Unicef 2009 State Of Women & Children Report

THE STATE OF THE WORLD’S CHILDREN 2009 Maternal and Newborn Health unite for children

© United Nations Children’s Fund (UNICEF) United Nations Children’s Fund December 2008 3 United Nations Plaza New York, NY 10017, USA Permission to reproduce any part of this publication Email: pubdoc@unicef.org is required. Please contact: Website: www.unicef.org Division of Communication, UNICEF 3 United Nations Plaza, New York, NY 10017, USA Cover photo: © UNICEF/HQ04-1216/Ami Vitale Tel: (+1-212) 326-7434 Email: nyhqdoc.permit@unicef.org Permission will be freely granted to educational or non-profit organizations. Others will be requested to pay a small fee. Commentaries represent the personal views of the authors and do not necessarily reflect positions of the United Nations Children’s Fund. For any corrigenda found subsequent to printing, please visit our website at <www.unicef.org/publications> For any data updates subsequent to printing, please visit <www.childinfo.org> ISBN: 978-92-806-4318-3 Sales no.: E.09.XX.1

THE STATE OF THE WORLD’S CHILDREN 2009

Acknowledgements This report was made possible with the advice and contributions of many people, both inside and outside UNICEF. Important contributions were received from the following UNICEF field offices: Afghanistan, Bangladesh, Benin, Brazil, Burundi, Central African Republic, Chad, Côte d’Ivoire, Ghana, Guatemala, Haiti, India, Indonesia, Kenya, Lao People’s Democratic Republic, Liberia, Madagascar, Mexico, Morocco, Mozambique, Nepal, Niger, Nigeria, Occupied Palestinian Territory, Pakistan, Peru, Rwanda, Sierra Leone, Sri Lanka, Sudan, Togo, Tunisia and Uganda. Input was also received from UNICEF regional offices and the Innocenti Research Centre. Special thanks to H. M. Queen Rania Al Abdullah of Jordan, the Honourable Vabah Gayflor, Zulfiqar A. Bhutta, Sarah Brown, Jennifer Harris Requejo, Joy Lawn, Mario Merialdi, Rosa Maria Nuñez-Urquiza and Cesar G. Victora. EDITORIAL AND RESEARCH PROGRAMME AND POLICY GUIDANCE Patricia Moccia, Editor-in-Chief; David Anthony, Editor; UNICEF Programme Division, the Division of Policy and Chris Brazier; Marilia Di Noia; Hirut Gebre-Egziabher; Practice and Innocenti Research Centre, with particular Emily Goodman; Yasmine Hage; Nelly Ingraham; thanks to Nicholas Alipui, Director, Programme Pamela Knight; Amy Lai; Charlotte Maitre; Meedan Division; Dan Rohrmann, Deputy Director, Programme Mekonnen; Gabrielle Mitchell-Marell; Kristin Division; Maniza Zaman, Deputy Director, Programme Moehlmann; Michelle Risley; Catherine Rutgers; Division; Peter Salama, Associate Director, Health; Karin Shankar; Shobana Shankar; Judith Yemane Jimmy Kolker, Associate Director, HIV and AIDS; Clarissa Brocklehurst, Associate Director, Water, STATISTICAL TABLES Sanitation and Hygiene; Werner Schultink, Associate Tessa Wardlaw, Chief, Strategic Information, Division Director, Nutrition; Touria Barakat; Linda Bartlett; of Policy and Practice; Priscilla Akwara; Danielle Burke; Wivina Belmonte; Robert Cohen; Robert Gass; Asha Xiaodong Cai; Claudia Cappa; Ngagne Diakhate; George; Christine Jaulmes; Grace Kariwiga; Noreen Archana Dwivedi; Friedrich Huebler; Rouslan Karimov; Khan; Patience Kuruneri; Nuné Mangasaryan; Mariana Julia Krasevec; Edilberto Loaiza; Rolf Luyendijk; Nyein Muzzi; Robin Nandy; Shirin Nayernouri; Kayode Nyein Lwin; Maryanne Neill; Holly Newby; Khin Oyegbite; David Parker; Luwei Pearson; Ian Pett; Bolor Wityee Oo; Emily White Johansson; Danzhen You Purevdorj; Melanie Renshaw; Daniel Seymour; Fouzia Shafique; Judith Standley; David Stewart; Abdelmajid PRODUCTION AND DISTRIBUTION Tibouti; Mark Young; Alex Yuster Jaclyn Tierney, Chief, Production and Translation; DESIGN AND PRE-PRESS PRODUCTION Edward Ying, Jr.; Germain Ake; Fanuel Endalew; Eki Kairupan; Farid Rashid; Elias Salem Prographics, Inc. TRANSLATION PRINTING French edition: Marc Chalamet Colorcraft of Virginia, Inc. Spanish edition: Carlos Perellón DEDICATION The State of the World’s Children 2009 is dedicated to Allan Rosenfield, MD, Dean Emeritus, Mailman School of Public Health, Columbia University, who passed away on 12 October 2008. A pioneer in the field of public health, Dr. Rosenfield worked tirelessly to avert maternal deaths and provide care and treatment for women and children affected by HIV and AIDS in resource-poor settings. He lent his energy and intellect to numerous groundbreaking programmes and institutions, and his passion, dedication, courage and commitment to bringing women’s health and human rights to the fore of development remain a source of inspiration. ii

Foreword Niger has the highest lifetime risk of maternal mortality Premature pregnancy and motherhood pose consider- of any country in the world, 1 in 7. The comparable risk able risks to the health of girls. The younger a girl is in the developed world is 1 in 8,000. Since 1990, the base when she becomes pregnant, the greater the health year for the Millennium Development Goals, an estimat- risks for herself and her baby. Maternal deaths related ed 10 million women have died from complications to pregnancy and childbirth are an important cause of related to pregnancy and childbirth, and some 4 million mortality for girls aged 15–19 worldwide, accounting newborns have died each year within the first 28 days of for nearly 70,000 deaths each year. life. Advances in maternal and neonatal health have not matched those of child survival, which registered a 27 Early marriage and pregnancy, HIV and AIDS, sexual per cent reduction in the global under-five mortality violence and other gender-related abuses also increase rate between 1990 and 2007. the risk that adolescent girls will drop out of school. This, The State of the World’s Children in turn, entrenches the vicious 2009 focuses on maternal and cycle of gender discrimination, neonatal health and identifies the poverty and high rates of mater- interventions and actions that nal and neonatal mortality. must be scaled up to save lives. Most maternal and neonatal Educating girls and young deaths can be averted through women is one of the most proven interventions – including powerful ways of breaking adequate nutrition, improved the poverty trap and creating © UNICEF/HQ05-0653/Nicole Toutounji hygiene practices, antenatal care, a supportive environment for skilled health workers assisting maternal and newborn health. at births, emergency obstetric Combining efforts to expand and newborn care, and post-natal coverage of essential services visits for both mothers and and strengthen health systems newborns – delivered through a with actions to empower and continuum of care linking house- protect girls and women has real holds and communities to health potential to accelerate progress. systems. Research indicates that around 80 per cent of maternal deaths are preventable if women have access As the 2015 deadline for the Millennium Development to essential maternity and basic health-care services. Goals draws closer, the challenge for improving maternal and newborn health goes beyond meeting the goals; A stronger focus on Africa and Asia is imperative to it lies in preventing needless human tragedy. Success accelerate progress on maternal and newborn health. will be measured in terms of lives saved and lives These two continents present the greatest challenges improved. to the survival and health of women and newborns, accounting for an estimated 95 per cent of maternal deaths and around 90 per cent of neonatal deaths. Two thirds of all maternal deaths occur in just 10 countries; India and Nigeria together account for one third of maternal deaths worldwide. In 2008, UNICEF, the World Health Organization, the United Nations Population Fund and the World Bank agreed to work together to help accelerate progress on maternal and Ann M. Veneman newborn health in the 25 countries with the highest Executive Director rates of mortality. United Nations Children’s Fund iii

CONTENTS Acknowledgements ......................................................................ii Adapting maternity services to the cultures of rural Peru........42 Dedication ......................................................................................ii Southern Sudan: After the peace, a new battle against Foreword maternal mortality ........................................................................43 Ann M. Veneman Executive Director, UNICEF ......................................................iii Figures 2.1 The continuum of care ........................................................27 2.2 Although improving, the educational status of young 1 Maternal and newborn health: Where we stand ......................................................1 women is still low in several developing regions ............30 2.3 Gender parity in attendance has improved markedly, but there are still slightly more girls than boys out of Panels primary school ......................................................................33 Challenges in measuring maternal deaths ..................................7 2.4 Child marriage is highly prevalent in South Asia and sub-Saharan Africa ..............................................................34 Creating a supportive environment for mothers and newborns by H. M. Queen Rania Al Abdullah of Jordan, 2.5 Female genital mutilation/cutting, though in decline, UNICEF’s Eminent Advocate for Children ..................................11 is still prevalent in many developing countries ................37 2.6 Mothers who received skilled attendance at delivery, Maternal and newborn health in Nigeria: Developing by wealth quintile and region ............................................38 strategies to accelerate progress ................................................19 2.7 Women in Mali receiving three or more antenatal Expanding Millennium Development Goal 5: Universal care visits, before and after the implementation of access to reproductive health by 2015 ......................................20 the Accelerated Child Survival and Development Prioritizing maternal health in Sri Lanka ....................................21 (ACSD) initiative....................................................................39 The centrality of Africa and Asia in the global challenges 2.8 Many women in developing countries have no say for children and women ..............................................................22 in their own health-care needs............................................40 The global food crisis and its potential impact on maternal and newborn health ....................................................................24 Figures 1.1 Millennium Development Goals on maternal and child 3 The continuum of care across time and location: Risks and opportunities ............................................................45 health ......................................................................................3 1.2 Regional distribution of maternal deaths ............................6 Panels 1.3 Trends, levels and lifetime risk of maternal mortality ........8 Eliminating maternal and neonatal tetanus ..............................49 1.4 Regional rates of neonatal mortality ..................................10 Hypertensive disorders: Common yet complex ........................53 1.5 Direct causes of maternal deaths, 1997–2002....................14 The first 28 days of life by Zulfiqar A. Bhutta, Professor 1.6 Direct causes of neonatal deaths, 2000 ..............................15 and Chairman, Department of Paediatrics & Child Health, 1.7 Conceptual framework for maternal and neonatal Aga Khan University, Karachi, Pakistan......................................57 mortality and morbidity ......................................................17 Midwifery in Afghanistan ............................................................60 1.8 Food prices have risen sharply across the board..............24 Kangaroo mother care in Ghana ................................................62 HIV/malaria co-infection in pregnancy ......................................63 2 Creating a supportive environment for maternal and newborn health ..........25 The challenges faced by adolescent girls in Liberia by the Honourable Vabah Gayflor, Minister of Gender and Development, Liberia ..................................................................64 Panels Figures Promoting healthy behaviours for mothers, newborns 3.1 Protection against neonatal tetanus ....................................48 and children: The Facts for Life guide ........................................29 3.2 Antiretroviral prophylaxis for HIV-positive mothers to Primary health care: 30 years since Alma-Ata ..........................31 prevent mother-to-child transmission of HIV ....................50 Addressing the health worker shortage: A critical action 3.3 Antenatal care coverage ........................................................51 for improving maternal and newborn health ............................35 3.4 Delivery care coverage ..........................................................52 Towards greater equity in health for mothers and 3.5 Emergency obstetric care: Rural Caesarean section ..........54 newborns by Cesar G. Victora, Professor of Epidemiology, 3.6 Early and exclusive breastfeeding ........................................59 Universidade Federal de Pelotas, Brazil ....................................38 iv

THE STATE OF THE WORLD’S CHILDREN 2009 Maternal and Newborn Health 4 Strengthening health systems Partnering for mothers and newborns in the Central African Republic............................................................................99 to improve maternal and UN agencies strengthen their collaboration in support newborn health ......................................................67 of maternal and newborn health ..............................................102 Panels Enhancing health information systems: The Health Using critical link methodology in health-care systems to Metrics Network..........................................................................105 prevent maternal deaths by Rosa Maria Nuñez-Urquiza, National Institute of Public Health, Mexico ................................73 Figures 5.1 Key global health initiatives aimed at strengthening New directions in maternal health by Mario Merialdi, health systems and scaling up essential interventions ....97 World Health Organization, and Jennifer Harris Requejo, 5.2 Official development assistance for maternal and Partnership for Maternal, Newborn and Child Health ..............75 neonatal health has risen rapidly since 2004 ....................98 Strengthening the health system in the Lao People’s 5.3 Nutrition, PMTCT and child health have seen Democratic Republic ....................................................................76 substantial rises in financing ............................................100 5.4 Financing for maternal, newborn and child health Saving mothers and newborn lives – the crucial first days from global health initiatives has increased sharply after birth by Joy Lawn, Senior Research and Policy Advisor, in recent years ....................................................................101 Saving Newborn Lives/Save the Children-US, South Africa ....80 5.5 Focal and partner agencies for each component of Burundi: Government commitment to maternal and child the continuum of maternal and newborn care and health care ....................................................................................83 related functions ................................................................103 Integrating maternal and newborn health care in India ..........85 References ..............................................................................106 Figures 4.1 Emergency obstetric care: United Nations process Statistical Tables ........................................................113 indicators and recommended levels ..................................70 Under-five mortality rankings................................................117 4.2 Distribution of key data sources used to derive the Table 1. Basic indicators ........................................................118 2005 maternal mortality estimates ....................................71 Table 2. Nutrition ....................................................................122 4.3 Skilled health workers are in short supply in Africa Table 3. Health ........................................................................126 and South-East Asia in particular ......................................74 Table 4. HIV/AIDS....................................................................130 4.4 Uptake of key maternal, newborn and child health policies by the 68 Countdown to 2015 Table 5. Education ..................................................................134 priority countries ..................................................................78 Table 6. Demographic indicators ..........................................138 4.5 Asia has among the lowest levels of government Table 7. Economic indicators ................................................142 spending on health care as a share of overall public Table 8. Women ......................................................................146 expenditure ..........................................................................79 Table 9. Child protection ........................................................150 4.6 Post-natal care strategies: Feasibility and Table 10. The rate of progress ..............................................154 implementation challenges ................................................81 4.7 Lower-income countries pay most of their private Acronyms ................................................................................158 health-care spending out of pocket ....................................82 4.8 Low-income countries have only 10 hospital beds per 10,000 people ................................................................84 5 Working together for maternal and newborn health ......................................................91 Panels Working together for maternal and newborn health by Sarah Brown, Patron of the White Ribbon Alliance for Safe Motherhood and wife of Gordon Brown, Prime Minister of the Government of the United Kingdom ..............................94 Key global health partnerships for maternal and newborn health ............................................................................96 v

T H E S TAT E O F T H E W O R L D ’ S C H I L D R E N 2 0 0 9 1 Maternal and newborn health: Where we stand © UNICEF/HQ06-2706/Shehzad Noorani

Each year, more than half a million women die from causes related to pregnancy and childbirth, and nearly 4 million newborns die within 28 days of birth. Millions more suffer from disability, disease, infection and injury. Cost-effective solutions are available that could bring rapid improvements, but urgency and commitment are required to implement them and to meet the Millennium Development Goals related to maternal and child health. The first chapter of The State of the World’s Children 2009 examines trends and levels of maternal and neonatal health in each of the major regions, using mortality ratios as benchmark indicators. It briefly explores the main proximal and underlying causes of maternal and neonatal mortality and morbidity, and outlines a framework for accelerating progress. P regnancy and childbirth are But the health risks associated with complications related to pregnancy generally times of joy for par- pregnancy and childbirth are far or childbirth is more than 300 times ents and families. Pregnancy, greater in developing countries than greater than for a woman living in birth and motherhood, in an in industrialized ones. They are an industrialized country. No other environment that respects women, especially prevalent in the least mortality rate is so unequal. can powerfully affirm women’s rights developed and lowest-income coun- and social status without jeopardiz- tries, and among less affluent and Millions of women who survive ing their health. marginalized families and communi- childbirth suffer from pregnancy- ties everywhere. Globally, efforts to related injuries, infections, diseases The enabling environment for reduce deaths among women from and disabilities, often with lifelong safe motherhood and childbirth complications related to pregnancy consequences. The truth is that depends on the care and attention and childbirth have been less suc- most of these deaths and conditions provided to pregnant women and cessful than other areas of human are preventable – research has newborns by communities and development – with the result that shown that approximately 80 families, the acumen of skilled having a child remains among the per cent of maternal deaths could health personnel and the availabil- most serious health risks for women. be averted if women had access ity of adequate health-care facili- On average, each day around 1,500 to essential maternity and basic ties, equipment, and medicines women die from complications health-care services.1 and emergency care when needed. related to pregnancy and childbirth, Many women in the developing most of them in sub-Saharan Africa Deaths of newborns in developing world – and most women in the and South Asia. countries have also received far world’s least developed countries – too little attention. Almost 40 per give birth at home without skilled The divide between industrialized cent of under-five deaths – or 3.7 attendants, yet their newborns are countries and developing regions – million in 2004, according to the usually healthy and survive past particularly the least developed coun- latest World Health Organization their first few weeks of life until tries – is perhaps greater on maternal estimates – occur in the first 28 their fifth birthday and beyond. mortality than on almost any other days of life. Three quarters of Despite the multitude of risks issue. This claim is borne out by the neonatal deaths take place in the associated with pregnancy numbers: Based on 2005 data, the first seven days, the early neonatal and childbirth, the majority average lifetime risk of a woman in a period; most of these are also of mothers also survive. least developed country dying from preventable.2 2 T H E S TAT E O F T H E W O R L D ’ S C H I L D R E N 2 0 0 9

The gap in risk of maternal death between the industrialized world and many developing countries, particularly the least developed, is often termed the ‘greatest health divide in the world’. The divide in neonatal deaths born health across the world, and in and newborn health based on respect between the industrialized countries the developing world in particular, for women’s rights, and the need to and developing regions is also wide. complementing last year’s report on establish a continuum of care for Based on 2004 data, a child born child survival. While the emphasis of mothers, newborns and children that in a least developed country is the report remains firmly on health integrate programmes for reproduc- almost 14 times more likely to and nutrition, mortality rates are tive health, safe motherhood, new- die during the first 28 days of life employed as benchmark indicators. born care and child survival, growth than one born in an industrialized Sub-Saharan Africa and South Asia, and development. The report exam- country. the regions with the highest numbers ines the latest paradigms, policies and and rates of maternal and newborn programmes and describes key initia- The health of mothers and new- mortality, are principal focuses. Key tives and partnerships that are striv- borns is intricately related, so pre- threads running through the report ing to accelerate progress. A series of venting deaths requires, in many are the imperative of creating a sup- panels, several of which have been cases, implementing the same inter- portive environment for maternal contributed by guest collaborators, ventions. These include such essential measures as antenatal care, Figure 1.1 skilled attendance at birth, access Millennium Development Goals on maternal to emergency obstetric care when and child health necessary, adequate nutrition, post-partum care, newborn care Millennium Development Goal 4: Reduce child mortality and education to improve health, Targets Indicators infant feeding and care, and hygiene 4.1 Under-five mortality rate behaviours. To be truly effective and 4.A: Reduce by two thirds, between 4.2 Infant mortality rate sustainable, however, these interven- 1990 and 2015, the under-five tions must take place within a mortality rate 4.3 Proportion of 1-year-old children immunized against measles development framework that strives to strengthen and integrate pro- Millennium Development Goal 5: Improve maternal health* grammes with health systems and Targets Indicators an environment supportive of 5.A: Reduce by three quarters, between 5.1 Maternal mortality ratio women’s rights. 1990 and 2015, the maternal 5.2 Proportion of births attended by mortality ratio skilled health personnel A human rights-based approach to improving maternal and neonatal 5.3 Contraceptive prevalence rate health focuses on enhancing health- 5.4 Adolescent birth rate care provision, addressing gender dis- 5.B: Achieve, by 2015, universal access to reproductive health 5.5 Antenatal care coverage (at least crimination and inequities in society one visit and at least four visits) through cultural, social and behav- 5.6 Unmet need for family planning ioural changes, among other means, and targeting those countries and * The revised Millennium Development Goals framework agreed by the United Nations General Assembly at the 2005 World Summit, with the new official list of indicators effective as of 15 communities most at risk. January 2008, has added a new target (5.B) and four new indicators for monitoring Millennium Development Goal 5. The State of the World’s Children Source: United Nations, Millennium Development Goals Indicators: The official United Nations site for the MDG indicators, <http://mdgs.un.org/unsd/mdg/Host.aspx?Content=Indicators/OfficialList.htm>, 2009 examines maternal and new- accessed 1 August 2008. M AT E R N A L A N D N E W B O R N H E A LT H : W H E R E W E S TA N D 3

address some of the critical issues in and affordable basic health care they “ensure to women appropriate maternal and newborn health and would lower mortality rates further services in connection with pregnan- nutrition today. still. These are not impossible, imprac- cy, confinement and the post-natal tical actions, but proven, cost-effective period, granting free services where The current situation of provisions that women of reproduc- necessary, as well as adequate nutri- maternal and neonatal health tive age have a right to expect. tion during pregnancy and lactation” (article 12.2). Furthermore, the Since 1990, the estimate of the Maternal health, however, goes Convention on the Rights of the global annual number of maternal beyond the survival of pregnant Child also commits States Parties to deaths has exceeded 500,000. women and mothers. For every “ensure appropriate pre-natal and Although the number of under-five woman who dies from causes related post-natal health care for mothers” deaths worldwide has fallen consis- to pregnancy or childbirth, it is esti- and to “develop preventive health tently – from around 13 million in mated that there are 20 others who care, guidance for parents and family 1990 to 9.2 million in 2007 – mater- suffer pregnancy-related illness or planning education and services” nal deaths have remained stubbornly experience other severe consequences. (article 24). The available evidence intractable. Limited gains have been The number is striking: An estimated suggests that many countries are fail- made worldwide towards the first 10 million women annually who sur- ing to deliver on these commitments. target of Millennium Development vive their pregnancies experience Goal (MDG) 5, which aims to such adverse outcomes.4 Improving women’s health is pivotal reduce the 1990 maternal mortality to fulfilling the rights of girls and ratio by three quarters by 2015; and That maternal health – as epitomized women under CEDAW and the progress on diminishing maternal by the risk of death or disability Convention on the Rights of the mortality ratios has been virtually from causes related to pregnancy and Child and achieving the Millennium non-existent in sub-Saharan Africa.3 childbirth – has scarcely advanced in Development Goals. In addition to decades is the result of multiple under- meeting MDG 5, enhancing reproduc- Maternal mortality ratios strongly lying causes. The root cause may lie tive and maternal health and services reflect the overall effectiveness of in women’s disadvantaged position will also directly contribute to attain- health systems, which in many low- in many countries and cultures, and in ing MDG 4, which seeks to reduce income developing countries suffer the lack of attention to, and accounta- the under-five mortality rate by two from weak administrative, technical bility for, women’s rights. thirds between 1990 and 2015. and logistical capacity, inadequate financial investment and a lack of The 1979 Convention on the Enhancing maternal nutrition will skilled health personnel. Scaling up Elimination of All Forms of also bring benefits for the achieve- key interventions – for example, ante- Discrimination against Women ment of Millennium Development natal HIV testing, increasing the num- (CEDAW), currently ratified by Goal 1, which seeks to eradicate ber of births attended by skilled health 185 countries, requires signatories extreme poverty and hunger by personnel, providing access to emer- to “eliminate discrimination against 2015. Undernutrition is a process gency obstetric care when necessary women in the field of health care which often starts in utero and and providing post-natal care for in order to ensure, on a basis of may last, particularly for girls and mothers and babies – could sharply equality of men and women, access women, throughout the life cycle: reduce both maternal and neonatal to health care services, including A stunted girl is likely to become a deaths. Enhancing women’s access to those related to family planning” stunted adolescent and later a stunt- family planning, adequate nutrition (article 12.1). It also stipulates that ed woman. Besides posing threats to 4 T H E S TAT E O F T H E W O R L D ’ S C H I L D R E N 2 0 0 9

The lifetime risk of maternal death for a woman in a least developed country is more than 300 times greater than for a woman living in an industrialized country. required data are not routinely recorded. Beyond the estimation of maternal mortality, determining and recording the causes of death is a complex process. For a death to be conclusively established as related to pregnancy or childbirth, both the cause of mortality and the pregnancy status and the timing of death in © UNICEF/HQ06-2055/Pablo Bartholomew relation to that pregnancy must be accurately noted. This level of detail is sometimes missing in the statistical reporting systems of industrialized countries, and its absence is commonplace in many developing countries, particularly the poorest.7 A strong referral system, skilled health workers and well equipped facilities are pivotal to reducing maternal and newborn deaths resulting from complications during childbirth. Efforts to improve data collection on Health workers treat babies in the Sick Newborn Care Unit, India. maternal mortality have been ongoing for the past two decades, initially her own health and productivity, mothers who died of maternal involving the World Health poor nutrition that contributes causes also subsequently died.6 Organization (WHO), UNICEF and to stunting and underweight Moreover, maternal complications the United Nations Population Fund increases a woman’s likelihood of in labour heighten the risk of (UNFPA), later joined by the World adverse pregnancy and birth out- neonatal deaths, which are rapidly Bank. This inter-agency collaboration comes. Undernourished mothers becoming a key focus of child pools resources and reviews method- also have a far higher risk of deliv- survival efforts as overall rates ologies to arrive at more precise and ering babies with low birthweight – of under-five mortality decline comprehensive global estimates of a condition that gravely heightens in most developing countries. maternal mortality. The figures for the baby’s risk of death.5 2005 are the most accurate yet and Trends in maternal and the first to estimate maternal mortali- Lowering a mother’s risk of newborn health ty trends by an inter-agency process. mortality and morbidity directly (Further details on the estimation of improves a child’s prospects for Maternal mortality maternal mortality ratios and levels survival. Research has shown can be found in the Panel on page 7.) that in developing countries, The most recent UN inter-agency babies whose mothers die during estimates suggest that in 2005, In recent years, new methodologies the first six weeks of their lives 536,000 women died from causes to calculate maternal and neonatal are far more likely to die in the related to pregnancy and childbirth. health status, service needs and mor- first two years of life than babies This figure may be far from precise, tality have been developed by the whose mothers survive. In a study however, as measuring maternal research community. These efforts conducted in Afghanistan, 74 mortality is challenging, and in are ongoing, enriching the process per cent of infants born alive to many developing countries the of arriving at more precise estimates M AT E R N A L A N D N E W B O R N H E A LT H : W H E R E W E S TA N D 5

Africa and Asia account for 95 per cent of the world's maternal deaths, with particularly high burdens in sub-Saharan Africa (50 per cent of the global total) and South Asia (35 per cent). and causes of mortality and morbidity. improvements by increasing access to resulted in higher numbers of maternal In turn, better data and analysis on basic maternity services. In the indus- deaths over the 15-year period. This health status and health services are trialized countries, the maternal mor- lack of progress is particularly worry- helping enhance the strategies and tality ratio remained broadly static ing, since the region has by far the frameworks, programmes, policies between 1990 and 2005, at a low rate highest ratios and lifetime risk of and partnerships – including those of 8 per 100,000 live births. Near maternal mortality and the greatest that support gender mainstreaming – universal access to skilled care during number of maternal deaths. In West that are striving to improve maternal delivery and emergency obstetric care and Central Africa, the regional mater- and newborn health. when necessary have contributed to nal mortality ratio stands at a stagger- these diminished levels of maternal ing 1,100 per 100,000 live births, One issue in the estimation of mortality; no industrialized countries compared to the average for develop- maternal mortality appears beyond with data have skilled attendance at ing countries and territories of 450 contention: The vast majority of birth of less than 98 per cent, and per 100,000 live births. This region maternal deaths – more than 99 most have universal coverage. includes the country with the highest per cent, according to the 2005 UN rate of maternal death in the world: inter-agency estimates – occurred in In all of the developing regions outside Sierra Leone, with 2,100 maternal developing countries. Half of these sub-Saharan Africa, both the absolute deaths per 100,000 live births. (265,000) took place in sub-Saharan numbers of maternal deaths and Africa and another third (187,000) maternal mortality ratios declined The West and Central Africa region in South Asia. Between them, these between 1990 and 2005. In sub- also has the highest total fertility rate, two regions accounted for 85 per cent Saharan Africa, maternal mortality at 5.5 children in 2007. (The total fer- of the world’s pregnancy-related ratios remained largely unchanged tility rate measures the number of chil- deaths in 2005. India alone had over the same period. Given the dren who would be born per woman if 22 per cent of the global total. region’s high fertility rates, this has she lived to the end of her childbearing The trend estimates available for mater- Figure 1.2 nal mortality indicates the lack of suf- Regional distribution of maternal deaths* ficient progress towards Target A of MDG 5, which seeks a 75 per cent Maternal deaths, 2005 East Asia/Pacific reduction in the maternal mortality 45,000 (8%) ratio between 1990 and 2015. Given South Asia Latin America/Caribbean that the global maternal mortality ratio 187,000 (35%) 15,000 (3%) stood at 430 per 100,000 live births in Industrialized countries 830 (<1%) 1990, and at 400 deaths per 100,000 CEE/CIS, 2,600 (<1%) live births in 2005, meeting the target will require more than a 70 per cent Eastern/Southern Africa 103,000 (19%) reduction between 2005 and 2015. Middle East/ North Africa 21,000 (4%) Global trends can obscure the wide West/Central Africa 162,000 (30%) variations between regions, many of * Percentages may not total 100% because of rounding. which have made appreciable progress in reducing maternal mortality and Source: World Health Organization, United Nations Children’s Fund, United Nations Population Fund and the World Bank, Maternal Mortality in 2005: Estimates developed by WHO, UNICEF, are laying the foundations for further UNFPA and the World Bank, WHO, Geneva, 2007, p. 35. 6 T H E S TAT E O F T H E W O R L D ’ S C H I L D R E N 2 0 0 9

