Caring for Mothers and Children:
Towards the Millennium
Development Goals
Philippa Musoke MBChB
Department of Paediatrics and Child Health
Makerere University
Kampala UGANDA and
MU-JHU Research Collaboration
Outline of Presentation
• Maternal and under five child mortality
• HIV infection in women and children
• Prevention of mother-to-child HIV transmission
• Achieving the Millennium Development goals
Maternal and Child Mortality:
the Global Picture
• 500,000 women die annually (1 women dies / minute)
– 99% from low and middle income countries
• 8 million children < 5 years die annually (1 child dies/ 3 sec)
– > 90% from low and middle income countries
• 4 million newborns die annually
• Contribute to 30 - 50% of all under five deaths
Most of these deaths are preventable and related to infectious
diseases and malnutrition
In this day and age………... this is unacceptable !
Causes of under five mortality
Global 2008
Prevalence of under nutrition in
regions of the world, 2008
Proportion of under 5 mortality
attributable to HIV Sub-Saharan Africa
Stanecki K et al Sex trans Infect 2010
Global distribution of causes of
maternal deaths 1997-2007
MM Ratio for 2000 by world region and medical cause
Lancet 2006
• UN Millennium Development goals (MDGs by 2015)
– PMTCT affects MDG 4, 5 & 6 and 3
• G8 Nations - Universal access for HIV prevention, care & treatment by
• UNGASS 2001 – reduce # of HIV infected infants by 50% (2010)
– Ensure 80% women accessing antenatal care receive
PMTCT services
• Abuja Call to Action in 2005 “Call to Action” for an AIDS free generation
• UNICEF – “Unite for children Unite Against AIDS”
Prevention of Mother to Child
Transmission of HIV contributes to
multiple MDGs
 MDG 4 - reduction in child mortality
 MDG 5 – reduction in maternal mortality
 MDG 6 – combat HIV/AIDS, malaria and other diseases
 MDG 3 - promote gender equality and empower women
 MDG 1 – reduce underweight
WHO – The 4 prongs of PMTCT
• Primary Prevention of HIV infection
• Prevention of unintended pregnancies in
HIV infected women
• Prevention of HIV transmission from HIV
infected women to their infants
• Provision of treatment , care and support
for HIV infected women, their infants and
their families
Virtual elimination of mother-to-child
transmission of HIV is possible!
MTCT HIV transmission by CD4 cell count
Children and AIDS 5th Stocktaking report 2010
Coverage and health-seeking behavior go
> 80% ARV coverage
Typology B
60-79% ARV coverage
Botswana – 99%
South Africa – 88%
Namibia – 88%
Swaziland -88%
Kenya – 73%
Tanzania – 70%
Mozambique – 70%
Zambia – 69%
Lesotho – 64%
Typology C
Typology D
30-59% ARV coverage
<30% ARV coverage
Malawi – 58%
Zimbabwe – 56%
Cote d’Ivoire – 54%
Uganda – 53%
Ghana - 27%
Cameroon - 27%
India – 26%
Ethiopia – 20%
Angola – 19%
Nigeria – 13%
Burundi – 12%
Chad – 6%
DRC – 6%
ARV coverage (2009) . Slide courtesy of Chewe Luo.
