Progress Towards Maternal, Newborn and Child Health
April 2, 2011
Share the proof:
Significant progress has been achieved over the past decade in improving the health of mothers and children around the world, and in reducing the number of children who die from treatable and preventable diseases. Increased global focus and innovative tools are needed to ensure that child death rates continue to fall and the health of mothers and their newborns greatly improves.
Child deaths have been declining steadily since the 1960s,1 and the rate of progress has accelerated in the past decade.2 Much of the recent progress has been due to the increased use of key interven- tions, such as immunizations, vitamin A supplementation and the use of insecticide-treated mosquito nets to prevent malaria. Mater- nal deaths have also declined, but they have not dropped as quickly or steadily as spelled out in the fifth Millennium Development Goal (MDG).
Encouragingly, there are now rising political and financial com- mitments to reduce maternal, newborn and child deaths through expanded access to priority interventions, health systems strength- ening, innovative technologies and behavior change programs.
Global action to improve child health in developing countries has gained significant momentum over the past decade. More recently, the health of mothers and their newborns has also been recognized as a key priority.
Global spending on maternal, newborn and child health (MNCH) in- creased by 64 percent, from $2.1 billion in 2003 to almost $3.5 billion in 2006, with child health accounting for more than two-thirds of total aid to MNCH.3 In the following years, between fiscal years 2007 and 2009, the U.S. alone contributed roughly $1.35 billion for MNCH, including some money for nutrition.4
In 2009, leaders of the G8 announced that they would be contribut- ing an additional $5 billion towards maternal, newborn and child health in developing countries over the next five years. The World Health Organization and World Bank estimate that, if fulfilled, these committed funds will prevent the deaths of 1.3 million children and 64,000 mothers over the next five years.
Recently, the Consensus for Maternal, Newborn and Child Health (2009)5 set out key action steps to save the lives of more than 10 million women and children between 2009 and 2015. Agreed to by a broad coalition of governments, nongovernmental organizations, and international health agencies, the Consensus aims to accelerate progress towards the MDGs for maternal and child health. These call for a reduction in deaths among children under age five by two-thirds (MDG 4) and among pregnant women by three-quarters (MDG 5) from 1990 levels by 2015.
The Consensus is also supported by pledges of substantial funding from members of the Task Force on Innovative Financing for Health Systems,6 with a strong focus on maternal and newborn health. It is also supported by a range of existing organizations and new partnerships:
• The most important organizations in the United Nations (UN) system dealing with maternal, newborn and child health are the United Nations Children’s Fund (UNICEF), the United Nations Population Fund (UNFPA), and the World Health Organization (WHO). UNICEF supports a range of programs on maternal, newborn and child health and is the world’s largest supplier of vaccines for children in developing countries. UNFPA focuses on reproductive health, supporting programs to promote safe pregnancy and childbirth, family planning and the sexual and reproductive empowerment of women. WHO provides normative guidance and tools for the support of MNCH, as well as critical technical assistance at the country level.
• The Partnership for Maternal, Newborn and Child Health, the White Ribbon Alliance and the Countdown to 2015 work with the global community towards achieving MDGs 4 and 5. Together, they have increased the visibility of child health, and more re- cently, that of maternal and newborn health.
• The GAVI Alliance (formerly the Global Alliance for Vaccines and Immunisation), launched in 2000, finances programs in the poor- est countries to scale up access to immunization and fosters the development and introduction of new vaccines and technologies. GAVI has committed $4.1 billion to countries through 2010.
Innovation and Scientific advances
Further improvements in child health are possible through continued innovation in prevention and treatment. New technological advances focused on maternal and newborn health also show great promise. Equally important are operational innovations focused on the delivery of life-saving interventions to mothers, newborns and children in countries where health systems are weak.