Challenges in measuring maternal deaths Maternal mortality is defined as the death of a woman while mortality rate by three quarters between 1990 and 2015. The pregnant or within 42 days of termination of pregnancy, Maternal Mortality Working Group, which originally comprised regardless of the site or duration of pregnancy, from any the World Health Organization, UNICEF and the United Nations cause related to or aggravated by the pregnancy or its man- Population Fund, developed internationally comparable global agement. Causes of deaths can be divided into direct causes estimates of maternal mortality for 1990, 1995 and 2000. that are related to obstetric complications during pregnancy, labour or the post-partum period, and indirect causes. There In 2006, the World Bank, United Nations Population Division are five direct causes: haemorrhage (usually occurring post- and several outside technical experts joined the group, which partum), sepsis, eclampsia, obstructed labour and complica- subsequently developed a new set of globally comparable tions of abortion. Indirect obstetric deaths occur from either maternal mortality estimates for 2005, building on previous previously existing conditions or from conditions arising in methodology and new data. The process generated estimates pregnancy which are not related to direct obstetric causes but for countries with no national data, and adjusted available may be aggravated by the physiological effects of pregnancy. country data to correct for under-reporting and misclassifica- These include such conditions as HIV and AIDS, malaria, tion. Of the 171 countries reviewed by the Maternal Mortality anaemia and cardiovascular diseases. Simply because a Working Group for the 2005 estimations, appropriate national- woman develops a complication does not mean that death level data were unavailable for 61 countries, representing one is inevitable; inappropriate or incorrect treatment or lack of quarter of global births. For these countries, models were appropriate, timely interventions underlie most maternal deaths. used to estimate maternal mortality. Accurate classification of the causes of maternal death, For the 2005 estimates, data were drawn from eight cate- whether direct or indirect, accidental or incidental, is challeng- gories of sources: complete civil registration systems with ing. To accurately categorize a death as maternal, information good attribution of data, complete civil registration systems is needed on the cause of death as well as pregnancy status, with uncertain or poor attribution of data, direct sisterhood or the time of death in relation to the pregnancy. This infor- methods, reproductive-age mortality studies, disease surveil- mation may be missing, misclassified or under-reported even lance or sample registration, census, special studies and no in industrialized countries with fully functioning vital registra- national data. Estimates for each source were calculated tion systems, as well as in developing countries facing high according to a different formula, taking into account factors burdens of maternal mortality. There are several reasons for such as correcting for known bias and determining realistic this: First, many deliveries take place at home, particularly in uncertainty bounds. the least developed countries and in rural areas, complicating efforts to establish cause of death. Second, civil registration Measures of maternal mortality are prepared with a margin of systems may be incomplete or, even if deemed complete, uncertainty, highlighting the fact that while they are the best attribution of causes of death may be inadequate. Third, estimates available, the actual rate may be higher or lower modern medicine may delay a women’s death beyond the than the average. Although this is true of any statistic, the 42-day post-partum period. For these reasons, in some cases high degree of uncertainty for maternal mortality ratios indi- alternative definitions of maternal mortality are used. One cates that all data points should be interpreted cautiously. concept refers to any cause of death during pregnancy or the post-partum period. Another concept takes into account Notwithstanding the challenges of data collection and meas- deaths from direct or indirect causes that occur after the urement, the 2005 inter-agency estimates for maternal mortal- post-partum period up to one year following pregnancy. ity were sufficiently rigorous to produce trend analysis, assessing progress from the 1990 baseline date of MDG 5 to The main measure of mortality risk is the maternal mortality 2005. The lack of improvement in reducing maternal mortality ratio, which is identified as the number of maternal deaths identified in many developing countries has helped bring during a given period of time per 100,000 live births during greater attention to achieving MDG 5. the same period, which is generally a year. Another key measure is the lifetime risk of maternal death, which reflects the The 2005 maternal mortality estimates are far from perfect, probability of becoming pregnant and the probability of dying and much work is still required to refine the processes of data from a maternal cause during a women’s reproductive lifespan. collection and estimation. But they reflect a strong commit- In other words, the risk of maternal death is related to two ment on the part of the international community to continual- main factors: mortality risk associated with a single pregnancy ly strive for greater accuracy and precision. These ongoing or live birth; and the number of pregnancies that women have efforts will support and guide actions to improve maternal during their reproductive years. health and ensure that women count. Working together to improve estimations See References, page 107. of maternal deaths Several agencies are collaborating to establish more accurate measurements of maternal mortality rates and levels worldwide, and assess progress towards Target A of Millennium Development Goal 5, which seeks to reduce the maternal M AT E R N A L A N D N E W B O R N H E A LT H : W H E R E W E S TA N D 7

Although the number of under-five deaths worldwide has fallen consistently – from around 13 million in 1990 to 9.2 million in 2007 – the toll of maternal mortality has remained stubbornly intractable above 500,000. Figure 1.3 years and bore children at each age in Trends, levels and lifetime risk of maternal mortality accordance with prevailing age-specific fertility rates.) High fertility rates increase the risk that a woman will die from maternal causes. While mortality Maternal mortality ratios, 1990 and 2005 risks are associated with all pregnan- West/Central Africa 1,100 cies, these risks rise the more times a 1,100 Eastern/Southern Africa 790 woman gives birth. 760 South Asia 500 650 Middle East/North Africa 270 1990 Elevated fertility rates, combined 210 2005 East Asia/Pacific 220 with weak access to basic health-care 150 Latin America/Caribbean 180 and maternity services, can have life- 130 CEE/CIS 63 long implications for women’s sur- 46 8 vival. In the developing world as a Industrialized countries 8 whole, a woman has a 1 in 76 life- 430 World 400 time risk of maternal death, com- Sub-Saharan Africa* 940 920 pared with a probability of just 1 in 480 Developing countries 450 8,000 for women in industrialized Least developed countries 900 870 countries. By way of comparison, the 0 200 400 600 800 1000 1200 lifetime risk of maternal mortality Maternal deaths per 100,000 live births ranges from just 1 in 47,600 for a mother in Ireland, to 1 in every 7 in Niger, the country with the highest Lifetime risk of maternal death, 2005 lifetime risk of maternal death.8 West/Central Africa 5.9 Eastern/Southern Africa 3.4 Neonatal mortality South Asia 1.7 Neonatal mortality is the probability Middle East/North Africa 0.7 of a newborn dying between birth East Asia/Pacific 0.3 Latin America/Caribbean 0.4 and the first 28 completed days of CEE/CIS 0.1 life. The latest estimates from the Industrialized countries 0.01 World Health Organization, which date from 2004, indicate that around World 1.1 3.7 million children died within the Sub-Saharan Africa* 4.5 first 28 days of life in that year. Developing countries 1.3 Within the neonatal period, however, Least developed countries 4.2 there is wide variation in mortality 0 1 2 3 4 5 6 7 risk. The greatest risk is during the Probability that a women will die from causes related to pregnancy cumulative across her reproductive years (%) first day after birth, when it is estimated that between 25 and 45 per *Sub-Saharan Africa comprises the regions of Eastern/Southern Africa and West/Central Africa. cent of neonatal deaths occur. Around three quarters of newborn deaths, or Source: World Health Organization, United Nations Children’s Fund, United Nations Population Fund and the World Bank, Maternal Mortality in 2005: Estimates developed by WHO, UNICEF, 2.8 million in 2004, occur within the UNFPA and the World Bank, WHO, Geneva, 2007, p. 35. first week – the early neonatal period. 8 T H E S TAT E O F T H E W O R L D ’ S C H I L D R E N 2 0 0 9

© UNICEF Mozambique/Emidio Machiana Expanded distribution of insecticide-treated mosquito nets to help prevent malaria and rapid scaling up of programmes to prevent and treat HIV infection are helping to save maternal and newborn lives. An HIV-positive mother and her newborn son under an insecticide-treated mosquito net are assisted by a nurse in a health centre, Mozambique. Like maternal deaths, almost all (98 particular, deaths in the first week prisingly, are found in industrialized per cent in 2004) neonatal deaths of life have risen from 23 per cent countries, where the neonatal mortal- occur in low- and middle-income of under-five deaths in 1980 to 28 ity rate in 2004 was just 3 per 1,000 countries. The total number of peri- per cent in 2000.10 live births. The highest rates of natal deaths, which groups stillbirths neonatal death in 2004 were found with early neonatal deaths owing to In part, the rising proportion of in South Asia (41 per 1,000 live the fact that they have similar obstet- neonatal deaths reflects two key fac- births) and West and Central Africa ric causes, was 5.9 million deaths in tors: the difficulty of reaching many (45 per 1,000). Owing to a higher 2004. Stillborns accounted for around babies who are born at home with number of births, South Asia has the 3 million perinatal deaths that year.9 effective and timely neonatal interven- highest number of neonatal deaths tions, and the success of many coun- among the world’s regions.11 Until the mid-to-late 1990s, neonatal tries in implementing interventions mortality figures were estimated from such as immunization that have The main causes of maternal rough historical data. But as more reli- markedly reduced post-neonatal and neonatal mortality and able data emerged from household deaths in the developing world as a morbidity surveys, it became evident that previ- whole. This has led in part to a rela- ous estimates had significantly under- tive neglect of cost-effective, simple Maternal mortality estimated the incidence of newborn neonatal survival interventions. deaths. The global neonatal mortality Reducing neonatal deaths therefore Direct causes rate declined by one quarter between has become a major component of 1980 and 2000, but its rate of reduc- new paradigms and strategies for The timing and causes of maternal tion was much slower than that of the diminishing child mortality and reach- and newborn deaths are well known. overall under-five mortality rate, which ing Millennium Development Goal 4. Maternal deaths mostly occur from fell by one third. As a consequence, the third trimester to the first week neonatal deaths currently constitute a Regional patterns of neonatal death after birth (with the exception of much higher proportion of under-five correlate closely to those for mater- deaths due to complications of abor- deaths than in previous years. In nal death. The lowest rates, unsur- tion). Studies show that mortality M AT E R N A L A N D N E W B O R N H E A LT H : W H E R E W E S TA N D 9

The latest inter-agency estimates suggest that 536,000 women died in 2005 from causes related to pregnancy and childbirth. risks for mothers are particularly to pregnancy but may be exacer- Maternal anaemia affects about half elevated within the first two days bated by pregnancy and childbirth. of all pregnant women. Pregnant after birth. Most maternal deaths are Attributing these causes to preg- adolescents are more prone to related to obstetric complications – nancy is difficult owing to the poor anaemia than older women, and they including post-partum haemorrhage, diagnostic capacity of many coun- often receive less care. Infectious dis- infections, eclampsia and prolonged tries’ health information systems. eases such as malaria, which affects or obstructed labour – and complica- Nonetheless, assessing the indirect around 50 million pregnant women tions of abortion. Most of these direct causes of maternal deaths helps living in malaria-endemic countries causes of maternal mortality can be determine the most appropriate inter- every year, and intestinal parasites readily addressed if skilled health per- vention strategies for maternal and can exacerbate anaemia, as can poor- sonnel are on hand and key drugs, child health. Collaboration between quality diets – all of which heighten equipment and referral facilities are condition-specific programmes – such vulnerability to maternal death. available.12 (For further details on as those to address malaria or AIDS – Severe anaemia contributes to the risk birth complications and emergency and maternal health initiatives may of death in cases of haemorrhage.14 obstetric care, see Chapter 3.) often be the most effective way to address some of these indirect causes, Anaemia is highly treatable with Indirect causes including those that are highly pre- iron supplements offered through Many factors contributing to a ventable or treatable, such as maternal health programmes. This mother’s risk of dying are not unique anaemia.13 intervention, however, remains limit- Figure 1.4 Regional rates of neonatal mortality West/Central Africa 45 Eastern/Southern Africa 36 South Asia 41 Middle East/North Africa 25 East Asia/Pacific 18 Latin America/Caribbean 13 CEE/CIS 16 Industrialized countries 3 World 28 Sub-Saharan Africa* 41 Developing countries 31 Least developed countries 40 0 5 10 15 20 25 30 35 40 45 50 Neonatal deaths (0–28 days) per 1,000 live births, 2004 *Sub-Saharan Africa comprises the regions of Eastern/Southern Africa and West/Central Africa. Source: World Health Organization, using vital registration systems and household surveys. 10 T H E S TAT E O F T H E W O R L D ’ S C H I L D R E N 2 0 0 9

Creating a supportive environment for mothers and newborns by H. M. Queen Rania Al Abdullah of Jordan, UNICEF’s Eminent Advocate for Children* In 1631, a beautiful empress, Mumtaz Mahal, died while women who die in childbirth each year. Why are maternal giving birth to her 14th child. Overwhelmed by grief, her deaths only partially enumerated? One possible reason is husband constructed a monument in her honour: the Taj that, in too many places, women’s lives do not fully count. Mahal, today one of the best-known buildings in the world. And as long as women remain disadvantaged in their soci- And yet, while the Taj Mahal’s domes and spires are instantly eties, maternal and newborn health will suffer as well. But recognizable, there is far less global awareness of the tragedy if we can empower women with the tools to take control of that inspired its creation. their lives, we can create a more supportive environment for women and children alike. Nearly 400 years after Mumtaz Mahal lost her life in childbirth, a woman still dies from causes related to pregnancy or Empowerment begins with education, the best development childbirth every minute of every day – more than 500,000 investment we can make – from ensuring that girls as well as women each year, 10 million per generation. How can it be boys are able to attend primary school to teaching women to that in our age of modern advances and medical miracles we read and write, and providing public health education. Although are still failing to safeguard women as they perpetuate the much remains to be done, many countries are beginning to human race itself? make strides in this direction. In Jordan, for example, nursing students from the University of Jordan are volunteering to The answer, of course, is that public health has made breath- educate girls in public schools about women’s health issues. taking strides, but those benefits have not been equally shared, either among countries or between the geographical areas and Study after study shows that educated women are better social groups within them. Even though the causes of pregnan- equipped to earn income to support their families, more cy and childbirth complications are the same around the world, likely to invest in their children’s health care, nutrition and their consequences vary dramatically from country to country education, and more inclined to participate in civic life and and region to region. Today, a young woman in Sweden has a to advocate for community improvements. 1 in 17,400 lifetime risk of dying of pregnancy-related causes. In Sierra Leone, her risk soars to 1 in 8. Educated mothers are also more likely to seek proper health care for themselves; according to the 2007 Millennium And for every woman who dies, another 20 are afflicted with Development Goals Report, “84 per cent of women who have serious infections or injuries. An estimated 75,000 women each completed secondary or higher education are attended by year become victims of obstetric fistula, a physically and psycho- skilled personnel during childbirth, more than twice the rate logically devastating condition that can result in social exclusion. of mothers with no formal education.” The toll in women’s lives is enormous. But they are not the Children of educated mothers are 50 per cent more likely to only ones who suffer. As a group of experts stated during a survive until the age of five and beyond than those whose global conference on women’s health in 2007: “In their prime mothers did not receive or complete schooling. For girls in par- reproductive years, women ‘deliver’ for their societies in ticular, education can make the difference between hope and multiple ways: They bear and raise the next generation, and despair. Research shows that young people who complete pri- they are critical actors for progress as workers, leaders, and mary school are less likely to be infected by HIV than those activists.” When women’s lives are cut short or incapacitated who never managed to graduate from primary school. as a result of pregnancy or childbirth, the tragedy cascades. Children lose a parent. Spouses lose a partner. And societies Educated girls are also more likely to delay marriage and less lose productive contributors. likely to get pregnant while very young, reducing the risk of dying in childbirth while they are still children themselves. As Our world cannot afford to keep sacrificing so many people girls continue their education, their earning potential increas- and so much potential. We know what it takes to prevent and es, enabling them to break the bonds of poverty too often treat the vast majority of pregnancy-related difficulties, from passed down through the generations. eclampsia and haemorrhage to sepsis, obstructed labour and anaemia. Indeed, the World Bank estimates that such basic Put simply, changing the trajectory for girls can change the interventions as antenatal care, attendance at delivery by course of the future. And if these girls grow into women who skilled health personnel, and accessible emergency treatment choose to become mothers themselves, they will view preg- for women and newborns could avert almost three quarters nancy and childbirth as something to celebrate, not fear. of maternal deaths. See References, page 107. But expanding medical interventions is just one part of improving maternal and newborn health. More fundamentally, *Her Majesty Queen Rania Al Abdullah of Jordan is UNICEF’s Eminent we need to boost women’s empowerment around the world. Advocate for Children and a tireless global advocate for child protec- Consider that in a century increasingly defined by information, tion, early childhood development, gender parity in education and we still do not have precise data regarding the numbers of women's empowerment. M AT E R N A L A N D N E W B O R N H E A LT H : W H E R E W E S TA N D 11

ed in both coverage and effective- The precise contribution of HIV and are ensuing. For example, coverage ness in some developing countries, AIDS to maternal deaths is difficult of antiretroviral prophylaxis for mostly as a result of low access to to assess since, despite the expansion HIV-positive mothers to prevent basic health care and, more specifi- of programmes to prevent mother-to- mother-to-child transmission rose cally, to quality antenatal care and child transmission of HIV, the HIV from 10 per cent of HIV-infected support. Encouragingly, there are status of many pregnant women is pregnant women in low- and signs that efforts to address anaemia still unknown. HIV and pregnancy middle-income countries in 2004 by fortifying staple foods like flour might interact in several ways. The to 33 per cent in 2007. Despite this are beginning to accelerate at the virus may heighten the risk of such appreciable progress, much more national level in a number of devel- obstetric complications as haemor- needs to be done to provide women oping countries.15 rhage, sepsis and complications of with interventions for HIV preven- Caesarean section. Pregnancy, in tion, care and therapy – including Maternal iodine deficiency during turn, may raise the risk of HIV-related testing and counselling, and quality pregnancy is associated with a higher illnesses such as anaemia and tuber- sexual and reproductive health serv- incidence of stillbirths, miscarriage culosis, or accelerate HIV progres- ices in addition to medicines.18 and congenital abnormalities. These sion. Current research findings are risks can be reduced and prevented indicative rather than conclusive, Although the consequences of by ensuring optimal maternal iodine and more research is needed to clar- co-infection with HIV and malaria status before or during pregnancy. ify the degree of causality in both parasites are not fully understood, Universal salt iodization and, in directions. It is believed that in available evidence suggests that the some cases, iodine supplementation countries with high prevalence of infections act synergistically and are essential to ensure optimum HIV, the AIDS epidemic may have result in adverse outcomes. Recent iodine intake during pregnancy reversed previous advances in evidence suggests that HIV-positive and childhood.16 maternal mortality. What can be women with placental malaria are assessed with greater certainty, at more likely to give birth to low- Malaria is another deadly risk for least partially, is the number of birthweight infants. Research also mothers and babies. In malaria- women identified as living with suggests that low-birthweight endemic areas, the disease con- HIV who gave birth – around infants are more susceptible to HIV tributes to around one quarter of 1.5 million in 108 low- and infection as a result of mother-to- severe maternal anaemia cases, middle-income countries in 2006. child transmission of the virus heightens the risk of stillbirth and than infants of normal birthweight. miscarriage, and contributes to low Efforts to address the AIDS epidem- Antiretroviral treatment for HIV- birthweight and neonatal deaths. ic and its impact on maternal and positive women and children and the Prevention of malaria through the newborn health are intensifying in use of insecticide-treated mosquito use of insecticide-treated mosquito four key areas: prevention of infec- nets can reduce the risk of malaria nets is therefore vital to reduce its tion among adolescents and young still further.19 (For further details on impact on pregnant women and people; antiretroviral treatment for HIV and malaria co-infection, see newborns. In addition, intermittent HIV-positive women and mothers the Panel in Chapter 3, page 63.) preventive treatment of malaria for who require antiretroviral therapy; pregnant women in the second and prevention of mother-to-child trans- For every woman who dies from third trimesters is increasingly used mission; and paediatric treatment of pregnancy-related complications, in sub-Saharan Africa to avert HIV. Advances are being made in all around 20 more incur injuries, infec- anaemia and placental malaria.17 four areas and encouraging results tions and disabilities – approximately 12 T H E S TAT E O F T H E W O R L D ’ S C H I L D R E N 2 0 0 9

and other routine tasks. A number of factors can cause uterine prolapse, including prolonged labour, difficult delivery, frequent pregnancies, inadequate obstetric care and heavy manual labour. Other forms of maternal morbidity include anaemia, infertility, chronic infection, depression and incontinence – all of which may result in domestic problems including physical and psychological abuse, household dissolu- tion and social exclusion.20 Neonatal mortality Some 86 per cent of newborn deaths UNICEF/HQ05-1222/Roger LeMoyne globally are the direct result of three main causes: severe infections – including sepsis/pneumonia, tetanus and diarrhoea – asphyxia and preterm births. Severe infections are estimated to account for 36 per cent Exclusive breastfeeding for the first six months of life helps protect newborns and infants of all newborn deaths. They can from disease, reduces the risk of mortality and encourages healthy child development. occur at any point during the first A woman breastfeeds her newborn at the Uskudar Ana ve Cocuk Sagligi Klinigi, a clinic operated by the Ministry of Health in Istanbul, Turkey. month of life but are the main cause of neonatal death after the first week. 10 million women each year. Among cal discomfort and emotional distress Clean delivery practices are clearly the most distressing conditions is of the condition, they also may risk important in preventing infection, obstetric fistula, which occurs when being shunned by their husbands but maternal infections also need to prolonged pressure from the baby’s and families. be identified and treated during preg- head during extended, problematic nancy. Infections in newborns require labour causes tissue damage in the Another debilitating condition is rapid identification and treatment as birth canal. In the period following uterine prolapse, which occurs soon as possible following childbirth. the birth, holes open up and there is when the muscles, ligaments and leakage from the bladder and/or the tissue supporting the pelvic struc- Asphyxia (difficulty in breathing after rectum into the vagina. Fistula can ture give way, causing the uterus to birth) causes 23 per cent of newborn be easily treated by health workers fall into the vaginal canal. Limited deaths and can largely be prevented with appropriate surgical skills, but mobility, chronic back pains and by improved care during labour and many of the estimated 75,000 women urinary incontinence are three con- delivery. The condition can be alleviat- afflicted by this condition each year sequences of prolapse, which, if ed by a trained health worker who never receive treatment. Instead, they severe, can also make it impossible is able to detect its signs and resusci- not only have to cope with the physi- for women to undertake household tate the newborn. Preterm birth (deliv- M AT E R N A L A N D N E W B O R N H E A LT H : W H E R E W E S TA N D 13

Pregnancy- and childbirth-related complications are an important cause of mortality for girls aged 15–19 years worldwide, accounting for 70,000 deaths every year. ery at less than 37 weeks of completed Saharan Africa, the regions with the health is not simply a practical mat- gestation) directly causes 27 per cent highest rates of undernutrition among ter of making available better and of newborn deaths. Infants born girls and women. Maternal undernu- more extensive maternal health serv- prematurely find it more difficult trition is correlated with a higher inci- ices. It also involves tackling head than full-term babies to feed, maintain dence of low birthweight in infants.22 on the neglect of women’s basic normal body temperature and with- rights in many societies. stand infection. Preventing malaria in Intrauterine growth restriction, which pregnant women can have a positive refers to restricted growth of the fetus In addition to adequate nutrition impact on the incidence of premature during pregnancy, is a leading risk for for women, birth spacing is also births in malaria-endemic areas.21 perinatal deaths. Like low birthweight, central to avoiding preterm births, it is also associated with maternal low birthweight in infants and According to the latest international undernutrition and ill health, among neonatal deaths; studies show estimates, which cover the period other factors. With correct identifica- that birth intervals of less than 2000–2007, 15 per cent of all new- tion and proper management, includ- 24 months significantly increase borns are born with low birthweight ing early treatment of maternal dis- these risks. It is also imperative (defined as infants weighing less than eases and good nutrition, the condition to secure girls’ access to proper 2,500 grams at birth). Low birth- can be contained and need not result nutrition and health care from weight, which is caused by preterm in lifelong consequences.23 birth through childhood and into birth or intrauterine growth restric- adolescence, womanhood and their tion, is an underlying factor in 60–80 The intergenerational nature of the potential childbearing years.24 per cent of neonatal deaths. The solution to intrauterine growth majority of such cases occur in South restriction underlines the fact that For every newborn baby who dies, Asia in particular, and also in sub- improving maternal and newborn another 20 suffer birth injury, com- Figure 1.5 Direct causes of maternal deaths, 1997–2002* Complications of abortion 4% Other causes 30% Obstructed labour Other causes Other causes Haemorrhage 4% 21% 21% Haemorrhage 21% Anaemia 31% 4% Complications Sepsis/ of abortion Complications infections HIV/AIDS 6% of abortion 8% 6% 12% Obstructed Hypertensive Haemorrhage labour disorders Sepsis/ 34% 9% Obstructed Hypertensive 9% infections Sepsis/ labour disorders Anaemia 12% infections 13% 26% 10% 13% Hypertensive disorders 9% Africa Asia Latin America/Caribbean * Data refer to the most recent year available during the period specified. Percentages may not total 100% because of rounding. Source: Khan, Khalid S., et al., 'WHO Analysis of Causes of Maternal Death: A systematic review', The Lancet, vol. 367, no. 9516, 1 April 2006, p.1069. 14 T H E S TAT E O F T H E W O R L D ’ S C H I L D R E N 2 0 0 9

For every woman who dies from a pregnancy-related cause, another 20 more incur injuries, infections and disabilities – around 10 million women each year. plications arising from preterm birth to nutritious food and essential survival. Studies show that women’s or other neonatal conditions. More micronutrients, poor environmental health throughout the life cycle, than 1 million children who survive health facilities and inadequate basic from childhood through adolescence birth asphyxia each year, for exam- health-care services and limited and into adulthood, is critical in ple, end up suffering disabilities access to maternity services – includ- determining maternal and neonatal such as cerebral palsy or learning ing emergency obstetric and newborn health outcomes. Access to institu- difficulties.25 care. There are also basic factors, tional facilities and skilled health such as poverty, social exclusion and personnel at birth are also important Underlying and basic causes gender discrimination that underpin factors; it should come as no sur- of maternal and neonatal both the direct and underlying causes prise that the countries with the mortality and morbidity of maternal and newborn mortality highest rates of neonatal mortality and morbidity. (For a fuller outline of have among the lowest rates of In addition to the direct causes of how these factors interact, see Figure skilled attendants at birth and maternal and newborn mortality and 1.7 on page 17.) institutional deliveries.26 morbidity, there are a number of underlying factors at the household, Of particular importance is the Poverty undermines maternal and community and district levels that restricted access to quality health neonatal health in several ways. It also serve to undermine the health care services that many women face. can heighten the incidence of direct and survival of mothers and new- Maternal health and access to quali- causes of mortality, such as maternal borns. They include lack of education ty contraception and reproductive infections and undernutrition, and and knowledge, inadequate maternal health services save women’s lives discourage care seeking or reduce and newborn health practices and and are also important factors access to health-care services. It can care seeking, insufficient access underlying newborn health and also undermine the quality of the Figure 1.6 Direct causes of neonatal deaths, 2000* Low birthweight, which is related to maternal malnutrition, is a causal factor in 60–80 per cent of neonatal deaths. Tetanus (7%) Congenital (7%) Sepsis/pneumonia (26%) Diarrhoea (3%) Preterm (27%) Asphyxia (23%) Other (7%) 0 20 40 60 80 100 * Percentages may not total 100% because of rounding. Source: Lawn, Joy E., Simon Cousens and Jelka Zupan, ‘4 million neonatal deaths; When? Where? Why?', The Lancet, vol. 365, no. 9462, 5 March 2005, p. 895. M AT E R N A L A N D N E W B O R N H E A LT H : W H E R E W E S TA N D 15

services provided even when they © UNICEF/HQ08-0302/Susan Markisz are available. Information from 50 Demographic and Health Surveys from 1995 to 2002 reveals that within regions, neonatal mortality rates are around 20–50 per cent higher for the poorest 20 per cent of households than for the richest quintile. Similar Improving maternity services is essential to enhancing maternal and newborn health and inequities are also prevalent for survival. A nurse examines a six-week-old baby during a check-up at a community health maternal mortality.27 centre, Jamaica. Providing a supportive social con- certainly know enough to implement • Access to skilled health personnel – text for the rights of women and interventions that could save millions a doctor, nurse or midwife – at girls is also critical to reducing of lives. The main methods of redu- delivery. maternal and neonatal mortality cing maternal and newborn mortality and morbidity. Efforts to increase and morbidity are well established • Basic emergency obstetric care at health interventions to address the and understood. These include: a minimum of four facilities per proximate causes of maternal and 500,000 population – adapted to neonatal deaths and ill health, and • Promoting access to family plan- each country’s circumstances – to ameliorate maternal undernutri- ning services, based on individual for women who experience some tion, curb infectious diseases and country policies. complication. improve hygiene facilities and practices will be only partly successful • Quality antenatal care providing a • Comprehensive emergency unless the social context in which comprehensive package of health obstetric care at a minimum of women and girls reside respects their and nutrition services. one facility in every district or rights. As Chapter 2 shows, expand- one per 500,000 population. ing service delivery may prove insuf- • Preventing mother-to-child transmis- ficient if women and girls are denied sion of HIV and offering antiretro- • A post-natal visit for every access to essential commodities or viral treatment for women in need. mother and newborn as soon services because of cultural, social, as possible after delivery, ideally or familial impediments. • Basic preventive and curative inter- within 24 hours, with additional ventions, including immunization visits towards the end of the Accelerating progress on against neonatal tetanus for preg- first week and at four to maternal and newborn health nant women, routine immuniza- six weeks. tion, distribution of insecticide- Many of the causal factors responsi- treated mosquito nets and oral • Knowledge and life skills for ble for maternal and neonatal mor- rehydration salts, among others. pregnant women and families bidity and mortality are well known on the danger signs of maternal and interrelated, as illustrated in the • Access to improved water and sani- and newborn health and about conceptual framework in Figure 1.7. tation, and adoption of improved referral systems. While there are still many gaps in our hygiene practices, especially at deliv- knowledge of the extent and causes ery. Clean water for hygiene and • Maternal nutrition counselling and of maternal and newborn deaths, we drinking is essential for safe delivery. supplementation as needed as part of 16 T H E S TAT E O F T H E W O R L D ’ S C H I L D R E N 2 0 0 9

The burden of neonatal deaths is also high, as each year almost 4 million newborns die within the first 28 days of life. Figure 1.7 Conceptual framework for maternal and neonatal mortality and morbidity This conceptual framework on the causes of maternal and newborn deaths illustrates that health outcomes are determined by interrelated factors, encompassing nutrition, water, sanitation and hygiene, health-care services and healthy behaviours, and disease control, among others. These factors are defined as proximate (individual), underlying (household, community and district) and basic (societal). Factors at one level influence other levels. The framework is devised to be useful in assessing and analysing the causes of maternal and newborn mortality and morbidity, and in planning effective actions to enhance maternal and neonatal health. Maternal and neonatal Outcomes mortality and morbidity Obstetric risks Congenital Diseases and Inadequate Direct causes incl. complications factors infections dietary intake of abortion Lack of education, Insufficient Inadequate Insufficient access Poor water/ health information, access to maternal and to nutritious food sanitation and life skills maternity newborn health and essential and hygiene, Underlying causes at the services – practices and micronutrients and inadequate household/community including care seeking including early basic health-care and district levels emergency and exclusive services obstetric and breastfeeding newborn care Quantity and quality of actual resources for maternal health — human, economic and organizational — Inadequate and/or inappropriate and the way they are controlled knowledge, discriminating attitudes limit household access to actual resources Basic causes at societal level Potential resources: environment, technology, people Political, economic, cultural, religious and social systems, including women’s status, limit the utilization of potential resources Source: UNICEF. M AT E R N A L A N D N E W B O R N H E A LT H : W H E R E W E S TA N D 17

