Archive for the ‘Child Survival in South Africa’ Category

Scent of the Plague

These two pictures are of an article I wrote published by the Mail and Guardian newspaper in 2001 during the terrible crescendo of the AIDS epidemic in South Africa. It played a small part in the eventual arrival of a Prevention of Mother to Child HIV Transmission programme in South Africa.

To read the text, I suggest that you download the pictures and enlarge them in your picture program.

If you want to hear more of the history-making fight for this programme, see Prof Haroon Saloojee’s short lecture, given at the South African Child health priorities conference in 2016. A paediatrician, he played a key role in the civil society challenge to the government of the day.

Chapter by Prof. Lesley Bamford in the SA Health Review 2012/13

Lesley has written an excellent article setting out what the current situation is in South African maternal, newborn and child health. I strongly recommend it to anyone wanting to get a grasp of the issues.

 

 

 

Child Health in South Africa – June 2013 Part 2

Part 1 described the context of children growing up in SA. Part 2 outlines some of the indicators of child health and health services in the country:

So what about those health care services? Where are we? Actually, I’m going to postpone

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looking at health services as such as I am hoping that when we get there, we can look at them from the point of view of there being a solution rather than a problem. So let’s look at some indicators of child health in South Africa.

 

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Here’s the first indicator which is in fact not an indicator of child health at all: infant mortality rate or IMR is well established as a measure of a community development, and not directly of health – the poor little canaries (otherwise known as infants) being those who tell us by dying whether we live in a dangerous, poor human environment for not so dangerous human environment. The arrow on this table which comes from the MRC Rapid Mortality Survey published in 2012 shows that South Africa’s infant mortality rate is dropping and has done so rapidly in the last few years. The same is true of the under five mortality rate. This is shown more starkly on the next slide.
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Many of us were desperate during the first few years of the millennium as high rates of death among children stubbornly refused to budge, as the president and his health minister on the subject of AIDS. Things are now shifting nicely. (Except the neonates – the red line at the bottom, – please note)
However there is not much room for complacency here. The absolute level is significantly high still and as the next slide shows –
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This slide shows in the circled area, things things vary considerably by province [the big ? here is the Eastern Cape whose figures based on vital registration seemed to be way out of kilter – led by the former Transkei area – the OR Tambo district – which we saw is one of the areas with high levels of deprivation.] What is more, things vary considerably within provinces. Even in that Nirvana known as the Western Cape province, you will find areas the child mortality levels similar to areas such as Limpopo, and well above the national average. So there is a journey required of us all.
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So what are the children dying of? The top of the list is diarrhoea: one in five deaths under 14 years of age in this country is due to diarrhoea. Perhaps I should say that again. Amongst the youngest children the proportion is even higher. Next on the list are causes of death within the first month of life and the majority of these are within the first week of life and relate to 2 big causes: prematurity with associated complications and, rather sadly, birth asphyxia (euphemistically called “perinatal problems” on this slide). Pneumonia and respiratory infections get in at number three in South Africa. Note that these figures refer to the period before the introduction of rotavirus and pneumococcal vaccines. Evidence from 2009 is diarrhoea and pneumonia deaths are dropping, but neonatal deaths as a whole have not risen to the top of the pile yet. But neonatal deaths are stubbornly sticking at the same level, presenting a challenge to us all.
Had a high status of TB is not only an adult phenomenon. Where did children get there TB bugs from? Why can’t we stop it when we know that their immune systems cannot contain the infection once they have inhaled it? Why do we allow contact tracing to miss children?
I have circled ”immune disorders” because, although there last on the list, this is largely AIDS. But AIDS is a big contributor to all the other causes because, as with adults, HIV is not usually put on the death notification form, or its presence has not been ascertained). Or it is not given as a direct cause of death, but of course it isn’t.
So these 10 causes constitute two out of three deaths. I think you will agree with me that pretty much all of them are preventable to a large degree. Keep this in mind when we come to everyone to go and how to get there. Very obvious where to; but how to get there?
Now looking at hospitals where, beyond neonatal units and wards, just under half of young child deaths happen. (Note that most neonatal deaths occur within the health system, largely in nurseries, in all provinces. We will come back to them soon.) Doctors do most of the therapeutic decision-making in hospitals, so concentrate please.
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This slide is covers admissions to paediatric wards in South Africa and does not include neonatal nurseries. We see that here too has been a gratifying reduction in in-hospital mortality rates – that is, the number of children who died hospital wards per 1000 admissions. If you look at the right hand column on this table, this indicator fell from 50 deaths per thousand admissions in 2009 to 2011. And note (in the centre column) but even though the number of hospitals doing audits and rose as the number admissions monitored, the number of deaths dropped. These figures come from hospitals that audit child deaths (nearly half of all hospitals in the country and predominantly district hospitals). The process involved comes from the Child Healthcare Problem Identification Programme or Child PIP. Things may not be so rosy overall have these figures come from hospitals with clinical enthusiasts. And the next slide…
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… shows causes of death in hospital, and you’ll see that it is very similar to the causes of death overall – with three quarters of all deaths being due to infectious causes. Our old enemy who still laughs at us, diarrhoea, heads the list here too. It is important for us in the health fraternity to recognise that these are deaths of children who have made it to hospital wards and then die. Could more of them have been saved? And we ask again, need the children got sick enough to need hospitalisation? Well, look at the next slide:
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It may explain why children get so sick. Malnutrition is a significant co-factor in hospital deaths – look at the purple and green segment; in many of these the management of malnutrition was sub-optimal, especially if it was severe. Food for thought, if you will pardon the pun.

