Objective 1. Provide timely estimates of the causes and determinants of child mortality reflecting the effects of accelerated child survival interventions.
In this project, CHERG will work with WHO and UNICEF to develop the methodologies and processes such that the total burden of childhood mortality and causes of death can be estimated and published annually beginning for the year 2008, with results available in 2009. These estimates will include, where the data permit, specific etiologies of diarrhea and respiratory disease/meningitis. Additional subjects of study will be co-morbidity in child mortality and the health system determinants of mortality. CHERG will work with selected countries to improve information on causes of child mortality, as well as review the global literature.
Objective 2. Provide comprehensive estimates of morbidities and disabilities for important child conditions.
CHERG has provided estimates of important child morbidities, i.e., pneumonia, diarrhea and malaria. Substantial new information on morbidity and etiology from studies funded by The Bill and Melinda Gates Foundation and GAVI will become available in the next several years, and must be incorporated in the country and regional estimates. CHERG will provide new “envelopes” of morbidity (total morbidity that all etiology-specific cases must fit within) and work to ensure that all major etiologies are accounted for using methods that do not result in double-counting cases of co-infection.
Objective 3. Improve knowledge of the causes of maternal mortality.
Information on the current level of maternal mortality is improving, but knowledge of the causes of maternal deaths is more limited and lags behind knowledge of the causes of child death in the same low-income settings that have high rates of both. This project would improve estimates of the causes of maternal mortality through the development and use of methods for the analysis of data from high-mortality countries when possible, as well as model approaches as have been used for causes of child mortality.
Objective 4. Determine the immediate, medium-term and long-term burden of maternal morbidity.
There is a need to quantify the extent and specific types of maternal morbidity. With this project, CHERG working groups will quantify the maternal morbidities ranging from acute complications during pregnancy, childbirth and the puerperium to longer-term pregnancy-related chronic morbidity, such as fistulae and infertility. We will also quantify the impact of these morbidities on women’s daily functioning and disabilities, using an analytical framework that will be developed during the early phase of this work to understand the larger ramification of acute complications.
Objective 5. Determine the disease burden attributable to selected risk factors for maternal and child morbidity and mortality.
CHERG has done previous work on nutritional risk factors, both as part of the WHO-coordinated Comparative Risk Assessment Project and recently for the Lancet series on maternal and child undernutrition. The nutritional risk factors that have had extensive recent work, i.e., stunting, wasting, underweight, and deficiencies of vitamin A and zinc, will need periodic reassessment because of health and nutrition intervention programs, which will require modification of methods to correctly incorporate short-term trends. More urgently, the methods used for some of the nutrition risk factors, e.g., deficiencies of iron and iodine are outdated and must be redone; other risk factors such as folic acid deficiency have not had their attributable disease burden estimated to date. Other risk factors needing extensive work are intrauterine growth restriction and premature birth, indoor and outdoor air pollution and environmental tobacco smoke exposure, and birth spacing/unwanted pregnancy. All of these areas of work will result in new estimates of attributable disease burden that will be important for understanding the contribution of these factors to the global disease burden, as well as the possible and actual effects of interventions.
Objective 6. Develop better information and methodologies to enable prioritizing, planning and monitoring maternal and child health interventions.
The effectiveness of interventions has been reviewed as part of several series in The Lancet and a thorough re-examination by CHERG working groups is now underway. These results will be incorporated into LiST (the Lives Saved Tool) when currently funded work for the interventions review is completed in 2008. After that time, there will be additional interventions for which the evidence will need to be reviewed and decisions made on whether to include in LiST and with what estimate of effectiveness and cost. LiST will be further enhanced, and during this project personnel from WHO, UNICEF, NGOs and low- and middle-income countries will be trained in its use. The best possible measures of coverage must be used to assess progress in these accelerated programs so that accomplishments and shortcomings are documented and acted upon, leading to heightened effectiveness. We propose to focus first on those interventions with the highest potential impact, as well as the most serious methodological limitations. CHERG will give priority to indicators of correct management of the leading causes of death among children under five (pneumonia, diarrhea, and malaria, the latter in collaboration with the Malaria Epidemiology Reference Group) and interventions with proven effectiveness in reducing child undernutrition (breastfeeding and complementary feeding). CHERG will also work with other groups to ensure that interventions related to maternal mortality are also incorporated into the model.
Objective 7. Provide technical leadership and knowledge management on maternal and child health.
For the greatest impact of work on measures of maternal and child health, it is important to prioritize the work and to disseminate the results. The process of setting priorities for CHERG will be expanded under this grant. In addition to use of a consensus process within CHERG and with the sponsoring agencies, we will employ systematic methods, such as those developed for research priority-setting by Child Health and Nutrition Research Initiative. Knowledge management is critical to the success of this project. In addition to the planned publications in peer-reviewed journals and other printed reports, CHERG will make a major commitment to web-based availability of data, methods and results. The creation of a dedicated Web site and process for provision of electronic information to stakeholders will be essential.