
for 1995 and 2009 (Cousens and others 2011). We use although its TU5MR fell to less than 100 in 2015; its
the rate of change in the stillbirth rate between 1995 disadvantage relative to HICs declined only slightly,
and 2009 for each MDG region to interpolate to 2000 however, from 8.3 to 7.9. The remaining regions had
and extrapolate to 2015. We then assume that these rates rather similar TU5MRs, between 44 and 59 per 1,000 in
for MDG regions, suitably aggregated, closely approx- 2000 and between 26 and 36 in 2015, slightly narrowing
imate those for World Bank regions for those years. their disadvantage relative to HICs.
Specifically, to approximate the World Bank region of At the global level, the neonatal period has the highest
East Asia and Pacific, we combine the MDG regions of age-specific risk in both 2000 and 2015. This is also the
East Asia, South-East Asia, and Oceania; for the World case for LMICs as a group and for all regions individ-
Bank region of Middle East and North Africa, we com- ually, except Sub-Saharan Africa in 2000 and East Asia
bine the MDG regions of Western Asia and North Africa; and Pacific in 2015. For all LMICs, and particularly for
and for the World Bank region of Europe and Central Sub-Saharan Africa, the age range of lowest risk shifts
Asia, we combine the Commonwealth of Independent from stillbirths in 2000 to ages one to five years in 2015.
States (CIS) Europe and CIS Asia. South Asias lowest risk is in the postneonatal group in
To estimate numbers of stillbirths, we use the rela- 2000; for all other regions, the lowest risk in both years
tionship between rates and numbers of events. The neo- is from ages one to five years. The absolute difference
natal mortality rate (NMR) is calculated as the number between the highest and lowest risk among age ranges
of neonatal deaths (ND) divided by the number of live decreased by more than 90 percent from 2000 to 2015.
births, so given the number of ND and the NMR, we can The mortality rate estimate for Sub-Saharan Africa is
calculate the number of live births. The stillbirth mortal- 2.4 times that of the next highest region (South Asia),
ity rate (SBR) is calculated as the number of stillbirths for both postneonatal and ages one to five years, despite
divided by the sum of the number of stillbirths and live similar neonatal and stillbirth rates.
births. We can estimate the number of stillbirths from Table 4.2 shows the ARR in probabilities of dying
the NMR, ND, and SBR as follows: between 2000 and 2015 for the age ranges and regions
shown in table 4.1. As noted, the ARR for TU5MR
SB = ND SBR/[NMR (1 SBR)]. globally was 3.2 percent, somewhat less than the rate
needed (4.4 percent) to achieve the MDG 4 target
These numbers are not affected by differences in num- for the conventional U5MR. If we apply the MDG 4
bers of live births between MDG and World Bank regions, target for U5MR to the TU5MR, the only region to
Table 4.2 Annual Rates of Reduction in Probabilities of Dying per 1,000 Pregnancy Completions from the 28th Week of
Pregnancy to Age Five Years, between 2000 and 2015
200015
World Bank region 28 weeks gestation to birth Birth to 27 days 28 days to 1 year 15 years TU5MR
Low- and middle-income countries 1.18 3.11 4.01 5.09 3.23
East Asia and Pacific 3.35 5.72 4.84 7.40 5.04
Europe and Central Asia 1.40 4.13 4.94 7.15 4.06
Latin America and the Caribbean 2.34 3.02 4.83 4.51 3.52
Middle East and North Africa 1.74 3.17 4.62 6.18 3.39
South Asia 0.89 2.87 4.17 5.42 2.95
Sub-Saharan Africa 0.65 2.36 4.35 5.36 3.37
High-income countries 1.68 2.88 2.81 3.54 2.59
World 1.16 3.06 3.97 5.05 3.19
Sources: Based on Cousens and others 2011; and 2015 UN Inter-Agency Group for Child Mortality Estimation (IGME).
Note: TU5MR = total under-5 mortality rate.
exceed the MDG 4 target ARR was East Asia and Pacific for postneonatal mortality exceeded the TU5MR, on
(5.0 percent), although LMIC countries of Europe and average, in most regions. It is interesting to note how
Central Asia (4.1 percent) came fairly close. All other similar the rates of decline are for postneonatal mortality
regions, with ARRs ranging between 2.6 percent and risks and risks between ages one and five years on the
3.5 percent, performed well below the MDG target. one hand, and how different stillbirth rates of decline are
Globally and in all regions, declines were slowest for from declines of risk after birth, on the other hand. The
stillbirths, averaging only about 1 percent per year in the ARR of mortality risk after the neonatal period was very
aggregate, and highest for child mortality rates except close to or greater than the rate of reduction required to
for Latin America and the Caribbean; rates of decline achieve the primary MDG 4 target in all LMICs; failure
Table 4.4 Annual Rates of Reduction in Numbers of Deaths from the 28th Week of Pregnancy to Age Five Years,
2000 and 2015
200015
World Bank region 28 weeks gestation to birth Birth to 27 days 28 days to 1 year 15 years TU5MR
Low- and middle-income countries 0.58 2.51 3.41 4.51 2.64
East Asia and Pacific 2.73 5.12 4.26 6.94 4.45
Europe and Central Asia 0.63 3.37 4.19 6.30 3.28
Latin America and the Caribbean 2.99 3.66 5.47 5.29 4.15
Middle East and North Africa 0.19 1.24 2.72 4.18 1.51
South Asia 1.33 3.33 4.64 5.83 3.40
Sub-Saharan Africa 1.21 0.49 2.49 3.50 1.50
High-income countries 1.31 2.64 2.51 2.85 2.27
World 0.59 2.52 3.39 4.49 2.63
Sources: Based on Cousens and others 2011; and 2015 UN Inter-Agency Group for Child Mortality Estimation (IGME).
Note: TU5MR = total under-5 mortality rate.
to achieve the target rate of decline overall was the result postneonatal period in 2000 but by stillbirths in 2015.
of relatively slower declines for stillbirths (especially) The numbers of deaths declined for all regions and for
and neonatal mortality. all age ranges, except for stillbirths in Sub-Saharan Africa
The numbers of deaths by age range are a product of and the Middle East and North Africa, which increased
risk (probability of dying) and numbers at risk (whether at 1.21 percent and 0.19 percent per year, respectively,
population, births, or viable fetuses). Table 4.3 shows reflecting slowly increasing risks, especially in Sub-
estimated numbers of deaths by age range, region, and Saharan Africa. The numbers of deaths under age five
year. The number of deaths between 28 weeks of ges- years declined fastest in Latin America and the Caribbean
tation and age five declined from 12.5 million in 2000 and in East Asia and Pacific; the slowest rate of decline,
to 8.4 million in 2015, a decline of 2.6 percent per year by a substantial margin, was in Sub-Saharan Africa and
(table 4.4). Globally, the numbers of deaths are highest the Middle East and North Africa (1.5 percent in both
in the neonatal period in both years, followed by the regions); the third-slowest were HICs (2.2 percent).
Table 4.6 Distribution of Single Causes of Stillbirth and Percentage of Contributing Causes in Six High-Income
Countries Using the Cause of Death and Associated Conditions Classification System
Percent
Single cause of stillbirth Contributing causes of death
Unknown 30 Lacking or despite documentation and autopsy results 30
Corresponding author: Gretchen A. Stevens, Department of Health Statistics and Information Systems, World Health Organization, Geneva; stevensg@who.int.
85
growth standards for each individual measurement of 059 months may have more variation relative to
(WHO 2006). the true levels than nationally representative data and
For data obtained as summary statistics, we extracted data that covered the full range of ages. Estimates by
the summary statistic for the entire population cov- sex were not made because little difference was found
ered by each data source, usually at the national level, between male and female stunting prevalence (Stevens
and, where possible, separately for urban and rural and others 2012).
areas. For the second analysis, the statistical model was
In cases for which only summarized statistics were extended to make separate estimates for urban and rural
calculated using the 1977 National Center for children. The urban-rural difference in HAZ distribu-
Health Statistics reference, regression equations were tion was allowed to vary by country and year. Both anal-
developed to convert these estimates to the 2006 yses were also carried out for childrens weight-for-age
WHO child growth standards (Stevens and others distribution, not reported here.
2012). Our final data set included measured heights Public health professionals usually report the preva-
of more than 7.7 million children under age five years. lence of stunting (as defined by the WHO as HAZ below
2), rather than other metrics, such as mean HAZ or
Despite the extensive data search, there were gaps the prevalence of severe stunting (HAZ below 3). In
in data availability; an average of 4.5 data sources this chapter, we report mean HAZ, prevalence of stunt-
were available for each country over the 26 years in ing (HAZ below 2), and prevalence of severe stunting
the study period. We therefore developed Bayesian (HAZ below 3).
hierarchical mixture models to estimate the complete
distribution of childhood HAZ for each country and
year, from which we calculated summary statistics GLOBAL AND REGIONAL TRENDS
such as mean HAZ and the prevalence of stunting. The
inputs for our model were individual-level records Global Trends
and summary statistics. Two statistical analyses were In LMICs the prevalence of stunting has declined
conducted: and mean HAZ has improved since 1985. In 1985,
47.2 percent (95 percent uncertainty interval 44.050.3)
An analysis of HAZ distribution in 141 low- and of children under age five years were moderately or
middle-income countries (LMICs) for each year from severely stunted; this rate improved to 29.9 percent
1985 to 2011 (27.132.9) in 2011 (figure 5.1). Mean HAZ increased
An analysis of HAZ distribution in urban and rural during the same period, from 1.86 (2.01 to 1.72) to
areas in the same 141 LMICs for each year from 1985 1.16 (1.29 to 1.04).
to 2011. Despite large improvements, many children remain
stunted. In 2011, 314 million (95 percent uncertainty
In the first model, estimates for each country-year interval 296 million to 331 million) children had HAZ
were informed by data from that country-year itself, below 1, a moderate improvement from 367 million
if available, and by data from other years in the same (352 million to 379 million) in 1985. Of the children with
country and in other countries, especially those in the HAZ below 1 in 2011, 46 percent had HAZ between 1
same region with data in similar periods. This hier- and 2, 31 percent had HAZ between 2 and 3, and
archical model shares information to a greater degree 23 percent had HAZ below 3.
where data are nonexistent or weakly informative (for
example, because they have a small sample size), and
to a lesser degree in data-rich countries and regions. Regional Trends
We modeled trends over time both as a linear trend Although child height improved in LMICs as a whole,
and as a smooth nonlinear trend. The estimates were progress was less consistent at the regional level
informed by time-varying covariates that help predict (figure 5.1). East Asia and Pacific and South Asia show
HAZ, including maternal education, national income the largest improvements in mean HAZ, increasing by
(natural logarithm of per capita gross domestic product about 0.4 per decade. Mean HAZ also increased to a
[GDP] in inflation-adjusted U.S. dollars), proportion lesser extent in Europe and Central Asia, the Middle East
of the population in urban areas, and an aggregate and North Africa, and Latin America and the Caribbean
metric of access to basic health care. Finally, the model (increases of 0.200.23 per decade). However, childrens
accounted for the fact that data did not cover the entire height in Sub-Saharan Africa showed inconsistent prog-
country; data that did not cover the complete age range ress. In Sub-Saharan Africa, stunting prevalence may
60
1.0 40
Z-score
Percent
Percent
40
2.0 20
20
3.0 0 0
1985 1995 2005 1985 1995 2005 1985 1995 2005
South Asia East Asia and Pacific All low- and middle-
Sub-Saharan Africa Europe and Central Asia income countries
Middle East and North Africa Latin America and the Caribbean
Source: Stevens and others 2012.
Note: Shaded areas show the 95 percent uncertainty interval. HAZ = height-for-age z-scores.
have increased from 41.4 percent (95 percent uncer- Improvement in mean HAZ at the national level can
tainty interval 37.345.6) in 1985 to more than 45 from be divided into three components:
1995 to 1999; it subsequently decreased to 37.7 percent
(35.340.2) by 2011. Improvement in mean HAZ in rural children
In 1985, mean HAZ was higher and the prevalence Improvement in mean HAZ in urban children
of stunting was lower in urban areas than in rural Increases in the proportion of children in urban areas.
areas in all regions (figure 5.2). Urban and rural mean
HAZ and prevalence of stunting largely improved at Figure 5.3 shows each components contribution in
the same pace; the urban-rural gaps in mean HAZ each region. In East Asia and Pacific and in South Asia,
and prevalence of stunting were, in most cases, both predominantly rural regions in 1985 (less than
maintained during the period. Nevertheless, some 30 percent urban) and in 2011 (less than 50 percent urban),
improvements were observed. In Europe and Central improvements in rural HAZ contributed 68 percent or
Asia and the Middle East and North Africa, both the more of the overall improvement in HAZ. In contrast, in
absolute and relative gaps in the prevalence of stunt- Latin America and the Caribbean, a predominantly urban
ing decreased. In Europe and Central Asia, the gap region (66 percent urban in 1985, increasing to 78 percent
between urban and rural prevalence of stunting fell urban by 2011), urban improvements contributed more
from 15 percent in 1985 to 7 percent, the narrowest than 70 percent of the overall improvement.
gap observed, in 2011.
The most impressive improvement in childrens height
occurred in China, followed by Vietnam, Bangladesh, Height-for-Age in 2011
India, Bhutan, Brazil, Nepal, and Tunisia; in these coun- Despite large improvements in HAZ in most regions,
tries, mean HAZ increased by 0.350.51 per decade. In only a few countries have mean HAZ and stunting prev-
most of these high-performing countries, the urban- alence that approach the ideal of a mean HAZ of at least
rural gap in mean HAZ also declined; the exceptions zero and stunting prevalence of 2.3 percent (maps 5.1,
are China, Vietnam, and with large uncertainty, Jamaica. 5.2, 5.3). Chile, Jamaica, and Kuwait have mean HAZ
HAZ may have deteriorated in 17 countries between greater than 0 and a prevalence of stunting of less than
1985 and 2011, nearly all in Sub-Saharan Africa and the 5 percent, as do urban areas of China.
Oceania region of East Asia and Pacific; most had large The majority of stunted children still live in rural
uncertainties, with the exception of estimated declines in areas. These stunted children live mainly in South Asia
Cte dIvoire and Niger. Overall, the rate of improvement (52 million [uncertainty interval 42 million to
in mean HAZ was positively correlated with a reduction 62 million]) and Sub-Saharan Africa (37 million
in urban-rural inequality in mean HAZ. [35 million to 40 million]). In rural areas in Afghanistan,
a. All low- and middle-income b. East Asia and Pacific c. Europe and Central Asia
countries
Percentage stunted
Percentage stunted
Percentage stunted
60 60 60
40 40 40
20 20 20
0 0 0
1985 1995 2005 1985 1995 2005 1985 1995 2005
Year Year Year
Percentage stunted
Percentage stunted
60 60 60
40 40 40
20 20 20
0 0 0
1985 1995 2005 1985 1995 2005 1985 1995 2005
Year Year Year
g. Sub-Saharan Africa
Percentage stunted
60
40
20
0
1985 1995 2005
Year
Rural Urban
Source: Paciorek and others 2013.
Note: Shaded areas show the 95 percent uncertainty interval of the trend.
Burundi, Guatemala, Niger, Timor-Leste, and the and 15 million (14 million to 16 million) in urban
Republic of Yemen, more than 50 percent of the children Sub-Saharan Africa.
under age five years were stunted in 2011.
Nevertheless, as urbanization increases, a rising per-
centage of stunted children live in urban areasfrom
IMPLICATIONS FOR PRIORITY SETTING
23 percent in 1985 to 31 percent in 2011 (figure 5.4). Stunting has received increased attention as a primary
In 2011, 18 million (uncertainty interval 14 million to indicator of childrens nutritional status. It has been
22 million) stunted children lived in urban South Asia included as one of three health status indicators by the
Prevalence of Stunting by
Country, 2011
Greater than 50
4049
3039
2029
1019
09
No estimate made
Source: Pacionek and others, 2013.
Prevalence of Stunting in
Urban Areas, 2011
Greater than 40
3039
2029
1019
09
No estimate made
Source: Pacionek and others, 2013.
Prevalence of Stunting in
Rural Areas, 2011
Greater than 50
4049
3039
2029
1019
09
No estimate made
Source: Pacionek and others, 2013.
mechanism for improvement has been population Although the relative importance of various popu-
improvements rather than targeted interventions. These lation forces is uncertain, several lessons have emerged
population improvements include enhanced health from the research:
promotion, such as breastfeeding and complemen-
tary feeding; improved environmental and sanitary Growth in national income seems to have a pos-
conditions; increased availability and affordability of itive effect on child nutrition but may be insuffi-
nutritious foods; and improved income and education cient, perhaps because improving nutritional status
levels. Because the burden of stunting is still largely in requires more equitable income distribution and
rural areas, evaluating potential interventions expected increased investments in health care and nutrition
benefits for rural children is appropriate. programs (Anand and Ravallion 1993; Haddad and
a. Number of stunted children in rural areas b. Number of stunted children in urban areas
200 200
180 180
160 160
140 140
120 120
Millions
Millions
100 100
80 80
60 60
40 40
20 20
0 0
03
05
07
09
11
85
87
89
91
93
95
97
99
01
85
87
89
91
93
95
97
99
01
03
05
07
09
11
20
20
20
20
20
19
19
19
19
19
19
19
19
20
20
19
19
19
19
19
19
19
19
20
20
20
20
20
Sub-Saharan Africa Middle East and North Africa Europe and Central Asia
South Asia Latin America and the Caribbean East Asia and Pacific
Box 5.1
Child wasting may be caused by acute illness, inap- North Africa, with estimated regional prevalence of
propriate feeding, or insufficient feeding. The World wasting ranging between 15 percent and 7 percent.
Health Assembly endorsed a target goal of reducing Of the 102 countries for which data on severe
and maintaining childhood wasting to less than wasting from 2006 to 2012 were available, 51 had at
5 percent by 2025 (World Health Assembly 2012). least one survey with a severe wasting prevalence of
The global prevalence of wasting in 2013 was 7.7 per- 2 percent or higher. Of the 110 countries reporting
cent (uncertainty interval 6.6 percent to 8.9 percent), data on wasting in the same period, 64 reported
and the global prevalence of severe wasting was prevalence of wasting greater than 5 percent in at
2.6 percent (uncertainty interval 2.1 percent to least one survey. In nine countriesBangladesh,
3.2 percent) (UNICEF, WHO, and World Bank Benin, Chad, Djibouti, India, Niger, Papua New
2014). According to these estimates, the prevalence Guinea, South Sudan, and Timor-Lestethe most
of wasting and severe wasting were highest in the recent survey data (excluding data before 2006) indi-
World Bank regions (in decreasing order) of South cate a prevalence of wasting greater than 15 percent
Asia, Sub-Saharan Africa, and the Middle East and (WHO 2014b).
others 2003; Ravallion 1990; Smith and Haddad 2002; Pongou, Salomon, and Ezzati 2006). The adverse
Subramanyam and others 2011). effects on nutrition were greatest in poorer house-
Macroeconomic shocks, structural adjustment, and holds, especially in rural areas, transmitted through
trade policy reforms have been implicated in the lower household earnings and assets, reduced food
worsening nutritional status in Sub-Saharan Africa in subsidies, and reduced health care use (Cooper Weil
the 1980s and 1990s (Cooper Weil and others 1990; and others 1990; Pongou, Salomon, and Ezzati 2006).
Corresponding author: John Stover, Vice President and founder of Avenir Health, Glastonbury, Connecticut, United States, JStover@avenirhealth.org.
95
shows positive links between slower population growth population conferences in 1974, 1984, and 1994 reaf-
and economic developmentat least in the initial phase firmed this right (Singh 2009).
of the demographic transition, when countries enjoy a The human rights rationale has focused on sexual
demographic dividend, if other economic and human reproductive health and rights, with family planning
capital policies are in place. The demographic dividend implicitly included. Efforts are underway to more explic-
allows countries to take advantage of a beneficial depen- itly define a rights-based approach to implementing
dency ratio between the working-age population and voluntary family planning programming (Hardee and
the groups who need support, that is, children and the others 2014). Ensuring equity is a fundamental principal
elderly (Bloom, Canning, and Sevilla 2003). It is impor- of human rightsbased programming. Wealth quintiles
tant to have supportive economic policies and labor analysis has shown that wealthier women have lower
regulations in place to reap the potential benefits of the fertility rates and better access to family planning than
demographic dividend; many countries in Sub-Saharan poorer women. Gillespie and others (2007), in a study
Africa need to coordinate development of their eco- of 41 countries, find that although variations were
nomic and reproductive health policies to fully realize observed among countries, the number of unwanted
this effect. births in the poorest quintile was more than twice that in
the wealthiest quintile, at 1.2 and 0.5, respectively.
Maternal and Child Health Rationale
The improved health of mothers and children has Environment and Sustainable Development Rationale
long been a rationale for the provision of family A resurgence of interest in global population dynam-
planning (Seltzer 2002). In the 2009 round of the ics is linked to growing attention to environmental
Family Planning Effort Index, measured periodically issues, climate change, and concerns about food security
since 1972, womens health was the dominant justi- (Engelman 1997; Jiang and Hardee 2011; Martine and
fication for family planning programs, followed by Schensul 2013; Moreland and Smith 2012; Royal Society
reducing unwanted fertility (Ross and Smith 2011). 2012). Although global population growth is slowing,
These reasons ranked higher than fertility reduction, the momentum built into past population trends means
economic development, and reduction of childbearing that the worlds population will continue to grow. The
among unmarried youth. Contraception can serve as worlds population surpassed 7 billion in 2012; the 2013
an effective primary prevention strategy in LMICs to UN Population Division projection estimates that it
reduce maternal mortality (Ahmed and others 2012). could grow to 9.6 billion by the middle of the century
By one estimate, increases in contraceptive use from and level off at about 10.9 billion by the end of the
1990 to 2008 contributed to 1.7 million fewer maternal century under their low scenario, or it could grow to
deaths (Ross and Blanc 2012). Reductions in fertility more than 16 billion by the end of the century under
rates accounted for 53 percent of the decline in mater- their high scenario. According to the United Nations
nal deaths; lower maternal mortality rates per birth Population Fund (UNFPA), Whether future demo-
accounted for 47 percent of the decline (Ross and graphic trends work for or against sustainable develop-
Blanc 2012). ment will depend on policies that are put in place today
Family planning can have significant effects on the (UNFPA 2013, 5). If the unmet need for family planning
health of children. Analysis of data from Demographic services were satisfied in all countries, world population
and Health Surveys (DHS) from 52 countries showed growth would fall between the UNs low and medium
that children born within two years of a previous projections (Moreland, Smith, and Sharma 2010).
birth have a 60 percent increased risk of infant death,
and those within two to three years have a 10 percent
increased risk of infant death, compared with children Health Consequences of High Fertility
born after an interval of three or more years from the High fertility affects the health of mothers and chil-
last sibling (Rutstein and others 2008). These analyses dren in several ways. Unwanted pregnancies may lead
have confirmed the usefulness of program initiatives to to unsafe abortions, which are associated with elevated
promote healthy timing and spacing of births. risks of maternal mortality. All births carry some risk
of maternal mortality, so women with a large number
Human Rights and Equity Rationale of births have higher lifetime risk of dying from mater-
The right of couples and individuals to decide freely and nal causes. The World Health Organizations (WHOs)
responsibly on the number and spacing of their children Global Health Estimates reports that there were 303,000
was articulated at the 1968 International Conference on maternal deaths in 2015; 300,000 of these deaths occurred
Human Rights (UN 1968). Subsequent international in LMICs (WHO 2015). The maternal mortality ratio
100
90
80
70
60
Percentage of births
50
40
30
20
10
0
<2 (N = 6) 23 (N = 28) 34 (N = 32) 45 (N = 38) 56 (N = 38) 67 (N = 32) 7+ (N = 6)
Total fertility rate (number of surveys)
Bl < 24 and BO > 3 Age > 34 and BI < 24 and BO > 3 Age > 34 and BO > 3 Age > 34 and BI < 24
Age < 18 and BI < 24 BO > 3 BI < 24 Age > 34
Age < 18 First birth No risk factor
The method mix in Kenya has evolved, and injectables are the population, resulting in greater reliance on methods
now the most popular form of contraception. In Turkey appropriate for those delivery channels, such as oral con-
and Ukraine, for example, withdrawal and condoms are traceptives, injectables, and condoms. In countries with
used most often; high rates of abortion compensate for higher access to medical providers, physician-supplied
the lower effectiveness of these methods (UN Population methods, such as IUDs, may be preferred.
Division 2013b). In countries with limited access to More than 180 new contraceptive methods are
health clinics, community-based distribution (CBD) in various stages of research and development
and social marketing are used to reach a large portion of (http://pipeline.ctiexchange.org/products/table).
Although many will never reach the market, some to programs that rely on community workers to reach
have the potential to address current barriers to use large numbers of users. In the longer term, it may even
for some users. Several new methods that may address be labeled for self-injection.
some limitations in current methods are becoming
available. Sino-implant (II), a subdermal contra-
ceptive implant consisting of two silicone rods with Organization of Family Planning Programs
75 milligrams of levonorgestrel, provides four years of Global Initiatives
protection. Although similar to other implants already Family planning programming has been guided by
on the market, Sino-implant (II) is considerably less global initiatives for decades, including through decen-
expensive and could potentially expand the avail- nial population conferences in 1974 in Bucharest,
ability of implants. It is registered for use in about 1984 in Mexico City, and 1994 in Cairo, as well as
20 countries. Sayana Press, an injectable contraceptive global frameworks, including the 2000 Millennium
(Depo-Provera) with a duration of three month, is Development Goals (MDGs). The twentieth anniversary
packaged in a Uniject system that allows subcutane- of the 1994 International Conference on Population and
ous injection. The main advantage of this system is Development (ICPD) has passed, and the UN recently
that field workers can easily administer it without the adopted the post-2015 development agenda. The ICPD
need for users to visit clinics. It is expected to appeal positioned family planning within a broad context of
100
90
80
70
60
Percent
50
40
30
20
10
0
Bangladesh Brazil Egypt, India Kenya Morocco Turkey Ukraine Zimbabwe
Arab Rep.
Sterilization IUD Implant Oral contraceptives
Injection Condom Other modern Traditional
Source: Demographic and Health Surveys, latest available survey for each country.
Note: IUD = intrauterine device.
Corresponding author: A. Metin Glmezoglu, Department of Reproductive Health and Research, World Health Organization, Geneva, gulmezoglum@who.int.
115
Map 7.1 Maternal Mortality Ratio per 100,000 Live Births, 2015
IBRD 42032 | DECEMBER 2015
119
2099
100299
300499
500999
1,000
Data not available
or not applicable
Misoprostol. A Cochrane review assessed the effect severe PPH (blood loss greater than 1,000 milliliters).
of prophylactic misoprostol compared with uteroton- However, misoprostol was significantly more effective
ics or no uterotonic given during the third stage of than placebo in reducing PPH and blood transfusions.
labor to women at risk of PPH (Tunalp, Hofmeyr, Misoprostol is associated with an increased risk of
and Glmezoglu 2012). The review included 72 tri- shivering and fever (temperature of 38C or higher)
als conducted in LMICs and HICs involving 52,678 compared with oxytocin and placebo. It does not appear
women. In comparison with oxytocin, oral or sublingual to increase or decrease severe maternal morbidity or
misoprostol was associated with an increased risk of mortality (Hofmeyr and others 2013).
Neonatal sepsis
Community-administered Reduces all-cause neonatal mortality Moderate Zaidi and others 2011
antibiotics and pneumonia-specific mortality
Note: This list is not comprehensive. PPROM = preterm premature rupture of membranes; RDS = respiratory distress syndrome.
a. Based on GRADE Working Group grades of evidence (Atkins and others 2004). The GRADE approach considers evidence from randomized trials to be high quality in the first
instance, and downgrades the evidence to moderate, low, or very low if there are limitations in trial quality suggesting bias, inconsistency, imprecise or sparse data, uncertainty
about directness, or high probability of publication bias. Evidence from observational studies is graded low quality in the first instance and upgraded to moderate (or high) if large
effects are yielded in the absence of obvious bias.
no significant difference in poor neonatal outcomes; (Roberts and Dalziel 2006). However, a large cluster
however, CS rates were nonsignificantly reduced in the randomized trial (Antenatal Corticosteroids Trial)
active management group (Brown and others 2013). conducted in LMICs to test provision of antenatal
corticosteroids at lower levels of the health system with
Preterm Labor and Preterm Prelabor Rupture of mainly unskilled workers and limited assessment of
Membranes gestational age finds no difference in neonatal mortal-
Antenatal corticosteroids. The administration of ante- ity with the administration of antenatal corticosteroids
natal corticosteroids to women in preterm labor, or (Althabe and others 2015). Neonatal mortality in the
in whom preterm delivery is anticipated (for example, intervention clusters overall was increased, which may
in severe preeclampsia), for the prevention of neo- have been due to overtreatment, as were maternal
natal respiratory distress syndrome (RDS) has been infections. This trial has important implications for
shown to be very effective in preventing poor neona- the setting, implementation, and scale up of this inter-
tal outcomes in well-resourced settings. A Cochrane vention, notably that antenatal corticosteroids should
review of 21 RCTs involving 4,269 neonates finds be used in the context of more accurate assessment of
that a single course of steroids administered between gestational age and assessment for maternal infection;
26 weeks and 35 weeks gestation reduced the risk of ensuring that maternal and newborn care can be pro-
neonatal death by 31 percent and reduced neonatal vided should also be a part of this intervention. In the
morbidity including cerebroventricular hemorrhage, Antenatal Corticosteroids Trial, half of the births were
necrotizing enterocolitis, RDS, and systemic infections at home (Althabe and others 2015).
CONCLUSIONS REFERENCES
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137
138
Table 8.1 Clinical Findings and Final Classification in Studies on Integrated Management of Fevers
139
be most practical and cost-effective (DCP3 volume 6, conditions, classification and treatment strategies, and a
Babigumira, forthcoming). In 2009, experts debated review of available diagnostic tests. In addition, different
whether sufficient information was available to aban- health systems approaches to diagnosis and treatment of
don presumptive treatment guidelines and move to an the febrile child at the community and health-facility levels
emphasis on diagnosis before treatment (DAcremont, are discussed, as is the evidence base for WHO-sponsored
Lengeler, and Genton 2007; DAcremont and others approaches such as IMCI and Integrated Community
2009; English and others 2009). Case Management (iCCM). Fever in adults and RDT use
Mounting evidence demonstrated the decline of for malaria are discussed further in volume 6 (Holmes,
Plasmodium falciparum infections in response to intense Bertozzi, Bloom, Jha, and Nugent, forthcoming).
national and multinational initiatives to control malaria.
In 2012 more than US$2.5 billion was invested from
global partners, including the Global Fund to Fight ETIOLOGY OF FEVER IN CHILDREN UNDER
AIDS, Tuberculosis and Malaria; the World Bank Malaria AGE FIVE YEARS
Booster Program; the U.S. Presidents Malaria Initiative;
the Bill & Melinda Gates Foundations Malaria Control and Infectious etiologies of fever differ according to age and
Evaluation Partnership in Africa; and the Roll Back Malaria geographic region. Recent evidence from multiple health
Partnership (DAcremont, Lengeler, and Genton 2010; care and low- and middle-income country (LMIC) settings
Feachem and others 2010; Leslie and others 2012; WHO confirms that viral infections are predominantly responsi-
2013a). Countries with previously defined high-transmis- ble for fever within all age groups (Animut and others 2009;
sion regions are reporting decreasing malaria incidence, Crump and others 2013; DAcremont and others 2014;
making the management of nonmalarial fevers critically Kasper and others 2012; Mayxay and others 2013). The
important (Feachem and others 2010; WHO 2013a; Hertz studies described in table 8.2 used different study designs
and others 2013; Ishengoma and others 2011). with significant variation in study population, case defi-
In 2010, the WHO revised its fever treatment guide- nitions, and available diagnostics. Although these studies
lines to recommend antimalarial treatment only for those are informative, they need to be interpreted in the context
with a positive malaria test result, either point-of-care or of the individual study design and context. Following are
microscopy (WHO 2010a). This new strategy is being common themes across the available research:
implemented in the public sector in most Sub-Saharan
African countries (Bastiaens and others 2011). However, Predominance of acute respiratory infections (ARIs)
many patients first present for care in the informal private in outpatient visits for fever
sector, and more research is needed to better understand Identification of multiple pathogens after molecu-
treatment decision making in this context and how to lar laboratory investigations, making it difficult to
reduce overuse of antimicrobials and ensure appropri- declare a specific diagnosis
ate care. The epidemiology of pediatric febrile illness High proportion of fever etiologies due to viral
is undoubtedly shifting; understanding the etiology of pathogens when appropriate viral diagnostic tests are
nonmalarial fevers in each context is the logical next step available; studies without viral diagnostics reveal a
to improve pediatric clinical outcomes of other treatable high proportion of undiagnosed febrile illnesses
serious febrile illnesses, such as pneumonia, sepsis, bacte- Clinically overestimated malaria, compared with
rial meningitis, enteric fever, rickettsioses, and influenza. RDT or microscopy-confirmed diagnosis.