 

 

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Nearly one in five, folks, for severe acute malnutrition. 20% overall mortality. True, sometimes it is the underlying disease that contributes malnutrition, that calls for early identification of illness, and earlier intervention to prevent and treat concomitant nutritional diseases. Anyone not want to promote breastfeeding after seeing this slide?
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HIV wields its sickle in our wards as well (red and green segments this time). I have recently reviewed the audit data from hospitals and unhappy report – as in the next slide…

 

 

 

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… that this particular Grim Reaper is having a harder time of it. HIV-associated diarrhoea deaths have dropped by 30% over three years – the third column of figures; HIV-associated TB deaths have dropped by the same margin. Bacterial meningitis deaths dropped by even more. PMTCT, ARV, PCV. More letters child health scrabble game

 

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But we need to be sober. When our intrepid auditors reviewed their own practice and that of the primary health care system that referred sick children, they found that much more could have been done a lot better. Nearly half the deaths might have been avoided if things had been handled better – please remember that we are talking about things like diarrhoea and pneumonia here. The top of this table indicates the sites where things might have been done better. Hospitals and homes of the main places where care must be improved if fewer South African children are not to die. Delaying getting to care is the main problem in homes raising questions both the recognition of danger signs but also ease of access to primary and urgent health care for our communities. In the lower half of the table, note that every death between one and two modifiable factors were ascribed to clinical personnel who should have done things better. For diarrhoea, this mainly relates to recognition of shock and dehydration and use of fluids – fundamental skills, surely!?
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And for neonates there is a lot that could have been done better too as this slide shows. Why are women presenting late in labour? Why are many pregnancies and booked? Why don’t we know how to look after sick newborns in our nurseries but we don’t equipment properly?

 

