How not to count the health benefits of family planning

Several influential organisations have attempted to quantify the costs and benefits of expanding access to interventions—like contraceptives—that are expected to decrease the number of pregnancies. Such health economic evaluations can be invaluable to those making decisions about how to allocate scarce resources for health. Yet how the benefits should be measured depends on controversial value judgments. One such value judgment is found in recent analyses from the Disease Control Priority Network (DCPN) and the Study Group for the Global Investment Framework for Women’s and Children’s Health. Noting the decrease in the number of pregnancies expected to result from providing access to family planning, DCPN and the Study Group claim that a substantial benefit of such interventions is averting the stillbirths and child deaths that would have resulted from those pregnancies. We argue that health economic analyses should not count such averted deaths as benefits in the same way as saved lives. First, by counting averted stillbirths and child deaths as a benefit but not counting as a cost the lives of babies who survive, DCPN and the Study Group implicitly commit themselves to antinatalism. Second, this method for calculating the benefits of family planning interventions implies that infertility treatments are harmful. Determining how potential people should be treated in health economic analyses will require grappling with population ethics.

Message of the WHO Representative to the Philippines

Globally, an estimated 2.4 million children died in their first month of life in 2019. This translated to 6,700 newborn deaths every day, and accounted for 47% of all child deaths under the age of 5 years. The world has made substantial progress in child and newborn survival since 1990. However, 75% of newborn deaths continue to occur in the first week of life and about 1 million newborns die within their first 24 hours of life. In the Philippines, an estimated 63,000 of 1.7 million children born in 2019 died before their fifth birthday, with half occurring among newborns. Preterm birth, intrapartum-related complications such as birth asphyxia, infections and birth defects, caused most neonatal deaths in 2019. While child deaths decreased by one-half between 1990 and 2018, newborn mortality declined at half that rate. Along with asphyxia and sepsis, complications of prematurity are the main causes of newborn deaths. Preterm (< 37 weeks gestation) and low birth weight (LBW) (<2500 g) babies have immature immune and organ systems, low fat reserves and reduced muscle mass, placing them at a much higher risk for hypothermia, infection, and death, compared to babies born with normal weight. Kangaroo mother care (KMC) is a technique of caring for preterm and LBW babies which consists of keeping them in skin-to-skin contact (SSC) on the chest of the mother (or other family members), as early and as long as possible, exclusive breastfeeding, and early discharge from the hospital with close monitoring on an outpatient basis. KMC has been demonstrated to reduce mortality in small babies by almost half compared to conventional incubator-based neonatal intensive care. Other benefits include prolonged duration of exclusive breastfeeding and better growth rates. Thus, the World Health Organization (WHO) recommends KMC for babies less than or equal to 2,000 grams. We also support widespread calls to introduce, accelerate, and sustain quality KMC implementation. It is with this note that I congratulate the Kangaroo Mother Care Foundation Philippines, and the research authors for all their original scientific papers on KMC. The publication of these studies, present added evidence that KMC is a cost-efficient, readily available, effective strategy for saving the lives of babies born either prematurely, or with low birth weight for age. Rabindra Abeyasinghe, MD, MSc, DTM&H (Public Health) WHO Representative to the Philippines

Effects of the Optional Protocols to the Convention on the Rights of the Child on the causes of child death: a statistical study on a global scale

The Convention on the Rights of the Child (CRC) and the Optional Protocol to the Convention on the Rights of the Child on a Communications Procedure (OPCP) make commitments and guarantees in relation to child health. The aim of the study is to verify the effects of these commitments on the causes of child death. To analyze these effects, we apply the one-way analysis of variance. For each group, we calculated the averages of child deaths in their respective countries for the years 2002, 2007, 2012, and 2017. The p-value resulting indicated whether there was a difference between the means of child deaths in those years that were compared. We also observed the time series for each cause of death over the years 2000 to 2017. The CRC has an expressive adhesion. OPCP has a smaller number of acceptors in all regions compared to CRC. The acceptance of OPCP did not significantly alter the results of the number of deaths in the accepting countries in any of the 13 causes of child death observed. In the non- accepting group, significant differences were found concerning five causes of child death: HIV/AIDS, diarrhoeal diseases, measles, meningitis/encephalitis, and acute lower respiratory infections (p-values 0.01, 0.01, 0.003, 0.002, and 0.003, respectively). Our results suggest that the group of countries that have accepted the OPCP are more committed to issues of child deaths causes studied. In all of them the annual death numbers were considerably lower in this group.

