Considerable progress has been made towards reducing under-5 childhood mortality in the Millennium Development Goals era. Reduction in newborn mortality has lagged behind maternal and child mortality. Effective implementation of innovative, evidence-based, and cost-effective interventions can reduce maternal and newborn mortality. Interventions aimed at the most vulnerable group results in maximal impact on mortality. Intervention coverage and scale-up remains low, inequitable and uneven in low-income countries due to numerous health-systems bottle-necks. Innovative service delivery strategies, increased integration and linkages across the maternal, newborn, child health continuum of care are vital to accelerate progress towards ending preventable maternal and newborn deaths.
Key points
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Considerable progress has occurred in the Millennium Development Goals era with substantial reductions in the mortality of children younger than 5 years.
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Reduction in newborn mortality has consistently lagged behind maternal and child mortality, and progress is uneven between countries and regions.
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Reduction of maternal, newborn, and child mortality is achievable through effective implementation of many innovative, high-impact, cost-effective, evidence-based interventions.
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Rapid scale-up of effective interventions, innovative service delivery strategies, and smart integration and linkages across the continuum of care is vital to accelerate progress toward improving maternal, newborn, and child survival.
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The goal of ending preventable maternal, newborn, and child deaths worldwide is achievable with the convergence of reproductive, maternal, newborn, child, and adolescent health with multi-stakeholder partnerships, multi-sectoral collaboration, and strong political leadership.
Introduction
In recent years, increased attention has been focused on global reproductive, maternal, newborn, and child health (RMNCH). The Millennium Development Goals (MDGs) were established in the year 2000 by leaders of 189 nations to achieve a set of targets by 2015 compared with the 1990 baseline level. ( Box 1 ). Health-related MDG4 was aimed at reducing child mortality by two-thirds, whereas MDG5 was aimed at reducing maternal mortality by three-quarters and achieving universal access to reproductive health by the year 2015; but other MDGs also impact the health of women and children. Although considerable progress has occurred in the MDG era with substantial reductions in child mortality for those younger than 5 years, MDG4 targets will not be met in 2015. In addition, decline in newborn mortality has consistently lagged behind the maternal mortality rate and the mortality rate of children younger than 5 years. Reduction of maternal, newborn, and child mortality is achievable through effective implementation of many innovative, evidence-based, cost-effective interventions. Targeted interventions aimed at the most vulnerable group results in maximal impact on mortality. However, maternal, newborn, and child health (MNCH) intervention coverage and scale-up remains low, inequitable, and uneven between low- and middle-income countries (LMIC) and regions because of numerous health-system bottlenecks, such as workforce, financing, and service delivery.
Goal 1: Eradicate extreme poverty and hunger
Goal 2: Achieve universal primary education
Goal 3: Promote gender equality and empower women
Goal 4: Reduce child mortality
Goal 5: Improve maternal health
Goal 6: Combat human immunodeficiency virus/AIDS, malaria, and other diseases
Goal 7: Ensure environmental sustainability
Goal 8: Develop a global partnership for development
The MDGs that end in September 2015 will be followed by a new set of goals: the Sustainable Development Goals (SDGs). Leaders representing the MNCH global community have recommended inclusion of new goals and targets for ending preventable newborn deaths and stillbirths as well as preventable maternal and child deaths in the post-2015 agenda. More intensified and coordinated efforts will be needed by governments, multilateral organizations, and other stakeholders, including nongovernmental organizations, civil society, private sector, and policy makers from high-income countries (HIC), to accelerate progress and achieve sustainable, high-quality services to improve MNCH in the post-2015 era.