Given rampant and expanding antimicrobial drug resis-
tance globally, care must be taken to use antibiotics only Although the available evidence suggests that most
when indicated and to develop careful guidelines when viral and some specific bacterial diseases, such as rick-
resources are limited. Present guidelines are based on ettsiosis and leptospirosis, are likely to be underdiag-
clinical features that are unfortunately poorly predictive nosed, data are either not available or are limited from
of the diseases causing fever. Low-cost, accurate, point-of- several countries where the fever burden is highest,
care diagnostics are needed to determine which children such as the Democratic Republic of Congo, India,
can benefit from antibacterial therapies to guide the most and Nigeria. Ongoing surveillance of fever etiology
effective use of antibiotics. in multiple representative geographies to establish
This chapter discusses the evidence that informs cur- trends in predominant pathogens and to identify
rent etiologies of fever, stratified by regional geography. It emerging infections early would be ideal. Additionally,
presents the clinical presentation, diagnosis, and treatment little research is available on fever etiology of young
of the most common diseases, with special considerations infants (age 02 months); a concerted research effort
for certain age groups, the burden of disease for different is underway to better understand the distribution
Study setting Tanzania: One Tanzania, Four outpatient Zanzibar, Uganda, study Lao PDR, two Pakistan, small Cambodia, Cambodia, nine
urban and one hospitalized clinics in Gojjam Tanzania clinic within a province-level peripheral clinic setting unknown outpatient clinics
rural outpatient patients zone in northwest referral third- hospitals in south central
clinic Ethiopia level hospital region
Study design N = 1,005 N = 467 (ages N = 653 (ages N = 677 cases, N =1,602 (less N = 1,938 (ages N = 1,248 febrile N = 1,193 febrile N = 9,997
(younger than 2 months to 13 317 years) 200 controls than age 10 5 months to 49 episodes, all patients, all ages, patients with
age 10 years years) (ages 259 years with fever years) with fever ages 282 controls fever, all ages,
with fever) Diagnoses by months) in last 24 hours) Case definition Tested for median 13 years
Computer- case definitions Diagnoses Clinical plus laboratory malaria, Lab
algorithm- and convalescent by IMCI diagnoses investigations leptospirosis, investigations
generated serum at four to classifications for RDT or rickettsial of respiratory
diagnosis using six weeks post plus laboratory microscopy diseases, scrub secretions, blood,
history, physical, discharge investigations negative for typhus, dengue, serum
and wide array of malaria per local influenza, and
lab investigations clinical guidelines bacteremia
Most 62 percent ARI 1.3 percent 62 percent 26 percent 10 percent 8 percent dengue 47 percent ARI 32 percent 19.9 percent
common (5 percent chest malaria malaria watery diarrhea diarrhea 7 percent scrub 23 percent RDT-confirmed PCR-confirmed
diagnoses X-ray-confirmed 3.4 percent 7 percent clinical 2 percent bloody 93 percent typhus diarrhea or malaria influenza
pneumonia) bacteremia pneumonia diarrhea ARIs: dysentery 68 percent 7.2 percent
6 percent
11.9 percent 0.9 percent Serologically 5 percent skin 47 percent URI Japanese 17 percent RDT-negative: microscopy-
nasopharyngeal fungemia diagnosed: infections encephalitis virus enteric fever 76 percent URI confirmed
viral infection 29 percent malaria
Zoonotic: 5.8 percent 0.2 percent common cold 6 percent 2 percent 0.6 percent LRI
10.5 percent typhoid malaria leptospirosis bacteremia other 6.3 percent
malaria 2 percent 12 percent 17 percent bacteremia
brucellosis 5.1 percent 65 percent pharyngitis 2 percent than S. typhi enteric fever
10.3 percent typhus ARIs: bacteremia 0.5 percent UTI
gastroenteritis 7.7 percent 4 percent
leptospirosis 2.6 percent 57 percent pneumonia less than 3 0.4 percent
5.9 percent UTI brucellosis pneumonia percent malaria malaria
2.6 percent Q 1 percent otitis
fever 9 percent media confirmed by
microscopy or
141
142
Table 8.2 Summary of Evidence for Etiology of Fever Studies (continued)
Multiple 22.6 Unknown Unknown Unknown Unknown Unknown Unknown Unknown 3.5 more than
diagnoses one pathogen
(percent) identified
Notes Availability of Limited viral Limited viral Of the viral ARIs Limited testing Role of influenza High proportion Clinical
extensive viral testing. testing most common for bacterial during outbreak of enteric disease presentation and
diagnostics High prevalence PCR results: illnesses such as lab diagnoses
correlated with of zoonoses; 16 percent RSV typhoid did not always
clinical diagnoses consider different correlate; many
9 percent pathogens found
empiric antibiotic influenza (A/B)
regimens in similar rates in
9 percent controls
rhinovirus
Note: ARI = acute respiratory infection; IMCI = Integrated Management of Childhood Illness; LRI = lower respiratory tract infection; PCR = polymerase chain reaction; RDT = rapid diagnostic test; RSV = respiratory syncytial virus; URI = upper respiratory
tract infection; UTI = urinary tract infection.
of infections in young infants via the Aetiology of studies report case fatality rates (CFRs) of 18 percent
Neonatal Infection in South Asia research group, and 19 percent (Ganatra and Zaidi 2010). A systematic
which is building on results from the WHO Young review that included 27 hospital-based studies of the
Infants Study Group and the WHO Young Infants etiology of neonatal sepsis reports CFRs in children
Clinical Signs Study Group (YICSSG) (WHO Young younger than 60 days as low as 3 percent in Europe and
Infants Study Group 1999; YICSSG 2008). Infection- as high as 70 percent in South-East Asia (Waters and
related neonatal deaths contributed at least 10 percent others 2011).
to overall mortality in children under age five years in Although a positive blood culture is the gold stan-
2013 (Liu and others 2015). dard for diagnosing bacteremia, cultures are known
to lack sensitivity, especially in children, and may take
several hours to days before results are available; cultures
DIAGNOSIS AND TREATMENT OF COMMON require significant laboratory infrastructure, which is a
CHILDHOOD FEBRILE ILLNESSES challenge in low-resource settings. Total leukocyte count,
leukocyte differential, levels of acute phase reactants (for
Febrile Illnesses in Young Infants
example, C-reactive protein), and screening panels using
Infection-related mortality and morbidity for young a variety of cytokine markers may provide supportive
infants from birth to age 59 days is one of the most evidence of infection when abnormal, but these mea-
challenging health issues to address; signs and symp- sures have been shown to have limited value in diagnos-
toms are often nonspecific, and illnesses can rapidly ing bacteremia (Remington and others 2006).
progress to severe disease. Care seeking for young According to a systematic review of 27 studies per-
infant illness often occurs too late or not at all, making formed by Waters and others (2011), the most com-
community-based efforts critical to increasing access to mon documented pathogens for early-onset sepsis
early treatment and addressing this disproportionate (N = 282 isolates) include Escherichia coli (16.3 percent),
morbidity and mortality. Using the CHERG estimates, Staphylococcus aureus (11.7 percent), nonpneumo-
sepsis (15 percent) and pneumonia (6 percent) are the coccal streptococcal species (8.5 percent), Klebsiella
highest infection-related contributors to neonatal death, species (7.8 percent), Pseudomonas species (7.8 percent),
with tetanus and diarrheal disease both contributing Group B streptococcus (GBS; 6.7 percent), Acinetobacter
approximately 1 percent (chapter 4 in this volume, Liu species (6.7 percent), and Streptococcus pneumoniae
and others 2016). None of the etiology studies discussed (4.6 percent). The distribution of pathogens for late-
in table 8.2 captures the causes of fever in the young onset sepsis (N = 1,784) was similar to early onset but
infant age group. with notably less GBS (1.7 percent) and a higher propor-
tion of Serratia species (2.2 percent), Salmonella species
Sepsis (1.5 percent), H. influenzae (1.7 percent), and Neisseria
Sepsis in young infants presents in two varieties: meningitidis (0.7 percent). Overall, there was a similar
early onset (fewer than seven days after birth) and proportion of gram-positive isolates (34.4 percent early
late onset (seven days or more). Early-onset neo- onset, 34.6 percent late onset) compared with gram-
natal sepsis is thought to be the result of exposure negative isolates (63.8 percent early onset, 60.5 percent
to pathogens in the maternal birth canal; late-onset late-onset) (Waters and others 2011). These results sug-
sepsis is thought to be secondary to environmental gest that empiric antibiotic regimens for both early- and
exposures. Symptoms of bacteremia and related sep- late-onset sepsis should be broad spectrum to treat both
sis in young infants are often vague and may include gram-positive and -negative infections.
fever, hypothermia, poor tone, jaundice, or inability
to suck. A decrease in urine production, poor perfu- Meningitis, Herpes Simplex Virus, and
sion, bulging fontanelle, excessive sleepiness, or alter- Urinary Tract Infections
natively, excessive irritability are signs of more serious In addition to bacteremia, a young infant presenting
disease. Without antibiotic treatment, many young with a nonfocal fever should be evaluated for meningitis
infants will rapidly progress to severe bacterial sepsis, and urinary tract infections (UTIs). A lumbar puncture
which may prove fatal. to check for pleocytosis (an elevated number of white
A review by Ganatra and Zaidi (2010) of five neona- blood cells in cerebral spinal fluid), elevated protein, or
tal sepsis studies reports incidences of blood culture low glucose levels can indicate whether infection is pres-
confirmed early-onset sepsis ranging from 2.2 to 9.8 ent in the central nervous system.
per 1,000 live births, and clinical sepsis incidence rang- Herpes simplex virus-2 (HSV-2) may cause enceph-
ing from 20.7 to 50 per 1,000 live births. Two of these alitis, an infection more common in the first three
Severe pneumonia (fast Children age 259 months: Strong recommendation, moderate quality of
breathing with danger Ampicillin 50 mg/kg IV every six hours for five days OR evidence
signs, with or without chest
indrawing) Benzyl penicillin 50,000 IU/kg every six hours for five days
AND gentamicin 7.5 mg/kg IV daily for five days
Third-generation cephalosporin as second-line therapyb
Wheezing Inhaled salbutamol delivered via metered dose inhaler with Strong recommendation, low quality of
spacer devices for up to three times 1520 minutes apart, to evidence
relieve bronchoconstriction and to assess the respiratory rate
again and classify accordingly
Oral salbutamol should not be used for treatment of acute or
persistent wheezing, except where inhaled salbutamol is not
availableb
Source: WHO IMCI Chart Booklet 2014 (http://www.who.int/maternal_child_adolescent/documents/IMCI_chartbooklet/en/).
Note: IMCI = Integrated Management of Childhood Illness; IU = international unit; IV = intravenous; mg/kg = milligrams per kilogram.
a. Fast breathing is defined as respiratory rate 50 breaths per minute in infants age 212 months, and 40 breaths per minute in infants age 1259 months.
b. Expert consensus.
viral exanthema are difficult to diagnose on darker reports a mortality burden of 190,000 for enteric fever
skin, are typically self limited, and do not require treat- in the 2010 Global Burden of Diseases (Lozano and
ment. Measles and, to a lesser extent, varicella are highly others 2012). In 2015, the IHME released updated mor-
contagious viruses and have the potential for serious tality estimates with disaggregated cause of death; they
sequelae. Parvovirus B19 is an important condition to report an estimated 54,262 paratyphoid-caused deaths
consider in patients with sickle-cell disease because and 160,645 typhoid-caused deaths worldwide annually
infection can lead to aplastic anemia. An emphasis on (GBD 2013 Collaborators 2015). These data come from
identifying these syndromes and prophylactic vaccina- 73 Gavi, the Vaccine Alliance, countries within which
tion for measles is warranted in refugee or displaced more than 70 percent of mortality burden comes from
populations, and in HIV-endemic areas where outbreaks Asia and more than 50 percent comes from South Asia
could spread rapidly. (Lozano and others 2012; GBD 2013 Collaborators
2015). CFRs, ranging from 10 percent to 30 percent
Enteric Fever without antibiotic treatment, drop to less than 1 percent
Enteric fever is an all-encompassing term for the dis- to 4 percent in the antibiotic-treated patient. As part of
ease caused by several serovars of Salmonella enterica Millennium Development Goal (MDG) 7, improve-
including S. typhi and S. paratyphi A. The clinical pic- ments in water, sanitation, and hygiene have reduced
ture of typhoid is nonspecific with symptoms of severe environmental contamination exposure to typhoid.
headache, nausea, and loss of appetite associated with However, treatment with antibiotics and prevention
sustained, high fever and few other specific signs. The through vaccination are ultimately needed to reduce
Institute for Health Metrics and Evaluation (IHME) typhoid mortality and morbidity (United Nations 2013).
However, the declining malaria burden in many Integrated Management of Childhood Illness
endemic regions and an increasing programmatic focus The WHO developed the IMCI strategy in the 1990s
on malaria elimination mean that novel target anti- to improve the quality of disease management and to
gens, use of gold nanoparticles, or other diagnostic reduce mortality of children under age five years (Gove
approaches may be needed to create point-of-care tests 1997). Using a series of algorithms and flow charts,
with increased sensitivity. Several diagnostic approaches IMCI gives health care providers a systematic way to
are based on selective microscopic detection of infected assess children for danger signs that trigger immediate
blood cells by methods such as third-harmonic gener- referral or hospitalization; to classify the illness based on
ation imaging (Blisle and others 2008), photoacoustic the level of severity for pneumonia, diarrhea, measles,
flowmetry (Samson and others 2012), and more recently, fever, otitis media, and malnutrition (Tulloch 1999);
magneto-optical detection of the malaria pigment (Mens and to identify those requiring antibiotic treatment.
and others 2010) hemozoin using hand-held devices The classifications are color coded, with pink calling
with polarized light and laser pulse detection of vapor for hospital referral or admission, yellow for treat-
nanobubbles generated by the parasite (Lukianova-Hleb ment at home, and green for children with mild illness
and others 2014). who require only supportive care at home and can be
counseled with return precautions (figure 8.1). IMCI
Respiratory and Other Bacterial Illnesses has been adapted at the national level with increasing
attention to HIV screening and management of illness
A detailed discussion of diagnostic tools available and in infants under age two months.
under development for ARI or other serious bacterial Several assessments of the quality of care delivered
illnesses can be found in annex 8B (available online). by IMCI have been performed since the early 2000s.
In Bangladesh, a systematic evaluation of 669 sick chil-
HEALTH SYSTEMS APPROACHES TO dren age 259 months, using a gold-standard physician
diagnosis and treatment decision, found a sensitivity of
CHILDREN WITH FEBRILE ILLNESSES 78 percent and specificity of 47 percent for identifying
Children with fever present to all levels and sectors of children with probable bacterial infections requiring
the health system. Trials of algorithmic approaches have antibiotics (Factor and others 2001). In this low malaria
been undertaken at the community and facility levels prevalence site, the majority of children with meningitis,
to identify seriously ill children to indicate referral to a pneumonia, otitis media, and UTIs fulfilled IMCI crite-
higher level of care. Two WHO-supported platforms to ria for at least one classification that would have resulted
identify and treat children with fever and common pedi- in antibiotic initiation. However, many children with
atric illnesses are IMCI for the facility level and iCCM bacteremia, skin infections, and dysentery would not
for the community level. Further research is needed to have received antibiotics. This evaluation was based on
identify best practice models for the formal and informal a comparison with an expert diagnosis that is subject to
private sector to create a synergistic approach to provid- clinical subjectivity and the limited accuracy of available
ing appropriate treatment and referral to more advanced diagnostic tools. A study assessing the safety of using a
care, when needed. slightly modified version of IMCI showed that the rate
Any general danger sign Pink: Give first dose of an appropriate antibiotic.
Stiff neck. Treat the child to prevent low blood sugar.
VERY SEVERE FEBRILE
No Malaria Risk and Give one dose of paracetamol in clinic for high fever (38.5C
DISEASE
No Travel to Malaria or above).
Risk Area Refer URGENTLY to hospital.
No general danger signs Give one dose of paracetamol in clinic for high fever (38.5C
Green:
If the child has measles Look for mouth ulcers. No stiff neck. or above)
now or within the last Are they deep and FEVER Give appropriate antibiotic treatment for an identified
3 months: extensive? bacterial cause of fever
Look for pus draining Advise mother when to return immediately
from the eye. Follow-up in 2 days if fever persists
Look for clouding of the If fever is present every day for more than 7 days, refer for
cornea. assessment
a. These temperatures are based on axillary temperature. Rectal temperature readings are approximately 0.5C higher.
b. Look for local tenderness; oral sores; refusal to use a limb; hot tender swelling; red tender skin or bolls; lower abdominal pain or pain on passing urine in older children.
c. If no malaria test available: High malaria risk - classify as MALARIA; Low malaria risk AND NO obvious cause of fever - classify as MALARIA.
d. Other important complications of measles - pneumonia, stridor, diarrhoea, ear infection, and acute malnutrition - are classified in other tables.
of clinical failure at day seven was very low (2.7 percent), studies also show that IMCI case management training
and lower than in the control group (8.0 percent) in resulted in improved quality of care, especially when
which routine care was used; only 15 percent received there were minimum standards of training quality and
an antibiotic compared with 84 percent in the control sufficient coverage of trained health workers (Arifeen
group (Shao and others 2015). and others 2005; Gouws and others 2004; Pariyo and
A multicountry evaluation of IMCI effectiveness, others 2005; Nguyen and others 2013). The multicoun-
cost, and impact was conducted in Bangladesh, Brazil, try evaluation also reveals that the IMCI approach pro-
Peru, Tanzania, and Uganda (Bryce and others 2005). In vided many benefits in addition to improved quality of
Tanzania, the survey results demonstrate that children care, including better record keeping and strengthened
in IMCI districts received higher-quality care, includ- supervision. However, four of the five countries encoun-
ing more thorough evaluations, a greater likelihood of tered challenges in expanding the IMCI strategy at the
being properly diagnosed and correctly treated, and national level (Bryce and others 2005).
better counseling and knowledge of caretakers of chil- A multicountry study finds that the quality of child
dren in IMCI districts relative to comparison districts health care associated with IMCI training was simi-
(Armstrong Schellenberg and others 2004). Several other lar across different cadres of health workers and that
No
Box 8.1
Corresponding author: Gerald T. Keusch, Boston University School of Medicine, Boston, Massachusetts, United States, keusch@bu.edu.
163
Figure 9.1 Regional Burden of Diarrhea, Ages 04 Years, 2010
Box 9.1
Europe Eastern
multitude of infectious causes, ranging from viruses and Mediterranean
154.3
bacteria to protozoa and occasionally worms, each with 208.8
distinctive effects. There are three discernable epidemi-
ological and clinical presentations with vastly different
consequences for the individuals affected:
Source: Fischer Walker and others 2013.
Box 9.2
Table 9.1 Cost-Effectiveness and Unit Cost of Interventions for Diarrheal Diseases
Cost-effectiveness
Intervention Region (US$/DALY averted) Unit cost (US$)
Oral rehydration solution (versus no ORS) AFR-E < 200 2.20/diarrhea episode
Prophylactic zinc with ORS (versus ORS alone) AFR-E and SEA-D < 100 0.61/diarrhea episode
Rotavirus vaccine (versus no vaccine) Low-income countries < 200 at 5/dose 5/dose for two doses (Gavi price); Gavi-eligible
(less at 0.20/dose) countries pay 0.20/dose for two doses
Clean water (at household: chlorination or AFR-E and SEA-D < 200 0.07/person/year SEA-D
solar disinfection versus untreated water) 0.13/person/year AFR-E (in 2000 U.S. dollars)
Improved rural water and sanitation (versus AFR-E and SEA-D < 2,000 28/household (well); 52/household (latrine)
unimproved)
Piped water and sewer connection (versus AFR-E < 2,000 136/household (water); 160/household (sewer)
no connections) SEA-D < 3,000
Cholera vaccine (versus no vaccine) High-endemicity countries 2,00010,000 1.33/person
Behavior change Low-income countries Large variation Large variation
RUTF added to standard rations (versus AFR-E > 10,000 considering only 527/child/year
standard rations) benefits for diarrhea
Source: See Horton and Levin 2016, chapter 17, on cost-effectiveness in this volume.
Note: AFR-E = high-mortality Africa (WHO subregion); DALY = disability adjusted life year; Gavi, the Vaccine Alliance; ORS = oral rehydration solution; RUTF = ready-to-use therapeutic foods;
SEA-D = high-mortality South-East Asia (WHO subregion). Costs and cost per DALY averted are higher in other regions. Interventions costing less than US$240 per DALY in 2012 would be very
cost-effective even in the poorest low-income country; those costing less than US$720 would be cost-effective even in the poorest low-income country (Burundis per capita gross national income
was US$240 in 2012) (World Bank 2014). All costs converted to 2012 U.S. dollars (except as noted otherwise).
Corresponding author: Daniel R. Feikin, Chief, Epidemiology Branch/Division of Viral Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia,
United States; drf0@cdc.gov.
187
Box 10.1
Rabies and influenza. Recommend further minimize the cost of vaccines, and ensure the
assessment of the impact and operational fea- availability of quality and innovative products.
sibility of supporting rabies and influenza Improved vaccine delivery strategies are needed to
vaccines for pregnant women, fund an observa- ensure that immunization programs and health sys-
tional study to address critical knowledge gaps tems are able to implement programs of increasing
around access to rabies vaccine, and monitor size and complexity at high levels of coverage and
the evolving evidence base for maternal influ- equity. It will be necessary to build on the unprece-
enza vaccination. dented momentum achieved in new vaccine intro-
duction and market shaping to take to scale innovative
By forecasting and pooling demand from eligible approaches to generating demand for immunization;
countries and purchasing large volumes of vaccines, upgrading country supply chain management systems;
Gavi has created a reliable market for vaccines strengthening country health information systems; and
in these settings. Gavis market-shaping strategy enhancing political will and country capacity related to
aims to ensure adequate supply to meet demand, leadership, management, and coordination.
Table 10.1 Impact of Vaccination: Children Immunized and Deaths Averted in 73 Gavi-Supported Countries, Based
on Strategic Demand Forecast Version 9
Estimates for 200112 Projections for 201320
Children Deaths DALYs Children Future deaths Future DALYs
immunized averted averted immunized averted averted
Hepatitis B 377,000,000 3,400,000 99,000,000 480,000,000 3,700,000 109,000,000
Haemophilus influenzae type B 160,000,000 830,000 52,000,000 440,000,000 1,800,000 126,000,000
Japanese encephalitis (campaign) 83,000,000 19,000 1,000,000 71,000,000 9,000 1,100,000
Japanese encephalitis (routine) 21,000,000 6,000 840,000 93,000,000 20,000 3,300,000
Measles (routine 2nd dose) 71,000,000 90,000 6,000,000 350,000,000 220,000 14,000,000
Measles (campaign) 1,000,000,000 2,800,000 167,000,000 800,000,000 1,900,000 117,000,000
Meningitis A (campaign) 103,000,000 140,000 7,700,000 215,000,000 310,000 14,000,000
Meningitis A (routine) n.a. n.a. n.a. 70,000,000 6,000 430,000
Pneumococcus 11,000,000 70,000 4,900,000 260,000,000 1,500,000 105,000,000
Rotavirus 4,000,000 4,000 320,000 230,000,000 380,000 24,000,000
Rubella (campaign) 105,000,000 20,000 1,800,000 650,000,000 190,000 18,000,000
Rubella (routine) 21,000,000 5,000 500,000 210,000,000 50,000 5,300,000
Yellow fever (campaign) 70,000,000 260,000 8,000,000 140,000,000 170,000 4,400,000
Yellow fever (routine) 84,000,000 540,000 21,000,000 120,000,000 570,000 23,000,000
Sources: Children immunized derived from the World Health OrganizationUnited Nations Childrens Fund Estimates of National Immunization Coverage and United Nations
Population Division; vaccine introduction and scale-up scenario based on Gavi Strategic Demand Forecast Version 9; future deaths averted derived from Lee and others (2013);
future DALYs averted derived from personal communication with S. Ozawa.
Note: Gavi = Gavi, the Vaccine Alliance; n.a. = not applicable; DALY = disability-adjusted life year.
Table 10.2 Approximate Range of Cost-Effectiveness of Various Childhood Vaccines, Various Contexts
(2012 U.S. dollars per DALY averted)
< US$100/DALYa US$100 to <US$1,036/DALYb Over US$1,036/DALYc
Original EPI-6: BCG, DTP, measles, polio Haemophilus influenzae type B Cholera (final price point pending)
Hepatitis B Yellow fever, where endemic Pneumococcus, low-child-mortality countries
Pneumoccocus, high-child-mortality countries Japanese encephalitis, where endemic Rotavirus, low-child-mortality countries
Rotavirus, high-child-mortality countries Pneumococcus, medium-child-mortality countries
Rotavirus, medium-child-mortality countries
Meningitis A, where endemic
Source: For details on sources and references, see table 17.1 of chapter 17 of this volume (Horton and Levin 2016).
Note: EPI = Expanded Program on Immunization; BCG = Bacille Calmette-Gurin; DALY = disability-adjusted life year; DTP = diphtheria, tetanus, and pertussis. For vaccines,
cost-effectiveness is sensitive to vaccine price as well as variability in underlying disease burden by country.
a. Vaccines in the first column are very cost-effective in all low-income countries because cost per DALY averted is less than per capita gross national income (GNI) of even the
poorest low-income country (World Bank definition of low-income country is per capita GNI of less than US$1,035 in 2012 and in 2012 the per capita income of the poorest
low-income country was approximately US$250).
b. Vaccines in the second column are very cost-effective in all lower-middle-income countries (World Bank definition of lower-middle-income country is per capita GNI in 2012
ranging between US$1,036 and US$4,085).
c. Vaccines in the third column may be very cost-effective in upper-middle-income countries (World Bank definition of upper-middle-income country is per capita GNI in 2012 ranging
between US$4,086 and $12,615).
Corresponding author: Zulfiqar A. Bhutta, Centre for Global Child Health, The Hospital for Sick Children, Toronto, Canada, zulfiqar.bhutta@sickkids.ca.
205
Global acute malnutrition (GAM) refers to MAM 2013). The framework defines basic, underlying, and
and SAM together; it is used as a measurement of immediate causes of undernutrition and demonstrates
nutritional status at a population level and as an how these causes are interconnected. This general frame-
indicator of the severity of an emergency situation work also aids in conceptualizing the reasons why chil-
(GNC 2014). dren might develop acute malnutrition.
Based on scientific literature investigating the rela-
Marasmus and kwashiorkor are common terms tionships among specific individual, household, and
historically used to differentiate between types of environmental factors and the development of acute
SAM. Marasmus refers to children who are very thin malnutrition in children, the following are significant
for their height (that is, they meet the WHZ or MUAC risk factors for MAM and SAM:
cutoff) but do not have bilateral pitting edema; kwash-
iorkor refers to edematous malnutrition. The most Inadequate dietary intake
recent WHO terminology for SAM has replaced these Inappropriate feeding
terms. Fetal growth restriction
Inadequate sanitation
Lack of parental education
Risk Factors and Causes of Undernutrition Family size
Undernutrition results from the complex interplay of a Incomplete vaccination
range of distal and proximal factors, as illustrated by the Poverty
United Nations Childrens Funds (UNICEF) conceptual Economic, political, and environmental instability
framework for undernutrition (figure 11.1) (UNICEF and emergency situations.
Intergenerational
consequences
Long-term consequences:
Short-term consequences: Adult height, cognitive ability, economic
Mortality, morbidity, disability productivity, reproductive performance,
metabolic and cardiovascular disease
MATERNAL
AND CHILD
UNDERNUTRITION
Immediate
Inadequate dietary intake Disease
causes
Unhealthy household
Underlying Inadequate care and
Household food insecurity environment and inadequate
causes feeding practices
health services
Map 11.1 Percentage of Children under Age Five Years Who Are Moderately or Severely Wasted, 200711
IBRD 41898 | OCTOBER 2015
Table 11.1 Hazard Ratios of All-Cause and Cause-Specific Deaths, by Degree of Wasting
Weight-for-height All deaths Pneumonia deaths Diarrhea deaths Measles deaths Other infectious
z-score HR (95% CI) HR (95% CI) HR (95% CI) HR (95% CI) deaths HR (95% CI)
<3 11.6 (9.8, 13.8) 9.7 (6.1, 15.4) 12.3 (9.2, 16.6) 9.6 (5.1, 18.0) 11.2 (5.9, 21.3)
3 to 2 3.4 (2.9, 4.0) 4.7 (3.1, 7.1) 3.4 (2.5, 4.6) 2.6 (1.3, 5.1) 2.7 (1.4, 5.5)
2 to <1 1.6 (1.4, 1.9) 1.9 (1.3, 2.8) 1.6 (1.2, 2.1) 1.0 (0.6, 1.9) 1.7 (1.0, 2.8)
1 1.0 1.0 1.0 1.0 1.0
Sources: Black and others 2013; Olofin and others 2013.
Note: CI = confidence interval; HR = hazard ratio.
Table 11.2 Nutritional Composition of Commonly Used, Specially Formulated Foods for the Prevention and
Treatment of Acute Malnutrition
F75 F100 Supercereal Plus
(100 g milk (100 g milk PlumpySup PlumpyDoz PlumpyNut (100 g dry
powder) powder) (100 g) (100 g) (100 g) matter)
Used for SAM SAM MAM MAM MAM or SAM Prevention of MAM
Recommended 80100 200 75 46.3 g/day SAM: 200 200 g/day
serving size MAM: 75
(kcal/kg/d)
Macronutrients
Energy (kcal) 446 520 520550 534587 520550 410
Protein (g) 5.9 >13 12.615.4 13.417.7 1316 >16.4
Lipid (g) 15.6 >26 31.538.6 26.739.1 2636 >4.1
Minerals
Potassium (mg) 775 1,100 9801,210 660870 1,1001,400 140
Calcium (mg) 560 300 300350 800980 300500 452
Phosphorus (mg) 330 300 300350 530660 300600 232
Magnesium (mg) 50 80 80100 115140 80100
Zinc (mg) 12.2 11 1215 8.7 1114 5
Sources: Nutriset catalogs; Supercereal Plus from USAID specifications.
Note: = not available; d = day; g = gram; kcal = kilocalorie; kg = kilogram; MAM = moderate acute malnutrition; mg = milligram; SAM = severe acute malnutrition.
7. Begin feeding
8. Increase feeding to recover lost weight (catch-up growth)
9. Stimulate emotional and sensorial development
10. Prepare for discharge
Key Priorities for Enhancing Effectiveness of Severe Acute Malnutrition (SAM) and Moderate
Acute Malnutrition (MAM) Management
Research Priorities for Effective Management and effective nutrition counseling for the preven-
of SAM tion and management of MAM (GNC 2014).
Develop mid-upper arm circumference cut-offs Investigate effective approaches for manage-
specific to age: 611 months, 1223 months, and ment of MAM with diarrhea (Annan, Webb, and
2459 months (WHO 2013). Brown 2014).
Understand specialized needs of subgroups (Picot Understand specialized needs of subgroups,
and others 2012; WHO 2013): including identification and management of
Identification and management of infants MAM in infants younger than age six months
younger than age six months with SAM (Annan, Webb, and Brown 2014).
Treatment and long-term support for children Clarify the appropriateness of different specially
with SAM and human immunodeficiency formulated foods and management strategies for
virus, tuberculosis, or other comorbidities. different contexts (GNC 2014).
Characterize relapse rates and morbidity later in
life through follow-up studies (Hall, Blankson, General Priorities for SAM and MAM Research and
and Shoham 2011; Lenters and others 2013). Programming
Understand the etiology of nutritional edema Define healthy recovery and investigate body
and effective strategies for the management of composition and long-term risk of morbidity in
SAM plus edema (WHO 2013). children treated with lipid-based specially for-
Investigate the role of the microbiome and envi- mulated foods (Annan, Webb, and Brown 2014).
ronmental enteropathy in the development of, Improve national and subnational capacity for
and recovery from, acute malnutrition (Petri, accurately and consistently measuring coverage
Naylor, and Haque 2014). rates of SAM and MAM programs (GNC 2014).
Clarify the appropriateness of antibiotics for Enhance active case finding in communities and
treatment of uncomplicated SAM (Picot and screening at health centers (WHO 2013).
others 2012; WHO 2013). Explore whether children experience issues when
Investigate the efficacy of daily low-dose versus they make the transition to standard family foods
single high-dose vitamin A supplementation in from a therapeutic diet (Hall, Blankson, and
children with SAM who have edema or diarrhea Shoham 2011).
(WHO 2013). Investigate relative effectiveness and costs of
Establish efficacy and effectiveness of local for- different packages of care that include SAM and
mulations of therapeutic foods that meet WHO MAM management (Lenters and others 2013).
specifications (WHO 2013). Investigate effectiveness of seasonal blanket
Determine effective fluid management strategies supplementation and other strategies (voucher
for children with SAM and dehydration or diar- schemes, cash transfers) for the prevention of
rhea (WHO 2013), as well as effective approaches SAM and MAM.
for managing shock in children with SAM (Picot Explore patterns of sharing of specially formu-
and others 2012). lated foods (GNC 2014).
Conduct research in more locations and contexts to
Research Priorities for Effective Management be able to assess regional differences in effectiveness
of MAM and acceptability of treatment and management
Expand understanding of specialized nutrient approaches (Annan, Webb, and Brown 2014).
needs for children with MAM (GNC 2014). Understand how products are used within
Investigate effective strategies for improving the community interventions, including rates and
home diet using locally available ingredients, patterns of sharing (Annan, Webb, and Brown
where feasible (Lazzerini, Rubert, and Pani 2013), 2014; GNC 2014).
Corresponding author: Zulfiqar A. Bhutta, Robert Harding Chair in Global Child Health and Policy, the Centre for Global Child Health, The Hospital for
Sick Children, Toronto, Canada, and Founding Director, Center of Excellence in Women and Child Health, Aga Khan University, Karachi 74800, Pakistan;
zulfiqar.bhutta@sickkids.ca.
225
Map 12.1 Global Stunting Prevalence Estimates among Children Younger than Age Five Years
IBRD 41899 | OCTOBER 2015
Greater than 40
3039.9
2029.9
Less than 20
Not available
Source: Pacionek and others, 2013.
Table 12.1 World Health Organizations Infant and Young Child Feeding Core Indicators
Breastfeeding indicators
Early initiation of breastfeeding Proportion of children born in the past 24 months who were breastfed within one hour
of birth
Exclusive breastfeeding under age six months Proportion of infants from birth to age five months who were exclusively breastfed
during the previous day
Continued breastfeeding at age one year Proportion of children ages 1215 months who were fed any breast milk during the
previous day
Complementary feeding indicators
Introduction of solid, semisolid, or soft foods Proportion of infants ages six months to eight months who received solid, semisolid, or
soft foods during the previous day
Minimum dietary diversity Proportion of children ages 623 months who received foods from four or more food
groups during the previous day
Minimum meal frequency Proportion of breastfed and nonbreastfed children ages 623 months who received solid,
semisolid, or soft foods (including milk feeds for nonbreastfed children) the minimum
number of times or more during the previous day
Minimum acceptable diet Proportion of children ages 623 months who had at least the minimum dietary diversity
and minimum meal frequency (apart from breast milk) during the previous day
Consumption of iron-rich or iron-fortified foods Proportion of children ages 623 months who received iron-rich food or iron-fortified
food specially designed for infants and young children, or fortified in the home, during
the previous day
Source: Jones and others 2014.
Because birth size depends on both gestational age are more pronounced in pregnancies involving young
and growth velocity, the term SGA is preferred to LBW. mothers, small maternal size, nulliparous, and multiple
A baby born with LBW but appropriate for gestational pregnancies (Gluckman and Hanson 2004). Maternal
age is expected to have better outcomes compared with a nutrition influences the availability of nutrients for
baby born SGA. However, LBW has been the most com- transfer to the fetus; during starvation, it is likely that
monly used indicator to describe fetal growth because low food intake results in a reduced nutrient stream
it can be difficult to determine true gestational age in from mother to fetus, giving rise to fetal growth restric-
LMICs (WHO 1995). In this chapter, SGA is used as a tion. Maternal undernutrition (body mass index of less
proxy indicator for IUGR. than 18.5 kilograms/square meter) has decreased overall
since 1980 but remains greater than 10 percent in South
Asia and Sub-Saharan Africa (Black and others 2013).
Causes of Intrauterine Growth Restriction
IUGR can have multiple causes. Some of the known risk
factors include maternal malnutrition, congenital mal- Consequences of Intrauterine Growth Restriction
formations, congenital infections, maternal smoking, IUGR is associated with a higher risk of preterm delivery
and maternal medical comorbidities such as primary and higher rates of fetal and neonatal morbidity and
hypertension and diabetes mellitus (Romo, Carceller, mortality (Arcangeli and others 2012; Baschat 2011).
and Tobajas 2009). In LMICs, maternal malnutrition This higher rate of neonatal mortality in IUGR infants
is an important risk factor for SGA babies; however, is due to conditions that include birth asphyxia and
in high-income countries (HICs), cigarette smoking is infections (such as sepsis, pneumonia, and diarrhea),
the most important single factor implicated in IUGR, which lead to mortality and together account for about
followed by poor gestational nutrition (Bhutta and 60 percent of all neonatal deaths (Salam, Das, and
others 2013; Salam, Das, and Bhutta 2014). The major Bhutta 2014).
nongenetic factor determining the size of the fetus at The short-term consequences of IUGR involve
term is maternal constraint, which is a set of mater- metabolic and hematological disturbances, as well as
nal and uteroplacental factors that act to limit the disrupted thermoregulation, which lead to morbidi-
growth of the fetus by limiting nutrient availability or ties such as respiratory distress syndrome, necrotizing
the metabolic-hormonal drive to grow; these factors enterocolitis, and retinopathy of prematurity (Salam,
Child interventions
Breastfeeding Exclusive breastfeeding rates increased by 43 percent at four to six weeks, with 89 percent and 20 percent
significant increases in LMICs and HICs, respectively. Exclusive breastfeeding improved at age six months by
137 percent, with a sixfold increase in LMICs.
Complementary and Statistically significant difference of effect for length during the intervention in children
supplementary feeding
Iron supplementation Anemia (RR: 0.51; 95 percent CI: 0.370.72)
Iron deficiency (RR: 0.24; 95 percent CI: 0.060.91), hemoglobin (MD: 5.20 g/l; 95 percent CI: 2.517.88),
ferritin (MD: 14.17 mcg/l; 95 percent CI: 3.5324.81)
Vitamin A supplementation All-cause mortality reduced by 24 percent (RR: 0.76; 95 percent CI: 0.690.83)
Diarrhea-related mortality reduced by 28 percent (RR: 0.72; 95 percent CI: 0.570.91)
Incidence of diarrhea reduced by 15 percent (RR: 0.85; 95 percent CI: 0.820.87)
Incidence of measles reduced by 50 percent (RR = 0.50; 95 percent CI 0.370.67)
Nonsignificant impacts on measles and ARI-related mortality
Zinc supplementation Height improved by 0.37 centimeters (SD 0.25) in children supplemented for 24 weeks
Diarrhea reduced by 13 percent
Pneumonia reduced by 19 percent
Nonsignificant impacts on mortality
nutrition data indicate considerable disparities among Figure 12.2 Deaths Younger than Age Five Years Averted by the
geographic regions, with South Asia bearing the highest Scale-Up of Selected Nutrition Interventions per Year by 2025
burden (Stevens and others 2012). Almost 75 percent
Therapeutic feeding-for
of all the worlds LBW infants are born in South Asia. severe wasting
In the 75 Countdown countries, more than one child in Zinc supplementation
three is stunted, and the median prevalence of wasting
is 7.1 percent. Within countries, wide disparities exist Promotion of breastfeeding
between the richest and poorest wealth quintiles; in Appropriate complementary feeding
20 percent of the Countdown countries, more than
Interventions
Calcium supplementation
Way Forward
0 100,000 200,000 300,000 400,000
Optimal IYCF means that mothers receive optimal
antenatal care, are empowered to initiate BF within one Number of U5 deaths averted (with range)
hour of birth, BF exclusively for the first six months, Source: Bhutta and others 2013.
and continue BF for two years or more, complemented Note: U5 = under age five years.
Corresponding author: Frances E. Aboud, McGill University, Department of Psychology, Montreal, frances.aboud@mcgill.ca.
