Rapid expansion of programs to prevent HIV transmission to babies and vaccinate children show how results can be achieved in relatively little time.
Some of the world's poorest countries have managed to cut maternal and young child mortality rates by half or more, according to a new report from Countdown to 2015.
The report, Accountability for Maternal, Newborn and Child Survival, highlights successes in improving maternal health and reducing child mortality in some countries, while pointing out where progress has been lagging in others.
There has been remarkable progress in expanding the reach of programs that prevent mother-to-child transmission of HIV and vaccinate children against life-threatening illnesses like diphtheria, pertussis (whooping cough) and tetanus. These successes highlight what can be accomplished through political commitment and increased investment in effective interventions for maternal, newborn and child health.
Greater effort is needed to improve coverage of other life-saving interventions like antibiotic treatment of pneumonia and post-natal care for women and newborns.
Rwanda, Botswana, and Cambodia have made notable progress in reducing mortality since 2000, each ranking in the top five among the 75 countries studied in this report in regard to rate of reduction of mortality. This success is particularly notable in light of much slower progress in the 1990s, where in some cases, mortality rates rose due to conflict and instability and/or high HIV prevalence rates.
More than half of these countries have reduced both maternal and child mortality at a faster rate since 2000 than they did during the decade from 1990 to 2000.
"We are very pleased to see that many countries are making a major leap forward and have managed to save so many lives in a relatively short period of time," says Mickey Chopra, MD, PhD, Chief of Health for UNICEF and Co-Chair of Countdown to 2015.
"Progress is especially happening in countries where governments are using evidence to guide investment and policy decisions, and where all stakeholders—including the UN, donors, corporates and civil society—are working together effectively to create real change for women and children."
An approaching deadline
The new Countdown report has been produced by a global collaboration of academics and health professionals from Johns Hopkins University, Aga Khan University, Federal University of Pelotas in Brazil, Harvard University, London School of Hygiene and Tropical Medicine, UNICEF, the World Health Organization, UNFPA, Family Care International, Save the Children, and other institutions from around the world. The secretariat of the Countdown to 2015 initiative is based at The Partnership for Maternal, Newborn & Child Health.
Countdown to 2015 assesses progress in the 75 countries that together account for more than 95% of all maternal and child deaths. This evidence is intended to support greater progress towards achieving UN Millennium Development Goals (MDGs) 4 and 5 by 2015. These MDGs call for reducing maternal deaths by three-quarters and the deaths of children under 5 years of age by two-thirds compared to 1990 levels.
Accountability for Maternal, Newborn and Child Survival reports on the extent to which women and children have access to key life-saving services in these 75 countries, including family planning, antenatal care, skilled birth attendance, post-natal care, vaccinations, and treatment for diarrhea, pneumonia and other leading killers of young children.
Together with one-page profiles for each of the 75 countries, this report provides a snapshot of progress on the 11 core indicators selected by the Commission on Information and Accountability for Women's and Children's Health, established in 2011 to develop a framework to monitor and track commitments to the Global Strategy for Women's and Children's Health, launched by UN Secretary-General Ban Ki-moon in 2010 to accelerate progress on the MDGs.
Findings reported by Countdown include:
- The number of women who die each year from pregnancy- or childbirth-related complications dropped significantly from 543,000 in 1990 to 287,000 in 2010. Thirty of the 75 Countdown countries showed reductions of 50% or more in their maternal mortality ratios between 1990 and 2010. However, nine countries in sub-Saharan Africa where HIV infections rates among women are typically high reported increases in maternal mortality over this time period.
- Deaths among children under five years of age dropped from nearly 12 million in 1990 to about 6.9 million in 2011. Thirty countries cut child mortality by half or more from 1990 to 2011, and two-thirds of the Countdown countries accelerated their progress since 2000 compared with the previous decade.
"Momentum is gathering," says Elizabeth Mason, M.D., Director for Maternal, Newborn, Child and Adolescent Health for the World Health Organization. "But we still need to move faster. With less than 1,000 days until the 2015 MDG deadline, we need to maximize the power of time-tested basics like breastfeeding, soap and clean water alongside new medicines and technologies to keep even more mothers and children alive and healthy."
Key areas for more progress
The report also highlights areas where more progress is needed, including:
Newborn Deaths. Newborn deaths, i.e., deaths within the first month of life, now account for more than 40 percent of child deaths in 35 Countdown countries, and 50 percent or more in 12 countries. As deaths in children under the age of five have decreased, the proportion of these deaths that occur during the newborn period has increased. At the same time, the rate of progress in reducing newborn deaths has been far slower compared with the rate of progress in reducing the deaths of older children.
Infectious Diseases. Malaria, pneumonia, diarrhea, sepsis, measles, AIDS, and other infectious diseases account for at least half of all young child deaths. Many of these deaths can be prevented with cost-effective interventions. These priorities are highlighted by several recent efforts to scale up action to reduce child mortality, including the Global Action Plan for the Prevention and Control of Pneumonia and Diarrhoea, launched last month by WHO and UNICEF; the Global Vaccine Action Plan, endorsed by the 194 member-states of the WHO in 2012; and Committing to Child Survival: A Promise Renewed, led by the governments of India, Ethiopia and the US, supported by UNICEF.
Breastfeeding. Although early and exclusive breastfeeding would improve nutrition and reduce susceptibility to disease, coverage levels of these interventions vary widely across the countries studied. In many countries, fewer than half of all babies are breastfeed immediately after birth or exclusively breastfed during their first six months of life.
