Call to Action to Reduce Global Maternal Neonatal and Child Morbidity and Mortality

Problem Statement

Millennium Development Goal 4 (MDG 4; reduce child mortality) and MDG 5 (improve maternal health) are indicators of critical importance to world development; however, these remain the least advanced of the MDGs. The actual decline of 1% per year in maternal mortality falls far short of the annual reduction rate of 5.5% needed to meet MDG 5 by 2015.¹ Infant and child mortality rates have been declining, but not fast enough to meet the MDG 4 goals. Among the 67 countries with the highest child mortality rates, only 10 are on track to meet the MDG target on child survival.¹

Globally, 80% of all maternal deaths are caused by hemorrhage, hypertensive disorders, infections, unsafe abortion, sepsis, and obstructed labor account, with important variations by region.² Of the remaining maternal deaths, a substantial number are related to HIV/AIDS³, malaria, and anemia during pregnancy.⁴ For each death of a childbearing mother, 20 others suffer severe morbidity and disability as sequelae of obstetric complications.⁵ Women who survive life-threatening maternity-related complications often require a lengthy recovery and long-term physical, psychological, social, and economic consequences. One of the most devastating sequelae is obstetric fistula. Others include anemia, infertility, damaged pelvic structure, chronic infection, depression, and impaired productivity, which can lead to marital problems, household dissolution, social isolation, shortened life spans, and suicide. Poverty is accentuated by costs of medical care and lost productivity.^5–7 Experts recommend revising current interventions to reduce maternal and perinatal mortality to target women in high-risk categories for severe obstetric complications who do not die, referred to as “near-misses.”⁷

The vast majority of deaths and disability among women due to pregnancy-related causes are preventable. Often, preventive measures are not accessible.¹ Access to safe abortion, contraception for child spacing, and emergency obstetric care are strongly linked to maternal health.8 Maternal morbidity and mortality are human rights issues since discrimination, inequity, and lack of accountability in national health systems are often their root causes.^9,10 Women of reproductive age need access to health services during preconception and interconception, not just during pregnancy. Early identification of chronic diseases such as cardiovascular disease, diabetes, and cancer would improve maternal, neonatal, infant, and child death rates.

Survival of the neonate is highly dependent on adequate intrapartum care, and child survival, health, education, and well-being are mediated by care of the child by the mother.^11,12 Furthermore, specific life-saving and health-promoting interventions such as breastfeeding demand the presence of a healthy mother.¹³Therefore, maternal survival is vital for both MDG 4 and MDG 5.

The World Health Organization 2015 target to reduce maternal deaths by 75% from 1990 levels is unlikely to be met.¹⁴ The decline since 1990 has been estimated at less than 1% per year, from 576|300 maternal deaths in 1990 declined to 535|900 maternal deaths in 2005; over 99% of these deaths occurred in the developing world.¹⁴ While in the United States there is 1 maternal death for every 7500 live births, in Afghanistan, the country with the highest mortality, 1 maternal death occurs for every 8 live births.

Using the same data but new analytical methods, a recent calculation produced an estimate of 342|900 (95% confidence interval|=|302|100–394|300) maternal deaths worldwide in 2008.¹⁵ The heterogeneity and validity of data sources and the estimation methods of these results are being discussed, and there are suggestions that continued improvement in data collection and evaluation methods on maternal mortality are essential.^16,17

Mortality in children aged younger than 5 years is 20 times higher in poor countries than in wealthier countries. In 2008, the average child mortality rate in low-income countries was 108 deaths per 1000 live births, compared with 5 deaths per 1000 live births in higher-income countries.¹⁸ Causes of death in children include mainly preventable communicable diseases such as HIV/AIDS, diarrhea, malaria, measles, and pneumonia, as well as perinatal-related conditions such as prematurity, birth asphyxia, neonatal sepsis, and congenital anomalies. In addition, neonatal mortality is increasing and has become the major contributor to child mortality over the past 20 years.¹⁹ Stillbirths are now recognized as the invisible problem of child health that is not measured in national statistics or MDGs or tracked by the United Nations (UN). An estimated 3 million stillbirths occur globally each year: up to 40 stillbirths per 1000 live births in poor countries²⁰ Increased attention to this problem is needed in the context of overall increased emphasis on maternal, neonatal, and child health and mortality.^20,21

According to a Lancet review,²² cost-effective preventive actions could prevent about 13 million infant deaths. The single intervention that would yield the most impact is increased exclusive breastfeeding for 6 months. This, coupled with immediate postpartum skin-to-skin contact, continued breastfeeding for at least 1 year, and proper complementary feeding, would reduce more than 1 in 5 of the preventable deaths.