Key innovations to improve maternal and newborn health include the following:
• Postpartum hemorrhage (severe bleed- ing after delivery—a leading cause of maternal deaths) can now be treated with oxytocin. It can be administered by community health workers to women in rural settings using Oxytocin Uniject, a pre-filled, single-use syringe which is being piloted in several countries.7
• Infections of the umbilical cord—very common among infants in developing countries—can be prevented by clean- ing the umbilical cord with a solution called chlorhexidine. Trials suggest that chlorhexidine could reduce newborn deaths by one-third.8
• Topical emollient therapy— application of sunflower seed oil to improve the function of the skin and prevent infections—decreased hospital- acquired infections in very preterm in- fants by 40 to 50 percent, and newborn deaths by 24 percent in one trial in Bangladesh.9, 10
Key innovations with significant potential to further reduce under-5 child deaths include:
• Pneumococcal vaccines prevent com- mon forms of pneumonia, the leading vaccine-preventable killer of children under age five worldwide.
• Rotavirus vaccines can prevent the most common cause of diarrhea, causing about 500,000 deaths and two million hospitalizations among children each year. Zinc supplementation, used in conjunction with oral rehydration therapy, can also significantly reduce diarrhea among children.11
• Prevention of mother-to-child trans- mission (PMTCT) of HIV/AIDS can be
achieved through the timely admin- istration of antiretroviral treatment to HIV-infected pregnant women and their newborns, as well as by adhering to breastfeeding guidelines. Following this PMTCT regimen greatly reduces the risk of HIV transmission from mother
• Intermittent Preventive Treatment in pregnancy (IPTp) and Long-Lasting Insecticide-Treated Bednets (LLINs)— the latter of which incorporates insec- ticides directly into net fibers— have each been proven to effectively reduce the risk of malaria infection among pregnant women.
Operational research on innovative strat- egies to ensure the delivery of life-saving interventions to mothers and their chil- dren is also yielding promising results:12
• A study in rural Nepal showed that great reductions in newborn and mater- nal deaths can be achieved through community-based strategies. Women who joined a woman’s group were more likely to seek prenatal care, to pursue delivery with a skilled birth attendant and to practice better hygiene, resulting in a 30 percent reduction in neonatal mortality and an 80 percent reduction in maternal mortality.13
Significant progress has been made in reducing child deaths: the global under-5 death rate dropped from approximately 180 deaths per 1000 live births in 1960 to 90 per 1000 in 1990. Since then, the global under-5 death rate has been further reduced (by 28 percent) to 60 deaths per 1000 live births in 2009. The total number of child deaths declined from 12.5 million in 1990 to 8.1 million in 2009.
One key reason for the global progress in child health is that many preventive child health interventions can be routinely scheduled, and many treatment interven- tions can be carried out at the community level. The following preventive interven- tions have been increased substantially:
• Dramatic increase in immunization coverage: Global coverage with key child immunizations has increased from less than 5 percent in 1974 to approxi- mately 80 percent today. More than 2.5 million deaths are avoided each year because of immunizations against diph- theria, tetanus, pertussis, and measles. New vaccines have been added to the original schedule of vaccines, including the hepatitis B and Hib vaccines.17 WHO estimates that, with GAVI support, a cu- mulative 257 million additional children had been reached with these new and underused vaccines by 2008, preventing 5.4 million deaths.18
• Scale-up of bednet distribution to prevent malaria: The Global Fund to Fight AIDS, Tuberculosis and Malaria has financed the distribution of 122 mil- lion insecticide-treated nets in malaria- endemic countries between 2002 and 2010.19 The number of African children protected by an insecticide-treated bed net increased from 1.7 million in 2000 to 20.3 million in 2007.20
• Increased vitamin A supplementation: Providing children with supplementa- tion is an effective strategy for eliminat- ing vitamin A deficiency, which makes children much more susceptible to seri- ous diseases. Coverage with two doses per year increased from 16 percent in 1999 to 72 percent in 2007.21
Health infrastructures have been es- tablished in many countries, allowing progress in providing HIV/AIDS preven- tion and treatment to mothers, infants, and children:
• Coverage of services to prevent mother- to-child transmission of HIV in develop- ing countries increased dramatically, from 15 percent in 2005 to 53 percent in 2010.22
• The number of children receiving anti- retroviral treatment increased rapidly from 75,000 in 2005 to 356,400 in 2010.22
Coverage with a number of interventions associated with maternal and newborn health is also increasing slowly:
• More than three-quarters of women in developing countries received prenatal care from a skilled health worker at least once during pregnancy in 2005,
compared to only 60 percent in the mid-1990s.23
• The percentage of births that were attended by a skilled birth attendant increased from 47 percent in 1990 to 66 percent in 2008.
