Risk still high for children under five

Jamila Nakku, 25, of Kasokwe village in Bugiri District is six months pregnant with her fourth child. In reality, this child is supposed to be her sixth. In a space of five years, Nakku has lost two children, all in the toddler age.

“Both children suffered from malaria. At first, I gave them traditional herbs to drink, which we, adults, also take when we fall sick. The herbs usually work on the other children, but for the two, the sickness got worse,” she says.
Unfortunately, the ride from Kasokwe to the government hospital at Iwembe Hospital (a distance of ten minutes by car) costs shs3,000 on a bicycle bodaboda, which is too high for the family of subsistence farmers. In both cases, the children contracted malaria during the dry season.

“By the time we reach the hospital, the children are too far gone for the medicine to have any effect on them.”
Nakku is not alone. According 2014 Report, Levels and Trends in Child Mortality, commissioned by The United Nations Children’s Fund (UNICEF), in 2013 about 17,000 children under the age of five died every day. More than half of these deaths occurred in sub-Saharan Africa.

Reduction in child mortality is the fourth of the United Nations (UN) Millennium Development Goals (MDG).

Dr Bonita Musoke, a paediatrician with International Hospital Kampala (IHK) says that as a country that adheres to the MDGs, Uganda is supposed to have reduced child mortality rates by two-thirds by 2015.

“Although on average the mortality rates have decreased from 131 to 66 per 1000 live births, we are only halfway there and now we are stuck in that place. The rates are not going down.”

Dr Jesca Nsungwa-Sabiiti, the Assistant Commissioner for Child Health in the Ministry of Health, says that the ministry is still using the 2011 Uganda Demographic and Health Survey results (UDHS), carried out by the Uganda Bureaus of Statistics (UBOS) as a benchmark to measure child mortality rates.

“The UDHS is done every five years and the next one will be carried out in 2016.”

In the 2011 UDHS, one of the key findings was that one in every 19 children dies before their first birthday, and one in every 11 children dies before their fifth birthday. The report further states that childhood mortality is higher in rural areas than in urban areas, with Kampala having the lowest mortality rates.

Prevention
According to the World Health Organisation (WHO), breast milk is the strongest foundation of baby health and nutrition.

Breastfeeding protects babies from diarrhoea and stimulates their immune systems.
According to the UDHS, immunisation of children against the eight vaccine-preventable diseases – tuberculosis, diphtheria, whooping cough, tetanus, Hepatitis B, haemophilus influenza, polio, and measles – is crucial to reducing infant and child mortality.

Mass immunisation schedules have been initiated by the government. Outside the schedules, referral hospital and health centre IVs carry out vaccination. However, the survey found that only 52 percent of children aged 12-23 months were fully vaccinated, while four percent had not received any vaccinations.

“There are challenges in implementation because sometimes, the vaccines, especially the pneumococcal vaccine, run out,” says Dr Musoke.

The Ministry of Health, on the recommendation of WHO, acquired the pneumococcal vaccination to prevent bacterial pneumonia in children. On the lack of vaccines in some hospitals, Nsungwa-Sabiiti says that like any other products, there may be shortages but the vaccines are always in the medical stores, and they are distributed by the National Medical Stores.

On the willingness of mothers to immunise their children, Nsungwa-Sabiiti says that “there will always be social and cultural issues which may limit mothers, especially in the rural areas from going for immunisation.”

Distribution of treated anti-malarial mosquito nets has also been a powerful tool of fighting child mortality that the government has used.

Empowering women
Empowering women with health information helps to improve child mortality.

“Mothers should be given adequate information about breastfeeding and proper disposal of human waste.
There are government awareness programmes on sanitation and health but what are people doing about them? If we do not educate them, how can the mortality rates go down? It is the people, after all, who make the statistics,” says Dr Musoke.
She adds that even with vaccines and medicines provided, if child nutrition does not improve, Uganda will still grapple with child mortality.

Leading causes of death for children under five years

According to Dr Musoke, children are dying from preventable diseases. “We have preterm babies making up a third – nearly 78 percent – of the child mortality rates.

And these are factors that also involve the mother, because there are reasons why these babies are born prematurely.”

Bacterial infections in newborn babies are a leading cause of death. However, with good and timely antenatal care, most mother-to-child infections during pregnancy or childbirth can be minimised.

