Despite the impressive progress gains for maternal and child health during the Millennium Development Goals era, over 5.6 million women and babies died in 2015 due to complications during pregnancy, birth and in the first month of life. In order to achieve the new mortality targets set out in the Sustainable Development Goals, there needs to be intentional efforts to maintain and accelerate action to end preventable maternal and newborn deaths and stillbirths. This paper outlines what progress is required to meet these new 2030 targets based on patterns of progress in the recent past; where the burden is the greatest; when to focus attention along the continuum of care; and what causes of death require concerted efforts.
Priority actions include intentional and intensified political attention and investment in maternal-newborn health with particular focus on improving quality and experience of care around the time of birth with implementation at scale of integrated maternal-newborn health interventions across the continuum of care with commensurate investment targeted at the most vulnerable populations. Looking forward, improved data for decision making and accountability will be required.
The health and survival of babies and their mothers are inextricably linked, and calls for coordinated efforts and innovation before and during pregnancy, in childbirth, and postnatally, in order to end preventable maternal, neonatal deaths and stillbirths.
Highlights
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A high proportion of deaths during pregnancy, birth and the first month of life are preventable.
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Increased attention and investment in maternal and newborn health requires action now.
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Improved data for decision-making and accountability are essential to achieving 2030 targets.
Background
The Millennium Development Goals (MDGs) have been called the greatest global success story for health and development, with unprecedented investments in global aid since their launch in 2000 . With the privilege of being the focus for two of the eight goals, maternal and child survival was expected to improve markedly. Yet despite a 44% reduction in the maternal mortality ratio since 1990, progress fell far short of the target of 75% in MDG 5 and still 303,000 maternal deaths were estimated to have happened in 2015 . Child deaths under the age of 5 years were also halved, but show uneven progress with slower progress for newborns compared to older children . Hence neonatal deaths now account for 2.7 million deaths a year, 45% of deaths in children under 5 globally. Newborn mortality reductions accelerated after 2000 (57% between 2000 and 2015). Similarly for maternal mortality progress was greater during 2005–2015 compared with 1990–2004. Absent from the MDG tracking and political visibility, stillbirths only declined by 19% between 2000 and 2015 . An estimated 2.6 million stillbirths occurred globally in 2015, of which over half were intrapartum . Almost all these were in low and middle income countries (LMICs), and just like maternal and newborn deaths, eminently preventable with improved coverage of high quality obstetric care.
As well as the variation in progress for these different outcomes, there is also a remarkable diversity of levels within individual countries between areas and populations sub-groups, and between world regions, and even neighbouring countries. As the world transitions into the era of the Sustainable Development Goals (SDGs) with an end-line date of 2030, there are 17 goals of which only one is regarding health. There remains however a remarkable demand from countries for sustained commitment to the health of women, children and adolescents. It is crucial that we take stock and use the available evidence to inform national investments, whilst also continuing to strengthen the reliability and coverage of local data to guide context-specific action.
Objectives
The overall aim of this paper is to review the agreed priority actions to end preventable maternal and newborn deaths and stillbirths by 2030. The specific objectives are to:
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Highlight the average annual rate reductions in maternal and neonatal mortality, and stillbirths, needed at global and regional levels to reach 2030 targets.
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Summarise the available evidence to inform investment in terms of where, when and on which causes of death to focus.
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Synthesise priority actions to accelerate progress.
Objectives
The overall aim of this paper is to review the agreed priority actions to end preventable maternal and newborn deaths and stillbirths by 2030. The specific objectives are to:
- 1.
Highlight the average annual rate reductions in maternal and neonatal mortality, and stillbirths, needed at global and regional levels to reach 2030 targets.
- 2.
Summarise the available evidence to inform investment in terms of where, when and on which causes of death to focus.
- 3.
Synthesise priority actions to accelerate progress.
Data and methods
The main sources of data used in this paper were the WHO, UNICEF, UNFPA, World Bank Group and the United Nations Population Division for maternal mortality estimates , the UN Inter-agency Group for Child Mortality Estimation for neonatal mortality estimates , and the Ending Preventable Stillbirths Lancet Series for stillbirth estimates .
Data for maternal deaths, neonatal deaths and stillbirths with time trends were used to calculate the national annual rate reduction (ARR) from 2000 to 2015 for maternal mortality ratio (MMR), neonatal mortality rate (NMR) and stillbirth rate (SBR). We present the SDGs, Strategies for Ending Preventable Maternal Mortality (EPMM) and Every Newborn Action Plan (ENAP) targets by 2030 for ending preventable maternal, newborn and child deaths and stillbirths with the ARRs required in order to achieve these. Finally, we updated data on timing of death and causal categories for maternal and newborn deaths and stillbirths in the year 2015.
