CLINICAL EPIDEMIOLOGY OF THE

LEADING CAUSES OF MORBIDITY

AND MORTARITY OF CHILDREN

A PRESENTATION BY GEORGE KASONDA

MMED PAEDIATRIC STUDENTS.
 United Republic of Tanzania
Ministry of Health and Social
Welfare
 OVERVIEW
When a woman
undertakes her biological
role of becoming
pregnant and undergoing
childbirth, the society has
an obligation to fulfil her
basic human rights,
which include the right to
life, liberty social
security, maternity
protection and non
discrimination
 OVERVIEW
Purpose
. The health of the mother is closely linked to the health
and survival of the child. In addition, the socio-economic level of the
mother and the maternal health status
(HIV/AIDS, malaria, nutrition) has an impact on the survival of the child.
Thus the primary purpose of One
Integrated Maternal Newborn and Child Health Strategic Plan is to
ensure improved coordination of
interventions and delivery of services across the continuum of care.
Another purpose of the document is to
guide implementation across operational levels of the system so that
policy drawn at national level will be
carried out at the district and community levels, with support from the
regional level. It is anticipated that a joint
strategy will contribute to more integrated implementation, improved
services, and ultimately a significant
reduction in morbidity and mortality of Tanzanian women and children
 Introduction
The total population of Mainland Tanzania is estimated
to be 39,384,223. Most of the
population (75%) resides in the rural area. The annual
growth rate is 2.9% with life expectancy at birth being
54 years for males and 56 years for females2.
The total fertility rate in Tanzania has been consistently
high over the past ten years and currently stands at 5.7
children per woman. There are regional variations with
urban-rural disparities, where rural women have higher
fertility rates than their urban counterparts3.
The Maternal Mortality Ratio (MMR) has remained high
for the last 10 years4 without showing
 The Maternal Mortality Ratio (MMR) has remained high for the
last 10 years4 without showing any decline and
is currently estimated to be 578 per 100,000 live births5. While
significant progress has been made to reduce
child mortality in Tanzania, the neonatal mortality rate remains
high at 32 per 1,000 live births, and accounts
for 47% of the infant mortality rate which is estimated at 68
per 1,000 live births.
The critical challenges in reducing maternal, newborn and child
morbidity and mortality comprise two
categories:
(a) Health system factors - inadequate implementation
of pro-poor policies, weak health infrastructure, limited
 a) Health system factors - inadequate implementation of
pro-poor policies, weak health infrastructure, limited
access to quality health services, inadequate human resource,
shortage of skilled health providers, weak referral
systems, low utilization of modern family planning services, lack of
equipment and supplies, weak health
management at all levels and inadequate coordination between
public and private facilities.
(b) Non health system factors- inadequate community
involvement and participation in planning,
implementation, monitoring and evaluation of health services,
some social cultural beliefs and practices, gender
inequality, weak educational sector and poor health seeking
behaviour.
1.2 Initiatives
 Newborn Health
Newborn morbidity and mortality
Tanzania is among those countries that have had
success in reducing child mortality, but there has been
no
measurable progress in reducing neonatal deaths. The
neonatal mortality rate was 40.4 per 1,000 live births
in 1999 and 32 per 1,000 live births in 2004/05. Up to
50% of neonatal deaths occur in the first 24 hours
of life, with over 75% of them arising in the first week
of life. Newborn mortality is a sensitive indicator
of the quality of care provided during the antenatal
period, delivery and immediate postnatal period
 According to modelled estimates for
Tanzania, 79% of newborn deaths are
due to three main causes:
infections including sepsis/pneumonia
(29%), birth asphyxia (27%); and
complications of preterm birth
(23%) . Sepsis was the most common
cause of death noted in a study
conducted in Mbulu and
 Hanang districts of rural northern Tanzania. Many
of these conditions are preventable and closely
linked to the absence of skilled birth attendance at
