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  1. 1

    Professional care delivery or traditional birth attendants? The impact of the type of care utilized by mothers on under-five mortality of their children.

    Muzyamba C; Groot W; Pavlova M; Rud I; Tomini SM

    Tropical Medicine and Health. 2018; 46(1)

    Background: Because of the high under-five mortality rate, the government in Zambia has adopted the World Health Organization (WHO) policy on child delivery which insists on professional maternal care. However, there are scholars who criticize this policy by arguing that although built on good intentions, the policy to ban traditional birth attendants (TBAs) is out of touch with local reality in Zambia. There is lack of evidence to legitimize either of the two positions, nor how the outcome differs between women with HIV and those without HIV. Thus, the aim of this paper is to investigate the effect of using professional maternal care or TBA care by mothers (during antenatal, delivery, and postnatal) on under-five mortality of their children. We also compare these outcomes between HIV-positive and HIV-negative women. Methods: By relying on data from the 2013-2014 Zambia Demographic Health Survey (ZDHS), we carried out propensity score matching (PSM) to investigate the effect of utilization of professional care or TBA during antenatal, childbirth, and postnatal on under-five mortality. This method allows us to estimate the average treatment effect on the treated (ATT). Results: Our results show that the use of professional care as opposed to TBAs in all three stages of maternal care increases the probability of children surviving beyond 5 years old. Specifically for women with HIV, professional care usage during antenatal, at birth, and during postnatal periods increases probability of survival by 0.07 percentage points (p.p), 0.71 p.p, and 0.87 p.p respectively. Similarly, for HIV-negative women, professional care usage during antenatal, at birth, and during postnatal periods increases probability of survival by 0.71 p.p, 0.52 p.p, and 0.37 p.p respectively. However, although there is a positive impact when mothers choose professional care over TBAs, the differences at all three points of maternal care are small. Conclusion: Given our findings, showing small differences in under-five child's mortality between utilizers of professional care and utilizers of TBAs, it may be questioned whether the government's intention of completely excluding TBAs (who despite being outlawed are still being used) without replacement by good quality professional care is the right decision. © 2018 The Author(s).
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  2. 2
    Peer Reviewed

    The African Development Bank, structural adjustment, and child mortality: a cross-national analysis of Sub-Saharan Africa.

    Pandolfelli LE; Shandra JM

    International Journal of Health Services. 2013; 43(2):337-61.

    We conduct a cross-national analysis to test the hypothesis that African Development Bank (AfDB) structural adjustment adversely impacts child mortality in Sub-Saharan Africa. We use generalized least square random effects regression models and two-step Heckman models that correct for selection bias using data on 35 nations with up to four time points (1990, 1995, 2000, and 2005). We find substantial support for our hypothesis, which indicates that Sub-Saharan African nations that receive an AfDB structural adjustment loan tend to have higher levels of child mortality than Sub-Saharan African nations that do not receive such a loan. This finding remains stable even when controlling for selection bias on whether or not a Sub-Saharan African nation receives an AfDB structural adjustment loan. We conclude by discussing the methodological implications of the article, policy suggestions, and possible directions for future research.
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  3. 3
    Peer Reviewed

    Child mortality estimation: Methods used to adjust for bias due to AIDS in estimating trends in under-five mortality.

    Walker N; Hill K; Zhao F

    PLOS Medicine. 2012 Aug; 9(8):e1001298.

    In most low- and middle-income countries, child mortality is estimated from data provided by mothers concerning the survival of their children using methods that assume no correlation between the mortality risks of the mothers and those of their children. This assumption is not valid for populations with generalized HIV epidemics, however, and in this review, we show how the United Nations Inter-agency Group for Child Mortality Estimation (UN IGME) uses a cohort component projection model to correct for AIDS-related biases in the data used to estimate trends in under-five mortality. In this model, births in a given year are identified as occurring to HIV-positive or HIV-negative mothers, the lives of the infants and mothers are projected forward using survivorship probabilities to estimate survivors at the time of a given survey, and the extent to which excess mortality of children goes unreported because of the deaths of HIV-infected mothers prior to the survey is calculated. Estimates from the survey for past periods can then be adjusted for the estimated bias. The extent of the AIDS-related bias depends crucially on the dynamics of the HIV epidemic, on the length of time before the survey that the estimates are made for, and on the underlying non-AIDS child mortality. This simple methodology (which does not take into account the use of effective antiretroviral interventions) gives results qualitatively similar to those of other studies.
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  4. 4
    Peer Reviewed

    Use of new World Health Organization child growth standards to assess how infant malnutrition relates to breastfeeding and mortality.