241
maternal mental health. Finally, the results of several due to fetal lead contamination and deficits in iodine
systematic reviews and meta-analyses are presented to can be detected with this early assessment (Kooistra and
show the effects of stimulation and nutrition, along others 2006; Patel and others 2006).
with disease-related interventions to promote mental The most common measures of mental develop-
development. Maternal interventions related to nutri- ment after the newborn period are standardized behav-
tion and mental health are also reviewed. A frame- ioral tests, such as the Bayley Scales of Infant and
work of critical components to include in programs Toddler Development, Third Edition (Bayley 2006)
is outlined. and the Griffiths Mental Development Scales (Griffiths
and Huntley 1996). Both measure cognitive, receptive
language, expressive language, fine motor, and gross
PREVALENCE AND MEASUREMENT: WHAT motor development from birth to age 3.5 years using
DOES MENTAL DEVELOPMENT ENTAIL AT a number of items of increasing difficulty. The cog-
nitive items mainly concern the ability to solve small
THIS AGE? problems. Receptive language items test the ability
In the absence of well-validated international indicators, to understand the meaning of words, sentences, and
the Ten Questions Survey was used in 18 countries as abstract categories. Expressive language items assess the
part of the Multiple Indicator Cluster Survey 200506. ability to use sounds, gestures, and the spoken word
Included were countries in the Caribbean, west Asia, to communicate. Fine motor items include eye-hand
southeast Asia, and Sub-Saharan Africa. The survey coordination tasks. Gross motor development, such as
screens for disabilities by asking mothers of children ages sitting and walking, is not strongly related to mental
29 years two cognitive questions (for example, does development (Hamadani and others 2013) and so is not
your child learn to do things like other children his or addressed here.
her age?) and four language questions (for example, can Social and emotional skills are an important domain
your child name at least one object?). Results indicate of mental development, but measures for this age are
that 7 percent of children had a cognitive disability, and not commonly applied in research, and determinants
21 percent had a language disability. Overall, 27 percent are not widely known. The Griffiths Scales include
of children screened positive for one of the sensory- items that address personal-social skills, such as recog-
motor-mental-social disabilities (Gottlieb and others nition of ones mother, enjoying playmates, and feeding
2009). However, because the answers depend on the and dressing oneself. The Bayley Scales also include a
ability of the mothers to notice disabilities, screening social-emotional subscale, with questions for parents
is likely to reveal only the tip of the iceberg (Yousafzai, that reveal the purposeful and social expression of
Lynch, and Gladstone 2014). Also, because the items emotions and interactive behaviors. However, secure
address disabilities rather than expected development, attachment is the most important capability acquired
measurement experts are working to create a list of 30 or in the first two years (Sroufe 2005). It is measured by
so mental milestones specific to the under-24-month age the Strange Situation, in which observers note how
group to be asked of mothers (see, for example, Prado much emotional security children derive from par-
and others 2014). ents when under some stress due to the presence of
The mental competencies of children during the first strange people and objects. Malnourished children and
24 months can now be directly assessed with behavioral those who receive less responsive warmth appear to be
tests and brain recordings. Both tools show that by the less emotionally secure than well-nourished and sup-
end of the first month, newborns respond to language ported children (Cooper and others 2009; Isabella 1993;
more than to other sounds; they like looking at bright Valenzuela 1990).
contrasts, movement, and color. The Brazelton Neonatal
Behavioral Assessment Scale (Brazelton and Nugent
1995) assesses these competencies through observa- CONDITIONS THAT AFFECT CHILD
tions of newborns interacting with others. Healthier
newborns show better regulation of physiological states
DEVELOPMENT
by self-soothing; better habituation to repeated sen- Many of the conditions that affect the health and growth
sory inputs, such as ringing bells; and greater response of children in the first 1,000 days could affect mental
to social speech. The measured competencies are development. These factors include the preconception
expected to facilitate engagement with physical and and pregnancy nutritional status of the mother, birth
social environments in ways that will promote mental weight and linear growth of the infant, and conditions
development. Impairments during the neonatal period of labor and delivery; maternal mental health; and
inventory
25
Psychosocial stimulation refers to an external object
20
or event that elicits a physiological and psychological
15
response in the child. A specific measure of psychosocial
stimulation is the Home Observation for Measurement 10
of the Environment (HOME) Inventory (Bradley and 5
Corwyn 2005). The infant and toddler version for chil- 0
dren younger than age 24 months includes 45 items
ca
ile
pia
m
h
Et 1
Co azil
d
es
na
da
an
Ri
da
Ch
hio
lad
Br
et
an
ail
sta
an
that are assessed through observation and interview.
Vi
ng
Ug
Th
Ug
Ba
The essence of stimulation is observed in mother-child
interaction that is verbal and responsive to the childs Country of study by region
state, and in play materials that can be manipulated in
Sources: Bangladesh: 23.5 (Aboud and Akhter 2011); Vietnam: 23.6 (Williams and others 2003);
different ways by the child. The caregiver is also ques- Thailand: 28.9 (Williams and others 2003); Uganda 1: 19.8 (Boivin and others 2013); Ethiopia: 24.0
tioned about activities that expose the child to places, (Bougma 2014); Uganda 2: 25.4 (Singla, Kumbakumba, and Aboud 2015); Brazil: 23.1 (Eickmann and
people, and conversation. The focus is on opportuni- others 2003); Costa Rica: 29.8 (Lozoff and others 1987); Chile: 30.8 (Lozoff and others 2010).
Note: HOME = Home Observation for Measurement of the Environment.
ties to play and converse in ways that stretch thinking
and understanding of speech. Scores on the HOME
Inventory from around the world have ranged from siblings are not able to deliver the sophisticated language
a low of 20 (Boivin and others 2013) to a high of 31 of adults or accurately perceive when young children
(Lozoff and others 2010); in other words, the scores are in danger (Morrongiello, Schell, and Schmidt 2010).
satisfied less than half to two-thirds of the items Across all 28 LMICs surveyed, the average number of
(figure 13.1). All studies showed very strong correlations caregiving practices out of six performed in the past
between HOME scores and childrens mental devel- three days with a child under age five years was 3.03.
opment, with low HOME scores associated with poor Many parents from countries in South Asia and Sub-
mental development. Saharan Africa practiced only one or two. Although no
A brief version of the inventory called the Family threshold score is available to identify inadequate levels
Care Indicators is available for use in national surveys. of stimulation, low levels such as these are unlikely to
Consisting of 10 interview questions for the caregiver, support expected levels of mental development (Bradley
it has been validated in South Asia and Sub-Saharan and Corwyn 2005).
Africa (Hamadani, Tofail, and others 2010; Kariger Both the HOME Inventory and its briefer version are
and others 2012) and used to evaluate responsive and highly correlated with childrens mental development,
stimulating caregiving in 28 LMICs (Bornstein and ranging from r = 0.20 to r =0.46 (Aboud and others
Putnick 2012). Mothers (caregivers) were asked what 2013; Boivin and others 2013; Hamadani, Tofail, and
they had done with their children under age five years others 2010; Tofail and others 2012). These correlations
in the past three days. Items largely focus on the variety and the theoretical framework presented here (figure 13.2)
of play materials available for the child (for example, support the design of stimulation interventions to
things for making music, things for pretending, things enhance mental development. One hypothesized path-
for drawing) and play activities (for example, reading or way proposes that an adults child-directed conversation
looking at pictures, telling stories, singing songs). Only stimulates speech perception sites in the brain, thereby
25 percent of mothers said they had read to their chil- maintaining neural connections throughout language
dren in the past three days, 25 percent had sung songs, sites in the brain. Also, if the conversation is directly
and 35 percent had told stories. Scores did not vary by related to childrens current state, it is expected to expand
childs gender but were lower in families with more the childrens receptive language and grammar. This
children. Thus, the presence of more children does not interaction helps children translate their own thoughts
necessarily mean more of the right kind of stimulation. and actions into speech and later into writing and read-
It is often mistakenly believed that older siblings provide ing. Play materials that children enjoy manipulating and
sufficient stimulation and supervision. However, older combining in multiple ways help them learn about mass
Six months of
Access to macro- and
Child malnutrition due to exclusive
micronutrients
deficits in breastfeeding, breastfeeding, diverse
in daily diet;
macro- and micronutrients diet, especially
nutrition education
animal-source foods
Free from
Use of latrines, Parent and child infectious Linear
Environmental
improved water, handwashing with diseases growth
infections, for example,
feces-free compound, soap at key times,
trachoma, diarrhea,
access to vaccines use of bednets
Mental
Access to macro- and Daily frequency, development
Mothers' pregnancy and micronutrients amounts, and
pre-pregnancy malnutrition in daily diet; safe quality of
delivery nutrients
Emotional Cognitive-
Mothers' mental support; reduce behavioral and
health problems intimate partner interpersonal
violence rewards
and mental development (figure 13.5). Typically changes Organizationsupported Baby-Friendly Hospital
are small, although significantly greater than changes in Initiative activities sooner than others. Mothers who
the control group. There are too few longitudinal studies delivered in these hospitals breastfed longer, and their
yet to confirm that parents are able to sustain the new children had higher verbal intelligence at age six years
practices and adapt them as children age. (Kramer and others 2008).
Overall, stimulation interventions, regardless of their One important nutrient in breast milk, fatty acids,
delivery strategy, successfully improved mental develop- has been studied in relation to mental development but
ment. This success may be partly attributed to the effect mainly in HICs. Long-chain polyunsaturated fatty acids
of the interventions on raising parental stimulation (PUFA), particularly n-3, that are present in the brain
practices, which, in addition to linear growth, is one of and breast milk are considered to be a promising can-
the strongest correlates of mental development. didate to support mental development. Multiple trials,
conducted mainly in HICs where it is possible to provide
Child Nutrition infants with formula milk with varying amounts of fatty
Exclusive breastfeeding from birth to six months is acids, found no effects on Bayley mental or motor scores
known to support healthy rates of growth and (Beyerlein and others 2010; Qawasmi and others 2012;
immunity. Correlational evidence argues that breastfed Smithers and others 2008). Similar tests of fatty acids
babies also have better mental development (Anderson, found in fish and fish oil have shown no advantage to
Johnson, and Remley 1999). This claim was affirmed Bangladeshi children whose mothers received fish oil
by a trial in Belarus, in which half of the hospitals during pregnancy (Tofail and others 2006). However,
were randomly assigned to start the World Health research on fatty acids continues to follow children as
Four delivery formats for stimulation programs are common to all parents are addressed during group
most common: home visits, group sessions, clinic sessions, and family-specific problems are addressed
appointments, and one of these three piggybacked during home visits. These combined interventions
onto conditional cash transfer (CCT) programs. usually had more than 15 contacts over 12 or 24
A fifth, combining group with home visits, has months.
become increasingly common. All delivery models The third model uses well- or sick-baby clinic
require a curriculum manual for providers. Those visits to inquire about what mothers know about
employing paraprofessionals require more training stimulating their children with toys and talk and
and supervision. counseling them on improved practices. This advice
Home visits entail weekly or fortnightly visits by a is usually provided by professionals, sometimes with
paraprofessional to the childrens homes. The home two to four contacts (Jin and others 2007; Potterton
visitors engage in specific age-appropriate play activ- and others 2010) and with at most 12 monthly
ities with the children, demonstrate these activities to contacts (Nair and others 2009). Group and clinic
watching mothers, and leave play materials that will models explicitly aim to change parents behavior,
be replaced at the next session. Interventions based particularly the opportunities that parents provide
on home visits usually entailed more than 24 visits for play and conversation.
over 12 months (Lozoff and others 2010; Tofail and The final model is the scale up of stimulation inter-
others 2013; Vazir and others 2013). ventions using the infrastructure of a CCT program.
Group sessions consist of meetings with 8 to 20 One example is the home-visiting program attached
mothers, and sometimes fathers, with their chil- to Colombias Familias en Accin program. Mother
dren at convenient locations in communities. Leaders from the community were trained to make
Paraprofessionals from the community or local weekly visits to the homes of children ages 1224
community health workers conduct the sessions. months to provide guidance on play (Attanasio and
Group leaders demonstrate specific activities and others 2014). Another Colombian example is the
coach mothers as they practice with their children. home-based group care offered to CCT beneficiaries,
Groups could engage in discussions and general whereby mothers were trained to provide stimulation
problem solving. Interventions using groups usually weekdays to 15 children (most under age three years)
had fewer sessions than those using home visits in their homes (Bernal and Fernndez 2013). Both
(Aboud and Akhter 2011). Many interventions com- large-scale effectiveness evaluations showed positive
bined home visits with group sessions (Aboud and effects on the order of 0.2 to 0.3 standard devia-
others 2013; Eickmann and others 2003; Yousafzai tion difference on childrens cognitive and language
and others 2014). Informational and social needs abilities.
they age (Colombo and others 2013). Supplementation Research is being conducted on multiple micronutri-
with a milk lipid, ganglioside, was found to have posi- ents with and without lipids. Some studies use vitamin A
tive effects on early mental development in Indonesia as the baseline and compare it with five other micronu-
(Gurnida and others 2012). Furthermore, research has trients (Black and others 2004); others provide a porridge
found mental development benefits of fatty acids in with carbohydrates and add micronutrients (Manno and
colostrum; 14-month-old children whose mothers had others 2012; Rosado and others 2011). Pollitt and others
high levels of n-3 PUFA in colostrum and who were (2000) gave all children eight micronutrients (vitamins
breastfed with greater intensity or duration had higher and minerals) with high-energy milk added to the diet
mental development scores (Guxens and others 2011). of intervention children only. The fortification in many
Thus, the clear cognitive benefits to breastfeeding appear cases was available for a period of six to eight months;
to stem from high levels of n-3 PUFA and cumulative the effects on mental development scores were small.
amounts of ingested breast milk. A review of 21 interventions examining the effects of
Effect size d
Currently multiple micronutrients are being combined
with a lipid base that provides macronutrients to exam- 0.6
ine their combined effects on linear growth. This combi-
0.4
nation has the potential to enhance mental development
in food-insecure sites. 0.2
0
Integrated Packages of Psychosocial Stimulation and
ica
ua
ta
Child Nutrition
sh
sh
da
da
ma
kis
g
de
de
an
an
ra
Pa
Ja
gla
gla
Ug
Ug
Pa
Researchers and program implementers are paying
n
Ba
Ba
closer attention to optimizing integrated packages of
Country of study by region
stimulation and nutrition care given the independent
and potentially additive benefits to promoting mental HOME Mental development
development. Although most small- and large-scale
Sources: Bangladesh 1: HOME 0.38, Language Development 0.40 (Aboud and Akhter 2011);
interventions have found little added benefit to mental Bangladesh 2: HOME 0.64, Cognitive Development 0.67 (Aboud and others 2013); Pakistan:
development from integrating nutrition with stimula- HOME 0.69, Cognitive Development 0.60 (Yousafzai and others 2014); Uganda 1: HOME 0.91,
tion (Attanasio and others 2014; Grantham-McGregor Language Development 0.44 (Boivin and others 2013); Uganda 2: HOME 1.07, Cognitive Development
0.35 (Singla, Kumbakumba, and Aboud 2015;) Paraguay: HOME 1.12, Mental Development 0.62
and others 2014; Yousafzai and others 2014), other (Peairson and others 2008); Jamaica: HOME 0.36, Cognitive Development 0.42 (Walker and
benefits of integration, such as cost and task-sharing, others 2004).
are being examined. This combination is illustrated in Note: HOME = Home Observation for Measurement of the Environment.
a completed stimulation and nutrition trial in Pakistan
(box 13.2). (Rahman, Vahter, and others 2007), but arsenic in water
appears to have little effect on mental development in
Reducing Infection Transmitted by Ground the first 24 months and up to age five years (Hamadani,
Contamination, Mosquitoes, and Flies Grantham-McGregor, and others 2010; Hamadani and
The most commonly implemented solutions to envi- others 2011).
ronmental causes of infection are constructing and Immunization with rotavirus vaccine as part of the
using latrines, improving access to clean drinking water, national immunization schedule has begun in more than
promoting facewashing and handwashing with soap, 35 countries, with support from the Global Alliance for
cleaning up animal feces around the home, immunizing Vaccines and Immunization. The rotavirus vaccine has
all infants with the rotavirus vaccine, and deworming been effective in reducing severe cases of diarrhea, mor-
children starting at age 12 months (Dangour and oth- tality, and hospital and clinic visits, and it provides pro-
ers 2013; Ejemot and others 2008; Fewtrell and others tection for several years. Mass treatment of children with
2005). Places where piped water and sewerage systems deworming medication and azithromycin for trachoma
are installed have experienced an immediate reduc- can be attached to outreach services that deliver vita-
tion in diarrheal diseases (Fewtrell and others 2005). min A drops. However, these are short-term solutions.
However, widespread provision of water and sanitation The WHOs recommended SAFE (surgery, antibiotics,
infrastructure is unrealistic in the near future, espe- facial cleanliness, and environmental improvements)
cially in rural areas of LMICs. Although 68 percent of strategy for trachoma elimination also includes hygiene
urban dwellers in LMICs have latrines, only 40 percent (facewashing) and environmental management (along
of rural people have them (UNICEF 2013). Improved with surgery and antibiotics) as the more sustainable
sources of water are commonly provided at the com- approaches (Mecaskey and others 2003).
munity level or preferably at point of use, so that the Environmental management of stagnant water is
urban-rural gap for improved water is narrower than only one of the means by which to control malaria.
that for sanitation (94 percent of urban dwellers have Bednets, intermittent preventive treatment, and vac-
access to improved sources of water compared with cines are the most studied preventive interventions
76 percent of rural dwellers). Concern about the effects (Ciss and others 2006; Gies and others 2009). The pro-
of very high levels of arsenic in drinking water is sup- vision of free insecticide-treated bednets led to high cov-
ported by evidence of fetal loss and infant mortality erage and protection (Alaii and others 2003); and three
Pakistan Early Child Development Scale-Up Trial: Case Study of a Successful Program
The Pakistan Early Child Development Scale-Up The intervention was delivered through a combina-
Trial successfully enhanced the cognitive, language, tion of home visits and group sessions. The group
and motor development of children whose parents sessions offered opportunities for problem solving
received counseling in psychosocial stimulation for and social support through encouragement, praise,
their children, with or without enhanced nutri- and peer-to-peer learning.
tion education and multiple micronutrient fortifi-
Nutrition Intervention
cation (Yousafzai and others 2014). The program
showed clear benefits from parenting practices that The nutrition intervention was designed to enrich
improved mother-child interactions and the quality the existing basic nutrition education curriculum
of home stimulation. Lady Health Workers (LHWs), in the LHW program delivered through home
who every month deliver basic maternal and child visits. This goal was achieved by the addition of
health services to rural and remote households as responsive feeding messages and the distribution
part of the government health system, added coun- of a multiple micronutrient powder for young chil-
seling on psychosocial stimulation and nutrition to dren ages 624 months. The LHWs were trained to
their activities for families with children under age move away from a traditional didactic approach to
two years. a counseling strategy for delivering nutrition edu-
cation. During the home visits, the LHWs provided
Psychosocial Stimulation Intervention information about recommended practices and
The psychosocial stimulation intervention, using the benefits, engaged in problem solving, and provided
Care for Child Development messages and materials encouragement.
developed by the United Nations Childrens Fund Critical to the success of the program was the use
(UNICEF) and the World Health Organization, of supportive supervision, on-the-job coaching, and
encouraged mother-child play and communication mentorship for LHWs. It was important for them to
activities (UNICEF and WHO 2009). The LHWs integrate the new practices with existing health mes-
provided information about recommended practices sages without burdening mothers. Group delivery
and benefits, suggested developmentally appropri- strategies combined with home visits permitted the
ate activities for caregivers to try with their young LHWs to reach a greater proportion of the commu-
children, and coached caregivers by providing nity, and the demand for community-based services
prompts and encouragement to respond to childrens increased. The cost of integrating the interventions
efforts and communication. The goal of the inter- into the existing LHW services was US$4 per month
vention was to enhance the quality of caregiver-child per child.
interactions and promote childrens cognitive,
language, motor, and social-emotional skills. Source: Gowani and others 2014; Yousafzai and others 2014.
intermittent doses of an antimalarial medication at the controlled experimental settings (Briscoe and Aboud
time of routine immunization reduced the incidence of 2012); they have been less successful when implemented
malaria by 20 percent (Macete and others 2006). Neither at the community level (Huda and others 2012; Hutton
hemoglobin levels nor future immunity were com- and Chase, forthcoming; Luby and others 2008).
promised with these preventive antimalarial measures.
Psychosocial stimulation interventions appear to be
effective at overcoming some of the deficits caused by Development-Sensitive Interventions
cerebral malaria. Maternal Nutrition
Latrine use and handwashing habits are very dif- Strategies to address the growing number of prema-
ficult to change. Interventions to increase latrine use ture births (Lawn and others 2014) have not yet been
and handwashing have met with success mainly in identified. High stress during pregnancy is a correlate
Corresponding author: Zulfiqar A. Bhutta, Robert Harding Chair in Global Child Health & Policy, Centre for Global Child Health, Hospital for Sick Children, Toronto,
Canada; Zulfiqar.bhutta@sickkids.ca.
263
component has the potential to substantially improve transmitted infections, malaria, malnutrition, compli-
maternal, newborn, and child health outcomes. cations during pregnancy and delivery, and inadequate
This chapter provides a summary of community- newborn and child care can be addressed through vertical
based programs for improving MNCH. The chapter programs. However, the best results can be obtained if
discusses strategies to improve the supply of services, these issues are tackled through interventions that target
including through community-based interventions and maternal, newborn, and child health care as a whole.
home visitations implemented by community health Coordinating care, from preconception to delivery and the
workers (CHWs), and strategies to increase demand health of the child, can lead to profound benefits for the
for services, including through community mobilization health and well-being of women and children and improve
efforts. The chapter summarizes the evidence about the subsequent pregnancy and child health outcomes. A recent
impact of such interventions, describes contextual fac- review of preconception risks and interventions shows that
tors that affect implementation, and considers issues of preconception care in community groups is associated with
cost-effectiveness. It concludes by highlighting research a lower neonatal mortality rate (risk ratio 0.76; 95 percent
gaps, the challenges of scaling up, and the way forward. confidence interval 0.660.88), and a significant increase
in antenatal care (ANC) (risk ratio 1.39; 95 percent con-
fidence interval 1.001.93), breastfeeding rates (risk ratio
COMMUNITY-BASED CARE 1.20; 95 percent confidence interval 1.071.36), and use of
It is widely agreed that communities should take an clean delivery kits (risk ratio 2.36; 95 percent confidence
active part in improving their own health outcomes interval 1.553.60) (Dean and others 2011).
(WHO 1979, 1986, 2008, 2011) and that CHWs can play There are many approaches to community-based
a vital role. Since 2000, national governments have real- care. This chapter describes interventions aimed at
ized the substantial potential of CHWs to achieve child improving the supply of services by delivering them in
survival goals; these governments have or are considering communities, often through CHWs, and interventions
national programs for CHWs. For example, since 2003, aimed at increasing demand for services and promoting
Ethiopia has trained thousands of community-based healthy behaviors.
health extension workers to focus on maternal, newborn,
and child health (Medhanyie and others 2012).
Although strategies vary considerably, community- COMMUNITY-BASED CARE TO IMPROVE
based interventions may encompass encouraging THE SUPPLY OF SERVICES
healthier practices and care seeking among commu-
nities and families; recruiting and training local com- Health care provided in communities, as opposed to
munity members to work alongside trained health care health facilities, is often provided by CHWs and may
professionals; and community member involvement in include home visitations and other intervention pack-
service provision, including diagnosis, treatment, and ages. The level of training CHWs receive, whether they
referral. Within these broad categories are a range of are employed by a nongovernmental organization or
approaches, including CHWS, traditional birth atten- the government and whether they are paid or volunteer,
dants (TBAs), health campaigns, school-based health varies widely between and within countries. In general,
promotion, home-based care, and even community they work in conjunction with frontline health workers
franchiseoperated clinics. across the primary health care spectrum to provide
Community-based care is an important component health education and promotion, distribute commodi-
of providing a continuum of care for low-resource com- ties, diagnose and manage illness, and provide referrals.
munities. The health and well-being of women, new- Substantial evidence suggests that community-based
borns, and children are inherently linked. When mothers interventions are an important platform for improv-
are malnourished, ill, or receive insufficient care, their ing health care delivery and outcomes (Bhutta and
newborns are at increased risk of disease and premature others 2010; Kerber and others 2007; Lassi, Haider,
death. In LMICs, a mothers death during childbirth and Bhutta 2010; Lewin and others 2010; Singh and
significantly raises the risk that the child will not survive Sachs 2013).
(Ronsmans and others 2010).
Better health requires that women and children have
the ability to access quality services from conception and Home Visits
pregnancy to delivery, the postnatal period, and childhood. For both at-risk pregnancies and healthy pregnancies,
Issues such as human immunodeficiency virus/acquired home visits by CHWs in the pre- and postnatal period
immune deficiency syndrome (HIV/AIDS), sexually to counsel mothers, provide newborn care, and facilitate
Pakistans lady health worker (LHW) program, a LHWs; external evaluations are conducted every
government-supported community health service three to five years.
begun in 1994, has expanded to cover more than Studies show that women are more likely to use
70 percent of the rural population. In the program, modern reversible contraceptive methods if offered
LHWs receive a regular salary and are trained to by LHWs, and coordination of traditional birth
promote health awareness and provide basic care to attendants (TBAs) and LHWs led to a reduction in
pregnant mothers, neonates, and children, including stillbirths and in hemorrhage-related complications.
ensuring up-to-date immunizations and monitoring In another study, LHWs were given additional train-
nutritional status. LHWs also provide contraceptive ing and were linked with dais (TBAs in Pakistan),
and family planning services. who were given training for newborn resuscitation
and immediate newborn care; this approach also led
LHWs serve the community, working from home, to reductions in stillbirths, improvements in institu-
and attend to approximately 200 households. tional deliveries, and increased initiation of early
Approximately 20 percent of the entire population and exclusive breastfeeding.
of Pakistan is covered by 69,000 LHWs. Lady health
supervisors are responsible for supervising the Source: Bhutta and others 2010.
Table 14.4 Forest Plot on a Community-Based Intervention Package and Its Impact on Health Care Seeking for
Neonatal Illnesses
Intervention Standard Log [risk ratio] Risk ratio IV, Risk ratio IV,
Study or subgroup package N care N (SE) random, 95% CI Weight (%) random, 95% CI
Azad and others 2010 15,695 15,257 0.117 (0.12) 22.5 0.89 [0.70, 1.13]
Bari and others 2006 520 548 0.068 (0.03) 24.6 1.07 [1.01, 1.14]
Kumar and others 2008 1,087 1,079 0.657 (0.08) 23.7 1.93 [1.65, 2.26]
Manandhar and others 2004 2,864 3,181 1.044 (0.277) 16.0 2.84 [1.65, 4.89]
Tripathy and others 2010 8,807 8,119 0.425 (0.35) 13.2 1.53 [0.77, 3.04]
Total (95% CI) 100 1.45 [1.01, 2.08]
2 2 2
Heterogeneity: Tau = 0.14; Chi = 63.42, df = 4 (P<0.00001); I = 94%
Test for overall effect: Z = 1.99 (P = 0.047)
interval 0.810.94) in school-going children. It also improve HIV/AIDS-related knowledge scores (standard
improves the mean hemoglobin levels significantly mean difference 0.66; 95 percent confidence interval
(standard mean difference 0.24; 95 percent confidence 0.251.07) and the frequency of protected sex (risk
interval 0.160.32) (Salam, Maredia, and others 2014). ratio 1.19; 95 percent confidence interval 1.131.25).
Home visits can also decrease HIV-related morbidity
HIV/AIDS. Similarly, community-based interventions by significantly increasing treatment adherence scores
can significantly improve HIV/AIDS status. Interventions (mean difference 3.88; 95 percent confidence inter-
such as educational activities, counseling sessions, home val 2.695.07). Community delivery of highly active
visits, mentoring, womens groups, peer leadership, and antiretroviral therapy during pregnancy and lactation
street outreach to increase awareness of HIV/AIDS also led to a 66 percent decrease in stillbirths (risk ratio
risk factors have shown significant impacts on sexual 0.34; 95 percent confidence interval 0.180.65) (Salam,
practices and health outcomes. These interventions Haroon, and others 2014).
A study from Ethiopia showed promising results previously been reserved for more highly trained profes-
when a group of women from the community were sionals (WHO 2012).
empowered and mobilized to recognize and treat However, no global consensus exists on the appro-
malaria (Rosato and others 2008). This process led to priate package of services for CHWs. The case of CHWs
an overall 40 percent reduction in mortality in children and misoprostol is illustrative. The WHO recommends
under age five years (Kidane and Morrow 2000). In the use of oxytocin (10 International Units, intrave-
communities with underresourced health systems, such nous/intramuscular) as the uterotonic drug for the
as in Jharkhand and Orissa, two of the poorest states in prevention of postpartum hemorrhage, and misoprostol
eastern India, 55 percent coverage of womens groups (600 microgram by mouth) administered by CHWs in
formed to facilitate participatory learning, safe delivery the absence of a skilled birth attendant (Department of
practices, and care-seeking behavior was believed to Reproductive Health and Research, WHO 2012).
be a factor in reducing maternal depression. Neonatal An RCT from Afghanistan shows that uterotonics
mortality rates were reduced by 45 percent in the inter- such as misoprostol are widely accepted in communities
vention arm (Tripathy and others 2010). and can potentially decrease significant postpartum
An effective community mobilization program led to hemorrhage-related maternal morbidity and mortality.
a 28 percent reduction in neonatal mortality in a study Results show that of the 1,421 women in the intervention
conducted in Hala, Pakistan, of LHWs who had received group who took misoprostol, 100 percent correctly took
training in home-based neonatal care and TBAs who it after birth. In the intervention area where community-
received voluntary training (Bhutta and others 2008). based distribution of misoprostol was introduced,
The Makwanpur trial was conducted in a rural near-universal uterotonic coverage (92 percent) was
mountainous community in Nepal, where 94 percent of achieved, compared with 25 percent coverage in the
babies are born at home (Pradhan and New 1997) and control areas (Sanghvi and others 2010).
only 13 percent of births are attended by trained health A systematic review suggests that in the community,
workers (Central Bureau of Statistics 2001). With the misoprostol distribution rates during home visits were
implementation of facilitated monthly group meetings higher compared with facility-based ANC distribution.
among pregnant women, a decrease in neonatal mortal- Coverage rates were also higher when CHWs and TBAs
ity was seen in the intervention arm, compared with the distributed misoprostol compared with ANC providers
control arm, with an odds ratio of 0.7 (95 percent confi- (Smith and others 2013). The review highlights that miso-
dence interval 0.530.94) (Manandhar and others 2004). prostol and other uterotonics may very well be widely
acceptable within the community and can be delivered by
QUESTIONS AND CHALLENGES CHWs. Usage is particularly seen more in the South Asia
region, with uterotonic usage rates of up to 69 percent
Expanding the Community Health Worker Mandate (Flandermeyer, Stanton, and Armbruster 2010).
Shortages in human resources and expanding popu- A community-based, cluster-RCT from Ghana
lations have given new relevance to training CHWs in evaluates the use of intramuscular oxytocin with
ever-more complex tasks. For countries with limited a Uniject device delivered by a CHW. In this trial,
resources for training or employing paid labor, task women receiving oxytocin had a reduced risk of post-
shifting may allow CHWs or less trained TBAs to receive partum hemorrhage (risk ratio 0.49; 95 percent confi-
training and perform interventions that might have dence interval 0.270.88) (Stanton and others 2013),
Outreach activities
interventions requires personnel, resources, training,
Outreach
primary
Referrals
Figure 14.3 Integrated Health Care System and Approaches for Reaching Community
Structural support Financial support Capacity building Supervision and monitoring Supply chain management
Community
mobilization
complications and provision of
Early identification of cases or
Outreach health services and
Social marketing
Community health workers
Behavior
change
Health facility
communication
programs
Home visitation
referrals
Community-
Provision of based
services interventions
School- or
community-based programs
Figure 14.4 Cost per DALY Averted in Community-Based Programs for Reproductive, Maternal, Newborn, and Child Health
Sources: Based on Bachmann 2009; Bang, Bang, and Reddy 2005; Fiedler and Chuko 2008; Jan and others 2011; Nonvignon and others 2012; Puett and others 2013; Ross and
others 2011; Sabin and others 2012; Sutherland and others 2010; Wilford, Golden, and Walker 2012; Yukich and others 2008; Yukich and others 2009.
Note: IPV = intimate partner violence.
Table 14.7 Average Intervention Costs for Community-Based RMNCH Services, 2012 U.S. Dollars
Mean cost per beneficiary
Community-based RMNCH services (range) (US$ 2012) Sources of costs
Maternal and neonatal
Volunteer peer counselling $30.60 ($4.97$68.04) Nepal; Borghi and others (2005)
Traditional birth attendants and birth preparedness Malawi; Lewycka and others (2013)
Home-based neonatal care India; Bang, Bang, and others (2005)
Community health worker maternal care Cambodia; Skinner and Rathavy (2009)
Bangladesh; LeFevre and others (2013)
Zambia; Sabin and others (2012)
Breastfeeding
Peer counseling, education, and support $166.50 ($162.55$170.44) Uganda; Chola and others (2011)
South Africa; Nkonki and others (2014)
Child health
Deworming campaigns $3.47 ($0.349.69) Lao PDR; Boselli and others (2011)
Child health days and weeks Ethiopia; Fiedler and Chuko (2008)
Honduras; Fiedler (2008)
Zambia; Fiedler and others (2014)
Somalia; Vijayaraghavan and others (2012)
Vietnam; Casey and others (2011)
Immunization
School-based and community-based vaccine programs $26.75 ($3.50$50) South Asia; Jeuland and others (2009)
Mobile community health workers Ecuador; San Sebastin and others (2001)
Malaria
IPT with volunteer health workers $5.02 ($1.350$10.10) Gambia, The; Bojang and others (2011)
Community health worker malaria treatment Ghana; Nonvignon and others (2012)
Ghana; Patouillard and others (2011)
Severe acute malnutrition
Community-based therapeutic care $153.85 ($116.11$180.37) Zambia; Bachmann (2009)
Bangladesh; Puett, Sadler, and others (2013)
Ethiopia; Tekeste and others (2012)
Gender-based violence
Microfinance $54.12 South Africa; Jan and others (2011)
Gender/HIV training for prevention of GBV
Note: GBV = gender-based violence; HIV = human immunodeficiency virus; IPT = intermittent preventive treatment; RMNCH = reproductive, maternal, newborn,
and child health; USD = U.S. dollars.
Corresponding author: Lori A. Bollinger, Avenir Health, Glastonbury, Connecticut, United States, LBollinger@avenirhealth.org.
285
percentage of children under age five years being taken and the Caribbean and the Middle East and North Africa
to health providers for treatment of acute respiratory each have 1.5 physicians per 1,000 people. East Asia and
infection, the percentage under age five years with a Pacific drops significantly below that figure, with only
fever receiving antimalarial drugs, and the percentage 0.9. This value drops again by half in South Asia, which
under age five years receiving a packet of oral rehy- has 0.4. Sub-Saharan Africa has only 0.16 physicians per
dration solution for the treatment of diarrhea. For 1,000 people, which is not quite 5 percent of the value
women, these indicators are the percentage of births observed in Europe and Central Asia, an even greater
being attended by skilled health staff and the percent- differential than that between the highest-covered and
age of pregnant women receiving antenatal care. lowest-covered regions for nurses and midwives.
Finally, we examine indicators for outcome mea-
sures. For children, these are the percentage ages Number of Hospital Beds per 1,000 People
1223 months being immunized against diphtheria, The number of hospital beds per 1,000 people varies from
pertussis, and tetanus (DPT); the percentage ages a high of 5.34 in Europe and Central Asia to a low of 1.41
1223 months being immunized against measles; the in Sub-Saharan Africa. Europe and Central Asia has more
percentage of newborns being immunized against than double the number of hospital beds as in the next
tetanus; the percentage under age five years using region, 2.56 in East Asia and Pacific. Latin America and
insecticide-treated bednets; and the percentage ages the Caribbean and the Middle East and North Africa have
659 months receiving vitamin A supplementation. similar values, at approximately 1.9 hospital beds; South
For women, this is the percentage of married or Asia and Sub-Saharan Africa have the fewest number of
in-union women ages 1549 years having an unmet hospital beds, at 1.50 and 1.41 per 1,000 people, respec-
need for contraception. tively. This value is approximately 25 percent of Europe
and Central Asia, indicating a relatively lower level of
inequality in the distribution of resources.
Structure of Service Delivery Platforms
Dramatic differences in absolute numbers of struc-
tural resources can be seen across regions. Europe and Process of Health Care Service Delivery
Central Asia contain the highest average number of Indicators Related to Children
resources, while South Asia and Sub-Saharan Africa The indicators measuring the health care delivery pro-
contain the lowest. cess, which contribute to the final set of indicators
Of the 49 countries that the World Bank has cate- health outcomesare displayed in table 15.1, panel B.
gorized as low income, only five meet the minimum The values for the two process indicators related to
standard established by the World Health Organization children are much more similar across regions than are
(WHO) of 23 nurses, midwives, and physicians per the values for the structural indicators. The values for
10,000 population (Global Health Workforce Statistics, the first indicator, the percentage of children with acute
http://www.who.int/hrh/workforce). respiratory infection taken to health providers, range
A number of structural resources is associated with from a high of 70 percent in Europe and Central Asia;
each region (table 15.1, panel A). to East Asia and Pacific and the Middle East and North
Africa, with values of 69 percent and 68 percent, respec-
Number of Nurses and Midwives per 1,000 People tively; to a low of 50 percent in Sub-Saharan Africa.
Europe and Central Asia has 5.36 nurses and midwives per Latin America and the Caribbean and South Asia fall in
1,000 people, almost twice as many as the next three best- between, at 64.5 percent and 56.7 percent, respectively.
served regions: Latin America and the Caribbean (2.76), The lowest value is fully 70 percent of the highest value,
East Asia and Pacific (2.52), and the Middle East and which is significantly better than the differential that
North Africa (2.40). After these four regions, the number exists for structural indicators.
of nurses and midwives per 1,000 people drops dramati- The same is true for the second process indicator
cally to about 1 in Sub-Saharan Africa; South Asia has only related to children, the percentage of children under age
about 0.5 nurses and midwives, less than 10 percent of the five years receiving oral rehydration solution for diar-
value observed in Europe and Central Asia. rhea. East Asia and Pacific displays the highest percentage
at 50.7 percent, followed by South Asia at 47.4 percent,
Number of Physicians per 1,000 People Latin America and the Caribbean at 44.5 percent, the
At 2.78, Europe and Central Asia also has the highest num- Middle East and North Africa at 38.8 percent, Europe
ber of physicians per 1,000 people. This is almost twice and Central Asia at 38.7 percent, and Sub-Saharan Africa
as high as the values for the next regions; Latin America at 34.2 percent. The difference between the highest and
Immunization, measles (percent of children 93.2 88.9 91.1 88.9 80.0 76.1
ages 1223 months)
Newborns protected against tetanus (percent) 83.9 82.1 83.2 86.0 79.6 80.7
Unmet need for contraception (percent of 15.2 21.4 16.1 13.8 20.5 25.1
married women ages 1549)
Vitamin A supplementation coverage rate 95.0 75.9 31.0 42.2 88.2 70.9
(percent of children ages 659 months)
Source: Calculations based on World Bank World Development Indicators database.