While significant progress has been made in improving child health, sus- tained efforts are essential to ensure that the number of deaths among children under age five continues to fall.24 In Africa, Oceania, and parts of South Asia, child mortality remains high and rates of decline are currently far too slow to achieve MDG 4.
This holds true even more so for mater- nal and newborn deaths. Between 1990 and 2010, the global maternal mortality ratio declined only by 34 percent and an estimated 358,000 maternal deaths still occur each year.25
Progress towards MDG 5 is also much too slow. Newborn deaths also need a focused effort, as nearly 41 percent of deaths among children under five occur in the first month of life.25
Additional funding—both from north- ern and southern governments—is essential to achieve stronger progress on maternal, newborn and child health.
Increase services and care at the community level
Identifying and expanding effective strategies that build on existing community capacities is critical to delivering health-care services to mothers and children, especially in situations where health systems are weak. Evidence indicates that simple actions at the community level can reduce newborn mortality by 37 percent.
Improve access to emergency services
While many life-saving interventions can be implemented at the household and community level, some services can only be provided by skilled health workers in well-equipped facilities. Reducing deaths among mothers and newborns requires 24-hour availability of emergency health services.27 This is also true for complicated cases of child and newborn illnesses.
Behavior change and supportive environment
Mothers often do not access existing care or practice preventive behaviors for various cultural, financial, and societal reasons. Creating a supportive environment is critical to ensuring that women seek out services, alter day-to-day behavior and adopt healthy practices that safeguard them from disease.
1. UNICEF, Progress for Children: A World Fit For Children Statistical Review, No. 6 (New York: UNICEF, 2007).
2. The average annual rate of decline for 2000–2008 is 2.3 percent, compared with 1.4 percent for 1990–2000, http://www.unicef.org/ media/media_51087.html (accessed September 30, 2009).
3. Funding is channeled through multiple avenues, including MNCH-specific initiatives, programs to strengthen health systems, and disease-specific interventions (e.g., immunization campaigns).
4. G. Greco, et al., “Countdown to 2015: Assessment of Donor Assistance to Maternal, Newborn, and Child Health between 2003 and 2006,” Lancet 371 (2008): 1268–1275. The four other major do- nors for MNCH in 2006 were the Global Fund to Fight AIDS, Tuberculosis and Malaria, the United Kingdom government, the European Union, and the GAVI Alliance, which together contributed $1.1 billion.
5. The Consensus for Maternal, Newborn and Child Health can be found at http://www.who .int/pmnch/en/.
6. Partnership for Maternal, Newborn and Child Health, “Investing in Our Common Future: Healthy Women, Healthy Children,” http://www. who.int/pmnch/events/2009/20090923_mnch- consensusstory/en/index.html (accessed September 30, 2009). Multi-year financial pledges announced at the UN High Level Event, on Sept 23, 2009, totaled more than $5 billion.
7. An alternative in pill form is Misoprostol, which can be self-administered and is recommended by the World Health Organization in situations where Oxytocin is unavailable.
8. PATH, “Chlorhexidine for Umbilical Cord Care,” 2009, http://www.path.org/files/TS_update_ chlorhexidine.pdf.
9. G. L. Darmstadt, et al., “Effect of Topical Treat- ment with Skin Barrier-Enhancing Emollients on Nosocomial Infections in Preterm Infants in Bangladesh: A Randomized Controlled Trial,” Lancet 365 (2005): 1039–1045.
