Maternal and child health

Question 1

Overview

Answer 1

» Why maternal and child health?
» The child survival revolution
» Current rates and causes of child and maternal death
» What is the real issue?

Question 2

Why the focus on child mortality?

Answer 2

Most people either die in their frst
fve years of life, or in older age.
If you survive until age 5, you will
likely survive until age 60-90.

Question 2

Children and mothers go together

Answer 2

Question 3

Terminology

Answer 3

» Under-fve child = frst fve years
» Infant = frst year
» Newborn (neonate, neonatal) = frst
month or frst 28 days

Question 3

Child and maternal mortality rates

Answer 3

» Under fve mortality rate (U5MR)
- the number of deaths of children under fve years old per 1,000 live births
» Neonatal mortality rate (NMR)
- the number of deaths of newborns (less than 28 days old) per 1,000 live births
» Maternal mortality ratio (MMR)
- the number of maternal deaths during a given time period per 100,000 live births during the
same time period

Question 3

Child mortality rates

Answer 3

Question 3

Child mortality in 1800

Answer 3

“[Until] at least the year
1800, more than one-third
of children failed to reach
the age of fve. In some
countries, rates could have
been as high as every 2nd
child.”
~ Our World in Data

Question 3

Child mortality in 1950

Answer 3

“By 1950, the outlook had
changed dramatically — but
only for some countries. For
the richest countries, child
mortality had fallen to less
than 5 percent (1-in-20). But
child mortality rates across the
rest of the world were still
unimaginably high.”
~ Our World in Data

Question 4

Child mortality in 2015

Answer 4

“By 2015, substantial
declines in child mortality
had occurred across all
regions. Average rates in
Africa are now lower than
the European average in
1950.”
~ Our World in Data

Question 5

Why the improvement?

Answer 5

From 1800-1950, in high-income countries…
» Development of vaccines (smallpox, pertussis, typhoid, tetanus, tuberculosis)
» Development of penicillin (antibiotics)
» Improved water, sanitation, and hygiene
» Improved nutrition

Question 6

However…

Answer 6

Even into the 1960s and
1970s, child mortality was
still unacceptably high in
most low-income
countries

Question 7

Selective primary health care

Answer 7

GOBI-FFF
» G for growth monitoring to detect undernutrition in small children
» O for oral rehydration solution (ORS) to treat childhood diarrhea
» B to encourage breastfeeding
» I for immunisation against six diseases: tuberculosis, polio, diphtheria, tetanus, whooping
cough, and measles
» FFF for food supplements, family planning, and female education.

Question 8

Child survival revolution

Answer 8

“The child survival revolution was an efort started by UNICEF (but joined by others) to reduce
child mortality in the developing world.”
“The efort lasted from 1982 to the 1990s.”
“Rather than treating child mortality as a measurement of development, the efort sought to
directly reduce child mortality as a way toward development.”

Question 9

Oral rehydration solution (ORS)

Answer 9

82% efective in preventing child death due to diarrhea

Question 10

Child survival revolution

Answer 10

“The child survival revolution is estimated to
have saved the lives of 25 million children.”

Question 10

Oral rehydration solution (ORS)

Answer 10

“In 1978, The Lancet called the discovery of the sodium-glucose transport mechanism as
perhaps the most important medical advance of the 20th century.”
“ORS would go on to save millions of lives and, under the leadership of Jim Grant, would
revolutionize UNICEF’s approach to child health and acute diarrheal disease case management.”
~ PATH, 2022

Question 11

Current causes of child death

Answer 11

Question 12

Current rates of maternal mortality

Answer 12

Question 13

Current rates of maternal mortality

Answer 13

Question 13

Current causes of maternal death

Answer 13

Answer 13

Most child death is preventable

Question 14

Most maternal death is preventable

Answer 14

“Most maternal deaths can be prevented if births are attended by skilled health personnel such
as doctors, nurses or midwives.”
“As complications require prompt access to quality obstetric services, these skilled health
personnel… can avert maternal death by providing life-saving drugs such as antibiotics, blood
transfusions, caesarean sections, and other surgical interventions.”

Question 14

Key points

Answer 14

» Child and maternal mortality has greatly reduced since 1800 due to the invention of basic,
life-saving treatments and improvements in quality of life.
» In low-income countries, child and maternal mortality only came down in the 1980s and
1990s because of an intense focus on a few key health interventions (GOBI-FFF).
» To this day, most child and maternal deaths are preventable.
» It is not a question of needing to invent diferent treatments. Rather, it is an issue of getting
children and mothers existing life-saving treatments when they need it.
- In other words, Universal Health Care!

Question 14

Most child death is preventable

Answer 14

Proportion of children younger than 5 years with diarrhoea who received ORS, 2017

Question 15

List three reasons why child mortality decreased
greatly from 1800 to 1950 in high-income countries

Answer 15

● Development of vaccines (smallpox, pertussis, typhoid, tetanus, tuberculosis)
● Development of penicillin (antibiotics)
● Improved water, sanitation, and hygiene
● Improved nutrition

Question 16

What are the three biggest causes of death for children 1-59 months old?