Note: ARI = acute respiratory infection; DPT = diphtheria, pertussis, and tetanus; ORS = oral rehydration solution; RMNCH = reproductive, maternal, newborn, and child health.
lowest observations is about the same as for the pre- distribution of values across regions. The highest value
vious indicator, with the lower statistic approximately is observed again in Europe and Central Asia, followed
67 percent the level of the higher statistic. even more closely by Latin America and the Caribbean
(94.4 percent), East Asia and Pacific (91.6 percent), and
Indicators Related to Women the Middle East and North Africa (87.5 percent); Sub-
The percentage of births attended by skilled health Saharan Africa is only slightly lower at 81.9 percent.
staff reaches 98 percent in Europe and Central Asia. South Asia lags, with only 59.4 percent of women
The next three regions follow closely: Latin America receiving some prenatal care; this lowest value is still
and the Caribbean at 86.7 percent, the Middle East about 60 percent of the value observed in Europe and
and North Africa at 84.8 percent, and East Asia and Central Asia.
Pacific at 81.2 percent. The value for the next region,
Sub-Saharan Africa, drops to 57.8 percent. The lowest
level is in South Asia; skilled health personnel attend Health Outcomes
only 40.3 percent of births; this rate is only 40 percent The indicators representing health outcomes as a
of the value in Europe and Central Asia. result of the performance of the RMNCH health care
The percentage of women receiving some ante- service delivery system are displayed in table 15.1,
natal care (ANC) shows a slightly more compressed panel C.
Broughton and Niger Increasing compliance with high-impact, 147.00 US$ (2008) 150.48
others (2013) evidence-based care standards in maternal
health care facilities
Colbourn and Malawi Community intervention: Participatory womens 79.00 $Int (2013) 1.30
others (2015) groups mobilizing communities around maternal
and neonatal health using volunteer facilitators
supported by program staff for monthly meetings
Colbourn and Malawi Facility intervention: Quality improvement to 281.00 $Int (2013) 4.63
others (2015) train staff, change packages, death reviews,
leadership training, protocol-based trainings
Colbourn and Malawi Both community and facility-based interventions 146.00 $Int (2013) 2.40
others (2015)
Grimes and Malawi To relieve physician workload, trained orthopedic 138.75 US$ (2012) 168.26
others (2014) clinical officers for six months to treat patients
needing a manipulation or operation
Note: DALY = disability-adjusted life year; $Int = International dollar; ORS-Z = oral rehydration solution plus zinc.
Assessing the returns on investments in the contin- To demonstrate that very high returns can be achieved
uum of care for RMNCH requires specification of a by strengthening investments in the delivery of a suite
package of interventions and an estimate of the full costs of high-impact interventions
incurred in the health system to deliver those interven- To underscore the importance of an accurate assess-
tions. On the benefits side, the outcome of the contin- ment of those returns, including the full range of
uum of care is evidenced in the many dimensions of the costs involved in delivering integrated care across the
health benefits arising from an integrated care program. continuum and the full range of benefits that flow
These benefits are not only lives saved; they also include from the interventions.
Corresponding author: Karin Stenberg, Department of Health Systems Governance and Financing, World Health Organization, Geneva, Switzerland,
stenbergk@who.int.
299
This chapter is based on the first attempt, to our communicable and noncommunicable diseases, priorities
knowledge, to undertake such a comprehensive analysis need to be set to allocate resources to the most effective
of the returns on investment in the continuum of care outcomes.
for RMNCH (Stenberg and others 2014).
INVESTMENT WINS
CONTEXT OF THE ANALYSIS
This chapter demonstrates the considerable social and
The benefits of improving the health of mothers and economic returns realized through the effect of invest-
children are indisputable, and considerable progress has ments in RMNCH interventions, building on and adding
been made in reducing maternal and child deaths since more specificity to earlier results. For example, it has
the publication of Disease Control Priorities in Developing previously been estimated that 30 percent to 50 percent
Countries, second edition (Jamison and others 2006). of East Asias dramatic economic growth during 196590
The global maternal mortality ratio decreased 25 percent, can be attributed to reduced child mortality and sub-
from 288 per 100,000 live births in 2005 to 216 in 2015 sequent lower fertility rates (Bloom and Williamson
(Alkema and others 2015; WHO, UNICEF, UNFPA, 1997), and that gross domestic product (GDP) per
and World Bank 2015). The global mortality rate for capita is increasing by 1.0 percent per year in China and
children under age five years decreased 32 percent, from 0.7 percent per year in India as a result of the effect of
63 per 1,000 live births in 2005 to 42.5 in 2015 (UNICEF, lower fertility on age structures (Bloom and others 2010).
WHO, World Bank, UN 2013; You and others 2015). There are additional reasons why investing in womens
Although several factors have contributed to these reduc- and childrens health is not only the right thing to do;
tions, including general socioeconomic development, the it is also the smart thing to do.
increased coverage of essential RMNCH interventions
has played an important role (WHO and UNICEF 2013).
Notwithstanding this progress, 5.9 million children Improved and Equitable Access
died before their fifth birthdays in 2015, and 303,000 preg- Well-targeted investments along the continuum of care
nant women died in 2015 from preventable complications can respond to a fundamental human right: the right to
related to pregnancy and birth. Moreover, progress has health. Increasing equitable access to RMNCH services
been unevenboth among countries and within countries is a key strategy for moving closer to universal health
(Barros and others 2012); a number of countries did not coverage, defined by the WHO as when all people obtain
reach Millennium Development Goal (MDG) 4, to reduce the health services they need without suffering financial
child mortality, and MDG 5, to improve maternal health, hardship when paying for them (WHO 2010, ix).
by 2015 (Alkema and others 2015; You and others 2015).
The remaining challenges in reducing maternal Health System Benefits
and child mortality are, to a large extent, the effects
of uneven attention to the full continuum of care. For Investments in womens and childrens health strengthen
example, in the 75 low- and middle-income countries the entire health system. For example, the capacity to
(LMICs) that account for more than 95 percent of provide 24-hour emergency obstetric care requires that
global maternal and child deaths, coverage of rou- health system components, such as qualified health
tine diphtheria-tetanus-pertussis immunization has workers, medications, facilities, and a functioning refer-
reached a median level of more than 80 percent; how- ral system, be in place across geographic areas.
ever, coverage of other life-saving interventions is much
lower, especially those delivered in the immediate post- Extended Lifecycle Benefits
natal period (median coverage of less than 45 percent) Investments in RMNCH bring benefits across age
such as postnatal care for mothers and babies (WHO groups. For example, investments in nutrition have
and UNICEF 2013). Similarly, adolescence remains long-lasting effects beyond the immediate improvement
a neglected period, as highlighted by a series in The in nutritional status, such as improvements in cognitive
Lancet on adolescent health (Cappa and others 2012). development, school performance, and future earnings
The continuum of care, including referral chain, is often (Ruger and others 2012).
less than fully functional in these countries (Bossyns
and Van Lerberghe 2004; Font and others 2002).
Additional investments are required to sustain gains Cost-Effective Interventions
achieved and to accelerate efforts to address the remain- A considerable body of research, including Disease Control
ing gaps. With LMICs facing the double burden of Priorities in Developing Countries, second edition, has
Benefit-cost analysis
(comparing scenarios)
- Benefit-cost ratio
Returns on Investment in the Continuum of Care for Reproductive, Maternal, Newborn, and Child Health 301
Estimation of the health and fertility impacts and the outlined in this chapter includes interventions that were
total cost of specific levels of additional investment in identified in a 2011 review as essential and cost-effective
these interventions RMNCH interventions (PMNCH, WHO, and Aga Khan
Assessment of the economic and social benefits aris- University 2011). Table 16.1 lists the 50 selected inter-
ing from these health and fertility impacts. ventions grouped into six broad packages that follow
program structures in many national health systems:
family planning, maternal and newborn health, malaria,
Selecting the Interventions HIV/AIDS, immunization, and child health, with nutri-
National policy makers must choose which services to tion included in several packages.
provide, taking into account budgetary constraints and The effective delivery of high-quality interventions
financial ceilings allocated by the ministry of finance and depends on key enablers, including national policies,
other financing partners. Evidence on cost-effectiveness, functional health systems, community engagement, and
current health system capacity, feasibility, and accept- innovation. Strategies modeled include those supporting
ability will inform investment strategies. The framework both the supply side (for example, expanding health
Malaria
Insecticide treated materials Treatment of malaria in children
Pregnant women sleeping under ITNs Treatment of malaria in pregnant women
Intermittent preventive treatment for pregnant women
HIV/AIDS
Prevention of mother-to-child transmission ART (first-line treatment) for pregnant women
Cotrimoxazole for children Pediatric ART
table continues next page
Child health
Breastfeeding counseling and support; complementary feeding Oral rehydration therapy
counseling and support Zinc for diarrhea treatment
Vitamin A supplementation in infants and children ages Antibiotics for treatment of dysentery
659 months
Pneumonia treatment in children
Management of severe malnutrition in children
Management of moderate acute malnutritionb
Vitamin A for measles treatment in children
Source: Based on Stenberg and others 2014.
Note: ART = antiretroviral therapy; BCG = bacille Calmette-Gurin; DPT = diphtheria, pertussis, and tetanus; Hib = Haemophilus influenzae type B; ITN = insecticide-treated bednet;
IUD = intrauterine device; LAM = lactational amenorrhea method.
a. Some interventions may have both preventive and curative elements.
b. Current analysis includes impact only, not cost.
c. In countries where abortion is legal.
system access by constructing new hospitals and facil- as well as some estimates of the time and related cost of
ities) and the demand side (for example, mass media health workers involved in providing the health services.
campaigns to encourage breastfeeding and care seeking Ideally, these studies would also include program support
for childhood illnesses). costs, for example, for training in disease-specific man-
agement, epidemiological surveillance, and provision of
vehicles specific to the program activities. However, the
Estimating the Costs studies may not always do so, or the specific methods used
The second stage of the analysis is to use modeling tools to estimate such costs are not always well described. Finally,
to estimate the health and fertility impacts of the inter- program- or disease-specific estimates may miss resources
ventions and the investment costs required. needed for broader health-system-strengthening activi-
With respect to costs, attempts have been made to ties, thereby underestimating the true resource needs for
estimate the resources required to scale up the provision the provision of services. Health-system-strengthening
of essential RMNCH services in LMICs. Most of these activities to consider include preservice training and
are disease- or program-specific cost studies that deter- deployment of clinical staff, development of a function-
mine costs more or less specific to the disease or age ing referral system, strengthening the health information
group (Bhutta and others 2013; Singh and Darroch 2012; system, and upgrading facility infrastructure. Figure 16.1
Stenberg and others 2007). Such studies tend to include shows the 12 components of the full cost of scaling up the
patient-level costs for intervention-specific commodities, interventions that are estimated in the analysis presented
such as vaccines, bednets, and nutritional supplements, in this chapter.
Returns on Investment in the Continuum of Care for Reproductive, Maternal, Newborn, and Child Health 303
Estimating Health and Fertility Impacts saved so that she is able to look after her children and
The scale up of a comprehensive package of care will support her community has great social value even if
have interactions across diseases and age groups. The she does not enter the paid workforce. Equally, the value
interlinkages built into the OneHealth Tool and accom- of a childs life saved does not depend only on his or her
panying impact modules (box 16.1) eliminate double participation in the labor force when an adult. We refer
counting of lives saved, and they take into account to the benefits not captured in existing GDP measures
the reduction in need for treatment as preventive care as social benefits.
is scaled up. Increases in coverage are translated into A strong consensus exists among economists that
reductions in maternal, newborn, and child mortality, measurements of economic and social change need to
along with declines in some aspects of morbidity such move beyond production or conventional GDP to sus-
as prevalence of wasting and stunting. Fertility rates are tainable well-being (Stiglitz and others 2009) and that
modeled to decrease with increasing targets for contra- these more inclusive measures are especially important
ceptive prevalence rates, in turn affecting population in relation to health (Arrow and others 2013; Suhrcke
growth projections over time. and others 2012). These more inclusive methods can
be referred to as full income methods. They include
additional benefits from improved health outcomes and
Assessing the Economic and Social Benefits of more inclusive gauges of income than those included in
Achieved Outcomes GDP as it is currently measured.
Once the improved health outcomes arising from The Lancet Commission on Investing in Health
the interventionslives saved, morbidity averted, and (Jamison and others 2013) argues strongly for a full
unwanted pregnancies avoidedare determined, the income approach to measuring the benefits of investment
task is to measure the benefits arising from these bet- in health, defined as measured increases in conventional
ter outcomes. Some of these benefits will be strictly GDP plus the value of additional life years gained.
economic, reflected in higher GDP from increased The approach presented in this chapter goes further,
workforce participation and from higher productivity. because it does not limit the analysis to the benefits aris-
However, other benefits, although equally real and cer- ing from lives saved. We attempt to include in an explicit
tainly economic in a broader welfare sense, will not be manner estimates of economic and social benefits from
reflected in conventional GDP measures. A mothers life morbidity averted, and to estimate the economic benefits
Box 16.1
Translating Coverage Increases into Cost and Health Impacts: The OneHealth Tool
The OneHealth Tool (OHT) is a software program prepopulated with demographic and epidemiologi-
that aims to support integrated planning processes cal data by country, as well as input assumptions for
in low- and middle-income countries by bring- prevention and treatment interventions based on
ing together disease-specific program planning and World Health Organizationrecommended treat-
health systems planning. The tool was born out of a ment protocols. The tool estimates the likely health
review of tools for strategic planning and costing that impact (mortality and morbidity) of scaling up
found that existing tools did not adequately allow for coverage. The OHT incorporates preexisting models
sector-wide scenario analysis (PMNCH 2008). The used by various United Nations epidemiological ref-
OHT aims to facilitate planning that incorporates erence groups such as the Lives Saved Tool (Winfrey,
health promotion, prevention, treatment, and dis- McKinnon, and Stover 2011); the AIDS Impact
ease management. Version 4 includes detailed mod- Model for HIV/AIDS interventions (USAID 2007;
ules for programs such as nutrition, child health, Stover and others 2010); and the FamPlan model,
malaria, and noncommunicable diseases, as well as which computes the relationship between family
modules for health systems planning, for example, planning and the total fertility rate (Bongaarts 1978;
human resources, logistics, and infrastructure. It is USAID 2004).
Costs considered
Service delivery costsa Inpatient care: Costs comprise the hotel component of hospital costs, that is, excluding the cost of drugs and diagnostic
tests but including costs for personnel and infrastructure running costs.
Outpatient care: Personnel and infrastructure running costs.
Community-based care: A proxy value is applied, assuming that the running cost of community-based care would be one-
third the cost of care provided at health centers.
Intervention-specific Drugs, vaccines, laboratory tests, and medical supplies based on treatment guidelines
direct costsb
Program administration General: Resource needs are estimated using a bottom-up ingredients approach for each specific area (child health, maternal
costsc health, immunization) and comprise in-service training activities, development of preservice training materials, distribution of
printed information materials, mass media campaigns, supervision of community health workers, routine program management,
conditional cash transfers, and other activities considered essential for ensuring an expansion of quality services.
Specific for improving adolescents access to health services: Costs for general program coordination at national
and district level of adolescent-friendly health services (AFHS), development and distribution of national standards for AFHS,
in-service training on AFHS, information and communication activities, and upgrade of infrastructure and equipment to
adolescent-friendly standards
table continues next page
Returns on Investment in the Continuum of Care for Reproductive, Maternal, Newborn, and Child Health 305
Table 16.2 Parameters of the Investment Analysis (continued)
Overall parameters Scope of the analysis
Health systems costsd Capital investments in infrastructure, primarily related to construction of hospitals, facilities, and health posts. Capital
investments are assumed to take place during the first 12 years only (201324) to accommodate expansion in service delivery
and effective referral systems.
Operational costs for transporting additional RMNCH commodities throughout the supply chain.e
Investments in equipment and procedures for better health information management.
Administration of social health insurance in 13 countries classified as having or planning to set up insurance schemes.
Investments in procedures for improved governance and management of resources.
scenarios; it is important to note that the main counter- accelerating progress compared with a Low scenario in
factual in our example is the Low scenario with constant which coverage remains at the 2012 level while popula-
coverage levels and a growing population. Accordingly, tion increases.
the results should not be interpreted as additional We applied tools that have been developed by the
spending above current levels of health expenditure, but international community, including the OneHealth
rather as the cost and impact of bending the curve and Tool (box 16.1) to assess intervention-specific costs and
Returns on Investment in the Continuum of Care for Reproductive, Maternal, Newborn, and Child Health 307
parameters, there is no reason to think that the social A labor supply effect because adults are able to devote
value is lower in poorer countries than in richer ones. more time to working. (With fewer births, women
Although we do not use any age adjustment for the and other caregivers will have an increased propen-
social value of a life, our procedure results in some dis- sity to enter the labor force, leading to increased
counting of the overall value of a life year for age, and the labor supply per capita and hence to increased GDP
economic benefits of childrens lives saved only begin to per head.)
accrue when they enter the labor force. A productivity effect covering a range of factors influ-
encing long-term productivity, such as higher saving
by households and higher investment in schooling.
Benefits of Morbidity Averted More generally, with lower birth rates, more of a
Many women and children who survive adverse societys resources can be devoted to capital deepen-
RMNCH events suffer serious and sustained disabilities ing, thereby increasing productivity, rather than to
(Ashford 2002; Blencowe and others 2013; Mwaniki and capital widening to meet the needs of the expanding
others 2012; Souza and others 2013) that undoubtedly population.
have substantial human, social, and economic costs.
The interventions studied here should be expected to The estimates of the demographic dividend draw
generate important benefits through lower morbidity. In on and adjust the methods of Ashraf, Weil, and Wilde
spite of its acknowledged importance, few attempts have (2013), who developed estimates of key parameters
been made to quantify the burden of maternal and child based on a review of relevant literature. We derive
morbidity or to estimate its economic and social cost; from their model an aggregate relationship between the
we attempt to begin the process in this study. reduction in the TFR and the change in GDP per capita
Although the OneHealth Tool estimates the lives over time, out to 2070, and apply this to the change in
saved as a result of scaling up the interventions, it does the TFR in each country to estimate the impact on per
not measure the morbidity averted (other than for capita GDP and hence on overall GDP.8
wasting and stunting) or the impact on mortality in In summary, we present economic benefits, valued in
subsequent years from averting morbidity in the initial GDP terms, derived from the following:
year. We estimate morbidity averted for four causes for
children (preterm birth complications, birth injury, Lives saved
congenital abnormalities, and malnutrition) and two Morbidity averted
for mothers (obstructed labor and other maternal dis- Demographic dividend.
orders), and calculate economic and social benefits.6
Moreover, we derive parameters relating improved Social benefits, also valued in GDP terms, are derived
nutritional outcomesprevention of low stature and from the following:
low birth weightto lifetime earnings and apply these
to estimates of reduced wasting and stunting by country. Lives saved
Morbidity averted.
Benefits of Reduced Fertility Rates In the Low scenario, GDP per capita paths converge
The third benefit is the economic impact of the reduc- to an annual growth rate of 2 percent by 2070. The
tion in fertility rates, which is well documented in the economic benefits here refer to the difference in GDP
literature.7 Ashraf, Weil, and Wilde (2013) identify a growth between the High and Low scenarios.
range of channels through which a reduction in the total
fertility rate (TFR), that is, the number of children born
to the average woman during her lifetime, affects growth Two Country Case Studies
in GDP per capita; these channels can be grouped into To illustrate how the investment framework could
three types of effect, each affecting GDP: be applied at the country level, we present two case
studies of LICs. One is a country in Asia that has
A dependency effect because a reduction in births seen increased coverage of RMNCH interventions and
reduces the dependent population. Given that the reductions in the fertility rate to about 2.5. The other is
nondependent population produces the GDP, the fall a country in Sub-Saharan Africa with low coverage of
in the dependent population for a given level of GDP many RMNCH interventions and continued high fertil-
increases the level of GDP per capita. ity rates (table 16.3).
RESULTS: INVESTMENT METRICS AND lives saved (the impact of the health interventions on
COMPONENTS OF COSTS AND BENEFITS those who are born). The distribution of deaths across
these two categories varies across countries and regions,
We present benefit-cost ratios of investing in RMNCH. largely reflecting the importance of fertility reduction in
For details on costs (in 2011 U.S. dollars) and health individual countries. In UMICs, for example, where fer-
benefits, see Stenberg and others (2014). In brief, the tility rates are in general already fairly low, 75.6 percent
High scenario would require an extra US$4.48 per capita of deaths prevented are lives saved.
in 2035, with country estimates ranging from US$1.2
to US$112.7, although the per capita numbers will be
higher in earlier years because of frontloading in infra- Benefit-Cost Ratios for Investments
structure costs and the increase in population over time. Applying a discount rate enables benefits and costs to be
Total costs reach US$30 billion in the third year and expressed as a net present value (NPV). The benefit-cost
remain at that level until 2035.9 ratio for a given discount rate is the ratio of the NPV of
Table 16.4 shows estimates of total deaths prevented, benefits and costs at that discount rate.
apportioned between deaths averted (the reduction in Table 16.5 reports for all countries considered as
births due to enhanced access to contraceptives) and a whole, and for groups of countries, the benefit-cost
Returns on Investment in the Continuum of Care for Reproductive, Maternal, Newborn, and Child Health 309
Table 16.4 Costs and Deaths Prevented, High versus Low Scenarios, 201335
Distribution of deaths prevented: Lives saved vs. deaths
averted (percent of total)
Maternal
Stillbirths deaths Child deaths
Country grouping Cost Deaths Lives Deaths Lives Lives Deaths Total lives
(number of countries in (billion prevented saved averted saved saved averted saved
parentheses) 2011 US$) (millions) (percent) (percent) (percent) (percent) (percent) (millions)
Low-income countries (35) 173.6 78.9 30 70 100 46 54 40.4
Lower-middle-income 316.3 98.1 40 60 100 58 42 59.9
countries (27)
Upper-middle- and high- 188.8 7.8 43 57 100 67 33 5.9
income countries (12)
Total (74) 678.1 184.9 36 64 100 53 47 106.3
Table 16.5 Benefit-Cost Ratios for High Compared with Low Scenarios, Selected Periods and Discount Rates
To 2035 To 2050 To 2070
Number of (3 percent (5 percent (7 percent
Country grouping countries discount rate) discount rate) discount rate)
All 74 countries 74 8.7 27.6 34.2
Low-income countries 35 7.2 16.9 18.5
Lower-middle-income countries 27 11.3 34.0 41.0
Upper-middle-income countries, excluding China 10 6.1 22.5 30.1
China 1 0.7 2.7 3.8
India 1 15.0 42.8 52.6
Sub-Saharan Africa 43 11.0 32.3 37.9
South Asia 5 12.7 36.2 43.4
a
High fertility impact countries 27 13.7 40.6 47.4
Asia case study country 1 4.0 9.4 10.5
Sub-Saharan Africa case study country 1 9.9 24.6 27.4
Source: Based on Stenberg and others 2014.
a. The 27 high fertility impact countries are those in which the estimated demographic dividend by 2035 (comparing the High and Low scenarios) is 8 percent of gross domestic
product or greater. These are Afghanistan, Angola, Benin, Burkina Faso, Cameroon, Chad, Comoros, the Democratic Republic of Congo, the Republic of Congo, Equatorial Guinea,
The Gambia, Guinea, Guinea-Bissau, Iraq, Kenya, Liberia, Malawi, Mali, Mozambique, Niger, Nigeria, Rwanda, Senegal, Sierra Leone, Somalia, Tanzania, Uganda, and Zambia.
Table 16.6 Analysis of Contribution to Benefit-Cost Ratio, High versus Low Scenarios, 5 percent Discount Rate for Net
Present Value, 201350
Direct workforce-related
benefits Social benefits
Lives Morbidity Increase Demographic Economic Lives Morbidity All
saved averted in GDP dividend benefits saved averted Total benefits
Benefit- (c) = (e) = (h) = (t) =
Country grouping cost ratio (a) (b) (a) + (b) (d) (c) + (d) (f) (g) (f) + (g) (e) + (h)
All 74 countries 27.6 5.7 1.4 7.1 13.3 20.4 6.7 0.5 7.2 27.6
Low-income countries 16.9 1.4 0.3 1.7 5.5 7.1 9.2 0.6 9.8 16.9
Lower-middle-income 34.0 4.2 1.2 5.4 20.0 25.4 8.0 0.6 8.6 34.0
countries
Upper-middle-income 22.5 6.7 1.8 8.5 11.0 19.5 2.8 0.2 3.0 22.5
countries, excluding China
China 2.7 1.3 0.3 1.5 0.0 1.5 1.1 0.0 1.2 2.7
India 42.8 5.1 1.5 6.6 21.3 27.9 13.9 1.0 14.9 42.8
Sub-Saharan Africa 32.3 4.1 0.8 4.9 17.4 22.3 9.4 0.6 10.0 32.3
South Asia 36.2 4.4 1.3 5.7 18.1 23.8 11.5 0.9 12.4 36.2
High fertility impact 40.6 4.7 0.9 5.6 22.0 27.6 12.2 0.7 13.0 40.6
countries
Asia case study country 9.4 1.0 0.4 1.4 1.8 3.2 5.5 0.7 6.1 9.4
Sub-Saharan Africa case 24.6 2.0 0.3 2.3 9.6 11.9 12.2 0.5 12.7 24.6
study country
Source: Based on Stenberg and others 2014.
Note: Total direct health benefits = increase in gross domestic product (GDP) from work-related benefits (c) + total social benefits (h). Numbers may not sum precisely because of rounding.
Returns on Investment in the Continuum of Care for Reproductive, Maternal, Newborn, and Child Health 311
Table 16.7 Analysis of Contribution to Benefits, High versus Low Scenarios, by percentage Shares, 5 percent Discount Rate
for Net Present Value, 201350
Direct workforce-related benefits Social benefits
Lives Morbidity Demographic Economic Lives Morbidity All
saved averted Total dividend benefits saved averted Total benefits
(c) = (h) = (t) =
Country grouping (a) (b) (a) + (b) (d) (e) = (c) + (d) (f) (g) (f) + (g) (e) + (h)
All 74 countries 20.6 5.1 25.7 48.3 74.0 24.2 1.7 26.0 100
Low-income countries 8.2 1.8 10.0 32.2 42.1 54.4 3.4 57.9 100
Lower-middle-income 12.4 3.4 15.8 58.9 74.7 23.4 1.9 25.3 100
countries
Upper-middle-income 29.7 7.8 37.5 49.0 86.6 12.6 0.7 13.4 100
countries, excluding China
China 46.4 10.6 57.0 0.0 57.0 41.9 1.1 43.0 100
India 11.9 3.5 15.5 49.7 65.2 32.4 2.4 34.9 100
Sub-Saharan Africa 12.6 2.5 15.1 54.0 69.1 29.1 1.8 30.9 100
South Asia 12.2 3.5 15.6 50.1 65.8 31.7 2.6 34.2 100
High fertility impact 11.5 2.3 13.8 54.3 68.1 30.1 1.8 31.9 100
countries
Asia case study country 10.5 4.8 15.2 20.0 34.3 58.1 7.6 65.7 100
Sub-Saharan Africa case 7.8 1.3 9.1 39.0 48.1 49.4 2.6 51.9 100
study country
Source: Based on Stenberg and others 2014.
Note: Total direct health benefits = increase in gross domestic product (GDP) from work-related benefits (c) + total social benefits (h).
to an increase in GDP per capita of 8 percent or more greater than workforce-related benefits in LICs, but the
by 2035. In these countries, which are mainly lower- reverse is true in UMICs. This finding presumably reflects
middle-income countries, the demographic dividend the lower economic value of lives saved and morbidity
on total investment generates a benefit-cost ratio of 22. averted in poorer countries, whereas the social benefits
are valued using a sample-wide metric.
High Direct Health Benefits
Second, the direct health benefits, excluding the demo- Significant Morbidity Benefits
graphic dividend, are very high at 14.3 for the sample Finally, in spite of the very preliminary nature of the
as a whole. These direct benefits are much more evenly morbidity analysis, the morbidity benefits are signifi-
distributed across countries, 11.4 for LICs and 11.5 for cant, representing 6.8 percent of the total benefits
UMICs, excluding China. (table 16.7). These results suggest that further detailed
work on maternal and child morbidity is both appropri-
Total Economic and Social Benefits Are Fairly Equal ate and necessary.
Third, the workforce-related economic benefits (excluding
the demographic dividend) and the social benefits are
about equal for the sample as a whole. The benefit-cost Results from Two Case Studies
ratio generated by the direct workforce benefits alone is The Asian country is considerably larger in both popu-
7.1, and that generated by the social benefits alone is 7.2 lation and GDP than the Sub-Saharan African country
for the 74 countries. The contribution of direct work- and has a somewhat higher level of GDP per capita. The
force benefits versus social benefits varies significantly Sub-Saharan African country has higher mortality rates
across country income groups; social benefits are much for both children and mothers in addition to a higher
Returns on Investment in the Continuum of Care for Reproductive, Maternal, Newborn, and Child Health 313
investment in the Sub-Saharan African case study coun- important to note that returns are realized well beyond
try, with low coverage of most RMNCH interventions, the investment period.
and therefore still facing high child and maternal mor-
tality rates and high fertility rates, are more than twice
as large as the case study country in Asia, which has An Extended Modeling Approach
managed to increase coverage of RMNCH interventions Finally, on a methodological note, the overall economic
and reduce fertility rates to less than 2.5. The country and social benefits are driven by the demographic divi-
case studies confirm the importance of investing in fam- dend generated by the investment. For example, in 2050
ily planning; the effect of the demographic dividend is the demographic dividend accounts for 48.3 percent of
substantial even when the investment reduces the TFR the benefit-cost ratio (for the 74 countries). Workforce-
by a small amount. related benefits and social benefits account for about
Similarly, we present results for China and India sepa- 25 percent each. The relative share of morbidity-averted
rately, given the size of their populations and economies. benefits compared with lives saved benefits is low
Given current low birth rates in China, no significant because only a few sources of morbidity are included
economic benefits are to be derived from increasing the in the model, and the gains in morbidity are adjusted
availability of family planning. This is not to argue that for the degree of disability averted. For LICs, the social
significant benefits could not be bought by increasing benefits predominate because these are valued using
the quality of current programs and ensuring their the average GDP per capita of all countries; the work-
responsiveness to population needs (Kane and Choi force-related benefits are valued using country GDP per
1999). In India, our model estimates high economic person in the workforce.
benefits from increasing the contraceptive prevalence
rate to respond to the unmet need.
CONCLUSIONS
The analysis extends the full income approach to
High Rates of Return for a Comprehensive Approach, include estimates of economic and social benefits from
Including Family Planning morbidity averted and estimates of the effect of the
Fourth, investment in each of the elements in the demographic dividend, thereby providing a more com-
continuum of care matters. The analysis finds that prehensive picture of the returns on investment in
family planning programs generate particularly high RMNCH interventions.
returns, especially in countries with current high The analysis is limited to the health sector and does
fertility rates, primarily through its effect on the not include all sexual and reproductive health interven-
demographic dividend. We have not separated out the tions; notably, surgical care is omitted because of a lack
rate of return on investment in maternal versus child of data to enable us to model related costs and impacts.
health because the analysis deals with investing across Estimates do not take into account costs and returns
the full spectrum of RMNCH; however, we note that of some interventions that contribute to improving
there may be specifically high returns on investment RMNCH outcomes, such as water supply, sanitation
in maternal care for adolescents, given that adolescent and hygiene, girls education, empowerment of women
pregnancies pose a much higher risk for both mother and girls, and food fortification. Moreover, it should
and newborn compared with pregnancies among be acknowledged that the high returns calculated here
women of older age groups (Patton and others 2009; are dependent on those investments being made, for
WHO 2008, 2011). example, in the education sector, to empower women
with greater decision-making authority in relation to
planning family size. To realize high returns, countries
Returns on Investment Vary over Time need to consider effective multisectoral policies to
Fifth, the different types of interventions often gener- deliver public goods associated with family planning
ate benefits in different time frames, so that the rate and maternal and reproductive health, including for
of return varies over time. Returns increase substan- adolescents.
tially over time, particularly beyond the investment Despite these limitations, the results underscore the
period of 201335. For example, at a discount rate of value of addressing remaining gaps. RMNCH concerns
3 percent, the benefit-cost ratio for the full sample of should feature prominently in the post-2015 landscape,
74 countries is about four times larger in 2070 (34.2) as for example, in the Sustainable Development Goals
in 2035 (8.7). Although policy makers often make deci- that are to supersede the MDGs. The development
sions in much shorter time horizons, it is nevertheless of models focused more strongly on the morbidity
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PMNCH, WHO, and Aga Khan University. 2011. Essential MortalityReport 2013. New York, New York: United
Interventions, Commodities and Guidelines: A Global Review Nations Childrens Fund. http://www.childinfo.org/files
of Key Interventions Related to Reproductive, Maternal, /Child_Mortality_Report_2013.pdf.
Returns on Investment in the Continuum of Care for Reproductive, Maternal, Newborn, and Child Health 317
Chapter
17
Cost-Effectiveness of Interventions
for Reproductive, Maternal, Neonatal,
and Child Health
Susan Horton and Carol Levin
Corresponding author: Susan Horton, Centre for International Governance Innovation Chair in Global Health Economics, University of Waterloo, sehorton@
uwaterloo.ca.
319
Table 17.1 Interventions Covered in This Chapter: Topics Covered METHODS
in Other Volumes
We undertook a systematic survey of the literature begin-
Topics covered in other ning in 2000 on the cost-effectiveness of interventions
Topics covered in this volume volumes for RMNCH, detailed in Horton and others (2015). The
Reproductive health: Family planning, safe Adult male circumcision in volume 6 studies discussed here are primarily those measured as
abortion, intimate partner violence (HIV/AIDS, STIs, Tuberculosis, and cost per discounted disability-adjusted life year (DALY)
Malaria) averted,1 the most commonly considered outcome, but
Maternal and child mortality: Antenatal, Intrapartum care also covered in we also provide figures showing results for deaths averted.
intrapartum, and postpartum care; care of volume 1 (Essential Surgery) Studies using cost per quality-adjusted life year (QALY)
newborns saved and life-year saved (LYS) are included in the
Febrile child: Diagnosis and treatment of Prevention of malaria covered working paper (Horton and others 2015), as are studies
malaria and pneumonia in volume 6 (HIV/AIDS, STIs, using other outcomes, for example, per patient correctly
Tuberculosis, and Malaria) treated. For studies that express outcomes in life-years or
Diarrheal diseases: Treatment of diarrhea; Water and sanitation also covered deaths, we have in some cases made an approximate con-
brief review of interventions to prevent in volume 7 (Injury Prevention and version to DALYs, where one life-year is approximately
diarrhea, including water and sanitation Environmental Health) 0.5 DALY for a newborn in low-income countries (LICs).
Vaccines: 16 conditions (BCG, DPT, HPV covered in volume 3 (Cancer) Similarly the conversion from deaths to DALYs assumes
polio, measles, hepatitis B, Haemophilus that a newborn life is approximately 32 DALYs (a life
influenzae B [HiB], Japanese encephalitis, expectancy of about 60 years, discounted at 3 percent).
meningitis A, yellow fever, pneumococcus, The flow charts for the searches on cost-effectiveness and
rubella, rotavirus, typhoid, and cholera) cost are presented in Horton and others (2015).
Nutrition: Management of severe acute In all, 222 articles were identified; of these, 21 covered
malnutrition, and infant and child growth reproductive care, 26 maternal and newborn morbidity,
Platforms for health care and public health 10 febrile conditions, 10 diarrheal diseases, 131 vaccines,
interventions 3 community management of severe acute malnutrition
Note: BCG = Bacillus CalmetteGurin; DPT = diphtheria, pertussis, and tetanus; HIV/AIDS = human (SAM), and 28 growth of infants and young children.
immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS); HPV = human papillomavirus; Seven articles covered more than one category, and 104
STIs = sexually transmitted infections.
included DALYs as one of the outcome measures. We ben-
efited from several recent systematic reviews, including
from old but cost-ineffective interventions to promising
Gyles and others (2012); Mangham-Jefferies and others
new ones, or coverage of older and very cost-effective
(2014); Ozawa and others (2012); and White and others
interventions could be completed before new ones that
(2011). All studies were read by two reviewers to extract
are less cost-effective are incorporated.
the cost-effectiveness data; one reviewer graded the article
The next section discusses the methods used for the
quality using the Drummond Checklist (Drummond and
search and analysis of the literature. The findings are
others 2005); grades are presented in Horton and others
then organized according to the sequence of chapters in
(2015). In some cases we augmented systematic reviews
this volume:
with additional searches. For vaccines (Ozawa and others
Reproductive health (chapter 6) 2012), we added literature from 2010 onward for HiB,
Maternal and newborn child morbidity and mortality meningitis, pneumococcal, rotavirus, and syncytial virus.
(chapter 7) Small, focused searches in PubMed only were undertaken
Febrile conditions (chapter 8) to find additional studies on meningitis, yellow fever, and
Diarrheal disease (chapter 9) rubella, which are not covered in Ozawas review; however,
Vaccines (chapter 10) no studies for these conditions report results in DALYs.
Treatment of severe acute malnutrition (chapter 11) Cost-effectiveness data were converted to 2012 U.S.
