Some of the world's poorest countries have achieved spectacular progress in reducing child deaths. Rates of child mortality in many African countries have been dropping twice as fast in recent years as during the 1990s. In Botswana, Egypt, Liberia, Madagascar, Malawi, Rwanda and the United Republic of Tanzania, the rate of decline was on average 5 percent or more a year between 2000 and 2010. Similar progress has been seen in reducing maternal deaths, although in fewer developing countries: Equatorial Guinea, Nepal, and Vietnam have each cut maternal deaths by 75 percent. But all the news is not good. Every two minutes, somewhere in the world, a woman dies from complications of pregnancy and her newborn baby’s chances of survival are very poor. For every woman who dies, an additional 20-30 suffer significant and sometimes lifelong problems, as a result of their pregnancy.
In these same two minutes nearly 30 young children die of disease and illness that could have been prevented or effectively treated.
Many countries, especially in Africa and South Asia, are not making progress. Of the 75 countries with the highest burden of maternal and child mortality, 25 have made insufficient or no progress in reducing maternal deaths and 13 show no progress in reducing the number of young children who die.
“Global efforts to save the lives of women, newborn babies and young children are not moving fast enough,” says Mickey Chopra, M.D., PhD., chief health officer of United Nation’s Children’s Fund (UNICEF) and co-chair of the Countdown to 2015 initiative. “Some countries are showing us what success looks like, but many other countries still have to learn the lessons of those successes.”
Progress on maternal, newborn and child health, in the 75 highest-burden countries, most in Sub-Saharan Africa and South Asia, where more than 95 percent of all maternal and child deaths occur, has been laid out in a new 220-page report, Building a Future for Women and Children, which is published by the Countdown to 2015 initiative (www.countdown2015mnch.org).
The report is authored by a global collaboration of academics and professionals from Johns Hopkins University, the Aga Khan University, the University of Pelotas in Brazil, Harvard University, London School of Hygiene and Tropical Medicine, UNICEF, the World Health Organization, UNFPA, Family Care International, and Save the Children. The secretariat of the Countdown to 2015 initiative is based at The Partnership for Maternal, Newborn & Child Health.
“The Countdown report shows the who, what, where — and most importantly the why — of maternal, newborn, and child survival,” says Zulfiqar Bhutta, M.D., PhD, of Aga Khan University, Pakistan, who is the co-chair of Countdown and an author of the report. “It offers a clear, consistent report card that countries, advocates, and donors can use to hold each other — and themselves — accountable for real, measurable progress.”
The report assesses the progress that the 75 highest-burden countries are making towards achieving UN Millennium Development Goals 4 & 5 (MDGs). These MDGs call for reducing maternal deaths by three-quarters and the deaths of children under 5 by two-thirds, both by 2015 compared to 1990 levels.
"This is a race against time," said Dr. Bhutta. "The pace has picked up, but countries need to make real change happen in the next three years if the world is going to keep its promise to millions of newborns, children, and women."
Countdown to 2015 reports were first published in 2005 to track the progress in the highest-burden countries, to identify knowledge gaps, and to promote accountability at global and national levels for improving maternal and child survival.
Since then, massive global attention and resources have been focused on Millennium Development Goals 4 and 5.
In 2010, UN Secretary General Ban Ki-moon launched a Global Strategy for Women's and Children's Health, an effort that has generated $40 billion in commitments to meet key goals supporting women’s and children’s health. These goals include more trained midwives, greater access to contraceptives and skilled delivery care, better nutrition, prevention of infectious diseases and stronger community education. Notably, 44 of the world’s poorest countries — among them Bangladesh, Ethiopia, Nigeria, Burundi, and Nepal — have now joined the Every Woman, Every Child effort, which takes forward the Global Strategy for Women’s and Children’s Health. This brings the total number of partners in this joint effort to 220, with low-income countries committing nearly $11 billion of their own limited resources. The Countdown reports help to hold governments and donors accountable for fulfilling their commitments to the Global Strategy, and it will be a key input to the first report to the Secretary General in September 2012 from the independent Expert Review Group, set up following the launch of the report of the Commission on Information and Accountability for Women’s and Children’s Health, ‘Keeping Promises, Measuring Results’.
“A commitment that doesn’t translate into concrete programs and services is only an empty promise,” said Ann Starrs, president of Family Care International and an author of the report. “By objectively measuring progress and identifying gaps, Countdown to 2015 is a critical tool to help civil society advocates make sure that their governments deliver on the commitments they’ve made to women and children.”
The release of the Countdown 2012 Report coincides with a two-day forum to chart a course toward the end of preventable child deaths, taking place June 14-15 in Washington, DC. The governments of the United States, India, and Ethiopia, in collaboration with UNICEF, will convene this Child Survival Call to Action. US Secretary of State Hillary Clinton will attend.
Following in July, the UK government and the Bill & Melinda Gates Foundation will hold a summit to emphasize the need for greater attention to family planning.
In September, the United Nations Secretary-General, Ban Ki-moon, will issue an update on the impact of his Every Woman Every Child effort.
Key findings of the new report
Country-by-country data gathered and analyzed for the 2012 report highlight the progress and show where greater efforts are needed in 75 high-burden countries:
• On reducing maternal deaths: Annual maternal deaths are down by 47 percent over the past two decades. Nine Countdown countries are on track to meet their 2015 MDG 5 goal by reducing the maternal mortality rate by 75 percent. But more than a third of the 75 Countdown countries have made little, if any progress.