A child born in a least developed country is almost 14 times more likely to die during the first 28 days of life than one born in an industrialized country. routine antenatal, post-natal and skilled professionals throughout preg- and infrastructure services and offer neonatal care. nancy, birth, post-partum and neona- security to citizens. Fragile states tal care, supported by referrals to hold around 8 per cent of the world’s • Essential care for all newborns, adequately staffed facilities equipped population, but they account for including initiation of breastfeeding to manage emergencies. The emerging 35 per cent of global maternal within the first hour of birth, role of mid-level providers such as deaths and comprise 8 of the 10 exclusive breastfeeding, infection nurses and midwives in broadening countries with the highest maternal control, warmth provision and access to emergency obstetric care is mortality ratios. These countries also avoidance of bathing during the also showing promising potential in account for 21 per cent of global first 24 hours. the developing world. neonatal deaths, and comprise 9 of the 10 countries with the most ele- • Extra care for small babies, multi- In particular, given that the risks of vated rates of neonatal mortality.29 ple births and severe congenital maternal and newborn death are abnormalities. greatest during the first 24–48 hours Strengthening governance and the rule after birth, post-natal care urgently of law and restoring peace and security • Integrated Management of needs to be expanded during this are requisites for accelerating progress Neonatal and Childhood Illness, or period, and greater emphasis needs on improving maternal and newborn the equivalent, in health facilities to be placed on follow-up visits for health. Donors and international agen- that provide care to women and babies and mothers. Visits shortly cies also face the challenge of moving children.28 after birth are vital for new mothers, beyond short-term humanitarian who may remain at higher risk of response to long-term development For these interventions to work, mortality and morbidity for up to a assistance, and ensuring that maternal, however, it is increasingly recognized year after birth. This is usually not child and newborn health and women’s that essential services must be provid- possible, however, as maternal and rights are among the key issues in ed, at key points in the life cycle, newborn services are often sorely negotiations and programmes aimed at through dynamic health systems that lacking in the poorest countries and improving governance, resolving con- integrate a continuum of home, com- communities where the most deaths flict and strengthening institutions.30 munity, outreach and facility-based occur. Particularly in sub-Saharan care. This concept of a continuum of Africa, factors such as distance, In the least developed countries, insuf- care for maternal, neonatal and child migration, urbanization, armed con- ficient resources have been dedicated health has arisen in recent years from flict, disease and lack of investment to maternal and neonatal health, with the recognition that an integrated in public health have left severe the result that the poor have been approach reaps more dividends than shortages of skilled health effectively denied access to clinics and myriad separate initiatives. The con- professionals. hospitals, especially in rural areas. tinuum must exist, however, in a sup- This may be due to the absence of portive environment that safeguards Women and newborns in fragile such a facility, the poor quality and women’s rights and prioritizes mater- states – countries that experience condition of health centres and hospi- nal and newborn health. Chapter 2 weak institutional policy, poor gov- tals, the lack of skilled health person- explores the elements required to cre- ernance, political instability and nel or personnel with low skills levels, ate and sustain such an environment. weak rule of law – require particular or the existence of user fees and other attention. Often these states lack the costs that the poor cannot afford. The Among the most vital elements in the institutional capacity and adequate continuum of care concept refers not continuum of care is the presence of resources to deliver basic social only to the needs of mothers and 18 T H E S TAT E O F T H E W O R L D ’ S C H I L D R E N 2 0 0 9

Focus On Maternal and newborn health in Nigeria: Developing strategies to accelerate progress Nigeria is Africa’s most populous country, with 148 million largest ethnic group in northern Nigeria and are therefore inhabitants in 2007, 25 million of them under age five. With critically affected by this region’s higher poverty rates. almost 6 million births in 2007 – the third highest number in the world behind India and China – and a total fertility rate Cultural attitudes and practices that discriminate against of 5.4, Nigeria’s population growth continues to be rapid in women and girls contribute to maternal mortality and mor- absolute terms. bidity. Child marriage and high rates of adolescent births are commonplace across Nigeria, exposing girls and In addition to its sizeable population, Nigeria is known for women of reproductive age to numerous health risks. its vast oil wealth. Nonetheless, poverty is widespread; according to the latest World Development Indicators 2007, Given these complex realities, developing strategies to published by the World Bank, more than 70 per cent of accelerate progress on maternal and newborn health Nigerians live on less than US$1 per day, impairing their remains a considerable challenge. But the Government of ability to afford health care. Nigeria, together with international partners, is attempting to meet the challenge. In 2007, it began to implement a Poverty, demographic pressures and insufficient investment national Integrated Maternal, Newborn and Child Health in public health care, to name but three factors, inflate lev- (IMNCH) Strategy to fast-track high-impact intervention els and ratios of maternal and neonatal mortality. The latest packages that include nutritional supplements, immuniza- United Nations inter-agency estimates place the 2005 aver- tion, insecticide-treated mosquito nets and prevention age national maternal mortality ratio at 1,100 deaths per of mother-to-child transmission of HIV. 100,000 live births and the lifetime risk of maternal death at 1 in 18. When viewed in global terms, the burden of mater- The strategy is to be rolled out in three phases, each lasting nal death is brought into stark relief: Approximately 1 in three years, and has been designed along the continuum of every 9 maternal deaths occurs in Nigeria alone. care model to strengthen Nigeria’s decentralized health system, which operates at the federal, state and local levels. In The women who survive pregnancy and childbirth may face the initial phase, covering 2007–2009, the key focus will be compromised health; studies suggest that between 100,000 identifying and removing bottlenecks, while delivering a and 1 million women in Nigeria may be suffering from basic package of services using community-based and obstetric fistula. Neonatal deaths in 2004 stood at 249,000, family-care strategies. A sizeable proportion of expenditure according to the latest World Health Organization figures, will go towards artemisinin-based combination therapy to with 76 per cent taking place in the early neonatal period combat malaria in women, children and newly recruited (first week of life). Inadequate health facilities, lack of trans- and trained health workers, particularly in rural areas. As portation to institutional care, inability to pay for services basic healthcare improves, it is anticipated that the demand and resistance among some populations to modern health for clinical services will increase. care are key factors behind the country’s high rates of maternal, newborn and child mortality and morbidity. The second and third phases of the IMNCH will place greater emphasis on building health infrastructure. Over Disparities in poverty and health among Nigeria’s nine years, the strategy aims to revitalize existing facilities, numerous ethnolinguistic groups and between its states construct clinics and hospitals, and create incentives – are marked. Poverty rates in rural areas, estimated at such as dependable salaries, hardship allowances and 64 per cent in 2004, are roughly 1.5 times higher than the performance-based bonuses – that will help retain skilled urban-area rate of 43 per cent. Moreover, the poverty rate health professionals in Nigeria’s health system. in the north-east region, which stands at 67 per cent, is almost twice the level of 34 per cent in the more The IMNCH strategy, if implemented in full and on time, prosperous south-east. can markedly improve maternal and newborn health. Together with this package, the country has recently passed Low levels of education, especially among women, and the National Health Insurance Scheme, which integrates discriminatory cultural attitudes and practices are barriers the public and private health sectors to make health care to reducing high maternal mortality rates. A study at the more affordable for Nigerians. If the government passes Jos University Teaching Hospital in the north-central region the National Health Bill, which is currently before the legis- shows that nearly three quarters of maternal deaths in 2005 lature, a direct funding line for primary health care will occurred among illiterate women. The mortality rate among become available. These health-system improvements have women who did not receive antenatal care was about 20 the potential to set a new course for meeting Millennium times higher than among those who did. Of the several eth- Development Goals 4 and 5 in Africa’s largest nation. nic groups represented among the patients, Hausa-Fulani women accounted for 22 per cent of all deliveries and 44 per cent of all deaths. The Hausa-Fulani represent the See References, page 107. M AT E R N A L A N D N E W B O R N H E A LT H : W H E R E W E S TA N D 19

For every newborn baby who dies, another 20 suffer birth injury, complications arising from preterm birth or other neonatal conditions. children across time, but also to grating and scaling up a range of Development Goal to reduce child increasing access to health services by actions. Chapter 4 examines the key mortality (MDG 4) and even further linking households and communities, paradigms, policies, and programmes behind on the goal to improve mater- clinics and hospitals. Chapter 3 looks that are driving the process forward. nal health (MDG 5). It is clear that in more depth at how to integrate and progress has to be significantly acceler- strengthen the services available to The final chapter of The State of the ated. The experiences of several devel- mothers and newborns and deliver World’s Children 2009 calls for con- oping countries, explored in depth in them at key points in the life cycle certed action and strong, cohesive subsequent chapters, have proved that and at key locations. partnerships to improve maternal and rapid progress is possible when sound neonatal survival and health. The strategies, political commitment, ade- Implementing and extending contin- goals are already clear – and it is also quate resources and collaborative ua of care for mothers, newborns evident that the world as a whole has efforts are applied in support of the and children will require both inte- fallen behind on the Millennium health of both mothers and newborns. Expanding Millennium Development Goal 5: Universal access to reproductive health by 2015 In 2005, Heads of State meeting at the United Nations to Antenatal care coverage – Percentage of women aged 15–49 review commitments made in the Millennium Declaration – attended at least once during pregnancy by skilled health per- the outcome document of the Millennium Summit of 2000 – sonnel (doctors, nurses or midwives) and the percentage not only reaffirmed the development goals elaborated in 2000 attended by any provider at least four times. and ever since known as the Millennium Development Goals (MDGs), they also added four new targets to support them. Unmet need for family planning – Refers to women who are fecund and sexually active but are not using any method of One of the major changes to the MDG configuration is contraception and report not wanting any more children or the inclusion of a specific target on reproductive health: wanting to delay the birth of the next child. Millennium Development Goal 5, Target B, which seeks to “Achieve, by 2015, universal access to reproductive The addition of the reproductive health target to the MDGs health.” This new target falls within the goal’s overarching reflects a long process linking reproductive health issues to objective of improving maternal health and complements development, human rights and gender equity, whose land- its original target and associated indicators. The indicators mark event was the International Conference on Population selected to monitor progress towards MDG 5, Target B, are and Development (ICPD) held in Cairo in 1994. Since then, shown below: other important events, notably the Fourth World Conference on Women (Beijing, 1995) and ICPD+5 – the UN General Contraceptive prevalence rate – Percentage of women aged Assembly Special Session on the International Conference on 15–49 in union currently using contraception. Population and Development held in 1999 – have confirmed and extended the recommendations of the original ICPD gath- Adolescent birth rate – Annual number of births to women ering, including the goal of universal access to reproductive aged 15–19 per 1,000 women in that age group. Alternatively, health services by 2015. it is referred to as the age-specific fertility rate for women aged 15–19. See References, page 107. 20 T H E S TAT E O F T H E W O R L D ’ S C H I L D R E N 2 0 0 9

Focus On Prioritizing maternal health in Sri Lanka Sri Lanka is a story of success against the odds. A lower- sionalize midwives, and a no-blame policy helped make middle-income country – in 2006, Sri Lanka’s annual gross inquiries into maternal deaths routine. national income per capita was less than US$1,500 – it has also experienced a protracted civil conflict and the devas- The results were dramatic – maternal mortality was halved tation of the 2004 Indian Ocean tsunami. Yet the country’s between 1947 and 1950. Thirteen years later, maternal mor- progress in human development, particularly in maternal tality rates were cut in half again. Once health structures and and child health and education, has been one of the key networks were in place, increasingly better organization success stories among developing countries in recent and clinical management have allowed Sri Lanka to cut the decades. Sri Lanka’s maternal mortality ratio declined from maternal mortality ratio by 50 per cent every 6 to 11 years. 340 per 100,000 live births in 1960 to 43 per 100,000 live In addition, women’s literacy rose from 44 to 71 per cent births in 2005, and 98 per cent of births now take place in between 1946 and 1971. The rates of skilled attendance at hospitals. Rates of antenatal care (at least one visit) and birth and institutional delivery also grew. The public health skilled attendance at birth stand at 99 per cent. In 2007, the midwife’s role became more that of an institutional delivery country had an overall fertility rate of 1.9 – compared to assistant, as home midwife-assisted deliveries declined from 3.0 for the South Asia region. These results have also had 9 per cent in 1970 to just 2 per cent in 1995. Beginning in positive effects on child survival: The under-five mortality 1965, midwives also played a role in expanding government rate has fallen from 32 per 1,000 live births in 1990 to 21 family planning services. per 1,000 live births in 2007. The latest available data suggest that the neonatal mortality rate has also fallen, to Sri Lanka’s development of its health system has long been around 8 per 1,000 births in 2004. a model for other developing countries, demonstrating the degree of success that can be achieved in maternal and In basic education, too, Sri Lanka’s performance has been out- child health when sound strategies, sufficient resources standing. According to the latest international estimates, net and political commitment are judiciously applied. Despite primary school enrolment stands at more than 97 per cent its noteworthy advances in maternal and child health, chal- for both girls and boys, while literacy rates among young lenges remain. In recent years, the country has faced a people aged 15–24 are 97 per cent for males and 98 per cent shortage of health workers; according to the World Health for females. Administrative data suggest that the comple- Statistics 2008, in the 2000–2006 period the country had tion rate for primary school is 100 per cent. Given the posi- only 6 doctors and 17 nurses and midwives per 10,000 tive correlation between education and maternal and child inhabitants. In addition, services have deteriorated as survival, these are the results of sustained investment in all financial resources have been squeezed, with health three areas. spending at around 4 per cent of GDP in 2005. Private spending on health, most of which is out-of-pocket, The key to Sri Lanka’s outstanding improvements in mater- accounts for more than half of total health expenditure. nal health was the expansion of a synergistic package of health and social services to reach the poor. The country’s A further challenge for Sri Lanka will be to ensure food health system, which dates back to the late 19th century, security, particularly if global food prices remain high. The first targeted universal provision of improved health care, country still has marked levels of undernutrition among sanitation and disease management. It subsequently added newborns and children under five. According to the latest specific interventions to improve the health of women and international estimates, more than 1 in every 5 newborns children. Over the years, successive governments have fol- are born with low birthweight, and 23 per cent of children lowed a prudent approach of prioritizing health-care servi- under five are moderately or severely underweight. ces to mothers and the poor while spending economic and Improving the level of exclusive breastfeeding for children human resources judiciously. The resulting improvements less than six months old from its current level of 53 per cent in women’s health are supported and strengthened by will be vital to sustaining Sri Lanka’s gains in neonatal and measures to empower women socially and politically child mortality. through education, employment and social engagement. See References, page 107. Sri Lanka’s early written records and colonial past give a unique perspective of the evolution of maternal health in the country, starting with 9th- and 10th-century medical texts. Formal midwifery training was established under the British colonial government in 1879, and the Registrar General has recorded maternal mortality since 1902. This wealth of information and knowledge makes it possible to evaluate results of differing approaches to maternal health over time. Clear mandatory competencies helped profes- M AT E R N A L A N D N E W B O R N H E A LT H : W H E R E W E S TA N D 21

The centrality of Africa and Asia in the global challenges for children and women The continents of Africa and Asia* present the largest global challenges to the survival of children and women. Their progress in such critical areas as child and maternal health, nutrition and education, among others, is pivotal to achievement of the Millennium Development Goals. Deaths of children under five, 2007 Maternal deaths, 2005 Rest of the world: Rest of the world: 0.7 million (8%) 28,000 (5%) Africa: 276,000 Africa: 4.7 million (51%) Asia: 232,000 Asia: 3.8 million (51%) (43%) (41%) Source: UNICEF global databases. Source: UNICEF global databases. Deaths among children Maternal deaths under five • In 2005, the latest year for which firm estimates are available, an estimated 536,000 women died from • In 2007, 9.2 million children died before age five. causes related to pregnancy and childbirth. Almost Africa and Asia together accounted for 92 per cent all – 95 per cent – of these maternal deaths occurred of these deaths. in Africa and Asia. • Half of the world’s under-five deaths occurred in Africa, • Africa is the continent with the highest rate of maternal which remains the most difficult place in the world for a mortality, estimated at 820 maternal deaths per 100,000 child to survive until age five. live births in 2005. Asia’s rate of maternal death is 350 per 100,000 live births. • Although Asia has seen a remarkable reduction in the annual number of child deaths since 1970, it still • In Africa, the lifetime risk of maternal death is 1 in 26, accounted for 41 per cent of global under-five deaths four times higher than in Asia and more than 300 times in 2007. higher than in the industrialized countries. 22 T H E S TAT E O F T H E W O R L D ’ S C H I L D R E N 2 0 0 9

The full burden of maternal and child deaths in Africa and Asia – for each continent and for the two combined – is frequently understated due to the lack of continent-wide estimates for key Millennium Development Goal indicators. This panel presents a snapshot of key child and maternal indicators for Africa and Asia, and in their totality provides a complementary perspective to the regional breakdown presented in the Statistical Tables, pages 113-157 of this report. Aggregating the data on children from these two vast continents provides a stark reminder of the overwhelming importance of making rapid progress across both Africa and Asia if global development goals are to be realized. In the push to accelerate progress at the continental level, however, the often startling disparities in the status of women and children and in rates of progress within countries and continents must not be forgotten. The issue of disparities and inequalities affecting children will be examined in greater detail in future editions of The State of the World’s Children. Underweight children under five, 2007 Primary-school-age children out of school, 2007 Rest of the world: Rest of the world: 10 million (7%) 12 million (12%) Africa: 39 million (27%) Africa: 49 million (49%) Asia: 40 million Asia: 99 million (39%) (67%) Source: UNICEF global databases. Source: UNICEF global databases. Nutritional status of young children Primary education • In 2007, 148 million children under age five in the develop- • In 2007, 101 million children of primary school age were ing world were underweight for their age. not in school. • Two thirds of these children live in Asia, and just over one • Almost half of these children live in Africa, and 39 per cent quarter live in Africa. live in Asia. • Together, Africa and Asia account for 93 per cent of all under- • Across the two regions, approximately 20 per cent of weight children under age five in the developing world. girls and 16 per cent of boys of primary school age are either not enrolled or are not attending primary school. * Africa includes all member states of the African Union. Asia includes the countries in the UNICEF regions of East Asia and the Pacific and South Asia. Numbers may not always add up due to rounding. M AT E R N A L A N D N E W B O R N H E A LT H : W H E R E W E S TA N D 23

The global food crisis and its potential impact on maternal and newborn health The recent, precipitous rise in global prices that began in 2006 however, it is the poorest sections of society – who spend and continued in 2007–2008 has illustrated the vulnerability of the largest proportion of their disposable income on food – millions to hunger and undernutrition, particularly those in that are likely to be hardest hit by the food crisis. countries where food security is still a major concern. The sharp increases involved such basic foodstuffs as vegetable Addressing the special nutritional needs of mothers oils, grains, dairy products and rice. Although fluctuations in and newborns the prices of commodities are common, what distinguished During an emergency such as a food crisis, pregnant and the situation in 2008 was that the hike in world prices affects lactating mothers, together with infants, are among those not just a selected few products but nearly all major food and considered most at risk of undernutrition, owing to their feed commodities. higher nutritional requirements. For example, pregnant women require almost 285 additional calories per day, and lactating women require an additional 500 calories per day. Figure 1.8 Their micronutrient needs are also higher, and they require Food prices have risen sharply across the board* adequate intake of iron, folate, vitamin A and iodine to ensure the health of both mother and infant. 350 1998–2000 = 100 In the face of the food crisis, FAO has urged a rapid supply Oils and fats response to restore a better balance between food supply 300 and demand, especially in the countries worst affected. In Index of food commodity prices addition, while food aid is being supplied to countries, poli- 250 cies must be applied to offset patterns of food distribution Dairy between family members that may result in pregnant and Cereals lactating women consuming less than their minimum require- 200 ments. Where food aid is being provided to those most at risk of shortages and undernutrition, additional food for pregnant Sugar women should be supplied, usually as a take-home ration, 150 either through the general ration distribution or through sup- Meat plementary feeding programmes. Pregnant and lactating women may also require other complementary, nutrition- 100 J J A S O N D J F M A M J related interventions, including food fortification, micronutrient supplementation, additional safe drinking water, malaria 2007/2008 management during pregnancy, prophylaxis for management * The food commodity price indices displayed above are the weighted averages of of internal parasites, and nutrition education counselling. price indices from a basket of basic goods under each commodity group. The weights are the average export trade shares for 1998–2000. For examples, the Oils and Fats Price Index consists of the price indices of 11 different oils (including ani- Communication and advocacy campaigns concerning food aid mal and fish oils) weighted with average export trade shares of each oil product for 1998–2000. For a fuller explanation of the composition of each food commodity should highlight the special nutritional needs of pregnant and group index, see Source. lactating women and include messages to families and com- Source: Food and Agriculture Organization of the United Nations, Food Price munities explaining why these women are being provided Indices, <http://www.fao.org/worldfoodsituation/FoodPricesIndex/en>, accessed 1 extra food. The information should stress the importance of August 2008. exclusive breastfeeding for the first six months of a child’s life, with complementary feeding for older infants. For HIV-positive By June 2008, the Food and Agriculture Organization of the mothers, breastfeeding practices may differ, since the virus United Nations (FAO) had identified 22 developing countries can be transmitted through breast milk, depending on the as being particularly vulnerable to the food crisis. Its assess- availability and safety of replacement feeding. ment was based on a combination of three risk factors: Information and early warning continue to have a crucial role • An underweight prevalence rate of 30 per cent or more in in ensuring that timely and appropriate action can be taken to the population. avoid suffering. FAO’s Global Information and Early Warning • A high degree of dependence on imports of food staples System is demonstrating its capacity to alert the world to such as rice, wheat and maize. emerging food shortages. More needs to be done, however, • A high degree of dependence on imported petroleum to create strong response mechanisms to food crises and to products. develop national and international policies that prioritize and safeguard food and nutrition security – and take into account Comoros, Eritrea, Haiti, Liberia and Niger are among the the special nutritional needs of women and young children. countries that demonstrate worrisome levels of all three of these identified risk factors. It comes as little surprise that See References, page 107. most of these nations are among the least developed and lowest-income countries. Even within these countries, 24 T H E S TAT E O F T H E W O R L D ’ S C H I L D R E N 2 0 0 9

T H E S TAT E O F T H E W O R L D ’ S C H I L D R E N 2 0 0 9 Creating a supportive environment for 2 maternal and newborn health © UNICEF /HQ05-2185/Giacomo Pirozzi

Improving maternal and newborn health requires delivering essential services at critical times and in key locations where they can be readily accessed by women and children. Establishing and consolidating these continua of care necessitate more than just enhanced primary-health-care interventions; it also demands a supportive environment for mothers and children that safeguards and promotes their rights. The second chapter of The State of the World’s Children 2009 explores the fundamentals of the supportive environment and the ways in which it strengthens efforts to enhance primary health care. I n October 2008, more than 500 mothers and children. Other core pri- practitioners that the interrelated health leaders from 65 countries orities included disease control, access health needs of women, newborns met in Almaty, Kazakhstan, at to family planning, safe water supplies and children require the type of an international conference mark- and sanitation. Citizens were to be integrated solutions championed ing the 30th anniversary of the Alma- encouraged to participate in their own in the Alma-Ata Declaration. This Ata Declaration on primary health health care, particularly in the provi- recognition has resulted in renewed care. The participants exchanged expe- sion of preventive care and adoption interest in and support for integrat- riences from the past three decades of healthy behaviours and practices.1 ed frameworks of health-service and renewed their commitment to the (See Panel on page 29) delivery. Regular refinement of principles of primary health care as a such frameworks as the Integrated way of strengthening health systems. Considerable progress has been Management of Childhood Illness, The World Health Organization achieved across the developing world introduced by UNICEF and the launched the World Health Report in the 30 years that have ensued, in World Health Organization in 1992, 2008, which also addressed the theme controlling several major diseases, and collaboration between national of primary health care, on the eve of including polio and measles, and in and international partners over the the conference. reducing child mortality – particularly past two decades have recently in the post-neonatal period (between consolidated into a comprehensive The Alma-Ata Declaration, which 29 days and five years of age). Yet paradigm that integrates the hitherto emerged from a similar meeting given the widening inequities in health- often disparate programmes for convened by UNICEF and WHO in care provision between and within maternal and child health: the 1978 in the same city, in effect charted countries across the developing world, continuum of care for mothers, a new course for public health. It the Alma-Ata agenda of comprehen- newborns and children. advocated that countries broaden the sive primary health care – which remit of health care beyond medical emphasizes the importance of a sup- The continuum of care interventions to address the social, portive environment and preventive cultural and infrastructure constraints and curative interventions in determin- The continuum of care aims to inte- on providing quality health services to ing health outcomes – is perhaps as grate maternal, newborn and child all their citizens. A principal focus of pertinent today as it was in 1978. health care. Its central premise can be the primary-health-care approach that summarized as follows: essential serv- emerged from Alma-Ata is the same There is a growing recognition ices for mothers, newborns and chil- as the subject of this report: care for among health policymakers and dren are most effective when they are 26 T H E S TAT E O F T H E W O R L D ’ S C H I L D R E N 2 0 0 9

The interrelated health needs of women and newborns require integrated primary-health-care solutions. delivered in integrated packages at Figure 2.1 critical points in the life cycle of The continuum of care mothers and children, in a dynamic Connecting care during the lifecycle (A) and at places of caregiving (B). Adapted from Partnership health system that spans key loca- for Maternal, Newborn and Child Health, with permission. tions, underpinned by an environment A cy Neonata l pe an supportive of the rights of women egn rio Pr d and children. In fa Birth nc 28 days y The critical points for service delivery are adolescence, pre-pregnancy, preg- Death nancy, birth, post-partum, neonatal, Ageing 1 year years Pr infancy and childhood. escho Adulthood Childhood e ctiv ol y du 20 years 5 years The essential services for mothers, ro ea 10 years newborns and children include p rs Re basic health care, quality maternal, nc e ho Sc sce ol newborn and child health care, ade- Adole age quate nutrition and improved water Adolescence and Post-natal Pregnancy Birth Maternal health and sanitation facilities, and hygiene before pregnancy (mother) Post-natal practices. (newborn) Infancy Childhood The key delivery modes for services B Appr are household and community, out- op Hospitals and health facilities ria reach and outpatient, and health te facilities.2 Outpatient and outreach services re ferral an The supportive environment requires df respect for the rights of women and Family and community care o llo w-u children; quality education; a decent p standard of living; protection from abuse, exploitation, discrimination Source: Kevbes, Kate J., et. al., 'Continuum of Care for Maternal, Newborn and Child Health: From slogan to service delivery', The Lancet, vol. 370, no. 9595, 13 October 2007, p.1360. and violence; equal participation in home, community, social and political life; empowerment of women; the World’s Children 2008 and are • Health systems are most useful when and greater involvement of men in summarized here. they integrate dynamically the differ- maternal and child care. ent modes of care – facility-based, • Actions to improve the health of outreach and outpatient services, The continuum of care broadly women, newborns and children and community and family care. reflects a set of strategic principles are most effective and sustainable based on lessons learned from a cen- when they are integrated and • Strengthening health systems to tury of evolving health-care systems delivered in convenient, cost- improve health outcomes for and practices. These principles were effective packages to communities mothers and children requires explored in depth in The State of and families. combining and integrating the C R E AT I N G A S U P P O R T I V E E N V I R O N M E N T F O R M AT E R N A L A N D N E W B O R N H E A LT H 27

Much ill health among women during pregnancy is preventable, detectable or treatable through antenatal visits. A health worker prepares to measure a pregnant woman’s blood pressure at a clinic, Bangladesh. © UNICEF/HQ06-0954/Shehzad Noorani the exploration of the continuum of care for mothers and newborns begins by examining the various constituents of a supportive environment for the rights of women and girls. strengths of vertical and horizontal much less effective, sustainable approaches to health-service or even possible. Creating a supportive delivery, rather than choosing environment for women either approach in isolation. Consider, for example, the problem and children of low birthweight, which is a back- • A results-oriented approach to ground factor in 70 per cent of Improving maternal and newborn health-systems development, cen- neonatal deaths. Most low birth- health is not simply a practical matter tred on effective and evidence-based weight babies suffered intrauterine of making available better and more interventions, is useful in setting growth restriction in the womb, usu- extensive maternity services. It also agendas and policies and in moni- ally as a result of the poor nutritional involves addressing and reversing the toring and evaluating progress. and health status of the mother neglect of women’s rights and the before and during pregnancy. The structural discrimination and mal- • Results are best achieved through majority of such cases occur in South treatment often suffered by girls collaborative action between pro- Asia, the region with highest rates and women. grammes, policies and partnerships of undernutrition among girls and working towards improving mater- women, and the only one with clear Discrimination on the basis of gender nal, newborn and child care.3 evidence of gender discrimination in – often passed on from generation to nutrition among children under five generation by cultural tradition and These precepts form the basis and in adolescence.4 economic, social and political norms – of programmes, policies and part- has numerous pernicious effects. It nerships seeking to establish and Reducing neonatal deaths necessi- can deny girls and women access to extend continua of quality health tates not only the provision of ante- education, which research shows care for mothers, newborns and natal care and the attendance of could lower their exposure to the children. To be truly effective, skilled health personnel at delivery; risks of maternal and infant deaths.5 however, and to move closer to it also requires that girls and women It may prevent them from receiving, meeting the Alma-Ata challenge receive adequate nutrition and or from seeking, adequate health care of delivering primary health care health care from birth through and vital life skills to protect them for all, essential services for childhood and into adolescence, against sexually transmitted infec- mothers and children require a womanhood and their potential tions – including HIV – inadequate supportive environment that safe- childbearing years. birth spacing, violence, abuse and guards and promotes their rights. exploitation. It can constrain their Without actions to address gender This is but one example – more are income-earning capacity when they discrimination, inequities and given in the remainder of this chap- become women and can force them abuses that are perpetuated ter – of how the survival and health into a life of servitude and sub- against women and girls in particu- of newborns and children depend servience when they marry – often lar, actions in support of enhanced critically on the fulfilment of when they are still children under primary health care risk being women’s rights. For this reason, 18 years of age. 28 T H E S TAT E O F T H E W O R L D ’ S C H I L D R E N 2 0 0 9

Promoting healthy behaviours for mothers, newborns and children: The Facts for Life guide Creating a supportive environment for maternal and newborn Clear, brief and practical key messages explained recom- health requires altering behaviours that discriminate against mended actions and offered supplementary information. women and girls and adopting healthy practices that safeguard them from disease and injury. Healthy practices, such One underlying principle of the guide is that communication as exclusively breastfeeding an infant for the first six months involves more than simply providing information. It also of its life or washing hands with soap, must be evidence- requires presenting the information in an interesting and based and established by medical experts. accessible way and helping people understand its relevance. The guide also discusses ways to take action and overcome Describing these practices to parents and other caregivers in bottlenecks and barriers. non-technical language is critical to empowering women and girls and supporting maternal and newborn health. Twenty Facts for Life has been widely disseminated, with more than years ago, eight UN agencies – UNICEF, WHO, UNFPA, 15 million copies in circulation in 215 languages by 2002. the United Nations Educational, Scientific and Cultural A new edition of the guide is being prepared. Organization, the United Nations Development Programme, the Joint United Nations Programme on HIV/AIDS, the World Food Programme and the World Bank – jointly published a guide to make such life-saving knowledge available to everyone. The guide, entitled Facts for Life, was addressed to communicators – health workers, the media, government officials, non-governmental organizations, teachers, religious leaders, employers, trade unions, women’s groups, community organizations and others. Its third edition, published in 2002, addressed a broad range of topics: • Timing of births • Safe motherhood • Child development and early learning • Breastfeeding • Nutrition and growth • Immunization • Diarrhoea • Coughs, colds and more serious illnesses • Hygiene • Malaria • HIV and AIDS • Injury prevention • Disasters and emergencies C R E AT I N G A S U P P O R T I V E E N V I R O N M E N T F O R M AT E R N A L A N D N E W B O R N H E A LT H 29

