Unicef 2009 State Of Women & Children Report

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The State of the World's Children 2009 examines critical issues in maternal and newborn health, underscoring the need to establish a comprehensive continuum of care for mothers, newborns and children. The report outlines the latest paradigms in health programming and policies for mothers and newborns, and explores policies, programmes and partnerships aimed at improving maternal and neonatal health. Africa and Asia are a key focus for this report, which complements the previous year's issue on child survival.

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Unicef 2009 State Of Women & Children Report

  1. 1. THE STATE OF THE WORLD’S CHILDREN 2009 Maternal and Newborn Health unite for children
  2. 2. © 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
  3. 3. THE STATE OF THE WORLD’S CHILDREN 2009
  4. 4. 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
  5. 5. 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 mater- nal 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
  6. 6. 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
  7. 7. 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
  8. 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 1 Maternal and newborn health: Where we stand © UNICEF/HQ06-2706/Shehzad Noorani
  9. 9. 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
  10. 10. 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 essen- tial 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
  11. 11. 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
  12. 12. 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 pregnan- cy 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 statisti- cal reporting systems of industrial- ized 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
  13. 13. 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
  14. 14. 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 meas- ure 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 world- wide, 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
  15. 15. 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 esti- mated 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
  16. 16. © 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
  17. 17. 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
  18. 18. 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 child- birth, 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
  19. 19. 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

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