Women, newborns, children, and adolescents: life-saving momentum after a slow start
The situation in 2007: dire prospects for progress
In 2007, WHO, UNICEF and the UN Population Fund issued new country-specific estimates for maternal mortality. Though 22 years had passed, the “neglected tragedy” looked no better than in 1985. The estimated number of maternal deaths stubbornly stood at 536 000 worldwide, with developing countries accounting for 99% of those deaths. In sub-Saharan Africa, around 900 women died during pregnancy and childbirth per 100 000 live births. In wealthy countries, that figure dropped 100-fold to just 9. The statistics were the starkest in all of public health. For example, the adult lifetime risk of dying during pregnancy and childbirth in Niger was 1 in 7. In Ireland, it was 1 in 48 000.
As the new estimates showed, maternal mortality had decreased at an average of less than 1% annually between 1990 and 2005, far below the 5.5% decline needed to achieve the fifth MDG. The decline in sub-Saharan Africa was the lowest, estimated at 0.1%.
The news for child mortality was better, but just barely. In 2006, the annual number of children dying before their fifth birthday fell to 9.7 million, marking the first time that yearly childhood deaths dropped below 10 million since records began. Though the slight decline was welcome, the millions and millions of deaths from largely preventable causes looked outrageous six years into the MDG era.
On its part, WHO recommended a life-course approach to the health of both women and children, ranked the leading causes of morbidity and mortality, and identified the interventions that were likely to have the biggest life-saving impact. WHO developed norms, tools, clinical standards, protocols and guidelines in areas ranging from antenatal care and the management of sexually transmitted infections, to the treatment of maternal peripartum infections and a simple colour-coded tool for the detection of anaemia, to human rights and contraception, optimal nutrition for girls and women, and appropriate feeding practices for infants. WHO also made a major effort to improve access to sexual and reproductive health services offering a wide choice of modern family planning options, and issued safe abortion guidance for use in countries where abortions are legally permitted.
"Births, deaths, and causes of death were not registered, leaving countries and their partners working in the dark."
Dr Chan, WHO Director-General
But efforts to reduce both maternal and childhood mortality shared two major challenges. First, the quality of country-specific data was abysmal. Some 85 countries, representing 60% of the world population, had no reliable systems for civil registration and vital statistics. Births, deaths, and causes of death were not registered, leaving countries and their partners working in the dark. In 2008, countries with medically certified vital registration accounted for only 4% of the 8.8 million childhood deaths estimated for that year.
Second, efforts to reduce maternal and child mortality had no single commodity, like antiretroviral therapy for HIV, cocktails of inexpensive drugs for tuberculosis, or insecticidal nets for malaria, that could be scaled up to have a dramatic impact on morbidity and mortality. Widely-used childhood vaccines were highly effective in protecting children from leading infectious killers, averting up to 3 million deaths each year, but that still left nearly 9 million yearly deaths occurring from largely preventable causes. As WHO argued, maternal and childhood deaths would not go down until access to quality health services improved. For maternal health, evidence was mounting that even the vastly improved access to services that followed the elimination of user fees would have little impact on deaths and “near misses” in the absence of high-quality standards of care.
Everyone agreed that, as economies grew and living conditions improved, many of the conditions – like undernutrition and especially anaemia, poor water supply and little sanitation, dirty environments, and dirty indoor air – that made women and children so vulnerable to early death would gradually get better. But that would take decades. No one wanted to wait.
In line with the culture of measurement and accountability that drove the MDG era, those dismal figures halfway to the 2015 deadline provoked the international community to take aggressive action on multiple fronts. Several new partnerships, initiatives and strategies were launched and operational by 2010. The results over the next five years would be dramatic.