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Lives Saved Analyses for Child Survival Projects:
Using LiST to Estimate the Impact of Maternal, Newborn and Child
Health Interventions
Debra Prosnitz, MPH; Rebecca Levine, MPH; James Ricca MD, MPH; and Ingrid Friberg, PhD
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Lives Saved Tool
Beginnings of LiST:Inspired by the “Bellagio” modeling exercise which served as the basis for the data in the Lancet Child Survival Series
Goal of LiST: To promote evidence-based decision making for planning the appropriate expansion of maternal, neonatal and child health interventions in low-income countries, and evaluation and estimation of Lives Saved (past and present).
Objectives of LiST: To estimate additional number of lives saved when scaling up key interventions and to provide a user-friendly tool for child survival planning in developing countries.
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LiST
The Lives Saved Tool A multi-cause model of mortality
Predicts changes in Under 5, infant and neonatal mortality rates and deaths Maternal mortality ratios and deaths Causes of death
Using Country specific health status
• Baseline Child Mortality from UNICEF Child and maternal health intervention coverage levels
• i.e. ORS, facility delivery, etc. Effect sizes of interventions based on the best available
evidence
How does LiST work
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Built into a demographic package DemProj in Spectrum
Links to other Spectrum modules AIM for AIDS FamPlan for Family Planning
Cohort-based model Children cannot die multiple times Impacts can be lagged to a later age
period Risk factors affect probability of mortality
General Framework of the Model
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Demographic estimates and
projections
UN Pop/Spectrum
Number of Child and Maternal Deaths
Deaths by CauseWHO/UNICEF Country estimates
Deaths averted -By cause-By intervention
Intervention ImpactC1 C2 C3 C4 …
Int1 Int2 Int3
Intervention Coverage•Current (database)•Future (user-defined)
Health Status
•% stunted•Malaria prevalence•Vit A deficiency•Zinc deficiencyWHO Database
Stunting
Interventions Included
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Proximal factors Not distal (i.e. poverty, lack of education)
Work through health programs Not included: income, education and crowding, etc. Sanitation is the exception
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 every year
Types of Interventions
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Maternal, neonatal, child
Periconceptual, 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)
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Peri-conceptual Interventions
• (Family planning (birth spacing))
• Folic acid supplementation or fortification
• Abortion services
Antenatal Interventions
• Syphilis detection
• Calcium supplementation
• Multiple micronutrient supplementation
• IPTp malaria (or ITN use)
• Tetanus toxoid
• Balanced energy supplementation
• Case management of maternal malaria
Care/Interventions During Child Birth
Antenatal corticosteroids for preterm labor Antibiotics for pPRoM Essential care for all women and immediate
ENC (institutional)* Basic emergency obstetric care* Comprehensive emergency obstetric care* Active management of the 3rd stage of labor
- AMTSL Newborn resuscitation (institutional & home) Clean practices and immediate ENC (home)
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Preventive Interventions
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Kangaroo mother care Routine postnatal care
(healthy practices & illness detection)
Breastfeeding promotion Complementary feeding
- Education only- Education and
supplementation Insecticide treated materials Vitamin A for prevention Zinc for prevention
Improved water source within 30 minutes
Water connection in the home
Improved excreta disposal (latrine, toilet)
Hand washing with soap Hygienic disposal of
children’s stools
Rotavirus vaccine Measles vaccine Hib vaccine Pneumococcal vaccine DPT3 vaccine Polio vaccine BCG vaccine
Curative Interventions
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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 Case management of pneumonia Vitamin A for measles treatment Therapeutic feeding Antimalarials (Cotrimoxazole for HIV) (ART for children)
NOT Included in the Model
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Education Motivation Gender issues Economic status Emergencies (i.e. famine, flooding) Delivery mechanism
Only as relates to total population coverage Quality of care
Can somewhat take this into account
Assumption:
Several of these factors are DISTAL factors which MAY work through COVERAGE
changes…thus MAY already be in the model
Interventions NOT in LiST
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Magnesium sulfate De-worming IPTi Breastfeeding initiation within 1 hour Birth spacing benefit Treatment of water in the home Iron (or iron-folate) supplementation
Data Needed to Run LiST
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Country-Specific Population data and trends
• Default: UN Population Division 1950-2050 (DemProj)• User entered (district) data
Cause of death structure• Default: WHO/UNICEF (2000-2003)• User entered data
Intervention coverage• Population based data• Default: Childinfo.org or DHS/MICS (closest to 2003)• User entered data
Global Intervention Efficacies
• User entered data
Building Blocks of the Model
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Preventions Treatments Risk factors Using 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
Age Groups
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Neonatal < 1 month
Post-neonatal 1-5 months 6-11 months 12-23 months 24-59 months
Multiple Interventions in LiST
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In the context of other interventions In the context of the baseline health
status In the context of changes over time
You create your own package!!!