Infant and young child growth (chapter 12) dollars using the original study country currency and
Platforms for the delivery of interventions (chapters consumer price index (World Bank 2013). Several stud-
14 and 15). ies provided multiple cost-effectiveness estimates for
different interventions. This chapter discusses those that
Following a discussion of the literature on the cost and provided an incremental cost-effectiveness ratio com-
affordability of interventions, we provide conclusions. pared with a clear alternative. Cost-effectiveness data
Throughout the chapter, unless otherwise specified, costs from more complex interventions, for example, switch-
and cost-effectiveness are converted to 2012 U.S. dollars. ing from fortification to supplementation combined
Cost-Effectiveness of Interventions for Reproductive, Maternal, Neonatal, and Child Health 321
Figure 17.1 Cost-Effectiveness of Interventions for RMNCH, in 2012 U.S. Dollars per DALY Averted
Note: DALY = disability-adjusted life year; EPI = Expanded Program of Immunization; Gavi = Global Alliance for Vaccines and Immunization; HiB = Haemophilus influenzae B; LIC = low-income
country; RMNCH = reproductive, maternal, newborn, and child health; WASH = water, sanitation, and hygiene.
a. Converted from life-years, assuming that a newborn life is equivalent to 32 DALYs or 60 life-years.
Bhutta and others (2014) undertake a more ambi- would reduce maternal and neonatal deaths and pre-
tious estimate of the cost-effectiveness of a package vent stillbirths at a cost of US$1,928 per life saved or
involving scaling up effective interventions in the 75 US$60 per DALY averted. Bhutta and others (2014) esti-
high-burden Countdown countries; the annual cost of mate that 82 percent of the effect in lives saved would be
the package would be US$5.65 billion. This investment from facility-based care.
Nutrition in pregnancy
Cesarean section for obstructed labor
IYCF (food and education)
Micronutrients
Pneumonia and diarrhea multiple interventions
Community management of SAM
Safe abortion, LIC
Womens groups for prenatal and newborn care
HiB vaccine, lower-middle-income country
Home-based and community-based neonatal care
HiB vaccine LIC
Train TBAs for safer births
Rotavirus vaccine, lower-middle-income countriesa
Treatment of severe malaria with artesunate
Train GPs to do cesarean sections, LIC
Rotavirus vaccine, LICa
Pneumococcus vaccine, LICa
Note: If country group is not specified, results refer to low- and lower-middle-income countries combined. GP = general practitioner; HiB= Haemophilus influenzae B; IYCF = infant and young child
feeding interventions (combine education with food distribution to poorest); LIC = low-income country; RMNCH = reproductive, maternal, newborn, and child health; SAM = severe acute
malnutrition; TBA = traditional birth attendants.
a. Cost-effectiveness of vaccines is sensitive to vaccine price. Rotavirus and pneumococcus vaccine costs to LICs are a fraction (for example, 5 percent) of the price paid by Gavi, the Vaccine
Alliance, to procure the vaccines; and Gavi in turn receives prices that are more favorable than in upper-middle income countries because of volume discounts and the like.
Cost-Effectiveness of Interventions for Reproductive, Maternal, Neonatal, and Child Health 323
microscopy is poorly done, RDTs become more cost- group includes rural sanitation; piped water; and in
effective. Microscopy has been considered the gold selected countries, cholera vaccine (US$2,000 per
standard for the diagnosis of malaria, but it is not always DALY averted). Urban sanitation and cholera vaccine
feasible in low-resource environments. If not well done, in lower mortality countries can cost US$3,000 or
it can lead to a relatively high rate of misdiagnosis, and more per DALY averted.
can entail long waits for treatment, depending on the The systematic search identified only one recent study
capacity for reading slides. In areas without microscopy, of behavior change. Behavior change interventions tend
presumptive diagnosis has been used. Clinicians use to have heterogeneous results, and some are not effective
their expert knowledge to determine whether a patient (let alone cost-effective), but the one identifieda hand-
presenting with fever has malaria or another infection washing education intervention in Burkina Faso (Borghi
and treat accordingly. Thus, RDTs are potentially more and others 2002)falls into the very cost-effective
cost-effective where P. falciparum predominates and the group (US$88 per DALY averted). It is quite possible that
more effective but more costly artemisinin combination well-designed behavior change interventions to increase
drugs are being used. RDTs are also cost-effective where the use of clean water, of latrines where available, of
transmission rates are low because presumptive treat- ORS, of prophylactic zinc, and of vaccines could all be
ment involves overuse of antimalarials and, possibly, cost-effective.
delays antibiotic treatment if the underlying infection Most studies estimate the cost-effectiveness of
is bacterial rather than malarial (Ansah and others adding a single intervention to usual care. If interven-
2013; Babigumira and Gelband, forthcoming; Lemma tions are added in combination, the incremental cost-
and others 2011; Rolland and others 2006). RDTs and effectiveness of each additional individual intervention
microscopy both perform more favorably if clinicians can decline. Fischer Walker and others (2011) estimate
are more likely to use the results of the diagnosis in the combined effect of 10 interventions designed to
their prescription behavior, that is, if they only prescribe reduce diarrhea in 68 countries with high child mor-
antimalarials if the test indicates malaria is the likely tality, using the Lives Saved Tool (LiST). Two scenarios
diagnosis, and only prescribe antibiotics if malaria is are modeled: an ambitious strategy designed to reach
not the likely diagnosis (Yukich and others 2010). Two MDG 4 goals; and a universal strategy designed to bring
studies with outcomes measured in cost per deaths coverage of many interventions to 90 percent or more,
averted (Chanda, Castillo-Riquelme, and Masiye 2009; and water, sanitation, and handwashing interventions to
Uzochukwu and others 2009) suggest that RDTs do not 55 percent or more. Both strategies are scaled up from
rank as particularly cost-effective in program settings current coverage to the target over five years.
because clinicians apparently do not always prescribe The ambitious strategy saves 3.8 million lives during
according to test results. Chapter 8 in this volume a five-year period, at a cost of US$49.2 billion, which is
(Hamer and others 2016) discusses some of these issues US$12,847 per death averted or approximately US$405
in more detail and cites other studies that did not fit the per DALY averted in 2008 U.S. dollars. The universal
inclusion criteria here. strategy saves 5 million lives at a cost of US$19,460
per death averted, approximately US$608 per DALY
averted in 2008 U.S. dollars. Although $608 per DALY
Diarrheal Disease averted certainly falls in the cost-effective or very
New developments for diarrheal disease since 2000 cost-effective range for most countries, affordability
include the use of zinc as adjunct therapy in combina- remains problematic. The water and sanitation com-
tion with oral rehydration solution (ORS), a substantial ponent is the main issue, accounting for 84 percent of
decrease in the cost of rotavirus vaccine, and additional the cost of the ambitious package and 87 percent of the
research separating the cost-effectiveness of water supply universal one.
from that of sanitation.
The most cost-effective interventions for diarrhea,
based on cost per DALY averted, are prophylactic Vaccines
zinc supplementation as an adjunct to ORS (US$10 Vaccines rank among the most cost-effective health
to US$50 per DALY averted), ORS (US$150 per interventions because of their life-saving potential. The
DALY averted), rotavirus vaccine (US$100 per DALY original EPI-6 vaccines (against tuberculosis, diphtheria,
averted at the Gavi price in LICs), and household-level tetanus, pertussis, measles, and polio) are very cost-
water treatment in rural areas using chlorination effective (less than $100 per DALY averted), although no
or solar disinfection (US$180 to US$200 per DALY studies on the basic six antigens that typically comprise
averted) (figure 17.1). The next most cost-effective a national EPI were identified by the systematic search.
Cost-Effectiveness of Interventions for Reproductive, Maternal, Neonatal, and Child Health 325
Incentives to households might help. Other interven- As in previous studies (Hoddinott, Rosegrant, and
tions have been tried, such as conditional cash transfers Torero 2012; Horton, Alderman, and Rivera 2008),
and use of text message reminders, but no results on micronutrient interventions remain very cost-effective
cost-effectiveness of these methods were found. (typically less than US$100 per DALY averted, and
often less than US$50 per DALY averted), with some
variation. Interventions are often more cost-effective
NUTRITION in LICs with more widespread deficiencies; for exam-
Interventions for Severe Acute Malnutrition ple, the cost per DALY averted is lower in South Asia
Community management of SAM is attractive from a and Sub-Saharan Africa than in China. Fortification is
cost-effectiveness perspective, ranging from US$26 to more cost-effective than supplementation for micronu-
US$39 per DALY averted across three studies. This find- trients where deficiencies are widely spread throughout
ing is driven in part by the high probability, as high as the population and the micronutrient is relatively
20 percent, that children will die if not treated. Initially, cheap, for example, iron; the opposite is true for micro-
programs cost as much as US$200 per child for a four- nutrients that are relatively more expensive, and where
month course of treatment; however, during the past the benefits are concentrated particularly in vulner-
decade or so the cost has declined by at least a third, able groups, for example, vitamin A. Biofortification
with greater program efficiency. Experience suggests appears to be very cost-effective, with some estimates
that substituting cheaper ready-to-use therapeutic food in the US$0 to US$20 range. However, the biofortifica-
for proprietary ones does not lead to outcomes that are tion estimates for staple food crops, such as rice, were
quite as good, although it may lower costs. All three early stage projections, and it remains to be proven
studies examined in this section used PlumpyNut, a whether these optimistic projections can be realized.
popular ready-to-use therapeutic food. There has been more success to date for more minor
crops (orange-flesh sweet potato, beans, and vitamin
Arich cassava), although iron-rich rice and wheat
Interventions for Infant and Young Child Growth seeds are now beginning to be disseminated to farmers
The majority (14) of the studies of nutrition for the (Harvest Plus 2013).
general population focus on micronutrient interven- The only intervention identified for nutrition educa-
tions, 1 on nutrition education, 1 on the effects of tion (Waters and others 2006) costs slightly more than
scaling up a comprehensive package of nutrition inter- US$100 per DALY averted; this was a modest-cost inter-
vention, and 1 on outcomes other than nutrition. No vention (US$6 per child in 2001 U.S. dollars). Estimated
new studies of cost-effectiveness were identified for costs per DALY averted for earlier, more elaborate inter-
breastfeeding. ventions were at least two to three times higher than the
Nutrition interventions are associated with impacts single case here.
on multiple outcomes of importance. Some nutrition Another innovation since 2000 has been the evalu-
interventions reduce morbidity and save lives in the more ation of packages of nutritional interventions. When
malnourished populations. In these cases, the outcomes interventions are combined, the cost-effectiveness of each
can be measured using cost-effectiveness methods, such individual component tends to become less attractive.
as deaths averted, LYS, QALYs saved, or DALYs averted. Either vitamin A supplements or measles immunization
In other cases, nutrition is associated with impacts on can save lives, but the combined effect of both vitamin
cognitive improvements, and these benefits are better A supplements and measles immunization saves fewer
measured using benefit-cost ratios because benefits can lives than the sum of the two individually. Bhutta, Das,
be measured in financial units (higher wages). Rivzi, and others (2013) estimate that the cost per DALY
From the literature search, five studies for folic averted of three components of a comprehensive nutri-
acid, iron, and iodine interventions all had very favor- tion interventionmicronutrients, nutrition education
able benefit-cost ratios (Horton, Alderman, and Rivera with selected supplements regarding infant and young
2008; Horton and Ross 2003, 2006; Sayed and others child feeding, and SAM managementranges from
2008; Sharieff, Horton, and Zlotkin 2006; Sharieff and US$240 to US$340 per DALY averted; this cost per DALY
others 2008). Hoddinott and others (2013) undertake a averted is three to five times higher than the cost per
benefit-cost analysis for a comprehensive set of nutrition DALY averted of the components introduced individu-
interventions. These studies cannot be compared with ally. Hoddinott and others (2013) use the same interven-
those using DALY outcomes without assigning a dollar tion package and estimate that the median benefit-cost
value to DALYs, a task that involves judgments about the ratio is 35 to 1 for a group of 17 LMICs for interventions
value of human life. provided to children.
Cost-Effectiveness of Interventions for Reproductive, Maternal, Neonatal, and Child Health 327
Bartlett and others (2014) use the LiST to model the Information on RMNCH unit costs comes from
effect of scaling up an integrated midwifery, obstetrics, a large selection of literature published primarily after
and family planning intervention in 58 LMICs. They 2007. The review assessed the quality of cost data found
conclude that scaling up any of the three individually is in 146 articles and chose to liberally include unit costs
attractive in cost per death averted, but that scaling up if the data sources and methods were clearly explained
midwifery combined with family planning costs half as (Levin and Brouwer 2014). Unit costs vary substan-
much per death averted as scaling up obstetrics com- tially across country settings for similar interventions.
bined with family planning; the lowest cost per death In addition, a variety of methodological approaches
averted occurs when all three are scaled up together. confound the expected variation in costs due to country
Midwifery saves lives across the continuum of prepreg- context and different choices of interventions evaluated.
nancy, prenatal, delivery, and neonatal care; obstetrical Identifying sources of heterogeneity is challenging
care has a strong effect on mortality during delivery. because many studies lack detailed information on
The only cost-effectiveness study undertaken for resource use and how costs were estimated (Crowell
Integrated Management of Childhood Illness finds that and others 2013; Pegurri, Fox-Rushby, and Walker 2004;
mortality was lower in the intervention district than Shearer, Walker, and Vlassoff 2010; Walker and others
in the control, and the costs were no higher and possi- 2004).
bly lower (Armstrong-Schellenberg and others 2004). In some areas in which cost or cost-effectiveness
However, experience was not uniformly positive in other studies have been conducted and published dating back
effectiveness trials, and there have been some difficulties to the 1990s, representative and standardized data on
scaling up this intervention. No cost-effectiveness stud- long-running interventions, such as vitamin A or iron
ies were identified on the Integrated Management of capsule supplementation or food-based strategies, is
Neonatal and Child Illness (IMNCI) or integrated com- surprisingly lacking despite consistent calls for improved
munity case management. Prinja and others (2013) note information on the costs and cost-effectiveness of nutri-
that even though overall health expenditures per case did tion interventions (Fiedler and Puett 2015; Gyles and
not increase as IMNCI was implemented, there was an others 2012; Morris, Gogill, and Uauy 2008; Ruel 2001;
increase from the perspective of the government, which Ruel, Alderman, and the Maternal and Child Nutrition
they estimate to be 1 percent to 1.5 percent of the gov- Study Group 2013). Similarly, in the area of family
ernments health budget (US$0.61 to US$2.60 per child planning, for which effective coverage of modern con-
covered), depending on which field workers implement traceptive use still lags, little new information is available
the program. The additional costs arose because the pro- on country-level costs of scaling up interventions to
gram was effective, which led to increased utilization as increase the supply of and demand for services (Singh,
households switched from using private health providers. Darroch, and Ashford 2014).
In general, average unit costs are relatively low for
family planning interventions, antenatal care visits for
COSTS
pregnant women, and normal deliveries at home or at
The country setting, type and level of the facility, severity health centers with trained birth attendants. Unit costs
of the event, and specific treatment offered influence tend to increase with the complexity of the service.
costs. Service delivery platforms that reach large num- For example, clinic-based breastfeeding support and
bers of beneficiaries close to their homes increase the prevention of micronutrient deficiencies are inexpen-
coverage and lower the cost of services. Child health sive, compared with home visits and peer counseling
days in Ethiopia, Somalia, and Zambia offer a package to support breastfeeding and optimal child feeding or
of preventive services that cost US$1 to US$2 per child community-based treatment of SAM. Treatment of
reached; facility-based integrated care offering similar febrile illness and diarrheal disease are less expensive
services is closer to US$10 per child treated and may be per child (US$20 to US$100) than treatment of pneu-
as high as US$20, as in Brazil (Adam and others 2005; monia and meningitis, which typically require inpatient
Adam and others 2009; Bryce and others 2005; Fiedler admission (US$150 per visit, or US$800 per child treated
and Chuko 2008; Vijayaraghavan and others 2012). For for pneumonia; US$300 to US$500 for inpatient care).
many interventions, effective and cost-effective interven- Although the treatment of diarrhea is typically between
tions exist but suffer from low uptake or coverage. Many US$2 and US$20 per visit for outpatient visits, treat-
of the studies that present specific costs of facility-based ment costs can be much higher and more variable when
programs do not capture the shared health system costs inpatient hospital care is required.
or costs of demand creation to increase access to and use Other interventions for which affordability is an
of services. issue, and has likely slowed the rate of scale up, include
Cost-Effectiveness of Interventions for Reproductive, Maternal, Neonatal, and Child Health 329
a time series for this price index. The resulting limita- 1. Note that the WHO uses the term DALY to mean the
tion is that none of those studies could be included here loss of a healthy year of life; hence, deaths and DALYs are
because they could not be updated to 2012 U.S. dollars. bad things that health interventions try to avert, whereas
For some interventions, particularly the nutrition ones, life-years and Quality-Adjusted Life Years are good things
that health interventions try to save (Health Statistics
benefits include improved quality of life rather than lives
and Information Systems: Metrics: Disability-Adjusted
saved, and a benefit-cost analysis is a more appropriate
Life Year [DALY]). http://www.who.int /healthinfo
methodology than cost-effectiveness. These and other /global_burden_disease/metrics_daly/en/).
methodological issues are addressed at more length in
volume 9 of this series.
A larger unresolved issue is that of the DALY measure
itself. More studies surveyed here used the discounted
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335
Figure 18.1 Newborn, Infant, and Child Mortality in India, 19902015 (Ministry of Health and Family Welfare 2011). The
ASHAs provide essential newborn care, particularly for
140
preterm and low-birth-weight infants; identify illnesses;
120 refer sick infants to health facilities; and provide infor-
Mortality rates per 1,000 births
Structure of Indias health system constitute the largest group of CHWs in the world
Indias primary care network consists of two types of (Perry and Zulliger 2012) and presently cover about
institutions: primary health subcenters and primary 60 percent of villages in rural India (IIPS 2010).
health centers. As of March 2014, India had 152,326 ANMs are posted at health subcenters and earn
primary health subcenters and 25,020 primary monthly salaries as employees of local health depart-
health centers (Health Management Information ments. They are responsible for providing treatment
System 2014). Subcenters are established at the rate for basic ailments; antenatal, postnatal, and delivery
of one per 5,000 people in most areas, and one per care; family planning services; and immunization
3,000 people in hilly, tribal, or remote areas. of children (Mavalankar and Vora 2008). Each
Types of Community Health Workers ANM is typically supported by three to five ASHAs
India has three main types of female community in carrying out these tasks (Sharma, Webster, and
health workers (CHWs) supporting child health: Bhattacharyya 2014).
accredited social health activists (ASHAs), auxiliary Anganwadi workers were introduced under the
nurse midwives (ANMs), and nutrition workers Integrated Child Development Scheme of 1975,
known as Anganwadi workers. a large-scale supplementary nutrition program
ASHAs were introduced in 2005 as part of the for pregnant women and young children. The
National Rural Health Mission, to serve a population Department of Women and Child Development
of 700 in tribal areas and 1,000 in rural villages. An employs them, and their primary focus is on
ASHA is typically a woman residing in the village, providing supplementary nutrition under the
reporting to the local ANM. Her primary responsi- scheme. However, they also provide health educa-
bilities are to improve health awareness in the local tion services, immunizations, and health check-ups
communities while facilitating the use of health care (Shashidhar 2012).
services (including antenatal and postnatal care and Although there is considerable overlap in the func-
ushering pregnant women to nearby health facilities tions of these three groups of CHWs, this study
at the time of delivery). She is also expected to track evaluates the rollout of home-based neonatal care
pregnant women and newborn children from the through the ASHA network because they are closest
village. ASHAs are not paid a salary but receive allow- to the communities and most suited to providing
ances based on tasks performed. The 800,000 ASHAs home-based care.
cost per disability-adjusted life year (DALY) averted Such economic shocks may have a lasting intergen-
(Brouwer and Koopmanschap 2000; Garber and Phelps erational effect if they reduce resources available to
1997; Jamison and others 2006; WHO 2003). children (Dillon 2012; Sun and Yao 2010). Free or subsi-
CEAs are relatively simple in application, but do dized health interventions can potentially prevent such
not include the nonhealth benefits of interventions. economic shocks.
Adverse health events in low- and middle-income Although the literature on economic impacts of new-
countries (LMICs) are often associated with economic born morbidity is limited, several studies have shown
hardship (ODonnell and others 2008; van Doorslaer that the financial burden of care is significant (Asian
and others 2006, 2007; Wagstaff 2008). Households Development Bank 2012). Bonu and others (2009) find
experiencing health shocks may need to finance health that 16 percent of households incur catastrophic expen-
care costs through out-of-pocket (OOP) expenditures, ditures of more than 10 percent of annual household
which may lead to borrowing or selling of assets, thereby consumption for antenatal and postnatal care in India.
causing impoverishment (Gertler and Gruber 2002; Complications caused by hemorrhage, sepsis, and dys-
Kruk, Goldmann, and Galea 2009; Wagstaff 2007). tocia were associated with 15 percent to 34 percent of
The Benefits of a Universal Home-Based Neonatal Care Package in Rural India: An Extended Cost-Effectiveness Analysis 337
total household expenditures in Benin and 5 percent to Data and Methods
8 percent in Ghana (Borghi and others 2003). We extract information on disease epidemiology from
Therefore, the impoverishing effects of newborn mor- existing studies; table 18.1 presents these input param-
bidity should not be ignored; the economic benefits of an eters and the interventions in our analysis. The lack of
intervention need to be incorporated into priority-setting recent disease data presents a significant challenge in
methodologies. Other methodologies, such as cost- generating health and economic estimates that we over-
consequence analysis and benefit-cost analysis, attempt to come in two ways.
incorporate the nonhealth benefits of health interventions; First, some of the parameters have been revised based
but these approaches are computationally intensive and on current conditions. For example, a newborns risk
do not explicitly capture the financial risk protection that of suffering from high-risk morbidity, such as sepsis,
interventions provide. congenital anomaly, or birth asphyxia, was observed to
In this study, we apply the method of extended be 48.2 percent by Bang and others (2001). This risk is
cost-effectiveness analysis (ECEA) to estimate the eco- likely to have changed significantly since the 1990s; there-
nomic benefits, in addition to health gains, of health fore we assume that the baseline probability that a neo-
interventions (Verguet, Laxminarayan, and Jamison nate suffers from high-risk morbidity equals 28.3 percent,
2014). ECEA has been used to examine the impacts of based on the most recently available neonatal mortality
publicly financed interventionsfor example, tubercu- rate of 29.2 per 1,000 live births in India (UN IGME
losis treatments in India (Verguet, Laxminarayan, and 2014). We continue to use the case fatality rate of 10.3 per-
Jamison 2014) and rotavirus vaccinations in India and cent from severe morbidity (Bang and others 1999) on
Ethiopia (Verguet and others 2013)and thus to mea- the assumption that the underlying mortality risk after
sure the distributional consequences of interventions contracting the disease is unlikely to have changed signifi-
on the health and financial outcomes for a population. cantly, even with progress in access or improved economic
Similarly, we measure the health benefits of scaling up conditions. Furthermore, because of the lack of disease
the HBNC package in India by the resulting reductions data disaggregated by population subgroups, we make the
in newborn morbidity and mortality. The economic simplifying assumption that the incidence and mortality
benefits are measured from the perspective of health rates are the same across all income quintiles.
systems accounting, that is, the amount of OOP private Second, recognizing the uncertainty surrounding
medical expenditures and associated financial risk that the true morbidity and mortality risks of newborns, we
could be averted by the HBNC.
Table 18.1 Disease, Treatment, and Newborn Care Package Intervention Parameters for Community Health
Worker Analysis
Parameter type Value Sensitivity analysis Source
Disease parameters Disease: Newborn morbidity
Incidence 0.283 0.1980.369 Based on NMR (UN IGME 2014)
Case fatality rate 0.103 0.0720.134 Bang and others 1999
Treatment parameters Treatment: Intensive care treatment
Demand for treatment (%) 75.00 52.5097.50 Assumed
Cost of treatment (US$) 108.97 76.28141.66 Prinja, Manchanda, and others 2013
Intervention parameters Intervention: Home-based newborn care as defined in Bang and others (2005)
Baseline coverage of intervention (%) 0 n.a. Assumed
Baseline coverage of ASHA workers (%) 54 n.a. IIPS 2010
Cost at 54% coverage (US$) 5.89 per neonate 4.127.66 Prinja, Mazumder, and others 2013
Cost at 83% coverage (US$) 6.54 per neonate 4.588.50 Prinja, Mazumder, and others 2013
Risk reduction in incidence 0.5035 0.35200.6550 Bang and others 2005
Risk reduction in mortality 0.540 0.3780.702 Kumar and others 2008
Note: ASHA = accredited social health activist; DLHS = District Level Household Survey; NMR = newborn mortality rate. n.a. = not applicable.
The Benefits of a Universal Home-Based Neonatal Care Package in Rural India: An Extended Cost-Effectiveness Analysis 339
on the efficacy literature available for the target country. network of ASHA workers were utilized with a coverage
In addition to health outcomes, we estimated economic rate of 54 percent of the population, the corresponding
benefits of the HBNC including incremental OOP reduction in incidence of morbidity and deaths would
expenditures averted and the money-metric value of be 805,000 (95 percent uncertainty range 477,000 to
insurance provided. For simplicity, we only considered 1,218,000) and 89,000 (95 percent uncertainty range
OOP expenditures related to treatment expenditure for 44,200 to 149,100), respectively, compared with the
newborn morbidity. Higher levels of access to HBNC are baseline. Extending the coverage of the care package
likely to lower the incidence of morbidity, reducing the in scenario 2 could avert a total of 1.25 million cases
need for treatment and associated expenditure. (95 percent uncertainty range 750,000 to 1,950,000)
The money-metric value of insurance is a metric of newborn morbidity and 138,000 deaths (95 percent
that measures the financial protection provided by the uncertainty range 76,400 to 244,100) compared with the
HBNC package. It estimates the risk premium, that is, baseline (figure 18.2). Even at a more conservative effi-
the amount of money an individual is willing to pay to cacy rate of 34 percent on mortality based on Baqui and
avoid an ailment. To calculate the value of insurance, others (2008), we found that the package averts 55,900
we started with a mean per capita gross domestic prod- deaths (95 percent uncertainty range 34,700 to 85,100)
uct (GDP) in India of US$1,489 (in 2013 U.S. dollars) when scaled up to the present ASHA coverage level, and
(World Bank World Development Indicators). 86,800 deaths (95 percent uncertainty range 49,000 to
We used a constant relative risk aversion utility 130,000) when scaled up in scenario 2.
y 1 The financial benefits of the estimated health reduc-
function of the form u( y ) = with a coefficient of tions are significantly large as well. At US$108.97 for
1
relative risk aversion of r = 3 (McClellan and Skinner newborn intensive care (Prinja, Manchanda, and others
2006). The probability of receiving treatment for a dis- 2013), the OOP expenditures averted by the care package
ease is denoted by r(y), a function of income. Therefore, amount to US$66 million (95 percent uncertainty range
the expected value of income will be as follows: $35 million to $106 million) at the existing ASHA cov-
erage, and US$102 million (95 percent uncertainty range
E(y) = (1 r)y + r(y c), (18.1) $51 million to $182 million) under intervention scenario 2.
At a relative risk averseness coefficient of 3 and income
in which c denotes the OOP cost of treatment. The cer- per capita of US$1,489, we estimate that the financial risk
tainty equivalent of this expected income, denoted by protection (value of insurance) afforded by the HBNC
y* is as follows: package amounts to US$474 (95 percent uncertainty
range $222 to $885) per 1,000 births in the cohort within
existing ASHA coverage levels, and US$826 (95 percent
y * = u 1[(1 r )u( y ) + ru( y c )]
(18.2) uncertainty range $351 to $1,626) per 1,000 births when
1
1 1 1 scaled up further in the second intervention scenario.
= [(1 r ) y + r( y c) ] .
The financial burden of the newborn care package
The money-metric value of insurance denoted by v is on the government would amount to US$33 million
as follows: (95 percent uncertainty range $24 million to $42 million)
when the package is rolled out within the present ASHA
network, and US$53 million (95 percent uncertainty
v = E( y ) y * range $41 million to $66 million) when extended to
1 83 percent of the population in scenario 2. To put this
= [(1 r ) y + r ( y c ) [(1 r ) y 1 + r ( y c )1 ]1 . figure in context, the government allocated US$386.1
million (23.2 billion Indian rupees, assuming US$1 = 60
(18.3) Indian rupees) for all child health-related programs in
fiscal year 2013/14 (CBGA 2013).
The value of this package measured by costs per
death averted indicates that it is cost saving under both
scenarios (if we include the OOP expenditure averted).
RESULTS Otherwise, if we only consider programmatic costs
Table 18.2 reports the health and financial conse- and ignore OOP costs averted, the first intervention
quences of the HBNC package based on the disease and scenario extending the package to current ASHA worker
intervention parameters listed in table 18.1. For our levels costs US$373 per death averted from the baseline;
study cohort of neonates, we found that if the current the second scenario costs US$387 per death averted from
Figure 18.2 Estimated Impact of Home-Based Neonatal Care For the purpose of this analysis, we assumed that the
Package on the Incidence of Morbidity and Mortality government bears the full cost of the intervention and
1,400,000
expands coverage to either 54 percent or 83 percent of
the population that does not have access to care. The total
1,200,000 cost to the government under these two intervention
Incidence or deaths averted
The Benefits of a Universal Home-Based Neonatal Care Package in Rural India: An Extended Cost-Effectiveness Analysis 341
least one antenatal checkup during their entire period of report on universal health coverage has also emphasized
pregnancy (Baqui and others 2007). Furthermore, only such public financing (High Level Expert Group on
5 percent of women were informed about thermal care Universal Health Coverage 2011).
and breastfeeding. These alarming statistics highlight The following factors circumscribe the conclusions of
the need to improve health education for mothers and our study. Because data on HBNC are limited, we have
increase incentives to seek proper care through pro- relied on a research study conducted in 1996 for newborn
grams like Janani Suraksha Yojana. morbidity and efficacy of interventions in a district of
In addition to improving the demand for care and India. Although this study is dated and localized, we over-
changing the practices of mothers, it is important to came the uncertainty in these estimates by conducting a
focus on improving health care delivery channels. The rigorous sensitivity analysis. The estimates of this model
quality of training provided to ASHAs, motivation levels, would be enriched by the availability of geographic or
and remuneration of workers are factors that contribute economic segmentation in the data on incidence and
to the effectiveness of the intervention and influence its mortality to provide an understanding of the distribu-
uptake among the population (Bang and others 1999). tional consequences of the intervention. As a result of
The challenges of delivery were highlighted by a recent the absence of such data, we were unable to estimate the
situational analysis of the new HBNC program in Uttar equity impacts of the HBNC intervention and account
Pradesh. The assessment found that ASHAs failed to for any spatial or economic heterogeneity, such as costs or
identify critical signs and did not follow program income, in our results. Furthermore, differences in qual-
guidelines. Furthermore, they were misclassifying sick- ity of interventions or factors that could affect behavioral
ness categories of a staggering 80 percent of newborn responses to the intervention were not included. A more
children (Das and others 2014). dynamic model could capture these heterogeneities.
Based on available evidence on the efficacy of the Despite these limitations, our analysis takes an
interventions, our results indicate that expanding the important step toward highlighting the overall magni-
HBNC package within the current network of ASHA tude of health and economic benefits provided by the
workers to 54 percent and further expanding it to 83 HBNC for the welfare of Indias newborn population.
percent would significantly prevent newborn morbidity, Further research on the role of community worker train-
extend the lives of neonates, and yield significant finan- ing and supervision, the health system in which they
cial risk protection. Considering that newborn mortality operate, and community mobilization would lead to a
constitutes 71 percent of infant mortality and 56 percent broader understanding about the impacts of home- and
of mortality under age five years in India (UN IGME community-based interventions in improving newborn
2014), the HBNC has tremendous potential to lower survival in a variety of conditions.
NMR in India. Recognizing this potential and its ability
to overcome the demand-side barriers to accessing post-
natal care at health facilities, HBNC was recommended NOTES
as the primary strategy for combating NMR by the
World Bank Income Classifications as of July 2014 are as
Eleventh Five-Year Plan of India (200712) (Planning follows, based on estimates of gross national income (GNI)
Commission of India 2008). per capita for 2013:
Furthermore, expanding coverage of the HBNC is in
complete alignment with the objectives of continuum of Low-income countries (LICs) = US$1,045 or less
care as outlined in Indias Newborn Action Plan (2014) Middle-income countries (MICs) are subdivided:
a) lower-middle-income = US$1,046US$4,125
which aims to reduce preventable newborn deaths and
b) upper-middle-income (UMICs) = US$4,126US$12,745
stillbirths. It is also in harmony with the future goals High-income countries (HICs) = US$12,746 or more.
of universal health coverage in India. The 2010 World
Health Report (WHO 2010) outlines the need for public 1. By comparison, the average NMR among countries in the
financing of health interventions in the developing world same economic category as India (lower-middle-income)
to reduce OOP private medical expenditure and protect is 20.7 per 1,000 live births.
2. In 1990, Indias NMR was 51.1 per 1,000 live births, which
vulnerable populations from catastrophic health shocks
declined to 29.2 in 2013 (UN IGME 2014).
in an equitable way. The report also highlights the need 3. Unless otherwise specified, all cost data in our analysis are
to ensure that interventions are prepaid (through some in 2013 U.S. dollars.
form of progressive taxation), to enable the poor and 4. In 2013, 68 percent of Indias total population of 1.252
the sick to benefit from the implicit subsidy provided billion was rural.
to them by rich and healthy population groups through 5. In a traditional CEA framework, priority setting is based
such a mechanism. The Indian Planning Commissions on the health benefits of an intervention, measured by
The Benefits of a Universal Home-Based Neonatal Care Package in Rural India: An Extended Cost-Effectiveness Analysis 343
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Corresponding author: Stphane Verguet, Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts,
United States, verguet@hsph.harvard.edu.
345
In 2013 in Ethiopia, about 60,000 children under The coverage of child health care services
age five years died as a result of pneumonia or diarrhea, remains very low compared with other low- and
the fifth-highest absolute level worldwide (IVAC 2013). middle-income countries (LMICs) (WHO 2015).
Studies have associated the incidence of both conditions According to Ethiopias 2011 Demographic and Health
with socioeconomic status (Fekadu, Terefe, and Alemie Survey (DHS) (Central Statistical Agency and ICF
2014; Mihrete, Alemie, and Teferra 2014), suggesting International 2011), coverage of measles vaccine, pen-
that an evaluation of the impact of prevention and tavalent 3 (third dose of diphtheria, pertussis, tetanus,
treatment services by income quintile would be suitable. Haemophilus influenzae type b, and hepatitis B vac-
This chapter uses ECEA methods to examine UPF of cines), care-seeking for acute respiratory infection, and
the prevention and treatment of pneumonia and diarrhea care-seeking for diarrhea were 56 percent, 35 percent,
in Ethiopia, with a focus on children under age five years. 27 percent, and 32 percent, respectively. Inequities in
The combination of prevention and treatment options child mortality and access to care between urban and
illustrates health and FRP benefits brought by the different rural dwellers and across wealth quintiles remain large.
intervention packages available to decision makers. This According to Ethiopias 2011 DHS, infant mortality is
analysis also examines these benefits by income quintile 29 percent higher in rural areas than in urban areas.
so that policy makers can better understand how each The urban-rural difference is even more pronounced
package affects different segments of the populationa for mortality in children under age five years, and up
critical element of UHC. A 20 percentage point increase in to 37 percent higher in rural areas than in urban areas.
coverage is modeled. Our purpose is to expose with sim- Furthermore, wide regional variations are observed
plicity the broad implications for policy makers rather than in mortality rates in infants and children, with more
to provide them with definitive estimates, hence the pre- than a twofold difference, for example, between Addis
sentation of limited rudimentary sensitivity analyses. After Ababa and Benishangul-Gumuz in the western part of
we summarize current child health services in Ethiopia, the country. In addition to the increased risk of diar-
we outline the methods used in this chapter, which draw rheal illnesses and pneumonia among children from
from the ECEA methodology (Verguet, Laxminarayan, the lowest wealth quintile, children from the wealthiest
and Jamison 2015). Then, we present resultsboth health quintiles were considerably more likely to receive care
and financial protectionfor the following: from health facilities or providers (Central Statistical
Agency and ICF International 2011).
Pneumonia treatment There are about 12 million children under age five
Combined pneumonia treatment and pneumococcal years in Ethiopia (table 19.1) and strong demographic
conjugate vaccination (PCV) and mortality disparities exist between the different
Diarrhea treatment wealth strata of the Ethiopian population (table 19.2).
Combined diarrhea treatment and rotavirus More specifically, strong inequalities in pneumonia- and
vaccination. diarrhea-related deaths can be observed in the country.
Using the Lives Saved Tool (LiST), a partial cohort
Finally, we discuss the implications of the findings model that projects mortality by age and cause of death
and conclude. using inputs on health status and intervention coverage
Disease-specific deaths
I (poorest) 6.0 137
II 5.7 121 8,000
III 5.3 96
6,000
IV 5.0 100
V (richest) 2.8 86
4,000
Source: Central Statistical Agency and ICF International 2011.
2,000
0
and effectiveness (Winfrey, McKinnon, and Stover
2011), and methods described elsewhere (Amouzou and 1 2 3 4 5
others 2010), we estimate total under-five deaths due to Income quintile (poorest to richest)
pneumonia and diarrhea by income group (figure 19.1). Deaths due to pneumonia Deaths due to diarrhea
Subsequently, we see that such disease-specific mortality
rates are about four times higher in the poorest quintile
than in the wealthiest quintile.
