5. Executive Summary v
Introduction 3
PART I. THE COIA INDICATORS: WHERE WE STAND
Indicator 1. Maternal mortality 8
Indicator 2. Child and neonatal mortality 11
Indicator 3. DPT3 among 12–23 month old children 13
Indicator 4. Childhood stunting 14
Indicator 5. Increase the proportion of demand for family planning
satisfied (met need for contraception) 17
Indicator 6. Antenatal care coverage at least four times during pregnancy 18
Indicator 7. Antibiotic treatment for suspected pneumonia in children
under 5 years of age 18
Indicator 8. Postnatal care for mothers and babies within two days of birth 18
Indicator 9. Antiretroviral (ARV) prophylaxis among HIV-positive pregnant
women to prevent HIV transmission and antiretroviral therapy
for women who are treatment-eligible 19
Indicator 10. Increase the proportion of births attended by a skilled attendant 19
Indicator 11. Increase the proportion of newborns who receive exclusive
breastfeeding for the first six months 21
PART II. EQUITY MAPPING, A FRAMEWORK FOR DISCUSSION
Universal health coverage 26
Categories of socioeconomic disparities 27
Challenges in data generation and analysis for informed decision-making 29
Improving participation in health systems and inclusion in national policy design 31
Identifying strategic shifts needed to reduce inequities 32
References 35
Contents
iiiReproductive, Maternal, Neonatal, and Child Health Indicators and Equity Mapping: A Framework for Discussion
7. he following review of evidence has been prepared for the A Promise
Renewed meeting in Panama in September 2013, to help frame dis-
cussions and inform subsequent policy design. The review applies
an equity focus to assess progress on indicators chosen by the
Commission on Information and Accountability (COIA) for Women’s and
Children’s Health (1). The Commission met in 2010, reviewed the Millennium
Development Goals (MDG) for maternal and child health set for 2015, and
evaluated the available evidence. Commission members then selected and
recalibrated 11 indicators to enable intensified tracking and reporting in a
handful of countries (“COIA countries”) where reproductive, maternal, and
child health were in danger of falling behind. That set of COIA indicators,
which we apply to the Region as a whole in this review, includes three
that assess progress in terms of impact on overall health status (maternal
mortality, under-5 and neonatal mortality, and stunting in children under
5 years of age) and eight that track advances in service coverage. The COIA
indicators are directly relevant to renewed efforts to improve child health
through the global A Promise Renewed campaign.
As we quickly approach the 2015 deadline for achieving the Millennium
goals, this review presents a timely, evidence-based appraisal of where we
stand, areas of progress, remaining challenges, and setbacks for the 11
key indicators. Also, in addition to reporting findings for the indicators,
this review addresses the underlying challenge of data quality and use. It
identifies persisting critical data issues in the Region, including the need
for better standardization and completeness of data gathering to allow
comparison across groups, geography, and over time, and improved data
analysis to guide programs and policy. Without quality data and systematic
analysis, evidence-based strategic policy design and resources deployment
is not possible.
Notwithstanding the need to improve information systems, the American
Region now has enough of an evidence base to recognize distinct patterns
of variability in outcomes, services, and systems that reveal systematic
inequities among groups of people. Indeed, the evidence of stark health
Executive Summary
Reproductive, Maternal, Neonatal, and Child Health Indicators and Equity Mapping: A Framework for Discussion v
T
8. inequities in the Region has been mounting for
decades. The structural nature of these inequi-
ties adds a strong human rights dimension to
the aim of improving the quality of health
for women and children throughout their life
course in keeping with a strategy of univer-
sal health coverage. Innovative approaches
have now worked in enough countries across
the Region that there is evidence, too, that
policy commitment and creative integration
of program strategies do succeed in establish-
ing effective models based on a healthy life
course approach with equity and universal
health care as its compass. This review dem-
onstrates the urgent need for a careful map-
ping of the landscape of barriers to equity and
identifying the paths to overcome them. It is
expected that this review will inform discus-
sion at the A Promise Renewed meeting for
the American Region and the development of
both regionwide and country roadmaps. With
appropriate adaptations, this review may also
be used at the national and subnational levels
to guide tracking and to consolidate evidence
in the technical and legislative facets of the
A Promise Renewed campaign. In these ways,
the information presented here is intended to
contribute to a renewed mobilization to end
of preventable child and maternal deaths and
enhance the longevity and quality of life of
women and children in our Region. These are
formidable goals. Going forward, the agencies
that sponsored the meeting and are signato-
ries to the Panama Declaration are committed
to work in close and sustained partnership
with governments, other agencies, and the
private sector to marshal the political will and
resources to achieve them.
Reproductive, Maternal, Neonatal, and Child Health Indicators and Equity Mapping: A Framework for Discussion
vi
11. Introduction
any countries in the Americas have made marked progress
in stopping the needless, preventable deaths of women and
children, yet too many of these deaths continue to occur. This
is happening mainly because they are poor, from ethnically
or other socially and politically excluded groups, or for some other reason
have insufficient access to enough food, safe water, clean surroundings,
and quality health services that are already in operation and available to
others in the same country. The number of women and children whose lives
are cut short for want of access to the know-how and resources available
has shrunk thanks to a concerted effort to stop this preventable tragedy.
But despite the overall economic improvement in many countries, there are
gaping differences in the distribution of wealth, life expectancy and quality
of life between them. And no matter how improved its national average,
almost every country has subgroups of its population that fare as poorly as
those in countries that remain at the low end of the social and economic
development spectrum.
The obstacles to saving women and children’s lives and improving their
quality of life are modifiable and their persistence need not be insurmount-
able. To secure the drive to stanch the loss of thousands of the Region’s
next generation, delegations from some 30 countries backed by a partner-
ship of bilateral and international agencies and civil society organizations
is publicly joining forces at the A Promise Renewed meeting in Panama
from 10 to 12 September 2013. Participants will renew their pledge to
safeguard the advances in reproductive, maternal, neonatal, infant, and
child health achieved to date, review the evidence available, and pinpoint
the gaps in access and coverage that must be addressed. The work plan laid
out in Panama will interpret the evidence available and devise strategies
to achieve established goals according to a set of criteria that reflect the
larger landscape where inequities prevent access to universal integrated,
life-course coverage by health and other services.
Meanwhile, acknowledging that progress takes concerted political will
to ensure backing and accountability for the technical commitment, the
ministries of health of the Americas have begun to create or enhance legal
and policy frameworks for the human rights protections needed to ensure
an Integrated Child Health approach. In September of 2012, the govern-
ments of the Region passed a resolution mandating PAHO/WHO to lead
the monitoring of compliance with this effort. The approach follows the
precepts of a continuum of care in an integrated healthy life course view
Reproductive, Maternal, Neonatal, and Child Health Indicators and Equity Mapping: A Framework for Discussion 3
M
16. Indicator 1: Maternal mortality
No matter which estimate is chosen to approx-
imate the reality of maternal mortality in the
Region, the underlying pattern is similar: pre-
ventable maternal mortality has declined but
remains far in excess of the established goal as
a Region and especially among certain popu-
lation groups. Joint WHO, UNICEF, UNFPA,
and the World Bank (MMEIG) estimates (3)
are the official numbers used to track progress
toward the Millennium Development Goal
of reducing preventable maternal deaths by
75% from 1990 to 2015. The MMEIG reported
that by 2010 the maternal mortality ratio had
declined 42.9%, from 140 per 100,000 live
births in 1990 to 80 per 100,000. Attaining
the Millennium Development Goal using this
joint estimate would mean that the ratio for
the Region would average 35 per 100,000 live
births in 2015. Unattainable at the current
annual rate of reduction (-2.6%), even if it
were reached this goal would still amount to
almost three times the current ratio in Canada
(12/100,000), and would be seven-fold higher
than in Finland (5/100,000). That is, even if
the goal of 35/100,000 deaths were attained,
23 to 30 of the 35 maternal deaths would con-
tinue to be preventable, or excess, mortality.
