GEO

Challenges of maternal and child health in Georgia

18 January, 2016

 

 

Georgia has one of the highest rates of child – under-five, infant and neonatal – and maternal mortality in Europe and post-Soviet space.

According to the 2015 World Bank data on Georgia, it is estimated that for every 1000 live births 12 children die before reaching the age of five, while infant (less than one year of age) and neonatal (less than 28 days of age) mortality rates stand at 11 and 7 per 1000 births, respectively. In 2013, an international non-governmental children rights organization Save the Children found that the under-5 mortality rate was at 13.1 per 1000 child in Georgia.

Also in 2013, the World Bank estimated that maternal mortality ratio (women who die from pregnancy-related causes while pregnant or within 42 days of pregnancy termination) was at 23 per 100 000 childbirths.

In Save the Children’s 2015 Mothers’ Index, which evaluates countries according to the well-being of mothers and children, Georgia ranks 86th among 179 countries.

For comparison, in 2012, under-5 child mortality stood at an average 5 per 1000 childbirths in the European Union. Further, according to the 2012 data, the only post-Soviet countries with child mortality higher than Georgia were Kazakhstan, Turkmenistan, Kyrgyzstan and Uzbekistan. Same trend is observed when infant and maternal mortality rates are compared.

Factors contributing to high maternal and child mortality are closely related, among other issues, to maternal health during pregnancy, childbearing conditions and circumstances occurred within the first hours or a week after childbirth. The conditions of stationary medical institutions and birth centers, and the quality of services provided are significant contributing factors, along with issues related to maternal nutrition during pregnancy.

According to GeoStat, the National Statistics Office of Georgia, approximately 600 infants die in Georgia annually. Precise information on the causes of death of these infants is not currently available. However, Georgian medical specialists and the World Health Organization (WHO) attribute infant mortality to the risk factors that hinder their healthy growth and development. These factors include iron-deficiency anemia, defects caused by folic acid deficiency, maternal malnutrition pre-pregnancy and folic deficiency, maternal malnutrition during pregnancy and low weight of infants at birth. Experience shows that food fortification (enrichment with microelements and vitamins) decreases such risks by almost 75%.

Table 1: Instances of child deaths at birth or before reaching the age of 1, Georgia





Year

Childbirths

Deceased infants

Infant mortality ratio per 1000 childbirths

2010

63238

701

11.09

2011

58577

703

12

2012

57695

715

12.39

2013

58445

640

10.95

2014

61275

578

9.43

Source: National Statistics Office of Georgia

It should be pointed out that, according to various studies, birth centers with the low record of childbirth, such as below 500, are not capable of obtaining and maintaining the expertise and equipment to provide high quality of services and safe conditions for after-birth care.

During the last five years, in Georgia there were 63 medical institutions with less than 500 child deliveries, on average, annually. For example, in 2014, out of 101 medical institutions that provided such services, less than 500 children were delivered by 60 institutions. Consequently, as international experience tells us, 60% of these facilities may not be sufficiently equipped to provide high-quality services. What is more, less than 100 childbirths occurred at approximately 20-25% of these institutions, on average, between 2010-2015.

Table 2: Medical institutions with low record of child delivery





Year

Number of medical institutions

< 500 child deliveries

< 100 child deliveries

2010

98

64

24

2011

96

60

26

2012

94

56

23

2013

98

63

26

2014

101

60

23

2015*

102

70

34

* preliminary data for January-September

Source: Ministry of Labor, Health and Social Affairs of Georgia

According to the best international practice, many countries solve this problem through regionalization. This implies organizing the healthcare system in a way that duplication of expensive medical services is avoided in certain regions and only emergency services are provided.

According to the information provided by the Ministry of Health to TI Georgia, in order to improve the quality at the institutions providing perinatal services (care for infants and women during pregnancy and after childbirth), regionalization of perinatal services will be undertaken and the referral scheme will be enacted, as  the 15 January 2015 order #012/ნ of the Minister of Labour, Health and Social Affairs of Georgia on The Levels of Regionalization of Perinatal Services and Patient Referral Criteria stipulates. According to the order, pilot regional leveling of perinatal services will take place in Imereti and Racha-Lechkhumi-Kvemo Svaneti regions.