As in many low-income countries, government per extension workers (HEWs), who have completed tenth
capita spending on health in Ethiopia is very low at grade, are recruited from the same community and
about US$15 (WHO 2015). The national health policy trained in HEP modules for one year; upon comple-
strongly emphasizes fulfilling the needs of the under- tion of their training, they return home as salaried
served rural population, which constitutes 84 percent of frontline health care staff. The major goals of the
the total population. Ensuring health care accessibility HEWs are to provide communities and households
for the whole population is one of the main strate- with increased knowledge and skills regarding pre-
gic objectives of Ethiopias health sector development ventable diseases, accessible health services at health
program IV (201115) (Federal Democratic Republic posts, and facilitated referrals to health centers and
of Ethiopia 2010). The Ministry of Health envisages the hospitals.
health extension program (HEP) as a primary vehicle Ample evidence suggests that community health
for delivering critical and basic preventive and curative workers can identify, refer, or treat childhood illnesses
care to the community (Banteyerga 2011). The HEP is outside of health facilities (Bang and others 1999; Baqui
an innovative, community-based program that makes and others 2009; Bhutta and others 2005; Haines and
essential health services available at the grassroots others 2007). The HEWs have substantial potential to
level. It proposes a package of basic preventive and increase coverage of highly cost-effective child survival
curative health services that targets rural households interventions at the community level. Starting in 2011,
(Banteyerga 2011). the government of Ethiopia took an additional step and
HEP comprises the following four health subpro- allowed the HEWs to provide community case man-
grams, which correspond to the elements of primary agement of childhood pneumonia, malaria, and diar-
health care as defined in the Alma Ata Declaration rheal illnesses. The HEP offers an opportunity to scale
(WHO 1978): up child health services in Ethiopia and is expected to
narrow the gap between different income quintiles and
Disease prevention geographic locations.
Family health Despite the governments current attempt to pro-
Environmental hygiene and sanitation vide certain essential services free of chargeincluding
Health education and communication. those that relate to family health, communicable disease
control, hygiene and environmental sanitation, and
Every village with at least 1,000 householdsabout health education and communication34 percent of
5,000 residentsbuilds a health post. Two female health health expenditure is privately financed as of 2012
Health Gains and Financial Risk Protection Afforded by Treatment and Prevention of Diarrhea and Pneumonia in Ethiopia 347
(WHO 2012). This expenditure consists of house- METHODS
holds direct outlays, including gratuities and in-kind
payments, for health services. Extended Cost-Effectiveness Analysis
To prevent deaths from pneumonia and diarrhea, ECEA (Verguet, Gauvreau, and others 2015; Verguet and
the two biggest killers for those younger than age five Jamison 2015; Verguet, Laxminarayan, and Jamison 2015;
years in Ethiopia (Liu and others 2012), preventive Verguet, Olson, and others 2015; Verguet and others
and curative interventions must be intensified to 2013) expands on the standard approach to economic
reach all segments of the population. Establishing evaluation proposed by CEA, by evaluating aspects of
healthy environments to protect children from health policies that are important for policy makers.
pneumonia and diarrhea, and increasing access to Specifically, in addition to health benefits, ECEA estimates
cost-effective interventions for both prevention and the impact of policies along three dimensions: (1) house-
treatment, will greatly reduce mortality rates from hold out-of-pocket (OOP) expenditures averted by the
those conditions. Although little work has examined policy, (2) FRP benefits provided, and (3) distributional
the cost-effectiveness of pneumonia and diarrhea consequences (for example, according to socioeconomic
interventions in an Ethiopian or other low-income status or geographical setting). Thus, this study exam-
setting (Kim and others 2010; Laxminarayan and ines provision of diarrhea and pneumonia interventions
others 2006; Rheingans, Atherly, and Anderson within the broader framework of UPF. The broader
2012; Sinha and others 2007), efficacious rotavi- household financial consequences of publicly financed
rus and PCVs have been licensed (Fischer Walker prevention and treatment interventions could then be
and Black 2011; Theodoratou, Johnson, and others analyzed, evaluating their impact on the reduction of
2010). Treatment interventions for pneumonia (for household OOP expenditures and FRP. The distribu-
example, community case management with antibi- tional impact is also considered across income quintiles,
otics) and diarrhea (for example, oral rehydration highlighting the equity potential of UPF.
salts) have proven to be effective (Munos, Fischer
Walker, and Black 2010; Theodoratou, Al-Jilaihawi, Interventions Analyzed
and others 2010). Evidence-based information on
the expected health, equity, and FRP outcomes for Pneumonia Treatment with Antibiotics
various diarrhea and pneumonia strategies is cru- We assume that current coverage of pneumonia treat-
cial for setting priorities. Verguet and others (2013) ment (antibiotics) across all income groups is increased
conducted a preliminary ECEA of public finance of by 20 percentage points (table 19.3). The average base-
rotavirus vaccination in Ethiopia that points to the line coverage of pneumonia treatment was 27 percent
substantial health benefits (such as deaths averted) before UPF. After UPF, coverage increases, on average, to
and FRP benefits (such as prevention of medical 47 percent. Health gains as measured by deaths averted
impoverishment) that would accrue to the poorest are calculated for the increase. We chose a 20 percentage
socioeconomic groups. point increase, a rather small increase, to capture a realis-
Here we use ECEA methods to evaluate the conse- tic scenario that can be achieved by the Ethiopian health
quences of UPF on health, equity, and impoverishment system. The effectiveness of pneumonia treatment also
for a hypothetical program targeting children under age drew on a meta-analysis of studies used for populating
five years in Ethiopia. This program would consist of LiST; community case management with antibiotics was
four interventions: found to reduce pneumonia-related deaths by 70 percent
(Theodoratou, Al-Jilaihawi and others 2010).
Epidemiology
Under-five deaths due to pneumonia in 2011, from 10,900; 11,000; 7,900; 6,800; 3,100 Authors calculations using LiST based on
poorest to richest (income quintiles 15) Amouzou and others 2010; Fischer Walker
and others 2013
Proportion of under-five pneumonia deaths attributed 33 percent Fischer Walker and others 2013
to pneumococcal disease
Interventions
Antibiotic effectiveness 0.70 Theodoratou, Al-Jilaihawi, and others 2010
Health Gains and Financial Risk Protection Afforded by Treatment and Prevention of Diarrhea and Pneumonia in Ethiopia 349
Table 19.3 Input Parameters Used for Analysis of Pneumonia Treatment and Combined Pneumonia Treatment and
Pneumococcal Conjugate Vaccination (continued)
Parameter Value Sources
Ethiopias gross domestic product per capita $360 World Bank 2013
Ethiopias Gini index 0.3
McClellan and Skinner 2006; Verguet,
y 1r
Utility function as a function of individual income y with r = 3 Laxminarayan, and Jamison 2015
1 r
(r = coefficient of relative risk aversion)
Note: LiST = Lives Saved Tool; PCV = pneumococcal conjugate vaccine; UPF = universal public nance.
a. Severe infections and hospitalizations were not included.
others 2010). We found no studies reporting serotype the product of the baseline number of diarrhea deaths,
distribution in Ethiopia. Our estimates of the efficacy the increase in treatment coverage, and the effectiveness
of PCV-13 come from clinical trials (Black and others of treatment.
2000; Cutts and others 2005; Hsu and others 2009) and
from a meta-analysis of PCV-9 and PCV-11 used for Combined Diarrhea Treatment and Rotavirus
populating LiST, where all-valent PCV was found to Vaccination
reduce radiologically confirmed pneumonia by 26 per- As a complement to the scale up of diarrhea treatment,
cent (Theodoratou, Johnson and others 2010). we assume that UPF scales up rotavirus vaccination
To estimate pneumococci deaths averted33 per- from 0 percent to 20 percent coverage across income
cent of all pneumonia deaths are due to pneumococci groups (table 19.4) to mimic coverage achievable by the
(Fischer Walker and others 2013)the model follows Ethiopian health system.
the current Ethiopian birth cohort. Depending on After determining the baseline number of diarrhea
disease-specific mortality (pneumonia, meningitis, non- deaths by income quintile, we attribute 27 percent of
pneumonia nonmeningitis), we estimated intervention diarrhea deaths to rotavirus (Fischer Walker and others
coverage, intervention effectiveness, and reductions in 2013). This yields the number of rotavirus-attributable
disease-specific deaths in each income group. This static deaths by income quintile (table 19.4). Although esti-
approach does not capture epidemiological changes mates of vaccine efficacy vary in Sub-Saharan Africa
such as herd immunity and serotype replacement from and by strain, we use an effectiveness of 50 percent
vaccination, which could be captured more fully in, for taken from a meta-analysis (Fischer Walker and Black
example, a dynamic transmission model. However, the 2011) and assume it prevented visits to health facil-
extent of such indirect effects on the nonvaccinated pop- ities as well as mortality (Verguet and others 2013).
ulation is unclear, leading to their exclusion from this Specifically, to estimate rotavirus deaths averted, the
analysis (Weinberger, Malley, and Lipsitch 2011). model follows the current Ethiopian birth cohort;
rotavirus deaths averted are the product of baseline
Diarrhea Treatment with Oral Rehydration Salts rotavirus deaths, vaccine coverage, and vaccine effec-
Oral rehydration salts (ORS) are evaluated as a treat- tiveness (Verguet and others 2013). This static approach
ment for diarrhea in this analysis. To determine the is unable to capture epidemiological changes such as
number of deaths averted by UPF of ORS, we assume herd immunity, which has only been documented in a
a 20 percentage point increase in treatment-seeking few countries (Buttery and others 2011; Tate and others
above the level reported for each income quintile in the 2011; Yen and others 2011).
DHS (Central Statistical Agency and ICF International
2011). We also assume ORS is 93 percent effective in
preventing deaths from diarrhea, following estimates Treatment Expenditures Averted
based on a systematic review from the Child Health Household private expenditures averted through
Epidemiology Reference Group (Munos, Fischer Walker, UPF of vaccinations are calculated differently than
and Black 2010). Deaths averted by income quintile are for treatment. Vaccine interventionrelated private
Epidemiology
Under-five deaths due to diarrhea in 2011, from poorest to 8,100; 7,100; 4,900; Authors calculations using LiST based on Amouzou
richest (income quintiles 15) 4,100; 1,100 and others 2010; Fischer Walker and others 2013
Proportion of under-5 diarrhea deaths attributed to rotavirus 27% Fischer Walker and others 2013
Interventions
ORS effectiveness 0.93 Munos, Fischer Walker, and Black 2010
Rotavirus vaccine effectiveness (per two-dose course) 0.50 Fischer Walker and Black 2011
Coverage of ORS, from poorest to richest (income quintiles 22%; 25%; 35%; 33%; Central Statistical Agency and ICF International 2011
15), before UPF 53%
Coverage of ORS, from poorest to richest (income quintiles 42%; 45%; 55%; 53%;
15), after UPF 73%
Coverage of vaccine, from poorest to richest (income quintiles 0%; 0%; 0%; 0%; 0% Central Statistical Agency and ICF International 2011
15), before UPF
Coverage of vaccine, from poorest to richest (income quintiles 20%; 20%; 20%; 20%;
15), after UPF 20%
Costs (2011 US$)
Hospitalization cost for diarrheaa $49 Stack and others 2011;
WHO-CHOICE 2014
Outpatient clinic visit cost for diarrhea $9 Stack and others 2011;
WHO-CHOICE 2014
Probability of hospitalization for diarrhea, from poorest to 0.02; 0.02; 0.01; 0.02; Authors calculations based on Central Statistical
richest (income quintiles 15) 0.01 Agency [Ethiopia] and ICF International 2011; and
Lamberti, Fischer Walker, and Black 2012
Probability of outpatient visit for diarrhea, from poorest to 0.22; 0.25; 0.35; 0.33; Central Statistical Agency and ICF International 2011
richest (income quintiles 15) 0.53
Rotavirus vaccine price (per vial, two doses needed) Gavi 2014
Base case $2.5
With Gavi subsidy $0.2
Vaccination system cost (per vial, two doses needed) $0.5 Griffiths and others 2009
Ethiopias gross domestic product per capita $360 World Bank 2013
Ethiopias Gini index 0.3
McClellan and Skinner 2006; Verguet, Laxminarayan,
y 1r
Utility function as a function of individual income y with r = 3 and Jamison 2015
1 r
(r = coefficient of
relative risk aversion)
Note: LiST = Lives Saved Tool; ORS = oral rehydration salts; UPF = universal public nance.
a. Severe infections and hospitalizations were not included.
Health Gains and Financial Risk Protection Afforded by Treatment and Prevention of Diarrhea and Pneumonia in Ethiopia 351
expenditures averted depend on the number of cases would prefer the certainty of insurance to the uncertainty
of a specific infection (a subset of total cases), vaccine or risk of possible OOP expenditures, and hence they
coverage, vaccine effectiveness, probability of seeking are willing to pay a certain amount of money to avoid
either inpatient or outpatient care in the absence of that risk.
the vaccine, and cost of inpatient and outpatient care. As explained in great detail in Verguet,
Details of the methods are given elsewhere (Verguet Laxminarayan, and Jamison (2015), to estimate
and others 2013). Before UPF is implemented, house- the FRP (for example, the money-metric value of
holds pay at a 34 percent level for inpatient and insurance) to an individual who is provided UPF,
outpatient care (the remaining 66 percent is covered we first estimate the individuals expected income
by the government) (WHO 2012). After UPF is imple- before UPF, depending on treatment coverage and
mented, individuals would pay 0 percent for inpatient associated costs. We then estimate the individuals
and outpatient care, and the government would pay certainty equivalent by assigning individuals utility
100 percent of the costs. functions that specify their risk aversion (tables 19.3
and 19.4), which is equivalent to calculating their
willingness to pay for insurance against risks of med-
Government Costs ical expenditures. This certainty equivalent reflects
Government costs due to UPF of the vaccine also dif- the final income that individuals are willing to accept
fer from those for treatment. Government costs for to make the outcome certain. Finally, we derive a
the vaccine are based on the size of the birth cohort, money-metric value of insurance provided (risk pre-
vaccine coverage, the costs of the vaccine itself, and the mium) as the difference between the expected value
associated system costs of delivery. Because the vaccine of income and the certainty equivalent (Brown and
also averts future government treatment costs, these Finkelstein 2008; Finkelstein and McKnight 2008;
averted costs are subtracted from the cost of delivering McClellan and Skinner 2006; Verguet, Laxminarayan,
the vaccine to estimate the net costs of the combined and Jamison 2015). Aggregating the money-metric
treatment-vaccine interventions from the governments value of insurance provided using an income distribu-
perspective. tion in the population (with a proxy based on country
Government costs for diarrhea and pneumonia gross domestic product per capita and Gini coefficient
treatment include 66 percent of the costs for inpatient [Salem and Mount 1974]) yields a dollar value of FRP
and outpatient care for currently covered households, at the societal level.
plus 100 percent of the costs for inpatient and outpatient All mathematical derivations used are presented in
care for the 20 percentage point increment in coverage. annex 19A. All calculations are estimated using the R
statistical software (www.r-project.org).
1,500
800
1,000 600
400
500
200
0 0
Income quintile (poorest to richest) Income quintile (poorest to richest)
160
140
120
100
80
60
40
20
0
Income quintile (poorest to richest)
Pneumonia treatment Pneumonia treatment and
pneumococcal vaccine
Health Gains and Financial Risk Protection Afforded by Treatment and Prevention of Diarrhea and Pneumonia in Ethiopia 353
averted and FRP. The poorest would have, in absolute Program Costs
terms, the lowest private expenditures averted but the The total costs of scaling up pneumonia treatment
highest FRP. This outcome occurs because the poorest by 20 percentage points across all income groups
quintile would have substantially lower disposable income (and of providing UPF for those who currently have
than the richest in absolute terms; therefore the change in access to pneumonia treatment) would be approxi-
income due to the interventions would be much higher. mately US$49.6 million. The costs of the combined
To illustrate the results per dollar of expenditure, an treatment-vaccine package vary substantially, depend-
arbitrary budget constraint of US$1 million is introduced ing on the vaccine price and Gavi eligibility. The total
(figure 19.3). The two dimensions of health gains and costs of the combined pneumonia treatment and
FRP afforded (measured by a money-metric value of PCV package would be approximately US$56.1 million
insurance) are given for the five income groups, for UPF (88 percent of which is for pneumonia treatment,
of pneumonia treatment, and UPF of combined pneu- 12 percent of which is for pneumococcal vaccine) based
monia treatment and PCV. Per dollar expenditure, the on a vaccine price of US$3.50 per dose, which is the
combined treatment-vaccine package would save slightly market price currently paid by Gavi. If the fully Gavi-
more lives compared with treatment alone. However, the subsidized cost of US$0.20 per dose were to be used, the
FRP afforded would be slightly reduced in each quintile. total cost of the combined treatment-vaccine package
This slight reduction in FRP, when vaccines are added, is would be US$50.6 million. Regardless of vaccine price,
due to the fact that vaccines provide less FRP per dollar more of the combined treatment-vaccine program fund-
spent than treatment. In particular, vaccines protect only ing would go to the richest groups of the population,
against pneumococcal pneumonia, whereas full public since they are expected to have higher utilization rates.
finance of treatment is more targeted. In both instances,
health and FRP benefits would disproportionally aid the
poorest income groups given that both the health and Diarrhea Treatment and Combined Diarrhea Treatment
FRP benefits would be substantially larger in the poorest and Rotavirus Vaccination
income quintile than in the richest income quintile. Deaths Averted
UPF for diarrhea treatment would avert 4,700 deaths each
year. Combined diarrhea treatment and rotavirus vaccina-
Figure 19.3 Health Benefits and Financial Risk Protection Afforded from tion would avert 5,400 deaths each year. Yet, 20,000 diar-
Investing $1 Million in Pneumonia Treatment and Combined Pneumonia rhea-related deaths would still occur; of these, 6,000 would
Treatment and Pneumococcal Vaccination occur in the poorest income quintile (figure 19.4, panel a).
3,500 I
OOP Expenditures Averted
I On an annual basis, UPF for diarrhea treatment would
3,000 avert US$43.8 million of OOP expenditures. It would
also provide insurance valued at US$93,000 at a cost of
Financial risk protection (US$)
6,000
1,000
4,000
500
2,000
0 0
Income quintile (poorest to richest) Income quintile (poorest to richest)
50
40
30
20
10
0
Income quintile (poorest to richest)
Diarrhea treatment Diarrhea treatment and rotavirus
vaccination
Program Costs would provide about US$1,000 in FRP benefits per US$1
Diarrhea treatment would save lives at a cost of approxi- million spent (figure 19.5). Combined diarrhea treat-
mately US$21,000 per death averted; combined diarrhea ment and rotavirus vaccination would avert 52 deaths
treatment and rotavirus vaccination would save lives at and US$430,000 in private expenditures averted per
an approximate cost of US$19,000 per death averted. If US$1 million spent.
we view these results per US$1 million spent, diarrhea These results provide two outstanding messages.
treatment would avert approximately 47 deaths and First, diarrhea treatment and combined diarrhea treat-
US$430,000 in private expenditures. Diarrhea treatment ment and rotavirus vaccination provide similar FRP
Health Gains and Financial Risk Protection Afforded by Treatment and Prevention of Diarrhea and Pneumonia in Ethiopia 355
Figure 19.5 Health Benefits (deaths averted) and Financial Risk poorest tend to gain more FRP benefits because their
Protection Afforded (Measured in 2011 US$) from Investing US$1 Million incomes are lower, and the marginal value of the reduc-
of Public Expenditures on Diarrhea Treatment and Combined Diarrhea tion of risk is of lower value for the wealthier quintiles.
Treatment and Rotavirus Vaccination
700
DISCUSSION
600 I I
This chapter illustrates the potential broader benefits of
Financial risk protection (2011 US$)
300
Main Findings
200 II II UPF for pneumonia treatment and for combined pneu-
monia treatment and PCV would provide substantially
100 IV higher FRP for the poor and save more lives for the
III III
IV poor. Similar results are seen for UPF for diarrhea
VV treatment and for combined diarrhea treatment and
0
rotavirus vaccine.
0 5 10 15 20 25
This analysis also highlights the role that orga-
Deaths averted nizations such as Gavi can play. In particular, for
Diarrhea treatment Diarrhea treatment and rotavirus vaccination rotavirus and pneumococcal vaccines, both health
and FRP benefits of the combined packages could be
Note: Results are shown for ve income quintiles (I is poorest; V is richest).
enhanced if Gavi were to fully subsidize the vaccine
prices to the Ethiopian government so that the gov-
ernment paid $0.20 per dose (tables 19.5 and 19.6).
benefits per income group, and combined diarrhea Although interesting in its own right, this situation
treatment and rotavirus vaccination averts more deaths may become a practical concern if Gavi support were
than diarrhea treatment alone. Second, the scale of the to expire. Acknowledgment of these altered benefits is
FRP benefits provided by UPF is small relative to the important when considering Gavi eligibility and the
health benefits and private expenditures averted. sustainability of the inclusion of vaccine interventions
The numbers provide important information on the in benefits packages. This issue is particularly compel-
overall impacts of these interventions. However, it is ling when a strong rationale, such as equity, supports
also critical to view the results through the equity lens an intervention that a country may not implement
to understand the effects of UPF. The figures show how under current incentives.
an investment of US$1 million in UPF in these inter- Although this analysis focuses on Ethiopia, the
ventions is distributed throughout the population. With findings may also speak to the value of these interven-
regard to deaths averted, both diarrhea treatment and tions in other countries facing similar coverage gaps
combined diarrhea treatment and rotavirus vaccination and mortality burdens related to diarrhea and pneu-
generally provide greater benefits to the poor. A major monia. Ethiopia is one of 15 countries that account
reason that both packages benefit the poorest is the for 75 percent of the worldwide child deaths from
higher burden of diarrheal disease among the poorest. pneumonia and diarrhea (IVAC 2013; Liu and others
An examination of private expenditures averted demon- 2012), all of which are characterized by inadequate
strates a different trend. For both diarrhea treatment and coverage of ORS and antibiotic treatment. This cover-
combined diarrhea treatment and rotavirus vaccination age issue underscores the relevance of using ECEA to
the wealthy tend to experience greater relative gains in understand distributional impact. Furthermore, future
private expenditures averted, since private expenditures applications of ECEA should examine the impact of
averted by UPF are relatively flat across income quin- UPF for all four interventions studied here combined,
tiles. Finally, the FRP benefits provided by UPF again and more broadly for a package of highly cost-effective
favor the poorest by a substantial margin. In general, the child health interventions.
Table 19.5 Deaths Averted and Financial Risk Protection Afforded by Combined Pneumonia Treatment and
Pneumococcal Conjugate Vaccines, under Different Gavi Subsidies for Vaccines
Income quintile
I V
(poorest) II III IV (richest)
Deaths averted
(per US$ 1million spent)
$0.20 per dose 33 37 31 26 17
$3.50 per dose 31 34 27 23 15
Financial risk protection afforded
(2011 US$)
$0.20 per dose 2,710 1,170 780 640 510
$3.50 per dose 2,490 1,060 700 580 440
Health Gains and Financial Risk Protection Afforded by Treatment and Prevention of Diarrhea and Pneumonia in Ethiopia 357
Table 19.6 Deaths Averted and Financial Risk Protection Afforded by Combined Diarrhea Treatment and Rotavirus
Vaccines, under Different Gavi Subsidies for Vaccines
Income quintile
I V
(poorest) II III IV (richest)
Deaths averted
(per US$1 million spent)
$0.20 per dose 22 15 11 15 5
$2.50 per dose 14 14 10 9 3
Financial risk protection afforded
(2011 US$)
$0.20 per dose 480 190 80 70 30
$2.50 per dose 470 190 80 70 30
Health Gains and Financial Risk Protection Afforded by Treatment and Prevention of Diarrhea and Pneumonia in Ethiopia 359
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DCP3 Series Acknowledgments
Disease Control Priorities, third edition (DCP3) We thank the many contractors and consultants
compiles the global health knowledge of institu- who provided support to specific volumes in the form
tions and experts from around the world, a task that of economic analytical work, volume coordination,
required the efforts of over 500 individuals, includ- chapter drafting, and meeting organization: the Center
ing volume editors, chapter authors, peer reviewers, for Disease Dynamics, Economics, & Policy; Center
advisory committee members, and research and staff for Chronic Disease Control; Center for Global Health
assistants. For each of these contributions we convey Research; Emory University; Evidence to Policy Initiative;
our acknowledgement and appreciation. First and Public Health Foundation of India; QURE Healthcare;
fore- most, we would like to thank our 33 volume University of California, San Francisco; University of
editors who provided the intellectual vision for their Waterloo; University of Queensland; and the World
volumes based on years of professional work in their Health Organization.
respective fields, and then dedicated long hours to We are tremendously grateful for the wisdom and
reviewing each chapter, providing leadership and guidance provided by our advisory committee to the
guidance to authors, and framing and writing the editors. Steered by Chair Anne Mills, the advisory com-
summary chapters. We also thank our chapter authors mittee assures quality and intellectual rigor of the high-
who collectively volunteered their time and expertise est order for DCP3.
to writing over 160 comprehensive, evidence-based The National Academies of Science, Engineering,
chapters. and Medicine, in collaboration with the Interacademy
We owe immense gratitude to the institutional spon- Medical Panel, coordinated the peer-review process for
sor of this effort: The Bill & Melinda Gates Foundation. all DCP3 chapters. Patrick Kelley, Gillian Buckley, Megan
The Foundation provided sole financial support of Ginivan, and Rachel Pittluck managed this effort and
the Disease Control Priorities Network. Many thanks provided critical and substantive input.
to Program Officers Kathy Cahill, Philip Setel, Carol The World Bank External and Corporate Relations
Medlin, and (currently) Damian Walker for their Publishing and Knowledge division provided excep-
thoughtful interactions, guidance, and encouragement tional guidance and support throughout the demanding
over the life of the project. We also wish to thank production and design process. We would particularly
Jaime Seplveda for his longstanding support, including like to thank Carlos Rossel, the publisher; Mary Fisk,
chairing the Advisory Committee for the second edition Nancy Lammers, Rumit Pancholi, and Deborah Naylor
and, more recently, demonstrating his vision for DCP3 for their diligence and expertise. Additionally, we thank
while he was a special advisor to the Gates Foundation. Jose de Buerba, Mario Trubiano, Yulia Ivanova, and
We are also grateful to the University of Washingtons Chiamaka Osuagwu of the World Bank for providing
Department of Global Health and successive chairs King professional counsel on communications and marketing
Holmes and Judy Wasserheit for providing a home base strategies.
for the DCP3 Secretariat, which included intellectual Several U.S. and international institutions contrib-
collaboration, logistical coordination, and administra- uted to the organization and execution of meetings that
tive support. supported the preparation and dissemination of DCP3.
363
We would like to express our appreciation to the National Cancer Institute cancer consultation
following institutions: (November 2013)
Union for International Cancer Control cancer con-
University of Bergen, consultation on equity (June 2011) sultation (November 2013, December 2014)
University of California, San Francisco, surgery
volume consultations (April 2012, October 2013, Carol Levin provided outstanding governance for
February 2014) cost and cost-effectiveness analysis. Stphane Verguet
Institute of Medicine, first meeting of the Advisory added invaluable guidance in applying and improving
Committee to the Editors ACE (March 2013) the extended cost-effectiveness analysis method. Shane
Harvard Global Health Institute, consultation on Murphy, Zachary Olson, Elizabeth Brouwer, Kristen
policy measures to reduce incidence of noncommu- Danforth, David Watkins, Jennifer Nguyen, and
nicable diseases (July 2013) Jennifer Grasso provided exceptional research assis-
Institute of Medicine, systems strengthening meeting tance and analytic assistance. Brianne Adderley ably
(September 2013) managed the budget and project processes. The efforts
Center for Disease Dynamics, Economics, and Policy of these individuals were absolutely critical to pro-
(Quality and Uptake meeting Sept 2013, reproductive ducing this series, and we are thankful for their
and maternal health volume consultation November commitment.
2013)
365
and implementation of standard methods for estimation Innovation (CIGI) Chair in Global Health Economics
and modeling related to disease burden. in the Balsillie School of International Affairs there.
She has consulted for the World Bank, the Asian
Development Bank, several United Nations agencies,
SERIES EDITORS and the International Development Research Centre,
Dean T. Jamison among others, in work carried out in over 20 low- and
Dean T. Jamison is a Senior Fellow in Global Health middle-income countries. She led the work on nutrition
Sciences at the University of California, San Francisco, and for the Copenhagen Consensus in 2008, when micro-
an Emeritus Professor of Global Health at the University of nutrients were ranked as the top development priority.
Washington. He previously held academic appointments She has served as associate provost of graduate studies
at Harvard University and the University of California, Los at the University of Waterloo, vice-president academic at
Angeles; he was an economist on the staff of the World Wilfrid Laurier University in Waterloo, and interim dean
Bank, where he was lead author of the World Banks at the University of Toronto at Scarborough.
World Development Report 1993: Investing in Health. He
was lead editor of DCP2. He holds a PhD in economics Prabhat Jha
from Harvard University and is an elected member of Prabhat Jha is the founding director of the Centre for
the Institute of Medicine of the U.S. National Academy of Global Health Research at St. Michaels Hospital and
Sciences. He recently served as Co-Chair and Study Director holds Endowed and Canada Research Chairs in Global
of The Lancets Commission on Investing in Health. Health in the Dalla Lana School of Public Health at
the University of Toronto. He is lead investigator of
Rachel Nugent the Million Death Study in India, which quantifies the
Rachel Nugent is a Research Associate Professor in causes of death and key risk factors in over two million
the Department of Global Health at the University of homes over a 14-year period. He is also Scientific
Washington. She was formerly Deputy Director of Global Director of the Statistical Alliance for Vital Events,
Health at the Center for Global Development, Director which aims to expand reliable measurement of causes of
of Health and Economics at the Population Reference death worldwide. His research includes the epidemiol-
Bureau, Program Director of Health and Economics ogy and economics of tobacco control worldwide.
Programs at the Fogarty International Center of the
National Institutes of Health, and senior economist at the Ramanan Laxminarayan
Food and Agriculture Organization of the United Nations.
See the list of Volume Editors.
From 199197, she was associate professor and depart-
ment chair in economics at Pacific Lutheran University.
She has advised the World Health Organization, the U.S. Charles N. Mock
government, and nonprofit organizations on the econom- Charles N. Mock, MD, PhD, FACS, has training as both a
ics and policy environment of noncommunicable diseases. trauma surgeon and an epidemiologist. He worked as a
surgeon in Ghana for four years, including at a rural hos-
Hellen Gelband pital (Berekum) and at the Kwame Nkrumah University
Hellen Gelband is Associate Director for Policy at the of Science and Technology (Kumasi). In 200507, he
Center for Disease Dynamics, Economics & Policy served as Director of the University of Washingtons
(CDDEP). Her work spans infectious disease, particu- Harborview Injury Prevention and Research Center. In
larly malaria and antibiotic resistance, and noncommu- 200710, he worked at the World Health Organization
nicable disease policy, mainly in low- and middle-income (WHO) headquarters in Geneva, where he was respon-
countries. Before joining CDDEP, then Resources for sible for developing the WHOs trauma care activities. In
the Future, she conducted policy studies at the (former) 2010, he returned to his position as Professor of Surgery
Congressional Office of Technology Assessment, the (with joint appointments as Professor of Epidemiology
Institute of Medicine of the U.S. National Academies, and Professor of Global Health) at the University of
and a number of international organizations. Washington. His main interests include the spectrum of
injury control, especially as it pertains to low- and mid-
dle-income countries: surveillance, injury prevention,
Susan Horton prehospital care, and hospital-based trauma care. He is
Susan Horton is Professor at the University of Waterloo President (201315) of the International Association for
and holds the Centre for International Governance Trauma Surgery and Intensive Care.
367
Mariel M. Finucane Kenneth Hill
Gladstone Institutes, University of California, San Harvard T. H. Chan School of Public Health, Boston,
Francisco, San Francisco, California, United States Massachusetts, United States
Christa Fischer Walker G. Justus Hofmeyr
Johns Hopkins Bloomberg School of Public Health, Effective Care Research Unit, East London Hospital
Baltimore, Maryland, United States Complex, East London, South Africa
Brendan Flannery Dan Hogan
Centers for Disease Control and Prevention, Atlanta, Department of Health Statistics and Informatics,
Georgia, United States World Health Organization, Geneva, Switzerland
Ingrid K. Friberg
Susan Horton
Johns Hopkins Bloomberg School of Public Health,
School of Public Health and Health Systems, University
Baltimore, Maryland, United States
of Waterloo, Waterloo, Canada
Bela Ganatra
Department of Reproductive Health and Research, Aamer Imdad
World Health Organization, Geneva, Switzerland SUNY Upstate Medical University, Syracuse, New York,
United States
Marijke Gielen
Department of Paediatrics, University Hospitals Dean T. Jamison
Leuven, Leuven, Belgium Department of Global Health, University of
Washington, Seattle, Washington, United States
Wendy Graham
The Institute of Applied Health Sciences, University of Kjell Arne Johansson
Aberdeen, Aberdeen, United Kingdom Department of Public Health & Centre for
International Health, University of Bergen, Bergen,
A. Metin Glmezoglu
Norway
Department of Reproductive Health and Research,
World Health Organization, Geneva, Switzerland Gerald T. Keusch
Demissie Habte Boston University School of Medicine, Boston,
Board of Trustees, International Clinical Massachusetts, United States
Epidemiological Network, Addis Ababa, Ethiopia Margaret E. Kruk
Mary J. Hamel Harvard T.H. Chan School of Public Health, Boston,
Centers for Disease Control and Prevention, Atlanta, Massachusetts, United States
Georgia, United States
Rohail Kumar
Davidson H. Hamer Division of Women and Child Health, Aga Khan
Department of Global Health, Boston University School University, Karachi, Pakistan
of Public Health, Boston, Massachusetts, United States
Zohra S. Lassi
Peter M. Hansen Division of Women and Child Health, Aga Khan
Gavi Alliance, Geneva, Switzerland University, Karachi, Pakistan
Karen Hardee Joy E. Lawn
Population Council, New York, New York, United States MARCH Center, London School of Hygiene & Tropical
Julie M. Herlihy Medicine, London, United Kingdom
Department of Global Health, Boston University
School of Public Health, Boston, Massachusetts, Theresa A. Lawrie
United States Department of Reproductive Health and Research,
World Health Organization, Geneva, Switzerland
Natasha Hezelgrave
Division of Womens Health, Kings College London Lindsey Lenters
School of Medicine, London, United Kingdom The Hospital for Sick Children, Toronto, Canada
368 Contributors
Carol Levin Lale Say
Department of Global Health, University of Department of Reproductive Health and Research,
Washington, Seattle, Washington, United States World Health Organization, Geneva, Switzerland
Li Liu Peter Sheehan
Johns Hopkins Bloomberg School of Public Health, Victoria Institute of Strategic Economic Studies,
Baltimore, Maryland, United States Melbourne, Victoria, Australia
Colin Mathers Joo Paula Souza
Department of Health Statistics and Informatics, Department of Social Medicine, Ribeiro
World Health Organization, Geneva, Switzerland Preto School of Medicine, University of
So Paulo, So Paulo, Brazil
Agustina Mazzoni
Institute for Clinical Effectiveness and Health Policy, Meghan Stack
Buenos Aires, Argentina Johns Hopkins Bloomberg School of Public Health,
Baltimore, Maryland, United States
Solomon Tessema Memirie
Department of Public Health & Centre for International Cynthia Stanton
Health, University of Bergen, Bergen, Norway Johns Hopkins Bloomberg School of Public Health,
Claudia Garcia Moreno Baltimore, Maryland, United States
Department of Reproductive Health and Research, Karin Stenberg
World Health Organization, Geneva, Switzerland Department of Health Systems Governance and
Sheila Mwero Financing, World Health Organization, Geneva,
African Population and Health Research Center, Switzerland
Nairobi, Kenya Gretchen A. Stevens
Arindam Nandi Department of Health Statistics
Center for Disease Dynamics, Economics & Policy, and Information Systems, World Health Organization,
Washington, DC, United States Geneva, Switzerland
Olufemi T. Oladapo John Stover
Department of Reproductive Health and Research, Avenir Health, Glastonbury, Connecticut,
World Health Organization, Geneva, Switzerland United States
Shefali Oza Kim Sweeny
MARCH Center, London School of Hygiene & Tropical Victoria University, Melbourne, Victoria, Australia
Medicine, London, United Kingdom Stphane Verguet
Christopher J. Paciorek Department of Global Health and Population,
Department of Statistics, University of California, Harvard T. H. Chan School of Public Health, Boston,
Berkeley, Berkeley, California, United States Massachusetts, United States
Contributors 369
Advisory Committee to the Editors
371
Carol Medlin Jaime Seplveda
Senior Health and Nutrition Specialist, Executive Director, Global Health Sciences, University
Health, Nutrition, and Population Global Practice, of California, San Francisco, San Francisco, California,
World Bank, Washington, DC, United States United States
Alvaro Moncayo Richard Skolnik
Researcher, Universidad de los Andes, Bogot, Lecturer, Health Policy Department, Yale School
Colombia of Public Health, New Haven, Connecticut,
United States
Jaime Montoya
Executive Director, Philippine Council for Health Stephen Tollman
Research and Development, Taguig City, the Professor, University of Witwatersrand, Johannesburg,
Philippines South Africa
Jrgen Untzer
Ole Norheim
Professor, Department of Psychiatry, University of
Professor, University of Bergen, Bergen, Norway
Washington, Seattle, Washington, United States
Folashade Omokhodion Damian Walker
Professor, University College Hospital, Ibadan, Senior Program Officer, Bill & Melinda Gates
Nigeria Foundation, Seattle, Washington, United States
Toby Ord Ngaire Woods
President, Giving What We Can, Oxford, United Director, Global Economic Governance Program,
Kingdom Oxford University, Oxford, United Kingdom
K. Srinath Reddy Nopadol Wora-Urai
President, Public Health Foundation of India, Professor, Department of Surgery, Phramongkutklao
New Delhi, India Hospital, Bangkok, Thailand
Sevkat Ruacan Kun Zhao
Dean, Ko University School of Medicine, Istanbul, Researcher, China National Health Development
Turkey Research Center, Beijing, China
373
Regina Moench-Pfanner Alexander K. Rowe
Global Alliance for Improved Nutrition, Geneva, Center for Global Health, Centers for Disease Control
Switzerland and Prevention, Atlanta, Georgia, United States
374 Reviewers
Index
Boxes, figures, maps, notes, and tables are indicated by b, f, m, n, and t following page numbers.