There is considerable variation in the point
estimates available for a given year, but all
databases reveal progress whose pace is too
slow (Figure 1.1). Official health ministry data
reported to PAHO place the regional aver-
age at 125/100,000 live births in 1990 and
75/100,000 in 2010, a decline of 44% (4). The
WHO Global Health Observatory (5) places the
ratio at 100/100,000 live births in 1990 and
63/100,000 in 2010. This represents a slower
decline but, given the starting point, would
result in a goal of 25/100,000 by 2015. The
Institute for Health Metrics and Evaluation
(IHME) publishes estimates based on internally
consistent methods of data verification and
modeling for under-reporting and misclassifi-
cation by subregion and individual countries
(6). Its assessment is similar to the official
MMEIG estimate.
Variation among estimates is due to a number
of factors, including differences in calculat-
ing the degree of likely under-reporting or
misclassification of maternal deaths and in
validating survey data on which estimates are
based (7). Countries have invested in improv-
ing surveillance and reporting of maternal
deaths and the quality of the data is gradually
improving and the divergence between esti-
mates is narrowing. All of the estimates have
uncertainty intervals that are wide enough to
include the others. Therefore, although the
wide intervals capture lack of precision, their
width also provides a worst case/best case
basis to plan shifts in resources, upgrades in
service patterns, and other measures needed to
attain the desired outcome.
The successful reduction of preventable mater-
nal deaths in some countries underscores
the interplay between health knowledge and
services on one hand and social policies that
explicitly address disparities. Given that cov-
erage of antenatal visits and skilled attendance
during labor are both reportedly high (see the
corresponding indicators 6 and 10), the mater-
nal mortality data suggest that it is not merely
a matter of access to services but also the
quality of care that requires urgent attention.
Even when there is access, the lack of prop-
erly trained personnel in sufficient numbers to
staff all settings means that access per se is no
guarantee of a better outcome (8,9).
Reproductive, Maternal, Neonatal, and Child Health Indicators and Equity Mapping: A Framework for Discussion
8
17. 1
FIGURE 1.1. Maternal mortality ratio,
Region of the Americas, 1990–2010.
Point estimates differ but the trends converge over
time. Sources: Interagency joint estimate http://www.
childinfo.org/maternal_mortality_ratio.php. WHO Global
Health Observatory. http://apps.who.int/gho/data/view.
main.1370?lang=en.
Accelerating the pace toward meeting the goal
for 2015 is not just a numbers game; lowering
preventable maternal deaths reflects improv-
ing access to social and economic resources
and the civic voice that comes with them.
Improved access to education, nutrition, clean
water, and sanitation go hand-in-hand with
quality prenatal and delivery care to prevent
deaths related to pregnancy. The same sectors
of the population that tend to lack one are
more likely to lack the others. Iron deficiency
anemia (<110 g/L), for instance was reported
to affect an average of 15.2% (11.7% –18.6%)
pregnant women in the Americas in 2011, a
rate similar to that found in Europe (10). Yet
country estimates released between 2000 and
2009 and published recently by PAHO (11)
show that the range at the national level is
wide: depending on the country, 6% to 57%
of pregnant women are anemic. Iron defi-
ciency accounts for about half of all anemias
and iron deficiency anemia contributes to
some 20% of maternal deaths during labor as
well as increasing the risk of low birthweight
and neonatal mortality (10). The proportion of
maternal deaths related to obesity is not well
studied, although the increased risks of mater-
nal morbidity, preterm birth, and infant death
are becoming apparent (10). The prevalence
of overweight and obesity in women of child-
bearing age in the Americas was estimated at
70% in 2008.
FIGURE 1.2. Maternal mortality ratio
according to gross national income, Region
of the Americas, 1990–2010.
Source: GINI index data. The World Bank, Development
Research Group PovcalNet. http://iresearch.worldbank.
org/PovcalNet/index.htm.
Maternal mortality ratios vary markedly
between countries. Among other determinants,
differences may be observed according to gross
national income. Figure 1.2 graphs the mortal-
ity ratio according to the gradient formed by
national incomes, illustrating one determinant
of unequal national mortality ratios.
0
100
200
300
400
500
600
700
0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1.0
Country-level gradient defined by income
1990
2010
20
60
100
140
1990 1995 2000 2005 2010
GHO
Joint Estimate
PART I The COIA Indicators: Where We Stand
9
Maternalmortality(per100,000livebirths)
Maternalmortality(per100,000livebirths)
18. FIGURE 1.3. Maternal mortality ratio by
country GINI coefficient grouping, Region
of the Americas, 1990–2011.
Source: WHO, UNICEF, UNFPA, The World Bank. Trends
in maternal mortality: 1990-2010. Geneva: WHO, 2012
and Gross National Income: Institute for Health Metrics
and Evaluation (IHME) Data Exchange file: Additional file
3: Annex 3.xlsx. http://www.pophealthmetrics.com/ime-
dia/1668401071660847/supp3.xlsx.
However, a country’s maternal mortality ratio
does not only reflect economic resources, but
also reveals social policies and other deter-
minants. For instance, Costa Rica, Cuba, and
Jamaica, all belonged to the World Bank “upper
middle income” country group in 2010 (12),
yet there was a considerable difference in their
maternal mortality ratios (40, 73, and 110 per
100,000 live births respectively). When coun-
tries are grouped according to another measure,
the internal distribution of national wealth as
expressed in the GINI index, worse outcomes
for women correlate with worse (higher) GINI
coefficients. Figure 1.3 displays the gaps and
gradient of disparities in average maternal
deaths when the countries of Latin America and
the Caribbean are grouped according to GINI
index. In one country, for example, the GINI
index worsened from 45.7 in 1986 to 48.1 in
2010, reflecting a slightly rising income share
(from 51.3% to 52.6%) for those already in the
highest 20% bracket and a drop for the lowest
20% (4.91% to 3.91%), an essentially stagnant
profile over almost 25 years (13).
Just as national maternal mortality ratios
may be better or worse than the Region’s as
a whole, there are variations by geographic
region, income, maternal age, marital status,
ethnic background, and other determinants
within each country. For example, adolescents
and younger women are at a greater risk of
dying from pregnancy-related causes, perinatal
deaths are 50% more likely if newborns’ moth-
ers are younger than 20 compared to those in
the 20–29 age range, and the babies of ado-
lescent mothers often are born at a low birth
weight, with the attendant risks. Yet an average
of 66/1,000 girls aged 15–19 became mothers
in the Americas in the 2005–2010 period, an
adolescent fertility rate that is the second high-
est in the world (14). Adolescents in the lowest
income quintile have higher pregnancy rates
than do those in the highest income quintile
(15). Violence against women, poverty, lack of
education, and other forms of social limits all
intersect in this trend, overlapping especially
behind the under-reported number of pregnant
girls between the ages of 10 and 14 (15).
Maternal mortality is estimated to be three-
fold higher among Indigenous than non-
Indigenous women. Despite the fact that
such deaths are largely preventable, they
are so common among tribal women that it
is customary to say “Women who give life
walk in the shadow of death,” according
to Bolivian Aymara leader Martha Gonzáles
Cochi (16,17). The inequities that lie at the
root of this grossly unequal outcome extend
beyond single-track technical or program
interventions, reaching into cross-sectoral,
Reproductive, Maternal, Neonatal, and Child Health Indicators and Equity Mapping: A Framework for Discussion
10
200
150
100
50
0
1990 2000 2011
Maternalmortality(per100,000livebirths)
19. legislative, cultural, and policy commitments.
Breaking down barriers that exclude and harm
population subgroups calls for an integrated
approach backed by an evidence-based policy
and legislative framework.
In sum, although far from complete and often
inconsistent, enough data have now been
obtained, reported, and monitored over time to
confirm that in the Americas, as in other parts
of the world, putting an end to excess maternal
mortality is a “human rights imperative (18).”