This system determines levels of regionalization and creation of a model for perinatal medical service delivery. It will provide classifications of medical institutions providing services, considering their capacities and existing risks. As a result, a differentiated system of maternal and infant care is being set up.

Another important issue causing child and maternal mortality is malnutrition. A potential solution to address the problem, therefore, is  enrichment of food products to improve their nutritional content.

Food fortification

Over 74 countries all over the world, including the United Kingdom, Turkey, Australia, United States and so on, engage in food fortification. Food fortification entails supplementing vital minerals and vitamins in food products of massive consumption. Based on the need, WHO urges countries to refer to this practice.

Back in 2006, Georgia launched a strategy to enrich wheat flour with iron and folic acid. A five-year project – Iron & Folic Acid Flour Fortification Programme in Georgia – was funded by the Global Alliance for Improved Nutrition (GAIN). In the nine years after launch, Georgia still has not conducted wheat flour fortification.

According to WHO, chronic malnutrition causes health complications in children and youth, as well as adversely affects productivity of the adult population. In some countries of Europe, iron-deficiency anemia causes developmental delays for every third child up to the age of five. Iron-deficiency anemia increases risks for a child to be born with low weight. Two billion of instances of anemia occur in developing countries, with iron-deficiency occurring in 70-80% of overall cases.

The 2015 Strategy on Food Products and Healthy Eating of Georgia’s National Center for Disease Control (NCDC), which is prepared based on WHO data, cites that iron-deficiency anemia most frequently occurs among reproductive age, pregnant and breastfeeding women, as well as very young infants.

In its Strategy, NCDC refers to global statistics that demonstrate that, in 2011, 6.9 million children died before reaching the age of five due to bad diets and malnutrition, and 35% of overall instances were caused by malnutrition. According to the data provided to us by GeoStat, between 2010-2014, 3337 children died in Georgia. It is, however, unknown if malnutrition was among the reasons for their death.

The gravity of the matter is the reason why WHO and the Food and Agriculture Organization of the United Nations (FAO), as mentioned above, have urged countries to launch food fortification programs for several years now. Food fortification is especially crucial for developing countries where poverty rates are high and large parts of the population cannot access food products enriched with vitamins and minerals.

In the 2006 manual by WHO and FAO, several approaches to food fortification are explained: mass, targeted and marketing fortification. Mass fortification entails enrichment of food products of mass consumption, such as wheat flour, rice, milk and so on with vitamins and minerals. Targeted fortification implies supplementing food with minerals and vitamins for the vulnerable groups, such as children, elderly, women, impoverished citizens, based on the need.

Any food product can be subject to fortification. A, B and D vitamins, as well as iron and folic acids can be used to supplement food. It is also frequent to supplement food with iodine, especially salt, which has been Georgia’s practice since 2007.

The NCDC Strategy discusses that, according to WHO’s suggestion, iron-deficiency anemia caused by malnutrition represents a problem of ‘medium’ level complexity. However, Georgia has a higher indicator than in the European states and North America. According to the 2009 study conducted by NCDC, 22.8% of children under five, 24.1% of non-pregnant women between the ages of 15 and 49 and 25.6% of pregnant women had anemia of various types.

Iron-deficiency causes problems such as mental impediments among the youth and lack of concentration among school-age children.

Along with iron-deficiency, a UNICEF study showed that Georgia has high rates of folic acid deficiency, reaching 37% in non-pregnant women between 15-49. Folic acid deficiency causes impediments in the development of the fetus’s cerebral and spinal cord at pregnancy.

According to NCDC, folic acid deficiency causes defects in neural cortex, and most frequently, side effects such as spina bifida, an incomplete closing of the backbone and membranes around the spinal cord. Children born with spina bifida experience health-related problems throughout their lifetime and require surgical interference. Anencephaly – insufficient development of the brain, is another disease caused by folic acid deficiency. Children with anencephaly die before birth or soon after birth. Encephalocele, or cranium bifidum, results in protrusions of the brain through openings in the skull.

