Knowledge summary 1 - Understand the burden
Women and children are essential to socio-economic progress around the world. Yet they also suffer from some of the greatest inequities and vulnerabilities in terms of the burden of preventable ill-health. Pregnancy and childbirth can be unique and joyous experiences. However, they are also times of stress, as health risks and economic and social issues combine to make a woman and her newborn susceptible to illness and death. From adolescence, through pregnancy, childbirth and motherhood, all these factors impact on a woman and her child’s health. The choices she can make for herself and her child to promote well-being and to access healthcare as and when needed, make a fundamental difference to current and future generations across the developing world.
Numbers alone do not tell the entire story. But the estimates are overwhelming. In 2008 alone:
- 358,000 maternal deaths1
- 8.1 million deaths among newborns and children under five2,3
- 22 million unsafe abortions4,5
And another stark fact: the vast majority of the burden borne by women, adolescent girls, newborns and children occurs among the poorest and most vulnerable individuals and is concentrated in sub-Saharan Africa and South Asia.
However, concerted global efforts are now being made to change this.With renewed pledges and financial commitments, between 2011 and 2015, the world aims to:
- prevent 740,000 women dying from pregnancy-related causes, including unsafe abortion
- prevent 15 million deaths among newborns and children under five
- protect 88 million children under five from stunting and 120 million from pneumonia
- prevent 33 million unintended pregnancies.
Where do we stand now?
The UN Millennium Development Goals (MDGs) 4 and 5 gave impetus to efforts to address many of the inequities that have been entrenched in countries and their health systems. Concerted efforts globally have helped to advance reproductive, maternal, newborn and child health. However, there is a long way to go before the goals are reached. Inequities persist, despite progress (see Knowledge Summary 9).
Reproductive health: slowdown in progress over the last ten years
About 200 million women would like to delay or stop childbearing, but are not using contraception.There is clearly an unmet need, and addressing this through family planning would, together with maternal and newborn services, reduce unintended pregnancies by two-thirds, maternal deaths by 70% and newborn deaths by 44%.6
Fig 1 - The unequal world of family planning
Progress in uptake of contraceptives has slowed since 2000, largely due to inadequate funding for supplies and lack of access, while differences in contraceptive prevalence have widened. Sub-Saharan Africa has the lowest prevalence and highest unmet need: one in four women of reproductive age who would like to use a contraceptive cannot obtain one (see Figure 1).
Teenage pregnancy rates continue to be high, with sub- Saharan Africa recording the highest birth rates in this age group (15 to 19), followed by Latin America.The poorest families, and those with little education, account for the lowest use of contraception and highest number of teenage pregnancies.7 In sub-Saharan Africa, a poor teenager is three times more likely to get pregnant and give birth than a teenager from a rich family (see Figure 2a).
Fig. 2a - Teenage pregnancy; Fig 2b - Contraceptive use
Unsafe abortions rates have declined in some regions, but continue to be high in parts of Africa and South America.8
Maternal health: slow progress towards MDG 5
Estimates show that the maternal mortality ratio (MMR) for 2008 was 260 deaths per 100,000 live births.9 Nearly 99% of the estimated 358,000 maternal deaths were in developing countries, and most of these deaths (65%) were concentrated in 11 countries. Forty-five countries had a fairly high MMR (300 or more deaths per 100,000 live births) and Afghanistan, Chad, Guinea-Bissau and Somalia had extremely high MMRs (1,000 or more deaths per 100,000 live births). The adult lifetime risk of maternal death was the highest in sub-Saharan Africa (1 in 31).
Globally, the number of maternal deaths has declined, with a 34% decrease between 1990 and 2008. Reductions have happened across all world regions, with the largest changes happening in East Asia (63% reduction). However, this reduction masks the high risks that many women face within the poorest countries. Moreover, the progress is insufficient to achieve MDG 5.The average annual decline in MMR was 2.3% between 1990 and 2008, instead of the required rate of 5.5% per year.
Fig 3 - Maternal mortality ratio across countries
More than half the maternal deaths in developing countries are due to heavy bleeding after childbirth, and hypertension. Obstructed labor and other complications at childbirth are responsible for 11% of the deaths, while indirect causes such as malaria and HIV/AIDS cause 18% of the deaths overall, although in some countries this proportion is much higher. Most of these deaths can be prevented if the woman receives the appropriate interventions from a skilled health worker, and with adequate equipment, drugs and medicines (see Knowledge Summaries 5 and 6).
Newborn and child health: progress, but not enough to meet MDG 4
Mortality rates for under-fives dropped by 28% between 1990 and 2008. Some poor countries such as Bangladesh, Bolivia, Malawi and others have been able to reduce mortality for under-fives. 67 countries continue to have rates of 40 or more under-five deaths per 1000 live births, and only 10 countries are on track to achieve MDG 4.
Despite progress, most of these deaths continue to happen in sub-Saharan Africa (see Figure 4).