A Adler, A., 60
Abbas, K., 103 adolescents
abortion, 2832, 1067 age-appropriate sex education, 104
access to safe abortions, 64, 1067 condom use, 105, 105b
as cause of maternal morbidity, 4, 6, 31, 31t, 57 education of girls and boys, equal retention of, 104
as cause of maternal mortality, 6, 2931, 3031t, 54 gender-inequitable norms and violence, 104
consequences of, 4, 2932, 31t legal protection of, 104
cost-effectiveness of safe abortion, 321 out-of-school and married adolescents, 105
definition of, 28, 54, 59b reduction in teen pregnancy, 28
economic and social consequences, 3132 sexual and reproductive health, 1035, 105b
incidence, 29, 3031t Advanced Market Commitment, 188b
induced, 54 Afghanistan
information and attitudes, 107 childbirth interventions in, 273
interventions to reduce, 106 maternal deaths in, care approaches to lower, 301
legal restrictions on abortion, 106 stunting and height-for-age in, 8788
measurement used in study of, 29 Africa. See also specific regions and countries
provider pool to improve safety, 1067 diarrheal diseases in, 164f
safe abortion technologies, 106, 107 female genital mutilation (FGM) in, 39
teenage pregnancy and, 103 malnutrition in, 208
Abortion Incidence Complications Methodology maternal mortality, disproportionate burden in, 53
(AICM), 29, 31 polio in, 191
access to health services stunting and height-for-age in, 7
equitable, 64 unintended pregnancy in, 28
maternal mortality related to limited access, 263 AICM (Abortion Incidence Complications
rights-based approach to maternal mortality and Methodology), 29, 31
morbidity, 64 AIDS. See HIV/AIDS
three delays model, 64 alcohol abuse disorders, 5
accreditation of health facilities, 292 Alderman, H., 254
Accredited Social Health Activists (India), 101 Aldy, J., 307
ACT (artemisinin-based combination therapy), ALRIs (acute lower respiratory tract infections), 14445
147, 154 Amsel criteria, 34
acute lower respiratory tract infections (ALRIs), 14445 anemia, 6, 59, 23132, 24445
acute respiratory infections (ARIs), 14445, 146t, 286 Angola, child mortality (under five) in, 79
Adam, T., 276 Annan, R. A., 209
375
antenatal care visits, 123, 287 outreach workers in, 327
antenatal corticosteroids, 127 pneumonia in, 145
antibiotics, use of preterm infants and neurodevelopmental
cesarean delivery, 12223 disabilities in, 247
diarrheal diseases, 17071, 179 reduced fertility, benefits of, 28
group B streptococcus (GBS), 129 stunting and height-for-age in, 87
malnutrition, 21516 teenage pregnancy in, 28
maternal sepsis, 122 wasting in, 91b, 207
neonatal sepsis, 129 Baqui, A. H., 339
pneumonia treatment in Ethiopia, 348 Barkat-e-Khuda, 327
preterm rupture of membranes, 128 Bartlett, L., 328
anticonvulsant prophylaxis, 120 Bayley Scales of Infant and Toddler Development
antihypertensive therapy in preeclampsia, 120 (Third Edition), 242
antiretroviral therapy for HIV (ART), 13t, 123, 125, 215 BCG (Bacille Calmette-Gurin) Vaccine, 18990
antiseptics. See vaginal application of antiseptics behavioral interventions, 17477, 25152
antithrombotic agents, use of, 126 benefit-cost ratios, 1, 16, 338
ARIs (acute respiratory infections), 14445, 146t, 286 continuum-of-care approach, 30911, 31011t
artemisinin-based combination therapy (ACT), early childhood development, 254
147, 154 Benin
artery embolization, 55, 118 costs of health care in, 338
Ashworth, A., 211 Integrated Community Case
Asia. See also specific regions and countries Management (iCCM) in, 153
female genital mutilation (FGM) in, 39 wasting in, 91b
Japanese encephalitis (JE) in, 195 Berkley, J. A., 215
maternal mortality, disproportionate burden in, 53 Bhutan
rubella vaccine in, 194 maternal mortality reduction in, 53
stunting and height-for-age in, 7 stunting and height-for-age in, 87
unintended pregnancy in, 28 Bhutta, Z. A., 129, 267, 289, 322, 326
unsafe abortion in, 29 Bill & Melinda Gates Foundation, 9b, 101, 189, 319
asphyxia. See birth asphyxia Gavi (Vaccine Alliance), 188b
aspirin as prophylactic, 119 Malaria Control and Evaluation Partnership
in Africa, 140
B Meningitis Vaccine Project, 195
Baby-Friendly Hospital Initiative, 235, 249 biofortification, 326, 329
Bacille Calmette-Gurin (BCG) Vaccine, 18990 birth asphyxia, 6, 78, 265
bacterial vaginosis, 3335, 34t birth control. See contraceptives; family planning
Bangladesh Black, R., 227
community-based interventions in, 270 blindness from trachoma, 24546
cost-effectiveness of, 277 Bolivia, family planning in, 102
contraceptive use in, 97, 100f Bongaarts, J., 101
delayed mental development in, 247 Bosch-Capblanch, X., 293
diarrheal diseases in, 167, 169 Brazelton Neonatal Behavioral Assessment Scale, 242
fever in children in, 148 Brazil
handwashing in, 175 Bolsa Famlia, 19, 103, 275, 290
home visits and reduction in newborn deaths in, child health services, costs of, 328
265, 336 contraceptive use in, 97, 100f
IMCI effectiveness in, 149 diarrheal diseases in, 170
Integrated Community Case IMCI effectiveness in, 149
Management (iCCM) in, 153 rotavirus vaccine costs in, 357
Integrated Management of Childhood Illness stunting and height-for-age in, 87
(IMCI) in, 266 breastfeeding
maternal mortality decline in, 65 early child development and, 249
Matlab program, 101 as intervention, 13t, 128, 173
376 Index
costs of support for, 328 early delivery options, 120
malnutrition and, 8, 215, 22930 fetal monitoring during, 126
WHO definition of appropriate indicators measuring health care delivery for
breastfeeding, 220n2 women, 287
Brenzel, L., 329 interventions, 12t
Brown, R., 209 obstructed labor, 6, 54, 59
Buchanan, J., 323 definition of, 59b
burden of disease/medical condition prevention of, 121
abortion, 2832. See also abortion treatment of, 12122
diarrheal diseases, 164 prolonged labor, 6, 59, 59b
female genital mutilation (FGM), 3940. See also vacuum and forceps delivery, 12122
female genital mutilation Child Health Epidemiology Reference Group
ill health, defined, 25 (CHERG), 9b, 52, 71, 76, 143, 350
infertility, 3537, 3637t. See also child health package. See child mortality (under age five
infertility, involuntary years, U5MR), at interventions
maternal morbidity, 61 childhood development. See early childhood
official development assistance increase for, 2 development
reproductive ill health, 2550. See also abortion; childhood illness (under age five). See also febrile
pregnancy children; specific disease or condition
data presentation and limitations, 25 child mortality and, 7879, 79t, 80f, 263
overview, 25 cost-effectiveness of interventions, 15f, 32326
unintended pregnancy, 2528. See also pregnancy cost of interventions, 16t, 17
violence against women, 3739. See also violence interventions. See interventions; vaccines
against women stunting. See stunting
Burkina Faso child mortality (under age five years, U5MR),
diarrheal diseases in, 17576, 324 7183
postpartum vaginal or uterine prolapse in, 60 causes of, 6, 7f, 7681, 79t, 80f
wasting in, 207 data and methods, 7677
Burundi, stunting and height-for-age in, 88 policy implications, 81
results, 7781
C challenges in reducing, 7576
Cabo Verde, maternal mortality reduction in, 53 cost of interventions, 16t, 17
calcium supplementation, 119, 124 data sources, 72, 76
Cambodia, maternal mortality reduction in, 53 deaths averted, 10f, 1314, 14f
Catalytic Initiative, 154 decline in, 1, 81, 300
CCTs. See conditional cash transfers family planning and, 96, 97
Centers for Disease Control and Prevention (CDC), 32, fertility rates and, 4, 5m
289 iCCM and, 154
Central Asia. See Europe and Central Asia interventions, 1, 814, 13t
cerebral malaria, 246 indicators measuring health care delivery for
cesarean section, 121, 12223, 321 children, 28687
Chad, wasting in, 91b levels and trends, 6, 7f, 7176
Chan, M., 345 malnutrition and, 227
checklists, use of, 18, 293 deaths averted by scaling up interventions, 235f
CHERG. See Child Health Epidemiology Reference maternal educations effect on, 7576
Group MDG 4 to reduce, 71, 7273, 75
chikungunya virus, 147 overview, 71
childbirth, 1 policy implications, 7576, 81
active management of, 12627 risk results from research studies, 7275, 7374t
cesarean section. See cesarean section stillbirths included, 71, 75, 76
checklists for safe childbirth, 18 unintended pregnancy and, 28
community-based interventions, 26566 Childrens Investment Fund Foundation, 319
death at. See stillbirths child sexual abuse, 38, 39
Index 377
Chile maternal and child mortality and morbidity, 8,
Hib in, 193 1113t, 14, 15
stunting and height-for-age in, 87 motivation for, 275
China nutrition, 23536, 270, 27172t
adolescent-friendly contraceptive services in, 105 overview, 26364
benefit-cost ratio in, 311, 314 Pakistans lady health worker program, 252b, 267b
child mortality (under five) in, 7879 quality of, 274
fertility rates and reduced child mortality in, 300 referral systems, 275, 275f
stunting and height-for-age in, 87 research agenda, 279
cholera, 170, 172, 188b, 325 scaling up, 275, 27778
chorioamnionitis, 123 severe acute malnutrition (SAM), 326
Clinton Health Access Initiative, 319 strategies, 264
CLTS (Community-Led Total Sanitation), 176 training of community health workers, 273, 274
CMAM (community management of acute tuberculosis, 270
malnutrition), 212, 21314, 217 Community-Based Management of Acute Malnutrition
CMAM (Community-Based Management of Acute (CMAM) Forum, 210
Malnutrition) Forum, 210 community health workers. See community-based
cognitive development. See early childhood interventions
development Community-Led Total Sanitation (CLTS),
Colombia 17677
continuous quality improvement (CQI) in, 293 community management of acute malnutrition
Familias en Accin program, 250b, 254 (CMAM), 212, 21314, 217
Columbia University study on pregnancy-related community mobilization and community health
complications, 61 workers, 290
Commission on Information and Accountability for complementary feeding, 23031
Womens and Childrens Health, 89 conditional cash transfers (CCTs), 19, 29091
community-based interventions, 2, 8, 26384 cost-effectiveness of, 329
continuum of care including, 264 education of adolescent girls and boys, equal
contraceptive use, 98 retention of, 104
cost-effectiveness of, 27679, 327 family planning, 103
costs of, 278t, 279 immunization programs, 326
delivery complications, neonatal care, and stimulation programs and, 250b, 254
childhood illnesses, 26566 Congo, Democratic Republic of
diarrheal diseases, 176 child mortality (under five) in, 7879
disability-adjusted life years (DALYs) and, diarrheal diseases in, 170
27778, 277f DTP vaccine in, 197
early child development and, 253 fever in children under age five years in, 140
empowering communities, 27073, 273t continuous quality improvement (CQI), 293
evidence on packages from literature review, continuum-of-care approach, 2, 16, 299317
26869t analytical framework for assessing,
expanding community health worker mandate, 3015, 301f
27374, 290 assessing economic and social benefits of achieved
family planning, 101 outcomes, 3045
helminths, 26769 benefits of morbidity averted, 308
HIV/AIDS, 269 benefits of reduced fertility rates, 308
home visits, 26566, 26566t of community-based interventions, 264
improving supply of services, 26470 cost-effective interventions, 300301
Indias community health workers, 337b, 338t estimating costs, 303
integrating with community and local health estimating full benefits of investment in, 3078
facilities, 27576, 276f estimating health and fertility impacts, 304
leveraging mobile technology, 27475 extended lifecycle benefits, 300
malaria, 267 global child and maternal mortality rates and, 300
malnutrition, 21314, 217, 233 health system benefits, 300
378 Index
implications of analysis, 31314 delivery platforms, 32728
affordable investments, 313 diarrheal diseases interventions, 17778, 177t, 324
extended modeling approach, 314 Ethiopias treatment and prevention of diarrhea and
high rates of return, 314 pneumonia, 34561. See also Ethiopia
large economic and social returns, 313 family planning, 103
over different timeframes, 314 febrile children, 32324
variable returns, 31314 India universal home-based neonatal care package,
improved and equitable access, 300 1516, 33544. See also India
increase in coverage level, model of, 3056t, 3057 infant and young child growth, 32627
integration of services, 301 innovations to expand access and improve health
investment metrics, 30913 care quality, 29394
analysis by type of benefit, 31112 literature biases, 319
analysis of contribution to benefits, 312t malnutrition treatment, 21617, 32627
benefit-cost ratios, 30911, 31011t maternal mortality and morbidity, 12930
high direct health benefits, 312 methodology of study, 32021
morbidity benefits, 312 overview, 31920, 32223t
total economic and social benefits, quality of care and, 29394, 294t
equality of, 312 reproductive health, 323
two case studies, comparison of, 30813, 309t returns on investment in continuum of care,
uneven distribution of demographic dividend, 300301
31112 vaccines, 19798, 198t, 32426
investment wins, 300301 costs
key methodological assumptions, 307 of community-based interventions, 278t, 279
maternal morbidity and, 64 of contraceptives, 17, 17t
measuring health impacts and full costs, 3057 of diarrheal diseases interventions, 17778, 177t, 328
overview, 299300 effect on care-seeking behavior, 176
selection of interventions, 3023, 3023t estimating for returns on investment in continuum
years of life saved, 3078 of care, 303
contraceptives, 1, 2, 10 of family planning, 17, 328
access to and promotion of condom use, 105 of interventions, 2, 32829
adolescent use of, 105, 105b of malnutrition interventions, 21617, 328
cost-effectiveness of, 321 of maternal morbidity and mortality, 130
cost of, 17, 17t of RMNCH interventions, 2, 16t, 20n1
family planning and, 96, 9799 scaling up interventions, 1618. See also scaling up
global distribution of methods, 100f of unsafe abortions, 3132
innovations to expand access and improve health of vaccines, 19798
care quality, 288 of water, sanitation, and hygiene interventions, 174
MDG 5b to improve access to, 51, 63 Cte dIvoire, stunting and height-for-age in, 87
methods, choice of, 97, 99t Countdown to 2015 initiative, 8, 17, 64, 129, 154, 230,
by countries, 100f 235, 322
postabortion, 107 CQI (continuous quality improvement), 293
primary health centers as service providers, 2 Cresswell, J. A., 58
Sino-implant (II) and future types of, 99 Cropper, M., 307
social and economic benefits, 26 Cryptosporidium infection, 167
controlled cord traction, 118
cord clamping, early vs. late, 118 D
cord cleansing, 12829 DALYs. See disability-adjusted life years
corticosteroids, 127 Das, J. K., 326
cost-effectiveness of interventions, xiii, 1, 2, 1416, 15f, dating violence, 38
31934. See also benefit-cost ratios DCP. See Disease Control Priorities in Developing
assessment of, 3b Countries
childhood illness (under age five), 32326 Declaration on the Elimination of Violence against
community-based interventions, 27679, 327 Women (UN), 37
Index 379
delivery platforms. See also community-based rotavirus, 165, 17172, 350, 351t
interventions; hospitals; primary health centers subclinical infections, 167
cost-effectiveness of interventions, 32728 therapeutic interventions, 16971, 169b
cost of scaling up, 1718 transmission and epidemiology, 16566
interventions for maternal and child mortality and tropical enteropathy, 167
morbidity, 8, 1113t vaccines, 171
demand-side interventions, 19 water, sanitation, and hygiene, 174
Democratic Republic of Congo. See Congo, Democratic watery, 166
Republic of zinc supplementation, 17374
Demographic and Health Surveys, 26, 51, 60, 85, 96, diet. See nutrition; vitamin and mineral supplements
174, 176, 188b, 346 diphtheria, tetanus, and pertussis (DTP) vaccines, 188b,
demographic dividend, 96, 305, 31112 189, 19091, 300, 32425
dengue fever, 147 disability-adjusted life years (DALYs)
depression, 5, 6, 39 in CEA vs. ECEA framework, 343n5
child development, effect of maternal community-base care and, 27778, 277f
depression on, 247 cost-effectiveness results using, 321, 330
postpartum depression, 60 diarrheal diseases and, 177, 178
Dettrick, Z., 289 malnutrition and, 217, 326
Development Assistance Committee (Organisation for maternal morbidity and, 61, 12930
Economic Co-operation and Development), 319 pneumonia and, 323
diabetes, 6 quality of services and, 29394, 294t
treatment, 125 vaccination and, 187, 189, 19798
diarrheal diseases, 1, 16385 WHO metrics and, 330n1
antibiotics, use of, 17071, 179 Disease Control Priorities in Developing
behavioral interventions, 17477 Countries (DCP)
burden of infection, 164 coverage of other volumes, 2, 320t
by region, 16465f evolution of series and third edition, xiii, 3b, 300,
child mortality (under five) and, 78, 79t, 163 319
cholera, 172 Djibouti, wasting in, 91b
community-based interventions, 176, 266 Dolea, C., 58
community-led total sanitation, 17677 domestic violence. See violence against women
cost-effectiveness of interventions, 17778, 177t, 324 Doppler ultrasound, use of, 12526
cost of interventions, 17778, 177t, 328 dysentery, 166, 169
scaling up, 18
definitions and classification, 16364 E
early childhood development and, 246 early childhood development, 8, 24161
environmental enteric dysfunction, 16769, 168b cerebral malaria and, 246
in Ethiopia, treatment and prevention, 34561. child nutrition and, 24951, 25455
See also Ethiopia conditions affecting, 24248, 249f
etiologies, 16465 cost-benefit of interventions, 254
handwashing, 17475 delayed mental development, 247
health care seeking, 17576 diarrhea and, 246
incidence, 163, 164 enteropathy and, 246
inflammatory diarrhea and dysentery, 166, 169 environmental conditions and, 24546
interventions, 163, 164b, 16977, 169b Family Care Indicators, 243
mortality due to, 78, 164 fatty acids and, 24950
natural history, 166 Home Observation for Measurement of the
nutrition, 173 Environment (HOME) Inventory, 243, 243f,
oral rehydration solutions (ORS). See oral 248, 251f
rehydration solutions infections and, 246, 25152, 255
overview, 163 interventions to enhance, 24854
persistent, 16667 macronutrients and, 244, 244f
preventive interventions, 169b maternal mental health and, 247, 255
380 Index
interventions, 25354 Integrated Community Case
maternal nutrition and, 24647, 255 Management (iCCM) in, 153
interventions, 25253 empowerment
mental development, measurement and community-based interventions, 27073, 273t
prevalence of, 242 freedom and right of women to control
micronutrients and, 24445, 244f their bodies, 63
neurodevelopmental disabilities, 247 encephalopathy, 129
overview, 24142 Ending Preventable Maternal Mortality, 115
psychosocial stimulation and, 24344, 244f, 24849, enteric fever, 146
250b, 254 enteropathy, 246
integrated with child nutrition, 251 entitlements, defined, 64
Pakistans Early Child Development Scale-Up environmental enteric dysfunction, 16769, 168b
Trial, 252b environmental factors
recommendations for future programs and for early child development, 24546
research, 255 for family planning, 96
trachoma and, 24546, 251 for maternal mortality and morbidity, 62t, 65
vitamin and mineral supplements and, 245 EPI (Expanded Program on Immunization), 14, 187,
East Asia and Pacific 18992, 319, 329
chikungunya in, 147 ergot alkaloids, 116
child mortality (under five) in, 7275, 7374t, 80f Ethiopia
community-base care, cost-effectiveness of, 276 abortion services in, 106
diarrheal diseases in, 164f, 246 Catalytic Initiative in, 154
health care service delivery in, 28687, 287t child health services, costs of, 328
iodine deficiency in, 245 child mortality (under five) in, 78, 346, 347f, 347t
malnutrition in, 208 community-based programs in
number of hospital beds per 1,000 people in, 286 innovative task-shifting, 289
number of nurses, midwives, and physicians per nutrition, 270
1,000 people in, 286 womens empowerment, 273
preterm infants and neurodevelopmental condom use in, 105
disabilities in, 247 contraception in, 101, 102
stunting and height-for-age in, 8687, 8788f DTP vaccine in, 197
ECEA. See extended cost-effectiveness analysis health extension program (HEP) in, 347
economic factors. See also social and economic benefits health spending in, 347, 352
for maternal mortality and morbidity, 62t Integrated Management of Neonatal and Childhood
for stunting, 90 Illness (IMNCI) in, 151
ectopic pregnancy, 54 iodine deficiency in, 253
Ecuador, cash transfer program for early child malnutrition, community-based treatment
development in, 254 programs in, 216, 217
edematous acute malnutrition, 216, 220n5 maternal depressions effect on child
education development in, 248
adolescent girls and boys, equal retention of, 104 treatment and prevention of diarrhea and
family planning, 10 pneumonia in, 178, 34561
in relation to school retention, 104 analysis, 35657
feeding practices, maternal education for, 231 antibiotics, use of, 348
fertility rates, and education of girls, 28 child demographics, 346, 34647t
health care seeking and level of education, 175 child health and health care services, 34648
maternal educations effect on child mortality, 7576 deaths averted, 350, 352, 35758t
nutrition education, 245, 326 diarrhea treatment combined with rotavirus
sex education, 11t, 104 vaccination, 35456, 355f
UNESCO, on children not attending school, 105 expenditures averted, 35052
Egypt extended cost-effectiveness analysis, 348
contraceptive use in, 97, 100f financial risk protection, 352, 35455, 35758t
IMCI effectiveness in, 150 methods of study, 34852
Index 381
OOP expenditures averted, 353 health consequences of high fertility, 9697
oral rehydration salts, use of, 350 human rights and equity rationale for, 96
overview, 34546 integration with other sectors, 101
pneumococcal conjugate vaccination, 15, 34850, mass media approaches to, 1045
34950t maternal and child health rationale for, 96
program costs, 352, 354, 355 methodology of study, 8
results of study, 35256 mHealth, 102
rotavirus vaccination, 350, 35456 mobile services, 102
Europe and Central Asia organization of programs, 99100
child mortality (under five) in, 73, 7374t, 80f out-of-school and married adolescents, 105
diarrheal diseases in, 164f public, nongovernmental, and commercial
health care service delivery in, 28687, 287t providers, 101
infertility in, 36t rationales for, 9596
maternal mortality, disproportionate burden in, 53 resilience-building and, 1056
number of hospital beds per 1,000 people in, 286 results-based financing, 102
number of nurses, midwives, and physicians per rights-based approach to, 96
1,000 people in, 286 school retention and, 104
stunting and height-for-age in, 8687, 87f, 88f services delivery, 101
European Medicines Agency, 196 social franchising, 102
Every Woman Every Child (UN), 100 social marketing, 1012
evidence-based policy making and interventions unsafe abortion, 1067
child mortality, 81 violence against women and, 1078
malnutrition, 217, 233 vouchers, 19, 1023
maternal morbidity and mortality, 116, 117t Family Planning Effort Index, 96, 97
perinatal morbidity and mortality, 124t, 127t fatty acids and early childhood development, 24950
Expanded Program on Immunization (EPI), 14, 187, febrile children, 13761
18992, 319, 329 acute respiratory infections, 14445, 146t, 286
extended cost-effectiveness analysis (ECEA) challenges and future research needs, 15455, 155b
Ethiopias treatment and prevention of diarrhea and chikungunya virus, 147
pneumonia, 34561. See also Ethiopia cost-effectiveness of interventions, 32324
Indias home-based neonatal care (HBNC) package, dengue fever, 147
33544. See also India diagnosis and treatment, 14347, 156
external cephalic version, 121 enteric fever, 146
etiology of fever, 14043, 14142t, 156
F group B streptococcus disease, 144
Family Care Indicators, 243 health systems approaches to, 14854
family planning, 95103 herpes simplex virus, 14344
adolescent programs, 1035, 105b Integrated Community Case Management (iCCM)
age-appropriate sex education, 104 and. See Integrated Community Case
child mortality reduction and, 81 Management
community-based programming, 101 integrated management of childhood illness. See
conditional cash transfers (CCTs) and, 103 Integrated Management of Childhood Illness
contraceptive methods, 9799. See also malaria, 147. See also malaria
contraceptives diagnostic tools for, 14748
access to and promotion of condom use, 105 management of, 15052
adolescent-friendly, 105 meningitis, 143
cost-effectiveness of, 103 most common presenting symptoms, 137, 13839t
costs of, 17, 328 newborns, 143
demographic rationale for, 9596 overview, 13740
environment and sustainable development respiratory and other bacterial illnesses, 148
rationale for, 96 sepsis, 143
fertility rates and, 97, 98f urinary tract infections (UTIs), 144
global initiatives, 99100 viral exanthems, 14546
382 Index
female genital mutilation (FGM), 25, 3940 childbirth interventions recommended in, 27374
consequences of, 40 costs of health care in, 338
measurement for study of, 3940 family planning in, 102
prevalence of, 40, 4142t Integrated Community Case Management (iCCM)
Ferguson, E., 211 in, 153, 154
fertility rates, 4, 4m. See also family planning stillbirth data from, 76, 78, 78t
child mortality and, 6, 75 Giardia infection, 167
continuum-of-care approach and, 304, 308 Gillespie, D., 96
family planning and, 96, 97, 98f Global Financing Facility to Advance Womens and
health consequences of high fertility, 9697 Childrens Health, 313
maternal mortality and, 97 Global Fund to Fight AIDS, Tuberculosis and
fetal movement counting, 126 Malaria, 140
fetal shoulder manipulation, 122 global initiatives
financial incentives to improve health, 233. See also for family planning, 99100
conditional cash transfers for vaccines. See Gavi; vaccines
financial risk protection, 15, 19, 352, 353f, Global Polio Eradication Initiative, 191
35455, 35758t Global Strategy for Womens and Childrens Health
Firth, S., 289 (UN Secretary-General), 2, 19, 52
Fischer Walker, C. L., 178, 324 Global Symposium on Health Systems Research
Fisher, J., 60 (Beijing 2012), 345
Flenady, V., 76 Global Vaccine Alliance. See Gavi
folic acid, 1, 8, 10, 124t, 253, 326 Goldie, S. J., 321
Food Aid Quality Review, 211 Grantham-McGregor, S., 8, 254
food-insecure populations, 211 Griffiths Mental Development Scales, 242
food-secure populations, 21011 group B streptococcus (GBS), 129, 144
freedom, concept of, 63 group sessions in stimulation programs, 250b
Fretheim, A., 291 Guatemala, stunting and height-for-age in, 88
full-income methods, 16, 304 Gunasekera, P., 60
Gurman, T. A., 104
G Guttmacher Institute, 17
Gabrysch, S., 65 Gyles, C. L., 320
The Gambia
diarrheal diseases in, 166, 167, 170 H
Hib in, 193 H. pylori infection, 167
Integrated Management of Neonatal and Childhood Haemophilus influenzae Type b (Hib) vaccine,
Illness (IMNCI) in, 151 81, 193, 325
pneumonia in, 145 Haines, A., 19
postpartum vaginal or uterine prolapse in, 60 Haiti, cholera in, 197
stunting and height-for-age in, 167 Hammitt, J., 307
Ganatra, H. A., 143 handwashing, 167, 17475, 251, 252, 324
Garca-Moreno, C., 37 Harner-Jay, C. M., 103
Garner, P., 293 health outcomes, 28788, 287t
Gavi (Global Vaccine Alliance), 14, 146, 178, 18889b, health workers/professionals
189, 192t, 199, 251, 319 abortion services, 1067
new and underutilized vaccines supported by, community-based health workers (CHWs).
19293, 325, 356 See community-based interventions
GBS (group B streptococcus), 129, 144 cost-effectiveness of training, 321
gender-based violence, 43n1. See also violence handwashing by, 175
against women maternal mortality and morbidity and, 65
Ghana midwives. See midwives
abortion services in, 106 newborn resuscitation training, 128, 151
adolescent-friendly contraceptive services in, 105 number of nurses and midwives per 1,000
Catalytic Initiative in, 154 people, 286
Index 383
number of physicians per 1,000 people, 286 hunger. See malnutrition
Pakistans lady health worker program, 252b, 267b Hussain, R., 26
performance-based rewards to, 292 hygiene. See water, sanitation, and hygiene
shortage of, 2 hypertensive disease, 6, 5758
task shifting, 1819, 28889, 327 antihypertensive therapy, 120
violence against women, assistance for, 108
height-for-age. See stunting I
Heise, L., 37 iCCM. See Integrated Community Case Management
helminths, 26769 ICD-10. See International Classification of Diseases
heparin, use of, 126 ICPD (International Conference on Population and
hepatitis B vaccines, 188b, 19293, 325 Development), 99
herpes simplex virus (HSV-2), 14344 IHME (Institute for Health Metrics and
high-income countries (HICs) Evaluation), 146
breastfeeding and early child development in, 249 IHME Global Burden of Disease, 61
child mortality (under five) in, 72, 7374t, ill health, defined, 25
79, 80f, 81 IMCI. See Integrated Management of Childhood Illness
Japanese encephalitis (JE) vaccine in, 195 immunizations. See vaccines; specific types of vaccines
postpartum hemorrhage in, 58 IMNCI. See Integrated Management of Neonatal and
stillbirth in, 77, 77t, 81 Childhood Illness
unintended pregnancy in, 2627, 27t improvements needed, 2
unsafe abortions in, 30t incentives. See conditional cash transfers;
HIV/AIDS performance-based financing; vouchers
burden of disease, 32, 35 incontinence, 60
child mortality (under five) and, 78 India
community-based interventions, 269 Accredited Social Health Activists, 101
condom use and, 105 adolescent-friendly contraceptive services in, 105
drug treatment, 125 benefit-cost ratio in, 311, 314
funding for, 319 checklists, use of, 293
Hib and, 193 Chiranjeevi Yojana program, 291
identification of children with, 150 community-based interventions in, 270. See also
malnutrition and, 215, 219 below: universal home-based neonatal care
mass media to educate about, 104 package in
maternal morbidity and, 61 cost-effectiveness of, 277
maternal mortality and, 6, 55, 55b perinatal packages, 151, 265
violence against women and, 45, 39 womens empowerment, 273
wasting and, 208 contraceptive use in, 97, 100f
Hoddinott, J., 326 diarrheal diseases in, 170, 178
home-based care, 15, 327 diphtheria in, 190
community-based interventions, 26465, 26566t District Level Household Survey, 335
Indias neonatal care package, 33544. See also India DTP vaccine in, 197
postnatal care, 336 fertility rates and reduced child mortality in, 300
stimulation programs and, 250b, 254 fever in children under age five years in, 140
Home Observation for Measurement of the home visits and reduction in newborn deaths in, 265
Environment (HOME) Inventory, 243, 243f, Integrated Management of Neonatal and Childhood
248, 251f Illness (IMNCI) in, 150
Horton, S., 217 malnutrition and wasting in, 207, 215
hospitals, 2, 9 maternal depressions effect on child
accredited, 292 development in, 248
checklists, use of, 293 maternal mortality, disproportionate burden in, 53
interventions for maternal and child mortality and newborn, infant, and child mortality (under five) in,
morbidity, 8, 1113t 7879, 335, 336f
supervision and training role of, 293 pregnancy-related infection in, 5859
human rights and equity. See rights-based approach stillbirth data from, 76, 78, 78t
384 Index
stunting and height-for-age in, 87 performance-based financing, 291, 29293
Tamil Nadu Integrated Nutrition Program, 270 process of health care service delivery, 28687
teenage pregnancy in, 28 service delivery platforms, 286
universal home-based neonatal care package in, task-shifting approaches, 1819, 28889, 327
1516, 33544 training and supportive supervision, 293
accredited social health activists (ASHAs), 336, user fee removal, 290
337b, 339, 342 vitamin A supplementation, 288
analysis, 34142 vouchers, 19, 291
anganwadi workers, 337b insecticide-treated bednets, 125, 251, 267, 286, 303, 327
auxiliary nurse midwives (ANMs), 337b Institute for Healthcare Improvement, 293
community health workers, 337b Institute for Health Metrics and
data and methods, 33839 Evaluation (IHME), 146
intervention and treatment data, 339 Integrated Community Case Management (iCCM),
Janani Suraksha Yojana (Safe Motherhood 140, 148, 15254, 266, 280n2
Scheme), 341, 343n6 impact of, 154
methods, 33940 quality and safety, 153
overview, 33536 Integrated Global Action Plan for Prevention and
priority-setting methodologies, 33638 Control of Pneumonia and Diarrhoea, 145
results of study, 34041, 341f, 341t Integrated Management of Childhood Illness (IMCI),
vaccine costs in, 197 130, 137, 140, 212, 266, 293, 339. See also World
wasting in, 91b Health Organization
Indonesia, mobile technology in, 274 cost-effectiveness study of, 328
infant and young child feeding (IYCF) guidelines, 225, Multi-Country Evaluation, 301
226t, 23536, 326 Integrated Management of Neonatal and Childhood
infants. See neonatal interventions; neonatal mortality; Illness (IMNCI), 15052, 328
newborns integrated preventive and therapeutic health
infections. See also febrile children interventions, xiv, 2, 16
in children with SAM, 13t, 215 community-based services as part of, 276, 276f.
