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Estimating the Impact of Maternal, Neonatal and Child Survival Interventions. Ingrid Friberg, PhD. The Lives Saved Tool - LiST. The Lives Saved Tool A multi-cause model of mortality Predict changes in Under 5 and neonatal mortality rates and deaths Maternal mortality ratios and deaths

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estimating the impact of maternal neonatal and child survival interventions

Estimating the Impact of Maternal, Neonatal and Child Survival Interventions

Ingrid Friberg, PhD

the lives saved tool list
The Lives Saved Tool - LiST
  • The Lives Saved Tool
    • A multi-cause model of mortality
  • Predict changes in
    • Under 5 and neonatal mortality rates and deaths
    • Maternal mortality ratios and deaths
    • Stillbirth rates and deaths
    • Causes of death
  • Using
    • Country specific health status
    • Changes in child and maternal health intervention coverage levels
      • i.e. ORS, facility delivery, etc.
    • Effect sizes of interventions based on the best available evidence
slide3
LiST

Beginnings:

Grew out of the “Bellagio” modeling exercise and the Lancet Child Survival Series (2003). Added in neonatal, nutrition, and updated information

Goals:

Promote evidence-based decision making

Aid in planning expansion of maternal, neonatal and child health interventions

Objectives:

Estimate lives saved when introducing or scaling up key interventions

slide4

General Framework

Demographic estimates and projections

UN Pop/Spectrum

Number of Child, Maternal and Fetal deaths

Deaths by Cause

WHO/UNICEF Country estimates

Effectiveness Estimates

Intervention Coverage

Current

Target/Goal/Endline

*Change is critical*

  • Health Status
  • Stunted, wasted
  • Malaria prevalence
  • Vit A deficiency
  • Zinc deficiency

Intervention Impact

C1 C2 C3 C4 …

Int1 

Int2 

Int3  

  • Deaths averted
  • By cause
  • By intervention

Stunting, Wasting, Breastfeeding

which interventions were included
Which interventions were included?
  • Proximate factors
    • Not distal
  • Work through health programs
    • Not included: income, education and crowding, etc.
    • Water and sanitation are the exceptions
  • Feasible in a low income country
    • 68 priority countries with highest MNCH mortality
  • Cause-specific evidence of effect
    • Research studies or systematic reviews
    • Delphi method if research is impossible (i.e. CEmOC)
    • Updated frequently
    • IJE April 2010, BMC Public Health April 2011
intervention types
Intervention Types
  • Maternal, fetal, neonatal, child
  • Periconceptional, antenatal, birth, immediate postnatal, child
  • Preventive, curative
  • Nutritional, vaccination, water/sanitation, treatment
  • Risk factors: Cause-of-death specific
  • Immediate, time-lagged
  • External (family planning, AIDS), internal (all others)
periconceptional interventions pregnancy interventions
Periconceptional InterventionsPregnancy Interventions
  • (Family planning)
  • Folic acid supplementation or fortification
  • Safe abortion services
  • Post abortion case management
  • Ectopic pregnancy case management
  • Tetanus toxoid vaccination
  • IPTp – malaria prevention in pregnancy
  • Syphilis detection and treatment
  • Calcium supplementation
  • Multiple micronutrient supplementation
  • Balanced energy supplementation
  • Diabetes case management
  • Maternal malaria case management
  • MgSO4 – management of pre-eclampsia
  • Fetal growth restriction and management
  • (PMTCT)
childbirth care interventions
Childbirth Care Interventions
  • Clean birth practices
  • Immediate assessment and stimulation of the neonate
  • Labor and delivery management
    • SBA at home or facility, BEmONC and CEmONC
  • Neonatal resuscitation
    • At home or facility
  • Antenatal corticosteroids for preterm labor
  • Antibiotics for pPRoM
  • MgSO4 – for eclampsia
  • AMTSL – active management of the third stage of labor
  • Induction of labor for pregnancies 41+ weeks
preventive interventions
Preventive Interventions
  • Thermal care
  • Clean postnatal practices
  • Breastfeeding
    • Promotion
    • Behavior
  • Complementary feeding
    • Education only
    • Education and supplementation
  • Vitamin A for prevention
  • Zinc for prevention
  • Insecticide treated materials
  • Improved water source
  • Water connection in the home
  • Improved sanitation
    • latrine, toilet
  • Hand washing with soap
  • Hygienic disposal of children’s stools
  • BCG vaccine
  • Polio vaccine
  • Pentavalent vaccine
    • DPT, Hib, HepB
  • Pneumococcal vaccine
  • Rotavirus vaccine
  • Measles vaccine
curative interventions
Curative Interventions
  • Maternal sepsis case management
  • Kangaroo mother care
  • Case management of serious neonatal illnesses
    • Oral antibiotics
    • Injectable antibiotics
    • Full supportive care: oxygen, IV fluids, IV antibiotics
  • ORS for diarrhea
  • Antibiotics for dysentery
  • Zinc for treatment of diarrhea
  • Oral antibiotics for management of pneumonia
  • Vitamin A for measles treatment
  • Therapeutic feeding
  • Antimalarials
  • (Cotrimoxazole for HIV+ children)
  • (ART for children)
what s not in the model
What’s NOT in the model?
  • Education
  • Motivation
  • Gender issues
  • Economic status
  • Emergencies (i.e. famine, flooding)
  • Delivery mechanism
    • Only as relates to total population coverage
  • Quality of care
    • Effectiveness values, adjustments

Assumption:

Several of these factors are DISTAL factors which MAY work through COVERAGE changes…thus MAY already be in the model

other things not in list
Other things not in LiST
  • De-worming (yet)
  • IPTi (yet)
  • Breastfeeding initiation within 1 hour (yet)
  • Birth spacing benefit
  • Treatment of water in the home
  • Iron (or iron-folate) supplementation
  • Indoor air pollution
what list is what list isn t
What LiST is, What LiST isn’t!

