sowc09 fullreport en

8/20/2019 SOWC09 FullReport En

1/168

THE STATE OF THE WORLD’S CHILDREN 2009

unite for

children


Maternal andNewborn Health


2/168

© United Nations Children’s Fund (UNICEF)December 2008

Permission to reproduce any part of this publication

is required. Please contact:Division of Communication, UNICEF3 United Nations Plaza, New York, NY 10017, USATel: (+1-212) 326-7434Email: [email protected]

Permission will be freely granted to educational ornon-profit organizations. Others will be requestedto pay a small fee.

Commentaries represent the personal viewsof the authors and do not necessarily reflectpositions of the United Nations Children’s Fund.

For any corrigenda found subsequent to printing, please visitour website at

For any data updates subsequent to printing, please visit

ISBN: 978-92-806-4318-3Sales no.: E.09.XX.1

United Nations Children’s Fund3 United Nations PlazaNew York, NY 10017, USAEmail: [email protected]

Website: www.unicef.org

Cover photo: © UNICEF/HQ04-1216/Ami Vitale


3/168

THE STATE OF THEWORLD’S CHILDREN2009


4/168

ii

AcknowledgementsThis 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, LaoPeople’s Democratic Republic, Liberia, Madagascar, Mexico, Morocco, Mozambique, Nepal, Niger, Nigeria, OccupiedPalestinian Territory, Pakistan, Peru, Rwanda, Sierra Leone, Sri Lanka, Sudan, Togo, Tunisia and Uganda. Input wasalso 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 RESEARCHPatricia Moccia, Editor-in-Chief ; David Anthony, Editor ;Chris Brazier; Marilia Di Noia; Hirut Gebre-Egziabher;Emily Goodman; Yasmine Hage; Nelly Ingraham;Pamela Knight; Amy Lai; Charlotte Maitre; MeedanMekonnen; Gabrielle Mitchell-Marell; KristinMoehlmann; Michelle Risley; Catherine Rutgers;Karin Shankar; Shobana Shankar; Judith Yemane

STATISTICAL TABLESTessa Wardlaw, Chief , Strategic Information, Divisionof Policy and Practice; Priscilla Akwara; Danielle Burke;Xiaodong Cai; Claudia Cappa; Ngagne Diakhate;Archana Dwivedi; Friedrich Huebler; Rouslan Karimov;

Julia Krasevec; Edilberto Loaiza; Rolf Luyendijk; NyeinNyein Lwin; Maryanne Neill; Holly Newby; KhinWityee Oo; Emily White Johansson; Danzhen You

PRODUCTION AND DISTRIBUTION

Jaclyn Tierney, Chief, Production and Translation;Edward Ying, Jr.; Germain Ake; Fanuel Endalew;Eki Kairupan; Farid Rashid; Elias Salem

TRANSLATIONFrench edition : Marc ChalametSpanish edition : Carlos Perellón

PROGRAMME AND POLICY GUIDANCEUNICEF Programme Division, the Division of Policy andPractice and Innocenti Research Centre, with particularthanks to Nicholas Alipui, Director , ProgrammeDivision; Dan Rohrmann, Deputy Director , ProgrammeDivision; Maniza Zaman, Deputy Director , ProgrammeDivision; Peter Salama, Associate Director , Health;

Jimmy Kolker, Associate Director , HIV and AIDS;Clarissa Brocklehurst, Associate Director , Water,Sanitation and Hygiene; Werner Schultink, AssociateDirector , Nutrition; Touria Barakat; Linda Bartlett;Wivina Belmonte; Robert Cohen; Robert Gass; AshaGeorge; Christine Jaulmes; Grace Kariwiga; NoreenKhan; Patience Kuruneri; Nuné Mangasaryan; MarianaMuzzi; Robin Nandy; Shirin Nayernouri; KayodeOyegbite; David Parker; Luwei Pearson; Ian Pett; BolorPurevdorj; Melanie Renshaw; Daniel Seymour; FouziaShafique; Judith Standley; David Stewart; AbdelmajidTibouti; Mark Young; Alex Yuster

DESIGN AND PRE-PRESS PRODUCTIONPrographics, Inc.

PRINTINGColorcraft of Virginia, Inc.

DEDICATIONThe 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 thefield of public health, Dr. Rosenfield worked tirelessly to avert maternal deaths and provide care andtreatment for women and children affected by HIV and AIDS in resource-poor settings. He lent hisenergy 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.


5/168

iii

Foreword

Niger has the highest lifetime risk of maternal mortalityof any country in the world, 1 in 7. The comparable riskin the developed world is 1 in 8,000. Since 1990, the baseyear for the Millennium Development Goals, an estimat-ed 10 million women have died from complicationsrelated to pregnancy and childbirth, and some 4 millionnewborns have died each year within the first 28 days of life. Advances in maternal and neonatal health have notmatched those of child survival, which registered a 27per cent reduction in the global under-five mortalityrate between 1990 and 2007.

The State of the World’s Children2009 focuses on maternal andneonatal health and identifies theinterventions and actions that

must be scaled up to save lives.Most maternal and neonataldeaths can be averted throughproven interventions – includingadequate nutrition, improvedhygiene practices, antenatal care,skilled health workers assistingat births, emergency obstetricand newborn care, and post-natalvisits for both mothers andnewborns – delivered through acontinuum of care linking house-holds and communities to healthsystems. Research indicates that around 80 per cent of maternal deaths are preventable if women have accessto essential maternity and basic health-care services.