“Women in the rural areas prefer to deliver with traditional birth attendants, basically because of the care they give. But some of these people promote practices that place mother and child at risk of infections. For instance, they wash newborns in herbal births, or smear ash on the cord to make it ‘heal faster’,” Dr Musoke adds.
Newborn babies are especially vulnerable because some of them suffer from colic and mothers, out of desperation, try many remedies such as mushroom soup and holy basil (omujaaja) all of which are too strong for a baby’s digestive system.

Postpartum diseases
The chances of rural children dying from malaria are high. In the UDHS survey, urban children are more likely than rural children to have been taken to a health facility or provider for advice or treatment when they got malaria.

On the other hand, acute respiratory infections, among which falls pneumonia, are the most serious causes of illness among young children.
Early diagnosis and treatment with antibiotics can prevent a larger proportion of deaths but Dr Musoke says, “In most cases, there is no access to healthcare in rural areas or the clinics lack sufficient medicine.”

Diarrhoea causes dehydration in children but it can be easily treated with oral rehydration therapy. Exposure to dirty water and unhygienic food make children prone to the condition.

Socioeconomic factors
Although not listed as the biggest cause of child mortality, nutritional deficiencies are a large contributing factor.

In the UDHS, it was found that the mother’s level of education is associated with the child’s probability of survival. Children born to mothers with higher education have much lower childhood mortality rates when compared with children of uneducated mothers.

For example, child mortality among children born to mothers with no education (59 deaths per 1,000 live births) is more than double that of children born to mothers with secondary or higher education (23 deaths per 1,000 live births).

Nsungwa-Sabiiti says that although the government has a strategic plan for child survival that spells out several interventions targeting killer diseases, mortality is not purely a health issue.

“Several factors in other sectors contribute to the death of children. People having enough to eat, is a food security issue. The ministry of agriculture and animal industry and fisheries is in a better position to tackle food security.”

“Mothers know what type of food would be good for their children, but they do not have it.
Malnutrition is a slow killer because a child becomes underweight, and then they have slow development and become dull,” says Dr Musoke.

In the rural areas and slums, malnutrition or under nutrition is due to poverty, with a mother giving her child the wrong food or small portions of food.
Once a child is underweight, any opportunistic infection like pneumonia can easily affect them.
Dr Musoke adds that, “At the end of the day, child mortality comes down to socioeconomic reasons. If the parents have some money, they can take a sick child to the health center immediately, and they will have enough left over to buy drugs and food.”

Kampala’s success in reducing mortality

Kampala has made good child survival progress while also experiencing a relatively rapid rate of population growth.

Data suggest under-five mortality in Kampala declined at an average rate of 7 per cent per year over six years of available data (from 94 deaths per 1,000 live births reported in 2006 to 65 in 2011).
This is one of the fastest declines seen among the 50 cities with available data and the fastest seen in any capital/largest city in Africa. At the same time,

Kampala experienced an above-average annual population growth rate of almost four percent.
Uganda hosts a large number of refugees (mostly from DR Congo and South Sudan), suggesting Kampala’s population growth may in part be attributable to in-migration from conflict.

Progress in this complex environment is another reason Kampala’s success deserves praise, and may serve as a model for other cities.

Kampala has also made good equity gains. Progress reducing child deaths has favoured the poorest urban residents and the urban survival gap has decreased. In 1995 and 2000, the poorest urban children in Uganda were almost three times as likely as the wealthiest urban children to die before their fifth birthday. In 2006, they were twice as likely to die.

How did Kampala achieve success?

Kampala has achieved good results from a variety of outreach efforts that take healthcare information and services to the communities where poor people live.

For example, family health days in places of worship have helped promote awareness of preventable diseases and reduced their occurrence, according to Dr Christopher Oundo, division medical officer for part of Kampala City. “Information sharing through community radio and village health teams have also helped,” says Dr Oundo.

“Through these vehicles we get to people individually in the different communities.” Currently, there are more than 300 village health teams in just one division of Kampala, Dr Oundo noted.
“Though we live in a congested place, sanitation-related diseases are no longer a problem,” says Brenda, 24, mother of a 2-year-old boy who is pregnant with her second child. “People now take the initiative to collect their rubbish and clean up their surroundings.” Joseline, 35, a businesswoman and mother of five, agrees: “Diseases such as measles and malaria are the only ones we still struggle with, in our area,” she said. “The sanitation-related diseases such as diarrhoea, typhoid and cholera are no longer heard of. We get health information from the different door-to-door health personnel.” Joseline added that clean water is not a problem in her area as it was before.

Extracted from the State of the World’s Mothers Report 2015, as published by Save the Children.

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