    Vesel L; Bahl R; Martines J; Penny M; Bhandari N; Kirkwood BR

    Bulletin of the World Health Organization. 2010 Jan; 88(1):39-48.

    OBJECTIVE: To compare the estimated prevalence of malnutrition using the World Health Organization's (WHO) child growth standards versus the National Center for Health Statistics' (NCHS) growth reference, to examine the relationship between exclusive breastfeeding and malnutrition, and to determine the sensitivity and specificity of nutritional status indicators for predicting death during infancy. METHODS: A secondary analysis of data on 9424 mother-infant pairs in Ghana, India and Peru was conducted. Mothers and infants were enrolled in a trial of vitamin A supplementation during which the infants' weight, length and feeding practices were assessed regularly. Malnutrition indicators were determined using WHO and NCHS growth standards. FINDINGS: The prevalence of stunting, wasting and underweight in infants aged < 6 months was higher with WHO than NCHS standards. However, the prevalence of underweight in infants aged 6-12 months was much lower with WHO standards. The duration of exclusive breastfeeding was not associated with malnutrition in the first 6 months of life. In infants aged < 6 months, severe underweight at the first immunization visit as determined using WHO standards had the highest sensitivity (70.2%) and specificity (85.8%) for predicting mortality in India. No indicator was a good predictor in Ghana or Peru. In infants aged 6-12 months, underweight at 6 months had the highest sensitivity and specificity for predicting mortality in Ghana (37.0% and 82.2%, respectively) and Peru (33.3% and 97.9% respectively), while wasting was the best predictor in India (sensitivity: 54.6%; specificity: 85.5%). CONCLUSION: Malnutrition indicators determined using WHO standards were better predictors of mortality than those determined using NCHS standards. No association was found between breastfeeding duration and malnutrition at 6 months. Use of WHO child growth standards highlighted the importance of malnutrition in the first 6 months of life.
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  5. 5

    The state of Africa's children 2008. Child survival.


    New York, New York, UNICEF, 2008 May. 54 p.

    Every year, the United Nations Children's Fund (UNICEF) publishes The State of the World's Children, the most comprehensive and authoritative report on the world's youngest citizens. The State of the World's Children 2008, published in January 2008, examines the global realities of maternal and child survival and the prospects for meeting the health-related Millennium Development Goals (MDGs) - the targets set by the world community in 2000 for eradicating poverty, reducing child and maternal mortality, combating disease, ensuring environmental sustainability and providing access to affordable medicines in developing countries. This year, UNICEF is also publishing the inaugural edition of The State of Africa's Children. This volume and other forthcoming regional editions complement The State of the World's Children 2008, sharpening from a worldwide to a regional perspective the global report's focus on trends in child survival and health, and outlining possible solutions - by means of programmes, policies and partnerships - to accelerate progress in meeting the Millennium Development Goals. (excerpt)
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  6. 6

    Malaria vaccine R & D: the case for greater resources.

    Moree M

    [Seattle, Washington], Program for Appropriate Technology in Health [PATH], Malaria Vaccine Initiative, [2002]. [2] p.

    Malaria kills more than one million people each year. In Africa, it is the leading cause of death among children under the age of five. Although prevention and treatment are crucial, a vaccine offers the greatest hope for controlling the disease. Despite malaria's tremendous social and economic impact, global spending for malaria vaccine research and development (R&D) is far less than the estimated $300 to $500 million required to advance one vaccine through the product development process. Industry-wide, the vast majority of vaccine candidates fail during development. To increase the odds of achieving a successful vaccine, malaria researchers must drive several candidates forward simultaneously. Given the urgency of the public health crisis, malaria vaccine R&D requires an aggressive development schedule--which will only be possible with a substantial increase in funding. (excerpt)
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  7. 7

    Reproductive health emergency assistance - United Nations Population Fund airlift to Eritrea - Brief article.

    Rutsch H

    UN Chronicle. 2000 Summer; 37(2):[1] p..

    The United Nations Population Fund (UNFPA) on 22 June began airlifting life-saving motherhood and reproductive health supplies to help Eritreans displaced by the recent fighting with Ethiopia. UNFPA's emergency assistance, including home delivery kits and tools for blood transfusions, will help reduce maternal and child deaths and unwanted pregnancies for some 450,000 displaced persons for about three months. The reproductive health kit was first used in the Great Lakes region of Africa in 1996. Since then, UNFPA has responded to emergencies in 33 countries and territories. (excerpt)
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  8. 8
    Peer Reviewed

    Francisco Songane: champion of maternal and child health. Profile.