Lagging progress in arresting the preventable
deaths of women reflects inequalities in the
access to resources, including social services,
as well as differences in the quality of services
when access is not the issue. Both the availabil-
ity and caliber of programs, and facilities, can
be lifesaving; they can enhance or detract from
wellbeing throughout the life course.
Rising income per capita, higher female edu-
cational attainment, and reduced fertility rates
have been credited with a recent positive
effect on lowering maternal mortality (19).
Health program efforts to make the most of
the general economic and social momentum
to intensify progress in this indicator would
sharply reduce preventable mortality while
anchoring broader achievements in infant
and childhood health in a context of broader
social and economic equality.
Severe, possibly lifelong, morbidity from acute
“near miss” (near death) complications of preg-
nancy is a related classification for which reg-
istration and evaluation is essential to improv-
ing the quality of antenatal and labor care,
thereby reducing mortality (20). Monitoring,
classifying, and reporting these events would
afford the opportunity to interview surviv-
ing women and improve the classification of
causes of maternal deaths, providing the evi-
dence basis to upgrade the quality of care at
health facilities, particularly referral hospitals,
including revising protocols. A pilot study
currently underway to review near-miss data
in the Americas found insufficient baseline
aggregates of clinic and hospital records of
such events at the national level (21).
PART I The COIA Indicators: Where We Stand
11
The Millennium Development Goal of reducing
mortality rates in children younger than 5 years
of age by two thirds from 1990 to 2015 appears
to be (Figure 1.4) within reach as a regional
average. Although the numbers differ slightly
in various databases, a reduction of roughly
57.2% had been attained by 2010 according to
WHO/GHO data (22). If this rate of reduction
is maintained, the 2/3rd goal will have been
handily surpassed by 2015. Neonatal mortality
(from birth to 28 days of age) also is declining,
albeit at a somewhat slower pace (51.4%) so that
it now represents a larger relative share (some
48%) of the deaths of children under 5 years of
age than it did in 1990 (about 42%).
Differences in child mortality rates can be
sizeable between countries as well as between
population groups within countries. Whereas
the regionwide average mortality in children
younger than 5 years of age was 17.8/1,000 as
of 2010, in some countries it reached 130/1,000,
and in others it was as low as 6/1,000. Not
surprisingly, within countries the rate varies
according to the economic position or asset
wealth of population subgroups: a country’s
Indicator 2. Child and neonatal mortality
20. Reproductive, Maternal, Neonatal, and Child Health Indicators and Equity Mapping: A Framework for Discussion
12
national average of 60.4/1,000 may mask a
rate of 17.6/1,000 in the wealthiest fifth of the
population and 92.6/1,000 among the poorest
20% (23). The highest income groups share
similar access to quality care, nutrition, and
environmental conditions adding up to a qual-
ity of life that leads to similar outcomes across
countries. Children who are born into poor
families, on the other hand, may be more than
five times more likely to die before their fifth
birthday than they would be if their families
were wealthy. In Figure 1.5, wide discrepancies
between groups within a country can be seen
from recently published Demographic Health
Survey data (23). When comparing income
subgroups in Bolivia, the poorest children are
three times more likely to die before their fifth
birthday than are their well-off peers. Although
the average child mortality rates are lower in
Peru, the gap between rich and poor is even
more pronounced (childhood mortality rates 5.3
times higher among the poorest than among
the richest), whereas in Colombia, also in the
World Bank’s lower middle income economic
group in 2005 (24), a pattern of less inequality
(2.5 times higher among the poorest) as well as
lower absolute numbers is reported (Figure 1.6).
As may be seen in the graphs, the gap between
the lowest and highest quintiles is the greatest
but, with few exceptions, a measurable gradient
of gaps occurs from quintile to quintile as well.
The stark contrast between the unequal health
status of rich and poor children reveals con-
clusively that nearly all causes of their deaths
before the age of 5 years are preventable.
The improvement over time in some coun-
tries illustrates that social policies have an
impact (25). Preventing child deaths in all
families is a matter of equitable access to the
social resources, equal coverage by health and
public services, such as water and sanitation,
maternal education, and timely and proper
treatment for respiratory or gastrointestinal
infections and injuries.
In 2010, roughly 48% of under-5 mortal-
ity occurred in the neonatal age group. Of
these deaths during the first 4 weeks of life,
FIGURE 1.4. Child and neonatal mortality,
Region of the Americas, 1990–2010.
FIGURE 1.5. Mortality rates in children
under 5 years old, by family wealth
quintile.
Source: U.N. Inter-agency Group for Child Mortality
Estimation. http://www.childinfo.org/mortality_tables.php.
Source: Gwatkin et al., eds. World Bank 2007.
45 52
50
48
46
44
42
40
38
40
35
30
25
20
15
10
5
0
1990 1995 2000 2005 2010
< 5 deaths
Neonatal deaths
Neonatal (%)
Neonataldeathsas%of<5deaths
140
120
100
80
60
40
20
0
Bolivia 2003 Peru 2003 Colombia 2005
<5andneonataldeathsper1,000livebirths
<5deathsper1,000livebirths
21. PART I The COIA Indicators: Where We Stand
13
31% were due to infections and 29% to birth
asphyxia (26). Deaths in the one-month to
one-year-old age group accounted for 29%
of the total under-5 mortality. The principal
causes include acute respiratory infections
(48%), diarrheal diseases (36%), and under-
nutrition (9%), also largely preventable (27).
An estimated 10.4% of deaths in all age
groups are under-registered and it is prob-
able that neonatal and childhood deaths are
disproportionately under-reported, especially
among the same population groups for which
births are often not registered. Vital registra-
tion has improved thanks to efforts such as the
campaign for universal birth registration (28,
29). Nonetheless, the overall under-registra-
tion rate among children under five was still
10% in 2011 (down from about 18% in 2006)
adding up to 6.5 million children for whom
there are no birth certificates. This regional
average suggests that there are countries with
far higher under-registration and that this is
especially likely to be the case inpoorer or
excluded population sectors that already bear
the burden of child mortality (30). This is in
fact what was found in a study published in
2006: some countries have far higher under-
registration than others, rural residents are
more likely to be under-registered than urban
dwellers, poor, single, and teen-aged moth-
ers are less likely to register the birth of their
infants or receive antenatal care (31). Without
formal identities, children are not counted,
and if they do not exist on paper, they have
difficulty accessing the health system when
needed, attain lower levels of education,
and often cannot be hired in the formal sec-
tor, all of which in turn affects their health
throughout the life course. Needless to say,
such underregistration makes the precision of
tracking indicators all the more problematic.
FIGURE 1.6. Mortality rates in children
under 5 years old, by family wealth quintile,
Colombia, 1995–2010.
Source: WHO. Global Health Observatory Data Repository.
http://apps.who.int/gho/data/view.main.947485.
60
50
40
30
20
10
0
1995 2000 2005 2010
Indicator 3. DPT3 coverage among 12–23-month-old children
Single intervention efforts such as vaccina-
tion coverage have done relatively well in
reaching the vast majority of the intended
infant beneficiaries. Remarkable achieve-
ments in eradicating or eliminating what
not long ago were scourges of childhood,
such as smallpox, poliomyelitis, rubella, and
measles (32), have been followed by other
immunization programs successfully target-
ing whooping cough, neonatal tetanus, and
diphtheria. As may be seen in Figure 1.7,
coverage with three doses of DPT among
12–23 month-old children—a demanding
service indicator for vaccines because of the
three contacts required—increased progres-
sively at an average annual rate of roughly
<5deathsper1,000livebirths
22. 6.7% (33). However, even this robustly fund-
ed, limited interface intervention with strong
logistical support and good tracking data hit
a ceiling and seems to have leveled off start-
ing in 2005, leaving some 7% of toddlers
unvaccinated yearly. This gap is far from
an immunization program failure. Rather, it
illustrates that even a limited focus program
with no major funding, supply, personnel or
technology obstacles, encounters other deter-
minants that stall even higher coverage and
will require creative approaches to identify
and reach those who are still missed.