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Most of the deaths I have covered so far are in children under the age of five years. What about the older children? This graph shows that as you get older, your chances of dying of a non-natural cause rise to nearly half of all causes in the ages 15 to 19. Other main causes include AIDS and cerebral palsy. Remember that much cerebral palsy in this country is due to secondary causes such as birth asphyxia and meningitis, so deaths in older children must be considered potentially preventable in this day and age. Taming gangs, alcohol and fast cars is a bigger challenge.
So that is a lot about child health at the extremes – death. But we talk to morbidity in children,
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… We’re talking about the same things that matter less severe scale. So what keeps the primary health care system in hospitals busy the same things that cause children to die. The same things that need to a lot of child disability.
It is important to recognise that children have long-term problems in significant numbers. Herein are the children with neuromuscular diseases and disabilities, congenital conditions such as cardiac disease and haematological disorders, acquired diseases such as type I diabetes, rheumatic disorders and the large number of learning disabled and attention deficit hyperactivity disorder children and young people. I have separated out mental health disorders because these go a long way beyond the severe things like autism to include a huge level of (often undiagnosed) problems of anxiety/depression and substance abuse. There is a lot here that represents the antecedents of adult somatiform disorders that keep the health system very busy. Almost untouched in this country.
One major concern is that the success of programmatic IMCI-based case management in providing primary health care to children, to the lack of access to more sophisticated care within the primary health care system. My corralling children into narrow IMCI-trained nurse-led to services, we have lost decade of clinical nurse practitioner who was able to recognise and treat a lot of common childhood disorders and make a much better referral to a doctor. In improving access to and quality of care for a narrow spectrum disorders, we have inadvertently reduced access to care for children with other disorders and children in the age of five years. I will talk to how this might be remedied later.
You’ll recognise that subliminally I have been sharing new issues around health services even though I said I was leaving for a while. So much of what kills aims children is because of sub-is optimal handling by our health systems, private and public. So let us talk about them overtly:
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The good first: mostly programmatic and acronymic as shown in the slide. The learning purposes it is worth looking up in the acronyms you do not recognise.
When it comes to the not so good, there is much that we know about that affects children as well as adults – in equitable distribution of services and resources, poor service management, staff attitudes, too few staff, waste. The big concern is how some flagship policies such as IMCI, EPI-SA, and PMTCT are inadequately implemented. But on a positive note, much is now being done to remedy this, such as a focused drive to improve efficacy of a complex sequence of activities known as PMTCT with the aim of eliminating new vertical infections by 2015. I have to mention breastfeeding. Do in the health services really believe and its benefits, you wouldn’t think so from the way we don’t provide spaces and energy for it, even some of our maternity services. And have you recognise that with a RVs, breastfeeding is the safer, even life-saving option of HIV-exposed babies in that very large deprived community I spoke earlier? With your support, it can be done with massive benefits for the country and the children.
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It is certainly our intention in the Western Cape – and not only because we looked like a breast with lacteals converging on Cape Town!

A reminder of the past

This week we have seen two children passing through our hands with invasive Haemophilus B diseases. Since South Africa introduced the conjugate vaccine against this pathogen, such cases have become rare. Two in one week has created a flutter.

One baby developed the disease before the time at which immunisation is initiated in the routine schedule, and the other had been fully vaccinated (though malnutrition may have reduced the effect of the course of injections). Both cases emanated from an area which had seen community action protesting about the poor state of health services in the area. This action had led to a break in service and the current replacement service has reduced access to immunisation for children through being geographically distant.

These two cases, though not directly related to this disruption in the immunisation programme, remind us rather starkly of how vulnerable children are to poorly managed health services, especially in terms of access.

Both children have died despite going to ICU (not a commonly accessible service in this country’s public health system). Reviewing the cases, we noted that they had both been ill for a couple of days before advice was sought from the formal health system. Was access to a health system close by part of this delay? Many believe that a system of community health workers would reduce such delays for sick children. The evidence for this belief is robust. Taking health care into vulnerable homes is one of the major thrusts of primary health care in South Africa now.  We must make it happen for children!

“Breast feeding is best for all babies”

This article Max Kroon of Mowbray Maternity Hospital and I wrote for the Western Cape at a time when the Department of Health was beginning a process of “Breast Feeding Restoration” policy, taking advantage of the window of opportunity new evidence on the very low transmission HIV-transmission rates now possible with exclusive breast feeding covered by anti-retroviral drugs provides. Breast feeding is a major saver of lives, especially among people with limited access to basic services and income generation. The Cape Times published it on 24th November 2011 with the sub-heading “HIV should not cause confusion” so the editor had clearly understood our point. This article was written two months after controversy was stirred when two sets of experts in child health had clashed over the issue of breast feeding and HIV in the Mail & Guardian newspaper. We put our perspectives to the people of the Western Cape (at least those who read the paper version of the Cape Times; unfortunately this is not available to non-subscribers online so I thought it worthwhile to put it here).