    Kapp C

    Lancet. 2006 Apr 8; 367(9517):1137.

    Francisco Songane, a former Mozambican health minister who took over as Director of the new Partnership for Maternal, Newborn and Child Health on Feb 1, 2006, is a man with a mission. His goal is to capitalise on emerging political will--after years of neglect by the international community-- to reduce the unacceptably high toll of 11 million women, infants, and children under the age of 5 years who die every year from largely preventable diseases. "Children are dying and mothers are dying", he told The Lancet. "It is not normal to die in childbirth. It is not normal to die as a newborn", he says, commenting that in some countries, such as Mozambique, many women do not name their children for the first month because so many babies die. "We have to change that kind of fatalism. We cannot accept that people who make up two thirds of the world's population are dying silently without anyone helping", Songane asserts. (excerpt)
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  9. 9
    Peer Reviewed

    Malaria deaths are the hardest to count.

    Iley K

    Bulletin of the World Health Organization. 2006 Mar; 84(3):161-256.

    In the early hours of the morning, Aurola Ngueve strapped her feverish daughter to her back and walked almost three kilometres to a tiny Angolan government health post, a white concrete structure sitting incongruously amid the mud huts of the village of Muinha in central Bié province. In the rudimentary examination room, Aurola anxiously tells the Bulletin that 18-month-old Rosalina, who is screaming as a nurse takes a tiny blood sample from her finger, has had chronic diarrhoea for days. Fifteen minutes later, Aurola receives the dreaded, if not unexpected, news. Rosalina has malaria. Malaria is believed to be one of the chief culprits behind Angola's appalling child mortality statistics. UNICEF estimates that one child in four in this south-western African country is unlikely to live beyond his or her fifth birthday. Rosalina is one of the lucky ones. At this health post, run by the Health Ministry and supported by nongovernmental organization Médecins Sans Frontières, she has been accurately diagnosed and prescribed medication. Her personal details, symptoms, diagnose sis and treatment have been entered into a logbook, and the nurse is confident that with the right care she will bounce back to health in a few days. (excerpt)
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  10. 10
    Peer Reviewed

    Vaccination and child mortality. [Vaccination et mortalité infantile]

    Hall AJ

    Lancet. 2004 Dec 18-25; 364:2156-2157.

    A report in 2000 from Guinea Bissau suggested a worrisome association between diphtheria, pertussis, and tetanus (DPT) vaccination and mortality. In this issue of The Lancet, Robert Breiman and colleagues respond to concerns about DPT with a highly detailed and reassuring study of vaccination and mortality in Bangladesh. At an epidemiology conference in Helsinki in 1989, Peter Aaby and I spent a few days discussing a problem: vaccines are usually introduced into developing countries with no assessment of their potential effect on overall mortality. The key issue is that if trials of vaccines are to show a beneficial effect, or at least that they cause no harm, the trials need to be so large that they are difficult to fund. Another problem is that once a vaccine has been shown to reduce the frequency of the target disease, it becomes ethically questionable to have an unvaccinated group. Aaby tried to address this issue by using observational data from demographic surveillance in Guinea Bissau. He has published papers suggesting unexpected associations between vaccine use and later patterns of mortality. His findings on DPT vaccine prompted WHO to look closely at his data (including a site visit by independent experts), to commission studies around the world where the association could be studied, and then to hold a meeting of experts to review and report all data in WHO’s Weekly Epidemiological Record. (excerpt)
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  11. 11

    Great Lakes Region: Burundi. [La région des Grands Lacs : Burundi]

    RNIS. Report on the Nutrition Situation of Refugees and Displaced Populations. 2003 Nov; 18-24.

    There was an upsurge in violence in August and September 2003, which, among other things, has led to the displacement of about 53,000 people in Bujumbura rural Province and 21,000 people in Bubanza Province (OCHA, 29/08/03; WFP, 26/09/03). After the signature of a peace agreement between the Burundian President and the country's largest Hutu rebel group, the Forces for the Defence of Democracy (FDD), in early October, the situation has calmed down but has remained volatile (AFP, 07/10/03; UNICEF, 06/11/03). An enlarged government with members of the FDD, should be formed by the end of November 2003 (AFP, 7/11/03). However, the other Hutu rebel group, the National Liberation Force (FNL) was not part of the cease-fire negotiations (AFP, 08/10/03). The deployment of about 3,000 peacekeepers from Ethiopia, Mozambique, and South Africa, to help in the demobilisation, disarmament, demobilisation and reintegration of rebel troops and to monitor the transition to democracy, has been completed (OCHA, 02/11/03). As of end October 2003, UNHCR reported 26,690 facilitated returns of Burundian refugees and 42,103 spontaneous returns in 2003 (OCHA, 02/11/03). (excerpt)
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  12. 12

    Health reformers' response to Zambia's childhood mortality crisis.