Roles, Responsibilities, and Rights: An Organisational Analysis of Provincial and Territorial Child and Youth Advocate Offices in Canada

Limited academic literature has explored the responsibilities of Provincial and Territorial Child and Youth Advocates in Canada. This paper analyses the responsibilities that constitute the role of Canadian Provincial and Territorial Child and Youth Advocates, as well as the forces that impact and shape these responsibilities. A total of 17 participants, including current and former members of the Canadian Council of Child and Youth Advocates (cccya) as well as their staff members are included in the study. Findings reveal that individual advocacy, systemic advocacy, investigations into critical injuries and child deaths, as well as educational outreach, constitute the primary responsibilities of the cccya. Additionally, at the provincial and territorial level, it is important for advocates to navigate the historical, cultural and political factors that inform discourses surrounding childhood as these factors impact the way advocacy is understood and carried out within these organisations.

PREVALENCE OF ACUTE DIARRHEAL DISEASES AND ASSOCIATED RISK FACTORS AMONG UNDER FIVE CHILDREN IN AN URBAN SLUM OF MUMBAI

Introduction: Diarrhoea is one of the single most common causes of death among children under age five worldwide. Diarrheal disorders in childhood account for a large proportion (18%) of childhood deaths, with an estimated 1.5 million deaths per year globally, making it the second most common cause of child deaths worldwide1.So the study was undertaken in order to study the prevalence and associated risk factors causing diarrhoea in urban slum of Metropolitan city. Methods- A cross sectional study was done from January 2012 to December 2012 in Cheetah Camp area. Toal 478 under five children were selected and the parent/guardian of the child was interviewed using pre-designed, semi-structured and pre-tested questionnaires. Results and Conclusion-The prevalence of diarrhoea in children under 5 years during past 2 weeks was 17.8%. Diarrheal episodes in the past 2 weeks was significantly associated with education of mother, socioeconomic status of family, type of family, source of water supply, housefly nuisance in home, child hand-washing before meals, mother hand-washing before meals and immunization status.

Postmortem investigations and identification of multiple causes of child deaths: An analysis of findings from the Child Health and Mortality Prevention Surveillance (CHAMPS) network

Background The current burden of >5 million deaths yearly is the focus of the Sustainable Development Goal (SDG) to end preventable deaths of newborns and children under 5 years old by 2030. To accelerate progression toward this goal, data are needed that accurately quantify the leading causes of death, so that interventions can target the common causes. By adding postmortem pathology and microbiology studies to other available data, the Child Health and Mortality Prevention Surveillance (CHAMPS) network provides comprehensive evaluations of conditions leading to death, in contrast to standard methods that rely on data from medical records and verbal autopsy and report only a single underlying condition. We analyzed CHAMPS data to characterize the value of considering multiple causes of death. Methods and findings We examined deaths identified from December 2016 through November 2020 from 7 CHAMPS sites (in Bangladesh, Ethiopia, Kenya, Mali, Mozambique, Sierra Leone, and South Africa), including 741 neonatal, 278 infant, and 241 child <5 years deaths for which results from Determination of Cause of Death (DeCoDe) panels were complete. DeCoDe panelists included all conditions in the causal chain according to the ICD-10 guidelines and assessed if prevention or effective management of the condition would have prevented the death. We analyzed the distribution of all conditions listed as causal, including underlying, antecedent, and immediate causes of death. Among 1,232 deaths with an underlying condition determined, we found a range of 0 to 6 (mean 1.5, IQR 0 to 2) additional conditions in the causal chain leading to death. While pathology provides very helpful clues, we cannot always be certain that conditions identified led to death or occurred in an agonal stage of death. For neonates, preterm birth complications (most commonly respiratory distress syndrome) were the most common underlying condition (n = 282, 38%); among those with preterm birth complications, 256 (91%) had additional conditions in causal chains, including 184 (65%) with a different preterm birth complication, 128 (45%) with neonatal sepsis, 69 (24%) with lower respiratory infection (LRI), 60 (21%) with meningitis, and 25 (9%) with perinatal asphyxia/hypoxia. Of the 278 infant deaths, 212 (79%) had ≥1 additional cause of death (CoD) beyond the underlying cause. The 2 most common underlying conditions in infants were malnutrition and congenital birth defects; LRI and sepsis were the most common additional conditions in causal chains, each accounting for approximately half of deaths with either underlying condition. Of the 241 child deaths, 178 (75%) had ≥1 additional condition. Among 46 child deaths with malnutrition as the underlying condition, all had ≥1 other condition in the causal chain, most commonly sepsis, followed by LRI, malaria, and diarrheal disease. Including all positions in the causal chain for neonatal deaths resulted in 19-fold and 11-fold increases in attributable roles for meningitis and LRI, respectively. For infant deaths, the proportion caused by meningitis and sepsis increased by 16-fold and 11-fold, respectively; for child deaths, sepsis and LRI are increased 12-fold and 10-fold, respectively. While comprehensive CoD determinations were done for a substantial number of deaths, there is potential for bias regarding which deaths in surveillance areas underwent minimally invasive tissue sampling (MITS), potentially reducing representativeness of findings. Conclusions Including conditions that appear anywhere in the causal chain, rather than considering underlying condition alone, markedly changed the proportion of deaths attributed to various diagnoses, especially LRI, sepsis, and meningitis. While CHAMPS methods cannot determine when 2 conditions cause death independently or may be synergistic, our findings suggest that considering the chain of events leading to death can better guide research and prevention priorities aimed at reducing child deaths.