Fig 4 - Under-five mortality rates
Newborn mortality accounts for a large proportion of child deaths: more than 40% of the under-five deaths in 2008 were among newborns. Newborn mortality is high in the same regions where maternal mortality is high (see Figure 5), which highlights the potential to improve outcomes for both women and children – particularly through timely and effective care at childbirth. Stillbirths are not part of the MDGs and hence have received less attention. An estimated 3.3 million stillbirths globally were reported for 2000, with 99% occurring in developing countries. A third of these happened during childbirth, mainly due to maternal conditions such as hypertension, obstructed labor, etc. but also partly reflecting poor quality of care in the management of these problems (see Knowledge Summary 7). However, better data and research are still needed to develop effective policies.10
Fig 5 - Newborn mortality rate
Pneumonia, diarrhea and malaria were the lead killers, accounting for 43% of under-five deaths in 2008 (see Figure 6). On the other hand, vaccine-preventable diseases have declined owing to improvements in routine immunization coverage in the last ten years. For example, measles-related deaths reduced by 78% between 1990 and 2008, as coverage of measles immunization increased (81% in 2008).11
Undernutrition contributes to one-third of the under-fives deaths. Children under two are most vulnerable, and stunted growth is largely irreversible after that age. In adult life, poor nourishment and short stature in mothers can increase the risk of low birth weight in babies, which in turn raises the risk of death in newborns. Although the global prevalence of underweight children has reduced between 1990 (31% prevalence) and 2008 (26% prevalence), sub-Saharan Africa and South Asia have not made much progress. Children from poorer and rural families are more likely to be underweight. Figures show that even in countries that have a low prevalence of underweight children, stunting is still a problem. For example, Peru has an underweight prevalence of just 6% but a stunting prevalence of 30%.12
Fig 7 - Proportion of children under 5 years who are underweight
Early initiation of breastfeeding reduces newborn deaths by 20%. However, less than 50% of newborns in developing countries are breastfed within one hour of birth. Many countries have improved rates of exclusive breastfeeding until six months, but the average rate is still less than 35%.13
Conclusion
Women, newborns and children in many parts of sub-Saharan Africa and South Asia continue to be the most vulnerable in the world. Some poor countries have, however, made progress toward achieving MDG 4 and 5, as can be seen in Figure 8, and provide a stimulus for accelerated action. Lessons from their successes can offer pointers to how progress can be achieved elsewhere. Improved health and survival can be extended to all women and children.
Fig 8 - Progress on the MDGs 4 and 5
References
1 WHO (2010). “Trends in maternal mortality 1990 – 2008.” (PDF). http://whqlibdoc.who.int/publications/2010/9789241500265_eng.pdf
2 WHO (2010). “Global Health Indicators – Part 2.” (PDF). www.who.int/entity/whosis/whostat/EN_WHS10_Part2.pdf
3 UN (2010). “Millennium Development Goals Report 2010.” (PDF). www.un.org/en/mdg/summit2010/pdf/MDG%20Report%202010%20En%20r15%20-low%20res%2020100615%20-.pdf
4 UNFPA (2010). “How universal is access to reproductive health? A review of evidence.” (PDF). www.unfpa.org/webdav/site/global/shared/documents/publications/2010/universal_rh.pdf
5 WHO (2010). “Unsafe abortion in 2008.” www.who.int/reproductivehealth/topics/unsafe_abortion/poster_unsafe_abortion.pdf
6 UNFPA and Guttamacher Institute (2010). “Adding it up:The Benefits of Investing in Sexual and Reproductive Health Care.” (PDF). www.unfpa.org/upload/lib_pub_file/240_filename_addingitup.pdf
7 UN (2010). “Millennium Development Goals Report 2010.” (PDF). www.un.org/en/mdg/summit2010/pdf/MDG%20Report%202010%20En%20r15%20-low%20res%2020100615%20-.pdf
8 WHO (2010). “Unsafe abortion in 2008.” www.who.int/reproductivehealth/topics/unsafe_abortion/poster_unsafe_abortion.pdf
9 WHO (2010). “Trends in maternal mortality 1990 – 2008.” (PDF). http://whqlibdoc.who.int/publications/2010/9789241500265_eng.pdf
10 Lawn JE, et al (2010). “Global report on preterm birth and stillbirth (1 of 7): definitions, description of the burden and opportunities to improve data.” BMC Pregnancy and Childbirth 2010, 10(Suppl 1):S1 www.biomedcentral.com/content/pdf/1471-2393-10-S1-S1.pdf
11 “Millennium Development Goals Report 2010.” (PDF). www.un.org/en/mdg/summit2010/pdf/MDG%20Report%202010%20En%20r15%20-low%20res%2020100615%20-.pdf
12 UNICEF (2010). “Progress for Children: Achieving the MDGs with Equity.” www.unicef.org/publications/index_55740.html
13 “Countdown to 2015 Decade Report (2000-2010):Taking stock of maternal, newborn and child survival.”
www.Countdown2015mnch.org/documents/2010report/CountdownReportAndProfiles.pdf