    Simms C

    [Brighton, England], University of Sussex, Institute of Development Studies, 2000 Nov. 30 p. (IDS Working Paper 121)

    This study examines the reasons for the rise in Zambian under-five mortality during the 1990s, paying particular attention to the relevance and effectiveness of health sector reform strategies and their impact on ordinary Zambians. In the 1980s, economic crisis and structural adjustment led to reduced public health spending in real terms so that by the early 1990s, Zambia's health care delivery system was characterised by a low-supply, low utilisation paradigm, typical of most of SSA. Health reform was designed to improve these trends by the integration and decentralisation of services, district capacity building and addressing issues of sustainability and financing. While large investments were made by the donors in the development of financial and health information systems, they did not actually improve the delivery of basic services. On the contrary, reform measures taken by government and donors appear to have further reduced access especially among the vulnerable populations through the implementation of user charges, and failed attempts to decentralise and integrate services. Although a variety of shocks are contributing to the rise in under-five mortality, particularly the HIV epidemic, there is strong evidence that a key factor explaining the rise over the last 20 years is that vulnerable populations have not received adequate protection from restructuring operations. Government and donors had little or no motivation to see that the poor had access to effective health care, were protected from the worst drought in 50 years, food subsidy withdrawal, falling living standards and rising prices. Poverty interest groups have never participated in the policy process and agencies which ought to have represented the poor have been a disappointment. As a consequence, health restructuring as social policy has been far removed from the reality of ordinary Zambians. An alternative set of reform strategies might have provided better protection for the poor by incorporating a livelihoods perspective, by being more flexible, attentive and responsive to changing needs in a turbulent environment. (author's)
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  13. 13

    The impact of mother's education on infant and child mortality in selected countries in the ESCWA region. Discussion note.

    United Nations. Economic and Social Commission for Western Asia [ESCWA]. Social Development and Population Division.

    [Unpublished] 1992. Presented at the International Conference on Population and Development [ICPD], 1994, Expert Group Meeting on Population and Women, Gaborone, Botswana, June 22-26, 1992. 21 p. (ESD/P/ICPD.1994/EG.III/DN.13)

    A number of researchers have associated child and infant mortality in developing countries with maternal education. The correlation has remained strong even when proximate variables and other socioeconomic variables were controlled. Setting was considered key to refinement of the associations. The illustrations from Jordan and Egypt showed that a particular level of education was needed before fertility declined and urban-rural differences prevailed. Analysis of 1980 Egyptian Fertility Survey data indicated a strong association between child survival and maternal education. Children of women with a secondary education had the lowest infant and child mortality. The impact of maternal education was strongest in Cairo and Alexandria. Findings showed that the child mortality rate for rural women with secondary education was 38% of that for illiterate women; the rate for educated urban women was 61% of that for uneducated women. Analysis of Egyptian Fertility Survey data for 1980 found that child mortality at any age was inversely related to maternal educational level. The infant mortality rate for uneducated mothers was 89% greater than for mothers with 6 or more years of schooling; neonatal mortality was 91% greater, postneonatal mortality was 86% greater, and child mortality was 108% greater. Multivariate analysis indicated that maternal education of at least 6 years decreased postneonatal mortality by 46.2%. Infant mortality was reduced by 26% with at least 6 years of maternal schooling. Child mortality was not affected by maternal education in the multivariate analysis. Data analysis based on data from the Egypt Pregnancy Wastage and Infant Mortality Survey, 1980, revealed that probability of dying in infancy decreased with increased levels of maternal and paternal education. Neonatal mortality was most affected by parental educational status. Multivariate analysis of Jordanian Fertility Survey data for 1976 and 1981 showed that mortality was higher for mothers with less than 6 years of education. Maternal and paternal education had independent effects, but paternal education had the greater impact. Paternal education lasting 9 or more years had an impact on urban child mortality, whereas paternal education must reach at least 12 years in rural areas in order for the effect to be observed. Inconsistent results were found for the impact of spousal differences in education. Rural lack of education had the strongest impact on child survival.
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  14. 14

    A troubled decade for Africa's children. Trapped by poverty, disease, war and insufficient aid.

    Fleshman M

    Africa Recovery. 2002 Apr; 16(1):6-8, 11.

