With only six years to go before the 2015 deadline to achieve the Millennium Development Goals (MDGs) to reduce child mortality and improve maternal health, some countries have made encouraging progress, while many have stagnated, or worse, slipped backwards since the Millennium Declaration was adopted in 2000.
Although the greater picture of overwhelming challenge remains, there are many glimmers of hope around the world. Communities across Africa and Asia have involved both families and caregivers in formulating solutions to their local challenges. They have succeeded in making essential care available to many, if not all, mothers and newborns. Governments have pledged money and other resources, while international aid organizations have developed programmes with local groups to drive change from the ground up.
Magnitude of the problem
Despite current programmes to improve the health of mothers and newborn babies, most recent figures show that one woman dies every minute due to pregnancy, childbirth or soon after giving childbirth. The figure is so staggering that seven newborns die each minute. The main causes of maternal deaths are severe bleeding, eclampsia, infections and obstructed labour. Just three causes—infection, asphyxia and preterm birth—together account for nearly 80 per cent of newborn deaths.
The “Countdown to 2015”, a multi-partner initiative to track progress towards MDGs 4 (to reduce child mortality) and 5 (improve maternal health), estimated in its 2008 report that 68 countries worldwide account for 97 per cent of maternal and newborn deaths. The report focused on the coverage of essential interventions for maternal, newborn and child health. Annually, maternal deaths are estimated at 536,000 and some 3.7 million babies die within the first 28 days of life, while at least 3.3 million are stillborn. Almost all (98 per cent) of these deaths occur in developing countries, with rates highest in sub-Saharan Africa and in South-East Asia.
In addition to the women who die as a result of pregnancy or childbirth, about 10 million to 20 million worldwide are left each year with physical and mental disabilities. Furthermore, millions of newborns who survive fail to reach their full potential due to complications during birth and the early newborn period.
A joint statement issued in September 2008 by the World Health Organization (WHO), the United Nations Children’s Fund (UNICEF), the United Nations Population Fund and the World Bank stated that “maternal mortality has root causes in gender inequality, limited access to education—especially for girls, early marriage, adolescent pregnancy, low access to sexual and reproductive health (including for adolescents) and other social determinants”.
Although there has been some improvement in the global maternal mortality ratio since 1990, progress is limited and too slow. An annual decline of 5.5 per cent in maternal mortality is required to reach MDG 5 by 2015; the actual average annual rate of decline is less than 1 per cent. Sub-Saharan Africa remains the most dangerous region in the world in which to give birth, with a negligible annual decrease in maternal and newborn deaths. Newborn deaths and stillbirths are strongly related to the availability and quality of care provided to mothers—and unless maternal health improves, there is little chance of progress in the health of newborn babies.
Adolescent pregnancy poses a particular challenge. About 16 million girls aged 15 to 19 give birth every year. Worldwide, one in ten babies is born to an adolescent mother. These infants and their mothers need special protection since they are at a higher risk of disease and death, as well as social exclusion. Almost 95 per cent of adolescent mothers live in developing countries, with the highest levels of adolescent pregnancy in sub-Saharan Africa, where every second a woman gives birth to a child before her 20th birthday. There are also high rates in Asian countries like Bangladesh and India, in Latin America and the Caribbean and in the United States.
In general, early pregnancies mean an increased risk to the life of the mother and her baby. In many countries the risk of death in pregnancy or childbirth is twice as high for mothers aged 15 to 19 compared to mothers in their twenties, and the situation is even worse for girls under 15. Babies of adolescent mothers are also more likely to die. Stillbirth and death in the first week of life are 50 per cent higher among babies born to women under the age of 20 than to older mothers. Moreover, many girls who become pregnant end their schooling, limiting their potential for themselves as well as their families.
It is possible to reduce maternal and newborn mortality
There are many reasons to be optimistic about the possibility of reducing maternal and newborn mortality. Some recent key advances include: the discovery of magnesium sulphate for treating eclampsia and severe pre-eclampsia; the ability to control heavy bleeding after birth through active management of the third stage of labour; care for infections with antibiotics; post-abortion care using manual vacuum aspiration by trained nurses and midwives; treatment of malaria and HIV in pregnancy and prevention of mother-to-child transmission of HIV; quality antenatal care; maternal death reviews as a means for improving quality of care; and an improved range of methods to measure progress.
Two thirds of newborn deaths could be prevented if all mothers and newborns had access to essential interventions that are well-known, feasible and deliverable without complex technology. These include tetanus immunization as part of antenatal care, skilled care during childbirth, early and exclusive breastfeeding, keeping the baby warm and timely management of life-threatening newborn conditions.
Actions to improve maternal and newborn health must be guided by what we call the “continuum of care”. This term has two meanings. Firstly, it means that care is provided continuously over different life stages—beginning at the time of adolescence and pre-pregnancy, through pregnancy and birth, and into the newborn period. Secondly, it also refers to the continuum of care that must be provided at all levels of the health system—in the home and community health centre and hospital.
Some developing countries, including Egypt, Honduras, Malaysia, Sri Lanka and Thailand, have dramatically reduced maternal mortality since 1987. They rapidly increased the access of a skilled attendant to childbirth and, when required, timely emergency obstetric care. They recognized that provision of services for mothers and newborns are at the centre of a strong health care system, and the resulting reduction in maternal and newborn mortality is a measure of the success of that health system.
Four priority actions
We propose four priority actions for improving the health of mothers and newborns that will contribute to the achievement of MDGs 4 and 5, as well as MDG 6 (combat HIV/AIDS, malaria and other diseases):
(1) access to family planning services;
(2) skilled care during pregnancy and childbirth, including access to emergency obstetric and newborn care;
(3) essential care for mothers and newborns in the days following birth;
(4) prevention and management of HIV and malaria in pregnancy and following birth.
1. Access to family planning services
By far, the most important way of reducing maternal deaths is simply by reducing the number of pregnancies. Family planning is a critical element for improving maternal and child health. Studies have shown that family planning has immediate benefits for the lives and health of mothers and their infants. Ensuring basic access to contraception could reduce maternal deaths by one third and child deaths by as much as 20 per cent.
While contraceptive use has grown enormously since it became available in the 1960s, there is still a significant need for family planning services, in particular among adolescents. A recent study of married women in 53 countries found that the unmet need for contraceptives was highest among women aged 15 to 24 years. Some 4 million adolescents become pregnant unintentionally every year; however, the majority of adolescent mothers are married and most of their babies are wanted. In the developing world, about 90 per cent of births to adolescents occur in marriage.
In addition to making pregnancy and delivery safer, it is essential to reduce the number of unintended pregnancies through access to contraception. Family planning improves maternal health and reduces maternal mortality in several ways:
Effective use of contraception reduces the number of unintended and unwanted pregnancies;
At the individual level, family planning reduces the number of times a woman becomes pregnant and prolongs birth spacing, thus reducing her overall risk of death;
At the national level, family planning reduces the number of pregnancies and births; and
Family planning can be targeted to reduce the number of pregnancies to women in groups at increased risk of maternal death.
