At the midpoint of the 15-year timetable for achieving the Millennium Development Goals, the majority of countries with high levels of maternal and child mortality are not on track to meet the targets for reductions in these outcomes by 2015, according to a recent analysis.1 Among the 68 countries that account for the vast majority of maternal and child deaths, only 16 are on track to reduce mortality among children younger than five to one-third of its 1990 level (Goal 4). Progress toward reducing maternal mortality by three-quarters (Goal 5) has been slow as well: In all 41 Sub-Saharan African countries included in the analysis, at least 300 maternal deaths occur per 100,000 live births.
The research was conducted by Countdown to 2015, a collaboration of researchers, policymakers and other stakeholders that has been tracking progress toward the Millennium Development Goals in the 68 countries in which 97% of deaths among women of childbearing age and children younger than five occur. Researchers focused on determining coverage rates (the proportion of individuals in each country who need a service and are able to obtain it) for interventions that have been proven to avert maternal, newborn and child deaths, that can be widely implemented in resource-poor countries, and whose levels can be reliably estimated across countries and over time; these interventions include provision of contraceptive and STI services, skilled care during childbirth, and pre- and postnatal care. Most of the data were obtained through nationally representative household surveys.
When possible, the investigators examined trends in coverage since 2000. Because data on maternal mortality were often too imprecise to allow trends to be tracked, the investigators simply classified each country's 2005 rate as very high (≥550 deaths per 100,000 live births), high (300–549 per 100,000), moderate (100–299 per 100,000) or low (<100 per 100,000). In no country were data available for every measure and intervention type.
Analyses revealed that most of the 68 Countdown countries have not made adequate progress in reducing child and maternal mortality. Only 16 countries have reduced the rate of death among children younger than five sufficiently to be considered on track for meeting Millennium Development Goal 4. Three of these countries, including China, have reached the necessary rate of reduction since the last Countdown report in 2005. Sub-Saharan African countries accounted for more than half of child deaths worldwide and, with the exception of Eritrea, are not on track to achieve Goal 4.
The maternal mortality statistics in Sub-Saharan Africa were similarly grim: Ratios were high or very high in all 41 countries, and the region accounted for 50% of maternal deaths worldwide (most of the remaining deaths occurred in south Asia). Of the 10 countries with the highest maternal mortality ratios, nine were in Sub-Saharan Africa, including Sierra Leone, which—with a maternal mortality ratio of 2,100 per 100,000 live births—ranked last among the 68 countries.
Progress toward increasing the coverage of maternal, newborn and child health interventions and approaches was uneven across and within the Countdown countries. In countries where intervention coverage had been assessed at least twice between 2000 and 2006, the proportion of women aged 15–49 who had received contraceptive services or skilled delivery care increased by an average of two percentage points per three years; the proportion of pregnant women who had had at least one prenatal visit with a skilled provider increased by four percentage points per three years. Coverage was higher for interventions that could be scheduled in advance, such as prenatal care services (which were available, on average, to more than 80% of the population in the 68 countries), than for services requiring 24-hour access to trained personnel, such as care for the mother and child immediately after delivery and management of childhood illness. Average coverage levels for the latter services were less than 60%; levels were only about 30% for promotion of exclusive breastfeeding and for contraceptive prevalence. Moreover, services that ideally would have been integrated—for example, routine prenatal care, prevention of mother-to-child transmission of HIV and malaria treatment during pregnancy—were not combined; some of these interventions had very limited coverage or were not offered at all.
Although such gaps in coverage constitute a major challenge for the 68 Countdown countries and for donor organizations, the researchers acknowledge that their analysis presents only a partial picture of progress (or lack thereof) toward Goals 4 and 5. Many data were not available, were outdated or involved measures that did not allow comparisons. Moreover, stillbirths are often not counted in infant mortality rates. Better systems are needed to collect the data required to support sound decisions at national and local levels, the researchers emphasize.
Despite the low levels of coverage for maternal and child health interventions in most Countdown countries, the investigators believe that "many of the necessary ingredients are in place to accelerate progress towards achievement of the health-related [Millennium Development Goals]." These include consensus on which interventions should be prioritized and the presence of programs to carry them out. Improving the survival rates for women, newborns and children will depend in large part on strengthening those programs by increasing 24-hour access to services and establishing "a functional continuum of care that encompasses women before pregnancy, pregnancy, childbirth, the postnatal period, and the first 24 months of a child's life."—H. Ball
1. Countdown Coverage Writing Group, Countdown to 2015 for maternal, newborn, and child survival: the 2008 report on tracking coverage of interventions, Lancet, 2008, 371(9620):1247–1258.