Study Finds Mothers' Education Levels Affect Child Mortality

Friday, September 17, 2010
A study published in the journal Lancet on Friday found that "a mother's education level has a huge, if indirect, effect on the health of her children," the Washington Post reports.

"Half the reduction in child mortality over the past 40 years can be attributed to the better education of women", according to the analysis ... Worldwide, there were 8.2 million fewer deaths in 2009 among children younger than 5 than there were in 1970. Of those 'averted deaths,' 4.2 million were the result of better-educated mothers," the newspaper writes (Bown, 9/16).

The study, conducted by researchers from the Institute for Health Metrics and Evaluation (IHME) at the University of Washington, "shows that education is rising in every region. Most dramatically, average years of schooling for women of reproductive age (ages 15 to 44) in developing countries have grown from 2.2 years to 7.2 years," states an IHME press release. At the same time, according to the release, in "six countries – Afghanistan, Burkina Faso, Chad, Mali, Niger, and Yemen–women receive less than one year of schooling" (9/16).

Researchers obtained results by using "915 censuses and surveys from 175 countries tracking education, economic growth, HIV rates and child deaths from 1970 to 2009," the Associated Press reports (Cheng, 9/16).

Study co-author Christopher Murray explained that a mother's education affects the health of her children in many ways, the Washington Post writes. "According to Murray, better-educated women are more likely to understand disease-prevention measures such as vaccines and mosquito nets, and to use them. They are more likely to take a sick child to a clinic early and to follow treatment instructions. They are more likely to understand germ theory and set clean water and sanitation as household priorities. With more schooling, women tend to have fewer children and space births more widely, both of which also reduce child mortality."

Al Bartlett, a child health expert at USAID, said the findings are not unexpected, "but the magnitude is impressive." Bartlett added, "It clearly justifies what many have been saying for a long time - that one of the investments we need to make is girls' education" (9/16).

AP notes that "not everyone was convinced that the study's conclusions were right."

"Education is not much good if the health facilities and infrastructure don't exist," said Philip Stevens, a senior fellow at the International Policy Network. "If a country is massively misgoverned, like Sierra Leone, no amount of education is going to put bread on the table for children."

William Easterly, an economics professor at New York University, said, "It sounds plausible that education is related to child mortality, but finding a correlation does not prove causation."

The Bill & Melinda Gates Foundation funded the study (9/16).
Thanks to Carol Meynen, M.D. for sending this in.

Breast Feeding and HIV Transmission in Infants: A WHO Policy Change

Each year 200,000 infants are infected with HIV virus from their mother’s breast milk. Because of the high risk of passing on a fatal disease by HIV positive mothers who nurse their babies, the World Health Organization and other agencies have recommended that these mothers not breastfeed, “if replacement feeding is acceptable, feasible, affordable, sustainable and safe.” Pretreatment of the HIV positive mother with a single antenatal dose of the antiretroviral nevirapine is also recommended, which reduces prenatal HIV transmission by 50%, and gives some protection to the nursing infant for 4-6 weeks postpartum. In the resource poor environment of many developing countries early exclusive breastfeeding is critical to infant survival. Early formula feeding or mixed feeding (breast milk + formula and or cereal products) exposes the vulnerable infant to a markedly increased risk of diarrhea and other infections, and results in a high mortality rate. Clinical studies have also shown that mixed feeding also results in a four times or greater rate of HIV acquisition in comparison to those infants who are exclusively breastfed. This unfortunate set of circumstances places health workers and agencies on the horns of a serious dilemma. Does the baby die from AIDS or from diarrhea? WHO recommended in 2000 that mothers in developing countries exclusively breastfeed to 4 or 5 months, then abruptly stop nursing and switch to formula and cereal. This approach has been challenged by recent clinical research. The final report of a long-term study in Zambia recently appeared in the New England Journal of Medicine. (1). This study showed that there was no benefit in HIV-free survival to 24 months among infants of HIV infected mothers who were encouraged to stop breastfeeding abruptly at 4 months as compared with infants of mothers who continued breast feeding for a median of 16 months.