It should be noted that the indicator for three
doses of DPT, as specified by the COIA, stipu-
lates that they be administered by the time
children are 12–23 months old. DPT coverage
data reported to PAHO refer to doses adminis-
tered to infants younger than one year of age,
the schedule to which the Region adheres.
The detailed surveillance and reporting sys-
tems of national vaccination programs backed
by seasoned cold chain logistics and labora-
tory networks, provide a wealth of opportu-
nities for cross-program and cross-sectoral
efforts to record and report other indicators
that could otherwise be missed. The begin-
nings of such collaboration are being devel-
oped in some countries to monitor vitamin A,
helminth infection prevalence and treatment,
and breastfeeding practices.
Reproductive, Maternal, Neonatal, and Child Health Indicators and Equity Mapping: A Framework for Discussion
14
FIGURE 1.7. Trend in percent coverage
with DPT3 at 12–23 months of age, Region
of the Americas, 1990–2010.
Source: WHO/UNICEF coverage estimates 1980-2011
http://www.childinfo.org/immunization_trends.php.
Indicator 4. Childhood stunting
The picture that emerges on inadequate
nutrition illustrates a facet of the need for
a comprehensive, cross-sectoral life course
approach to human development. Stunting
in children under the age of 5 years is a
long-standing, reliable measure of nutritional
deprivation, especially in the first two years
of life (34). Childhood stunting is a telling
sign of a constellation of intergenerational
poverty and lack of access to education,
water and sanitation in addition to food secu-
rity (35). Stunting contributes to 17% of all
deaths in children under the age of five years
of age, even as obesity is on the rise in the
same age group and also is more common
among poor children (10, 36). The combina-
tion of insufficient food, poor dietary quality,
and repeated, often untreated, infections that
impede nutrient absorption causes lower than
average growth rates, and may impair cogni-
tive and neuromuscular function (37). If the
pregnant mother is herself undernourished
the damage may begin during gestation,
resulting in fetal growth restriction and the
increased likelihood of neonatal death or
postnatal stunting.
95
80
65
1990 1995 2000 2005 2010
PercentDPT3coverage
23. PART I The COIA Indicators: Where We Stand
15
As may be seen in Figure 1.8 (38), the preva-
lence of stunting in children under the age of
5 years dropped by about 44% regionwide,
from 24.6% in 1990 to 13.8% in 2010. This
represents an average annual reduction of
2.25% over the 20-year period. Should this
rate be maintained, the Region as a whole will
achieve the 50% reduction goal set for 2015.
Nonetheless, the regional average masks
patterns of intractable nutritional risk that
emerge when the rates of individual countries
are examined (39). The World Bank country
income group categories afford one way to
see the differences. In the United States—a
high income country—for instance, the preva-
lence of stunting among children under the
age of 5 years was 3.9% (roughly the frequen-
cy expected due to genetic variation) in 2001,
whereas for the same year in Guatemala—
classified as lower middle income—stunting
affected over 50% of children the same age
and continued to occur among 48% in 2010,
almost 10 years later (40). The rates improved
from 1990 onward but the 20% decline by
2010 represents a modest yearly reduction,
and most of that took place in the first ten
years, after which progress all but stagnated.
The prevalence of stunting does not usually
decline in response to single-approach strate-
gies (41). Multiple, interacting, effects of nutri-
ent deficiency, inadequate health care, infec-
tions, and other environmental insults are more
common among the poor. Large disparities
may be seen within countries when the preva-
lence of childhood stunting is analyzed accord-
ing to the wealth quintile to which the family
belongs. In Peru in 2000 for example, 47% of
children in the poorest 20% of the population
were stunted, whereas just over 4.5% of those
in the richest 20% of the population were,
roughly a ten-fold difference (42). After no
improvement for most of the decade, by 2010
stunting was less prevalent in both groups
(35.9% vs. 2.9%) but it declined more steeply
among the wealthy (Figure 1.9) (43). In Bolivia,
as illustrated in Figure 1.10, stunting declined
for all income groups between 1998 and 2008,
yet the improvement was unequal, dropping
30% among the richest and only 7% among
the poorest people (23). In other countries,
stunting prevalence declined over time, and
also improved notably, among the poorest seg-
ments of society. In the Dominican Republic,
for example, the 26.7% prevalence of stunt-
ing among the poorest children in 1996 had
dropped to 16.4%–a 38.6% reduction—by 2007
(44). However, stunting reportedly increased
over the same period among children of the
wealthiest 20%, a change that cannot readily
be interpreted. In Brazil, meanwhile, the preva-
lence of stunting diminished successively over
FIGURE 1.8. Prevalence of stunting in
children under 5 years of age (%), regional
and Guatemala, 1990–2010.
Sources: UNICEF-WHO-The World Bank: Joint child mal-
nutrition estimates. http://www.who.int/nutgrowthdb/sta-
tistical_tables.pdf. WHO Global Health Observatory Data
Repository. Child Malnutrition. http://apps.who.int/gho/
athena/data/download.xsl?format=xml&target=GHO/MDG
_0000000027&profile=excel&filter=COUNTRY:*;SEX:*;RE
GION:AMR.
60
40
20
0
1990 1995 2000 2005 2010
Guatemala*
Regional*
*some years interpolated
Prevalence(%)ofstuning
24. a 10-year period, due to multiple overlapping
factors, including increased maternal school-
ing, increased purchasing power, expansion
of access to healthcare, and improvements
in sanitation (45). Not only did the overall
prevalence drop by half overall from 1996 to
2006, but the greatest decline took place in
population groups that had the highest rates
of stunting at baseline. The impact of provid-
ing conditioned cash transfers to poor fami-
lies (Bolsa Familia) on reducing stunting and
other health outcomes is under review but, as
is the case with other approaches, appears to
be limited unless enhanced with concurrent
interventions (46). To date, 15 countries in the
Americas have instituted similar cash transfer
programs with varying impact (15). A detailed
evaluation of the Mexican Oportunidades pro-
gram found that its impact was marked and
significant overall and on the reduction of
anemia in children in particular but the avail-
ability of cash in itself had a less pronounced
effect than the accompanying social marketing
and provision of fortified weaning foods (47).
In all, the evidence available indicates that
a high prevalence of stunting and under-
lying nutritional risks persist but can be
remedied by instituting cross-sectoral efforts
that require close monitoring and adjustment.
The contrasts that exist between countries
and between population groups within them
(Figure 1.11) provide a clear example of the
need to review current approaches, integrate
nutrition with other social and health services,
and frame policy formulation in light of the
distribution of disparities that affect individu-
als’ full life course.
The data also signal a need for quality review
and investigation of inconsistencies in order to
interpret trends for policy and programmatic
purposes, especially to address inequities.
According to the 2008/2009 National Health
Survey 65.9% of Guatemala’s Indigenous chil-
dren were stunted (48). On average, up to
95% of Indigenous children are malnourished
(under or over), stunting is 20% more preva-
lent among them, their life expectancy is 7
to 13 years shorter than the average for their
Reproductive, Maternal, Neonatal, and Child Health Indicators and Equity Mapping: A Framework for Discussion
16
FIGURE 1.9. Prevalence of stunting in
children under 5 years of age, by wealth
quintile, Peru.
FIGURE 1.10. Prevalence of stunting in
children under 5 years of age, by wealth
quintile, Bolivia.
Source: WHO Health Equity Database. http://apps.who.int/
gho/data/node.main.HE-1540.
Source: WHO Health Equity Database. http://apps.who.int/
gho/data/node.main.HE-1540.
Prevalence(%)ofstuning
50
40
30
20
10
0
2000 2005 2010
Prevalence(%)ofstuning
50
40
30
20
10
0
1998 2003 2008
25. country, and they have a ten-fold higher like-
lihood of dying before their first birthday (49).