Gender equality produces a double dividend, enhancing the lives of both women and children. In addition, the heavy workloads of life; and empowering them to claim Declaration of Human Rights, the women – who in general work longer their rights and essential services for 1989 Convention on the Rights of the hours than men – can deny them the themselves and their children. Greater Child and other human rights instru- time for leisure and rest. involvement of men in maternal and ments.6 It is also pivotal to improving newborn health care and in addressing maternal and neonatal health, reduc- Creating a supportive environment for gender discrimination and inequalities ing the incidence of child marriage – maternal and newborn health requires is also critical to establishing a sup- with its largely inevitable consequences challenging the social, economic and portive environment. The remainder of of premature pregnancy and mother- cultural barriers that perpetuate gender this chapter will briefly examine each hood, eliminating extreme poverty inequality and discrimination. This of these challenges in turn. and hunger, and enhancing knowledge will involve several key actions: edu- of health risks and life skills. Since dis- cating girls and women, and reducing Quality education and a crimination against girls and women is the poverty they experience; protecting decent standard of living known to begin early, promoting gen- girls and women from abuse, exploita- der equality and respect for the rights tion, discrimination and violence; fos- Securing a quality education of women and encouraging fathers to tering their participation and their play active roles in child care, should involvement in household decision- Education is a right for children and begin with early childhood education making and economic and political adolescents under the 1948 Universal programmes. Figure 2.2 Although improving, the educational status of young women is still low in several developing regions 26 Female net secondary West/Central Africa 66 school attendance 18 Female youth (15–24 years) Eastern/Southern Africa 69 literacy rate 43 South Asia 74 52 Middle East/North Africa 85 63 East Asia/Paciﬁc 98 N/A Latin America/Caribbean 97 CEE/CIS 76 99 44 World 85 22 Sub-Saharan Africa* 68 43 Developing countries 84 24 Least developed countries 65 0 20 40 60 80 100 percentage, 2000–2007 * Sub-Saharan Africa comprises the regions of Eastern/Southern Africa and West/Central Africa. Sources: Female youth literacy rate—UNESCO Institute of Statistics. Female net secondary school attendance—Demographic and Health Surveys and Multiple Indicator Cluster Surveys. 30 T H E S TAT E O F T H E W O R L D ’ S C H I L D R E N 2 0 0 9

Primary health care: 30 years since Alma-Ata The 1978 Declaration of Alma-Ata was groundbreaking The International Conference on Primary Health Care was itself because it linked the rights-based approach to health to a a milestone. At the time, it was the largest conference ever viable strategy for attaining it. The outcome document of the held devoted to a single topic in international health and devel- International Conference on Primary Health Care, the declara- opment, with 134 countries and 67 non-governmental organi- tion identified primary health care as the key to reducing zations in attendance. Yet there were obstacles to fulfilling its health inequalities between and within countries and thereby promise. For one thing, the declaration was non-binding. to achieving the ambitious but unrealized goal of “Health for Furthermore, conceptual disagreements over how to define All” by 2000. Primary health care was defined by the docu- fundamental terms such as ‘universal access’, which persist ment as “essential health care” services, based on scientifi- today, were present from the beginning. In the context of the cally proven interventions. These services were to be univer- cold war, these terms revealed the sharp ideological differ- sally accessible to individuals and families at a cost that com- ences between the capitalist and communist worlds, discord munities and nations as a whole could afford. At a minimum, perhaps heightened by the fact that the Alma-Ata conference primary health care comprised eight elements: health educa- took place in what was then the Union of Soviet Socialist tion, adequate nutrition, maternal and child health care, basic Republics. sanitation and safe water, control of major infectious diseases through immunization, prevention and control of local- As the 1970s gave way to a new decade, a tumultuous ly endemic diseases, treatment of common diseases and economic environment contributed to a diversion away from injuries, and the provision of essential drugs. primary health care in favour of the more affordable model of selective health care, which targeted specific diseases and The declaration urged governments to formulate national poli- conditions. Nonetheless, despite the mixed success of pri- cies to incorporate primary health care into their national health mary health care in the countries where it has been imple- systems. It argued that attention be given to the importance mented, advances in improving public health illustrate the of community-based care that reflects a country’s political community-based model’s flexibility and applicability. and economic realities. This model would bring “health care as close as possible to where people live and work” by Insufficient progress towards the Millennium Development enabling them to seek treatment, as appropriate, from Goals, coupled with the threats posed to global health and trained community health workers, nurses and doctors. It human security by climate change, pandemic influenza and would also foster a spirit of self-reliance among individuals the global food crisis, have led to renewed interest in com- within a community and encourage their participation in the prehensive primary health care. Yet the many challenges that planning and execution of health-care programmes. Referral prevented Alma-Ata’s implementation have evolved and systems would complete the spectrum of care by providing must be confronted to achieve its goals now. Drawing on the more comprehensive services to those who needed them growing body of evidence about cost-effective initiatives that most – the poorest and the most marginalized. integrate household and community care with outreach and facility-based services – such as those for maternal and child Alma-Ata grew out of the same movement for social justice health described in Chapter 3 – will enable governments, that led to the 1974 Declaration on the Establishment of a international partners and civil society organizations to New International Economic Order. Both stressed the interde- revitalize primary health care. pendence of the global economy and encouraged transfers of aid and knowledge to reverse the widening economic and See References, page 108. technological divides between industrialized countries and developing countries, whose growth had, in many cases, been stymied by colonization. Examples of community-based innovations in poorer countries after World War II also provided inspiration. Nigeria’s under-five clinics, China's bare- foot doctors and the Cuban and Vietnamese health systems demonstrated that advances in health could occur without the infrastructure available in industrialized countries. C R E AT I N G A S U P P O R T I V E E N V I R O N M E N T F O R M AT E R N A L A N D N E W B O R N H E A LT H 31

© UNICEF/HQ05-2374/Anita Khemka Outreach health providers bring vital services to communities and households. A community health worker holds up an infant growth chart during an education session for young mothers, India. Securing quality education for girls to wait until they are out of their than that of an infant born to a and young women is a key challenge teenage years – when pregnancy mother older than 19.11 of the Millennium Development risks are highest – before starting a Goals, which aim to achieve univer- family, and are also likely to have • Even if the child survives, he or sal primary education (MDG 2) and healthier babies.8 The benefits of she is more likely to suffer from to eliminate gender disparity at all delaying pregnancy until after ado- low birthweight, undernutrition levels of education by 2015 as part of lescence are high. Consider the fol- and late physical and cognitive efforts to promote gender equality lowing facts: development.12 and empower women (MDG 3). • Maternal deaths related to preg- The gains from education go Although considerable progress has nancy and childbirth are an impor- beyond reducing the risk of maternal been made in reaching gender parity tant cause of mortality for girls and newborn deaths and ill health. in primary education – all regions are aged 15–19 worldwide, accounting Research shows that educated women currently deemed to be on track to for 70,000 deaths each year.9 are more likely to delay marriage, meet this target – there are sizeable ensure their children are immunized, gaps in several countries and in West • The younger a girl is when she be better informed about nutrition and Central Africa in particular. becomes pregnant, the greater the for themselves and their children, and Furthermore, gaps have closed less health risks. Girls who give birth undertake improved birth spacing rapidly in secondary education.7 before the age of 15 are five times practices. In turn, their children have more likely to die in childbirth higher survival rates than those of Research has long confirmed the than women in their twenties.10 uneducated women and tend to be merits of education not only for better nourished.13 women and girls, but also for fami- • If a mother is under the age of 18, lies and societies. Studies show that her infant’s risk of dying in its first Education is also essential to the educated adolescents are more likely year of life is 60 per cent greater fulfilment of women’s rights. It 32 T H E S TAT E O F T H E W O R L D ’ S C H I L D R E N 2 0 0 9

Creating a supportive environment for maternal and newborn health requires challenging the social, cultural and economic barriers that perpetuate gender inequity. enhances women’s influence in Convention on the Rights of the young daughters and sons due to household decision-making and Child, it is linked to other rights strong social pressures at the com- opens up opportunities for women’s and is recognized in the Universal munity level. Worldwide, more than economic and political participation. Declaration of Human Rights as 60 million women aged 20–24 were the “right to free and full consent married before they reached the age Protection from abuse, to marriage” (article 16). The of 18.14 In the developing world exploitation, discrimination Convention on the Elimination of excluding China, the latest interna- and violence All Forms of Discrimination against tional estimates indicate that 36 Women states that “the betrothal per cent of women aged 20–24 were Preventing child marriage and the marriage of a child shall married or in union before the age have no legal effect” and calls upon of 18. In some regions, the incidence Child marriage is a violation of child states to set legal minimum ages for of child marriage is particularly rights, compromising the develop- marriage and to make marriage reg- high, at 49 per cent in South Asia, ment of girls and often resulting in istration compulsory (article 16). and 44 per cent in West and Central premature pregnancy and social Despite international commitment to Africa, according to the latest isolation. Although child marriage change, many societies and commu- estimates.15 is not directly addressed in the nities continue the marriage of their In addition to an increased risk of Figure 2.3 maternal death from pregnancy and childbirth, adolescent wives are also Gender parity in attendance has improved markedly, susceptible to violence, abuse and but there are still slightly more girls than boys out of exploitation. Child marriage also primary school increases the risk that adolescent girls Male will drop out of school – with atten- West/Central Africa 12 14 dant negative implications for mater- Eastern/Southern Africa 10 10 Female nal and newborn health and for South Asia 16 19 income-earning capacity, described Middle East/North Africa 3 4 previously. This, in turn, contributes East Asia/Pacific 2 3 to the vicious cycle of gender discrimi- Latin America/Caribbean 2 2 nation, with poorer families being CEE/CIS 1 1 more willing to permit the premature Industrialized countries 2 1 marriage of daughters out of econom- World 48 53 ic necessity.16 Sub-Saharan Africa* 22 24 Developing countries 47 52 Given the health risks associated with adolescent pregnancy and birth (see Least developed countries 21 22 page 32), the greater likelihood of ado- 0 10 20 30 40 50 60 70 80 90 100 110 Absolute number of primary-school-age children lescent pregnancy for girl wives, and out of primary school (millions), 2006 the high incidence of this practice across several developing regions, it is * Sub-Saharan Africa comprises the regions of Eastern/Southern Africa and West/Central Africa. evident that improving maternal health Source: Estimates derived by the Statistical Information Section, United Nations Children’s Fund, requires ending child marriage. This using attendance data from household surveys (Demographic and Health Surveys and Multiple Indicator Cluster Surveys) and UNESCO Institute of Statistics. will require, among other actions, C R E AT I N G A S U P P O R T I V E E N V I R O N M E N T F O R M AT E R N A L A N D N E W B O R N H E A LT H 33

stronger government legislation to set foster an open dialogue to address have undergone this practice. Though and enforce the age of 18 as the mini- and challenge the economic pressures the practice has declined, its preva- mum legal age of marriage, and to and societal traditions that perpetu- lence is still strong in several coun- promote both birth and marriage ate child marriage. tries and communities.17 registration; the former is required to establish the age of the child. Abandoning female genital In addition to being a rights violation, mutilation/cutting female genital mutilation and cutting While child marriage is becoming less Female genital mutilation and cutting pose serious risks for childbirth, common overall, the pace of change violates girls’ and women’s human heightening the possibility of such is slow. Challenging prevailing atti- rights, denying them their physical complications as obstructed labour tudes towards child marriage will also and mental integrity, their right to and post-partum haemorrhage in con- require addressing gender inequality. freedom from violence and discrimi- texts outside the hospital setting. Action by parties other than govern- nation and, in the most extreme ments is crucial, including religious cases, their lives. A study by the World Health and community leaders, as is the pro- Organization showed that not only motion of education, particularly at Around 70 million girls and women does female genital mutilation/cutting the secondary level. For their part, aged 15–49 in 27 countries of Africa (FGM/C) affect the reproductive civil society and the media can help and the Middle East are estimated to health of women and cause severe Figure 2.4 Child marriage is highly prevalent in South Asia and sub-Saharan Africa West/Central Africa 44 Eastern/Southern Africa 36 South Asia 49 Middle East/North Africa 18 East Asia/Pacific* 19 Latin America/Caribbean N/A CEE/CIS 11 Sub-Saharan Africa** 40 Developing countries* 36 Least developed countries 49 0 10 20 30 40 50 60 Percentage of women aged 20–24 years who were married or in union before they were 18 years old, 1998–2007 * Excludes China. ** Sub-Saharan Africa comprises the regions of Eastern/Southern Africa and West/Central Africa. Source: Demographic and Health Surveys, Multiple Indicator Cluster Surveys and other national surveys. 34 T H E S TAT E O F T H E W O R L D ’ S C H I L D R E N 2 0 0 9

Addressing the health worker shortage: A critical action for improving maternal and newborn health One of the biggest challenges for maternal and neonatal Organisation for Economic Co-operation and Development health is the shortage of skilled health personnel. A 2006 countries was equivalent to 23 per cent of the doctors still World Health Organization survey reveals that while Africa domestically employed in those countries. accounts for more than 24 per cent of the global disease burden, it has only 3 per cent of the world’s health workers and Demographic trends within countries are also strong influ- spends less than 1 per cent of total global resources dedicat- ences on the health worker shortage. Rapid urbanization in ed to health, even after loans and grants from abroad are developing countries is exacerbating the shortage of health taken into account. In contrast, the Americas region, which workers in rural areas, as trained professionals seek work covers Latin America and the Caribbean along with North in more affluent urban conurbations. Health workers, who America, has only 10 per cent of the global burden of disease usually qualify in urban settings, are often reluctant to base but commands 37 per cent of the world’s health workers and themselves in a rural location on the grounds that it involves spends more than 50 per cent of global resources allocated greater hardship, more basic living conditions and less to health. access to urban amenities and entertainment. One survey in South and South-east Asia found, for example, that rural According to the World Health Organization, the world is postings were shunned because of lower income, low pres- facing a shortage of 4.3 million health workers, with every tige and social isolation. region except Europe showing a shortfall. More specifically, there are not enough skilled health workers – doctors, nurses AIDS, too, is having a deleterious effect on health systems or midwives – to attend all the world's births. A study by the in the countries where it has reached epidemic proportions. Joint Learning Initiative found that countries needed an aver- Health workers in these countries face the same risks in their age of 2.28 health-care professionals per 1,000 people to private lives as other people in high-prevalence countries, achieve the minimum desired level of coverage for skilled but are also exposed to significant risks at work in circum- attendance at delivery. Of the 57 countries that fall below this stances where protective equipment and practices are often threshold, 36 are in sub-Saharan Africa. Although the coun- deficient. A 2004 study in South Africa indicated that younger tries with the largest shortages of health workers in absolute health workers there had an HIV-prevalence rate of 20 per terms are found in Asia – notably in Bangladesh, India and cent. Such workers deserve much greater protection and Indonesia – the largest relative need is in sub-Saharan Africa. care, including better supplies of protective equipment, safe- This region would need to increase its numbers of health ty schemes to prevent needle-stick injuries, prophylaxis in workers by 140 per cent to reach the requisite density. An the event of possible exposure to the virus, and antiretroviral earlier WHO estimate calculated that 334,000 skilled birth treatment if they become infected with HIV. attendants would need to be trained worldwide in the coming years to cover 73 per cent of births. Establishing continua of quality health care to reduce maternal and neonatal mortality and morbidity will require strate- Shortages of skilled health workers arise from many factors, gies to reduce the shortfalls in health-care personnel. While including underinvestment in training and recruitment, weak part of this gap will be filled by the recruitment and training incentives for health-care workers, low remuneration and of community health workers – whose resourcefulness has high levels of stress. Heavy migration of skilled health work- been shown to have great potential to provide basic services ers from developing countries to industrialized nations – – much more needs to be done to train and retain skilled spurred by the burgeoning demand for health workers in health-care workers, particularly in sub-Saharan Africa and industrialized countries with ageing populations – has also South Asia. taken its toll. A survey of 10 African countries showed that the number of locally trained doctors now working in eight See References, page 108. pain, it can also result in prolonged leads to an extra one to two perinatal Abandoning female genital mutila- bleeding, infection, a variety of deaths per 100 deliveries.18 tion and cutting is critical to ensur- reproductive health problems including safe motherhood and reducing ing infertility, and even death. It also The risks to both mothers and neonatal deaths. Successful initia- affects newborns of women who babies increase according to the tives in Senegal and other countries have been subjected to the practice. severity of the mutilation, but can where female genital mutilation and The study provides clear evidence include shock, haemorrhaging, cutting is widespread are based on that complications in deliveries are infection and ulceration of the the collective abandonment of this significantly more likely among genital area – all of which increase practice through community women with FGM/C. It also found the risks of maternal and neonatal empowerment, open dialogue that FGM/C is harmful to babies and mortality and distress.19 and a collective consensus.20 C R E AT I N G A S U P P O R T I V E E N V I R O N M E N T F O R M AT E R N A L A N D N E W B O R N H E A LT H 35

© UNICEF/HQ06-2778/Bruno Brioni Enhancing health facilities and strengthening referral systems are effective ways of improving maternal and newborn health. A mother watches as her infant is weighed by a health care worker at a maternal and child health centre, Côte d'Ivoire. Eliminating violence, abuse and women and girls and increased risk • Violence before or during pregnan- exploitation of women and girls of maternal mortality and morbidity. cy can lead to multiple health risks Violence is prevalent in all societies. for the mother and child, including It undermines the physical health • A study of 400 villages in rural miscarriage, preterm labour and and emotional and psychological India revealed that 16 per cent of fetal distress. It can also prevent well-being of its victims. Gender all deaths among pregnant women them from seeking medical care. A inequities within households, work- were due to partner violence.22 study from Nicaragua has shown places and societies can foster a that around 16 per cent of low permissive context for violence. • Sexual violence, especially rape, birthweight in infants was related can result in involuntary pregnan- to physical abuse of a partner The extent of violence against cies, particularly when used as a during pregnancy.25 women and girls and its impact on weapon of war in such conflicts as them has long been acknowledged. those in Bosnia and Herzegovina • There are also reproductive impli- Until relatively recently, however, its and in Rwanda, when women cations of violence against women, measurement was largely restricted to were raped repeatedly until they including chronic pain, genital specific studies. Large-scale studies conceived.23 bruising and scarring, and un- by the World Health Organization healthy weight loss.26 and the recent United Nations studies • Data suggest that involuntary preg- on violence against women and chil- nancies carry a greater risk than • The psychological consequences of dren have revealed astounding levels those that are wanted and that violence against women can also be of violence against women and chil- women with unwanted pregnancies devastating: depression, stress and dren, but also sharp disparities in lev- are less likely to receive early ante- anxiety disorders, post-traumatic els within countries and regions.21 natal care or give birth under med- stress and suicide.27 The health consequences of violence ical supervision. Such pregnancies increase the risk of poor physical and may also carry a greater risk of • Violence against mothers can create reproductive outcomes. Although unsafe abortion – a significant difficulties for the care and feeding many of the studies are indicative cause of maternal death – depres- of newborns. In addition, increasing rather than conclusive, they show a sion, suicide and adverse family evidence suggests that infants and correlation between violence against reactions to the pregnancy.24 young children are also at risk from 36 T H E S TAT E O F T H E W O R L D ’ S C H I L D R E N 2 0 0 9

Combating violence against women and children is critical to improving maternal and newborn health. violence, and that deaths from phys- regions reported that they were not newborn health. When women are ical violence are underestimated.28 fully involved in household able to participate in key decisions, decision-making.29 studies have shown that they are Combating violence and abuse more likely to ensure that their chil- against women and girls is a multi- Enabling women to participate more dren are well nourished and to seek faceted process that will require equally in the critical and routine appropriate medical care for them- strong action from governments, civil decision-making processes that affect selves and their children.30 societies, international partners and their lives, and those of their chil- communities to confront and address dren, is pivotal to creating a support- Enhancing women’s ability to parti- both the direct and underlying causes ive environment for maternal and cipate in household decisions is only and consequences. Comprehensive mechanisms, covering legislation Figure 2.5 and its enforcement, research, pro- Female genital mutilation/cutting, though in decline, grammes and budgets, increasing is still prevalent in many developing countries women’s voices in the debate and sustaining attention on the issue, Somalia 98 will be imperative to reduce violence Egypt 96 from its current level. Guinea 96 Sierra Leone 94 Djibouti 93 Participation in family, Eritrea 89 community, economic, social Sudan 89 Mali 85 and political life Gambia 78 Ethiopia 74 Discrimination on the basis of gen- Burkina Faso 73 der can prevent women – the pri- Mauritania 72 45 mary caregivers for children in all Chad Guinea-Bissau 45 societies – from fully participating Côte d’Ivoire 36 in the critical decisions and actions Kenya 32 taken in households and communi- Senegal 28 ties that can affect maternal and Central African Republic 26 Yemen 23 child health. This issue was exam- Nigeria 19 ined extensively in The State of the United Republic of Tanzania 15 World’s Children 2007: The double Benin 13 dividend of gender equality, which Togo 6 Ghana 4 showed that in a number of coun- Niger 2 tries across sub-Saharan Africa, Cameroon 1 South Asia and the Middle East and Uganda 1 North Africa, more than one third Zambia 1 of women surveyed said that their 0 20 40 60 80 100 husbands alone made the decisions Percentage of girls and women aged 15–49 who have been mutilated/cut, 2002–2007* regarding their health care. A considerable percentage of women sur- * Data refer to the most recent year available during the period specified. veyed in 30 countries across six Source: Demographic and Health Surveys, Multiple Indicator Cluster Surveys and other national surveys. C R E AT I N G A S U P P O R T I V E E N V I R O N M E N T F O R M AT E R N A L A N D N E W B O R N H E A LT H 37

Towards greater equity in health for mothers and newborns by Cesar G. Victora, Professor of Epidemiology, Universidade Federal de Pelotas, Brazil The issue of equity in health outcomes, and in access to mothers from the richest income quintile in that region. The essential primary-health-care services, is receiving greater other developing regions exhibit similar disparities; even in attention in the field of maternal, newborn and child health. Europe and Central Asia – where most countries with survey This focus is increasingly supported by emerging evidence information are former socialist republics – the proportion of and research on the extent of disparities in health and other deliveries attended by skilled health personnel is significantly development areas. Inequities are defined as systematic lower for the poorest women than for the most affluent. differences between population groups that are unfair and avoidable, and generally include disparities related to Other measures of disparity in health-care provision are also socio-economic position, gender, ethnic group and place pronounced. Urban mothers and children in developing coun- of residence, among other factors. tries tend to have greater access to health care and better health status than their rural counterparts. Socio-economic Having a skilled attendant at delivery – a key intervention for inequities are similarly marked within urban areas, where improving maternal and neonatal health and survival – is health conditions among slum dwellers are particularly among the most inequitably distributed health interventions. adverse. Within countries, state and provincial differentials in Figure 2.6 shows the average share of births attended by maternal and child health are also often wide, as exemplified skilled health personnel, based on results from recent nation- by the sharp variations in health indicators between Brazil’s al surveys of low- and middle-income countries. There are more prosperous southern states and its more impoverished marked inequalities between the regions of the world, with north-eastern regions. Europe and Central Asia showing the highest coverage levels for all income groups, and sub-Saharan Africa and South Asia Poor mothers and children are underserved along the whole in particular trailing well behind. continuum of care. Data from several sub-Saharan African countries were used to document the proportion of mothers In addition to variations between regions, within each region and children who received a package of four essential inter- there are important disparities by socio-economic position – as ventions: antenatal care, skilled attendance at delivery, post- observed by comparing skilled attendance at delivery across natal care and childhood immunization. Coverage with all income quintiles. Among the poorest 20 per cent of South four interventions was two to six times higher – depending Asian mothers, fewer than 10 per cent of births are delivered on the country – among the richest groups than it was in the by a skilled attendant, compared to 56 per cent of births for poorest groups. This inequitable pattern of health-care Figure 2.6 Mothers who received skilled attendance at delivery, by wealth quintile and region Delivery attended by a medically trained person (%), 1991–2004 100 Europe and Central Asia* Latin America and Caribbean* 80 East Asia and Pacific* 60 Middle East and North Africa* Sub–Saharan Africa* 40 South Asia* 20 0 Poorest 2nd 3rd 4th Richest Wealth quintiles * See References on page 108. Source: Gwatkin, D. R., et al., Socio-economic differences in health, nutrition, and population within developing countries: An overview, Health, Nutrition and Population, World Bank, Washington, D.C., September 2007, pp. 123–124. 38 T H E S TAT E O F T H E W O R L D ’ S C H I L D R E N 2 0 0 9

provision both reflects and entrenches the social exclusion sector. Figure 2.7 shows how implementation of the Accelerated faced by the poorest and the most marginalized groups and Child Survival and Development (ACSD) strategy has reduced helps explain why maternal, neonatal and child mortality show inequities in access to antenatal care in Mali. Whereas both such marked socio-economic variations. ACSD and control districts showed marked social disparities before the programme was deployed in 2001, five years later Health systems have an important role in overcoming these access to antenatal care was significantly more equitable in dis- disparities. Examples from across the developing world show tricts with ACSD than in the control areas. The ACSD strategy that much can be, and is being, done to address and reduce relied heavily on outreach initiatives aimed at improving access disparities in access to essential services. for rural mothers living in remote areas. This finding, however, was not replicated in other ACSD countries where outreach • In the United Republic of Tanzania, prioritizing interventions activities were not strongly implemented. to combat diseases that affect poor mothers and children, and allocating district health budgets preferentially to these The reduction of inequalities in health is essential for the full conditions, led to marked reductions in mortality. achievement of human rights. Gaps in health-care provision contribute to the generation of these inequalities; consequently, • In Peru, the poorest departments (provinces) in the country health systems also play a role in their elimination. This is par- are earmarked as the first to receive new vaccines; only after ticularly true because the greatest gains in maternal, neonatal high coverage levels are reached in these districts are vac- and child survival depend on effectively reaching the poorest cines rolled out to the rest of the country. and the most marginalized, who suffer the greatest burden of disease. There are many examples of successful initiatives that, • In Bangladesh, the Integrated Management of Childhood when implemented with sufficient political support and ade- Illness (IMCI) strategy was systematically deployed in the quate resources, have led to substantial reductions in health poorest areas of the country; a similar strategy is employed inequities. The main challenge for countries and societies is to by Brazil’s Family Health Programme. disseminate these success stories, adopt best practices, and generate and sustain the political will to put equity at the top of Because the poor are more likely to live in rural and remote the health agenda. areas, use of appropriate channels for reaching them with essential services should be a primary concern of the health See References, page 108. Figure 2.7 Women in Mali receiving three or more antenatal care visits, before and after the implementation of the Accelerated Child Survival and Development (ACSD) initiative 80 ACSD districts (2006, Women receiving 3 or more antenatal visits (%) 70 post-implementation) Control group 60 (2006) ACSD (2001, 50 pre-implementation) Control group 40 (2001) 30 20 10 0 Poorest 2nd 3rd 4th Richest Wealth quintiles Source: Johns Hopkins University 2008. C R E AT I N G A S U P P O R T I V E E N V I R O N M E N T F O R M AT E R N A L A N D N E W B O R N H E A LT H 39

Figure 2.8 part of the solution. Evidence from Many women in developing countries have no say in Demographic and Health Surveys indicates that much of women’s their own health-care needs decision-making power is exerted Mali 75 at the community level.31 When women are empowered to participate Burkina Faso 74 in their communities, they can chal- Nigeria 73 lenge the attitudes and practices Malawi 71 that entrench gender discrimination, Benin 61 share work, pool resources and col- Cameroon 58 lectively devise and sustain initiatives Nepal 51 to improve maternal and newborn Bangladesh 48 health. It is the acumen of women Rwanda 48 acting collectively that is among the Zambia 47 strongest reasons why most newborns Kenya 43 and mothers survive pregnancy and Egypt childbirth. 41 United Rep. of Tanzania 39 Increasing women’s participation in Uganda 38 key decision-making processes in Ghana 35 employment and political life is also Morocco 33 critical to improving maternal and Mozambique 32 newborn outcomes. Improving Zimbabwe 32 economic status can be vital to Haiti 21 enhancing women’s participation Armenia 20 in decision-making, with attendant Peru 16 implications for the health of their Indonesia 13 children. When women have greater Madagascar influence in the management of 12 household decisions, they are more Jordan 12 likely than men to ensure that chil- Nicaragua 11 dren eat well and receive medical Bolivia 10 care.32 Owning assets can also enhance Turkmenistan 9 women’s influence in household Eritrea 9 decision-making; a study in rural Colombia 9 Bangladesh showed that women who Philippines 5 have a greater share of assets than 0 10 20 30 40 50 60 70 80 their husbands before their own wedding have a stronger influence Percentage of women who say their husbands alone made the decisions regarding their health care, 2000–2004* on household decision-making.33 * Data refer to the most recent year available during the period specified. Source: UNICEF calculations based on data derived from Demographic and Health Surveys. Despite some progress at increasing their representation in national legisla- 40 T H E S TAT E O F T H E W O R L D ’ S C H I L D R E N 2 0 0 9

Encouraging women to participate more fully in decision-making is key to creating a supportive environment for mothers and newborns. tures, women still accounted for less fits of women’s participation go well best possible care during pregnancy than 19 per cent of parliamentarians beyond their impact on health out- and delivery and will safeguard the worldwide as of May 2008.34 comes. They enable communities and health of their babies. According to United Cities and Local societies to focus attention on the criti- Governments, an organization that cal issues that affect two thirds of their Cooperation between women at has been publishing data on women citizens – women and children – and a local level is often a vital encour- in local decision-making since 2003, to arrive at decisions from a richer agement for women’s empowerment. they are also underrepresented in base of influences and considerations. Informal women’s groups generally municipal governments, accounting gather for a practical purpose, such for just 9 per cent of mayors in 60 Empowering women and girls as organizing a vegetable garden countries surveyed and 21 per cent to provide a source of income inde- of local councillors in 67 countries There is a considerable body of pendent of their husbands – though surveyed.35 Given their limited, and evidence testifying to the multiplier the sense of solidarity and the prob- relatively recent, engagement in par- effects of investing in gender equal- lems shared in such groups can add liamentary politics, the influence of ity and women’s empowerment. to the sense of empowerment and women parliamentarians in determin- Targeted investments in the edu- to the demand for better maternal, ing maternal and newborn health out- cation, reproductive health, and neonatal and child health services. comes is still unclear. The evidence economic and political rights of suggests, however, that women parlia- women can bring about progress Involving men and mentarians are likely to strongly sup- in poverty reduction, sustainable adolescent boys in port and promote measures to assist development and peace. maternal and newborn women and children – prioritizing ini- health and care tiatives to provide improved child The focus on wider economic care and strengthen women’s rights.36 and social benefits in international Men are often conspicuously absent reports is understandable – they from reports advocating gender Women’s groups can also make a dif- are often making a case for invest- equality – except in so far as they ference at the local level. In 2004, ment that competes with other represent the problem. They may the advocacy by women’s rights development priorities for limited appear in the guise of abusers or activists persuaded the Government funds. But it is easy to lose sight domestic tyrants, as wasters frittering of Morocco to support a landmark of the benefits of women’s empower- away precious family income on family law countering gender ment in and of itself. Women who inessentials or as irresponsible sexual inequality and protecting children’s are empowered are more able to partners taking no responsibility for rights. In the same year, women’s take control of their own lives, act contraception. groups in Mozambique successfully as change agents in their communi- campaigned to raise the legal age of ties and actively pursue the best In the field of maternal and newborn marriage by two years to 16 with interests of their children and fami- health, men are generally missing parental consent and to 18 without.37 lies. This may take the form of from the literature. The hundreds of ensuring that income entering the millions of fathers and partners who Empowering women to participate household is spent on the things are actively involved in seeking the more fully in household decisions, the that matter most, such as nutritious best possible maternity care and who economy and political life is key to food, education and health care. take full parental responsibility for creating a supportive environment for It may also mean demanding the their children’s well-being could be mothers and newborns. But the bene- services that will afford women the forgiven for feeling disregarded. C R E AT I N G A S U P P O R T I V E E N V I R O N M E N T F O R M AT E R N A L A N D N E W B O R N H E A LT H 41