Introduction
In recent years, increased attention has been focused on global reproductive, maternal, newborn, and child health (RMNCH). The Millennium Development Goals (MDGs) were established in the year 2000 by leaders of 189 nations to achieve a set of targets by 2015 compared with the 1990 baseline level. ( Box 1 ). Health-related MDG4 was aimed at reducing child mortality by two-thirds, whereas MDG5 was aimed at reducing maternal mortality by three-quarters and achieving universal access to reproductive health by the year 2015; but other MDGs also impact the health of women and children. Although considerable progress has occurred in the MDG era with substantial reductions in child mortality for those younger than 5 years, MDG4 targets will not be met in 2015. In addition, decline in newborn mortality has consistently lagged behind the maternal mortality rate and the mortality rate of children younger than 5 years. Reduction of maternal, newborn, and child mortality is achievable through effective implementation of many innovative, evidence-based, cost-effective interventions. Targeted interventions aimed at the most vulnerable group results in maximal impact on mortality. However, maternal, newborn, and child health (MNCH) intervention coverage and scale-up remains low, inequitable, and uneven between low- and middle-income countries (LMIC) and regions because of numerous health-system bottlenecks, such as workforce, financing, and service delivery.
Goal 1: Eradicate extreme poverty and hunger
Goal 2: Achieve universal primary education
Goal 3: Promote gender equality and empower women
Goal 4: Reduce child mortality
Goal 5: Improve maternal health
Goal 6: Combat human immunodeficiency virus/AIDS, malaria, and other diseases
Goal 7: Ensure environmental sustainability
Goal 8: Develop a global partnership for development
The MDGs that end in September 2015 will be followed by a new set of goals: the Sustainable Development Goals (SDGs). Leaders representing the MNCH global community have recommended inclusion of new goals and targets for ending preventable newborn deaths and stillbirths as well as preventable maternal and child deaths in the post-2015 agenda. More intensified and coordinated efforts will be needed by governments, multilateral organizations, and other stakeholders, including nongovernmental organizations, civil society, private sector, and policy makers from high-income countries (HIC), to accelerate progress and achieve sustainable, high-quality services to improve MNCH in the post-2015 era.
Current scope of the problem
Maternal Health and Global Mortality Trends
Maternal health is defined as the health of women during pregnancy, childbirth, and post partum (first 42 days after delivery). In 2010, the maternal mortality ratio (MMR) in LMIC was estimated at 240 per 100,000 live births compared with 16 per 100,000 live births in HIC. Between 1990 and 2013, maternal mortality rates declined by 45%; in 1990, an estimated 523,000 maternal deaths occurred compared with 289,000 deaths in 2013. Although progress has been made, this decline in maternal mortality rates fails to meet the MDG target of a 75% reduction between 1990 and 2015. The MMR can vary markedly from country to country. For example, South Sudan has an MMR of 956.8 (685.1–1262.8), whereas Iceland has an MMR of 2.4 (1.6–3.6) in 2013. Besides the risk of dying during pregnancy, labor, and post partum, women in LMIC also experience severe acute or chronic morbidities and disabilities with impaired quality of life.
Most of the maternal deaths are largely preventable and occur in sub-Saharan Africa and Southern Asia; approximately 50% of maternal deaths occur in India, Nigeria, Pakistan, Afghanistan, Ethiopia, and the Democratic Republic of Congo. Although the causes of death may vary from region to region, severe hemorrhage, pregnancy-induced hypertensive disorders, and sepsis account for more than half of preventable maternal deaths globally ( Box 2 ). The highest risk of maternal mortality occurs during the intrapartum or postpartum period. Other important causes of maternal mortality include unsafe abortion and obstructed labor. Indirect and late causes of maternal mortality include infectious diseases of poverty, such as human immunodeficiency virus (HIV), malaria, and tuberculosis, and other preexisting conditions, such as diabetes, obesity, anemia, sickle cell disease, and chronic kidney disease.
Maternal
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Hemorrhage (27%)
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Pregnancy-induced hypertensive disorders (14%)
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Sepsis (11%)
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Unsafe abortions (8%)
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Other direct causes (12%)
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Other indirect causes (28%)
Younger-than-5 deaths
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Preterm birth complications (15.4%)
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Pneumonia (14.9%)
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Intrapartum complications (10.5%)
Child and Newborn Global Mortality Trends
Child health is defined as the health of children younger than 5 years (perinatal <7 days old, neonate <29 days old, child <5 years of age). Between 1990 and 2013, mortality rates of children younger than 5 years declined by approximately 50%; in 1990, an estimated 12.7 million deaths occurred in children younger than 5 years compared with approximately 6.3 million deaths in 2013. From 2000 to 2012, remarkable declines in child deaths have been noted in 22 high-burden countries in sub-Saharan Africa and South Asia, with annual rates of reduction in the mortality rates of children younger than 5 years of 4.4% or higher.