Soil-transmitted helminth infections (STH) are
diseases of poverty that cause morbidity and
contribute, along with concurrent risk factors,
to stunting as well as impaired intellectual
growth of children (50). Although infection
prevalence data are not widely available, it is
estimated that 13.9 million preschool children
are at risk of helminth infections in 30 coun-
tries of the Region. Despite the likelihood of
reinfection, periodic deworming confers ben-
efits, including reducing micronutrient loss
and improving nutritional absorption (51). If
women in endemic areas are dewormed once
or twice during the pregnancy (after the first
trimester), substantial reductions in maternal
anemia result, along with higher birthweight
and lower infant mortality at six months (52).
PART I The COIA Indicators: Where We Stand
17
FIGURE 1.11. Change in prevalence of
stunting in children under 5 years of age,
by wealth quintile, Colombia, 1995–2010.
Source: WHO Global Health Observatory Data Repository.
http://apps.who.int/gho/data/view.main.94120.
Indicator 5. Increase the proportion of demand for family planning
satisfied (met need for contraception)
The countries of the Americas have not
reported sufficient data on this indicator for
long enough to ascertain whether there has
been a trend for the better in the Region as
a whole. WHO (53) data estimate that 91.9%
of the women of the Americas had their need
for family planning met in 2005 and again in
2008. Contraceptive prevalence was reported
at 74.5% for each of those years with a wide
range among countries—contraceptive use was
estimated to be around 25% in Bolivia, for
example. In a sample of 12 countries, CEPAL
reported that the unmet need for family plan-
ning ranged from 4.7% to 37.3% (15).
Unwed teenagers in all countries are less likely
to avail themselves of family planning services
and are more likely to have unintended preg-
nancies and to suffer complications, including
death from abortion (54). Pregnancies among
15–19 year old adolescents are under-record-
ed. The 11 countries for which there are data
between 2006 and 2010 reported that 11.6%
to 25.2% of young women in that age group
were pregnant or already had children. It is
not clear what the unmet need for contra-
ception is among other minority or socially
excluded groups of women.
As is the case with other indicators in repro-
ductive, maternal, and child health, there are
gaps in service coverage depending on popu-
lation wealth quintile. In Colombia, one of
the few countries consistently reporting these
data over time, Figure 1.12 illustrates a gap in
met need for family planning that has gradu-
1995
2000
2005
2005
35
30
25
20
15
10
5
0
%ofchildren<5stunted
26. ally narrowed. The met need was reported
at 86.3% in 1990 and 92.0% in 2010 for the
country as a whole and the gaps were not as
pronounced as for other services. Nonetheless,
despite a narrowing disparity, the poorer
groups continued to lag behind in 2010.
Reproductive, Maternal, Neonatal, and Child Health Indicators and Equity Mapping: A Framework for Discussion
18
FIGURE 1.12. Met need for family planning,
by wealth quintile, Colombia, 1995–2010.
Source: WHO Global Health Observatory from DHS. http://
apps.who.int/gho/data/node.main.HE-1611?lang=en.
The percentage of women in the Region who
reportedly received antenatal care at least
4 times before delivery in 2008 was 84%,
increasing to 87% in 2009 (see the discussion
of Indicator 10) (55). Data tracking over the
1990–2010 timeframe are not available for
most countries of the Region.
%ofwomenwithmetneed
100
80
60
40
20
0
1995 2000 2005 2010
Indicator 6. Antenatal care coverage at least four times during pregnancy
Indicator 7. Antibiotic treatment for suspected pneumonia in children
under 5 years of age
Regional data are not available for this indicator in the Americas.
Indicator 8. Postnatal care for mothers and babies within two days
of birth
Regional data are not available for this indicator in the Americas.
27. Coverage with antiretroviral treatment to pre-
vent vertical transmission of HIV increased by
94% in the Region between 2005 and 2011, the
years for which data have been consolidated.
In 2005, 36% coverage had been attained
regionwide, with 42% in Latin America and
14% in the Caribbean. By 2011, coverage had
increased to 70% (15,300 women), reflect-
ing 67% in Latin America and 79% in the
Caribbean (56). Coverage of HIV testing among
pregnant women increased from 29% in 2005
to 53% in 2008 and 66% in 2011 (57). Some
countries report that 20% to 30% of infants
exposed perinatally to HIV are lost to follow
up. Estimated regional trends indicate that HIV
testing and treatment are having an impact:
the number of children acquiring HIV infection
has declined by 32% in the Caribbean and 24%
in Latin America from 2009 to 2011. Several
countries (Costa Rica, Panama, and Uruguay)
have achieved mother-to-child, or vertical
transmission, rates below 2% (virtual elimina-
tion). Overall, mother-to-child transmission of
HIV in Latin America and the Caribbean was
estimated at 14.2% (5.8%–18.5%) for 2011, a
rate that is somewhat lower than the 18.6%
(10.5%–22.9%) estimated for 2010. As may
be noted from the overlapping uncertainty
intervals, however, the models used to calcu-
late the estimates are imprecise. Country-level
information systems report counts of pregnant
women or those giving birth who test positive
and are treated. These numerators, however,
are then used in models for which the esti-
mated denominator may give coverage ranges
of 22%–88%, making the indicator of ques-
tionable practical use for policy and resource
deployment at this time.
Data for the second measure in the COIA indi-
cator (treatment-eligible women who receive
antiretroviral therapy) are not reported sys-
tematically. In part, this may be due to limited
capacity of information systems to provide
sex disaggregated data and may also be
because of the expense entailed in systematic
data monitoring and quality control. Other
program costs can be high, especially when
test kits and antiretroviral supplies are pur-
chased outside of the PAHO/WHO Strategic
Fund network, at a far higher cost.
PART I The COIA Indicators: Where We Stand
19
Indicator 9. Antiretroviral (ARV) prophylaxis among HIV-positive
pregnant women to prevent HIV transmission and antiretroviral therapy
for women who are treatment-eligible
Indicator 10. Increase the proportion of births attended by a skilled
attendant
At a regional level, this indicator would
be difficult to track or interpret even if the
data were reported for successive years. The
data available at PAHO/WHO generally are
point estimates for one or two years for each
country averaging 93% of births that were
reportedly attended by skilled health person-
nel. Almost every country reports that skilled
attendant coverage during labor is greater
than 80% and many countries record that it
is about 100%. The few that published cov-
erage rates of less than 80% were Bolivia
28. (71.1% in 2008), Guatemala (51.3% in 2009),
Haiti (26.1% in 2006), and Honduras (66.3%
in 2006).
Given the contrast between the reported near
perfect coverage of births attended by skilled
attendants and the glaring excess of prevent-
able maternal and neonatal deaths, it may be
necessary to provide a more specific formula-
tion of the criteria for “skilled” and/or clarifi-
cation of the clinical conditions and essential
medical supplies required to fulfill the indica-
tor’s intent.
After reviewing the evidence, the Commission
for Information and Accountability for
Women’s and Children’s Health determined
that the skill of care makes a difference and
reworded the MDG indicator accordingly.
The inconsistency between the reported high
coverage levels for antenatal care and attended
labor on the one hand and the unacceptably high
maternal and neonatal mortality on the other
lends support to the COIA view and suggests pos-
sibly inaccurate data, marked differences between
national and regional averages, regional averages
composed from few reporting countries, and other
data quality issues in addition to inadequate crite-
ria for the quality of care and “skilled” services. In
November 2003 the International Confederation of
Midwives (ICM) and the International Federation
of Gynecologists and Obstetricians (FIGO) issued
a joint statement specifying the standard of care
for the third stage of labor in recognition that
medical, nursing, or other training doesn’t neces-
Reproductive, Maternal, Neonatal, and Child Health Indicators and Equity Mapping: A Framework for Discussion
20
FIGURE 1.13. Causes of maternal mortality (%), Region of the Americas, 2000 and 2007.
Source: PAHO Health in the Americas. Washington D.C. PAHO 2012.