delivery. Eighty-six percent (86%) of neonatal
deaths in Tanzania are also low birth weight, many
of whom are preterm. On average in Tanzania, new
born deaths are 67% higher in the poorest families
as compared to the wealthier families, and the
majority of deaths occur in rural areas.
 Low birth weight (birth weight less than
2500 grams) and preterm birth (less than
36 completed weeks of gestation) together
contribute to 28% of neonatal deaths
globally28. The recent Tanzania DHS
(2004/05) asked mothers to estimate
whether their infant was very small,
small, average, or large. They were
 They were also
asked to report the actual birth weight, if it
was known. The TDHS data cite a
neonatal mortality of 86% in the five-year
period prior to the survey among
small/very small newborns. However,
other all-cause mortality estimates indicate
a mortality rate of 23% for preterm infants
(who are most likely also of low birth
weight.).
 Estimated causes of neonatal
death
1.Infection ---- 29%
2.Asphyxia ----- 27%
3. Preterm ------ 23%
4. Others ------- 8%
5.Congenital------- 7%
6.Diarrhea ------- 3%
7.Tetanus ------ 3%
Source TDHS 2004/5
 Continuum of care
It is important to address the coverage of interventions
along the continuum of care from pregnancy,
neonatal period, infancy and childhood. It is critical to note
that the coverage of essential interventions is
lowest at the time when needed most: that is, during child
birth and the early neonatal period when
more than 50% of maternal and newborn deaths occur
(Figure 3).
Source: 2004/5 TDHS
Figure 2: Estimated Causes of Neonatal Deaths
Figure 3: Coverage of Interventions along the
Continuum
 Furthermore, quality newborn and child care faces
other challenges including poor health
infrastructure
and referral for neonatal care, child care and poor
skills of service providers related to inadequate
incorporation of neonatal content in pre- and in-
service training curricula. A recent study conducted
in Dar
es Salaam in 2005 showed that none of the primary
and secondary level health facilities was providing
basic/essential newborn care.
 Only 20% of women
receive Vitamin A
supplementation
within 2months
after childbirth
 Child Health
Immunization
The Expanded Programme of Immunization (EPI) has performed well over the
past decade with immunization coverage of 71% for all vaccines for
children 12-
23 months (TDHS, 2004/05). Currently the policy is to provide each child
with
one dose of BCG, four doses of OPV, three doses of DTP-HB and one
dose of
measles vaccine. As expected, children born to mothers in the lowest
wealth
quintile are less likely to be fully immunized than those born to mothers
in the
highest wealth quintile.
Pneumonia is one of the major contributors towards under five mortality
 Measles outbreaks are still
happening despite high measles
routine immunization coverage
(above 80% in
almost all districts). Tanzania has
been implementing the Reaching
Every District (RED) strategy to
 The achievement of TT and polio vaccines is evident
by the significant reduction in neonatal tetanus deaths
and polio cases. The last polio case in the country was
identified in 1996; however, there is a high risk of
wild polio virus importation from polio-endemic
countries. In this regard polio eradication initiatives
need
to be sustained until polio is eradicated.
Tanzania is close to achieving Maternal Neonatal
Tetanus (MNT) elimination; however, there are still
some pockets in high risk districts. Implementation of
MNT elimination strategies will focus more in h
 Malaria contributes to 23% percent of under five mortality
in Tanzania. Use of ITNs contributes to
7 percent reduction of overall deaths among under-fives .
Only 47% of under fives in Tanzania sleep
under ITNs. ITNs are distributed through the health system
by vouchers, as well as by free distribution of
long lasting insecticide treated nets (LLINs) through catch
up campaigns and replacement campaigns to
replace worn out ITNs in the period 2008 2012 when
appropriate.
Malaria management has been improved using the
combination therapy of Artemether and Lumefantrine
(ALu).
CAUSES OF DEATH FOR UNDER FIVE

1.Malnutrition ---- 50%

2.Neonatal ----- 26.9%
3.Malaria -------- 22.7%
4.Pneumonia ------ 21.1%
5.Diarhea disease 16.8%
Hiv AIDS ----- 9.3%
6.Measles --------- 1.3%
7.Injuries -------- 2%
8. others --------- 0%
Source WHO 2006
T H A N K YO U