Community participation and community-based strategies are essential for making progress in MDGs 4 and 5.²³

The achievement of high coverage of effective interventions and MDGs 4 and 5 requires adequate financing. Global overseas development aid increased from 2003 to 2008 for maternal, newborn, and child health, and there was improved targeting of countries with high rates of maternal, neonatal, and child health, although several targeted countries continued to receive less funding per capita than other countries with lower mortality rates and greater income levels.²⁴ By 2006, only one third of the annual amount needed had been invested in maternal, newborn, and child health.²⁵

In recognition of this serious shortfall, maternal survival and health, and mothers’ skills in caring for their newborn and young children, have been given renewed emphasis and political support in the past 5 years, and especially in 2010, through various major international channels: 
a. The Partnership for Maternal, Neonatal and Child Health was launched in 2005 to join the maternal, newborn, and child health communities into an alliance of more than 350 members with the mission to achieve MDGs 4 and 5 by linking the global health community to improve knowledge, fund raising, and accountability.²⁶ 
b. The UN secretary general launched in September 2010 the “Global Strategy for Women’s and Children’s Health” and a new high-level UN commission charged with the task of improving global reporting, oversight, and accountability for women’s and children’s health, and tracking results and resources for women’s and children’s health.²⁷ 
c. Numerous major international conferences were held in 2010 that highlighted global maternal, neonatal, and child health: the Group of Eight (G8) summit in June, the African Union Summit on Maternal, Neonatal and Child Health, the Global Maternal Health Conference 2010 in India, the MDG Summit–UN General Assembly in September, and the Partnership for Maternal, Neonatal and Child Health Forum in New Delhi in November.²⁸
d. The Global Fund to Fight AIDS, Tuberculosis and Malaria broadened its portfolio in December 2010 to include maternal, neonatal and child health programming, requiring it to be linked to AIDS, tuberculosis, and malaria programming.²⁹
e. The Global Health Initiative aims to improve health outcomes in partner countries through strengthened health systems—with a particular focus on improving the health of women, newborns, and children through programs including infectious disease, nutrition, breastfeeding, maternal and child health, and safe water, using a business model based on a woman- and girl-centered approach.³⁰

Despite this evidence of major international advocacy for increased political and financial support for global maternal, neonatal, and child health, and the existence of proven and cost-effective measures to reduce maternal, neonatal, and child mortality^31,32, funding remains far below need to reach the MDGs 4 and 5. In particular, among all the MDGs, MDG 5 for maternal health is the one that lags farthest behind. Among development goals, the health of mothers, neonates, and children has historically received lowest priority.³³ The US international affairs budget allocated for maternal and child health in the context of global health funding in the 2011 federal budget continues at previous low levels. A major move towards prioritizing maternal, neonatal, and child health is required in US foreign assistance programs as well as among nongovernmental donors to make possible any chances of reaching MDGs 4 and 5 on maternal, neonatal, and child health.^33,34

Recommendations
APHA recommends

1. Increased political commitment to global maternal, neonatal, and child health by the United States and by all world governments; 
2. Increased targeted funding for research, development, implementation, documentation, and dissemination of effective strategies for improving global maternal, neonatal, and child health in the poorest populations, including sufficient funding for scientifically based program evaluation to ensure measurement of the effectiveness of programs that address maternal, neonatal, and child health in these populations.

Proposed Action Steps
APHA recommends that the US Congress, the Executive Branch, federal agencies, and partners

1. Make a sustained political commitment to global maternal, neonatal, and child health at all levels of the US Government that concern foreign assistance; 
2. Make a sustained commitment to maintain and increase targeted funding for maternal, neonatal, and child health within the context of robust funding for all global health areas in US Government international health accounts;
3. Ensure that US Government foreign assistance funds are earmarked to support research, development, documentation, and dissemination of effective strategies, including health behavior change methodologies, for improving maternal, neonatal, and child health in developing populations;
4. Ensure that US Government foreign assistance funds are earmarked to support effective and scientifically based program evaluation that measures the effectiveness of programs that address maternal, neonatal, and child health in developing populations. 