Typology A
Maternal antiretroviral therapy improves
health and survival of mother and infant
• Maternal antiretroviral therapy
– improves maternal health
– Improves maternal survival
• A mother who is alive and healthy
– Improves child survival and child health
– Improves health seeking behaviour for herself and
her infant
Early Cessation of Breastfeeding Was Particularly
Harmful for Children Who Became HIV-Infected
Survival of HIV-infected Children with Positive Results before Age 4
Months by Group Assignment (Abrupt vs Standard Weaning)
Continued Breastfeeding
Stopped Breastfeeding
p = 0.01
Kuhn L et al. NEJM 2008
Early Infant HIV diagnosis
using DBS for HIV DNA PCR
Blood collected by dried blood spots (DBS)
Photo by Pathfinder Kenya PMTCT
•Collection of specimens from remote places
•Easy storage of samples
•Centralized testing for HIV DNA PCR – reduces costs
•Early HIV infected infants diagnosis
•Referral of infected infants for early care and treatment
Percentage of children <15 years receiving
antiretroviral therapy by region, 2009
PMTCT Benefits
• Reduced the number of HIV infected children
• Increased number of infected children on ART with
improved survival
GLOBAL MORTALITY reduced in children < 5 years
• Increased the number of women on ART with
improvement in their health and survival
– Leading to improve health and survival of HIV exposed
and infected children
– Reduced the number of orphans
Scale-up of PMTCT
Commitment required from ALL
Decentralization and improvement of service delivery
• Integration
– PMTCT into routine antenatal, delivery and postnatal care
– Paediatric HIV care into routine MNCH services
– Paediatric HIV treatment into existing treatment programs
• Linkage of mother and infected partner to HIV care and treatment
• Goal 4: Reduce child mortality rates
• Target 4A: Reduce by two-thirds, between
1990 and 2015, the under-five mortality rate
– Under-five mortality rate
– Infant (under 1) mortality rate
– Proportion of 1-year-old children immunized
against measles
Achieving the MDGs – Global progress
Proportion of under 5’s who received
survival intervention ( 42 countries)
Stanecki K et al Sex Transm Infect 2010
Reducing neonatal mortality
• Improving maternal health
• Reducing maternal mortality
• Delivery with a skilled birth attendant
• Identification of early danger signs in new
born infants and referral for appropriate care
Rotavirus vaccine
• Rotavirus accounts for 39% of all diarrhoeal disease
– 500,000 children die from rotavirus disease per year
• Rotavirus vaccines can prevent severe diarrhoeal disease
– Efficacy ranges 50%-90% (lower in regions with higher
– RotaTeq and Rotarix vaccines – available internationally
• Effective in HIV infected children (57% - Steele AD et al
PIDJ 2011)
WHO, Rotavirus position paper: Weekly epidemiological report 2009
Pneumococcal Vaccine
• Pneumococcal disease
– Leads to 700, 000-1 million deaths per year
• Polyvalent conjugated pneumococcal vaccine
– Invasive disease reduced by 75- 100 % in both
resource-rich and resource-poor countries
– Effective in HIV infected children but lower efficacy
(Thanee C et al Vaccine 2011, Madhi SA et al PIDJ 2005)
WHO, Pneumococcal vaccine position paper: Weekly epidemiological record 2007
Malaria Vaccine
• Malaria causes 10% of under five deaths worldwide
• RTS,S/AS01E lead candidate vaccine
• Randomized clinical trial of 894 children ( age 5-17 months)
from Tanzania and Kenya
• 447 malaria vaccine vs 447 rabies vaccine
• Protective efficacy - (per protocol analysis)
– 46% (24.1 -63.1) p=0.0004 after 15 months of FU
• Promising results but higher efficacy required
Olotu A et al Lancet Inf Dis 2011
Global Alliance for Vaccines and
Immunizations (GAVI)
“Saving childrens lives” – June 13th 2011 London
• Major public and private donors – $ 4.3 M
• GAVI committed to immunizing 250 million
children in the next 5 years ( $ 7.6 M)
• Goal 5: Improve maternal health
• Target 5A: Reduce by three quarters, between 1990
and 2015, the maternal mortality ratio
– Maternal mortality ratio
– Proportion of births attended by skilled health
• Target 5B: Achieve, by 2015, universal access to
reproductive health
– Contraceptive prevalence rate
– Adolescent birth rate
– Antenatal care coverage
– Unmet need for family planning
Reduction in maternal mortality
• Education of the girl child
• Economic empowerment of women
• Family planning and child spacing
• Access to a skilled birth attendant for delivery
– ART for their own health and for PMTCT
Unmet needs for family planning in
countries with generalized epidemic,
2006-2008 (> 30%)
UNAIDS Report 2010
Coverage of skilled birth
attendant at delivery, 2008
Trends in maternal mortality in
select countries
MDG report 2010
• It is a human right for every woman to survive
pregnancy and child birth and their child to reach their
5th birthday
• The interventions needed to prevent the majority of
maternal and child deaths are well known ….
– And yet MOST countries will not achieve the MDGs unless
drastic measures are taken
THEREFORE governments, civil societies and
international donors need to commit to scale up these
well known high impact, low cost interventions that
can prevent most of these deaths
and Care for the Mother and Child
C Giaquinto
MG Fowler
D Mbori-Ngacha
L Mofenson