Causes of death after biannual azithromycin treatment: A community-level randomized clinical trial

The MORDOR study, a masked, community-level randomized clinical trial conducted in Niger, Malawi and Tanzania (2015 to 2017), showed that biannual administration of single-dose azithromycin to preschool children reduced all-cause mortality. We sought to evaluate its impact on causes of death in children aged 1–59 months in Tanzania. A random sampling of 614 communities was conducted in Kilosa District, Tanzania, with simple random assignment of communities to receive either azithromycin or placebo. In these communities, a census was carried out every 6 months and children aged 1–59 months received biannual (every 6 months), single-dose azithromycin (~20mg/kg) or placebo depending on community assignment, over a 2-year period. Mortality was determined at the time of the biannual census. For child deaths, a verbal autopsy was performed to ascertain the cause using a standardized diagnostic classification. A total of 190- (0.58 /100 person-years) and 200 deaths (0.59/100 person-years) were reported in the azithromycin and placebo arms, respectively. Malaria, pneumonia and diarrhea, accounted for 71% and 68% of deaths in the respective arms. Overall, the mortality was not different by treatment arm, nor were the distribution of causes of death after adjusting for community clustering. The cause-specific mortality for diarrhea/pneumonia was no different over time. In children aged 1–5 months, 32 deaths occurred in the placebo arm and 25 deaths occurred in the azithromycin arm; 20 (62.5%) deaths in the placebo- and 10 (40%) in the azithromycin arm were attributed to diarrhea or pneumonia. Neither differences in the number of deaths nor the diarrhea/pneumonia attribution was statistically significant after adjusting for community clustering. In conclusion, azithromycin was not associated with a significant decline in deaths by specific causes compared to placebo. The non-significant lower rates of diarrhea or pneumonia in children <6 months who received azithromycin merit further investigation in high-mortality settings. Trial registration: NCT02048007.

Interventions to improve vaccination coverage of children in hard-to-reach population: A systematic review

In the last decade, vaccination has reduced a quarter of child deaths worldwide. Vaccination coverage increased, but the coverage remains low in the hard-to-reach population. We searched articles from Pubmed MEDLINE, SCOPUS, Web of Science, and Science Direct to systematically review interventions to improve children's vaccination coverage in hard-to-reach populations. The expected outcome was vaccination coverage, which mentioned Odds Ratio, mean difference, or difference-in-difference with a 95% CI or p-value. Out of 102 articles identified, five articles from four different countries met the inclusion criteria. Four of the five studies reported a positive impact in increasing vaccination coverage. Interventions that showed good effectiveness in increasing the coverage of childhood immunizations were the application of mHealth given to vaccinators, multiple interventions involving the community, modification of immunization schedules during outreach activities, and immunization screening cards. Despite the inconsistent finding, mHealth with SMS reminders was the most effective intervention to increase vaccination coverage and relatively low-cost. More research was needed in developing a strategic intervention to increase vaccination coverage of children in hard-to-reach populations.

Trends and Characteristics of Mortality Associated with Congenital Anomalies in Korean Children under 5 Years of Age

Purpose: Studies have been conducted on the prevalence and infant mortality rate of congenital anomalies; however, studies on child mortality are rare. Therefore, we evaluated the characteristics of deaths associated with congenital anomalies among children born in Korea who died within 5 years of age.Methods: Birth-to-death cohort linked data of children under the age of 5 years from 2010 to 2013, and statistical data on the cause of death by age from 1999 to 2019, both provided by the Korea National Statistical Office's Microdata Integrated Service, were retrospectively investigated. We investigated the trends and characteristics of mortality associated with congenital anomalies.Results: Among 1,858,945 children, 6,510 children who died were under 5 years of age, and among them, 1,229 deaths were associated with congenital anomalies, while 5,281 deaths were due to other causes. Deaths associated with congenital anomalies accounted for 18.9% of all deaths. When comparing congenital anomalies by systems, anomalies of the cardiovascular system (52.6%) were the most common. The mortality rate associated with congenital anomalies and those of other causes showed similar declining trends in 21 years.Conclusion: The mortality rate of congenital anomalies during the first 5 years of life did not increase differently from the prevalence of congenital anomalies but rather decreased. Deaths associated with congenital anomalies accounted for 20.5% of all infant deaths and 12.1% of child deaths, since the major causes of death in infants and children are slightly different, continuous and careful monitoring is required.