Cause of death (%)
Indirect obstetric causes
Complications predominantly related to the puerperium
Complications mainly of pregnancy and childbearing
Edema, proteinuria, and hypertensive disorders in pregnancy,
childbirth, and the puerperium
Abortion
05 10 15 20 25 30
%ofpregnantwomencovered
100
80
60
40
20
0
Bolivia Peru Colombia
FIGURE 1.14. Four antenatal care visits to
a doctor, by family wealth quintile, three
countries, 2005.
Source: The World Bank. Gwatkin et al 2007.
Hemorrhage in pregnancy, children, and the puerperium
29. sarily ensure the skills needed to save women
from dying of hemorrhage (57). Even if all those
attending labor were fully skilled, the lack of a
guaranteed safe blood supply, especially in out-
lying areas, means that transfusions may not be
available when needed in emergencies (58). There
are no systematic records of such instances, the
adequacy of blood supply quantity and qual-
ity, storage conditions, supplies of oxytocin and
magnesium sulphate, equipment, attendant skills
in administering transfusions, or other related
data that would help identify critical needs in this
life saving component of attending birth.
In 2007 abortion ranked among the top six
causes of mortality in pregnant women, a
reality that requires attention and may be
significantly under-reported. This is especially
true if an unintended pregnancy resulted from
violence or abuse. Half of the pregnancies that
occur in such circumstances are aborted, often
in unsafe conditions (59). Latin America and
the Caribbean have the highest rate of abor-
tions and the highest proportion of unsafe
abortions in the world (60). The resulting
death rate is 12% overall and in some coun-
tries abortion accounts for 30% of all mater-
nal deaths (61).
A view of antenatal care by family wealth
position shows large gaps between rich and
poor in some countries and less pronounced
gaps in others, again suggesting that even
when the difficult-to-consolidate regional
data are relatively uninformative, mapping
indicators according to social equity grids
helps focus on clusters of inequalities in both
services and outcomes. Quantification of the
quality of services is a missing dimension
without which analytic comparison of service
gaps is even more uncertain.
PART I The COIA Indicators: Where We Stand
21
FIGURE 1.15. Percent of children under 6
months of age breastfed exclusively,
selected countries, Region of the Americas,
1990–2010.
Source: The World Bank. Gwatkin et al 2007.
Indicator 11. Increase the proportion of newborns who receive exclusive
breastfeeding for the first six months
Consolidated data over time are not available
for this indicator in the WHO data repository
for all of the countries of the Region (62). One
unpublished WHO survey (63) provides regional
averages for the period spanning 1990 to 2010
based on a small subset of countries. Regional
averages are of limited analytical use given the
large variation between countries. For instance,
in 2010 the Dominican Republic reported that
7.7% of infants were breastfed exclusively for
the first six months after birth. In the same year,
Peru reported that 68.3% of infants were being
breastfed exclusively. A recent consolidation of
data from 17 countries that started tracking and
reporting for this indicator will be published
later this year (64).
Proportionbreastfedexclusively
40
35
30
25
20
15
10
5
0
1990 1995 2000 2005 2010
30. In Colombia, a marked increase in the propor-
tion of women breastfeeding their infants exclu-
sively started in 1995, when the percentage
was about 11.4%, and continued a steep trend
upward until 2005, when it reached 46.8% (65).
At that point, a slight reversal of the trend was
observed, declining to 42.8% (see Figure 1.16).
Data indicating an increase in the practice of
breastfeeding imply that promotion programs
are succeeding. Where there is strong advocacy
for breastfeeding, monitoring its practice also is
more likely. Some countries reporting the high-
est rate for this indicator also have some of the
highest rates of childhood stunting. Since early
and exclusive breastfeeding protects against
infectious diarrhea and nutrient deficiency in
infants, promotional efforts may be more con-
centrated in known risk areas, leading to higher
rates. NGOs strongly active in countries with
large Indigenous populations with high rates of
child mortality are among the strongest propo-
nents of breastfeeding, for example. However,
one study found that, despite promotion efforts,
exclusive breastfeeding did not always increase
in poorer areas and raised the question of how
to improve the equity of outreach efforts (66).
A recent review of the evidence found that the
long-term developmental effects of breastfeed-
ing and complementary feeding require more
robust documentation (67).
Among other factors, monitoring breastfeeding
practice provides insights into the boundaries
where health services and health behavior may
be constrained by social policy. An article
paper in April 2013 noted that where national
legislation exists to guarantee breastfeed-
ing breaks at the workplace, a significantly
higher percentage of women practice exclusive
breastfeeding during the first six months after
giving birth (see Table 1.1) (68).
Reproductive, Maternal, Neonatal, and Child Health Indicators and Equity Mapping: A Framework for Discussion
22
FIGURE 1.16. Percentage of infants
exclusively breastfed during the first 6
months, Colombia and Peru, 1990–2010.
Source: Organización Panamericana de la Salud. Situación
actual y tendencia de la lactancia materna en América
Latina y el Caribe: Implicaciones políticas programáticas.
Washington DC: OPS (forthcoming).
Proportionbreastfedexcluively
100
80
60
40
20
0
Peru Colombia
31. 23
PART I The COIA Indicators: Where We Stand
Source: Organización Panamericana de la Salud. Situación actual y tendencia de la lactancia materna en América Latina y
el Caribe: Implicaciones políticas programáticas. Washington DC: OPS (forthcoming).
TABLE 1.1. Precentage of infants breastfed exclusively during first six months, 17 Latin
American countries, 1990–2010.
Country 1990 1995 2000 2005 2010
Bolivia 50.5 43.1 50.3 53.6 60.4
Brazil 2.5 29.4 38.6
Chile 44.2 51 58.1 62.7
Colombia 11.9 11.4 25.9 46.8 42.8
Costa Rica 44.3 53.1
Dominican Republic 10.8 7.4 14.8 10.3 7.7
Ecuador 25.7 28.7 34.8 39.6
El Salvador 15 15.8 24 31.4
Guatemala 46.1 38.8 50.6 49.6
Haiti 2.5 23.6 40.7
Honduras 33.1 34.9 29.7
Mexico 28.8 20.3 22.3
Nicaragua 21.8 31.1 30.6
Paraguay 7.8 21.9 24.4
Peru 27.6 33.4 60 63.9 68.3
Uruguay 28.4 50.7 54.1 57.1
Venezuela 4.8 27.9
34. Reproductive, Maternal, Neonatal, and Child Health Indicators and Equity Mapping: A Framework for Discussion
26
n light of the evidence that has accrued
to date—and that which may be lack-
ing—the A Promise Renewed meeting
will apply a human rights and equity
framework to review current conditions and
socially determined health gradients to iden-
tify necessary strategic shifts for improving
gains and accountability consistent with uni-
versal health coverage. The framework pre-
sented here provides one of a number of pos-
sible approaches to mapping socioeconomic
gradients in health status, access to type and
quality of services, and possible underly-
ing inequities in service coverage as well as
other determinants of health. The framework
arrays the evidence according to five catego-
ries or analytic layers that can be applied to
the current landscape and its challenges. The
same categories can be used to chart policies,
redirect resources, fine tune data reporting
and interpretation, and guide accountability
as efforts are focused on reproductive, mater-
nal, and child health outcomes that also are
markers of larger health and social dispari-
ties. As the previous discussion of the COIA
indicators suggests, assessing them accord-
ing to these criteria will require expanding
individual technical program approaches and
developing innovations toward the cross-
program and cross-sectoral use of resources,
data, and quality improvement strategies.
When the layers are applied, systematic
outcome gradients may emerge which sug-
gest underlying inequities that need to be
addressed. The goal for each indicator, within
the larger context of universal coverage, will
be the target toward which policies, resource
deployment, and accountability (69) standards
will be aimed, not just as regional averages but
on a country and subnational level.
