Child and adolescent health/nutrition

Situation analysis

WHO/Olivier Asselin

Mozambique made considerable progress in terms of reducing the child mortality rate: the Demographic and Health Surveys of 1997 and 2003 show that the neo-natal mortality rate decreased from 59/1000 live births to 48/1000 live births while the infant and under five mortality rates decreased respectively, from 147 to 124 and from 219 to 178 per 1,000 live births.

Nevertheless, these mortality rates still remain high and, in spite of this significant progress, it is important to highlight that these gains have not been identical across the country. Disparities of the mortality rate and of the health outcomes are found among provinces, with the Northern provinces presenting the highest child mortality rates. Significant variations between urban and rural areas are also found.

Newborns die mainly due to premature birth, low birth weight, sepsis and neonatal asphyxia. Neonatal tetanus is still a concern in the country. That is understandable because, although 84.2% of pregnant women attend at least one antenatal care session, only 48% of the deliveries are institutional while the remaining occurs at home.

In 2006, data from the paediatrics wards of every hospital show that among the under-five years old, malaria remains the main killer (36.7%). This is followed by malnutrition (13.8%), HIV (12.4%), pneumonia (8.2%) and diarrhoea (3.1%).

The proportion of one year old children fully immunized against the six main preventable diseases (tuberculosis, polio, diphtheria, pertussis, tetanus, and measles) has increased from 47% in 1997 to 63% in 2003.

According to the WHO international classifications, stunting prevalence and underweight prevalence among children under five are very high (respectively 41 % and 24 %).

The main micronutrient deficiencies are: vitamin A deficiency (68.8%), iron deficiency anaemia (74.7%) and iodine deficiency (42% of children aged 6-12 years moderately iodine deficient). The overall prevalence of goitre in the country was estimated at 15%.

The main reasons explaining malnutrition are inadequate and/or insufficient dietary intake, multiple and repetitive infectious diseases, poor feeding practices (exclusive breastfeeding rate the 1st 6 months of life: 30% and nearly one quarter (22%) of children less than six months of age receiving other foods, in addition to breast milk).

Poor access to safe water and sanitation, and the low level of education of the mothers also contribute to the poor child health care and nutrition.

Maternal malnutrition in Mozambique is of particular concern considering the effect this has on foetal and infant growth as well as other birth outcomes. 8.5% of mothers of children under five years old have a body mass index or Body Mass Index less than 18.52 showing chronic energy deficiency.

Vulnerability to malnutrition is now also exacerbated by HIV which is becoming a major cause of under five years old mortality. The number of new HIV infections among children has continuously increased from an estimated 23.400 in 2000 to 37.300 in 2006, which represents about 102 new infections every day . By September 2007, there were 211 sites providing ARV, and 86000 ART beneficiaries, of whom 6320 children under the age of 15.

In 1998, the Ministry of Health adopted the Integrated Management of Childhood Illnesses (IMCI) as a main strategy to reduce child mortality.

Key partners are WHO, UNICEF, and USAID through its NGOs.

Achievements

• Integrated Management of Childhood Illnesses (IMCI) is now implemented nationwide and 70% of health facilities at national level have at least one health worker trained on IMCI caring for sick children. The health facility survey carried out in 2005 with support from WHO and other partners showed a net improvement of the health workers skills on case management of the sick children.
• Multiple actions have taken place within the IMCI strategy in order to strengthen the system, such as:
  • the incorporation of IMCI drugs into the essential drugs kits;
  • the supply of drugs for injection needed for pre-referral treatment of seriously ill children;
  • the establishment of Oral Re-hydration Therapy (ORT) corners;
  • and the provision of bicycle ambulances to communities for emergency transport.
• In 2003, IMCI pre-service training was introduced in the curricula of health sciences training institutions and later at the medical school as a means of supporting the sustainability of the strategy.
• Since 2004, Mother and Child health nurses are trained on both Emergency Obstetric and Newborn Care.
• IMCI training material was updated in 2006, to address the 1st week of newborn life, and to include the HIV component as well as the new WHO recommendations related to breastfeeding, diarrhoea (the new ORS & zinc) and malaria treatment.
• Mozambique adopted in 2005 the Code of Marketing of breastmilk substitutes and drafted the infant feeding policy which addresses HIV issues.
• Along 2006 and 2007, Mozambique developed the newborn and child health policy and the newborn and child health strategic plan;
• The child health card was updated in 2007 to the new WHO child growth standards and also to include PMTCT;
• Establishment of a technical working group for maternal, newborn and child health within the Health SWAp under the leadership of the Ministry of Health.

Next steps

• To achieve the Millennium Development Goal Number 4, meaning a reduction from 246 deaths per 1,000 live births in 1997, down to 82 in 2015;
• Strengthen national capacity including the provincial and district team in planning and implementing priority child health interventions taking advantage of the Reach Every District (RED) approach for scaling up towards universal access and coverage;
• Strengthen national capacity for effective monitoring and evaluation of child survival and use of the findings to improve the child health program implementation;
• WHO will continue to support the Ministry of Health to improve and strengthen collaboration and coordination mechanisms among child health related programs and among partners aimed at better delivery of integrated interventions through MNCH services;
• WHO will continue to advocate among partners towards a common agenda ensuring the continuum of care throughout the life course at all levels including the promotion of community based interventions and contributing to strengthening the health system.
• Renewed interest in strengthening community involvement and community based services.