    Despite ambitious child health targets set in 1990, life for millions of Africa's children remains difficult, dangerous, and tragically short. Children in sub-Saharan Africa are more likely to be ill, less likely to be in school and far more likely to die before the age of 5 than children in other region. Statistics for another key indicator of well being for children and their families, maternal mortality, are equally disturbing. Nearly half of the estimated 515,000 women who die annually from pregnancy or childbirth are African. In addition, chronic malnutrition, inadequate immunizations, AIDS and war, insufficient investment, and the decline of official development assistance from wealthy countries aggravate the situation. However, there are reasons to hope that the next 10 years will be better. Efforts of individual countries have proved to forge new alliances to challenge the spread of HIV/AIDS and other diseases, strengthen health and education systems, open up the political process and strengthen transparency and accountability in budgeting and governance.
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  15. 15

    Health catastrophe.

    POPLINE. 2001 Mar-Apr; 23:3.

    Nearly 1 in 3 children born in Sierra Leone's diamond-rich Kenema district died last year before turning 1 year old, according to a recently released report. Issued by Sierra Leone's Health and Sanitation Ministry and the International Rescue Committee (IRC), the report came on the heels of a mortality survey in the West Central African country. The UN International Children's Emergency Fund (UNICEF) previously reported that Sierra Leone's infant mortality level of 157 newborn deaths per 1000 births is the world's highest. The new study, however, demonstrates that the rate in Kenema is almost twice that level. Robin Nandy of IRC called the findings “a public health catastrophe”. Additionally, the survey revealed an overall death rate for Kenema that was 3 times the normal level for sub-Saharan Africa--44 deaths a year per 1000 people. UNICEF estimated in 1999 that the overall mortality rate in Sierra Leone was much lower--24 deaths per 1000 people--though even that number is considered among the world's highest mortality rates. Most of the deaths were attributed to common illnesses that are easily treatable, with ailments involving fever proving to be the most fatal. Malaria was the leading cause of death, followed by diarrheal disease and respiratory infections. Nandy called the findings worse than anticipated since Kenema was fairly peaceful last year, compared to considerable fighting the year before. She said that IRC assumes death rates are even higher in areas where conflict continues. With a fertility rate of 6.3 children per woman, Sierra Leone is on course to double its population of 5.2 million in only 26 years and triple its human numbers in 50 years. (full text)
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  16. 16

    UNICEF partners Uganda in new programme. [Partenariat UNICEF/Ouganda pour un nouveau programme]

    AFRICA HEALTH. 2001 Jan; 23(2):38.

    UNICEF has signed a 5-year program of collaboration with the Ugandan government in which it will provide US$101 million, while the latter provides US$40 million in new financial commitments to children. The agreement was signed in Kampala by Michel Sidibe, UNICEF representative to Uganda, and Minister of Finance, Planning and Economic Development, Gerald Sendawula. The program is anchored to the theme of human rights, and recognizes how poverty erodes the gains made in the area of child survival and development. Specific aims of the program are to reduce the infant mortality rate from 97 per 1000 live births to 68, the under-five mortality rate from 147 per 1000 live births to 103, and the maternal mortality rate from 506 per 100,000 live births to 354. Other commitments include the reduction of HIV infections by a further 25% and reducing moderate to severe stunting in under-3-year-olds from 38% to 28%. UNICEF noted that the government's increasing expenditure on UNICEF-supported programs has contributed to their success in reducing the main threats to children's lives, and the new partnership will build on the good work of the 1995-2000 program. At present, 51% of Ugandans have access to health care services, compared with only 42% in 1996, while average life expectancy has risen from 41.8 years in 1991 to 50.4 years in 1999. Other statistics show infant mortality has fallen sharply from 121 to 97 per 1000 live births between 1980 and 1995, while polio and Guinea worms are close to eradication and measles and diarrhea have largely been brought under control. In its fight against iodine-deficiency disorders, UNICEF supported legislation against importation of non-iodized salt, resulting in an increase in the percentage of households consuming iodized salt from 2% in 1995 to 67% in 1999. With the formation and training of more than 1200 parish development and healthcare unit management committees, communities are now participating in the management of their healthcare services. (full text)
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  17. 17
    Peer Reviewed

    Children and AIDS in Africa.

    Decosas J

    Lancet. 2000 Dec; 356 Suppl:S33.