Panel 1 provides more details on the data sources, definitions and analyses undertaken.
Maternal deaths estimates
Data source
Data was taken from the latest maternal mortality estimates from the Maternal Mortality Estimation Inter-Agency Group (MMEIG) comprising the World Health Organization (WHO), the United Nations Children’s Fund (UNICEF), the United Nations Population Fund (UNFPA), the World Bank Group and the United Nations Population Division (UNPD) . For data on causes of maternal deaths we used findings on the global distribution of causes of maternal death from Say et al. .
Definitions
Maternal deaths were defined according to the definition of the International Classification of Diseases (ICD: 10th edition): “death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management but not from accidental or incidental causes”. Maternal mortality ratio was defined as maternal deaths, per 100,000 live births.
Neonatal deaths estimates
Data source
Data was taken from the most recent report on neonatal, infant, and under-five mortality levels and trends from the United Nations Inter-agency Group for Child Mortality Estimation (UN IGME) for all United Nations member states—195 countries or entities at the time of the most recent estimation . For the neonatal causes of death we used the global distribution for neonatal deaths presented by Oza et al. .
Definitions
Neonatal deaths were defined as the death of a liveborn child during the first 28 days after birth. Neonatal Mortality Rate was defined as the number of neonatal deaths, per 1000 live births.
Stillbirth estimates
Data source
Data on stillbirths, their trends from 2000 to 2015 and risk factors were taken from the Ending Preventable Stillbirths Lancet Series .
Definitions
According to the International Classification of Diseases, definitions include:
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Late fetal death 1000 g or more, or 28 weeks or more, or 35 cm or more
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Early fetal death 500 g or more, or 22 weeks or more, or 25 cm or more
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Miscarriage as a pregnancy loss before 22 completed weeks of gestational age
Stillbirths were defined as in the Ending Preventable Stillbirths Lancet Series as the death of a fetus prior to the complete expulsion from the mother at 28 weeks or more of pregnancy. This represents third trimester stillbirths, and hence undercounts the true burden if early stillbirths were included. Stillbirth rate was calculated as number of stillbirths, per 1000 total births.
Methods
Annual rate of reduction was calculated with the formula: (((rate in endline year/rate in baseline year) ˆ(1/(endline year-baseline year))−1) × 100.
Results
What progress is required to meet the 2030 targets?
Fig. 1 show the trends in the global numbers and rates of maternal and neonatal deaths and stillbirths since 1990 and the projections to 2030 under two scenarios – continuation of the average ARR since 1990 and with accelerated declines. Although rates have indeed fallen, what is striking immediately is that business as usual will not achieve the global targets, and that unless efforts to steepen declines are coupled with addressing the unmet need for family planning and women’s education and empowerment, the number of deaths will remain high. However, the picture is also strikingly different at a country level – in part reflecting the challenge of a universal target. Some countries have already passed the target, whilst for those with the highest mortality, the ARR needed will necessitate a major shift in the trajectory. This is most marked for stillbirths, where the ARR (2.0%) between 2000 and 2015 was slower than that for maternal (ARR 3.0%) and neonatal (ARR 3.1%) mortality.
For maternal mortality, the global target is an MMR of less than 70/100,000 live births by 2030 ( Fig. 1 a), with different sub-targets for specific country contexts. Countries, depending on the baseline level in 2015, should either reduce their MMR by at least two-thirds of their baseline, not have an MMR greater than 140/100,000 live births by 2030, or achieve reductions in inequalities in MMR at a subnational level. These sub-targets will necessitate an ARR greater than 5.5% in the countries with the highest MMRs (MMR >420) .
For newborn deaths, the ENAP set an absolute target of 12 or fewer neonatal deaths per 1000 live births in every country by 2030 ( Fig. 1 b). An ARR of 4.3% will be needed to achieve the global NMR target, but this varies considerably between countries, with 29 countries needing to at least double their ARR . Turning to stillbirths, the ENAP set an absolute target of 12 or fewer stillbirths per 1000 total births in all countries by 2030. To achieve this, a global ARR of 4.2% and 56 countries will need to at least double their ARR .
What do we know about patterns of progress in the recent past?