10. G. L. Darmstadt, et al., “Effect of Skin Bar- rier Therapy on Neonatal Mortality Rates in Preterm Infants in Bangladesh: A Randomized, Controlled, Clinical Trial,” Pediatrics 121 (2008): 522–529.
11. Countdown to 2015 Working Group, Tracking Progress in Maternal, Newborn & Child Survival: The 2008 Report (New York: UNICEF, 2008).
12. WHO/UNICEF Joint Statement, Home Visit for the Newborn Child: a Strategy to Improve Survival (Geneva: WHO, 2009).
13. D. Manandhar, et al., “Effect of a Participatory Intervention with Women’s Groups on Birth Outcomes in Nepal: Cluster Randomized Con- trolled Trial,” Lancet 364 (2004): 970–979.
14. Maternal health refers to the health of women during pregnancy, childbirth, and the postpar- tum period. Newborn health refers to the health of children during the first 28 days
15. Trends in Maternal Mortality: 1990 to 2008. WHO, UNICEF, UNFPA, World Bank, 2010. http://whqlibdoc.who.int/publica- tions/2010/9789241500265_eng.pdf.
Also: Countdown to 2015: taking stock of maternal, newborn & child survival. WHO, 2010. http://www.who.int/child_adolescent_health/ documents/9789241599573/en/index.html.
16. V. Rhee, et al., “Maternal and Birth Attendant Hand Washing and Neonatal Mortality in South- ern Nepal,” Archives of Pediatric & Adolescent Medicine 162 (2008): 603–608.
17. WHO, Global Immunization Data, 2009, http:// www.who.int/immunization/newsroom/ GID_english.pdf.
18. GAVI Alliance, Progress Report 2008 (Geneva: GAVI Alliance, 2008).
19. Global Fund to Fight AIDS, Tuberculosis and Malaria, Scaling Up for Impact: Results Report 2008 (Geneva: Global Fund, 2009).
20. A. Noor, et al., “Insecticide-Treated Net Coverage in Africa: Mapping Progress in 2000–07,” Lancet 373 (2009): 58–67.
21. UNICEF, “ChildInfo: Monitoring the situation of children and women,” http://www.childinfo.org/ vitamina_progress.html (accessed September 30, 2009).
22. WHO, UNAIDS, UNICEF, Towards Universal Access: Scaling Up Priority HIV/AIDS Interventions in the Health Sector–Progress Report 2009 (Geneva: WHO, 2009).
23. UNICEF, Progress for Children: A Report Card on Maternal Mortality, No. 7 (New York: UNICEF, 2008).
24. C. J. L. Murray, et al., “Can We Achieve Millen- nium Development Goal 4? New Analysis of Country Trends and Forecasts of Under-5 Mor- tality to 2015,” Lancet 370 (2007): 1040–1054.
25. UNICEF, The State of the World’s Children 2009: Maternal and Newborn Health (New York: UNICEF, 2009).
26. Partnership for Maternal, Newborn and Child Health, “A Global Call for G8 Leaders and Other Donors to Champion Maternal, Newborn and Child Health,” press statement, 19 April 2008, http://www.who.int/pmnch/media/news/2008/ g8globalcall.pdf.
27. UNFPA, “Safe Motherhood: Providing Emergen- cy Obstetric and Newborn Care to All in Need,” http://www.unfpa.org/mothers/obstetric.htm (accessed September 30, 2009).
28. V. Kumar, et al., “Impact of Community-Based Behavior Change Management on Neonatal Mortality: A Cluster-Randomized, Controlled Trial in Shivgarh, Uttar Pradesh, India,” Lancet 372 (2008): 1151–1162.
29. G. L. Darmstadt, et al., “Introduction of Community-Based Skin-to-Skin Care in Rural Uttar Pradesh, India,” Journal of Perinatology 26 (2006): 597–604.