APHA calls on public health professionals and international organizations to

1. Encourage and provide technical assistance to government health systems to prioritize national financing, policy development, policy research, and preventive health programming for maternal, neonatal, and child health in the most vulnerable populations in developing countries with high rates of mortality among mothers, newborns, and children;
2. Promote and support the establishment of vital health statistics systems that identify maternal-related, neonatal, and child deaths in developing countries with high rates of mortality among mothers, newborns, and children;
3. Support the development and testing of reliable methods to identify deaths and advocate for reporting mandates in order to ensure improved reporting of maternal and neonatal deaths; 
4. Support the development of maternal and neonatal mortality review committees at country and local levels in developing countries with high rates of mortality among mothers, newborns, and children; 
5. Promote and support programs to scale up effective interventions in developing countries for preventing mother-to-child transmission of HIV/AIDS; 
6. Promote and support efforts to increase the professional and cultural competencies of health providers as skilled maternity, neonatal, and child care providers in developing countries with high rates of mortality among mothers, newborns, and children;
7. Support provision of supplies and equipment for emergency obstetrical and neonatal care, child spacing, and prevention and treatment of mother-to-child transmission of HIV/AIDS, malaria, and anemia in pregnant and lactating women, newborns, and children in developing countries with high rates of mortality among mothers, newborns, and children;
8. Support more intensive promotion of breastfeeding, including measures to dissuade the promotion and use of breastmilk substitutes; and
9. Promote and support the development, testing, implementation and scaleup of effective community-based strategies linked to health systems for community education and the promotion of home-based maternal, neonatal, and child health, including child spacing, home identification of danger signs, and early care seeking for prevention and treatment of childbearing women, newborns, and children in developing countries with high rates of mortality among mothers, newborns, and children.

References

1. United Nations. The Millenium Development Goals Report 2010. Available at: http://www.un.org/millenniumgoals/pdf/MDG%20Report%202010%20En%20r15%20-low%20res%2020100615%20-.pdf. Accessed February 9, 2011.
2. Khan KS, Wojdyla D, Say L, Gülmezoglu AM, Van Look PF. WHO analysis of causes of maternal death: a systematic review. Lancet. 2006;367(9516):1066–1074.
3. Grange J, Adhikari M, Ahmed Y, et al. Tuberculosis in association with HIV/AIDS emerges as a major non-obstetric cause of maternal mortality in Sub-Saharan Africa. Int J Gynecol Obstet. 2010;108:181–183.
4. World Health Organization. Maternal mortality. Fact sheet No. 348. November 2010. Available at: http://www.who.int/mediacentre/factsheets/fs348/en/index.html. Accessed February 9, 2011.
5. United Nations Fund for Population Activities (UNFPA). Maternal morbidity: surviving childbirth, but enduring chronic ill-health. Available at: http://www.unfpa.org/public/mothers/pid/4388. Accessed February 9, 2011.
6. Child Health Epidemiology Reference Group (CHERG). Incidence and sequelae of maternal morbidity. Available at: http://cherg.org/projects/maternal_morbidity.html. Accessed February 9, 2011.
7. Souza JP, Cecatti JG, Faundes A, et al. Maternal near miss and maternal death in the World Health Organization’s 2005 global survey on maternal and perinatal health. Bull World Health Organ. 2010;88(2):113–119. 
8. Campbell OM, Graham WJ, on behalf of Lancet Maternal Survival Series steering group. Strategies for reducing maternal mortality: getting on with what works. Lancet. 2006;368:1284–1299. 
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13. American Public Health Association. APHA Policy Statement 200714: A Call to Action on Breastfeeding: A Fundamental Public Health Issue. Available at: http://www.apha.org/advocacy/policy/policysearch/default.htm?id=1360. Accessed February 9, 2011.
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21. Froen JF, Cacciatore J, McClure EM, et al. Stillbirths: why they matter. Lancet. 2011;377(9774):1353–1366.
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26. Partnership for Maternal, Neonatal and Child Health. PMNCH vision and mission. Available at: http://www.who.int/pmnch/about/vision/en/index.html. Accessed February 9, 2011.
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28. Partnership for Maternal, Neonatal and Child Health. PMNCH partners’ forum: from pledges to action. Available at: http://www.who.int/pmnch/events/2010/20101113_14_pmnch_governance/en/index.html. Accessed February 9, 2011.
29. The Global Fund to Fight AIDS, Tuberculosis and Malaria. Decision Point GF/B22/DPxx. December 14, 2010. Available at:http://maternalhealthtaskforce.org/components/com_wpmu/wp-content/uploads/blogs.dir/1/files/2010/12/Global-Fund-MNCH-Decision-Point-14-Dec.pdf. Accessed February 9, 2011.
30. The Global Health Initiative. The plan: partnering With Countries for Better Health . Available at: http://www.pepfar.gov/ghi/index.htm. Accessed February 9, 2011.
31. Nyamtema AS, Urassa DP, van Roosmalen J. Maternal health interventions in resource limited countries: a systematic review of packages, impacts and factors for change. BMC Pregnancy Childbirth. 2011;11:30.
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33. Global Visions. US Maternal Health Donors: A Landscape Analysis. Prepared for the New York, NY: EngenderHealth–Maternal Health Task Force; April 2011. 
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