Focus On Adapting maternity services to the cultures of rural Peru Peru, a lower-middle-income country where 73 per cent of the • Fostering family and community support to make maternity population lives in urban areas, has made enormous progress and the mother’s condition a priority. in reducing child deaths from 1 in every 6 children in 1970 to 1 in 50 by 2006. Between 1990 and 2007, the country’s under- • Increasing access to the lntegral Health Service, which five mortality rate dropped by 74 per cent – the fastest rate of covers the cost of antenatal, intrapartum and post-partum decline in the entire Latin American and Caribbean region for care for poor families. that period. It has had less success, however, in the area of maternal health. Its maternal mortality ratio, estimated at 240 • Adapting maternity services to eliminate barriers between maternal deaths per 100,000 live births in 2005, is among the the staff at health facilities and mothers who have deeply highest in the region. Moreover, Peruvian women face a life- rooted cultural traditions for childbirth. time risk of maternal mortality estimated in 2005 at 1 in 140, twice the regional average of 1 in 280. The maternal waiting houses, dubbed ‘Mamawasi’, are constructed to encourage women in rural areas to choose the The country’s relative lack of progress in reducing maternal option of giving birth in health centres instead of at home. deaths has resulted in its inclusion on the expanded list of Currently, there are almost 400 houses located on grounds priority countries for the Countdown to 2015 initiative, whose belonging to health centres or hospitals; others are in rented criteria have now been broadened to include maternal mor- buildings in the regions of Apurímac, Ayacucho and Cuzco. tality thresholds in addition to those for child mortality set Pregnant women from near and distant communities can out in 2005. According to the Ministry of Health, women in stay in the waiting rooms until they deliver. Women from rural areas are twice as likely as those in urban areas to die remote villages may stay for weeks or months. The from causes related to pregnancy. A skilled attendant was Mamawasi is designed to resemble a typical indigenous present at just 20 per cent of deliveries in rural communities family home in a farming village. Expectant mothers are in 2000, compared to 69 per cent in urban areas. allowed to bring family members with them to the houses, which increases their confidence and comfort level in Like other Latin American and Caribbean countries, Peru’s using the service. challenge for improving maternal and newborn health – and greatest potential for progress – is to address disparities Health centres have also changed their practices. For due to ethnicity, geography and extreme poverty. This will instance, the vertical birth position is accommodated, a require delivering quality services to women and infants in family member or traditional midwife is allowed to accompa- or near their places of residence and providing integrated ny women during birth, and the centres are kept at a warmer routine and emergency maternity and newborn care. temperature. Part of the challenge is to adapt current health services, often This programme has transformed everyday health services facility-based or outreach, to the customs of the communities by promoting cultural sensitivity in health care. Huancarani currently underserved by the health system. For example, district, located in the Andean province of Paucartambo, in following tradition and cultural practice, rural women may the Cuzco region, has been the most successful in imple- prefer to give birth at home in an upright position, under the menting the new strategy. Overall, almost 3 out of every 4 guidance of traditional birth attendants, rather than in a health pregnant women now visit health-care centres in the regions centre delivery room. Moreover, even if these mothers did served, especially for childbirth, whereas previously the ratio decide to seek formal care, distance to a health facility, cost was 1 in 4. The programme has been integrated into district of services, language barriers and other impediments might and provincial health policies and was adopted in 2004 by deter them. the Ministry of Health as a national standard to be implemented throughout the country. The Ministry of Health has Ensuring that mothers have the option of delivering in their also created training modules to teach health personnel how homes, with the assistance of skilled birth attendants and a to make services culturally appropriate. strong referral system to emergency obstetric care, if it is needed, may be an appropriate way to integrate formal See References, page 108. health services with traditional practices. Towards this end, the Ministry of Health, in conjunction with UNICEF Peru, has developed a maternal health project that includes four key strategies: • Establishing maternal waiting houses to resolve the difficulty posed by geographic distance from health services. 42 T H E S TAT E O F T H E W O R L D ’ S C H I L D R E N 2 0 0 9

Focus On Southern Sudan: After the peace, a new battle against maternal mortality After 21 years of conflict, civil war between the north and ment and supplies, poor referral systems and inadequate south of the Sudan came to an end in 2005. While the physical infrastructure and transportation also impede fighting has mostly ceased, Southern Sudan is facing health-care delivery. Post-natal care services are virtually another struggle – against maternal and neonatal mortali- non-existent, despite the fact that most of the maternal ty. According to the 2006 Sudan Household Health and newborn deaths in Southern Sudan occur during the Survey, the maternal mortality ratio for Western Equatoria, post-natal period. a province in Southern Sudan, stood at 2,327 deaths per 100,000 live births, one of the highest in the world. The Against this background, the Government of Southern 2006 neonatal mortality rate was 51 deaths per 1,000 live Sudan and its partners are making efforts to strengthen births, significantly above the Sudan’s national ratio of maternal health services. The Interim Health Policy for 41 per 1,000 live births. 2006–2011 outlines an integrated approach that recognizes the need to improve health services while protecting Overall health-care coverage, mostly managed through a women's rights. The Ministry of Health has committed to small number of non-governmental organizations, is esti- establishing more primary, reproductive and maternal mated at just 25 per cent. Even when health care is avail- health facilities, while supporting the use of mass media able, maternal health services are limited and not often and counselling services to disseminate information on used. Part of the reason may be a lack of education. The nutrition, harmful traditional practices and sexual health. United Nations Population Fund (UNFPA) estimates that in To meet immediate health-care needs, community 2006 the literacy rate for Southern Sudanese women was midwives who hold basic qualifications are being ‘fast- just 12 per cent, compared to 37 per cent for men; women tracked’, with support from UNFPA. In June 2006, the first therefore have limited access to health information. fistula repair centre in Southern Sudan was established at the Juba Teaching Hospital. Another possible reason is that pregnant women must travel long distances on foot to reach antenatal centres; To accelerate implementation of this strategy, the consequently, attendance rates vary sharply depending on Government has already established a Reproductive location, from 17.4 per cent in Unity State in 2006 to nearly Health Directorate and is recruiting state coordinators to 80 per cent in Western Equatoria. Fewer than 15 per cent facilitate, monitor and coordinate maternal and neonatal of births in Southern Sudan are attended by skilled health health activities in each state. UNICEF is supporting the personnel, and 80 per cent take place at home under the expansion of antenatal and emergency obstetric services supervision of relatives, traditional birth attendants or vil- in several states and the dissemination of key health mes- lage midwives (a female birth attendant who has typically sages over the radio and through community outreach. received around nine months of training). Yet most of the causes of maternal death – including prolonged obstructed There are challenges ahead. The return of refugees and labour, haemorrhage, sepsis and eclampsia – could be the movements of many displaced populations, Southern managed by better-trained attendants. Sudan’s high fertility rate (6.7) and increasing rates of HIV infection among some populations necessitate a system- The quality of available antenatal and delivery services is atic health programme. The struggle may be a long one, low due to a lack of technically skilled service providers. but those committed to winning it are already at work. In all 10 states of Southern Sudan, midwives, traditional birth attendants and other maternal and neonatal care See References, page 108. providers lack the necessary training required to perform simple lifesaving or nursing procedures. Lack of equip- C R E AT I N G A S U P P O R T I V E E N V I R O N M E N T F O R M AT E R N A L A N D N E W B O R N H E A LT H 43

The other side of the coin is that in Evidence has shown that men the sexes and encouraging a more removing men from the picture, they are more likely to be engaged, equal division of childcare duties. may somehow be let off the hook, participatory fathers when they In addition, workplaces need to validated in their lack of responsibili- feel positive about themselves recognize the role played by both ty for this most essential aspect of and their relationships, and parents in child rearing, so that family life. when families and friends sup- men as well as women are encour- port their involvement in their aged to reconcile their work and The birth of a child, particularly children’s lives. A man who family responsibilities. a first child, is often a landmark shares the responsibility for moment in a man’s life. It can parenthood is also more likely Linking the supportive crystallize his sense of himself as a to share the household decision- environment to the caring, responsible human being on making with his female partner, continuum of care whom other people depend. More thereby contributing to her own generally, involving men in the care empowerment.38 Creating a supportive environment of their pregnant partners and for maternal and neonatal health newborn children can be a signifi- Programmes that encourage the will provide a strong foundation cant opportunity to establish participation of both men and for upscaling essential interventions a positive, supportive relation- women can help this process by within a dynamic continuum of care, ship that will last a lifetime. increasing communication between which is the focus of Chapter 3. 44 T H E S TAT E O F T H E W O R L D ’ S C H I L D R E N 2 0 0 9

T H E S TAT E O F T H E W O R L D ’ S C H I L D R E N 2 0 0 9 3 The continuum of care across time and location: Risks and opportunities © UNICEF/HQ06-0567/Shehzad Noorani

An effective continuum of care delivers essential services for mothers and children at critical points in adolescence, pre-pregnancy, pregnancy, birth, post-natal and neonatal periods and at key locations of the household and community, through outreach/outpatient interventions and in health facilities where they can be readily accessed by women and children. Community partnerships in health are essential components of a continuum of care. Perhaps most vital to reducing maternal and newborn mortality, however, are quality antenatal care, skilled health personnel attending deliveries and post-natal care for mothers and newborns. Ensuring that emergency obstetric and newborn care is available to address birth complications could save many lives currently lost during childbirth and the early neonatal period. The third chapter of The State of the World’s Children 2009 examines the key services underpinning the continuum of care and how these interventions can be expanded and improved. The continuum of care: Chapter 3 outlines the essential Subsequently, a new MDG frame- Delivering services at services required to support a con- work was adopted and the revised critical points tinuum of maternal and neonatal goals of January 2008 include a At every stage of life, from childbirth care, including enhanced nutrition; reproductive health target (see Panel, to old age, there are pressing health safe water, sanitation and hygiene page 20, for details of the new demands. The services that aim to facilities and practices; disease target and indicators). respond to the interrelated health prevention and treatment; quality needs of mothers and newborns reproductive health services; The new target reflects, in part, require high levels of continuity adequate antenatal care; skilled a growing consensus on the need and integration – characteristics assistance at delivery; basic and to improve reproductive health. that have not always been evident comprehensive emergency obstetric Another goal is to curb the growing in national and international health and newborn care; post-natal incidence of reproductive tract and policies, programmes and partner- care; neonatal care; and Integrated sexually transmitted infections, ships seeking to improve maternal Management of Neonatal and including HIV. The World Health and newborn health. Childhood Illness. Organization (WHO) has identified unsafe sex as the second most The continuum of care framework This chapter also briefly examines important risk factor for death and aims to transcend the traditional the points of delivery for health serv- disability in the poorest countries emphasis on single, disease-specific ices: at the household and communi- and the ninth most important in interventions. It advocates a model ty level, outreach and outpatient developed countries.2 Almost half of primary health care that embraces services, and facility-based care. of all new HIV infections occur in every stage of maternal, newborn young people, particularly women, and child health. The success of Quality reproductive health with around double the number of services this framework, however, depends women as men infected with HIV in on delivering essential services and While targets for reproductive health sub-Saharan Africa.3 implementing improved practices were not initially included in the at key points in the life cycle, link- Millennium Development Goals Building reproductive health capaci- ing mothers, newborns and their (MDGs), at the World Summit in ty at the national level will necessi- households and communities with September 2005 the decision was tate identifying problems, setting quality basic health care and mater- taken to achieve universal access to priorities and formulating strategies nity services.1 reproductive health by 2015. with the participation of all stake- 46 T H E S TAT E O F T H E W O R L D ’ S C H I L D R E N 2 0 0 9

Adequate nutrition for women, including increased food intake and micronutrient supplementation, is critical to the health and survival of mothers and newborns. holders. WHO has identified five 18.5 kg/m2) for pregnant women to strengthen the nutritional status of key priorities for action on repro- increases the risk of both maternal pregnant women and mothers. ductive health-care services. These and neonatal mortality; the same include strengthening health systems applies if a mother is stunted. Low Folic acid supplementation to prevent capacity; improving information body mass can restrict the growth neural tube defects has proved suc- for setting priorities; mobilizing of the fetus, which is a risk factor cessful, and in general, antenatal political will; creating supportive for neonatal conditions such as programmes should also offer other legislative and regulatory frame- low birthweight.5 micronutrients, such as zinc. There are works; and strengthening monitor- proven links between zinc deficiency ing, evaluation and accountability.4 Programmes targeted towards improv- and stunting, diarrhoea and malaria.6 ing maternal health are increasingly Enhancing nutrition for mothers focusing on enhancing the nutrition of Gaining the confidence of pregnant and newborns girls and women across the life cycle. women through such programmes Adequate nutrition for adolescent Along with increased food intake, of micronutrient supplementation girls and pregnant women is criti- folic acid and iron supplementation can be a useful way to encourage cal for the health and survival are being encouraged during pre- their continued attendance for other prospects of both mothers and pregnancy and pregnancy, and vitamin forms of professional antenatal newborns. The undernutrition of A supplementation during the post- care. Increased use of clinics and young mothers increases the health partum period. In addition, dietary hospitals will also help in collecting risks for both them and their babies. diversification, the use of iodized salt data on the health of pregnant A low body mass index (less than and deworming are key interventions women and mothers, which is More skilled health work- © UNICEF/DJBA00265/Giacomo Pirozzi ers are needed to provide vital services to women at critical points during pregnancy. A pregnant woman lies on a table as a nurse performs an antenatal consultation at the Engueila Health Centre, Djibouti. T H E C O N T I N U U M O F C A R E A C R O S S T I M E A N D L O C AT I O N : R I S K S A N D O P P O RT U N I T I E S 47

Reducing the incidence of infectious conditions and preventing and treating HIV and malaria are vital to improving maternal and newborn health. particularly scarce in the least transmitted infections, and preventing the 17 countries with sufficient data, developed regions and poorest and treating HIV and malaria, are HIV prevalence rates among pregnant countries and communities. therefore critical to improving mater- women aged 15–24 have declined nal and newborn health (see Panel on since 2000/2001.7 This positive devel- Addressing infectious diseases, Eliminating maternal and neonatal opment is encouraging, but much HIV and malaria tetanus, page 49). more needs to be done to boost HIV As Chapter 1 underscored, severe prevention activities and to address infections are among the leading Preventing HIV infection in women the social, economic and political direct causes of maternal and neo- of childbearing age and treating drivers of the AIDS epidemic. natal deaths. They accounted for infected pregnant women with avail- roughly 36 per cent of neonatal able drug combinations can greatly In line with the new MDG focus on deaths in 2000, the latest year for reduce the transmission of the virus reproductive health, programmes which firm estimates of cause of death to children. Raising levels of compre- aimed at improving maternal survival are available. Reducing the incidence hensive knowledge of HIV among should include interventions to help of infectious conditions such as sep- young women and men aged 15–24 is reduce the incidence of, and treat, sis/pneumonia, tetanus and sexually vital to averting infection. In 14 of sexually transmitted infections. Figure 3.1 The distribution of insecticide- Protection against neonatal tetanus treated mosquito nets to pregnant women in malaria-endemic areas West/Central Africa 71 can reduce the incidence of malaria infection, improving the health of Eastern/Southern Africa 81 both the pregnant woman and her South Asia 85 unborn child. Intermittent preventive treatment of malaria during Middle East/North Africa 77 pregnancy is being used to both prevent and treat the disease. It East Asia/Pacific N/A consists of administering a single Latin America/Caribbean 83 dose of a combined antimalarial medicine at least twice during preg- CEE/CIS N/A nancy whether the pregnant woman has the disease or not. Although considered efficacious, coverage World 81 of this treatment remains limited in malaria-endemic areas.8 Sub-Saharan Africa* 76 Expanding antenatal care Developing countries 81 Much ill health among pregnant Least developed countries 81 women is preventable, detectable or 0 10 20 30 40 50 60 70 80 90 treatable through antenatal visits. Percentage of pregnant women vaccinated against tetanus, 2007 Antenatal care provides an opportu- * Sub-Saharan Africa comprises the regions of Eastern/Southern Africa and West/Central Africa. nity to reach pregnant women with Source: UNICEF and the World Health Organization. multiple interventions that could be 48 T H E S TAT E O F T H E W O R L D ’ S C H I L D R E N 2 0 0 9

Eliminating maternal and neonatal tetanus Tetanus remains a significant cause of maternal and neonatal between 1999 and 2005. The results have been impressive at deaths, taking the lives of more than 180,000 newborns and the country level: between 15,000 and 30,000 mothers in 2002. The condition develops when a bacterium, Clostridium tetani, infects a cut • In Nepal, before immunization started in the early 1980s, or wound. Unclean delivery or abortion practices can result surveys showed high rates of neonatal tetanus among new- in maternal tetanus, while neonatal tetanus is caused by the borns. After the introduction of immunization of adult unhygienic care of the umbilical cord or umbilical stump in women and the implementation of the high-risk approach, babies. In the absence of intensive hospital care, neonatal the rate had fallen by 2005 to less than 1 death from neona- tetanus is nearly always fatal. As with other causes of mater- tal tetanus per 1,000 live births in every district. nal and neonatal deaths, most of the fatalities from tetanus take place in sub-Saharan Africa and Asia, especially in poor • A survey conducted in Egypt in 1986 indicated that and marginalized communities where women have limited or for every 1,000 children born, 7 would die of neonatal no access to quality health care and little knowledge of safe tetanus, with rates of 10 per 1,000 live births in rural areas. delivery practices. Following implementation of the high-risk approach, by 2007, the rate was brought down to less than 1 death per 1,000 live Tetanus is readily preventable through the vaccination births in all districts. of adult women and through hygienic delivery practices. Increasing implementation of both measures, particularly • In the mid-1980s, Bangladesh had a high rate of neonatal immunization of pregnant women, has significantly tetanus, which stood at 20–40 cases for every 1,000 live reduced the number of cases and deaths from maternal births in some parts of the country. At that time, only 5 per and neonatal tetanus since 1980, the earliest year for which cent of women of childbearing age were immunized with comprehensive data are available. In 1988, tetanus was tetanus toxoid and only 5 per cent of pregnant women responsible for causing around 800,000 neonatal deaths, were able to have a clean delivery. Adoption of the high- and more than 90 countries reported one or more cases of risk approach helped Bangladesh reduce its mortality from neonatal tetanus per 1,000 live births at the district level. neonatal tetanus to less than 1 death per 1,000 live births By mid-2008, the number of countries reporting one or by 2008. more cases of maternal and neonatal tetanus at the district level had dropped to 46. Some places have used the high-risk approach to deliver other interventions alongside tetanus toxoid vaccine, includ- Immunization has been among the most significant countering measles vaccine (e.g., Kenya, Southern Sudan) and vita- actions against maternal and neonatal tetanus. Tetanus tox- min A (e.g., Democratic Republic of the Congo). Others, such oid has proved efficacious against the disease, with two as Ethiopia, Uganda and Zambia, have incorporated the doses providing protective concentrations of antitoxins in the approach in mechanisms for delivering packages of essential majority of cases, and almost 100 per cent immunity after the interventions. A key benefit of the high-risk approach is that, third dose. The global rate of vaccination against neonatal in addition to reducing neonatal tetanus, it diminishes tetanus for pregnant women has risen sharply since 1980, inequities in access to maternal and neonatal health care when it stood at just 9 per cent, to 81 per cent in 2007. within countries and shows that it is possible to deliver Nonetheless, this still leaves almost 1 in every 5 newborns health interventions to populations that have often been for- without protection. In part, this is due to missed opportuni- gotten or omitted. ties for vaccinating pregnant women who visit facilities to receive antenatal services, to women arriving too late for See References, page 109. immunization, or to the failure to provide post-partum immunization to protect future pregnancies. Those at risk of tetanus live in communities that have little access to health and immunization services. To reach them, an innovative solution – dubbed the ‘high-risk approach‘ – was initiated. This approach aims to immunize all women of childbearing age living in areas deemed to be high risk with at least two doses of tetanus toxoid (TT) vaccine. The risk factors for tetanus, which include unhygienic delivery practices and lack of immunization, are explained to the communities. Improvements in delivery practices are promoted, and surveillance for neonatal tetanus is strengthened. Booster shots are provided to women with no recorded history of receiving tetanus toxoid vaccine when they were children. The high-risk approach has been widely adopted, enabling 64 million women to receive at least two doses of tetanus toxoid T H E C O N T I N U U M O F C A R E A C R O S S T I M E A N D L O C AT I O N : R I S K S A N D O P P O RT U N I T I E S 49

Antenatal care provides an opportunity to reach pregnant women with multiple interventions, such as immunization, micronutrient supplementation and improved hygiene practices. vital to their well-being and that of ing measures to detect and treat In the developing world as a whole, their babies. Nutritional supplements malaria and anaemia; tetanus three quarters of pregnant women for protein, folic acid and iron pro- immunization; management of sexu- receive antenatal care from a skilled vided by skilled health workers or ally transmitted infections and anti- health provider at least once, though community health workers can have retroviral therapy for HIV-positive the household surveys that record beneficial effects, reducing the likeli- pregnant women; and provision this data give no indication of the hood of undernutrition and anaemia of vital information to pregnant quality of the care or the informa- in the mother and low birthweight in women on risks in pregnancy and tion conveyed. the newborn. delivery. Owing to data limitations, and the fact that many countries are In three regions – Latin America and The minimum number of antenatal delivering far below the UN inter- the Caribbean, Central and Eastern care visits during pregnancy recom- agency minimum recommendation, Europe and the Commonwealth of mended by UNICEF and WHO is most of the data relate to women Independent States, and East Asia and four. These visits help provide key who have received at least one the Pacific – around 9 out of every services to pregnant women, includ- antenatal visit.9 10 pregnant women receive antenatal visits one or more times. These per- Figure 3.2 centages are far lower in the Middle Antiretroviral prophylaxis for HIV-positive mothers to East and North Africa, sub-Saharan prevent mother-to-child transmission of HIV Africa (both 72 per cent) and South Asia (68 per cent). West/Central Africa Even at the relatively low coverage 11 rates in these regions, however, antenatal care represents a significant Eastern/Southern Africa 43 opportunity to reach a large proportion of pregnant women with essen- South Asia 13 tial interventions.10 Packaging essential interventions, East Asia/Pacific 38 including those for which there is already a strong interest — such as Latin America/Caribbean 36 insecticide-treated mosquito nets — has the potential to strengthen demand CEE/CIS 71 for, and use of, antenatal services. It may also encourage women to attend clinics and outreach events for antena- Low- and middle-income 33 countries tal care earlier in their pregnancies. 0 10 20 30 40 50 60 70 80 90 Ensuring skilled attendance Estimated percentage of HIV-positive pregnant women who received antiretrovirals for prevention at delivery of mother-to-child transmission of HIV, 2007 Childbirth can be a time of risk not Source: UNICEF, UNAIDS and WHO, Towards Universal Access: Scaling up HIV services for women and children in the health sector – Progress Report 2008, UNICEF, New York, 2008, p.43. only for the baby but also for the 50 T H E S TAT E O F T H E W O R L D ’ S C H I L D R E N 2 0 0 9

In the least developed countries, 1 in 3 women do not receive any antenatal care during pregnancy, and 3 in 5 women deliver their babies without the assistance of a skilled health worker. Figure 3.3 Antenatal care coverage Antenatal visits from West/Central Africa 71 skilled health personnel 44 during pregnancy: Eastern/Southern Africa 72 40 At least four times South Asia 68 34 At least once Middle East/North Africa 72 N/A East Asia/Pacific 89 66** Latin America/Caribbean 94 83 CEE/CIS 90 N/A World 77 47 Sub-Saharan Africa* 72 42 Developing countries 77 46** Least developed countries 64 32 0 10 20 30 40 50 60 70 80 90 100 Percentage of women aged 15–49 receiving antenatal care during pregnancy, 2000–2007 * Sub-Saharan Africa comprises the regions of Eastern/Southern Africa and West/Central Africa. ** Excludes China. Source: Demographic and Health Surveys, Multiple Indicator Cluster Surveys and other national household surveys. mother. Three quarters of all mater- complications, they should also rec- Saharan Africa. In the 2000–2007 nal deaths occur from complications ognize when serious complications period, skilled health workers attend- either during delivery or in the imme- arise that require more specialized ed 61 per cent of the total number of diate post-partum period. These com- emergency care. Even skilled health births in the developing world. The plications include: haemorrhage (25 workers, however, require access to improvement has been particularly per cent of maternal deaths); infections essential drugs, supplies and equip- striking in the Middle East and (15 per cent); complications of abor- ment to provide adequate care – par- North Africa, which increased its tion (13 per cent); eclampsia or related ticularly when complications such as coverage from 55 per cent in 1995 hypertensive disorders (12 per cent); haemorrhage, sepsis and obstructed to 81 per cent in 2000–2007. The and obstructed labour (8 per cent).11 labour occur. They also require the two regions with the lowest levels skills and judgement to recognize of skilled birth attendance – sub- Reducing maternal deaths from birth serious complications and to manage Saharan Africa (45 per cent) and complications is possible through an effective referral. South Asia (41 per cent) – are also increasing the number of births the regions with the highest incidence attended by a skilled health worker – There has been a marked increase of maternal mortality.12 a doctor, nurse or trained midwife. in the number of deliveries attended Trained health personnel should not by skilled personnel across the devel- A quarter of the world’s unattended only be able to assist with a normal oping world over the last decade, deliveries take place in India, which delivery or a delivery with moderate with the notable exception of sub- is also one of the 10 countries that T H E C O N T I N U U M O F C A R E A C R O S S T I M E A N D L O C AT I O N : R I S K S A N D O P P O RT U N I T I E S 51

With three quarters of all maternal deaths occuring during childbirth or the immediate post-partum period, having skilled health personnel attend deliveries is pivotal to reducing maternal mortality. together account for two thirds of holds are around half as likely to management of the third stage of births not attended by skilled health be attended by skilled health work- labour, which follows the completed workers. India is currently seeking to ers as those from the richest house- delivery of the newborn child and address the problem by encourging holds.14 (For a fuller discussion of lasts until the completed delivery of facility-based care with financial disparities in access to maternity the placenta. Active management incentives13 (see Panel on Integrating services, see Panel on page 38, involves administering a uterotonic maternal and newborn health care in Towards greater equity in health to facilitate contractions for delivery India, page 84). for mothers and newborns.) of the placenta and delayed clamping, cutting and traction of the Worldwide, births in urban areas WHO has made several recommen- umbilical cord. are twice as likely to be attended by dations for reducing post-partum skilled health personnel as those in bleeding or haemorrhage, a leading WHO recommends active manage- rural areas. In West and Central cause of maternal death. The most ment by skilled attendants for all Africa, where the disparity is great- common causes of post-partum mothers but does not recommend the est, they are two and a half times as bleeding are failure of the uterus to package for unskilled attendants. The likely. Disparities along economic contract sufficiently, tears of the gen- agency has called for further research lines are also notable; for the devel- ital tract and retention of the placen- on optimal times for cord clamping oping world as a whole, deliveries tal tissue. The most widely accepted and what drugs, if any, non-skilled of women from the poorest house- method of intervention is active attendants should administer. Figure 3.4 Delivery care coverage 46 Institutional** West/Central Africa 49 deliveries Eastern/Southern Africa 33 40 Skilled attendant*** 35 at birth South Asia 41 Middle East/North Africa 71 81 East Asia/Pacific 73 87 86 Latin America/Caribbean 85 89 CEE/CIS 94 54 World 62 Sub-Saharan Africa* 40 45 Developing countries 54 61 Least developed countries 32 39 0 20 40 60 80 100 Percentage, 2000–2007 * Sub-Saharan Africa comprises the regions of Eastern/Southern Africa and West/Central Africa. ** Institutional deliveries refers to the proportion of women aged 15–49 years who gave birth in the two years preceding the survey and delivered in a health facility. *** Skilled attendant at birth refers to the percentage of births attended by skilled health personnel (doctors, nurses and midwives). Source: Demographic and Health Surveys, Multiple Indicator Cluster Surveys, World Health Organization and UNICEF. 52 T H E S TAT E O F T H E W O R L D ’ S C H I L D R E N 2 0 0 9

Addressing disparities will be critical to improving maternal health. Women from the poorest quintile of households are only half as likely to be attended by skilled health workers as those from the richest households. Hypertensive disorders: Common yet complex Hypertensive disorders are the most common medical prob- both industrialized and developing countries, and follow-up lems in pregnancy and account for a significant proportion – studies have produced strong evidence that magnesium between 12 and 20 per cent – of maternal deaths worldwide. sulfate given to women in the pre-eclampsia stage can They affect women in every region, causing nearly 10 per reduce their risk of progression to eclampsia. Subsequent cent of maternal deaths in Africa and Asia, over 16 per cent in studies have strengthened the evidence base for this critical industrialized countries, and more than one quarter in Latin and cost-effective intervention. America and the Caribbean. Hypertension in pregnancy can result in a range of conditions, from elevated blood pressure, Ideally, care should begin before conception, so that a repro- the least severe, to cerebral haemorrhage, which is fatal. It ductive woman’s medical history can be tracked and her can result in fetal death, preterm delivery and low birthweight options for managing chronic hypertension known. in newborns. Hypertensive women also need information about their risks in pregnancy and changes in their lifestyle that illness may The causes of hypertension are still not fully understood, but require. Bed rest is a common recommendation for hyperten- research suggests that obesity, high salt intake and genetic sive pregnant women. Regular examinations by skilled health predisposition are factors. Some forms of hypertension in personnel are required to monitor the onset and development pregnancy may arise from the biology of pregnancy itself. Pre- of pre-eclampsia and other hypertensive conditions. eclampsia, which develops after the first 20 weeks of pregnancy, is defined as pregnancy-induced hypertension accompa- Hypertension in pregnancy has long been understood as an nied by excess protein in the urine, and brings the greatest obstetric condition, with interventions focusing mostly on risk to maternal and fetal health, particularly when it accompa- outcomes for the pregnancy and less on long- and short-term nies chronic hypertension. It is a leading cause of premature effects on the mother. New research has shown, however, births. that hypertension in pregnancy can also affect the post-natal health of a mother, increasing her risks of developing chronic Several risk factors predispose mothers to these disorders, hypertension and cardiovascular disease. With high maternal including first pregnancy, multiple pregnancy, history of mortality and morbidity resulting from these disorders, fur- chronic hypertension, maternal age over 35, gestational dia- ther research is warranted. Treatment betes, obesity and fetal malformation. One study showed or management of these conditions will have great signifi- that intervals of 59 months or longer between pregnancies cance for the continuum of care model of maternal and new- were also associated with higher rates of pre-eclampsia and born health care. eclampsia. Researchers have also proposed that hormonal imbalances, calcium deficiency and insulin resistance are See References, page 109. possible causes. Calcium supplementation has been shown to be an effective intervention in developing countries where pregnant women may be calcium deficient, reducing the incidence of pre-eclampsia by 48 per cent. If this intervention has a similar effect on maternal deaths from hypertensive disorders, calcium supplementation could prevent some 21,500 maternal deaths. The Magpie Trial, the largest trial for hypertensive disorders of pregnancy, conducted in 1998–2002 in T H E C O N T I N U U M O F C A R E A C R O S S T I M E A N D L O C AT I O N : R I S K S A N D O P P O RT U N I T I E S 53