Is

Isn’t

  • Multi-cause mortality model
  • Mathematic model
  • Models coverage impacts
  • Potential impact assessment
  • National or sub-national prioritization tool
  • Discussion points
  • Evidence-based
  • Truth
  • Probabilistic model
  • Natural history model
  • Detailed costing or planning tool
  • Bottlenecks, budgeting
  • Exhaustive
data needs
Data Needs
  • Country-Specific
    • Population data and trends
      • Default: UN Population Division 1950-2050 (DemProj)
      • User entered (district) data
    • Cause of death structure
      • Default: WHO/UNICEF/CHERG (2008)
      • User entered data
    • Intervention coverage
      • Population based data
      • Default: DHS/MICS/JMP/WHO-UNICEF (closest to 2008)
      • User entered data
  • Global
    • Intervention Effectiveness data
      • User entered data
slide16

Stunting

Appropriate ComplementaryFeeding

IUGR

Zinc

Diarrhea

incidence

Previous Stunting

Complementary feeding education and/or supplementation

slide17

Malaria

Mortality

Antimalarials

Wasting

Stunting

ITN/IRS

Disease

Specific

Treatments

Disease

Specific

Preventions

Risk factors

slide18

Breast Feeding Promotion

Pneumococcal vaccine

Hib vaccine

Improved H2O source within 30 minutes

Hand washing with soap

Breast Feeding

Improved sanitation

Diarrhea

incidence

Water connection in the home

Pneumonia

Mortality

Hygienic disposal of children’s stools

Stunting

Complementary feeding education/supplementation

Pregnant women protected via IPT or sleeping under an ITN

IUGR

Multiple micronutrient supplementation

Balanced energy supplementation

Zinc for prevention

Wasting

Therapeutic feeding

Oral antibiotics for pneumonia

how are the models built
How are the models built?
  • Preventions
  • Treatments
  • Risk factors
  • Multiple interventions?
    • Two Preventions (or Risk Factors):
      • Proportional impact by coverage/effect size
        • Calculated on residual deaths
      • No double counting
    • Preventions and Treatments:
      • Enter prevention(s), then treatment(s)
      • Deaths not already averted
some limitations
Some Limitations
  • Data availability
    • If no baseline, can’t evaluate impact accurately
  • Data quality
  • Sensible scale up targets
    • Feasible, acceptable, funds available
  • Interventions included in software
    • Some evaluated for one outcome, not others
  • Maternal
    • No country specific cause of death yet; regional causes
    • No risk factors yet
    • Not yet vetted intervention impacts through CHERG and other groups
how can list be used
How canLiST be used?
  • Planning, Evaluation, Research, Advocacy
  • Strategic planning
    • Which interventions are necessary to reduce mortality? (maternal, neonatal, under-5)
    • Will the targets reduce mortality as much as needed?
  • Evaluation and intermediate-term follow-up
    • What is the impact of observed coverage changes?
    • Evaluation of historic trends (i.e. multiple DHS/MICS surveys)
  • Predict lives saved (past and future)
    • How many lives could be saved with full scale-up of proven interventions in priority countries?
    • How many deaths remain left after vaccination scale ups?
how has list been used
How hasLiST been used?
  • Globally
    • Global Action Plan for Pneumonia
    • ‘Impatient Optimist’ speech by Bill Gates
  • Regionally
    • ASADI, by Saving Newborn Lives
  • Country level
    • Catalytic initiative: to guide planning and priority setting (Malawi, Ghana, Niger)
    • Ethiopia
  • Sub-nationally
    • CSHGP
    • DFID in Nigeria (PRRINN-MNCH)
who has used list
Who has used LiST?
  • Gates Foundation, GAVI
  • USAID, DFID, CIFF
  • MCHIP
  • Save the Children, Saving Newborn Lives, MSH
  • WHO (GAPP), UNICEF
  • CHAI
how not to use list
How NOT to use LiST
  • As the correct answer
    • It depends on what you put in and what your goals are
    • Also must consider cost, feasibility, accepability
  • To suggest decreasing coverage of any interventions
    • Mortality has declined BECAUSE of those interventions
  • To suggest taking funds away from interventions
  • To suggest that things in LiST are “GOOD” while everything else is “BAD”
    • It is based upon data availability unless otherwise stated
  • To decide HOW to do anything!!!
    • That is for the programmers to decide!
what can i get out of list
What can I get out of LiST?
  • Number of deaths
    • Total, by cause, by age group
  • Mortality rates/ratios (NMR, U5MR, MMR, SBR)
  • Deaths averted,
    • Total, by cause, by intervention, by age group
  • Intermediate outcomes
    • Stunting, wasting, breastfeeding
  • Displays
    • Tables, graphs, pie charts
    • Single country, multiple scenarios within one country
    • Multiple countries, single or multiple scenarios
future directions for list
Future Directions for LiST
  • Costing tie-ins
    • Both a CHOICE based costing tool and MBB
    • Part of the new One Health Model
  • Yes, we will be adding in uncertainty
  • Improve the maternal model
  • A new tool for multi-country analyses
list resources
LiST Resources
  • FREE
  • Web Links
    • www.futuresinstitute.org
    • www.healthpolicyinitiative.com/index.cfm?id=software&get=Spectrum
    • www.jhsph.edu/iip/list (join the listserv there)
    • list.cherg.org
  • Software + Manual Languages
    • English, French, Spanish, Portuguese
  • Contact
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