    In 1988, the impressive effort to eradicate the health-service inequalities of the racist White regime was showing signs of success in Zimbabwe. The child mortality rate had sunk to an all-time low of 23 deaths per 1000. However, in 1997, the national statistic was back at 36 deaths per 1000, and the rate continues to climb. The main cause of this increase in child mortality is AIDS, in which 1 in 4 children in the country is born to a woman living with HIV. Consequently, a new demographic structure emerged with the onset of HIV epidemics. Meanwhile, the growing childhood mortality due to HIV in Africa is capturing the world's attention and prevention efforts are being initiated. Although logistical problems exist, money exists to solve them. In their resource allocation decisions, international agencies should count the disability-adjusted life-years saved through mother-to-child transmission projects.
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  18. 18

    Validation of outpatient IMCI guidelines.

    United States. Agency for International Development [USAID]. Child Health Research Project

    SYNOPSIS. 1998 Jan; (2):1-8.

    The World Health Organization (WHO)/UN Children's Fund (UNICEF) Integrated Management of Childhood Illness (IMCI) guidelines were designed to maximize detection and appropriate treatment of illnesses due to the most common causes of child mortality and morbidity in developing countries: pneumonia, diarrhea, malaria, measles, bacterial infections in young infants, malnutrition, anemia, and ear problems. The health worker first examines the child and checks immunization status, then classifies the child's illness and identifies the appropriate treatment based on a color-coded triage system. By May 1997, 17 countries had introduced IMCI and 16 others were in the process of introduction. This issue reports on field tests of the guidelines conducted in Kenya, the Gambia, Uganda, Bangladesh, and Tanzania. Health workers who used the guidelines performed well when compared to physicians who had access to laboratory and radiographic findings as well as health workers trained in full case management. Of concern, however, are research findings suggesting the potential for overdiagnosis in some disease classifications. Current IMCI research priorities include the following: 1) determining health workers' ability to learn to detect lower chest wall indrawing; 2) identifying clinical signs to increase the specificity of referral for severe pneumonia; 3) identifying other clinical signs to increase the specificity of hospital referrals, thereby reducing unnecessary referrals; 4) investigating how clinical care for severely ill children could be expanded in areas where referral is not feasible; 5) finding ways to increase the specificity of the diagnosis of malaria; and 6) recognizing clinical signs to increase the specificity of the diagnosis of severe anemia and the specificity of the diagnosis of moderate or mild anemia, with the possible goal of regional adaptation of the anemia guidelines.
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  19. 19

    The socioeconomic determinants of fertility in Sub-Saharan Africa. A summary of the findings of a World Bank research project.

    Ainsworth M

    [Washington, D.C.], World Bank, 1994 Aug 1. iii, 28 p.

    This paper describes and summarizes the key findings of a World Bank research project on the economic and policy determinants of fertility in sub-Saharan Africa. The study focuses upon the effect of individual background characteristics, environmental factors, and public policies on cumulative fertility, contraceptive use, and child mortality. Findings are based upon background papers conducting microeconomic analyses of existing household data sets from the Demographic and Health Surveys and the Living Standards Measurement Study in 15 sub-Saharan countries, ongoing qualitative data collection sponsored by the African Population Advisory Committee, and a review of the population policy environment in twelve of the countries. The relation between women's schooling and fertility was examined in all of the countries and data sets. Women's schooling was found to be the most consistently significant determinant of fertility and contraceptive use. Levels of female schooling are very low across the continent, with only a few exceptions. In most cases, men's schooling is also relatively low. Most governments must therefore work to raise the levels of schooling for both men and women. Reducing the levels of child mortality will also help to lower fertility. In some countries, easing constraints to providing and receiving family planning services would result in higher contraceptive use. For example, lack of physical access to services limits contraceptive use in Nigeria, rural Ghana, and Zimbabwe. The author notes that Botswana, Kenya, and Zimbabwe are the three countries with declining fertility. These countries also have the highest levels of female schooling, the lowest levels of child mortality, and the widest availability of family planning. Prohibitively greater resources may not be needed to effect positive change in countries in need. Instead, reallocating current expenditures could go a long way to reducing fertility, increasing levels of contraceptive use, and increasing levels of male and female schooling.
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  20. 20

    Tackling population in Sierra Leone.

    JOICFP NEWS. 1994 Jun; (240):6.