Providing emergency obstetric and newborn care, and making post-natal care available, are key challenges and opportunities for enhancing maternal and newborn health. Other risks from childbirth can also tions. The quality of care delivered rates of Caesarean section are around be addressed with skilled care. The by the facility is critical: To provide 2 per cent.16 World Health Organization recom- adequate assistance it must have mends that a woman with eclampsia adequate medicines, supplies, equip- Factors hindering the provision of or pre-eclampsia be hospitalized in ment and personnel. In addition, it emergency obstetric care include dis- the days leading up to delivery to should be able to perform potential- tance, direct user charges, transporta- receive treatment with magnesium ly life-saving functions such as tion and accomodation costs, knowl- sulphate. Most infections are treat- Caesarean sections, blood transfu- edge and cultural barriers, among oth- able with antibiotics. Some infections, sions and newborn resuscitation. ers. Furthermore, the quality of care such as tetanus, can easily be avoided offered may also prove a deterrent, as through immunization programmes Data on emergency obstetric care in shown in a study in northern United and sterile umbilical cord practices15 developing countries are often scarce. Republic of Tanzania, which indicated (see Panel on page 49, Eliminating Studies have shown that around 15 that the poor quality of care in facili- maternal and neonatal tetanus). per cent of live births are likely to ties was the main barrier to access.17 need emergency obstetric care, and Providing emergency obstetric Caesarean sections may be required Making post-natal care available and newborn care in 5–15 per cent of births. It is evi- There is a clear need for far greater Timely care in a medical facility is dent that there are many important emphasis on post-natal care – an often necessary to save the life of a gaps in coverage, especially in rural intervention that has long been neg- woman experiencing birth complica- areas of sub-Saharan Africa, where lected in many developing countries, and one that represents a gap in the Figure 3.5 continuum of care. An urgent need is for care in the immediate post-partum Emergency obstetric care: Rural Caesarean section period, as evidence indicates that the risks of maternal mortality and mor- West/Central Africa 1 bidity are high in the 48 hours imme- Eastern/Southern Africa 2 diately following birth. Post-natal South Asia 5 care is often critical for newborns, Middle East/North Africa 12 particularly immediately after birth. East Asia/Pacific* 4 Around three quarters of neonatal Latin America/Caribbean 13 deaths take place in the first week, with up to half of these occurring CEE/CIS 6 within 24 hours of birth. World 4 In many developing countries, moth- Sub-Saharan Africa** 2 ers are likely to be discharged from a Developing countries* health facility within 24 hours of giv- 4 ing birth or may lack access to skilled Least developed countries 2 professional care. Evidence shows 0 2 4 6 8 10 12 14 that even once the high-risk period is Percentage of live births in rural areas delivered by Caesarean section, 2000–2006 over, the risks of maternal mortality * Excludes China. ** Sub-Saharan Africa comprises the regions of Eastern/Southern Africa and West/Central Africa. and morbidity continue for at least 42 Source: Demographic and Health Surveys, other national household surveys and UNICEF. days after birth, and can even extend 54 T H E S TAT E O F T H E W O R L D ’ S C H I L D R E N 2 0 0 9

Establishing a continuum of quality maternal and neonatal health care will require the recruitment and training of skilled health personnel and community health workers. A nurse tends to a newborn baby at a paediatric hospital, Democratic People’s Republic of Korea. (See Panel on page 62, Kangaroo life events, the experience of mother- mother care in Ghana). hood and infant temperament as critical factors in the onset of depression Even mothers who benefit from during the post-natal year. immediate post-partum care are often neglected in the days and weeks that While it is estimated that around follow. Their next contact with 10–15 per cent of women in industri- health workers may be at the six- alized countries may experience © UNICEF/HQ07-0367/Dan Thomas week period, when the baby is due to depression during the weeks and receive the first round of immuniza- months after delivery, information on tions. Evidence shows that mothers this condition in the developing world seek post-natal care less often than is scarce. Small-scale studies from antenatal care or a supervised deliv- Pakistan and Viet Nam indicate that ery, even if they are suffering from women who suffer from depression post-partum bleeding or conditions tend to have underweight infants, and to six months to a year. The main such as fistula and uterine prolapse.20 research from India suggests that chil- causes of post-partum mortality are dren of depressed mothers may face a severe bleeding, infections and hyper- Effective post-natal care requires care higher risk of stunting.21 tensive disorders. Treating these con- and attention during the immediate ditions will require the skilled care post-partum period and also several Healthy practices for newborn care and attendance at birth outlined in follow-up visits. Enabling mothers to earlier sections of this chapter.18 return to health facilities, or follow- Prevention of newborn deaths ing up with outreach visits in the requires skilled care more than Routine post-natal visits are necessary days and weeks following childbirth, technology, and demands flexible in the high-risk post-partum period, can be challenging – there may be and responsive systems of interven- when any complications need to be costs or difficulties in arranging tion. The state of the health system, promptly detected and referred to transport and visitation, or cultural social context and local practices more expert services if required. Even reasons that make a return to the matter just as much as epidemiolog- in the absence of complications, these clinic or hospital unlikely. This is ical risks. Neonatal health can be visits can provide essential informa- why outreach visits can have a vital improved, for example, by practices tion and guidance on maternal and part in maintaining maternal and that do not have high costs attached, newborn health – especially on the neonatal health, irrespective of such as clean delivery conditions care and feeding of babies, the dan- where the birth took place. (See and the promotion of early and ger signs of illness, referral processes Panel on page 57, The first 28 days exclusive breastfeeding, and by and improved hygiene practices. of life, and Panel on pages 80–81, ensuring that the mother is healthy Studies show that fewer neonatal Saving mothers and newborn lives – when she gives birth. deaths occur when mother and baby the crucial first days after birth). are visited within 48 hours of birth. Recent progress has been achieved Mothers who are HIV-positive and Little is known about the effects and in providing simple, cost-effective babies born prematurely need partic- extent of depression during pregnan- interventions that have a positive ular attention.19 Low birthweight cy and the post-partum period in impact on neonatal health, including infants require special attention, par- developing countries. Research has tetanus immunization, the use of ticularly for temperature management. identified partner and social support, insecticide-treated nets to combat T H E C O N T I N U U M O F C A R E A C R O S S T I M E A N D L O C AT I O N : R I S K S A N D O P P O RT U N I T I E S 55

Promoting healthy behaviours for mothers and newborns, particularly in nutrition and hygiene, is vital to reducing health risks and morbidity. © UNICEF/HQ05-1795/Giacomo Pirozzi Skilled health personnel, with access to proper equipment and support, can provide critical life-saving interventions when emergencies arise during labour and childbirth. A newborn is monitored by a medical worker in a children's hospital, Ukraine. malaria and micronutrient supple- UNICEF and the World Health incentive for people to use them and mentation. A study tracking cover- Organization, became known as the greater opportunity to extend and age of interventions for maternal, Integrated Management of Childhood enhance coverage. The goal is to newborn and child survival found Illness (IMCI), and it has met with develop a comprehensive primary- greater improvement in the delivery increasingly positive results. More health-care system that provides of these types of preventive interven- recently, this integrated model has women and children with essential tion than of curative care. Progress been incorporated into the maternal, interventions and strengthens the on actions focusing on behavioural newborn and child health continuum links between households and health changes, such as breastfeeding, was of care. facilities that have so often been mixed.22 missing in the past. The continuum of care: Since the early 1990s, the emphasis Household practices and Linking lives to places behaviours in coping with these manifold threats to the lives of children has been on a It is now recognized that linking When children fall ill, the first point broad, cross-cutting approach that interventions in packages can also of intervention inevitably lies in the recognizes there is normally more increase their efficiency and cost- hands of their families, especially than one contributory cause to any ail- effectiveness. In addition, when serv- their parents, close relatives and ment. This approach, introduced by ices are integrated there is both more guardians. The initial diagnosis of 56 T H E S TAT E O F T H E W O R L D ’ S C H I L D R E N 2 0 0 9

The first 28 days of life by Zulfiqar A. Bhutta, Professor and Chairman, Department of Paediatrics & Child Health, Aga Khan University, Karachi, Pakistan It is widely recognized that a large proportion of child deaths deliver an integrated package of preventive and curative occur in the newborn period, the first 28 days of life. Of an newborn care in Sylhet, rural Bangladesh. While home-based estimated 9.2 million deaths of children under five around care provision was important in these studies, it is possible the world in 2007, around 40 per cent occurred in the new- that major benefits also accrued from improved family prac- born period. In many developing countries, deaths of new- tices and newborn care. In a study in Makwanpur, in rural borns account for over half of all deaths in infancy, with the Nepal, women’s support groups, assisted by trained facilita- vast majority occurring in the first few days of life. The major tors, effected a significant reduction in neonatal mortality. causes of such deaths are serious infections (36 per cent), Further studies have shown that a concerted strategy of prematurity (27 per cent), birth asphyxia (23 per cent) and community-based education in newborn care can lead to congenital malformations (7 per cent). These figures do not significant change in practices and reductions in neonatal include an estimated 3 million stillbirths annually. Some mortality. 30–40 per cent of these stillbirths may be related to events during labor and delivery, which in turn may result from All of these recent studies provide evidence that community- intrauterine problems and asphyxiation. based education in improved maternal and newborn care and home-based treatment for newborn infections can signif- The relative lack of progress in reducing newborn deaths is icantly enhance newborn survival. To affect public-health due to several factors. Most important is that, unlike health systems in the foreseeable future, these strategies need to be in the post-natal period (29 days to 59 months), newborn replicated at scale using feasible motivation and training of health is closely tied to maternal health. Improving it available health-care workers. Such an expansion has taken requires interventions that address complex issues such place in rural Pakistan, where community-based Lady Health as maternal empowerment, sociocultural taboos and health- Workers work with village health committees and women’s system responsiveness. groups. A recent evaluation of the Pakistan initiative has shown a significant reduction in perinatal and neonatal mor- Specific factors leading to neonatal deaths include: tality and improved care-seeking for skilled maternal care. • A lack of attention to maternal health, with limited access This emerging evidence provides support for strategies to to skilled care providers. improve maternal and newborn health in the very communities and families with the highest burden of mortality and least • The poor state of maternal health care, especially during access to quality health care. The challenge is to integrate home births, which are associated with at least half of all effective strategies and interventions across the continuum of newborn deaths. maternal and newborn care in both community settings and • Inadequate recognition of newborn illnesses and insuffi- health facilities. Recent estimates indicate that providing basic cient care-seeking among families and communities. preventive and curative interventions for mothers and new- • A limited repertoire of interventions for early neonatal borns in primary-health-care settings at pragmatic levels of disorders such as birth asphyxia and problems due to coverage has the potential to reduce maternal and newborn premature birth. deaths by 20–40 per cent. • A lack of consensus on interventions and delivery strategies to prevent and treat serious neonatal infections – While these measures show promise, particularly when sever- other than neonatal tetanus – in community settings. al complementary interventions are packaged together and delivered through a range of health-care providers, important Recent years have brought significant improvement in our bottlenecks to improved service delivery remain in many understanding of neonatal illnesses and mortality. Inequities developing countries, including poorly functioning health- in distribution of maternal and newborn deaths indicate that system facilities and limited numbers of skilled health-care most deaths occur in poor, rural populations and in often- providers. These bottlenecks can and must be addressed ignored urban squatter settlements. Many countries also through strategies targeted to reach those families, communi- recognize that reaching the Millennium Development Goal ties and districts most at risk of missing out on basic health for reducing child mortality will not be possible without care and maternity services. Despite these difficulties, and the improving care for mothers and newborns, focusing efforts still important gaps in our knowledge of how best to tackle on reducing deaths during the first 28 days of life. difficult newborn problems such as birth asphyxia, the fragili- ty of preterm infants and serious bacterial infections in community settings, one point is clear: We know enough about The evidence supporting strategies and interventions that what works to make a difference. The critical need is to imple- use community partnerships has also improved. A number of ment what we know and create the policy framework for programmes, largely based in South Asia, have attempted to appropriate maternal and newborn care where it matters: reduce newborn morbidity and mortality in community set- among the rural and urban poor. tings using innovative approaches. In a landmark study undertaken in rural Maharashtra, India, Dr. Abhay Bang and his colleagues trained community health workers, working See References, page 109. with traditional birth attendants, to recognize serious neonatal illnesses such as birth asphyxia or suspected bacterial infections and treat them with home-based resuscitation or oral and injectable antibiotics, respectively. The programme showed a significant reduction in neonatal mortality through these home-based newborn care strategies. More recently, researchers from Johns Hopkins University have demonstrated the efficacy of using trained community health workers to T H E C O N T I N U U M O F C A R E A C R O S S T I M E A N D L O C AT I O N : R I S K S A N D O P P O RT U N I T I E S 57

© UNICEF/HQ07-1494/Anita Khemka Community partnerships in health care can help expand coverage of essential services and improve practices in health and nutrition. A community health volunteer who is also a trained birth assistant visits a pregnant woman in a village, Nepal. any childhood illness is most often any problem that arises before, during identifying and coping with child- made not by a doctor or nurse, but and after birth, but families inevitably hood or maternal illness. In addi- by a mother, who assesses the symp- play a key role, especially in deciding tion, although in the developing toms, decides on their severity and whether it is necessary to seek exter- world as a whole a small majority either settles on a form of care and nal, and often expensive, medical (54 per cent) of births take place treatment within the home or decides assistance. In addition, sociocultural in clinics or hospitals, in both sub- that a trained health worker must be factors may mean that women need Saharan Africa and South Asia – the consulted. Irrespective of whether a to receive the permission of their regions with the greatest burden of health worker is sought, it also falls husbands or other family members to maternal and neonatal mortality – to family members to nurse sick chil- seek care during pregnancy, childbirth more than 60 per cent of women dren and to administer any necessary or the post-partum period. give birth at home.23 Even those medicines or other remedies. women who give birth in a health The competence of family members facility are often discharged from A similar process often applies to to make judgements on medical hospitals within 24 hours of deliv- women who are pregnant or have matters varies enormously, of ery, and the main burden of post- recently given birth, although to a course, but no health system can partum and neonatal care and lesser extent. The woman herself will afford to ignore the vital part played supervision falls on family members have her own view of the severity of by families or household members in of the mother and newborn. 58 T H E S TAT E O F T H E W O R L D ’ S C H I L D R E N 2 0 0 9

Community partnerships in health can promote early and exclusive breastfeeding, which provides vital protection for newborns against ill health and disease. At a more basic level, nutrition and considerable potential to improve the Community partnerships in hygiene practices in the household are health and well-being of families. primary health care prime determinants of the health risks faced by mothers and newborns. Simple messages regarding basic Communities have a vital role in Inadequate maternal nutrition, unhy- hygienic practices in food prepara- health care and nutrition of mothers, gienic practices at delivery, and in car- tion – such as keeping food in cov- newborns and children. The notion ing for the umbilical stump or cord, ered containers to exclude insects of the community as a cornerstone of inattention to basic hygiene practices and drying cloths used to clean dish- primary health care was asserted in such as hand washing with soap or es or pans in the sun – can have the Alma-Ata Declaration of 1978, ashes after using latrines and before beneficial results. Improving house- and it is clear that the goal of health preparing and eating meals, and hold knowledge of elementary care for all cannot be achieved with- indoor air pollution can accentuate health, nutrition and environmental out community participation, especial- the spread of infections and diseases health interventions, along with ly in poorer and more remote areas. It such as tetanus, diarrhoea and acute increased empowerment of women is beneficial that communities take an respiratory infections. Raising aware- to make decisions about their own active part in improving health care, ness of improved individual house- or their children’s health, could have hygiene practices, nutrition and water hold practices and behaviours, such a strong positive impact on health and sanitation services. This is, how- as exclusively breastfeeding newborns outcomes both for children and new ever, not merely a necessary tool in and infants up to six months, has or expectant mothers. the absence of more expensive alterna- Figure 3.6 Early and exclusive breastfeeding West/Central Africa 23 Eastern/Southern Africa 39 South Asia 44 Middle East/North Africa 26 East Asia/Pacific* 43 Latin America/Caribbean N/A CEE/CIS 20 World 38 Sub-Saharan Africa** 31 Developing countries* 38 Least developed countries 37 0 10 20 30 40 50 Percentage of infants less than six months old that are exclusively breastfed, 2000–2007 * Excludes China. ** Sub-Saharan Africa comprises the regions of Eastern/Southern Africa and West/Central Africa. Source: Demographic and Health Surveys, other national household surveys and UNICEF. T H E C O N T I N U U M O F C A R E A C R O S S T I M E A N D L O C AT I O N : R I S K S A N D O P P O RT U N I T I E S 59

Focus On Midwifery in Afghanistan Decades of conflict and instability have disrupted Although much remains to be done to improve maternal Afghanistan’s basic health infrastructure. Women in and newborn health in Afghanistan, many successful particular have suffered from a lack of access to health efforts to date have focused on expanding and strength- services. As a consequence, maternal mortality among ening midwifery. Afghan women is extremely high, standing at 1,800 deaths per 100,000 live births in 2005, according to the Afghanistan’s Government is collaborating with local latest inter-agency estimates. and international partners, including UNICEF, to develop a comprehensive approach that includes strengthening Women in Afghanistan face a lifetime risk of death from and expanding midwifery education, creating policies to causes related to pregnancy or childbirth of 1 in 8, the ensure the pivotal role of midwives in providing essential second highest rate in the world. More women die in obstetric and newborn care, supporting the establishment Afghanistan from these causes than from any other, with of a professional association for midwives, and develop- haemorrhage and obstructed labour the most common. ing initiatives to increase access to skilled care during The proportion of maternal deaths ranges from 16 per cent childbirth. of all deaths of women of childbearing age in Kabul (the largest urban center in Afghanistan) to 64 per cent in the The Community Midwifery Education (CME) programme, Ragh district of Badakhshan. an 18-month, skills-based training programme that has less stringent entry requirements than previous midwifery The high rates of maternal death reflect several factors, programmes, is considered an appropriate approach to including limited access to quality maternal health care, scaling up training and deployment of skilled birth atten- particularly in rural parts of Afghanistan; a lack of knowl- dants. In 2008, there were 19 CME programmes, each edge of maternal health and safe delivery; and the scarci- with 20–25 trainees. This represents a marked increase ty of qualified female health providers, since there is a in training capacity over 2002, when there were only six strong cultural preference for women to be cared for by nurse midwifery training programmes run by the Institute other women. It is estimated that 9 out of 10 rural women of Health Science at regional centres, and one community deliver their babies at home, without skilled birth atten- midwifery programme in Nangahar province. The number dants or access to emergency obstetric care. Sociocultural of midwives available in the country has increased rapid- factors that inhibit women’s mobility without the permis- ly, from 467 in 2002 to 2,167 in 2008. sion or escort of male relatives can also limit their access to essential services. Other factors contributing to mater- The CME encourages applications from women in dis- nal mortality are the low social status of women and girls, tricts with shortages, with the understanding that they will poverty, poor nutrition and lack of security. work in those districts once they are trained. This policy has resulted in a sharp increase in facilities having skilled Improving the survival rates of mothers in Afghanistan is female health personnel (doctors, nurses or midwives), an issue of immense importance. Midwives can provide from 39 per cent in 2004 to 76 per cent in 2006. It is also crucial care. The World Health Organization recommends having a tangible impact on maternal care; the number one midwife or other skilled birth attendant for every 175 of deliveries attended by skilled workers has risen from women during pregnancy, childbirth and the post-natal roughly 6 per cent in 2003 to 19.9 per cent in 2006. The period. Using this estimate with the estimated number of success of the skills-based training approach has resulted births, Afghanistan should have 4,546 midwives to cover in the existing midwifery programmes adopting the CME 90 per cent of pregnancies. The country actually had only curriculum and certification process. 467 trained midwives in 2002. Fewer than half of health facilities had any female staff. In rural Nooristan, the ratio See References, page 109. of male to female health personnel was as high as 43 to 1. 60 T H E S TAT E O F T H E W O R L D ’ S C H I L D R E N 2 0 0 9

Outreach and outpatient services can act as a bridge between the household and health facilities, providing reproductive, antenatal, intrapartum and post-natal services. © UNICEF Peru/2005 Addressing cultural, social and geographic barriers to health care helps increase access to health services in rural communities. A mother and her newborn are attended by a health worker in a health centre, Peru. tives but rather a desirable route for voluntary, while others involve pay- improve people’s access to services empowerment and participation.24 ment of some sort. Some operate inde- and facilitate closer contact between pendently of the national health-care health workers and individuals or Community partnerships are especial- system, while others are fully integrat- households, but also encourage ly valuable in improving maternal, ed within it. Programmes seeking to behavioural change and social mobi- newborn and child health. There are use community partnerships as an lization. At their most challenged, almost as many different kinds of approach have to be careful to adapt community partnerships are short- community partnerships as there are to the particular local context. staffed, poorly coordinated, under- communities. Some are small and funded and ill-supplied. Examples of local, while others form part of a At their best, community partner- successful community partnerships in national network. Some are entirely ships in health and nutrition not only health across the developing world T H E C O N T I N U U M O F C A R E A C R O S S T I M E A N D L O C AT I O N : R I S K S A N D O P P O RT U N I T I E S 61

demonstrate that the balance sheet as better caring or hygiene practices. Nepal provides one such example. a whole is positive.25 Exclusive breastfeeding, hand wash- Trained community health workers ing with soap or ashes and the use of collaborate with skilled health per- The role of community health insecticide-treated mosquito nets for sonnel to provide care to mothers, workers in maternal and malaria prevention are three of the newborns and children. A random- newborn health most common interventions advocat- ized study in rural Nepal shows that Community partnerships in health ed by community health workers. In these partnerships have reduced often involve training people as addition, many community partner- neonatal mortality by 30 per cent. community health workers. These ships in health include workers who These findings are complemented by workers undertake basic health care advise on prevention of mother- a study in rural India, which shows and nutrition activities – whether to-child transmission of HIV and a 62 per cent reduction in neonatal through home visits or at an estab- contribute to the management of mortality when community health lished location. Community health childhood illnesses such as malaria, workers provided home-based care workers also lead campaigns for pneumonia and neonatal sepsis. for the newborn, including resuscita- Kangaroo mother care in Ghana Kangaroo mother care for low-birthweight babies was participants to focus on one aspect of newborn care, introduced in Colombia in 1979 by Drs. Hector Martinez and implement it well and in the process integrate it into the Edgar Rey as a response to, inter alia, high infection and normal spectrum of newborn care practices. mortality rates due to overcrowding in hospitals. It has since been adopted across the developing world and has The implementation model identifies specific roles for become an essential element in the continuum of neonatal districts and regions, depending on the way authority is care across the world. devolved in a country. In Ghana, the region is the nodal point for implementation, with districts being responsible The four components of kangaroo mother care are all essen- for the actual implementation actions. Although half of all tial for ensuring the best care options, especially for low births still occur at home, one of the cornerstones of the birthweight babies. They include skin-to-skin positioning of KMC Ghana project is the establishment of centres of excel- a baby on the mother’s chest; adequate nutrition through lence at regional hospitals and 24-hour, continuous kangaroo breastfeeding; ambulatory care as a result of earlier mother care in each district hospital. discharge from hospital; and support for the mother and her family in caring for the baby. Implementation is overseen by a KMC Steering Committee in each region, consisting of one member from each of the The most important method of spreading kangaroo mother districts. These representatives, in turn, establish steering care has been by means of training programmes. Often, committees at the district level. Although the focus is on the training remains confined to hospital settings. A new introducing KMC in district hospitals, other health care approach was adopted in Ghana under a kangaroo mother facilities and community organizations are also sought care (KMC Ghana) project undertaken in four regions, with as partners. the support of UNICEF and the South African Medical Research Council’s Unit for Maternal and Infant Health Care While a comprehensive evaluation of the KMC Ghana Strategies. Instead of merely providing training, a longitudi- programme has yet to take place, preliminary evidence nal, ‘open door’ approach based on continuous support from suggests that it is effective in improving the survival of low health-care facilities was adopted. birthweight babies and strengthening the bond between mothers and newborns. Under the programme, kangaroo mother care is singled out for special attention for two to three years. This requires See References, page 109. 62 T H E S TAT E O F T H E W O R L D ’ S C H I L D R E N 2 0 0 9

HIV/malaria co-infection in pregnancy Co-infection with HIV and malaria presents specific com- meaning that HIV-positive women in their second, third and plications for pregnant women and fetal development. fourth pregnancies have the same low immunity to malaria HIV lessens pregnancy-specific malaria immunity normally as women in their first pregnancy. Pregnant women infected acquired during the first and second pregnancies. Placental with HIV become twice as susceptible to clinical malaria, malaria is associated with increased risk of maternal anaemia regardless of gravidity. In these women, malaria can restrict and HIV infection, especially among younger women and fetal growth, cause preterm delivery and low birthweight in those experiencing their first pregnancy. The role of co- newborns and reduce the transfer to children of maternal infection in mother-to child transmission of HIV is unclear, immunities and cellular responses to infectious diseases with some studies reporting an increase and others reporting such as streptococcus pneumonia, tetanus and measles. no change. The potential risks of adverse drug interactions Recent evidence suggests that HIV-positive mothers with have critical implications for effective management of malaria are more likely to have low-birthweight infants; in co-infection, and call for increased research. turn, low-birthweight infants were shown to have significantly higher risks of mother-to-child transmission of HIV Although malaria affects Asia, Latin America and the compared with infants of normal birthweight. Caribbean, and sub-Saharan Africa, the largest burden of co-infection lies in Africa, the continent with the greatest The effects of malaria on HIV are less clear, though episodes burden of malaria, and where more than three quarters of of acute malaria can increase viral load and hasten disease all HIV-infected women live. Variations exist across the progression. Malaria infection during pregnancy may increase African continent. Most affected by HIV/malaria co-infection the risk of mother-to-child transmission of HIV in utero and are the Central African Republic, Malawi, Mozambique, during birth, and higher viral load can result in greater risk of Zambia and Zimbabwe, where some 90 per cent of adults transmission during breastfeeding. Some research shows are exposed to malaria and average adult HIV-prevalence that viral loads can return to pre-episode levels following surpasses 10 per cent. In parts of southernmost Africa, malaria treatment, which suggests that management of where the HIV epidemic is most severe, there is a lower malaria may be critical to slowing the spread of HIV and incidence of malaria, although outbreaks do occur in its progression to AIDS. particular areas, such as Kwazulu-Natal, South Africa. One of the most pressing questions about co-infection Data for other regions are not as clear, but the overlap of concerns drug therapies. The World Health Organization infections may be present in the general populations of recommends that all pregnant women in areas of high HIV Belize, El Salvador, Guatemala, Guyana and Honduras – and, prevalence (>10 per cent) receive at least three doses of to a lesser extent, Brazil. Research indicates that certain pop- sulfadoxine-pyrimethamine as intermittent preventive treat- ulations, such as migrant goldmine workers in Brazil and ment (IPT), even in asymptomatic cases, unless they are Guyana, may have greater risk of co-infection. The HIV epi- receiving cotrimoxazole for the treatment of opportunistic demic is generalized in Asian countries such as Myanmar infections of HIV. and Thailand, but malaria transmission is unstable and het- erogeneous across this region, as in Latin America and the Many African governments use artemisinin-based combina- Caribbean. The most common species of malaria in each tion therapy for malaria case management in pregnancy; region also differs – P. falciparum in Africa, P. vivax in Asia with research still limited, WHO continues to recommend and Latin America and the Caribbean – and the effects of the this treatment be used for uncomplicated malaria in preg- disease may vary by the degree of immunity a women has nancy during the first trimester, if it is the only effective achieved by the time she becomes pregnant. Women in Asia treatment available. In cases of severe anaemia, treatment are less exposed to intense malaria transmission and there- with either artemisinin-based therapy or quinine, should be fore have less opportunity to develop acquired immunity. administered, although the former is preferred in the sec- This is also true of areas of unstable malaria transmission in ond or third trimester. There is little published information parts of southern Africa. Most studies of malaria in pregnan- on the risks of co-administration of antiretrovirals and anti- cy are from Africa, and more are needed from other regions malarials, including artemisinin derivatives, but artemisinins and non-falciparum species. have not yet been observed to have important toxicities when co-administered with antiretrovirals or when given Malaria sufferers with severe anaemia who require blood in early pregnancy. transfusions, particularly children, also are at higher risk of acquiring HIV. Every year, between 5,300 and 8,500 children See References, page 109. in areas of endemic malaria in Africa become infected with HIV from blood transfusions administered for severe malaria. Regional differences notwithstanding, co-infection affects all pregnant women in similar ways. HIV in pregnancy combined with malaria increases the risk of severe anaemia and reduces any acquired immunity that women living in areas of stable malaria transmission may have developed – effectively T H E C O N T I N U U M O F C A R E A C R O S S T I M E A N D L O C AT I O N : R I S K S A N D O P P O RT U N I T I E S 63

The challenges faced by adolescent girls in Liberia by the Honourable Vabah Gayflor, Minister of Gender and Development, Liberia Ensuring that adolescent girls have a supportive environment from causes related to pregnancy and childbirth than those for their growth and development and are protected from of ages 20–24. abuse, exploitation, violence and premature entry into adult roles such as marriage and labour is particularly challenging – may be left with a delivery-related injury if she survives in my country, Liberia. her pregnancy, such as fistula or uterine prolapse. An adolescent girl living in Liberia: – faces a high lifetime risk of death from her first and subsequent pregnancies; the lifetime risk of maternal deaths – has probably not been to primary school; the net primary stands at 1 in 12. school enrolment for girls stands at only 39 per cent, according to the latest national estimates. – may see her child die within the first year of life, with almost 1 in every 10 infants dying before their first birthday. – is unlikely to go on to secondary school; just 14 per cent of girls of secondary school age are enrolled in – will probably not have support from a partner, even if secondary education. she is married. – is at high risk of being illiterate, like 24 per cent of adoles- – has little or no recourse to protection from further abuse, cent girls and young women aged 15–24 in the country. exploitation and disempowerment. – has a high risk of suffering rape – the most frequently Creating a supportive environment for adolescent girls in reported crime, with girls aged 10–14 the most frequent Liberia begins with protecting them from violence and abuse, victims of rape. and ensuring that they obtain a quality education. – probably has limited knowledge of HIV and AIDS; only 21 It will also necessitate ensuring that families do not allow per cent of young women aged 15–24 have comprehensive their girls to marry before age 18 or allow them to be knowledge of HIV and AIDS. engaged in exploitative labour. – has a high probability of either being married or in union; It requires that knowledge of HIV and AIDS be promoted 40 per cent of women aged 20–24 in Liberia were married among young people, and that victims of sexual violence before the age of 18. have recourse to justice. – faces the strong likelihood of being pregnant; the adoles- It necessitates investment in reproductive, maternity and cent birth rate for girls aged 15–19 stands at 221 per 1,000 – basic health care for millions of adolescent girls. the second highest rate in the world. Most of all, it demands that communities and society respect – is unlikely to give birth in a hospital or health facility, as the rights of women and girls, and have the courage to only 37 per cent of births take place in institutional settings. address customs and practices that harm and discriminate against them. – will possibly have to give birth without the assistance of a skilled health worker, which only attend 51 per cent of births. Under the leadership of President Ellen Johnson-Sirleaf, the Government of Liberia is striving to provide the protection – runs a high risk of death from pregnancy and childbirth; adolescent girls need and to help them acquire the skills that the maternal mortality rate stands at 1,200 per 100,000 will enable them to protect themselves. We welcome the sup- live births. port of the international development community in assisting us to act quickly and effectively. – has an even higher risk of death from maternal causes if under 15; girls aged 10–14 are five times more likely to die See References, page 109. 64 T H E S TAT E O F T H E W O R L D ’ S C H I L D R E N 2 0 0 9