Fig. 2 a compares the neonatal mortality rate with the maternal mortality ratio in 2015 for 182 countries. 92 nations have achieved already the 2030 targets for NMR and MMR. Overall there is a clear relationship between levels of neonatal and maternal mortality, with approximately 60% of the variation in the former explained by the variation in the latter, however Fig. 2 a shows some notable outliers. For example, Pakistan has managed to achieve a MMR of less than 200 due to an impressive ARR of 3.6% between 2000 and 2015 in its MMR. Nevertheless, the country still has one of the highest NMRs (46 per 1000 live births) and a lower rate of progress for neonatal deaths (ARR: 1.9). Two countries – DRC and Cameroon, have considerably lower NMRs than expected from their MMRs, suggesting potential issues of underestimation of newborn deaths and/or uncertainties in the denominator of live births. Sierra Leone stands out for having the highest maternal mortality ratio in 2015 (1,360 per 100,000 live births) reflecting the weak health care system left by a 10-year civil conflict that ended in 2002, and more recently by the Ebola outbreak. From such a high baseline situation, it has been argued that dramatic progress should be possible assuming continuing political stability and with major strengthening of health services and infrastructural developments .
Fig. 2 b shows that ARRs were greater for NMR than MMR in 84 of the 163 countries for which the comparison can be made. The countries with fastest progress in reducing their NMR were Bahrain, China, Estonia and Belarus, and for MMR were Belarus, Kazakhstan and Turkey. ARRs for NMR ranged from 9.7% for Bahrain to −0.75% for Zimbabwe, which was the only country where the NMR increased from 2000 to 2015. For MMR, the range of ARRs varied from 12.1% for Belarus to −3.3% for South Africa. In total, 12 countries did not reduce their MMR between 2000 and 2015, including mostly middle or high-income countries such as United States of America, Venezuela, Uzbekistan and South Africa.
Where in the world to focus attention in the SDG period?
Priorities from a geographical perspective can crudely be identified by looking at world, regional and national level data. In terms of numbers, the vast majority of stillbirths, neonatal deaths and maternal deaths occur in LMICs, with at least three-quarters in sub- Saharan Africa and south Asia (76%, 80%, 88%, respectively). Table 1 shows the top 10 countries with highest burden of maternal deaths, neonatal deaths and stillbirths, accounting for around 59%, 63% and 65% of their global totals, respectively. Population size is an important factor since the countries with the most deaths are also those with most births, notably India (45,000 maternal deaths, 695,900 neonatal deaths, 592,100 stillbirths) and Nigeria (58,100 maternal deaths, 240,100 neonatal deaths, 313,700 stillbirths). It is important to note that some of these countries such as India and China did in fact make rapid progress from 2000 to 2015 in reducing maternal and neonatal mortality rates, but owing to their large population size they still contribute significantly to the global total number of deaths. The variation in rates between areas and population sub-groups within their borders is also large, emphasizing the masking of inequalities when using national averages. As noted earlier, reducing inequalities is acknowledged as a sub-target in both the EPMM and ENAP strategies. Significant gaps between rich and poor groups in service uptake and in mortality outcomes have been highlighted among all relevant recent Lancet series – for newborns, stillbirths and most recently for maternal health .
| Maternal deaths | Stillbirths | Neonatal deaths | |||
|---|---|---|---|---|---|
| Country | No of maternal deaths (ARR:2000-15) | Country | No of stillbirths (ARR:2000-15) | Country | No of neonatal deaths (ARR:2000-15) |
| Nigeria | 58,100 (−2.4) | India | 592,100 (−2.4) | India | 695,900 (−2.4) |
| India | 45,000 (−5.0) | Nigeria | 313,700 (−1.3) | Pakistan | 244,700 (−1.9) |
| Dem Rep Congo | 22,300 (−1.5) | Pakistan | 242,600 (−1.4) | Nigeria | 240,100 (−2.3) |
| Ethiopia | 11,200 (−6.0) | China | 122,300 (−4.6) | Dem Rep Congo | 94,300 (−1.7) |
| Pakistan | 9,700 (−3.6) | Ethiopia | 96,500 (−1.8) | China | 93,400 (−8.6) |
| United Rep Tanzania | 8,200 (−4.9) | Dem Rep Congo | 87,800 (−1.5) | Ethiopia | 87,400 (−3.7) |
| Kenya | 8,000 (−2.6) | Bangladesh | 83,100 (−3.4) | Bangladesh | 74,400 (−3.9) |
| Indonesia | 6,400 (−4.8) | Indonesia | 73,400 (−1.9) | Indonesia | 73,900 (−3.3) |
| Uganda | 5,700 (−3.9) | United Rep Tanzania | 47,100 (−2.3) | Angola | 53,200 (−1.2) |
| Bangladesh | 5,500 (−5.3) | Niger | 36,200 (−0.4) | United Rep Tanzania | 38,600 (−3.5) |
| Total | 180,000 maternal deaths (59% world total) | 1.7 million stillbirths (65% world total) | 1.7 million neonatal deaths (63% world total) | ||
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