Keep the promise for mothers and children: an agenda to improve maternal and child health.

Despite the concerted efforts of many players, global progress in child survival has slowed compared to the advances of previous decades. Maternal mortality--deaths of women in pregnancy and childbirth--remains at almost the same level as 20 years ago. Halfway to 2015, the target set in 2000 by world leaders to reach the Millennium Development Goals (MDGs) 4 and 5 on child and maternal health are furthest off track. (1)

Figures paint a stark picture. As of 2005, only 7 out of 60 countries with high child mortality rates were making sufficient progress to reach MDG 4. (2) Almost 10 million children under five years old still die every year, with 40 per cent of them newborns--infants in their first 28 days of life. Until recently, newborn health was often overlooked by health decision makers, who have devoted too little attention or funding to this grave problem. The MDG 4 target is to reduce under-five mortality by two thirds, while MDG 5 is to reduce the maternal mortality ratios by 75 per cent, between 1990 and 2015.

In 2007, leading institutions on maternal health concluded that progress for the achievement of MDG 5 was too slow. There was a minimal change in the global number of women dying in pregnancy and childbirth between 1990 (576,000) and 2005 (536,000). As a result, the world has yielded a decline of less than 1 per cent in maternal mortality ratios, when the required rate to achieve this goal was 5.5 per cent. (3,4) The gravest concern is in sub-Saharan Africa, where the number of maternal deaths has even increased since 1990.

Why does the world seem to stand by idly and accept a 200-fold gap in the lifetime risk that a pregnant woman in a developing country faces compared with a woman in a developed country? And why does the world seem not to notice that almost 10 million children die every year from largely preventable causes? The answer is both obvious and complex. For decades, the health of mothers, newborns and children has ranked low on the global health and development agenda; they have also not been a high priority for political leaders. This has created a vicious cycle of low investment in health services, both in the workforce and in infrastructure, resulting in poor coverage for essential, life-saving care, such as skilled attendance at childbirth for women, protection for newborns and treatment for diarrhoeal diseases and pneumonia for under-fives.

The lack of investment in health services for women and children is all the more indefensible in a twenty-first century world, which possesses incredible wealth. In 2000, when the MDGs were adopted, global economic output was already $31 trillion. (5) Yet every year developing countries are unable to access the $9 billion in additional funding needed to deliver basic maternal, newborn and child health care. (6) As a result of this shortfall, about 70 million mothers, newborns and children have died since 2000, virtually all in poor nations.

The reality is that MDG 4 is achievable--and so is MDG 5. A number of countries have already demonstrated their ability to reduce maternal deaths by an average 75 per cent. (7) Thailand reduced its maternal mortality ratio by 87.5 per cent between 1960 and 1982. Malaysia and Sri Lanka have also seen reductions of more than 50 per cent during the same period.

Based on global evidence and country experiences, there are four key steps we can undertake today, which could save up to 50 million lives between now and 2015.

Country leaders and policy decision makers must make maternal, newborn and child health a real political priority. Pregnancy is not a disease, and women should not die in the hundreds of thousands to give life. Access to decent health care is a basic human right that women and mothers should enjoy, as should their newborns and children.

Women play an essential role in their homes and communities, as well as in the global economy. They lead 25 to 33 per cent of all households as sole income earners. (8) When we fail to save their lives, we are not only leaving families and communities with tragic and irreplaceable losses, but also missing an enormous opportunity for human development. It has been estimated that maternal and newborn deaths cost $15 billion per year in lost productivity, of which half is associated with women themselves, the other half with their newborns. (9) As a result, every politician and leader must be held accountable for empowering women and their families to enjoy this fundamental right to life and health.

All health-care providers should be involved and empowered to play their parts. While investing in basic health systems, we need to also utilize a hidden potential of health-care providers, many of whom are women and mothers themselves. Globally, 70 per cent of nurses are female. (10) Being on the front line and witnessing real tragedies first-hand, health workers--doctors, nurses and midwives--demonstrate an indisputable potential to be part of the solution to deliver the services, and in determining what is needed as a priority and how this can be implemented. They can make a great impact by exerting pressure and demanding change in the ways maternal, newborn and child health care are provided through existing global and national organizations of healthcare professionals. Furthermore, these professionals are increasingly required to adopt effective and practical solutions to the problems faced today.