    In this interview (April 21) with Yoshio Koike, United Nations Population Fund (UNFPA) country director, the population situation in Sierra Leone is described. 4.5 million persons inhabit an area of 74,000 sq. km. Independence was achieved in 1961, but the country was under the patronage of the United Kingdom until April 1992 when a military coup occurred. The new leaders are young (22-29 years) and enthusiastic; a democratic general election will be held in 1996 and the municipal assembly election will occur in 1995. Sierra Leone was the ninth African country receiving aid from UNFPA to establish a population policy (1989). A National Population Commission, which has remained dormant, was also established. The population growth rate is 2.4% annually (average for west African countries); the total fertility rate is 6.8. The maternal mortality rate is estimated to be 1400-1700/100,000 live births. The infant mortality rate (IMR) is about 180; for those under 5 years of age, it is 275. Although the country has 470 clinics available on paper, only 25% are operational according to UNFPA. This is the third year of the MCH/FP project, but only 76 clinics provide family planning information and services. Through coordination of nongovernmental and governmental efforts, 20,000 newcomers and acceptors are being recruited for family planning annually. If expansion continues at this rate and repeaters are maintained for 5 years, the contraceptive prevalence rate (CPR) should reach 20%. Currently, it is 2% in rural areas and 9% in cities. The national average is about 4-6%. The CPR should approach the goal of 60% in 10 years. There is no serious objection to family planning on the basis of religion; however, people are not informed about the importance of birth spacing and about where they can obtain services. Information, education, and communication (IEC) activities are being improved.
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  21. 21

    Hunger and malnutrition: the determinant of development: the case for Africa and its food and nutrition workers.

    Maletnlema TN

    East African Medical Journal. 1992 Aug; 69(8):424-7.

    Hunger and malnutrition in Africa have been on the increase since the 1960s. During the 1970s, it is estimated that 30 million people were directly affected by famine and malnutrition. About 5 million children died in 1984 alone. In Mozambique during the 1983-84 famine, about 100,000 people perished. In Ethiopia, Sudan, Somalia, Liberia, and Angola armed conflicts compound the problem. Ethiopia alone had 9 million famine victims in 1983. The most common form of malnutrition in Africa is protein energy deficiency affecting over 100 million people, especially 30-50 million children under 5 years of age. Almost another 200 million are at risk. Iron deficiency, commonly called anemia, also affects 150 million people, mostly women and children. Iodine deficiency leads to disorders like mental retardation, cretinism, deafness, abortion, low resistance to disease, and goiter and this affects 60 million with about 150 million more at risk. Vitamin A deficiency causes blindness and low resistance to disease and affects about 10 million. Protein energy deficiency is treated by using donated foods in hospitals, rehabilitation centers, day care centers, and feeding centers. There are no community programs for anemia, or vitamin A or iodine deficiencies. Vaccines for preventing and drugs for treating diseases that cause malnutrition are imported. Therefore, African food and nutrition professionals met in 1988 and created the Africa Council for Food and Nutrition Sciences (AFRONUS) to eliminate famine and malnutrition in Africa. Activities have started in: 1) developing contacts between the workers in food and nutrition; 2) assessing the situation of food and nutrition in Africa; 3) developing an action plan; 4) implementing the plan; and 5) monitoring progress. Food and Nutrition Policy Guidelines have also been prepared by AFRONUS for food and nutrition workers. Africa has enough natural resources to solve the problem of hunger and malnutrition, but these resources have to be harnessed.
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  22. 22

    WHO in action.

    WORLD HEALTH. 1992 Sep-Oct; 28-9.

    Adding a tiny bit of iodine to salt is the standard and proven long-term strategy for controlling iodine-deficiency disorders such as endemic goiter and cretinism, physical and mental retardation, impaired school performance and work capacity, and increased rates of abortion, stillbirth, congenital anomalies, and perinatal, infant, and child mortality. The 1990 World Summit for Children acknowledged the magnitude and seriousness of this problem and called for efforts to eliminate the root cause of these conditions by the year 2000. Salt industry representatives and government officials from Botswana, Lesotho, Malawi, Mozambique, Namibia, Zaire, Zambia, and Zimbabwe subsequently met in April 1992 to decide how to ensure that all salt consumed in the region is iodinated at the production source. Workshop participants agreed on appropriate levels of iodine and suitable packaging to ensure the retention of iodine even after salt has been transported over great distances or stored for long periods. Moreover, the Botswana Company agreed to assume the cost of iodinating all salt for human and animal consumption which it will supply to 10 countries in southern and central Africa.
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  23. 23

    The state of the art of education for child survival and development in Kenya.

    Mbkikusita-Lewanika I

    BERC BULLETIN. 1987 Mar; (15):12-5.