Reaching the most vulnerable
The Countdown report shows that some countries are moving more quickly than others, reporting wide differences in coverage levels for key interventions and services across countries where data is available (2007-2012).
- The median coverage of skilled birth attendance is slightly more than 60% for the countries studied (54), but the coverage between these countries ranges from 10% to 100%:
- The median for postnatal care of babies is 26%, ranging from 5% to 77% among the 11 countries studied;
- The median for antibiotic treatment for pneumonia is 42%, but the range is 7%-88%.
The Countdown report also reveals vast inequalities in coverage within countries, as richer families are more likely to seek and receive essential care, such as skilled attendance at birth, compared with poorer families. In every country studied, women with secondary or higher education are more likely than uneducated women to give birth with a skilled attendant. Greater attention is needed to providing universal access to care by reaching the poorest, and to educating girls and women.
Focus on newborn survival
"Around the world, 43% of child deaths occur during the first month of life and this percentage is continuing to rise. Reducing newborn deaths is essential if countries are to achieve MDG 4 and ultimately eliminate preventable child deaths, as the world has promised to do," says Jennifer Requejo, Ph.D, lead author of the new Countdown report and manager of Countdown to 2015.
"By scaling up cost-effective interventions that can be delivered through antenatal, childbirth and postnatal care services—like antenatal corticosteroids, neonatal resuscitation, drying and thermal care for the newborn, cord care, kangaroo mother care and treatment for newborn sepsis—that terrible toll of newborn deaths can be reduced by three-quarters, without the need for intensive care," she says. "And, improving antenatal, childbirth and postnatal care services has the added benefit of saving women's lives and reducing stillbirths and preterm deliveries."
Tracking reproductive health funding
Family planning is another key concern of Countdown to 2015 because of its contribution to reducing unintended pregnancies and unsafe abortions, as well as its contribution to enabling women to control their reproductive lives. More than half of the 75 countries studied in the report have a total fertility rate of four or more children per woman; 35 of these countries are in sub-Saharan Africa where contraceptive use is low.
A companion Countdown paper, Reproductive health priorities: Evidence from disbursements of official development aid, published in the May 19 issue of The Lancet medical journal, tracked the amount of official development assistance (ODA) for reproductive health over two years. This is the first time such a global analysis of ODA for reproductive health has been undertaken. Specific reproductive health activities tracked in this analysis includes prevention, care and treatment of HIV/AIDS for women of reproductive age (15-49); family planning; treatment of sexually transmitted infections; and sexual health.
The results show an increase from $5,579 million in 2009 to $5,637 million in 2010—a slight increase of about 1%. However, more than half of ODA for reproductive health was directed to HIV/AIDS services; the share of funding for treatment of other sexually transmitted infections actually decreased. Only 7% of this ODA went for family planning. For example, when ranked by amount of reproductive health funding received per capita, countries from southern Africa top the list, but when funding for HIV/AIDS is excluded, those countries move further down the list, despite the high unmet need for family planning for many countries in the region.
"Although the volume of aid for reproductive health is quite substantial, such funding is not balanced across activities – if international targets are going to be met for universal access to reproductive health, more balanced aid needs to go to essential reproductive health services such as family planning," says Justine Hsu, MSc, lead author of the paper and a researcher in health economics with the London School of Hygiene and Tropical Medicine.
Ms. Hsu notes that many commitments have been made to family planning over the past year, due largely to the London Family Planning Summit held last July. "We need to continue to analyze trends and breakdowns of data to understand what aspects of reproductive health are being supported, and to ensure donors are keeping to their commitments," she says.
"While it is great news that funding for reproductive health overall has increased, this analysis highlights the importance of breaking down funding flows into their various components," notes Ann Starrs, President of Family Care International. "The fact that funding for family planning actually declined between the two years is a serious concern, given that more than 220 million women around the world lack access to contraceptive services."
Concern about inequities
Countdown to 2015 reports on inequities in care between richer and poorer populations, both within and across countries.
"Poor women and children are not getting the same access to life-saving interventions. Ethically and morally, these inequities are unacceptable," says Cesar Victora, M.D., PhD, of the Federal University of Pelotas in Brazil and Chair of Countdown's working group on equity.
In addition to addressing inequities in access to care, it is also important to improve the quality of care. Understanding the populations that need to be reached helps local health officials plan better services for underserved areas.
Some countries, notably Brazil and Peru, have managed to reduce the service gap between rich and poor. Bangladesh is also making progress toward that goal, while others, like Ethiopia and Malawi, are now training and deploying community health workers to reach rural populations in order to improve access
"The first step is to identify who is being left out," says Dr. Victora. "Then, community delivery— training health workers to treat common diseases and conditions in the community—is a key strategy for reaching them with needed care."
"Ten years ago, this data on equity just wasn't generally available and the issue wasn't getting enough attention," he reports. "Now, a lot is happening on many fronts. Equity is a major focus in the development of post-2015 development goals."
The work won't stop in 2015
Countdown is also moving toward 2015 with in-depth case studies to identify key factors contributing to national progress. The initiative is supporting "Country Countdowns," country-led efforts to increase the use of evidence in health planning and prioritization.
"It's great news so many countries are making faster progress and that more countries than anticipated are showing potential to fulfill MDGs 4 and 5 and integrating services," says Dr. Zulfiqar Bhutta, Professor at Aga Khan University in Pakistan and Co-Chair of Countdown to 2015. "The work must not stop, though, until we end preventable deaths for women and children."
"We're not closing shop in 2015," he adds. "We can pause and congratulate the countries that have done well, but there is a lot more to do to helping others reach these goals; we have to keep going."
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