The five layers are:
1. Universal health coverage
2. Categories of socioeconomic disparities
3. Challenges in data generation and analysis
for informed decision-making
4. Improving participation in health systems
and inclusion in national policy design
5. Identifying strategic shifts needed to reduce
inequities
Universal health coverage
Universal health coverage refers to universal
access to comprehensive, quality, people-
centered services without the risk of impover-
ishment due to illness. Universal health cover-
age addresses social determinants, and thus
requires strengthening health systems, includ-
ing financing and human resources, with a
human rights and social protection approach.
This overlay examines tracking data for the
eleven indicators from the standpoint of an ideal
100% access to the quality health programs,
interventions (services), and resources needed
to live healthily throughout the life course as a
fully integrated member of the society. Thus, if
universal access to quality health services with
universal health coverage is applied to analyze
a population, the areas or subgroups where such
access does not occur can be traced and com-
pared. It may be that the services exist but their
quality varies so that access does not mean access
to the same quality or even quantity of services,
for example. Or, access to services may be avail-
able for DPT3 immunization, single-encounter
immunization days, active case finding, or hel-
minth control interventions, but not be within
reach for multiple-encounter pre- and post-natal
care, especially if services by trained and certi-
I
35. 27
PART II Equity Mapping, a Framework for Discussion
fied personnel in adequately equipped facilities
are involved. Inadequate cultural sensitivity to
the requirements of minority groups or unmar-
ried teen-aged, or HIV-positive mothers may
diminish the real universality of quality services
even access exists on paper. Recognition of
financial barriers to services and pharmaceuti-
cals prompted a number of countries to actively
promote subsidies and other means to extend
coverage. Yet despite increases in the utiliza-
tion of services, in most countries the wealthy
continue to be more likely to seek care than the
poor for the same health condition, and social
position disparities in the utilization of services
persist even in countries where public coverage
is now almost universal (greater than 90%) (70).
Categories of socioeconomic
disparities
Socioeconomic disparities often have complex,
interacting roots. Wealth, as measured in mone-
tary income per capita or family unit, is one mea-
sure (Figure 2.1) and at the extremes of a spec-
trum it suffices to affect health status. However,
a gradient of gaps often may be observed along
the wealth spectrum in addition to the pro-
nounced gap between richest and poorest. The
wealth quintiles used by way of example in this
discussion paper reflect an index of assets rather
than reported monetary income (71).
However, even such a construction of health
outcomes along the poverty-wealth gradient
is not sufficient to explain barriers to uni-
versal access. There are those, for instance,
who may be poor but by virtue of living in
an agricultural setting with access to clean
water and intergenerational community sup-
port fare better than others who appear to be
“wealthier” yet cannot afford to purchase the
food they need and are exposed to greater
environmental hazards, such as violence, HIV
infection, and biohazard contaminated sur-
roundings. Within the same wealth grouping,
social discrimination and exclusion—as is fre-
quently seen to occur to political and ethnic
minorities—may prevent families from using
health services that policymakers believe to be
available and accessible by coverage legisla-
tion. People who have been displaced—wheth-
er for economic reasons, natural disasters, or
to escape political or domestic violence—often
migrate to areas where they are subjected to
the additional burdens of geographic isola-
tion, stigma, and discrimination even if it is
within the same country.
The disparities in gains attained in reducing
child mortality are not only apparent between
countries and between income groups within
countries, but also can be mapped to the local
levels where the unequal outcomes may be due
to factors—such as geographic, cultural, or eth-
nic isolation—other than those seen at a lower
0.0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
1.0
0.00 .1 0.20 .3 0.40 .5 0.60 .7 0.80 .9 1.0
Childdeaths(cummulativeproportion)
Country-level gradient defined by access to water
1990
2010
FIGURE 2.1. Proportion of deaths of
children under 5 years of age, by access
to improved water services, Region of the
Americas, 1990 and 2010.
Source: WHO-UNICEF Joint Monitoring Program.
36. Reproductive, Maternal, Neonatal, and Child Health Indicators and Equity Mapping: A Framework for Discussion
28
resolution. Figure 2.2 illustrates a clear gradient
in mortality rates for children under the age of
5 years by municipal jurisdiction in Peru, the
effect of multiple overlapping categories.
Such variations in categories of disparities
mean that if maternal mortality is analyzed
only from the standpoint of financial resourc-
es or wealth quintiles, underlying inequities
that are not necessarily reflected in financial
measures may inadvertently be overlooked.
Overlooking the different categories of socio-
economic disparities and their interplay, in
turn would hamper creative designs to improve
health outcomes throughout the life course.
As may be seen in the concentration curve in
Figure 2.3, by way of example, there is an asso-
ciation between the average years of schooling
in a country’s female population and the same
country’s maternal mortality ratio. If the risk of
FIGURE 2.2. Probablility a newborn child will die before the age of 5 years, by municipality,
Peru (ca. 2005).
Source: Peru DHS data http://www.statcompiler.com.
Loreto
San
M
artínH
uánuco
H
uancavelica
C
usco
Puno
M
adre
de
D
iosApurim
ac
AncashAyacucho
Lam
bayeque
JunínM
oquegua
U
cayali
PascoAm
azonasArequipa
IcaC
ajam
arcaTum
bes
La
Libertad
Piura
Tacna
Lim
a
60
30
0
FIGURE 2.3. Maternal deaths according
to education level attained by female
population, Region of the Americas, 1990
and 2010.
Source: Health Metrics and Evaluation Data Exchange file:
Educational attainment by country, sex and age in relation
to child mortality 1970-209_IHME_0910.xls.
0.0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
1.0
Maternaldeaths(cummulativeproportion)
1990
2010
%DPT3<5deathsper1,000livebirths
37. 29
PART II Equity Mapping, a Framework for Discussion
maternal mortality were the same irrespective
of female educational level, there would be no
line above the diagonal (equal proportions for
each educational level). Instead, inequalities
in the distribution of maternal mortality are
observed: when the cumulative proportion of
maternal deaths is ranked by female educa-
tional attainment, the least educated female
population (left end of the horizontal axis)
has a considerably higher burden of death
than those with higher levels of education.
The excess mortality in 1990 (about 40% of
maternal deaths occurred among the 20% with
the least schooling) had dropped somewhat by
2010 (about 32% of maternal deaths were like-
ly to occur in the same education level group)
but still demonstrate an overlap: the burden
of deaths due to pregnancy and labor remains
heaviest among the least educated.
Challenges in data generation
and analysis for informed
decision-making
Indicator data do not tell all of a story or
describe all the essential details, but the slo-
gan “better data for better results” adopted in
2011 by the Commission on Information and
Accountability for Women’s and Children’s
Health captures a critical need succinctly:
resources cannot be allocated wisely or reas-
signed in a timely manner without the right
information (evidentiary basis). All sorts of
data are increasingly abundant yet key indi-
cators to assess progress toward goals and the
corresponding resource and legislative poli-
cies often are not regularly monitored or are
gathered or interpreted inconsistently. The 11
COIA indicators have been chosen carefully
with the intent to flag successes or hurdles in
a large, often complex, set of metrics where
health programs, social policies, economic
position, and environmental conditions inter-
sect. Yet some indicators may be more infor-
mative in some nations or provinces than in
others. In the data analysis phase, different
criteria are understandably applied depending
on the purpose, agency, or government con-
ducting the interpretation, and at what level.
One of the challenges in the current land-
scape is at the national or subnational level,
where overworked and understaffed health
teams who often are also underequipped and
undertrained are required to report to multiple
different places on numerous different forms,
sometimes on paper and other times electroni-
cally. Neonatal health programs may find that
it is all that they can do to identify and stay
in touch with expectant mothers, and ensure
their proper antenatal and postnatal care,
much less fill out the paperwork with cor-
rect information. The worse the compound-
ing components of social and economic dis-
parities, the more problematic accurate data
reporting and analysis will be. Less accurate
or missing data, meanwhile, could occur more
frequently in some areas than others, thereby
exacerbating the inequities their collection
and analysis are intended to help remedy with
policies that use the data as guideposts. The
set of indicators reflecting nearly 95% child-
hood immunization coverage, for example,
may mistakenly be interpreted as adequate
access to all services, thereby missing service
coverage during the neonatal or pregnancy
periods (Figure 2.4).
