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 - ifriberg@jhsph.edu