This study and others recently completed have caused the World Health Organization to revise its developing countries recommendations to include

1. Extension of the time of exclusive breastfeeding to 6 months.
2. Continuation of breastfeeding with addition of complementary foods, if replacement feeding is still not acceptable, feasible, affordable, sustainable and safe, (2)

A recent NEJM editorial on HIV and breastfeeding, (3), points out that this important issue is far from settled. Further research is indicated, including more extended use of antiretroviral therapy, and further efforts to tailor breastfeeding options to obtain optimal HIV free survival.

1. Kuhn, L., Effects of Early, Abrupt Weaning on HIV-free Survival of Children in Zambia, NEJM 2008; 359:130-141.
2. WHO, UNICEF, UNAIDS, UNFPA. HIVAND Infant Feeding: Update. Geneva WHO, 2007
3. Gray, G. E. Breast Feeding, Antiretroviral Prophylaxis and HIV. NEJM 2008; 359:189-191.

Reported by Roger Boe MD. UMVIM Medical Consultant.

SAVING NEWBORNS IN DEVELOPING COUNTIRES

Newborn babies are dying. Four million babies die each year during their first days of life, most during the first hours after birth. 98% of these deaths occur in developing countries. Three fourths, or 3 million of these deaths are preventable. They are preventable not with our new expensive technology, but with simple proven interventions that are universally available, inexpensive and can be easily used in every corner of the world.
Recent years have seen marked reductions in maternal mortality in developing countries, and a 50% reduction in child mortality. However there has been no accompanying decrease in the mortality of newborns in the developing world. According to some experts, the Global Community has made the newborn a second tier priority. Most deliveries and most deaths occur at home without any intervention by the health care system. There is often a fatalistic attitude about newborns within families and communities, and even on the part of health care personnel. The underlying expectation is that the baby may die.
Many factors affect neonatal survival, including larger societal issues such as poverty, lack of education, social inequalities, cultural practices, and the chaos of war and civil unrest.
Approximately 1/3 of new babies die of pregnancy related causes, 1/3 from complications of delivery, and 1/3 from infection. We need to look at the pregnant mother for part of the explanation, the birth itself for another part, and those critical first few weeks of life for the rest.
Antenatal care is often sporadic or non-existent. The pregnant mother is subject to infection, malnutrition, and anemia. Sexually transmitted diseases are prevalent. Recurrent chronic malaria is the rule during pregnancy in Sub-Saharan Africa.
Over 90% of babies in developing countries are born at home. Very few births are attended by a trained health worker. Most deliveries are supervised by a traditional birth attendant (TBA), or by a family member. TBAs have little or no relationship with the local health system. They often use traditional practices related to local customs, some good and some not so good. They often do not use basic sanitation, such as hand washing and a clean cloth. They usually pay most attention to the mother and sometimes neglect the baby. They have no training in basic resuscitation. The cord is sometimes cut with an unclean instrument and at times smeared with mud or cow dung. The baby is often not fed for some time, and colostrum is discarded. Most newborn deaths in developing countries occur at home without medical intervention. This massive loss of new life is morally wrong and spiritually unacceptable.
During the past few years, this relative neglect has markedly changed. Care of the newborn has rapidly emerged as a global priority. A worldwide effort has been marshaled to address this alarming situation. The Bill and Melinda Gates Foundation-Save the Children has been a major agent of change, and contributed major funding. The World Health Organization has launched several important programs supported by a number of governmental and non-governmental agencies. During the past 2 years a number of major comprehensive reviews have appeared in the medical literature that have summarized current work in the field and made a number of important recommendations.