I note here that this a complex issue: there are many unknowns and variables; perspectives will be different on the meaning and weighting of  any risk/benefit equation. Amid all of this, policy has to be made and adjusted. Max and I stated what we thought policy should do in our province, and tried to lay before the lay public our reasons for this position. We may also have laid our heads on the line in the volatile and sometimes polarised South African HIV context.

“Breast feeding is best for all babies”

South Africa is in the invidious position of being one of only a handful of countries in which child mortality rates are not falling. In this regard we are sadly not on track to meet the United Nations Fourth Millennium Development Goal (MDG4) – to reduce child mortality by two thirds between 1990 and 2015 – and time is running out. There are welcome initiatives to address this with improvements in the national Programme for Prevention of Mother-to-Child Transmission of HIV (PMTCT) and the introduction of important new childhood vaccinations. But in the face of widespread poverty and unemployment, these interventions alone cannot get us to MDG4 unless the scourge of child malnutrition, a potent cause of child mortality, is addressed as well. This is true for the Western Cape province despite the fact that its infant mortality is the lowest in the country.

We therefore focus on the most logical way to significantly enhance the health and survival of children: BREASTFEEDING.

The well-established benefits of breastfeeding are more pronounced with exclusive breastfeeding (that is: no other liquids, no solids, only breast milk). These benefits include a perfectly tuned growth pattern in early life which has life-long positive effects, excellent protection from common life threatening infections such as diarrhoea and pneumonia, enhanced mental health and development, and lower rates of some allergic diseases. The benefits also extend well beyond childhood, producing lower rates of obesity, diabetes, cardiovascular disease and other diseases of adulthood. These benefits have significant economic spin-offs through decreased health spending and greater human productivity. Breastfeeding is an affordable and effective intervention with an irresistible per capita reduction in health costs. It is a single intervention that has multiple lifelong impacts and empowers individual citizens to make a difference to the health of the nation in a very meaningful way.

Exclusive breastfeeding is all that most infants require for the first six months of life. Breast milk is complete low-cost, purpose-perfect nutrition with added immune system enhancers. There is no need for extra liquids. Studies in the hottest, most arid climates have shown that even under these conditions, infants require no added water or other fluids for the first six months of life. In addition, children who are exclusively breastfed never become severely malnourished unless they have an underlying illness. In contrast, the addition of other liquids or solids during the first six months undermines the health benefits of breastfeeding, increases the risk of infections and at least doubles the risk of mother-to-child transmission of HIV.

Even in the all too common instance of maternal HIV, exclusive breastfeeding in the first months of life confers a significant health, nutrition and survival advantage while incurring a similar overall risk of HIV transmission as formula feeding. Breastfed HIV-infected infants grow better, are healthier and have a better survival rate. The WHO recommends that they breastfeed for two years and more.

Antibodies and other immune substances in breast milk play a crucial anti-infection role and are significant factors that explain why breastfeeding continued beyond six months is so important for child health and survival even in HIV-exposed infants. Solid food needs to be added after six months to meet increased nutrient requirements and breastfeeding is necessarily no longer exclusive after this time.

The link between South Africa’s high infant mortality rate and the fact that we have one of the lowest exclusive breastfeeding rates globally needs to be spotlighted. The argument that this is primarily due to HIV ignores the reality that seventy percent of infants are not HIV-exposed and that sixty percent of children who die are malnourished. Improving our exclusive breastfeeding rate is central to improving our population’s health status and achieving MDG4.

How are we to do this? What is preventing so many babies from being breastfed?

Obstacles to sustained breastfeeding include the absence of laws against the promotion of formula milks, and inadequate legal protection of maternity leave for young female temporary workers in the Basic Conditions of Employment Act. There is a lack of private space and opportunity for breastfeeding and expressing breast milk in our public buildings and private businesses.  Suboptimal implementation of policy and practice at community level to support breastfeeding  in the crucial first weeks after birth truncates the duration of exclusive breastfeeding. A lack of knowledge and understanding of the immediate and life-long benefits of breastfeeding for mother and child in general society conspires to perpetuate widespread and dangerous practices such as giving babies porridge or rooibos tea well before the recommended six months of age. Easy access to formula milk for HIV-infected women has had a ‘spill-over’ effect on general breastfeeding rates.