Facility-based care is essential for referrals and providing a range of routine and emergency services for mothers and newborns. tion for birth asphyxia and treatment sexual and reproductive health. For detect sexually transmitted infections of sepsis with antibiotics.26 example, antenatal care can of and treat them promptly. Many out- course be offered at clinics or hospi- patient or outreach services in repro- Community partnerships in health tals, but it is entirely appropriate as ductive health currently offer only care can help expand coverage of an outreach service. poor-quality interventions, however, essential services and improved prac- which deter people from using them.30 tices in health and nutrition. Perhaps Antenatal outreach services should even more importantly, such partner- screen for and treat disorders such Facility-based care ships can also enable health systems as anaemia, hypertension, diabetes, Health facilities generally provide to reach out to their communities, syphilis, tuberculosis and malaria, the broadest range of preventive and however poor or marginalized they as well as check the baby’s position. curative treatments for maternal and may be. They should also provide tetanus child health, and potentially the most immunization, distribute insecticide- skilled pool of health-care workers. Outreach and outpatient services treated mosquito nets and offer These facilities generally fall into two Outreach and outpatient services, intermittent preventive treatment of main categories: clinics and hospitals. such as antenatal care and immu- malaria in malaria-endemic areas, The facility closest to the community nization, are delivered on a routine in addition to counselling on such is likely to be a clinic providing basis through one of two modes: sta- matters as diet, hygiene, the danger immediate, generalized care, possibly tionary clinics visited by pregnant signals in pregnancy and breastfeed- overseen by a nurse. Clinic staff can women and their children, or mobile ing. It is also important, however, often cope with uncomplicated births services whereby health workers not to overburden outpatient or and offer support and advice on the undertake essential interventions to outreach services to the point at care of the newborn. They should mothers and children in their com- which they become overstretched.28 also be able to deal with some of the munities. In almost all cases, recipi- key complications – able, for exam- ents are not assessed as clinical cases Outreach services can also be ple, to remove the placenta manually, but receive a standardized service. adapted to provide post-natal care, or to offer resuscitation to a new- Many of these interventions do not as mentioned earlier in this chapter. born. Given the potential risks asso- need to be delivered by skilled med- Key services include recognizing and ciated with labour and childbirth, ical staff to prove beneficial, but can checking for danger signs for moth- however, staff in clinics, as well as be dispensed by semi-skilled health ers and newborns, guidance on those engaged in outreach attendance workers and by community health feeding – particularly early and at birth, need the skilled knowledge workers with some training. This, exclusive breastfeeding – and caring to recognize swiftly when a complica- in turn, makes it easier and more for the newborn, referral for treat- tion in the delivery, or the degree of cost-effective to increase coverage ment of mother or baby if appropri- sickness in the newborn, is beyond of outreach-based services to large ate, and support and counselling on their competence and to refer it to a sectors of the population.27 healthy practices.29 higher level. Outreach and outpatient services Reproductive health is another area That next level is likely to be a can act as a bridge between home appropriate to outreach and out- district hospital where doctors can and community care and facility- patient services. Outreach services can offer medical diagnosis, treatment, based care. They are vital mecha- raise awareness of options for repro- care, counselling and rehabilitation nisms for delivering antenatal and ductive health services and practices, services. In some health systems post-natal care, as well as promoting including birth spacing. They can also there may be a referral hospital T H E C O N T I N U U M O F C A R E A C R O S S T I M E A N D L O C AT I O N : R I S K S A N D O P P O RT U N I T I E S 65

providing complex clinical care, Geographical distance is not the The continuum of care: but in many communities across the only impediment to accessing Practical steps towards developing world, the facility-based health-care facilities, however; there primary health care for health needs of mothers and infants are cases where women living in the mothers and newborns are met by clinics or the district vicinity of a health facility will only hospital, if at all.31 visit for antenatal care but not the Health-care services function best delivery itself. Cultural reservations when they link care in the home Access to emergency obstetric care about a woman’s delivery being through the community to outreach can pose a major challenge for preg- attended by strangers, and economic services and beyond to clinics and nant women living in rural areas, costs of skilled attendance at deliv- hospitals. This is by no means a new owing to the distance to be covered ery, are examples of deterrents that insight: The evidence and knowledge to reach a suitable facility and the impede usage of health-care facili- have been available for decades. lack of transport or adequate roads ties. Lack of health-care personnel Their application has the potential by which it can be reached. Even if and inadequate medical equipment to reduce markedly the toll of pre- transportation vehicles and infra- and drugs can also deter families ventable maternal and neonatal structure are available, travel and from seeking an institutional deliv- deaths. The challenge now is to put accommodation costs, together with ery. One particular challenge is to in place the levels of investment in indirect costs such as the income lower the incidence of facility- health services that will guarantee foregone by accompanying family acquired diseases – a serious risk a continuum of care. Chapter 4 members, may prove prohibitive. in sub-Saharan Africa – that can outlines a framework for devising Families living in geographically iso- increase the risk of infection from strategies and apportioning lated communities therefore face ele- blood transfusions and the reuse resources to deliver the improve- vated risk of maternal and neonatal of needles.33 Despite these impediments in maternal and neonatal mortality when birth complications ments, it is clear that upgrading health that the developing world arise. A recent study of maternal maternity clinics, health centres and urgently requires. deaths in Afghanistan, for example, hospitals to provide at least basic showed that physical remoteness emergency obstetric care would be a added to the epidemiological risks major step towards reducing mater- that women faced.32 nal and neonatal mortality. 66 T H E S TAT E O F T H E W O R L D ’ S C H I L D R E N 2 0 0 9

T H E S TAT E O F T H E W O R L D ’ S C H I L D R E N 2 0 0 9 4 Strengthening health systems to improve maternal and newborn health © UNICEF/HQ05-1797/Giacomo Pirozzi

Establishing effective continua of care will involve taking practical steps to strengthen health systems. The key elements for health systems development – deepening the evidence base, expanding and enhancing the health workforce, upgrading and broadening infrastructure and logistics, providing equitable financing solutions and stimulating demand for care through social mobilization, ensuring the quality of care and fostering political commitment and leadership through collaboration – are increasingly accepted by national governments and local and international agencies. Chapter 4 of The State of the World’s Children 2009 examines each of the first six steps, illustrating their practical application through country examples. The seventh step – political leadership and commitment – is addressed in the final chapter of the report. M eeting Millennium progress are being continually communications technology, Development Goal enriched through data collection, facilities and management 5 will be challeng- research and analysis, monitoring capacity to ensure quality care ing. As a whole, and evaluation, and collaborative and effective referral. the world is far behind on improv- actions. Chapter 4 contributes to • Improving the quality of care ing maternal health, with little these efforts by summarizing a across the health system. progress achieved in sub-Saharan series of practical steps towards • Fostering political commitment Africa in particular since 1990. strengthening health systems to and leadership through stronger Even within those developing support the continuum of care collaboration between partners. countries and regions that have outlined in Chapter 3. These seen more progress, pockets of involve the following actions: This chapter examines the first six poverty and marginalization con- of these steps, illustrating their prac- tinue to exclude many from essen- • Enhancing data collection and tical application through country tial maternity and basic health- analysis of trends, levels, risks, examples. The seventh step will be care services. (See Chapter 1 for causes of and interventions for addressed in Chapter 5. a full description of trends in maternal and newborn mortality maternal mortality.) and morbidity. Step 1: Enhancing data • Expanding the primary health-care collection and analysis Faster progress and major workforce in developing countries Since no single indicator can improvements in maternal and and enriching skills levels. adequately describe the varied newborn survival and health are • Mobilizing societies to demand dimensions of either maternal or possible through packaging and better maternal and newborn newborn health, a wide array of scaling up proven, affordable health care and a supportive envi- indicators is useful to guide and interventions, delivered through ronment for the rights of women monitor programmes. Vital infor- a continuum of care and under- and children. mation for policies and pro- pinned by a supportive environ- • Establishing practical, equitable grammes includes demographics, ment for the rights of women and sustainable financing mecha- nutritional status, socioeconomic and children. nisms for basic health care and status, health-care provision, care- maternity services. seeking practices and the applica- Policy recommendations on the • Investing in infrastructure, tion of improved health and frameworks required to accelerate logistics, information and nutrition practices. 68 T H E S TAT E O F T H E W O R L D ’ S C H I L D R E N 2 0 0 9

Good data on maternal and newborn health and survival form the foundation for sound policies, effective programmes and collaborative partnerships. These measures strengthen understanding of the burden, trends, risks and causes of maternal and newborn mortality and morbidity. But much more needs to be done. Gaps in knowledge of many aspects of maternal and newborn health – from the estimation of mortality figures to risks to pregnancy posed by HIV and AIDS, to name but two elements – remain significant. Health information systems remain incomplete in many developing countries, complicating efforts to determine the status of maternal and newborn health and apply the most appropriate strategies and interventions.1 Strengthening the knowledge base that forms the foundation for policies, programmes and partnerships is therefore an essential component for developing health systems. Work has begun on the process of enriching data collection. The World Health Organization has developed guidelines to assist governments and other agencies in expanding data collection and improving data quality on maternal health. WHO recommends that health information systems should strive to capture data in five key areas relevant to maternal © UNICEF/HQ04-1257/Giacomo Pirozzi and child health: • Maternal and newborn mortality rates. • Factors or determinants contributing to morbidity and mortality. • Community perceptions of these health problems and appropriate Providing essential care such as immunization and micronutrient supplementation to pregnant women protects them against disease and undernutrition. A health worker provides actions, including types of services consultations that include weight and blood-pressure measurements, tetanus vaccination and attitudes towards care seeking. and iron supplementation, Papua New Guinea. S T R E N G T H E N I N G H E A LT H S Y S T E M S T O I M P R O V E M AT E R N A L A N D N E W B O R N H E A LT H 69

A wide array of methods is being employed to enhance data collection on maternal and newborn survival, including censuses, household surveys, and facility-based data gathering. Figure 4.1 Emergency obstetric care: United Nations process indicators and recommended levels UN process indicator Definition Recommended level 1. Amount of EmOC services Number of facilities that provide EmOC Minimum: 1 comprehensive EmOC facility and 4 available basic facilities for every 500,000 people 2. Geographical distribution of Facilities providing EmOC well-distributed Minimum: 100% of subnational areas have the EmOC facilities at subnational level minimum acceptable numbers of basic and comprehensive EmOC facilities 3. Proportion of all births in Proportion of all births in the population Minimum: 15% EmOC facilities that take place in EmOC facilities 4. Met need for EmOC services Proportion of women with obstetric Minimum: 100% (estimated as 15% of expected complications treated in EmOC facilities births) 5. Caesarean sections as a Caesarean deliveries as a proportion of Minimum: 5% percentage of all births all births in the population Maximum: 15% 6. Case fatality rate Proportion of women with obstetric com- Maximum: 1% plications admitted to a facility who die Source: United Nations. • Availability of and access to quali- the only household-level survey verbal-autopsy questionnaires – one ty health-care services. large enough to allow for the meas- to ascertain deaths within the first • Quality of care.2 urement of geographic and socio- four weeks of life, another for chil- economic variations in maternal dren aged four weeks to 14 years, A number of tools exist to facilitate mortality. A census may include fol- and a third for persons aged 15 and the collection of this information, low-up questions aimed at assessing over – with the goal of helping stan- including censuses, verbal autopsy, the timing of deaths of women of dardize measurement criteria and death registration, surveys or studies, child-bearing age in each household methods. This level of scrutiny takes data obtained from health facilities within the past 12 months. It into account the critical issue of and health surveillance. Since each should be noted, however, that timing that has in the past not method has strengths and weakness- some countries are not using their been adequately emphasized.3 es, more than one mechanism should censuses to collect this information, be employed to assess maternal and missing out on an opportunity to Obtaining information on cause of newborn health. collect valuable information on death can be challenging. According maternal health. to the World Health Organization, Censuses, questionnaires and only 31 of its 193 member states household surveys Verbal autopsy is another method of report high-quality cause-of-death National censuses are a key source gathering information on mortality statistics. Several countries are now of data and information on mater- and morbidity. The World Health using surveillance tools such as nal health. Often they provide Organization has developed three Demographic Surveillance Systems in 70 T H E S TAT E O F T H E W O R L D ’ S C H I L D R E N 2 0 0 9

Household surveys such as DHS and MICS are providing vital data on a wide range of outcome and coverage indicators. smaller geographic areas to ascertain topics. Since 1995, nearly 200 MICS misses’ – life-threatening complica- cause of death. Methods used include have been conducted in 100 countries. tions that heightened the risk of follow-up investigations of deaths mortality but which ultimately using verbal autopsy to ask family Facility- and community-based did not result in death – that are data collection members, health-care providers and important for improving service community members to explain Data derived from health facilities quality.5 circumstances of death. These systems across the wide range of public are called sample vital registration and private health-care providers Governments, research institutions with verbal autopsy systems. A no- are also useful in assessing the state and other agencies also conduct blame policy, in which the respon- of maternal and newborn health. health surveillance, defined by the dents are not held liable for answers The number of deaths in facilities Centers for Disease Control as ‘‘the to survey questions, is pivotal to can be readily monitored and pro- ongoing, systematic collection, analy- enlisting and retaining community vide opportunities to learn about sis, interpretation, and dissemination support for these endeavours.4 improvements needed to avert of data regarding a health-related further deaths, particularly those event that is for use in public health A number of factors influence in institutional settings, in a process action to reduce morbidity and mor- maternal and newborn health out- known as ‘maternal death review or tality and improve health.”6 This comes, including biological factors audit’. This type of data can also method of data gathering can be such as nutritional status; socioeco- provide insights into the ‘near- combined with others to assess the nomic determinants such as income and education; health-seeking Figure 4.2 behaviours and healthy practices; barriers to accessing health services; Distribution of key data sources used to derive the 2005 and behavioural risk factors such maternal mortality estimates as domestic violence and smoking. Total number of countries: 171 Household surveys and studies are the primary methods used to assess Civil registration, complete, good the frequency of these types of No national data attribution of cause 35% determinants, which can then be of death 35% analyzed to better understand the population for which health programmes are intended. Civil registration, complete, Special studies uncertain/poor 4% Important periodic cross-sectional attribution of cause Census of death household surveys include the 3% 4% Direct sisterhood Demographic and Health Surveys Disease estimates surveillance/sample (United States Agency for International registration 16% Development), Multiple Indicator 1% Reproductive age Cluster Surveys (UNICEF) and Repro- mortality studies ductive Health Surveys (Centers for 2% Disease Control). These international Source: World Health Organization, United Nations Children's Fund, United Nations Population surveys provide comprehensive quan- Fund and the World Bank, Maternal Mortality in 2005: Estimates developed by WHO, UNICEF, titative data on a wide range of health UNFPA and the World Bank, WHO, Geneva, 2007, p. 9. S T R E N G T H E N I N G H E A LT H S Y S T E M S T O I M P R O V E M AT E R N A L A N D N E W B O R N H E A LT H 71

© UNICEF/HQ06-0550/Shehzad Noorani Increasing the number of births attended by skilled health workers can reduce maternal deaths arising from complications during childbirth. Two teachers demonstrate proper procedures for holding a baby after delivery during a training session for women at a midwives training centre, Sudan. health of a population over time and Averting Maternal Death and Beyond the Numbers, which describes by geographical area. Disability Project.7 methods that can be used to relate the story of a woman’s death as part of Other aspects of maternal health care The Health Metrics Network, an efforts to reduce maternal mortality. are also being measured, with strong international partnership dedicated These methods included community- support from international agencies. to helping countries strengthen their based verbal autopsies, facility-based Facility-based data are being collect- health management information sys- maternal death or near-miss reviews, ed by UNICEF and its partners to tems, has developed a tool to assess clinical audits, and larger regional provide indicators for emergency the completeness and quality of such or national confidential enquiries.8 obstetric care. Needs assessment for systems (see Panel on Enhancing In Mozambique, a review of maternal emergency obstetric care has also health information systems: The deaths in health facilities has provided been undertaken by UNICEF, the Health Metrics Network, page 104). valuable insights into the preventable United Nations Population Fund The World Health Organization has factors behind these deaths and guided and Columbia University in the led the development of a guide entitled policy and system responses.9 72 T H E S TAT E O F T H E W O R L D ’ S C H I L D R E N 2 0 0 9

Using critical link methodology in health-care systems to prevent maternal deaths by Rosa Maria Nuñez-Urquiza, National Institute of Public Health, Mexico Critical link methodology (CLM) examines each maternal One such example is provided by a CLM study of women death as a sentinel event. It reviews all the health-care inter- with post-partum haemorrhage who died as they were trans- actions between a woman and health personnel prior to her ferred from community hospitals to referral hospitals. The death, providing a timeline of health-seeking actions and assessment identified the lack of stabilization of women prior corresponding care provision across the health system. to transportation as a fatal omission. In the seven states where the percentage of maternal deaths due to post-partum CLM assesses health care through three dimensions: haemorrhage was above the national average, up to 60 per cent of maternal deaths occurred while transporting patients • clinical performance (delays, omissions and compliance to larger hospitals. When ambulances and trained personnel with quality standards compared to established guidelines). were provided in one of those health districts, the maternal mortality rate from post-partum haemorrhage fell by 30 per • internal hospital organization. cent the following year. • continuity of care between health-care facilities. CLM is helping to redesign the way facilities are networked in each district health system. In addition, applying CLM Through this process of review, CLM focuses on those crucial necessitates involving a broader group of stakeholders than interventions that, if provided in an expeditious manner, can those traditionally engaged in safe motherhood committees, avert future maternal deaths. It enables safe motherhood i.e., heads of clinical laboratories and blood banks, as well as committees to shift their focus from a medical cause of death health district administrators. to a managerial perspective of missed opportunities. This change in perspective is highlighted through the following One outcome of CLM is that the reproductive health divisions lines of enquiry: at both the Ministry of Health and the Instituto Mexicano de Seguridad Social (IMSS, the Mexican social security system) • During which interactions between the woman and the now report the Causes of maternal deaths not only as medical health system could the condition leading to her death have causes, like “pre-eclampsia, sepsis, etc.,” but also by detected been better addressed? failures in the process of care. For example, the report of maternal mortality of a given district or state health system • Based on this analysis, what specific steps must be done will now state, “15 per cent of maternal deaths due to lack of differently in the future to prevent the deaths of women in IV solutions in health centres leading to failure to stabilize the similar circumstances? women before transfer” or “10 per cent of maternal deaths due to delays in bringing in the surgeon on call to district • To sustain these specific changes, what processes in each hospitals during weekends.” Seeing beyond the medical care unit require modification to ensure quality of care, and causes helps to diagnose health-system failures which, if what factors of the health system should be redesigned to immediately addressed, will avert maternal deaths. ensure the continuity of care during obstetric emergencies? See References, page 111. Furthermore, the comparison of near-miss cases (complications that lead to severe morbidity but which ultimately do not prove fatal) with cases of maternal mortality highlights the imperative of timely provision of care. This has resulted in a new category of analysis: therapeutic time interval, which calls for clinical research to establish the time interval during which interventions are effective. The therapeutic time interval helps demonstrate that even when appropriate treatment is provided, it may fail to save women’s lives unless applied in a timely manner. From single-case red alerts to further research Open and regular communication between CLM field supervi- sors and federal authorities ensured that alerts detected by individual case studies spurred further analysis of routine data systems (hospital registries of 1,029,000 obstetric patients yearly from 617 public hospitals) to explore the mag- nitude and distribution of these gaps in maternal care across the health system. S T R E N G T H E N I N G H E A LT H S Y S T E M S T O I M P R O V E M AT E R N A L A N D N E W B O R N H E A LT H 73

New technologies are also showing potential to assist in data collection on maternal and newborn health. Methods have also been devised to In one study conducted by the entry, often cited as a problem assess the quality of care delivered by Initiative for Maternal Mortality in paper-based surveys. It also health providers. Two such frame- Programmed Assessment trained and employed local school- works include the Performance (IMMPACT) in eastern Burkina children with the requisite linguistic Quality Improvement method devel- Faso, 127 interviewers using competence and familiarity with oped by the United States Agency for personal digital assistants captured mobile phones.11 International Development, and the data from 86,376 households in just client-oriented, provider-efficient over three months. Each unit cost It is apparent that there are numer- services (COPE) method developed approximately US$ 350, amounting ous means of data collection that by EngenderHealth.10 to US$ 60,000 for the equipment; can provide useful information although no cost-effectiveness to guide programmes and policies. In addition to new measurement analysis was completed, a paper Dissemination and analysis of tools, new technologies are also being approach would have required over this data is essential, at local, applied to assist in intelligence gath- 1 million printed pages, 100 global national and international levels, ering. For example, surveys using positioning satellite receivers and to inform resources allocation digital technologies show hope for 20 desktop computers and cost and policy responses, and achieve improving data collection in the more. The PDA experiment had the the greatest impact in reducing remotest areas. advantage of immediacy of data maternal deaths. Figure 4.3 Skilled health workers are in short supply in Africa and South-East Asia in particular WHO regions Europe 78 32 The Americas 49 19 Nurses and Western Pacific 20 14 Midwives Eastern Mediterranean 15 physicians 10 South-East Asia 12 5 Africa 11 2 Country groups by income level Global 28 13 High income 87 28 Upper middle income 41 21 Lower middle income 17 13 Low income 11 5 0 10 20 30 40 50 60 70 80 90 100 Skilled health personnel (doctors, nurses or midwives, per 10,000 population), 2005 Source: World Health Organization, World Health Statistics 2008, WHO, Geneva, 2008, pp. 82–83. 74 T H E S TAT E O F T H E W O R L D ’ S C H I L D R E N 2 0 0 9

New directions in maternal health by Mario Merialdi, World Health Organization, and Jennifer Harris Requejo, Partnership for Maternal, Newborn and Child Health Twenty-one years ago, the global health community came complications. Coverage indicators for proven interventions together under the auspices of the Safe Motherhood Initiative and approaches linked to each of these three pillars – including to focus on maternal mortality, whose upper and lower bounds antenatal care, availability of emergency obstetric care, represent the starkest disparity in international public health. Caesarean section rates, contraceptive prevalence, skilled atten- Yet by 1990, the baseline year for the Millennium Development dance at delivery, post-natal care and unmet need for family Goals, more than half a million women, 99 per cent of them in planning – are now being tracked in the Countdown to 2015 ini- developing countries, were still dying every year due to compli- tiative, by national governments, UN agencies, international cations related to pregnancy and childbirth. Maternal mortality health partnerships and non-governmental organizations. estimates for 2005 indicate that around 536,000 women continue to die each year in pregnancy and childbirth, equivalent to Improvements in documenting the global distribution of roughly one woman dying every minute from largely preventa- maternal mortality and morbidity, and identifying and tracking ble causes. These deaths, which are heavily concentrated in the effective interventions, have been complemented by impor- most disadvantaged population groups within low-resource tant research findings on ways of countering maternal health countries, are reflective of a persistent, unjust, social inequality risks. Several interventions, shown to improve maternal sur- that is long overdue for greater attention. These deaths are dis- vival in epidemiological studies and appropriate for universal proportionately occurring in sub-Saharan Africa, which accounts application, are now ready for wide-scale implementation. for half of annual maternal deaths, and South Asia (35 per cent), These include magnesium sulphate and calcium supplementa- leaving the world a long way from its target of reducing the tion for the prevention of hypertensive disorders of pregnan- maternal mortality ratio by three quarters between 1990 and cy, effective dissemination strategies for guidelines on the pre- 2015 (Millennium Development Goal 5, Target A). vention and treatment of post-partum haemorrhage, and the recommended provision of at least four antenatal visits to Despite the disappointing lack of progress in reducing pregnant women and one post-partum visit to new mothers. maternal mortality since the launch of the Safe Motherhood Increasing awareness of the inextricable link between mater- Initiative, important advances in maternal health have been nal and newborn health has also resulted in the introduction achieved on several fronts. An unprecedented amount of of effective programmes for the prevention and treatment of resources apportioned to health at the international level, malaria and HIV, through measures to expand provision of combined with renewed political commitment to primary insecticide-treated mosquito nets and intermittent preventive health care and with new complementary initiatives focusing treatment of malaria in pregnancy, interventions to prevent specifically on maternal, newborn and child health, suggests mother-to-child transmission of HIV, preventive measures to that momentum is building to address the historically neglect- avoid HIV infection – particularly among young people – and ed issue of maternal mortality. Other developments in this antiretroviral treatment for HIV-positive women and children. direction include the adoption of the continuum of care as a core framework for public health programs; the establishment Key areas of promising research include activities focused on of the Partnership for Maternal, Newborn and Child Health in developing strategies for ensuring the delivery of comprehen- 2005 to guide and promote the continuum; ratification of the sive packages of maternal and newborn health services along Maputo Plan of Action to implement the continental frame- the continuum of care. An essential component of these work for sexual and reproductive health and rights in Africa; strategies is the establishment of mechanisms for integrating the addition of a new MDG 5 target (5.B) that seeks universal services traditionally delivered through vertical approaches – access to reproductive health by 2015; and the inclusion of such as immunization and micronutrient supplementation – maternal survival in the Countdown to 2015 assessments. with antenatal and post-natal care as part of health-system These developments are testament to the revitalized focus strengthening. Recent years have also witnessed an encourag- in the global health community on maternal and newborn ing trend towards the establishment of collaborative partner- survival and well-being. ships between international organizations, governmental agencies, research institutions, non-governmental organiza- Improvements in procedures for estimating maternal mortality, tions and the private sector to promote multi-country research new estimates of the incidence of abortion and increased projects on major complications in pregnancy and childbirth – efforts to map the global burden of maternal ill-health are including preterm delivery, stillbirths, impaired fetal growth, important epidemiological advancements that will enable better hypertensive disorders, post-partum haemorrhage and decision-making by governments and their partners. The grow- obstructed labour and obstetric fistula. ing recognition of the causal role of undernutrition in maternal mortality has resulted in renewed interest in micronutrient sup- The growing political and financial support for programmatic plementation during pregnancy and a stronger emphasis on the and research initiatives aimed at improving maternal and need to address underlying and basic factors, such as poverty newborn health, and the shift from single issue, sectoral and gender discrimination and disempowerment – including approaches to health care to collaborative forms of delivering limited access to education for many girls and young women primary health care in a continuum of care, raises hopes and and their high exposure to infections. A broad consensus has expectations that the long-awaited gains in maternal, newborn also emerged about the core health-sector strategies required and child health that are so critical for the well-being and to reduce maternal mortality. Comprehensive reproductive development of populations will become increasingly health care is now considered to include family planning, skilled apparent in the near future. care for all pregnant women during pregnancy and delivery, and emergency care for all women and infants with life-threatening See References, page 111. S T R E N G T H E N I N G H E A LT H S Y S T E M S T O I M P R O V E M AT E R N A L A N D N E W B O R N H E A LT H 75

Strengthening the health system in the Lao People’s Democratic Republic The Lao People’s Democratic Republic is a mountainous, The programme also prioritizes education for women in largely rural, country in South-East Asia with an average gross improved nutrition practices, including breastfeeding and com- national income per capita of less than US$ 600 in 2007. Nearly plementary foods, since studies have shown strong linkages 40 per cent of the population in this ethnically diverse nation – between inappropriate feeding practices and child undernutri- which comprises nearly 50 different ethnic groups – lives below tion in the Lao People’s Democratic Republic. The dissemination the poverty line. Although the country is on track to meet of other health information, including clinical care and immu- Millennium Development Goal 4, having managed to reduce its nization, is also an important component of the programme. under-five mortality rate by 57 per cent between 1990 and 2007, significant health challenges remain for mothers and newborns. The Sayaboury programme has shown significant success, at a highly affordable cost of around US$4 million over a Chief among them are undernutrition, improving feeding and 12-year period, representing a per capita expenditure of just hygiene practices, immunization, environmental health and US$ 1 per year. The district’s maternal mortality ratio fell ensuring adequate skilled health personnel to deliver quality from 218 per 100,000 live births to 110 per 100,000 live births health services. More than 1 in 7 newborns suffer from low between 1998 and 2003. The median age at which infants birthweight, a condition that is often associated with poor received complementary foods increased from 2.8 months in maternal nutrition. Exclusive breastfeeding, at 23 per cent 1999 to 3.7 months in 2001, while the rate of exclusive breast- according to the latest estimates, is far below the regional aver- feeding for the first four months rose from 28 per cent in 1999 age of 43 per cent for East Asia and the Pacific. Only 60 per cent to 66.2 per cent in 2004. Vaccination coverage remained inade- of the population have access to improved drinking-water sup- quate, however, with only 50 per cent of children under age plies, and just 48 per cent have access to adequate sanitation one receiving three or more doses of diphtheria, pertussis and facilities. Access to both of these critical services is far lower still tetanus vaccine – the benchmark indicator for routine immu- in rural areas. In 2007, only 40 per cent of infants under age one nization coverage – in 2007. were immunized against measles and just 47 per cent of pregnant women were immunized against neonatal tetanus. With Complementing efforts to improve maternal and newborn maternal mortality standing at 660 deaths per 100,000 live births health, the Caring Dads communication campaign encourages in 2005, the Lao People’s Democratic Republic has the highest fathers to support pregnant women and mothers in caring for rate of maternal deaths in the region. The lifetime risk of mater- themselves and their babies. The Ministry of Health, in collab- nal death stood at 1 in 33 in 2005. oration with UNICEF and the Lao Trade Union, has collaborat- ed on comprehensive methods to advocate for greater Notwithstanding these challenges, advances are steadily involvement by men in family care. These campaigns are being made to expand health services to the country’s large aimed primarily at wage-earning fathers, who have been rural population. One such programme involves Save the identified as the group most likely to engage in commercial Children Australia, which has worked with the Provincial sex, the source of the growing HIV prevalence within the Health Office and other partners in Sayaboury to expand and country. While the Lao People’s Democratic Republic has a enhance primary-health-care infrastructure in four three-year lower adult HIV prevalence rate than some of its neighbour- phases. Their goals are: ing countries, poverty and cross-border migration are contributing to the spread of the virus. Posters and booklets on • Phase I: Strengthen the provincial management team themes such as the Caring Dad in Pregnancy have been responsible for training district teams and village health vol- reprinted because of unexpectedly high demand. unteers and traditional birth attendants, develop fixed and mobile maternal and child health clinics and provide essen- Such programmes aimed at community initiatives in health, tial equipment. together with expanded immunization and supplementation • Phase II: Integrate primary health care at all levels – campaigns supported by UNICEF in 2007 and health provincial, district and village. infrastructure-building, are steadily beginning to help • Phase III: Expand programmes into four remote districts. reduce the still high burden of maternal and newborn • Phase IV: Strengthen the skills of health workers through deaths in the Lao People’s Democratic Republic. adoption of the Integrated Management of Childhood Illness framework. See References, page 111. 76 T H E S TAT E O F T H E W O R L D ’ S C H I L D R E N 2 0 0 9