Further, NCDC provides that “numerous studies reveal that women who take 400 mkg folic acid daily before and during pregnancy, the risk for development of neural cortex defects is decreased by 50-70%. It is known that, on average, about 50% of pregnancies are unplanned (in Georgia, according to the 2010 data released by RHS, this indicator was at 36%; in 2005 it stood at 52% and in 1999 at 59%). Every woman, who may become pregnant, should be taking folic acid.”

It is, therefore, important for the development of the healthy and productive generations that before pregnancy and during pregnancy women of reproductive age avoid having folic acid deficiency. And since a high share of pregnancies in Georgia (36% in 2010) is not planned, it is important that the government provides food products fortified with folic acid to the public, to provide sufficient fetal development in case of unplanned pregnancies. Enrichment of wheat flour with folic acid will decrease related defects and infant mortality.

An additional problem that can be tackled through fortification is decreasing low-weight infant mortality incidence. A 2010 UNICEF report found that, in Georgia, 5.5% of newborns weighed less than 2500 grams, 2954 newborns weighed between 2000-2499 grams, while 458 children weighed less than 2000 grams at birth. According to WHO, mortality risks are 20 times higher among children who weigh less than 2500 grams at birth. Main causes for the child’s low weight at birth are poor maternal nutrition before and during pregnancy. It is, therefore, important that food products are enriched with substances that provide for proper development of the infant. These substances, first and foremost, are folic acid, iron and minerals.

Breastfeeding is a significant factor contributing to a healthy development of a child with both low and normal birth weight. WHO recommends for breastfeeding to begin within several hours after birth. It is especially welcome to breastfeed exclusively, without artificial supplements, which further helps physical and mental development of a child. The preferable length of breastfeeding is two years.

UNICEF’s 2010 study found unfavorable results for Georgia. 13% of children have never been breastfed, and only half of children are exclusively breastfed up to six months. On average, breastfeeding stops at nine-ten months of age (while WHO recommends, two years). Breastfeeding is very rare for children between 12-14 and 20-23 months. Only in one thirds of children are breastfed and given an allowable amount of artificial supplements up to 24 months. An important consideration is that iron-deficiency anemia occurs among nursing women as well; therefore, wheat flour fortification may also address this problem in part.

It is important that wheat flour fortification does not require additional expenditures and will not result into price increase for important food products, such as bread.

Levan Silagadze, Executive Director of Wheat Flour Producers Association states that both Georgia-produced and imported wheat flour should be fortified. He explains that fortification does not create risks for bread becoming more expensive, while the resulting benefits are rather high.

The economic research conducted in the United States showed that folic acid fortification of wheat flour cost USD 3 million annually and ended up saving the federal budget USD 145 million. A USD 1 investment in fortification results in a USD 45 saving.

According to 2006 data, neural tube defects among infants were decreased by 37% due to fortification. In Canada, the same indicator reached 46% and in Chile – 41%. According to this strategy, it is possible to save approximately 60 children per day.

UNICEF estimates that malnutrition has cost Georgia a GEL 1.3 billion and the lives of 4300 infants. To address the problem, UNICEF proposes nutritional intervention. Global statistics show that implementing the proposal can decrease the USD 1.3 expenditure of every decade and save up to 1000 child. Through programs implemented by governmental organizations and through private sector funding with a cost of USD 15 million can save USD 343 million in a ten-year’s time. This means that for every USD 1 spent there will be a more than USD 20 return. This approach is in compliance with the Ten-Point Strategic Development Plan of Georgia and the investment conducted or to be conducted as part of this plan.

Health problems caused by malnutrition, iron or folic acid deficiency are rather frequent. Therefore, for a country such as Georgia, with a high share of social assistance receivers (371 323 individuals, according to the November 2015 data), mass fortification to provide the public with healthy food products is a way out.

Dimitri Khundadze, Chair of the Healthcare and Social Issues Committee of the Parliament of Georgia stated that Parliament is ready to draft legislative amendments to address this issue but only after a qualified study on the needs of food fortification and microelements is available. Khundadze explains that it also needs to be determined which method of fortification would be justified for Georgia, targeted or mass fortification.

As a result of fortification, Georgia will save on the expenditures required to treat medical problems arisen from folic acid deficiency, as well as costs for incubation of children born with low weight and in a longer-term perspective increase productivity of adult population, which will provide the benefit of USD 343 million to Georgia.

Author: TI Georgia