• On reducing deaths of children under age 5: Twenty-three Countdown countries are expected to achieve MDG 4. But 13 countries have made no progress in reducing child deaths.
• Forty percent of child deaths occur during the first month of life and most of these deaths are preventable through better nutrition and access to health services before, during and immediately after childbirth.
• Complications due to preterm birth are the leading cause of newborn deaths and the second leading cause of death in children under 5.
• More than 10 percent of all babies are born too soon. Preterm births are rising, instead of declining.
• Inadequate nutrition is a crisis in most Countdown countries, contributing to more than one-third of child deaths under 5 and one-fifth of maternal deaths.
• In most of these countries, more than one-third of the children are stunted, a condition especially common among the poorest populations where children are small because of a lack of good nutrition.
• Short maternal stature, often a result of stunting in childhood, and micronutrient deficiencies place pregnant women at greater risk for complications and low birth weight babies.
• Forty Countdown countries allocate less than 10 percent of total government spending to health.
• Fifty-three of the 75 Countdown countries face a severe shortage of health workers. Countries including Ghana, Malawi, the Lao People’s Democratic Republic and Tanzania have implemented innovative policies to hire, retain and motivate skilled health workers.
Data pinpoint areas of need
The Countdown report relied on all available data, though there are significant data gaps for many of the poorest countries. The data that are available highlight the obstacles that remain to meeting the goals for some countries.
“The detailed country-by-country data show where each country has made progress and pinpoint where greater effort is needed,” says Jennifer Requejo, Ph.D. of the Bloomberg School of Public Health at Johns Hopkins University and a lead author of the report.
"The report allows countries to compare their efforts with other countries and also to see if services across the continuum of care are equally available to everyone, urban and rural, rich and poor." Data show, for instance, that vaccine coverage has increased to 80 percent in all Countdown countries and rapid progress has been made in the distribution of bed nets to prevent malaria.
In contrast, diarrhea and pneumonia still cause more than two million deaths that could be avoided through prevention or prompt treatment.
The data also show that newborn survival is lagging in most countries; Bangladesh, Nepal and Rwanda have achieved success in reducing newborn mortality and offer a model for other countries to follow.
According to Joy Lawn, M.D., PhD, of Save the Children and an author of the report, for preterm babies, antenatal steroid injections help develop immature fetal lungs and prevent respiratory problems. These injections cost $1 and could save almost 400,000 lives a year in low-income countries. They are only available and provided for 10 percent of premature babies in these countries.
“Also kangaroo care, where premature infants are held skin-to-skin on the mother's chest to keep warm, could save 450,000 lives a year,” says Dr. Lawn. “It makes frequent breastfeeding easy and provides constant maternal supervision for the infant.”
“Besides using the data to drive our priorities and guide where the funding is spent, we need to focus on efforts to bring maternal and newborn services close to women and children in their own communities,” says Jennifer Bryce, PhD, of the Bloomberg School of Public Health and a lead author of the report.
The data also show that services must expand faster than population growth in order to improve coverage. Nigeria, for instance, has doubled the number of births attended by a skilled health care provider since 1990, but has increased its coverage rate by only 8 percent during that period, because the number of births has grown from 4.3 million in 1990 to 6.3 million in 2008, and is expected to reach 7 million by 2015.
The Countdown report highlights the fact that, whether or not countries are making progress in their national statistics, poor people have less access to health services than better-off people. Across the Countdown countries, for example, some 90 percent of the wealthiest women have access to a skilled birth attendant, while three-quarters of the poorest women give birth without lifesaving skilled childbirth care.
“Inequity in coverage for lifesaving interventions leads to inequity in health outcomes,” said Cesar Victora, M.D., PhD. of the University of Pelotas, Brazil and a lead report author. “Too many women and children are dying because they are poor, members of ethnic minorities or indigenous groups, or live in remote rural villages. Countries must ensure that every citizen has access to lifesaving health care.”
Accountability is crucial
The Global Strategy for Women's and Children's Health has generated more than $40 billion in commitments for maternal, newborn and child health. An update on the implementation of these commitments is expected from The Partnership for Maternal, Newborn & Child Health in September of this year.
"That money could make a big difference, if it is really delivered and used where it will have the greatest impact," says Peter Berman, PhD, of Harvard School of Public Health, who leads the Countdown group that tracks how and where money is spent for women’s and children’s health.
It is still essential to maintain and try to increase current funding, according to Dr. Berman. The Countdown report shows that funding from official aid sources has increased steadily, but that increase started to slow with the global economic downturn.
"Meeting the Millennium Goals will take more money, better programs, and better use of existing money,” says Dr. Berman. “We need to pay more attention to how we use what we have. We need to ensure that both donor and developing countries allocate the additional funds that are needed to save women’s and children’s lives.”
"In the last two years, we have seen real change," Dr. Bhutta says. “It is possible that in the next three years, by the end of 2015, we could see many more countries achieving their goals for maternal and child survival, if we concentrate on the strategies that will have the greatest impact. This race against time is not about politics, or money,” he says. “It is about saving lives.”