    UNICEF-supported work (GOBI/FFF) has proposed to early childhood mortality and disease which are free, relevant and available: 1) growth mortality, which can expose malnutrition before it's too late; 2) oral rehydration therapy for diarrhea which is a major killer and is remedied by rehydration salts; 3) breast feeding, which provides immunity, nutrition at low cost, and warmth, and security, and 4) immunization from measles, TB, diphtheria, tetanus, polio, and whooping cough. GOBI/FFF recommends strengthening female education, providing nutritious food, and providing family planning which involves child spacing. Most children in the east African regions are denied the rights outlined in the 1959 UN Declaration of the Rights of the Child, even though governments do provide some level of care. Kenya, with the highest birth rate, has all departments providing some input into the well-being of the child. Several national programs are supported by UNICEF in concert with the Kenya government. The 3 neediest rural districts receive concentrated resources, and the health department has been reorganized to focus on child survival. Integrated community rural development projects are underway. Basic urban services with be provided in Kisumu Municipality in a participatory process with civil servants which will focus on female headed households with lots of children. The emphasis will be on increasing family income. In order to relieve mothers of some of the work burden, technology in food production, and in water and fuel collection will be introduced. Educational materials for young and old people need to be developed. Greater coordination and utilization of resources need to be implemented to insure that all parents are informed of birth spacing, prenatal care, low cost ways of preventing and managing childhood illnesses, how to promote normal physical and mental growth, and birth control.
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  24. 24
    Peer Reviewed

    HIV infection and breast-feeding: policy implications through a decision analysis model.

    Hu DJ; Heyward WL; Byers RH Jr; Nkowane BM; Oxtoby MJ; Holck SE; Heymann DL

    AIDS. 1992 Dec; 6(12):1505-13.

    HIV/AIDS specialists have developed and applied 3 different scenarios to a comprehensive decision analysis model to estimate mortality rates for children of mothers infected with HIV during pregnancy and for children of mothers who were not infected with HIV during delivery. Scenario I represents Central Africa where HIV prevalence and incidence are high. Some scenario I assumptions are HIV prevalence in pregnant women of 30% and proportion of initially uninfected women who become infected after delivery during lactation (d) of 6%. Scenario II is a population where HIV epidemic is rather recent (e.g., some parts of Asia). Its assumptions are HIV prevalence of 5%, and s is 2%. Scenario III symbolizes high-risk populations in North America and Western Europe (HIV prevalence and s = 1%). The scenarios also consider child mortality rates and relative risks (RRs) of mortality of breast fed children and those who were not breast fed. Universal breast feeding would effect equal or higher mortality than non-breast feeding, when the RR of mortality is no more than 1.5 and HIV prevalence/incidence is high (high prevalence = > 10% and high incidence = > 5%). In developing countries, where the RR of mortality is high if children are not breast fed (RR > 3), breast fed children have almost always lower child mortality than those who are not breast fed, regardless of HIV infection status. The decision to breast feed when the HIV status is known depends greatly on the degree of an additional mortality risk if an infant is not breast fed. The model substantiates WHO and CDC recommendations: HIV-positive women in the UK and the US should not breast feed, while those in developing countries with high RR of child mortality should breast feed. Additional research would define the range of HIV transmission rates from breast feeding and increase specific assessments of RRs for various parts of the world.
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  25. 25

    Usefulness of clinical case-definitions in treatment of childhood malaria or pneumonia [letter]

    Gove S; Tulloch J; Cattani J; Schapira A

    Lancet. 1993 Jan 30; 341(8840):304-5.

    WHO provides health workers with guidelines for case management strategies for children with acute respiratory infections (ARI) to reduce child mortality. Its clinical case definitions for ARI do not assume that a child has only 1 disease, however. The guidelines also help health workers diagnose and treat other conditions in those children with fever who live in malaria endemic areas such as Africa where Plasmodium falciparum is transmitted. They also guide health workers on how to refer children with danger signs of severe malaria, meningitis, or severe malnutrition to the hospital. Based on studies in Malawi and the Gambia, WHO 1st recommended using co-trimoxazole and chloroquine to treat children with malaria who have a cough and fever and who are breathing quickly. Experts at a WHO meeting in April 1991 now recommend 5 days of co-trimoxazole alone to treat such children in areas where malaria is moderately to highly endemic, the leading parasite is P. falciparum, and it is sensitive to sulfadoxine/pyrimethamine. WHO has incorporated this change into its clinical guidelines and training materials. The guidelines emphasize that local health workers must adapt the guidelines for children with concomitant malaria as necessary to guarantee appropriate identification and referral of children with severe anemia. WHO and UNICEF are developing a fully integrated training package to address case management of children with pneumonia, diarrhea, malaria, measles, and/or malnutrition. This package also instructs health workers on how to manage middle ear inflammation, anemia, meningitis, and acute ocular problems from measles and vitamin A deficiency. WHO and UNICEF hope to have this integrated training package available in late 1993.
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