Of the 6.3 million deaths of children younger than 5 years in 2013, 51.8% (3.257 million) were caused by infectious disease. Pneumonia, diarrhea, and malaria are major causes of preventable deaths of children younger than 5 years beyond the neonatal period. Pneumonia and diarrhea accounted for 15% and 9% of the estimated 6.3 million deaths of children younger than 5 years in 2013 globally. It is estimated that childhood undernutrition (stunting, wasting, and micronutrient deficiencies) contributes to nearly 50% of child deaths (3.1 million deaths) annually.
From 1990 to 2013, the annual rate of reduction (ARR) in maternal mortality was 3.5% and reduction in the mortality of children younger than 5 years was 3.6%; in contrast, ARR in neonatal mortality (deaths in the first 28 days of life) has lagged behind (2.2%). In 2013, neonatal deaths accounted for 44% (2.761 million) of the 6.3 million deaths of children younger than 5 years. There is variation in neonatal mortality rates across countries ( Table 1 ). The 5 highest-burden countries account for more than 50% of neonatal deaths.
| Country | Neonatal Deaths, 2012 (No.) | Maternal Deaths, 2013 (No.) |
|---|---|---|
| India | 779,000 | 50,000 |
| Nigeria | 267,000 | 40,000 |
| Pakistan | 202,400 | 7900 |
| China | 157,400 | 5900 |
| Democratic Republic of the Congo | 118,100 | 21,000 |
| Ethiopia | 87,800 | 13,000 |
| Bangladesh | 75,900 | 5200 |
| Indonesia | 72,400 | 8800 |
| United Republic of Tanzania | 39,500 | 7900 |
| Kenya | 40,000 | 6300 |
Preterm birth complications, intrapartum complications (birth asphyxia), and infections (sepsis, meningitis, pneumonia) remain primary causes of neonatal mortality (see Box 2 ). In sub-Saharan Africa and South Asia, more than 80% of the neonatal deaths occurred in low-birthweight babies (typically preterm infants). Data from 2000 to 2012 indicate slow progress (<20% reduction) toward prevention of deaths due to prematurity. Approximately 2.6 million stillbirths (defined by the World Health Organization [WHO] as fetal death at a weight ≥1000 g and/or ≥28 weeks’ gestation) occur annually; of these, 1.2 million deaths occur during the intrapartum period, usually due to poor care.
Factors Affecting Maternal, Newborn, and Child Health
In LMIC, women are at an increased health risk during pregnancy and childbirth. There are many social, economic, cultural, or behavioral factors that affect maternal and child health. Key determinants, such as maternal education, poverty and poor housing, inequity in intervention coverage, community and social network systems, nutrition, lack of empowerment, financial autonomy, and armed conflict, can adversely affect MNCH outcomes. About 800,000 neonatal deaths each year are attributable to maternal undernutrition.
In South Asia and sub-Saharan Africa, children living in congested, urban informal settlements (or slums) are at an increased health risk because of air pollution or absence of clean water and sewage systems. In both rural areas and urban slums, poor access to quality health care poses a serious threat to maternal and child health and survival.
Conflicts, displacement, and natural disasters account for 60% of preventable maternal mortality, 54% of younger-than-5 mortality, and 45% of neonatal mortality. Other unique health risks for girls and women include gender inequity and social inequalities in health. Stigma and discrimination faced by HIV-infected women remain a hurdle to eliminate mother-to-child HIV transmission and achieve maternal and child health goals in LMIC.
Interventions to reduce maternal, newborn, and child mortality
Many essential, evidence-based, low-cost, and high-impact interventions across the continuum of care can reduce maternal, newborn, and child morbidity and mortality ( Box 3 ).