early child development and, 246, 255 See also community-based interventions
maternal infections, treatment of, 125 compelling case for, 19
pregnancy-related infection, 5859, 59b in continuum of care, 301
subclinical, 167 cost of, 329
transmitted by ground contamination, mosquitoes, family planning and, 101
and flies, 25152 febrile children and, 15254
infertility, involuntary, 4, 3537, 3637t malnutrition interventions and, 21920
definition and measurement, 35 psychosocial stimulation and child nutrition, 251
influenza vaccines, 189b, 196 intergenerational consequences
information and communication technologies, 102 of health care economic shocks, 337
innovations to expand access and improve health care of violence against women, 39
quality, 2, 1819, 28598 International Child Development Committee, 8
checklists, use of, 18, 293 International Classification of Diseases (ICD-10)
community mobilization and community health on AIDS-related maternal death, 55b
workers, 290 on child mortality, 76
conditional cash transfers (CCTs), 19, 29091 on maternal death, 51
continuous quality improvement, 293 on unsafe abortion, 54
contraception, need for, 288 International Code of Marketing of Breast-milk
cost-effectiveness of, 29394 Substitutes, 235
expanding coverage and improving quality International Conference on Human Rights, 96
of care, 28993 International Conference on Population and
health outcomes, 28788, 287t Development (ICPD), 99
immunizations, 288 interventions, xiii, 8, 95114
landscape analysis of indicators, 28588 abortion. See abortion
measurement and accreditation, 292 contraceptives. See contraceptives
Index 385
cost-effectiveness. See cost-effectiveness of contraceptive use in, 98, 100f
interventions diarrheal diseases in, 170
demand-side, 19 Integrated Community Case Management (iCCM)
diarrheal diseases, 16977, 169b in, 153
early childhood development and, 24854 integrated services for HIV, malaria, and diarrhea
family planning, 95103. See also family planning in, 327
Indias universal home-based neonatal care package, mobile technology in, 274
339. See also India pneumonia in, 145
maternal mortality and morbidity, 814, 11536. TRAction Project in, 64
See also maternal mortality and morbidity, Khan, A., 103
interventions to reduce Khan, A. A., 103
scaling up. See scaling up Kirby, D., 104
stunting, 22539. See also stunting Kruk, M. E., 292
supply-side, 1819 Kumar, V., 336
violence against women. See violence against women Kuwait, stunting and height-for-age in, 87
intimate partner violence (IPV), 46, 37, 108, 248. kwashiorkor, 206, 216
See also violence against women
microfinance initiative combined with gender L
training on, 321 Lagarde, M., 19
intrapartum-related complications, 6 Lancet Commission on Investing in Health, 304
child mortality (under five) and, 7879, 79t Lao Peoples Democratic Republic, maternal mortality
interventions, 12628, 127t reduction in, 53
intrauterine growth restriction (IUGR), 7, 8 Latin America and the Caribbean. See also specific
causes of, 228 countries
consequences of, 22829 cash transfer programs in, 290
definition of, 22728 early child development, 254
early childhood development and, 247 chikungunya in, 147
prevention of, 12526, 229 child mortality (under five) in, 7275, 7374t, 80f
intussusception, 194 health care service delivery in, 28687, 287t
in vitro fertilization, 36 maternal mortality, disproportionate burden in, 53,
iodine deficiency and interventions, 8, 245, 253, 326 55, 65
Iran, Islamic Republic of number of hospital beds per 1,000 people in, 286
cost-effectiveness of family planning in, 103 number of nurses, midwives, and physicians per
maternal mortality reduction in, 53 1,000 people in, 286
iron supplementation, 23132, 245, 253, 326 stunting and height-for-age in, 7, 86, 8788f
IYCF (infant and young child feeding) guidelines, 225, teenage pregnancy in, 28
226t, 23536, 326 unintended pregnancy in, 2728
unsafe abortion in, 29
J Laxminarayan, R., 352
Jamaica legal restrictions
delayed mental development in, 247 on abortion, 106
psychosocial stimulation in, 254 on adolescents, 104
stunting and height-for-age in, 87 Lehmann, U., 277
Jamison, D. T., 352 Lenters, L. M., 20910, 211, 219
Japanese encephalitis (JE) vaccine, 188b, 195 Leonard, K. L., 292
Jimenez Soto, E., 289 Lewin, S., 327
Jones, K. D. J., 215 Liaqat, S., 293
Liberia, accredited hospitals in, 292
K Liu, A., 279
Kahn, J. G., 327 Liu, L., 144
kangaroo mother care, 81, 128 Lives Saved Tool (LiST), 8, 9b, 10, 178, 324, 330,
Kenya 339, 346
adolescent-friendly contraceptive services in, 105 London Summit on Family Planning (2012), 100
386 Index
low- and middle-income countries (LMICs), 2. commonly used, specially formulated foods for
See also specific diseases/conditions and prevention and treatment of, 209, 209t
interventions; specific regions and countries community-based interventions, 217, 233,
accredited hospitals in, 292 23536, 270
benefit-cost ratio for interventions in, 16 community management of acute malnutrition
child mortality (under five) in, 7275, 7374t, (CMAM), 212, 21314, 217
80f, 263 complementary feeding, 23031
cost of contraceptives in, 17 cost-effectiveness of interventions, 21617, 326
diarrheal diseases in, 164, 164f costs of interventions, 21617, 328
family planning in, 9596 definition of, 2056
maternal mortality, disproportionate burden in, edematous acute, 216
53, 115 enhancing study design and standardizing
stunting and height-for-age in, 88f reporting, 21719
unintended pregnancy in, 2728, 27t environmental enteric dysfunction and, 168
unsafe abortions in, 29, 3031t evidence gaps, need to address, 217
low height-for-age. See stunting key priorities, 218b
low weight-for-height. See wasting financial incentives to counter, 233
food-insecure populations, 211
M food-secure populations, 21011
macronutrients, 244, 244f fortified blended flours (FBFs) and, 209
Madagascar, contraception in, 101 global acute malnutrition (GAM), 206
magnesium sulphate, use of, 128 Global Nutrition Cluster decision-making tool, 210
Magpie study, 120 height-for-age and. See stunting
malaria, 1 hidden hunger, 205
cerebral malaria, 246 HIV/AIDS and, 215, 219
child mortality (under five) and, 7879, 79t implementation research and integrated
community-based interventions, 267 programming, 21920
cost-effectiveness of interventions, 32324 inpatient treatment programs, 21617
cost of scaling up interventions, 18 interventions, 13t, 23236, 23435t
diagnostic tools for, 14748 intrauterine growth restriction (IUGR) and, 22729
febrile children and, 137, 155 iodine deficiency, 8, 245, 253
malnutrition and, 215 iron, 23132
prevention strategies, 124t, 125, 140, 147, 148t lipid-based nutrient supplements (LNS), 209, 210,
vaccines, 187, 196, 325 211, 220n4
Malawi management of, 21012
Catalytic Initiative in, 154 maternal nutrition and fetal growth, 7, 8, 22729
community-based interventions in micronutrient supplementation, 229, 23132
cost-effectiveness of, 277 moderate acute malnutrition (MAM)
nutrition, 216 consequences of, 207m, 2078
womens groups, 290 definition of, 205
malnutrition in, 215, 216 food-insecure populations, 211
mobile technology in, 274 food-secure populations, 21011
Malaysia, malaria in, 147 management of, 21012
Maldives, maternal mortality reduction in, 53 research priorities for, 218b
Mali risk factors for, 206
Catalytic Initiative in, 154 strategies for prevention, 210
pneumonia in, 145 multiple micronutrient supplementation, 232
malnutrition, 78, 20523. See also stunting prevention of, 20810
anemia. See anemia ready-to-use-foods (RUFs) and, 209
antibiotic treatment, 21516 risk factors and causes of, 2067
breastfeeding, 22930 seasonal supplementation, 21112
causes and consequences of, 207m, 2078, 208t severe acute malnutrition (SAM)
challenges and future interventions, 23334 community management of, 326
Index 387
complications in, 21213, 212t levels and trends, 6, 7f, 5253, 116m
consequences of, 207m maternal death causes, 55
cost of scaling up treatment, 18 MDG 5a to reduce, 51, 115
definition of, 205 medical causes of maternal death, 7f, 52b, 5355
follow-up phase, 214 abortion, 2931, 54
infections in children with, 13t, 215 definitions of, 59b
initial treatment phase, 214 ectopic pregnancy, 54
interventions, 1, 14, 21216 indirect causes, 54
rehabilitation phase, 214 obstructed labor, 54, 59b
research priorities for, 217, 218b medical causes of maternal morbidity, 5661
risk factors for, 2067 abortion, 57. See also abortion
stunting as result of. See stunting anemia, 59
therapeutic foods for preventing, 2089 definition of maternal morbidity, 56
UNICEF undernutrition framework, 206, 206f definitions of, 59b
vitamin A, 231. See also vitamin A global burden of, 61
WASH strategies, 23233 HIV/AIDS, 61. See also HIV/AIDS
WHOs 10-step program, 213, 213f, 214 hypertensive disease, 6, 5758
zinc and. See zinc deficiencies incontinence, 60
MAM (moderate acute malnutrition). See malnutrition obstetric fistula, 6, 60
Mangham-Jefferies, L., 289, 320 obstetric hemorrhage, 6, 58
marasmus, 206 perceived morbidity, 56
Maredia, H., 267 postpartum depression, 60
Mariam, D. H., 292 postpartum vaginal or uterine prolapse, 6061
Marie Stopes International, 102 pregnancy-related complications, 61
Martorell, R., 231 pregnancy-related infection, 5859
maternal education, decline in child mortality principal diagnoses, 5657, 5758f
associated with, 7576 prolonged and obstructed labor, 6, 59, 59b
maternal mental health, 247, 255. See also depression severity of conditions, 56, 58f
interventions, 25354 overview, 5152
maternal mortality and morbidity, 5170 perceived morbidity, 56
abortion and, 6, 2931, 54, 57 quality of services, 64, 66
broader determinants of, 6165 research studies of, 5152
fourth delay, newly identified, 63 need for better data, 66
health system factors, 64 trends in maternal death, 55
individual risk factors, 6163, 62t underlying causes of maternal deaths, 52b
intersectoral issues, 65 unintended pregnancy and, 28
rights-based approach, 6364 violence against women and, 39
three delays model, 63, 64 maternal mortality and morbidity, interventions to
cost-effectiveness of interventions, 15f, 12930 reduce, 1, 814, 11536
deaths averted, 10f, 13, 14f, 352 active management of labor, 12627
decline in, 1, 65, 27980n1, 300 antenatal corticosteroids, 127
definition of maternal death, 51 antibiotics, use of
definition of maternal morbidity, 56 cesarean delivery, 12223
ecological studies of, 65 group B streptococcus (GBS), 129
embolism as cause of death, 55 neonatal sepsis, 129
family planning rationale, 96 preterm rupture of membranes, 128
fertility rates and, 4, 5m, 97 anticonvulsant prophylaxis, 120
global distribution of maternal death, 5455 antihypertensive therapy, 120
HIV/AIDS and, 6, 55b antithrombotic agents, use of, 126
indirect causes of death, 54, 6566 artery embolization, 118
interventions, 1, 814, 11536. See also maternal aspirin as prophylactic, 119
mortality and morbidity, interventions breastfeeding, 128
to reduce calcium supplementation, 119
388 Index
cesarean section, 121, 12223 sepsis
controlled cord traction, 118 neonatal, management of, 1, 129
cord clamping, early vs. late, 118 prevention of, 12223
cord cleansing, 12829 treatment of, 123
cost-effectiveness of, 15f, 12930 stillbirths, 814, 12329
cost of, 16t antenatal interventions, 12326
deaths averted, 10f, 13, 14f, 352 intrapartum interventions, 12628
diabetes treatment, 125 neonatal interventions, 12829
Doppler ultrasound, use of, 12526 surgical intervention, 119
drug interventions, 118 symphysiotomy, 122
early delivery options, 120 syphilis detection, 125
external cephalic version, 121 tetanus immunization, 125
fetal monitoring during labor, 126 training of birth attendants to give newborn
fetal movement counting, 126 resuscitation, 128
fetal shoulder manipulation, 122 uterine massage, 118
heparin, use of, 126 uterine tamponade, 118
HIV drug treatment, 125 vacuum and forceps delivery, 12122
hygiene, 126 vaginal application of antiseptics
interventions in development, 119, 122, 129 for cesarean delivery, 123
intrauterine growth restriction (IUGR), for vaginal delivery, 123
12526 zinc supplementation, 125
kangaroo mother care, 128 maternity waiting homes, 121
magnesium sulphate, use of, 128 Mazumder, S., 339
malaria prevention strategies, 125 McAuliffe, E., 293
maternal infections, treatment of, 125 McCord, G. C., 279
maternity waiting homes, 121 MDGs. See Millennium Development Goals
neonatal encephalopathy, 129 measles, 79
newborn care, 128 vaccines, 188b, 19192, 325
newborn resuscitation, 128 media
nonpneumatic antishock garment, 119 abortion information, 107
nutrition and supplementation, 12425 to reach adolescents on sexual and reproductive
obstructed labor, 12122 health issues, 1045
prevention of, 121 Meeting the Reproductive Health Challenge: Securing
treatment of, 12122 Contraceptives, and Condoms for HIV/AIDS
overview, 11516 Prevention (Istanbul conference 2001), 100
partograph, use of, 126 Megiddo, I., 15
postnatal care, 12829 meningitis
postpartum endometritis, 123 child mortality (under five) and, 7879, 79t
postpartum hemorrhage interventions, 143
prevention of, 11618, 117t cost of scaling up, 18
treatment of, 11819 Meningitis Vaccine Project, 195
postterm pregnancy, 126 meningococcal meningitis serogroup A conjugate
preeclampsia and eclampsia, 11921 vaccine, 188b, 195, 325
prevention of preeclampsia, 119 Mexico
treatment of, 11920 Cuidate program for sexual-risk reduction, 106
research programs on Oportunidades program, 103, 290
obstructed labor, 122 mHealth, 102
postpartum hemorrhage, 119 micronutrients, 229, 231, 24445, 244f, 326. See also
preeclampsia and eclampsia, 12021 vitamin and mineral supplements
stillbirth, 129 Middle East and North Africa. See also specific countries
respiratory distress syndrome, management of, 129 child mortality (under five) in, 7374t, 74, 80f
routine antenatal care visits, 123 contraceptive use in, 97
rupture of membranes, 123, 12728 female genital mutilation (FGM) in, 3940
Index 389
health care service delivery in, 28687, 287t neonatal mortality, 1, 6, 115, 265. See also child
number of hospital beds per 1,000 people in, 286 mortality
number of nurses, midwives, and physicians per in India, 335, 336f
1,000 people in, 286 Nepal
stunting and height-for-age in, 8687, 87f, 88f abortion services in, 106, 107
wasting in, 91b community-based interventions in, 270
midwives, 106, 286, 321, 328 birth attendants, 273
auxiliary nurse midwives (ANMs) in India, 337b cost-effectiveness of, 277
mifepristone and misoprostol, 106, 107 perinatal packages, 151
Millennium Development Goals (MDGs), 1, 2, 6, 19, contraception in, 102
99, 319, 330 family planning in, 102
MDG 4 (reduction of child mortality), 71, 7273, maternal morbidity in, 56
75, 178, 187, 266, 289, 300, 346 stunting and height-for-age in, 87
MDG 5 (improvement of maternal health), neurodevelopmental disabilities, 247
289, 300 newborns
MDG 5a (reduction of maternal mortality), care, 128
51, 115, 266 febrile, 143
MDG 5b (access to contraception), 51, 63 mortality. See child mortality; neonatal mortality
MDG 7 (improvements in water, sanitation, and resuscitation, 128
hygiene), 146, 174 Nguyen, P., 231
misoprostol, 11718, 117t, 273, 289 Nicaragua
Mliga, G. R., 292 adolescent-friendly contraceptive services in, 105
mobile services quality improvement collaboration in, 294
family planning and, 102 Red de Proteccon Social, 103
outreach clinics, 189, 327 Niger
mobile technology as part of community-based Catalytic Initiative in, 154
interventions, 27475 malnutrition and wasting in, 91b, 21112
moderate acute malnutrition (MAM). stunting and height-for-age in, 87, 88
See malnutrition Nigeria
Mongolia, maternal mortality reduction in, 53 child mortality (under five) in, 7879
Moore, S. R., 166 cost-effectiveness of family planning in, 103
Morocco, contraceptive use in, 97, 100f diphtheria-tetanus-pertussis vaccine in, 188b
Mozambique DTP vaccine in, 197
Catalytic Initiative in, 154 fever in children under age five years in, 140
malnutrition in, 215 maternal mortality, disproportionate burden in, 53
Multi-Country Evaluation of the Integrated vaccine costs in, 197
Management of Childhood Illness (IMCI), 301 nonpneumatic antishock garment, 119
Multi-country Study on Womens Health and Domestic non-sexually transmitted reproductive infections,
Violence against Women, 38 3235
Multiple Indicator Cluster Surveys (DHSs & UNICEF), bacterial vaginosis, 3335, 34t
3940, 85, 242 vulvovaginal candidiasis (VVC), 3233, 33t
Myanmar, contraception in, 102 Nonvignon, J., 323
nutrition. See also folic acid; malnutrition; vitamin A;
N vitamin and mineral supplements
Nakhaee, N., 103 biofortification, 326, 329
Nandi, A., 15 child deaths averted by scaling up, 235f
National Center for Health Statistics, 86 child interventions, 23236, 23435t
neonatal interventions, 814, 12829 community-based nutrition programs, 270, 27172t
community-based interventions, 26566, 270 cost-effectiveness of interventions, 177, 32627
neonatal encephalopathy, management of, 129 costs of interventions, 328
respiratory distress syndrome, management of, diarrheal diseases and, 173
129, 151, 266, 274 early childhood development, 24445, 244f, 24951,
sepsis, management of, 1, 129 25455
390 Index
height-for-age and. See stunting Palmer, N., 19
iron supplementation, 23132 Pan-American Health Organizations revolving
maternal mortality and morbidity, 12425, 124t fund, 325
maternal nutrition, 23435t, 24647 Papua New Guinea
interventions, 25253 Integrated Management of Neonatal and Childhood
psychosocial stimulation integrated with child Illness (IMNCI) in, 151
nutrition, 251 wasting in, 91b
Nutrition Impact Model Study (NIMS), 85 parasite infestations, 26768
partograph, use of, 126
O Peabody, J. W., 18
obstetric fistula, 6, 60 pelvic inflammatory disease (PID), 3435
obstetric hemorrhage. See postpartum hemorrhage performance-based financing, 18, 102, 291,
obstructed labor. See childbirth 29293
official development assistance, 2 perinatal morbidity and mortality
OneHealth Tool, 304, 304b, 307, 308 evidence-based policy making and interventions,
Onwujekwe, O., 103 124t, 127t
open defecation, 176, 232 levels and trends, 6
oral cholera vaccine, 188b, 197 pertussis immunization. See diphtheria, tetanus, and
oral rehydration salts, use of, 350 pertussis vaccines
oral rehydration solutions (ORS), 16970, 171, 173, Peru
179, 28687, 324, 350 diarrheal diseases in, 167, 170
Ouagadougou Declaration (West Africa, 2011), 100 IMCI effectiveness in, 149
overweight, 7, 8 maternal depressions effect on child
oxytocin, 116, 117t, 118, 273 development in, 248
Ozawa, S., 320 Philippines
accredited hospitals in, 292
P Integrated Management of Neonatal and Childhood
Paciorek, C. J., 85 Illness (IMNCI) in, 151
Paczkowski, M., 292 payment-for-performance incentives in,
Pakistan 18, 292
child mortality (under five) in, 7879 physicians, 286. See also health workers/professionals
community-based interventions in, 270 PID (pelvic inflammatory disease), 3435
home visits and reduction in newborn pneumococcal conjugate vaccines, 14, 15, 81, 188b,
deaths, 265 19394, 199, 325, 34850, 34950t
lady health worker program, 252b, 267b, 273 pneumonia, 1
perinatal packages, 151 antibiotics, use of, 348
contraception in, 102 child mortality (under five) and, 79t
DTP vaccine in, 197 in children under age of five, 6, 78
Early Child Development Scale-Up Trial, 252b community-based care, 266
family planning in, 102 cost-effectiveness of interventions, 323, 353f
cost-effectiveness of, 103 cost of scaling up treatment, 18
handwashing in, 175 in Ethiopia, treatment and prevention, 34561.
home visits and reduction in newborn See also Ethiopia
deaths in, 336 universal public finance for pneumonia treatment,
Integrated Community Case Management (iCCM) 15
in, 153, 154 Pneumonia Etiology Research for Child Health
maternal depressions effect on child development project, 145
in, 248 Polio Eradication and Endgame Strategic
pneumonia in, 153 Plan 2013-2018, 191
stillbirth data from, 76 polio vaccines, 188b, 191, 325
Thinking Healthy program, 253 postnatal care, 12829
vaccine costs in, 197 postpartum depression, 60, 248
wasting in, 207 postpartum endometritis, 123
Index 391
postpartum hemorrhage, 6, 58 cost-effectiveness of, 29394, 294t
definition of, 59b innovations to improve, 29193
prevention of, 11618, 117t Integrated Community Case Management (iCCM), 153
treatment of, 11819 maternal mortality and morbidity and, 64, 66
postpartum vaginal or uterine prolapse, 6061 supply-side interventions, 18
poverty and the poor Quimbo, S. A., 292
diarrheal diseases interventions and, 178
financial risk protection for, 15. See also financial R
risk protection rabies, 189b
maternal mortality and morbidity of, 62t, 130 Ramakrishnan, U., 231
stunting and, 8, 92 referral systems, 275
unconditional cash transfers (UCTs) and, 290 reproductive, maternal, newborn, and child health
vouchers for. See vouchers (RMNCH). See also childbirth; childhood
wasting and, 207 illness; child mortality; maternal mortality and
preeclampsia and eclampsia, 11921 morbidity; newborns; reproductive health
definition of, 59b community-based care, 26384. See also
prevention of preeclampsia, 119 community-based interventions
treatment of, 11920 continuum-of-care approach, 2, 299317. See also
pregnancy continuum-of-care approach
anemia in, 59 cost-effectiveness, 1416, 15f, 31934. See also
complications related to, 61 cost-effectiveness of interventions
ectopic pregnancy, 54 cost of, 2, 16t
infection related to, 5859 delivery platforms, 2, 8, 1113t. See also
interventions, 1112t community-based interventions;
partner violence reported during, 5, 39 hospitals; primary health centers
teenage. See adolescents funding levels, 319
unintended, 2528 innovations to overcome weaknesses in services,
consequences of, 28 28598. See also innovations to expand access
measurement approach for study of, 26 and improve health care quality
prevalence and incidence, 2628, 27t interventions. See interventions
reasons for, 28 levels and trends in indicators, 46
unsafe abortion. See abortion overview, xiii, 2
preterm births, 1, 6, 28 summary of major topics, 12
African-American women and, 253 reproductive health
child mortality (under five) and, 78, 79t abortion. See abortion
early childhood development and, 247 burden of reproductive ill health, 2550. See also
maternal morbidity and mortality and, 12728 burden of disease
primary health centers, 2, 9 contraceptive services. See contraceptives
interventions for maternal and child mortality and cost-effectiveness of interventions, 15f, 321, 323
morbidity, 8, 1113t, 14 cost of interventions, 16t, 17
Prinja, S., 328, 339 delivery platforms, 11t
prolonged labor. See childbirth family planning. See family planning
psychosocial stimulation, 24344, 244f, 24849, funding for, 2
250b, 254 importance of, 1
integrated with child nutrition, 251 interventions to improve, 1013, 11t, 95114
Pakistans Early Child Development Scale-Up levels and trends in indicators, 45
Trial, 252b unintended pregnancies, 4, 2528
Puett, C., 217 Reproductive Health Supplies Coalition, 100
research studies
Q on community-based interventions, 279
quality of services on early childhood development, 255
child mortality reduction and, 81 future research needs, 19, 155
community-based care, 274 on malnutrition, 218b, 21920
392 Index
on maternal mortality and morbidity, 5152 Scaling-Up Nutrition initiative, 89
on obstructed labor, 122 schistosomiasis, 26768
on postpartum hemorrhage, 119 Seamans, Y., 103
on preeclampsia and eclampsia, 12021 Sedgh, G., 26
on stillbirth, 129 sepsis
resilience-building, 1056 child mortality (under five) and, 7879, 79t
respiratory and other bacterial illnesses, 14445, 146t, 148 febrile children, 143
respiratory distress syndrome, management of, 129 maternal, 6, 12223
results-based financing. See performance-based neonatal, 1, 129
financing severe acute malnutrition (SAM). See malnutrition
rights-based approach sex education, 11t, 104
to family planning, 96 sexual abuse. See also violence against women
to maternal mortality and morbidity, 6364 child sexual abuse, 38, 39
Rizvi, A., 326 sexually transmitted infections (STIs), 5, 25, 32
Robberstad, B., 178 Shigella infection, 16569, 171, 172
Robinson, L., 307 sickle-cell disease, 146
Roll Back Malaria Partnership, 140, 323 Sierra Leone, contraception in, 102
Ross, J., 97 Singh, P., 279
rotavirus, 17172 Singh, S., 26
diarrhea and, 165, 350, 351t Sino-implant (II), 99
vaccine, 81, 188b, 194, 350, 35456 Smith, M. I., 216
Routh, S., 327 social and economic benefits, 16
rubella vaccine, 188b, 19495, 325 of continuum-of-care approach, 304, 3078, 312, 313
rupture of membranes, 12728 of contraception, 26
preterm and term prelabor, 123 of family planning, 81
rural areas of immunization, 19899
health centers, iCCM and, 154 social costs and stigma
home-based neonatal care (HBNC) package in of infertility, 36
rural India, 33544. See also India of open defecation, 176
stunting and height-for-age in, 8790, 8889f, of unsafe abortions, 32, 54
90m, 91f social factors for maternal mortality and
Rusa, L., 292 morbidity, 62t
Rwanda social franchising, 102
maternal mortality reduction in, 53 social marketing, 1012
performance-based financing in, 18, 291 social networking, 107
South Africa
S HIV/AIDS in, 150
Sabin, L. L., 327 microfinance initiative combined with gender
Safe Motherhood Initiative, 63, 130, 321, 329 training on intimate partner violence in, 321
Salam, R. A., 267 pneumonia in, 145
SAM (severe acute malnutrition). See malnutrition South Asia
Sanders, D., 277 Aetiology of Neonatal Infection study in, 151
sanitation. See water, sanitation, and hygiene anemia in, 231, 244
Sayana Press, 99 chikungunya in, 147
scaling up, 1 childbirth interventions recommended in, 273
child mortality reduction, 81, 235f child mortality (under five) in, 6, 7275, 7374t,
community-based interventions, 275, 27778 79, 80f
cost of, 1617t, 1618 community-base care, cost-effectiveness of, 276
Indias HBNC package, 338 cost-effectiveness of malaria interventions in, 323
of Integrated Community Case Management diarrheal diseases in, 164, 164f, 246
(iCCM), 155 early childhood development in, 243
interventions in maternal and newborn health and Expanded Program on Immunization (EPI) in, 187
child health, 14, 130 health care service delivery in, 28687, 287t
Index 393
infertility in, 36t in urban areas, 88, 8889f, 90m, 91f
iodine deficiency in, 245 Sub-Saharan Africa. See also specific countries
malnutrition in, 208, 230, 235 accredited hospitals in, 292
maternal depressions effect on child anemia in, 231, 244
development in, 248 chikungunya in, 147
maternal mortality and morbidity in, 4m, 6 child mortality (under five) in, 6, 19, 7275, 7374t,
disproportionate burden in, 54, 55 78, 80f
number of hospital beds per 1,000 people in, 286 community-base care, cost-effectiveness of, 276
number of nurses, midwives, and physicians per condom use in, 105
1,000 people in, 286 contraception in, 101
preterm infants and neurodevelopmental cost-effectiveness of malaria interventions in, 323
disabilities in, 247 diarrheal diseases in, 164, 164f, 167, 246
safe abortion technologies in, 106 early childhood development in, 243
stunting and height-for-age in, 8688, 8788f, 225 Expanded Program on Immunization
wasting in, 91b (EPI) in, 187
South Sudan, wasting in, 91b febrile children in, 137
Souza, J. P., 291 fertility rates in, 4, 4m, 6, 19
Stein, C., 58 group B streptococcus (GBS) in, 144
sterilization, 97, 102 health care service delivery in, 28687, 287t
stillbirths, 1, 814, 12329 HIV mortality in, 6, 55
antenatal interventions, 12326 infertility in, 36t
cause of, 7778, 7778t iodine deficiency in, 245
child mortality including, 71, 75, 76, 115 malaria vaccine in, 196
data sources, 72, 76 maternal depressions effect on child
interventions, 1, 814, 12329 development in, 248
intrapartum interventions, 12628 maternal mortality and morbidity in, 4m, 6, 19,
levels and trends, 6 65, 27980n1
neonatal interventions, 12829 disproportionate burden in, 5355, 263
by regions, 77t meningococcal meningitis serogroup A conjugate
research needs on, 81 vaccine in, 195
STIs (sexually transmitted infections), 5, 25, 32 number of hospital beds per 1,000 people in, 286
Stover, J., 97 number of nurses, midwives, and physicians per
stunting, 7, 8593 1,000 people in, 286
by country, 89m obstetric fistula in, 60
Cryptosporidium infection and, 167 pneumococcal conjugate vaccines in, 193
environmental enteric dysfunction and, 168 preterm infants and neurodevelopmental
Giardia infection and, 167 disabilities in, 247
global trends, 86, 226m rubella vaccine in, 194
H. pylori infection and, 167 safe abortion technologies in, 106
height correlated with mental development, 245 stunting and height-for-age in, 8688, 8788f, 225
height-for-age in 2011, 8788 teenage pregnancy in, 28
interventions, 22539 trachoma in, 245
child malnutrition, 23236, 23435t unintended pregnancy in, 2728
complementary feeding, 23031 unsafe abortion in, 29
maternal malnutrition, 22730, 228f, 23435t wasting in, 91b
micronutrient supplementation, 23132 Sudan
WASH strategies, 23233 community-based nutrition
malnutrition and, 225. See also malnutrition programs in, 216
methods of study, 8586 Integrated Community Case Management (iCCM)
overview, 85 quality and safety in, 153
priority setting and, 8892 supply-side interventions, 1819
regional trends, 8687, 87f, 91f surgical intervention for pregnancy and maternal
in rural areas, 8790, 8889f, 90m, 91f morbidity, 119
394 Index
Sustainable Development Goals, 19, 51, 187, 314, 330 Integrated Community Case
symphysiotomy, 122 Management (iCCM) in, 153
syphilis detection and treatment, 5, 124t, 125 Ukraine, contraceptive use in, 98, 100f
ultrasound, use of, 12526, 289
T unconditional cash transfers (UCTs), 290
Tanzania Underwood, C., 104
adolescent-friendly contraceptive services in, 105 UNESCO, on children not attending school, 105
IMCI effectiveness in, 149 UNICEF, 52
Integrated Community Case Management (iCCM) Child Health Epidemiology Reference Group
in, 153 (CHERG). See Child Health Epidemiology
mobile technology in, 274 Reference Group
quality of care in, 292 Ethiopias community-based nutrition initiative,
TRAction Project in, 64 evaluation of, 270
training of health care providers in, 293 Gavi (Vaccine Alliance). See Gavi
telemedicine, 107 Global Action Plan for Prevention and Control of
tetanus immunization, 124t, 125, 191, 288. See also Pneumonia, 145
diphtheria, tetanus, and pertussis vaccines Joint Malnutrition data set, 208
Thailand nutrition guidelines, 225
diarrheal diseases in, 166, 167 undernutrition framework, 206, 206f
pneumonia in, 145 unintended pregnancy. See pregnancy
three delays model of maternal mortality and United Kingdom
morbidity, 63, 64 Confidential Enquiry into Maternal Death, 122
Timor-Leste Department for International Development, 101
maternal mortality reduction in, 53 United Nations
stunting and height-for-age in, 88 Childrens Fund. See UNICEF
wasting in, 91b Declaration on the Elimination of Violence against
Tofail, F., 247 Women, 37
Tozan, Y., 323 Every Woman Every Child, 100
trachoma, 24546, 251 on family planning spending, 95
TRAction Project in Kenya and Tanzania, 64 Global Strategy for Womens and Childrens Health,
training and supportive supervision. See also health 2, 19, 52
workers/professionals Population Division (UNPD), 40, 52, 96
birth attendants training for newborn resuscitation, 128 Population Fund, 52, 96, 101
innovations to expand access and improve health United States, continuous quality improvement (CQI)
care quality, 293 in, 293
tropical enteropathy, 167 United States Agency for International Development
tuberculosis (USAID), 101, 292, 293
Bacille Calmette-Gurin Vaccine, 18990 universal health coverage, 19, 300, 345
community-based interventions, 270 University of York, 329
malnutrition and, 215 unsafe abortion. See abortion
Tufts Cost-Effectiveness Analysis Registry, 329 urban areas, stunting and height-for-age in, 88, 8889f,
Tulane University and evaluation of Ethiopias 90m, 91f
community-based nutrition initiative, 270 urgent care, 14
Tunisia, stunting and height-for-age in, 87 urinary tract infections (UTIs), 144
Turkey, contraceptive use in, 98, 100f U.S. Presidents Malaria Initiative, 140
typhoid vaccine, 325 user fee removal, 290
uterine massage, 118
U uterine tamponade, 118
Uganda
adolescent-friendly contraceptive services in, 105 V
cerebral malaria in, 246 vaccines, 13t, 14, 187204. See also Gavi
early child development in, 254 Advanced Market Commitment, 188b
IMCI effectiveness in, 149 Bacille Calmette-Gurin Vaccine, 18990
Index 395
cost and cost-effectiveness, 19798 vitamin A
cost-effectiveness of, 15f, 19798, 198t, 32426 deficiency, 7, 8, 227
diarrheal diseases, 171 supplementation, 13t, 231, 288
diphtheria, tetanus, and pertussis, 188b, 189, 19091, vitamin and mineral supplements, 7, 13t, 229, 245, 288
32425 vouchers, use of, 19, 1023, 291
direct social and economic benefits, 19899 vulvovaginal candidiasis, 3233, 33t
Expanded Program on Immunization (EPI),
14, 187, 18992, 319, 329 W
Haemophilus influenzae Type b (Hib), 193 Wagner, K., 59
hepatitis B, 188b, 19293, 325 Walker, G. J. A., 60
indirect social and economic benefits, 199 Walker, S. P., 247
influenza, 189b, 196 wasting, 7, 8, 89, 91b, 205. See also malnutrition
innovations to expand access and improve health water, sanitation, and hygiene (WASH), 13t
care quality, 199, 288 community-led total sanitation, 17677
Japanese encephalitis (JE), 188b, 195 cost of interventions, 329
malaria, 187, 188b, 196, 325 diarrheal diseases and, 165, 167, 174
measles, 188b, 19192, 325 early childhood development and, 251
meningococcal meningitis serogroup A conjugate malnutrition and, 207, 219, 23233
vaccine, 188b, 195, 325 maternal mortality and morbidity and, 65, 126
methods, 189 Waters, D., 143
oral cholera vaccine, 188b, 197, 325 Webb, P., 209
pneumococcal conjugate, 188b, 19394, 325 weight. See overweight; wasting
polio, 188b, 191, 325 well-child visits
rabies, 189b immunizations at, 189
rotavirus, 188b, 194 stimulation programs and, 250b
rubella, 188b, 19495, 325 West Africa
timeliness of administration, 198 anemia in, 59
vaccine-preventable diseases, 18997, 32425 Ouagadougou Declaration (2011) on family
yellow fever, 188b, 195, 325 planning and reproductive health, 100
vacuum and forceps delivery, 12122 White, M. T., 320
vaginal application of antiseptics WHO. See World Health Organization
for cesarean delivery, 123 whooping cough. See diphtheria, tetanus, and pertussis
for vaginal delivery, 123 vaccines
value of life years saved (VLY), 3078 World Bank, 52
verbal autopsies, 76, 81 Ethiopias community-based nutrition initiative,
Verguet, S., 327, 348, 352 evaluation of, 270
Vietnam Gavi (Vaccine Alliance). See Gavi
community-based interventions, Joint Malnutrition data set, 208
costs of, 279 World Development Indicators, 321
contraception in, 102 World Bank Malaria Booster Program, 140
immunizations in, 325 World Health Assembly
Integrated Community Case on stunting, 85
Management (iCCM) in, 153 on wasting, 91b
maternal depressions effect on child World Health Organization (WHO), 6
development in, 248 acute respiratory infections (ARIs) and, 144
stunting and height-for-age in, 87 antiretroviral therapy (ART) and, 125
violence against women, 45, 25, 3739 artery embolization and, 118
definitions and measurements, 3738 breastfeeding until age six months and, 128, 220n2
health and other consequences, 39 calcium supplementation for pregnant
interventions, 1078 women and, 124
magnitude of the problem, 38, 38m, 64 childbirth interventions recommended by, 273
viral exanthems, 14546 childbirth safety checklist, 18
Viscusi, W., 307 Child Growth Standards, 225
396 Index
Child Health Epidemiology Reference Group Immunization and Malaria Policy Advisory
(CHERG). See Child Health Epidemiology Committee, 188b, 196
Reference Group 10-step malnutrition program, 214
chlorhexidine application to umbilical cord, 129 universal health coverage and, 300, 345
cholera vaccines, approval of, 197 unsafe abortion
Choosing Interventions that are Cost-Effective definition of, 28
project, 329 indirect approach to study of, 29, 31
complementary feeding guidelines, 230 uterine massage, 118
essential newborn care, 128 violence against women
Expanded Program on Immunization, 178 clinical and policy guidelines, 108
female genital mutilation (FGM) study, 40 estimates on, 38
fever treatment guidelines, 140, 148, 149f WHO/CHOICE model, 276, 329
Gavi (Vaccine Alliance). See Gavi WHO/PRE-EMPT Calcium in Pre-eclampsia
Global Action Plan for Prevention and Control of (CAP), 120
Pneumonia, 145 World Health Report (2010), 342
Global Database on Child Growth and Young Infants Study Group and Young Infants
Malnutrition, 85 Clinical Signs Study Group, 143
Global Health Estimates, 61, 96 World Report on Disability (WHO & World Bank), 36
Guidance Panel on Task Shifting, 18 worm and parasite infestations, 26768
health system building blocks, 64
hepatitis B vaccine recommendations, 193 Y
infant and young child feeding (IYCF) guidelines, yellow fever vaccine, 188b, 195, 325
225, 226t, 23536 Yemen
infertility, definition and measurement of, 3536 female genital mutilation (FGM) in, 3940
Integrated Management of Childhood Illness stunting and height-for-age in, 88
(IMCI), 130, 137, 145, 146t, 14850, teenage pregnancy in, 28
149f, 266 youth centers, 105
Japanese encephalitis (JE) vaccine
recommendations, 195 Z
Joint Malnutrition data set, 208 Zaidi, A. K. M., 143
malaria vaccine recommendations, 147, 196 Zambia
maternal morbidity study, 56 accredited hospitals in, 292
Maternal Morbidity Working Group, 56 child health services, costs of, 328
maternal mortality study, 52 community-based interventions in, 266
measle vaccine recommendations, 191 Lufwanyama Neonatal Survival Project, 277
Multi-country Study on Womens Health and nutrition, 217
Domestic Violence against Women, 38, 119 Integrated Community Case Management (iCCM)
nutrition guidelines, 216 in, 153, 154
oral rehydration solutions, malnutrition in, 215
recommendations for, 169 maternal mortality and morbidity in, 65
pneumonia guidelines, 145 pneumonia in, 145
polio vaccine recommendations, 191 training of birth attendants to administer neonatal
preeclampsia and eclampsia prevention, 119 resuscitation in, 151
rotavirus recommendations, 194 Zimbabwe
safe abortion technologies, 106 adolescent-friendly contraceptive services in, 105
SAFE (surgery, antibiotics, facial cleanliness, and cash transfers in, 290
environmental improvements) strategy for cholera in, 197
trachoma elimination, 251 contraceptive use in, 97, 100f
Special Programme for Research and Training in zinc deficiencies, 7, 8, 173, 227, 231
Tropical Diseases, 152 diarrheal diseases and, 169, 17374, 324
Strategic Advisory Group of Experts on supplementation, 13t, 125
Index 397
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