How does this change if you include children 0-1 months old?

Answer 16

Current causes of child death

● In children 1-59 months…
○ Lower respiratory infections (pneumonia) - 10.1%
○ Diarrhoea - 8.5%
○ Malaria - 7.8%

● However, 46% of under-five death occurs in children 0-1 months

○ As we reduce the risk of death from pneumonia, diarrhoea, and malaria in older children, a greater proportion of deaths occur in neonates.

These causes of death are typically harder to manage, hence they are contributing an increasing share over time, as the other causes reduce.

Question 17

Every day, across the world, around 700 women die from causes related to pregnancy or childbirth.

Are most of these deaths PREVENTABLE or UNAVOIDABLE?

Answer 17

● Women die in childbirth because they do not have access to life-saving emergency obstetric care when they
need it. We have good treatments for the main causes of death (post-partum hemorrhage, eclampsia,
sepsis).

Question 18

Every day, across the world, around 700 women die from causes related to pregnancy or childbirth.

Are most of these deaths PREVENTABLE or UNAVOIDABLE?

Answer 18

Maternal deaths

● PREVENTABLE!
● “Almost 95% of all maternal deaths occurred in low and lower middle-income countries in 2020, and most
could have been prevented.”

Question 19

Do we need to invent more medicines in order to reduce child mortality in low-income countries?

Answer 19

● We do NOT need to invent more medicines
● There are cheap, easy-to-administer, life-saving medications for the main cases of child death. We have
antibiotics for pneumonia, ORS for diarrhea, and ACTs for malaria. The issue is getting these treatments to
children when they need it.

Question 19

Every day, across the world, around 700 women die from causes related to pregnancy or childbirth.

Are most of these deaths PREVENTABLE or UNAVOIDABLE?

Answer 19

The issue is that in some parts of the world, women are not delivering in a health facility that can
offer these treatments, so if they have an obstetric complication, their risk of injury or death is much
higher.

Question 20

Do we need to invent more medicines in order to reduce child mortality in low-income countries?

Answer 20

● In other words, it is an issue related to health systems. We need to ensure timely access to health care for
everyone in the world, even those in remote, rural parts of low-income countries.
● Having said that… there will always be some benefit to having medicines that are even more effective, or
even cheaper

Question 21

Activity: Logic model for maternal/child health

Answer 21

● Draw a logic model that illustrates the positive effects that education can have on child survival rates, in a
country where only half of people complete primary school.

Question 22

Activity: Logic model for maternal/child health

Answer 22

● On the left side of your logical model, draw a box that says, “Increased female participation in school”. On the right side of your logical model, draw a box that says, “Reduced child mortality”.

Question 23

Activity: Logic model for maternal/child health

Answer 23

● In between these two boxes, draw approximately 8 to 12 boxes, with arrows connecting them, to illustrate
how increased participation of girls in primary and high school can contribute, in different ways, to
reduced child mortality (or increased child survival).

Answer 23

Question 24

Four tips for logic models

Answer 24

1. Make sure all boxes are connected with incoming/outcoming arrows, and there is a general flow from left to right (or top to bottom).

Question 25

Four tips for logic models

Answer 25

2. Start all boxes with words such as “increased…”, “reduced…”, “improved…”,
   etc., as this reinforces the idea of factors getting better or worse, and the idea of a causal chain of effects.

Question 25

Four tips for logic models

Answer 25

3. Have distinct columns in the middle. The column nearest to the starting box will
   have the immediate effects of the starting box. For health-related logic models,
   the column nearest to the end box will typically have health-related effects (e.g.,
   increased nutrition, increased treatment, reduced obstetric complications).

Question 26

Four tips for logic models

Answer 26

4. A useful logic model shows how one thing (e.g., female schooling) can affect one
   other thing (e.g., child mortality) in multiple ways (e.g., by increasing care
   seeking, by improving nutrition, etc.) – these different ways are what we call
   “impact pathways”.

Answer 27

Answer 27

Answer 27

Answer 28

Question 28

Instructions on final exam paper

Answer 28

● This exam has SIX questions worth a total of 40 points. Questions 1-4 are worth 5 points each. Questions 5-6 are worth 10 points each. The length of your answers and the time you spend on each question should
reflect the number of points each question is worth.

● You have 120 minutes (2 hours) to complete the exam.

● You may bring 2 x A4 pages of notes (i.e., 4 sides of A4) into the exam. These will be collected at the end of the exam, so if you want to keep a copy, please make sure you take a photo before the exam.

● It is not necessary to use formal referencing or citations in your exam. However, if you quote or paraphrase
a source as part of your response to a question, you should mention the source as part of your response. For
example, by writing “As Huynen et al. say in their 2005 journal article…” or “One of the points made by Kelley Lee in her paper is that…”. In other words, simply be clear in your response where you have taken
text from other people, and do not present other people’s work as your own.