Preconception and adolescent health interventions
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Reduce unintended pregnancy
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Sex education
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Universal access to family planning services
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Optimize birth spacing
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Improve nutritional status (micronutrient supplementation)
Antenatal interventions
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Antenatal care (at least 4 visits)
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Vaccination (tetanus toxoid)
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Screening, treatment, and prevention of infectious diseases (HIV, syphilis, other sexually transmitted infections, malaria [intermittent preventive therapy], insecticide-treated bed nets)
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Management of chronic noncommunicable diseases (diabetes, hypertension)
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Management of pregnancy-induced disorders
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Diagnosis and management of in utero growth retardation
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Prevention of rhesus D alloimmunization
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Promotion of psychosocial health and support
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Cessation of smoking and substance use during pregnancy
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Nutritional supplementation for mothers before and during pregnancy
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Folic acid supplementation and fortification
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Multiple micronutrient supplementation (including iron and balanced energy supplementation)
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Intrapartum interventions
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Skilled attendant at birth
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Emergency obstetric care
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Antenatal corticosteroids for preterm labor
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Antibiotics for premature rupture of membranes
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Management of preterm labor and post-term pregnancy
Newborn and neonatal interventions
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Essential newborn care at time of birth
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Warming, drying, tactile stimulation, hygiene, and thermal care
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Neonatal resuscitation for babies who do not breathe at birth
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Umbilical cord care (including chlorhexidine application) and skin care
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Newborn immunization
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Early exclusive breastfeeding
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Vitamin K administration
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Diagnosis and management of neonatal infection
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Management of birth-related complications
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Interventions for small and ill babies
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Prevention of hypothermia
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Kangaroo mother care (skin-to-skin care)
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Management of respiratory distress syndrome
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Management of infection (pneumonia and sepsis)
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Management of hyperbilirubinemia
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Topical emollient and massage therapy
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Child health interventions
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Detection and management of severe childhood illness
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Pneumonia, diarrhea, malaria
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Management of malnutrition
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Immunization (pneumococcus, Haemophilus influenzae type b, rotavirus, measles, and diphtheria and tetanus toxoids and pertussis vaccine)
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Nutritional interventions (vitamin A and zinc supplementation)
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Infant and young child feeding
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HIV prevention and treatment
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Water, sanitation, and hygiene interventions
Scale-up of effective high-impact, low-cost interventions during preconception (before and between pregnancy), antenatal, intrapartum, and postnatal periods could avert an estimated 71% of neonatal deaths, 33% of still births, and 54% of maternal deaths annually. Care provided is cost-effective: savings are estimated to be $1298 for each life saved for an annual investment of $5.65 billion ($1.15 per person). Innovative new newborn interventions, such as chlorhexidine cord cleansing and management of small and ill newborn infants, can be nested within other care packages and could save nearly 600,000 newborns per year by 2025 when care is delivered in subdistrict and district-level facilities. Chlorhexidine cord cleansing is associated with a 27% reduction in incidence of omphalitis and a 23% reduction in the risk of neonatal mortality. Most effective packages of care are cost-effective and can avert 87% of maternal and neonatal deaths.
Gaps in coverage, equity, and quality of care
Substantial progress has been made toward achieving the MDG targets related to health. According to the 2015 WHO “Statistics Report,” child undernutrition has declined by four-fifths, child mortality by two-thirds, maternal mortality by three-fifths, and in increasing access to sanitation by three-fifths. Despite these advances, approximately 17,000 children younger than 5 years die each day, primarily from preventable causes. High newborn mortality and stillbirths in Bangladesh, Afghanistan, Nepal, India, Pakistan, Malawi, and Uganda remain a major concern. Uneven progress and significant disparities have been observed across many countries of the South Asian Association for Regional Cooperation. High coverage of key MNCH interventions correlates with lower maternal and child death rates. Table 2 depicts the current coverage of selected key maternal and newborn interventions in the 75 high-burden countries. Major emphasis for scaling-up essential interventions is focused on the 75 countdown countries where greater than 95% of all maternal and child deaths occur.