The national Minister of Health, Aaron Motsoaledi, is personally leading the national onslaught on all that prevents babies being breastfed.  The August 2011 Tshwane Declaration of Support for Breastfeeding in South Africa is a very welcome development and constitutes high level support for the crucial national public health priority to promote, protect and support breastfeeding. The Western Cape province requires similar bold governmental leadership on this matter.

Breastfeeding is a noble task that most mothers, no matter how poor, are biologically empowered to perform, but they are often hampered by lack of support, misinformation, inadequate maternity benefits and other difficulties in their daily lives. They should be supported in this endeavour with all the means at our disposal including health care facilities that are friendly to breastfeeding and policies, as well as workplace legislation and social development policies that promote, protect and support breastfeeding.

The Tshwane declaration comes out strongly in support of the development of a donor milk service. Breast milk compared to formula milk reduces the risk of infection and death in preterm babies and donated human milk supports the practice of exclusive breast milk feeding in this particularly vulnerable group. Milk banks could also be used to increase access to safe human milk for infants whose mothers are too sick to breastfeed. Policy briefs commissioned by the Human Milk Banking Association of South Africa (HMBASA) prepared by the Programme for Appropriate Technology in Health (PATH) were presented at the Tshwane summit and are available to inform health system planners.

Specific mention needs to be made of breastfeeding and HIV in this province. Data from recent randomised controlled trials shows that maternal or infant antiretroviral therapy (ART) is safe and reduces HIV transmission during breastfeeding to less than one percent. This is “game-changing” evidence that argues strongly for breastfeeding to be the default infant feeding policy position in the province’s PMTCT program. The public health imperative to promote breastfeeding also argues strongly for a simplification of our PMTCT regimen to Option B of the World Health Organisation 2010 PMTCT guidelines i.e. ART for all pregnant and breastfeeding women living with HIV.

In the light of this new evidence, there has even been a recent argument in a respected peer-reviewed journal for the consideration of breastfeeding by HIV-infected mothers in industrialised countries!

We can talk with one voice: HIV need no longer be a source of confusion in the promotion of breastfeeding.

Some argue for the retention of state-subsidised formula milk for HIV-infected mothers who cannot financially afford it, but this loses sight of the central issue that formula milk cannot replace the protective effects of breast milk. Making it simple for many mothers to select an unsafe infant feeding option is ethically questionable. Provision of ‘free’ formula also ignores the reality that the highest burden of HIV is in the very communities where not to breastfeed is most dangerous. In our most deprived communities, not breastfeeding will always incur significant morbidity and mortality for children, and it can never be safe in the unhygienic, under-serviced and overcrowded living conditions that prevail in much of this province. These conditions will persist until the immense disparity in wealth between the richest and poorest is addressed. Providing formula for ‘free’ also creates the impression that government endorses an unsafe infant feeding practice resulting in potential “spill-over” to mothers who are not HIV-infected.

In Cape Town it is reassuring to note that increasing numbers of women living with HIV are choosing to breastfeed their babies. Systems to support them in their choice that have a strong evidence base from international studies, such as baby friendly health facilities, community worker programs and breast feeding support groups, need to be upscaled rapidly.

All good people believe that apartheid was a bad thing. The alliance of forces that opposed apartheid had one goal – its elimination. Likewise, all good people would say that child hunger; malnutrition; illness and death are bad things that need to be eliminated. Exclusive breastfeeding for the first six months of life and ongoing breastfeeding until two years of age or more gives our children the best possible start in life and is a vital and logical way to significantly reduce these scourges before 2015.

The time has come for government, civil society and the mothers of this province and the nation to rally behind the call to promote and protect breastfeeding, eliminate obstacles to its widespread use and restore it to the very heart of efforts to improve child health and survival.

“There can be no keener revelation of a society’s soul than the way in which it treats its children” – Nelson Mandela.

 

Tony Westwood and Max Kroon, School of Child and Adolescent Health, Faculty of Health Sciences, University of Cape Town

 

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