Sixty years ago the so-called developed nations had newborn mortality rates that looked like Africa’s do today. The greatest reductions were achieved in three basic areas of intervention
Universal (often free) prenatal care
Skilled birth Attendants
Availability of antibiotics
The same interventions are indicated today. These simple practices are all well known, proven, and inexpensive
Interventions which need to take place during pregnancy

Mother needs to be incorporated into a prenatal care system
The “prenatal care package” includes
Treatment for anemia
Folate supplementation
Maternal tetanus toxoid, in order to prevent 250,000/year fatal cases of neonatal tetanus
Rx of Urinary Tract Infections and Sexually Transmitted Disease. Nivirapine to prevent AIDS transmission from mother to infant
Rx of malaria-- some recommend interval presumptive treatment during pregnancy
Nutritional advice

At Birth, the attendant
washes hands
Uses clean cloth
Uses clean instrument to cut cord
Keeps cord dry. No stuff on it
Keeps baby warm and dry.
Focuses on the baby as well as the mother
Is trained in simple resuscitation measures

The newborn
Is treated with silver nitrate or antibiotic drops in the eyes
Is breast fed early and the colostrum is used
Is observed for signs of infection.

Items necessary for basic care during birth have been incorporated into delivery kits and packaged for wide distribution. The kits are inexpensive and can be used by families and birth attendants with basic instruction. They are heavily promoted by WHO and Save the Children. Many studies have shown remarkable success when the kits are widely distributed and used appropriately.

The key to the success of all of these interventions is in their implementation. We need to implement what has already been shown to work. The reality is that the majority of women in developing countries will not have access to trained health workers as birth attendants. The obvious strategy is to train the traditional birth attendants and the families. This is not easy. The delivery of a baby in the home is often a private matter outside of the health system. Practices that have existed for centuries require a change in ways of thinking. Education has to be available and it also needs to be acceptable to the TBA and the family. This education has to be part of a community program that uses educators, health workers and promoters that are a part of that community. Many excellent, community based primary health care programs have successfully used many or all of these interventions as part of a comprehensive health program, and have achieved developed nation status in regard to both maternal and neonatal mortality.
As short-term volunteers with different language and culture, it is very difficult for us to integrate ourselves into the community and build a trust relationship sufficient to actively participate in these interventions.
What we can do is:
Observe and listen. Learn as much as we can about local status of pregnant women and newborns, birth practices and patterns of newborn care.
Encourage and support programs that train community Traditional Birth Attendants, families, and local health workers in the elements of maternal and newborn care.
Participate in the training process, if feasible
Encourage and support programs that distribute and train in the use of delivery kits and “packages” of care WHO and Save the Children
Help supply and promote the use of basic equipment, including delivery and cord care kits, bag and masks, as well as basic medicines and vitamins.
Encourage data collection and clinical research by the agencies with which we work.
Conclusions:
We need a global political commitment to Newborn Health at all levels of government from local to national.
We must promote an increased focus on the newborn within existing child and maternal programs
We need to implement the interventions that have already been shown to work in reducing neonatal mortality
We must reach out to the weakest and most helpless of all humanity, the newborns of the developing world.
In partnership with families and communities, local health providers and local health systems, we can work together to make a difference in the survival and well being of newborns in developing countries.

“No investment in Global Health has a greater return than saving the life of a child”

Melinda Gates

Article submitted by Roger Boe, MD

A Volunteer's View on Child Health

While it has been my experience to see many children born into poverty in Haiti and Nicaragua, I believe that the most important challenge facing us as "missionaries" to developing countries is to the children yet conceived, yet born, yet to face hunger and disease. It may be desirous to address the nutritional and health needs of infants and children, but I believe that it is even more important to educate the young women and men before another unsustainable child is born into grinding poverty. It is important to empower women with the right to choose whether to have a child, for it is often the women who will bear the primary responsibility to nurture the new child. Often, these women do not have a choice whether to become a mother, due to cultural, social and economic pressures. Once the child is conceived, it falls on the mother to find food for two when it is often difficult to find it even for herself. The result is pre-natal protein malnutrition, stunted brain growth and developmental delay even before birth.
Since the year I was born, the population of the world has increased from 2 billion people to 6+ billion people. Developed nations today have a negative growth rate, if the contribution of immigration is excluded. People given a third grade education (able to read the news) and enough food to eat realize that there is a lifetime responsibility to have a child with a partner. Therefore, I believe that the most important globa l child health issue takes place before conception of a child in a developing nation. As either the primary cause, or significant secondary cause, the explosion of the world's population is at the root of all poverty and should be the fundamental target of global child health efforts.
Robert H. Hoy, Pharm.D.
Bloomington, IL USA

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