More Needs To Be Done To Improve Maternal Health and Reduce Child Mortality

The Millennium Development Goals 4 and 5 envisage reducing child mortality by 33% and maternal mortality ratio by 75%, between 1990 and 2015. But going by the latest study, “Progress toward Millennium Development Goals 4 and 5 on maternal and child mortality: an updated systematic analysis,” published in The Lancet, this seems to be a far cry. Recent trends show that very few countries are going to achieve the international targets for improving maternal and child health. In fact, only 9 out of 137 developing countries -- China, Egypt, Iran, Libya, Maldives, Mongolia, Peru, Syria, and Tunisia-- will achieve both the goals by the deadline of 2015, while 5 other countries Bhutan, El Salvador, Morocco, Oman, and Turkey are likely to achieve them by 2020.

An updated analysis by the Institute for Health Metrics and Evaluation (IHME) at the University of Washington shows that more than half the countries around the world, including China, India, and some countries of sub-Saharan Africa (Kenya, Swaziland, Zimbabwe, and Botswana),  have accelerated their efforts to save the lives of mothers and children.  28•6% of the decline in maternal deaths during 2005—2011 was in India, whereas Ethiopia, Pakistan, Nigeria, Indonesia, China, and Afghanistan together accounted for a further 32•1% of the decline. It is heartening to note that India ranks 1st in child mortality deaths in 2011.  But it ranks 22nd in annualized rate of decline in maternal mortality from 1990 to 2011 at 4.9%, with Maldives topping the list at 9.6%.

Likewise, several countries in east and southern Africa have had substantial declines in HIV-related deaths during pregnancy because of the expansion of anti retroviral drug programmes. It is estimated that during the next four years, 31 developing countries will achieve Millennium Development Goal 4 (with another 11 countries achieving the target by 2020) and 13 developing countries will achieve Millennium Development Goal 5 (15 more countries will achieve the goal by 2025).

Over the past decade, many countries, including Kenya, Morocco, Zambia, and Zimbabwe, saw declines of more than 8% annually in maternal mortality, which is twice the global rate. Afghanistan, which has one of the worst maternal death rates in the world, has seen a 4.9% annual decline in maternal mortality since 2000, after increasing 2.2% annually over the previous decade. Also, in Cambodia, Ecuador, Rwanda, Malaysia, and Vietnam, child mortality fell by 5% or more annually, which again is nearly twice the global rate of 2.6%.

Maternal mortality has declined faster in 125 countries, and child mortality rates have declined faster in 106 countries between 2000 and 2011 than in the previous decade. The number of deaths related to pregnancy and childbirth decreased from 409,100 in 1990 to an estimated 273,500 deaths (56 100 of these were HIV related deaths during pregnancy) in 2011. At the same time, the number of deaths in children under the age of 5 fell from 11.6 million deaths to an estimated 7.2 million over the same period.  However, even as the mortality rate in children under 5 fell by 2.2% annually, the mortality rate for infants during the first week of life declined by only 1.7% annually. 

“The difference between neonatal mortality and overall mortality in children under 5 might seem small to someone outside of global health, but it’s worrisome because it can be a sign of other problems in the health system,” said Dr. Haidong Wang, Assistant Professor of Global Health at IHME and one of the paper’s co-authors. “If countries can’t make sure that children survive during that first week, they may not be effectively providing prenatal care to mothers, good obstetrical care during the birth, or important follow-up care.”

Although the target for MDG 4 was set lower than for MDG 5, most countries have made faster progress in reducing child mortality compared with maternal mortality. There is substantial variation in the rate of decline in the maternal mortality ratio and the decline in under-5 mortality. For countries with a pace of decline in the maternal mortality ratio between 1% and 3% per year, decline in under-5 mortality ranges from under 1% to over 7% per year. For countries with declines in under-5 mortality at or near the MDG 4 pace, the rate of change in maternal mortality ranges from increases in Liberia to decreases over 9% per year in Maldives.  This weak correlation between progress on maternal mortality and under-5 mortality highlights that different factors influence success for each.

The researchers feel that the decline in maternal mortality in much of sub-Saharan Africa is partly due to improved prevention and treatment efforts for HIV/AIDS. Other key drivers for the mortality declines are efforts to educate more women,  prevent infectious diseases, targeted global health programs, such as the scale-up of insecticide-treated bed nets in malaria high burden countries, and country-level programs, such as the Government of India’s ongoing investment in rural health clinics. Educational attainment among women of reproductive age has been a key factor and accounted for 51% of the decline in child mortality.

Still many aspects of health systems limit the scale-up of child and maternal interventions--bottlenecks in the health workforce, health system infrastructure, health information systems, supply chain logistics, and managerial capacity. Some intervention strategies for children, such as immunisations, distribution of insecticide-treated bed -nets, vitamin A supplementation, and de-worming can be delivered even without a fully functional health system. But progress on reducing maternal mortality is likely to require more concerted efforts to address some key health system bottlenecks. In September, 2010, donors committed $40 billion to save 16 million lives by 2015. However, development assistance for health seems to be growing at a slower pace in recent years. It is not enough to allot resources. Unless resources are well spent, and do not involve large scale bungling (India’s National Rural Health Mission scheme is under the scanner), we cannot hope for faster progress.

“If the world is going to achieve these goals, we need to see immediate, concerted action on the part of governments, donors, and bilateral agencies to move these trends in the right direction,” said Dr. Rafael Lozano, Professor of Global Health at IHME and the paper’s lead author. “We know that accelerated progress is possible because we are seeing it already.”


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