The international community needs to support "One Health Plan for All". A key cause of the uneven progress in child and maternal health over the past 20 years is the very manner in which international aid for health has been provided to developing countries. Often, donor organizations have focused on specific diseases or interventions, which hampered the adoption of a comprehensive approach aimed at strengthening basic health services. With the launch of the Global Campaign for the Health Millennium Development Goals in September 2007, there are now welcome signs the international community is moving towards a more balanced and harmonized approach to support countries.

In order to achieve all the health goals, we need to ensure that: donor organizations help countries attract additional resources in accordance with their actual health needs and disease burden; countries are supported with more predictable funding to enable them to plan and implement long-term health strategies; and national governments and donors must collaborate within the framework of one health plan, including maternal, newborn and child health. Indeed, availability and affordability of quality basic services for women and children must be seen as key indicators for the effectiveness of a country's health system.

Civil society and communities need to take centre stage in a global movement to achieve the MDGs on maternal and child survival. In many poor and underserved communities, it is the lack of information that contributes to the "taboos" and fatalism around maternal, newborn and child deaths. In the United Republic of Tanzania, for example, less than half (46%) of all women received skilled attendance during childbirth in 2005. (11) In many communities in developing countries, even death during pregnancy or childbirth is regarded as natural. Community and civil society organizations have an important role to play to jointly address this lack of good information to raise awareness of the importance of the issues.

The Partnership for Maternal, Newborn and Child Health (PMNCH) was set up in 2005 to promote advocacy and action for achieving MDGs 4 and 5. All steps mentioned above are part of the Partnerships role that spans across four key strategic pillars: global advocacy; coordination in countries; promoting effective interventions; and monitoring and evaluation. Today, the Partnership unites more than 200 members--UN agencies, donor Governments, developing countries, civil society and health-care professional organizations--committed to improving effective health care for mothers, newborns and children in developing countries.

In November 2007, Masahiko Koumura, Minister of Foreign Affairs of Japan--the host country for the G8 Summit in 2008--announced his country's intention to prioritize the MDGs on global health, including maternal, newborn and child health during its G8 presidency. Many would agree that the attention and commitment of G8 leaders, representing the most powerful nations in the world, could have an enormous and positive impact on this neglected area. We look forward to working with all partners in the months ahead to take advantage of this historic opportunity to improve the survival and well-being of women, newborns and children--our world's most under-served communities. Together, we can--and must--make a difference.

Notes

1. United Nations, The Millennium Development Goals Report 2007 (New York, 2007).

2. PMNCH, Tracking Progress in Child Survival: The 2005 Report (UNICEF, 2005). See (www.pmnch.org).

3. K. Hill et al., "Estimates of maternal mortality worldwide between 1990 and 2005: An assessment of available data", Lancet 370 (2007): 1311-19.

4. WHO, UNICEF, UNFPA and WB, "Maternal Mortality Declining in Middle-income Countries; Women Still Die in Pregnancy and Childbirth in Low-income Countries", Joint News Release 56 (11 October 2007).

5. International Monetary Fund, World Economic Outlook Database (October 2007).

6. WHO, The World Health Report 2005: Make Every Mother and Child Count (2005).

7. Carine Rosnmans et al., Maternal Mortality: Who, when, where, and why, Lancet 368 (2006): 1189-1200.

8. K. Gill, R. Pande and A. Malhotra, Women Deliver for Development, Washington, D.C.: International Center for Research on Women (24 July 2007), 37-41.

9. USAID Congressional Budget Justification FY2002: Program, performance and prospects--The global health pillar, (Washington, D.C.: United States Agency for International Development, 2001).

10. WHO, The World Health Report 2006: Working Together for Health (2005).

11. Tanzania Demographic and Health Survey 2004/05, National Bureau of Statistics, Tanzania (www.nbs.go.tz/DHS/index.htm).

Francisco Songane is Director of the Partnership for Maternal, Newborn and Child Health, hosted by WHO. A former Minister of Health of Mozambique, he is credited for using a partnership approach for averting a disease outbreak during the 2000/2001 floods and for assisting in the launch of a national health strategy. Dr. Songane worked to introduce innovative interventions into the Mozambican health system, including a Hepatitis B vaccine and trials on a candidate malaria vaccine. He served on the Board and the Executive Committee of the CAVI.

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