The need for capacity building to strengthen
and standardize data gathering, reporting and
analysis for policy led to a university-private
sector-USAID-PAHO partnership (RELACSIS)
to form a Spanish language network (see
www.relacsis.org) to exchange methods and
approaches for metrics and evaluation, includ-
ing those to better classify causes of mortality
38. Reproductive, Maternal, Neonatal, and Child Health Indicators and Equity Mapping: A Framework for Discussion
30
FIGURE 2.4. Almost every country shows disparities in health service coverage rates.
The pie charts below illustrate DPT3 coverage rates as the proportion of national
jurisdictions with low (< 80%), medium (80–94%), and high (≥ 95%) coverage at the age
of 12 months. Municipality population densities vary.
Source: CL Pacis, PAHO/WHO. DPT3 coverage ranges n < 80% n 80–94% n ≥ 95
39. 31
PART II Equity Mapping, a Framework for Discussion
and morbidity. Improvements in tracking and
reporting of maternal mortality are expected
and the system is expected to expand into the
English and Francophone countries.
Establishing surveillance and reporting sys-
tems with quality laboratory backup and rou-
tine quality control is a major, difficult under-
taking in vaccination programs, outbreak
investigations, and other temporally focused
undertakings. Yet these program activities
rapidly avail themselves of established, coor-
dinated surveillance systems that apply at
regional, national, subnational, and local lev-
els. With these in mind, as well as the experi-
ences in countries that have successfully man-
aged data monitoring and analysis streamlin-
ing for reproductive, maternal, neonatal, and
child health, the A Promise Renewed meeting
will explore ways to look at each life course
program for deficits that can be improved, les-
sons that can be learned, and ways to unify
criteria and approaches to the collection and
interpretation of the relevant numbers in a
way that can be readily collected, recorded,
analyzed, interpreted, and acted upon. Several
large agencies represented at the A Promise
Renewed meeting have begun the process of
sharing data and standardizing their presenta-
tion and interpretation.
At the national level more needs to be done
to inform the process at the subsequent levels
of consolidation and analysis. For example,
despite recent efforts to improve data gather-
ing and analysis, national data often are not
disaggregated by ethnicity. In the Americas,
a large group in the “ethnic” category is
made up of the 48.5 million or so indigenous
peoples. The human rights imperative of
improving reproductive, maternal, and child
health is universally acknowledged as all the
more urgent among children and women who
belong to these groups, which historically
have been systematically excluded from social
integration, social services, and the possibility
of advancement. The only way to determine
whether systematic exclusion occurs is to
examine the evidence. The account of health
conditions among the Indigenous peoples
of the Americas is incomplete and the same
groups who are excluded from access are like-
ly to not be counted in attempts to ascertain
coverage. Averages, such as those in the COIA
indicators, provide a first general appraisal, but
are insufficient to determine where resource
allocations need changing, and where inequi-
ties may lie. Such policies require that tracking
data be analyzed according to strata such as
the commonly used socioeconomic position,
sex or gender, ethnicity, and geographic area,
in addition to education, access to water and
sanitation, and/or other informative social
determinants of health status throughout an
individual’s life course. When tracking indica-
tors are analyzed, gaps between the groups
within the strata should narrow over time as
the health status indicator’s value improves.
Two and three-way tables are an approach for
which there are published examples (72).
Improving participation in health
systems and inclusion in national
policy design
Barriers to participation in health systems and
policies may compound barriers to universal
health coverage. If population subgroups who
are traditionally underserved or excluded from
service coverage also are excluded from the
education and training that would enable them
to take part in the health system workforce,
the barriers to services will not be overcome.
Exclusion from participation in the system
as doctors, nurses, pharmacists, accountants,
building architects, managers, and the like
40. Reproductive, Maternal, Neonatal, and Child Health Indicators and Equity Mapping: A Framework for Discussion
32
excludes the cultural, gender, linguistic, geo-
graphic, and other particular knowledge and
insights from being incorporated in the health
system’s interface with the population, gath-
ering of data, and their interpretation. Staff
recruitment and retention in areas requiring a
greater effort or a shift in focus may also be
impaired. If the legislative framework set by
policymakers at the national level doesn’t take
into account the system issues that emerge
in an inventory of barriers, an inequitable
distribution of supplies and equipment may
result, and similar effects might be seen along
the cold chain, laboratory networks, or other
logistical and system components. Some of the
apparently technical obstacles may be there
because the systems and national policy set-
ting do not allow for adequate funding and
training of health, nutrition, surveillance, and
other personnel. By way of example, little is
accomplished by testing women during ante-
natal visits if there is no adequate laboratory
support or transportation to ensure processing,
timely feedback, and appropriate treatment, if
necessary. Moreover, health system decision
making will respond to the needs of a popula-
tion or region more effectively if representa-
tives of the communities being served par-
ticipate as formal voting members of advisory
boards, management review committees, and
legislative and other health system policy and
oversight bodies.
Even if programs seek to identify and cover
specific traditionally excluded groups with
targeted outreach strategies, those groups may
not be represented in the staffing, hierarchy,
or policy levels of the health systems nor be
identified in policies intended to make “catch
up” possible. No matter how clear what has
to be done may be to those “on the ground,”
therefore, it may not be possible to do it
sustainably if the necessary inclusion provi-
sions have not been made at a system or
policy level. Execution and accountability are
therefore not on solid footing. This is one of
the reasons that the health ministries of the
Region approved the 2012 Strategy and Plan
of Action mentioned in the Introduction (73).
Identifying strategic shifts needed
to reduce inequities
When reviewing coverage and health outcome
data for given programs, such as antenatal care
or immunizations and the respective changes
in maternal mortality or childhood infection
rates, inequities may be seen more clearly in
one than another. If vaccination with three
doses of DPT by the age of 23 months reaches
over 90% coverage nationally, it may be dif-
ficult to ascertain that inequities underlie
systematic disparity in access to this service
in some populations unless the 10% not cov-
ered are analyzed in the context of nutritional
status, antenatal care, maternal schooling,
family wealth position, the percent of children
who are breastfed during the first six months
of life or other indicators often examined
separately. Overlapping gaps in services sug-
gest systematic exclusions. The nature of the
exclusion, if not already known, is then ready
to be identified. Geographic isolation, ethnic
minority, sex, poverty driven invisibility from
vital registration, low water and sanitation
coverage, low educational attainment, other
determinants—each of these, or specific com-
binations, inform decision makers about the
degree and kind of increase in effort required.
When gaps signal the need for strategic shifts,
the best selection and execution of the shifts
may be significantly improved by comparing
notes with those who have done something
similar successfully and, just as important,
those who have tried an approach, failed to
41. 33
PART II Equity Mapping, a Framework for Discussion
obtain the desired outcome, and documented
the reasons.
The A Promise Renewed meeting in Panama
will approach strategic shifts in programs and
interventions by applying the equity overlays
systematically in a cross-sectoral effort to
drill down on the gaps in coverage, quality of
data, and other hurdles. Participants will share
accounts of successful strategies to slash pre-
ventable disparities in reproductive, maternal,
neonatal, and child health. The planned out-
come will be a cross-disciplinary, cross-agen-
cy, cross-sectoral plan for the future that cuts
across national boundaries, cultural divides
and institutional barriers to define a health
landscape by quantifiable equity criteria that
can be traced along a continuum of coverage
for a healthy life course. The initial mapping
charted at the A Promise Renewed meeting
will provide the first draft to be fleshed out,
improved upon, and put into effect at the
country level over the next two years. The
government and institutional delegations who
will craft this new approach are pledging their
political will to see it accomplished as set out
in the Panama Declaration.
44. Reproductive, Maternal, Neonatal, and Child Health Indicators and Equity Mapping: A Framework for Discussion
36
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