Odds and Ends
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Effect sizes do not vary on based on either coverage of disease prevalance Exception: *Herd Immunity*
Some components are grouped
Multiple nutrition impacts
Groupings
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Antenatal Care Components
• Case management, syphilis Child Birth Care
Facility and Home based deliveries Components
• Corticosteroids, antibiotics, labor monitoring/ emergency obstetric care, resuscitation, clean delivery
Water Components
• Water within 30 minutes, water in the home
Nutrition Impacts
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Direct impact Therapeutic feeding Balanced energy supplementation Multiple micronutrient supplementation Complementary feeding (education ± supplementation) Breast feeding prevalence/promotion Zinc supplementation Water and sanitation
Indirect impact Water and sanitation – via diarrhea IPTp – on IUGR Zinc – via diarrhea
None Vitamin A supplementation
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Stunting
Zinc
Diarrhea incidence
IUGRAppropriate Complementary Feeding
Complementary feeding education and/or supplementation
Previous Stunting
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Malaria Mortality
DiseaseSpecificTreatments
DiseaseSpecific Preventions
Risk factors
ITN/IRS
Antimalarials
Stunting
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Stunting
Post-Neonatal DiarrhealMortality
Rotavirus vaccine
Vitamin A
Zinc
Water/Sanitation (5)
Zinc
Antibiotics for dysentery
ORS
DiseaseSpecificTreatments
DiseaseSpecific Preventions
Risk factors
IUGR
Syphilis detection and treatment
IPTp
Maternal energy and/or micronutrient supplementationZinc Complementary
Feeding
Complementary feeding education and/or supplementation
Diarrhea incidence
Improved H2O source within 30 minutes
Hand washing with soap
Water connection in the home
Improved excreta disposal (latrine, toilet)
Hygienic disposal of children’s stools
DistantFactors
Breast Feeding
Breast Feeding Promotion
Advanced TopicsFamPlan and AIM in LiST
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LiST can be linked to AIM (HIV) and FamPlan (Family Planning) Spectrum
modules
To examine combined, estimated, impact multiple models must be compared.
Please contact a LiST trainer to assist with any LiST, FamPlan, or AIM integration
What LiST Is, What LiST Isn’t
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Is Multi-cause mortality
model Mathematic model Models coverage
impacts Potential impact
assessment National or sub-national
planning tool Discussion points Evidence-based
Isn’t Natural history model Truth Probabilistic model Detailed costing or
planning tool Bottlenecks, budgeting Exhaustive
Projection of Additional Lives Saved
Projections of additional lives saved are based on the assumption that all other coverage levels remain the same!!!
This is important to keep in mind for mature interventions (i.e. Immunization)
We do not want projections to inadvertently make the case for decreasing funding/coverage for these interventions
Some Limitations
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Data availability If no baseline, can’t evaluate impact
accurately Data quality Sensible scale up targets
Feasible, acceptable, funds available EX: Project presented to MOH a plan to scale up
handwashing from 3% to 80%
Interventions included in software
Some Limitations: Maternal Health Intervention
Assumptions
Because of the much smaller numbers of maternal deaths & the continuing work to determine the impact that some interventions have on maternal survival, LiST may not be the best tool to weigh the relative value of different investments in maternal survival
MH interventions included in LiST are packages that are only effective in reducing mortality if all services are provided at quality
LiST Validation
“How do you know that this works?”
“How can it be used in reality?”
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Neonatal Package Modeling
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Source: Friberg, et al. Comparing modelled predictions of neonatal mortality impacts using LiST with observed results of community-based intervention trials in South Asia. International Journal of Epidemiology 2010; 39: i11-i20
ACSD Countries
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Ghana (1% underestimate) - Good Mali (10% underestimate) – OK
Predominantly post-neonatal interventions
Data from DHS and other sources Adequate correlation
Modeling Mortality Rates and Equity
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How Can LiST be Used?
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Planning, Evaluation, Advocacy Strategic planning
Which interventions are necessary to reduce mortality? (maternal, neonatal, under-5)
By how much will project targets reduce mortality? Evaluation and intermediate-term follow-up
What is the impact of observed coverage changes? Evaluation of historic trends (i.e. multiple DHS/MICS/KPC
surveys) Predict estimated lives saved (past and future)
How many lives were saved, total and by intervention, over the course of your project (in your project area)?
How many deaths remain after intervention scale ups?
How Has LiST Been Used?
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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
Sub-National Lives Saved by CSHGP projects
Who Uses LiST?
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United Nations− WHO/CAH − UNICEF-ESARO
Development Partners− USAID− BMGF− CIFF− CIDA− Save the Children− MCHIP partners− PMI − JSI
Other organizations− Abt− JHSPH− ICF Macro
Countries− Catalytic Initiative
• Malawi• Burkina Faso• Ghana
Doris Duke Foundation
Future Directions for LiST
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Add the new CHERG Cause of Death structure - 2008 Birth spacing benefit of family planning Additional costing tie-ins
Finalization of CHOICE based costing tool Links to the fiscal and bottleneck portions of MBB
Updated interventions – continuous Research, Reviews, Model updated Documentation – to be published in the winter
‘Research’ version To predict the impact of future developments
Who Owns LiST?
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WHO? UNICEF? US Fund for UNICEF? CHERG? Gates Foundation? Futures Institute? JHSPH?
INDEPENDENT
LiST Contributors
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Institute for International Programs
How to Get LiST
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FREE www.futuresinstitute.org www.healthpolicyinitiative.com/index.cfm?
id=software&get=Spectrum www.jhsph.edu/iip
Languages English, French, Spanish, Portuguese
Manuals English, French, Spanish, Portuguese
Contact Ingrid Friberg - [email protected]