Addressing the health worker crises is critical to improving maternal and newborn health. The greatest shortages are in Africa and Asia. © UNICEF/HQ07-1307/Anita Khemka Averting maternal death helps safeguard the survival and health of newborns. A mother lies in bed with her newborn daughter in a maternity ward after a successful delivery, Pakistan. Step 2: Enhancing human workers is uneven, with greater con- fall below this threshold, 36 are in resources, training and centration in developed countries com- sub-Saharan Africa. The greatest supervision pared to developing countries, and in shortage of health workers in urban areas relative to their rural absolute terms is in Asia, especially Many developing countries are facing counterparts within countries. India, Indonesia and Bangladesh, but an acute shortage of skilled health the largest relative need is in sub- workers. Mass migration, AIDS and In 2006, research by the World Saharan Africa, where the number armed conflict are among the key Health Organization recommended of health workers must increase by factors debilitating national health that countries should have an average 140 per cent to reach the requisite workforces, which in turn is constrain- of 2.28 health-care professionals per density.12 In the World Health Report ing progress in reducing maternal and 1,000 population to achieve adequate 2005, the World Health Organization newborn mortality and morbidity. coverage of skilled health personnel estimates that increasing coverage of Furthermore, the distribution of health at delivery. Of the 57 countries that maternal health care for women by S T R E N G T H E N I N G H E A LT H S Y S T E M S T O I M P R O V E M AT E R N A L A N D N E W B O R N H E A LT H 77

57 countries – 36 in sub-Saharan Africa – have less than the WHO minimum threshold of 2.28 health workers per 1,000 population that would provide adequate skilled assistance at delivery. 2030 would require coverage levels ering maternal mortality rates. A described as ‘birth attendants’ have to rise threefold, with 334,000 skilled skilled birth attendant is defined the skills required. health attendants needed to reach 73 by the World Health Organization per cent coverage of births world- as “an accredited health profession- Midwives or other mid-level wide by 2015 – along with thousands al – such as a midwife, doctor or providers who have been trained for more doctors, surgeons, anaesthetists, nurse – who has been educated or shorter periods and require lower technicians and maternity units trained in management of uncompli- entry education qualifications should within facilities.13 cated deliveries and post-natal care form one cadre within a spectrum of and in the identification, manage- health workers who can undertake No substitute exists for the presence ment and referral of complications different roles, distribute workloads, of skilled health workers at delivery, in women and newborns.”14 Yet the and build a referral system for preg- which has been a common factor skills of health workers who fall nant women and newborns. It is across a set of countries with diverse into this category vary widely by also critical to ensure that trained profiles that have succeeded in low- country, and not all health workers birth attendants are supported by an Figure 4.4 Uptake of key maternal, newborn and child health policies by the 68 Countdown to 2015 priority countries International Code of 25 Marketing of Breast Milk 28 13 Substitutes 2 Yes 0 Maternity protection in 20 Partial accordance with ILO* 48 Convention 183 N/A No 18 No data Community management of pneumonia with 11 31 antibiotics 8 New oral rehydration 34 salts formula and 17 zinc for management 10 of diarrhoea 7 IMCI** adapted to cover 39 3 newborns 0–1 week 21 of age 5 23 Specific notification of 14 maternal deaths 18 13 Midwives authorized to 27 administer a core set of 25 5 life-saving interventions 11 0 5 10 15 20 25 30 35 40 45 50 * ILO: International Labour Organization ** IMCI: Integrated Management of Childhood Illness Source: Countdown to 2015, Tracking Progress in Maternal, Newborn and Child Survival: The 2008 report, UNICEF, New York, 2008, pp. 200–201. 78 T H E S TAT E O F T H E W O R L D ’ S C H I L D R E N 2 0 0 9

Strengthening the health workforce through recruitment, training and retention of skilled health personnel and community health workers is a key challenge for countries across the developing world. A doctor con- ducts a midwifery training course at a hospital, Afghanistan. © UNICEF/HQ07-1414/Anita Khemka ating overdependence on an over- worked, small staff. Countries also face the challenge of developing worker-retention strategies environment that enables their skills munity health workers pay monthly that adequately remunerate health to be used. This requires effective visits to ‘high risk’ households – workers and respond to their needs. teams, supplies, supervision and defined as homes including children In Mali, for example, the Ministry of referral systems. In Mozambique, under one, pregnant women and Health offers newly graduated doctors for example, midwives and nurse women of childbearing age – and training, accommodation, equipment, midwives have helped obstetricians assist babies with breathing difficul- and transportation in exchange for provide cost-effective quality emer- ties.16 The distribution of responsi- service in rural areas.17 In Pakistan, gency obstetric care functions in bilities can give pregnant women the Punjab Safe Motherhood Initiative under-serviced areas.15 In Peru, com- and children more care while allevi- rotates postgraduate doctors from Figure 4.5 Asia has among the lowest levels of government spending on health care as a share of overall public expenditure WHO regions The Americas 18 16 2000 Europe 15 14 2005 Africa 9 8 Eastern Mediterranean 7 7 South-East Asia 5 4 Western Pacific 3 4 Country groups by income level Global 8 9 High income 18 16 Upper middle income 10 9 Lower middle income 2 2 Low income 5 4 0 2 4 6 8 10 12 14 16 18 20 General government spending on health care as share of total government expenditure, 2005 Source: World Health Organization, World Health Statistics 2008, WHO, Geneva, 2008, pp. 90–91. S T R E N G T H E N I N G H E A LT H S Y S T E M S T O I M P R O V E M AT E R N A L A N D N E W B O R N H E A LT H 79

Saving mothers and newborn lives – the crucial first days after birth by Joy Lawn, Senior Research and Policy Advisor, Saving Newborn Lives/Save the Children-US, South Africa Investing in post-natal care can generate high • Who for? Integration of post-natal care for mothers and returns in maternal and newborn survival newborns provides more effective and efficient care than Across the human lifespan, an individual faces the greatest separate approaches to post-partum and newborn care. risk of mortality during birth and the first 28 days of life – the • Where? Routine post-natal visits should be provided at neonatal period. Each year, nearly 4 million newborns die home or close to home, both to promote healthy behav- during this period – equivalent to around 10,000 per day. iours and to link with curative care – instead of just hoping Three quarters of these deaths take place within one week of that the mother or baby will be brought to a health facility birth, and 1–2 million die during the first day following birth. if problems arise. Most of these deaths occur at home, are unrecorded, and • When? Early contact with mothers and babies is critical, remain invisible to all but their families. Millions more suffer ideally within 24 or at most 48 hours of birth for the first severe illness each year, and an unknown number are affect- visit – instead of the more common visit six weeks after ed with lifelong disabilities. Moreover, the risks of maternal birth. The indicator measuring post-natal care published mortality and morbidity also are highest at birth and in the by the Countdown to 2015 in its 2008 report focuses on immediate post-natal period. care within two days of birth. Large-scale surveys are changing to measure this indicator in more countries For babies and mothers facing such complications as neona- and communities. tal sepsis or post-partum haemorrhage, delay of even a few hours before appropriate care is delivered can be fatal or Closing the gap between policy and action result in long-term injuries or disability. Important new data Changing policies and indicators to reflect the importance of from Bangladesh show that a home visit on the first or sec- post-natal care is necessary, but not sufficient, to save lives. ond day after birth can reduce neonatal deaths by two thirds, Services must also be scaled up to ensure high coverage and but later visits are less effective at reducing mortality. The quality care during this period. While the content of a post-natal early post-natal period – the first seven days of life – is also care package is fairly clear, the most effective delivery mecha- the critical period for initiating high impact life-saving behav- nism will vary, especially to provide services in remote rural iours, including exclusive breastfeeding. Optimal breastfeed- areas and to reach newborns and mothers immediately after ing does not start at the six-week visit for infant immuniza- birth. Figure 4.5 maps delivery options with conditions of access tion – evidence shows that effective support and coun- to health facilities and human-resource availability in facilities selling in the first days of a child’s life directly increase rates and at community level. Many of the tasks involved in post- of exclusive breastfeeding. Other key behaviours during the natal care can be delegated to an extension worker who is ade- neonatal period, such as hygienic cord care and keeping the quately supervised and effectively linked with the health system. baby warm, can make the difference between life and death – particularly for babies who are born prematurely. The post- Case management of neonatal infections is an natal period is also a critical time for preventing mother-to- urgent priority child transmission of HIV and for providing women with While early post-natal care visits for preventive care are access to family planning options. immensely important, these are most effective at reducing mortality rates when integrated with curative care. Almost Coverage gap for early postnatal care one third of newborn deaths result from infections; in poor, Providing effective care for mothers and newborns during high-mortality settings, this proportion is far higher. Many of the early post-natal period has the potential to generate the these babies are born preterm. greatest gains in survival and health of any period in the continuum of care. Despite this promise, however, the first days With an effective post-natal care package, infections in new- following birth are the time when coverage of appropriate borns will be identified early. In most countries, however, services and behaviours is currently lowest. Among the 68 newborn illness can only be treated through referral to a priority countries identified by the Countdown to 2015 initia- health facility; even then, only a low percentage of those tive, a median of just 21 per cent of women received post- referred will actually seek the care. One option is to have natal care. first level, routine IMCI health-care workers begin antibiotic treatment. In countries where community health workers Changing paradigms in post-natal care already provide case management for pneumonia or malaria, Growing recognition of the critical importance of providing case management of neonatal infections may also be consid- care to mothers and newborns, and the substantial gaps in ered to bring care closer to home. Several Asian studies have coverage that currently exist, along with evidence generated shown how such strategies can result in large reductions in mostly from trials in South Asia, have prompted paradigm neonatal mortality, and community case management of shifts. Three tenets have emerged: neonatal sepsis is now being scaled up in Nepal, linked to case 80 T H E S TAT E O F T H E W O R L D ’ S C H I L D R E N 2 0 0 9

management of childhood pneumonia. Of the 68 Countdown pri- provision of life-saving interventions where the majority of ority countries, 39 have changed policy to include case manage- newborn deaths occur and particularly where access to health ment of neonatal sepsis within the Integrated Management of facilities is low. A network of studies is under way in eight Childhood Illness framework. The key challenge now is to identi- African countries examining nationally adapted packages and fy the appropriate providers of such care in each country. potentially scalable cadres of workers. Analysis of lives saved and costs will help guide policies and programmes to improve Closing the knowledge gap maternal and newborn care in the earliest days of life. Almost all (98 per cent) of newborn deaths occur in low- and middle-income countries. Yet most research and funding have See References, page 111. focused on incremental advances in highly technical care for the 2 per cent of newborn deaths occurring in high-income countries. An increasing number of studies are providing new guidance on the ‘how, who, when and where?’ questions for Figure 4.6 Post-natal care strategies: Feasibility and implementation challenges Possible strategies for Mother- Provider- Implementation challenges post-natal care contact friendly friendly 1 Mother and baby go to * *** Requires mother to go to the facility within a very short time after facility birth. More likely following a facility birth, but still challenging in first days after birth. 2 Skilled provider visits *** * Conditional on sufficient human resources, which is challenging. the home to provide Providing post-natal care may not be highest priority for skilled post-natal care for health personnel in settings where their attendance at birth is mother and baby still low. Many post-natal care tasks can be delegated to another cadre. A skilled provider may be able to provide home visits during the post-natal period if rural health facilities are quiet during afternoons. 3 Community health worker *** * Requires sufficient numbers of community health workers with visits home to see mother adequate training, supervision and incentives. and baby 4 Combination: Facility birth ** ** Requires team approach between facility-based and community and first post-natal care visit health workers, sufficient human resources, management and in facility, then home visit supervision, effective referral systems and an efficient information within two to three days, tracking system so that the progress of the mother and baby is with subsequent post-natal easy to track. care visits at a health facility Note: * Low degree. ** Moderate degree. *** High degree Source: Lawn Joy, and Kate Kerber, editors, Opportunities for Africa’s Newborns: Practical data, policy and programmatic support for newborn care in Africa, Partnership for Maternal, Newborn and Child Health, Cape Town, 2006. S T R E N G T H E N I N G H E A LT H S Y S T E M S T O I M P R O V E M AT E R N A L A N D N E W B O R N H E A LT H 81

Initiatives to include community partnerships in supporting maternity services are showing promise in several developing countries. sub-district hospitals to the district hos- for quality health care at the level of women themselves may be blamed pital in Sheikhupura, providing quality households and communities. Social for their own ill health and disease, obstetric and emergency care 24 hours inclusion must be prioritized and indi- and the mortality and morbidity of a day.18 Other non-financial incentive vidual families – particularly women – newborns. Where stillbirths and new- schemes, such as short-term rotation and communities must be included born deaths are common, they may of midwives, training opportunities and treated as partners in health-care not be seen as preventable. While and psychosocial support groups, provision. Numerous cases show that communities cannot be forced to have been used in southern and east- negative experiences from contacts accept alternative practices, they can ern Africa, with varying degrees of with formal health-care facilities can become partners in the promotion of success, but larger-scale implementa- dissuade families and even entire their own health and well-being and tion and further research are required communities from seeking care. that of their mothers and children. to fully evaluate their impact.19 One of the most important interven- Although health education is cen- Step 3: Fostering social tions to improve maternal and tral to fostering healthy practices mobilization neonatal health is the recognition and behaviours and appropriate of preventable risks. Entrenched cul- knowledge for care seeking, part- Supply-side measures cannot be suc- tural attitudes and beliefs often sur- nerships that involve key communi- cessful without strengthening demand round pregnancy and childbirth, and ty stakeholders directly in health Figure 4.7 Lower-income countries pay most of their private health-care spending out of pocket WHO regions South-East Asia 90 88 Eastern Mediterranean 88 88 2000 Western Pacific 83 88 Europe 68 2005 69 Africa 48 52 The Americas 31 34 Country groups by income level 51 Global 53 High Income 36 39 Upper middle income 65 69 Lower middle income 85 91 Low income 91 90 0 10 20 30 40 50 60 70 80 90 100 Out-of-pocket expenditure on health as a percentage of private expenditure on health, 2005 Source: World Health Organization, World Health Statistics 2008, WHO, Geneva, 2008, pp. 90–91. 82 T H E S TAT E O F T H E W O R L D ’ S C H I L D R E N 2 0 0 9

Mobilizing families, including men and other relatives, to recognize and respond to health risks is essential to strengthen the supportive environment for maternal and newborn health. Burundi: Government commitment to maternal and child health care Burundi is one of the world’s least developed countries. and UNICEF. Another important step was taken in 2007, when Protracted civil war and halting political restructuring have Burundi was one of eight countries to join the International stymied economic and social progress. Poverty rates are Health Partnership, a country-led and outcome-driven collab- soaring, with nearly 88 per cent of Burundians living on just oration between governments, international organizations US$ 2 a day. Undernutrition affects 66 per cent of the popula- and non-governmental organizations. A major objective of tion, and more than half of children under age five suffer this partnership is to identify a set of key goals, which from moderate or severe stunting. In 2005, women faced a include raising the number of institutional deliveries and lifetime maternal death risk of 1 in 16. The adjusted maternal increasing services to prevent mother-to-child transmission mortality ratio stood at 1,100 deaths per 100,000 live births in of HIV. 2005, and the neonatal mortality rate was 41 per 1,000 live births in 2004. Burundi’s National Reproductive Health Policy now includes newborn care as a critical strategy in reducing child mortality. Burundi has learned through experience the importance of A central feature of this policy will include scaling up services providing affordable, quality health care for the poor in gen- to prevent mother-to-child transmission of HIV. The median eral, and for mothers and children in particular. In February HIV-infection prevalence rate for young pregnant women aged 2002, the Government implemented a cost-recovery pro- 15–24 in Bujumbura stood at 16 per cent in 2005. One area for gramme that required patients to pay for medical consulta- future programming may be securing greater male support tions, tests and drugs. The initiative aimed to generate for prevention of mother-to-child transmission strategies. resources for a nascent health-care system and was implemented in 12 of 17 rural provinces, covering 5 million of the The country has also embarked on providing badly needed country’s 8.5 million inhabitants. The programme’s intro- basic health care that will positively affect women and chil- duction increased the numbers of patients who were unable dren. Immunization programmes have provided tetanus tox- to pay for the medical services they received in public hos- oid vaccine to nearly three quarters of women in high-risk pitals, and many of them were subject to detention in the districts. Such efforts have galvanized stakeholders at the facility. Women who had delivered by Caesarean section national and local levels. But sustained governmental prioriti- comprised an estimated 35 per cent of indigent hospital zation of health care for the poor will be necessary for the patients included in a 2006 Human Rights Watch report on continued support of international and grass-roots actors in patient detentions; 10 per cent of the indigent patients in building Burundi’s health infrastructure. the study were children. In addition to the burdensome expenses, health-care services for women and children See References, page 112. were often of poor quality. The current Government, led by President Nkurunziza, has begun to take steps towards tackling this health-care crisis. In 2005, when Burundi joined the International Monetary Fund- World Bank ‘Heavily Indebted Poor Countries Initiative’ with interim debt relief in 2005, the health budget was tripled. In 2006, the Government took the critical step of announcing free health care for pregnant women and children. A new policy, ‘Road Map for the Reduction of Neonatal and Maternal Mortality’, was drawn up and launched in that same year with the assistance of the United Nations Population Fund, World Health Organization, World Food Programme S T R E N G T H E N I N G H E A LT H S Y S T E M S T O I M P R O V E M AT E R N A L A N D N E W B O R N H E A LT H 83

Financing quality health care is a global challenge. Almost one third of the 68 priority Countdown to 2015 countries spend less than the initiative’s minimum threshold of US$ 45 per person each year. provision are also important. One may help address the belief of some disease prevention, care, nutrition, such example is under way in indigenous women that their cultural and other health determinants.22 Burundi, where traditional birth practices, such as vertical positioning attendants have been included in during delivery, were excluding them Just as male and female parents can institutional deliveries as assistants from modern health services.21 be mobilized, so, too, can other to formal health-care workers and family members. In many societies new mothers, who share food and Engaging men and other family where extended kin live in close members other gifts rather than paying the proximity, in-laws and other older attendants money.20 The goal of greater unity requires relatives have influence in health- not just inclusion of more women care decision-making. In Mali, for Health systems can also enlist com- but of men as well. Studies suggest example, the involvement of grand- munities through inclusion rather that men perceive a myriad of compli- mothers in community education than coercion. Policymakers in cations that result in maternal mortal- led to increased awareness of good Ecuador took such an approach ity, yet they do not always recognize nutrition for mothers and babies by legally integrating intercultural their own roles in preventing these and the detrimental effects of heavy approaches in reproductive and deaths. More extensive research on work for mothers as well as greater sexual health, with the aim of men’s roles in maternal and child sur- involvement by fathers in the care encouraging greater participation vival and health is needed because of their partners and newborns. of indigenous women in sustainable most currently available studies focus The programme also improved health development. This strategy on economic provision and less on relations between women and their Figure 4.8 Low-income countries have only 10 hospital beds per 10,000 people WHO regions Europe 63 The Americas 24 Western Pacific 33 Eastern Mediterranean 14 South East Asia N/A Africa 9 Country groups by income level Global 30 High income 59 Upper middle income 42 Lower middle income 23 Low income 10 0 10 20 30 40 50 60 70 Hospital beds per 10,000 population, 2005 Source: World Health Organization, World Health Statistics 2008, WHO, Geneva, 2008, pp. 82–83. 84 T H E S TAT E O F T H E W O R L D ’ S C H I L D R E N 2 0 0 9

Integrating maternal and newborn health care in India India’s progress is critical to improving maternal and newborn Some states have also taken the initiative to inaugurate health on a regional and global scale. According to the latest health partnerships with the private sector. In Gujarat state, international estimates, India’s maternal mortality ratio stood one of India’s most developed provinces, the shortage of at 450 per 100,000 live births in 2005, while the neonatal mor- skilled health-care providers has prompted the state govern- tality rate was 39 per 1,000 live births in 2004. Both figures ment to join with private hospitals to provide free obstetric represent reductions of rates in previous years. Yet even as its care for pregnant women living below the poverty line, economy grows rapidly – with real gross domestic product especially those of scheduled castes and scheduled tribes. expanding at an average annual rate in excess of 9 per cent in Chiranjeevi Yojana – meaning ‘a programme for long life’ – 2007–2008 – widening disparities are prevalent in health out- was launched in 2005 and operates through a memorandum comes between income groups and between social and caste of understanding between the Government of Gujarat and pri- groups. Growing inequities, combined with shortages in the vate obstetricians. For every delivery, the Government pays provision of primary health care and the rising cost of care, Rs 1,795 (US$ 40), which also includes Rs 200 towards trans- are complicating the country’s efforts to meet the health- portation costs for each patient and Rs 50 for the person related Millennium Development Goals. accompanying the beneficiary, to compensate for the loss of earnings. With a total population of roughly 1.1 billion, broad environmental and sociocultural diversity and an intricate political In 2006, a United Nations Population Fund study of system comprising 28 states and 7 union territories, India’s Chiranjeevi Yojana reported that the programme had success- efforts to manage its citizens’ health care have been largely fully raised the number of births delivered in health facilities, decentralized. The Government of India has emphasized and that private practitioners were mostly enthusiastic about expanding primary health care, which is, by constitution, their participation in the initiative. It also noted the reluctance under the purview of the states. Beginning in 2000, it began a of patients to utilize facilities for births, and that their spouses greater push to provide care to women and children in rural and in-laws had great influence on decision-making, which areas and in poor-performing states such as Bihar, Orissa and limited their ability to actively seek healthcare. The study Rajasthan. It has also encouraged private health care, which made several recommendations, including the establishment few can yet afford, while spending on public health care has of an independent body to ensure quality fallen to just 2 per cent of gross domestic product. control and equitable implementation. To address the widening disparities, the Government of The Gujarat Government’s initiative is a departure from India has issued a commitment to ‘inclusive growth’. One previous practice in that it took sole responsibility for the such initiative is Janani Suraksha Yojana, a government- reimbursement of private health-care providers, rather than sponsored project under the National Rural Health Mission relying on intermediary parties such as insurers. The state that provides cash incentives for antenatal care during preg- government is working with professional agencies such as nancy, assisted institutional delivery, and post-partum care associations of obstetricians and academic organizations to by field-level workers. The benefits extend to all pregnant plan and implement the new arrangements. women aged 19 and older living below the poverty line in 10 states, for up to two pregnancies. Women who are not Showing remarkable successes, the programme has been enrolled in the programme but who experience complica- expanded from five to all 25 districts of Gujarat. Between tions such as obstructed labour, eclampsia and sepsis are January 2006 and March 2008, 180 doctors were enlisted. also eligible for benefits. The programme also includes a Nearly 100,000 deliveries were performed, with each doctor mechanism for accrediting and compensating participating performing an average of 540. While a promising experience, private practitioners. ongoing monitoring and evaluation are required to ensure improvements are made and the desired impact is achieved. According to one follow-up study undertaken in select districts in Rajasthan in 2007–2008, Janani Suraksha Yojana has See References, page 112. increased access to antenatal and post-natal care. The review also revealed that 76 out of 200 participants in the study, or nearly 40 per cent, were girls under 18, the legal age of marriage in India. The programme is successfully expanding access to care while allowing the Government to monitor more closely the situation of girls and women. S T R E N G T H E N I N G H E A LT H S Y S T E M S T O I M P R O V E M AT E R N A L A N D N E W B O R N H E A LT H 85

© UNICEF/HQ08-0043/David Turnley Strengthening and integrating maternal and neonatal care requires national and international commitment and global health partnerships among agencies and institutions. A woman holds her toddler and a cup of complementary food, Sierra Leone. mothers-in-law, reducing shame associated with poor health out- in equitable social and economic and mistrust that had created comes, gaps in staffing, and weak development. Many governments, distances between them.23 investment in health-care infra- even in low-resource areas, are structure and logistics.25 Data exploring different strategies for Step 4: Ensuring equitable and from the Pan-American Health helping families manage the costs of sustainable financing Organization have shown that in routine and emergency obstetric and 2004, the average expenditure on newborn care. Various options are Financing quality health care is a public health was just 2.6 per cent possible, including reducing or elimi- global challenge for industrialized of gross domestic product for low- nating direct user charges; imple- and developing countries alike. and middle-income countries as a menting social protection initiatives Although there are no international- whole, in sharp contrast to the such as cash transfers and vouchers ly agreed thresholds on minimum near 7 per cent of GDP spent by on either a conditional or uncondi- per capita total spending, the high-income countries. South Asia tional basis; and introducing nation- Countdown to 2015 initiative has had among the lowest rate of al or community health insurance estimated that per capita spending spending, at just 1.1 per cent of or subsidizing private provision of of less than US$45 is insufficient gross domestic product. While health care for poor households.27 to provide quality basic health care sub-Saharan Africa spends slightly services. Among the 68 priority more of its GDP on health care Direct user charges countries for maternal, newborn (2.4 per cent in 2004), only a few A key area of debate in health finan- and child health identified by the countries in this region are meeting cing is direct user charges, which are Countdown to 2015 initiative, the commitment made in the 2001 an important barrier to accessing 21 have spending of less than Abuja Declaration of apportioning health services, particularly for poor US$45 per capita.24 15 per cent of their national budg- people. Removing user fees has the ets to health care spending.26 potential to improve access to health Public expenditure on health can services, especially for the poor. be a key determinant of health sys- Countries and donors are increasing- Several countries across the develop- tem capacity. Countries with low ly recognizing the pivotal importance ing world have already abolished, or rates of spending per capita may be of maternal and newborn health care are in the process of eliminating, 86 T H E S TAT E O F T H E W O R L D ’ S C H I L D R E N 2 0 0 9

Options for improving equity in maternal and newborn health care include increasing health budgets, eliminating direct user charges, implementing insurance initiatives and cash transfer programmes. some or all direct charges – often It should be emphasized that user It should be noted that the context with encouraging increases in access fees are not the only barrier that for user fee removal is critical, and to health-care services. These coun- the poor face. Other cost barriers no blanket policy is likely to address tries range from Burundi in Eastern include informal fees; the cost of the needs of each country. Careful Africa (see Panel on page 83) and medicines, laboratory and radiology analysis of the country-specific situa- Ghana in West Africa to selected tests not supplied in public health tion, the equity implications of alter- districts of Nepal.28 facilities; travel, food and accom- native financing and delivery strate- modation; and charges in private gies and the multiple financial and No systematic evaluation of user fee health-care facilities. These costs non-financial barriers to access is removal across developing countries generally make up a significant pro- required to support decisions on the has taken place so far. Preliminary portion of the total costs that house- most appropriate course of action. evidence suggests that in countries holds face and disproportionately where user fee removal was not affect the poor.31 Insurance and transfers supported by other policy measures, National health insurance schemes such as increased national budgets In addition, a number of quality, such as Bolivia’s social insurance for for health care or careful planning information and cultural barriers maternal and child health-care servi- and deliberate implementation must also be overcome before the ces can increase access for the poor- strategies, health system problems poor can access adequate health serv- est women to antenatal and delivery tended to increase and performance ices. The evidence indicates that the care.33 Yet this form of financing is weakened. In countries where fee poor are disproportionately affected hard to expand in countries with lim- removal was carefully planned and by these non-cost barriers. ited formal sector employment, low managed, however, there are signs of incomes, dispersed households and increased utilization of services and Although user fees are only one of minimal infrastructure. indications that the poor may have many barriers facing the poor, they benefited most, although the inci- are among the most amenable areas Community health insurance schemes, dence of catastrophic expenditures for policy action. As the recent expe- which operate more informally and among the poor did not fall.29 rience from Uganda has shown, the on a smaller scale than social insur- policy process of fee elimination can ance schemes, have increased institu- The experiences of Uganda and have a catalytic effect in allowing tional-delivery rates by 45 per cent South Africa suggest that for fee governments to confront other issues, in Rwanda and by 12 per cent in the removal to be effective, it needs to such as drug supply and procurement, Gambia.34 A cost-sharing scheme in be part of a broader package of budget allocation or financial man- an urban district of Burkina Faso reforms that includes increasing agement, which pose further barriers increased the number of emergency budgets to offset lost revenue, to progress.32 referrals from 84 to 683 in a year.35 maintain quality and respond to It may be difficult to expand such increased demand. It also requires Clearly, removing user fees is not a schemes for wider coverage, however, clear communication and wide simple exercise. Countries that seek and they require government or donor stakeholder buy-in, careful monitor- to move in this direction require sup- support because they may not be self- ing to ensure that official fees are port in planning and implementating financing and are dependent on effec- not replaced by informal fees, and this policy change, and need to link tive community mobilization. appropriate management of the the removal of direct user charges to alternative financing mechanisms broader measures for strengthening Conditional cash transfers and that are replacing user fees.30 health systems. voucher schemes are being piloted S T R E N G T H E N I N G H E A LT H S Y S T E M S T O I M P R O V E M AT E R N A L A N D N E W B O R N H E A LT H 87

Financing and development strategies should take account of the national and local context, and also focus on indirect barriers to access, such as transport costs and infrastructure. to generate demand for specific serv- Attention to the emerging public- logistics, transportation and the ices among the poor. Cash transfers private mix in health systems is referral process. Greater investment have increased antenatal care during urgently required as inequitable in expanding health-care facilities is the first trimester among poorer financing profiles and the unregulat- urgently needed, particularly in low- women in Mexico by 8 per cent ed nature of the private sector can income countries. The latest WHO and in Honduras by 15–20 per cent.36 affect government commitments to estimates indicate that there are just India has provided financial incen- health care, public confidence and 10 hospital beds per 10,000 popula- tives for deliveries in facilities for socio-economic disparities. Findings tion in low-income countries, com- women from marginalized groups from studies of private services in pared with almost six times that in priority districts. While these India, Indonesia and Mexico show number for higher-income countries.39 initiatives have increased access the challenges of assessing quality to health-care services, effective of care across the public and private Where facilities exist, governments improvements in maternal health sectors and the importance of taking and other supervising agencies must outcomes may not be realized without into consideration the national ensure that they are properly func- concomitant improvements in quality context before drawing definitive tioning and maintained. In Uganda, of services. Continued monitoring conclusions about either sector.38 where declines in maternal mortality and evaluation of these financing Governments face the challenge of have been registered, a review of innovations are required to inform improving the regulation of private emergency obstetric care facilities appropriate scale-up by policymakers. health-care providers, using interna- showed that in 54 districts out of 56 tional guidelines to develop national throughout the country, over 97 Private-sector providers policies that mandate minimum per cent of facilities expected to pro- The private sector has become an standards for such services as ante- vide basic emergency services were important health-care provider, par- natal care, case management of HIV not able to do so. Lack of running ticularly in Asia, but the evidence and AIDS, maximum acceptable water, electricity, and functioning base to measure its effectiveness is rates for Caesarean-section deliveries operating theatres were among the still limited, with most evaluations and other critical issues in maternal key impediments to service delivery.40 measuring short-term changes in and newborn care. Further reviews are urgently required provider behaviour, not health out- to ensure that existing facilities are comes or other impacts on beneficiar- Step 5: Strengthening upgraded and new ones are estab- ies. The private sector is heteroge- infrastructure, transportation, lished in a sustainable manner. neous in nature and encompasses a logistics, supplies and the Funding for medical supplies, includ- variety of providers, including tradi- referral process ing essential medicines, is a further tional healers and birth attendants, priority. The UN inter-agency list of church-based hospitals, spas and cor- Strengthening health systems to sup- essential medicines for reproductive porate global entities that may oper- port maternal and newborn care health serves as a useful guide to the ate without r

Unicef 2009 State Of Women & Children Report

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Unicef 2009 State Of Women & Children Report - Presentation Transcript