A stronger focus on Africa and Asia is imperative toaccelerate progress on maternal and newborn health.These two continents present the greatest challengesto the survival and health of women and newborns,accounting for an estimated 95 per cent of maternaldeaths 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 onethird of maternal deaths worldwide. In 2008, UNICEF,the World Health Organization, the United NationsPopulation Fund and the World Bank agreed to worktogether to help accelerate progress on maternal andnewborn health in the 25 countries with the highestrates of mortality.

Premature pregnancy and motherhood pose consider-able risks to the health of girls. The younger a girl iswhen she becomes pregnant, the greater the healthrisks for herself and her baby. Maternal deaths relatedto pregnancy and childbirth are an important cause of mortality for girls aged 15–19 worldwide, accountingfor nearly 70,000 deaths each year.

Early marriage and pregnancy, HIV and AIDS, sexualviolence and other gender-related abuses also increase

the risk that adolescent girlswill drop out of school. This,in turn, entrenches the viciouscycle of gender discrimination,poverty and high rates of mater-nal and neonatal mortality.

Educating girls and youngwomen is one of the mostpowerful ways of breakingthe poverty trap and creatinga supportive environment formaternal and newborn health.Combining efforts to expandcoverage of essential servicesand strengthen health systemswith actions to empower andprotect girls and women has realpotential to accelerate progress.

As the 2015 deadline for the Millennium DevelopmentGoals draws closer, the challenge for improving mater-nal and newborn health goes beyond meeting the goals;it lies in preventing needless human tragedy. Successwill be measured in terms of lives saved and livesimproved.

Ann M. VenemanExecutive DirectorUnited Nations Children’s Fund

© U N I C E F / H Q 0 5 - 0

6 5 3 / N i c o l e

T o u t o u n j

i


6/168

iv

CONTENTS

Acknowledgements ......................................................................iiDedication ......................................................................................iiForeword

Ann M. VenemanExecutive Director, UNICEF ......................................................iii

1 Maternal and newborn health:Where we stand ......................................................1PanelsChallenges in measuring maternal deaths ..................................7

Creating a supportive environment for mothers andnewborns by H. M. Queen Rania Al Abdullah of Jordan,UNICEF’s Eminent Advocate for Children ..................................11

Maternal and newborn health in Nigeria: Developing

strategies to accelerate progress ................................................19Expanding Millennium Development Goal 5: Universalaccess to reproductive health by 2015 ......................................20

Prioritizing maternal health in Sri Lanka ....................................21

The centrality of Africa and Asia in the global challengesfor children and women ..............................................................22

The global food crisis and its potential impact on maternaland newborn health ....................................................................24

Figures1.1 Millennium Development Goals on maternal and child

health ......................................................................................3

1.2 Regional distribution of maternal deaths ............................6

1.3 Trends, levels and lifetime risk of maternal mortality ........8

1.4 Regional rates of neonatal mortality ..................................10

1.5 Direct causes of maternal deaths, 1997–2002....................14

1.6 Direct causes of neonatal deaths, 2000..............................15

1.7 Conceptual framework for maternal and neonatalmortality and morbidity ......................................................17

1.8 Food prices have risen sharply across the board..............24

2 Creating a supportive environmentfor maternal and newborn health ..........25PanelsPromoting healthy behaviours for mothers, newbornsand children: The Facts for Life guide ........................................29

Primary health care: 30 years since Alma-Ata ..........................31

Addressing the health worker shortage: A critical actionfor improving maternal and newborn health ............................35

Towards greater equity in health for mothers andnewborns by Cesar G. Victora, Professor of Epidemiology,Universidade Federal de Pelotas, Brazil ....................................38

Adapting maternity services to the cultures of rural Peru........42

Southern Sudan: After the peace, a new battle againstmaternal mortality........................................................................43

Figures2.1 The continuum of care ........................................................27

2.2 Although improving, the educational status of youngwomen 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 ofprimary school ......................................................................33

2.4 Child marriage is highly prevalent in South Asia andsub-Saharan Africa ..............................................................34

2.5 Female genital mutilation/cutting, though in decline,is still prevalent in many developing countries ................37

2.6 Mothers who received skilled attendance at delivery,by wealth quintile and region ............................................38

2.7 Women in Mali receiving three or more antenatalcare visits, before and after the implementation ofthe Accelerated Child Survival and Development(ACSD) initiative....................................................................39

2.8 Many women in developing countries have no sayin their own health-care needs............................................40

3 The continuum of care acrosstime and location: Risks andopportunities ............................................................45

PanelsEliminating maternal and neonatal tetanus ..............................49

Hypertensive disorders: Common yet complex ........................53

The first 28 days of life by Zulfiqar A. Bhutta, Professorand Chairman, Department of Paediatrics & Child Health,Aga Khan University, Karachi, Pakistan ......................................57

Midwifery in Afghanistan ............................................................60

Kangaroo mother care in Ghana ................................................62

HIV/malaria co-infection in pregnancy ......................................63

The challenges faced by adolescent girls in Liberia by the Honourable Vabah Gayflor, Minister of Gender and Development, Liberia ..................................................................64

Figures3.1 Protection against neonatal tetanus ....................................48

3.2 Antiretroviral prophylaxis for HIV-positive mothers toprevent mother-to-child transmission of HIV ....................50

3.3 Antenatal care coverage ........................................................51

3.4 Delivery care coverage ..........................................................52

3.5 Emergency obstetric care: Rural Caesarean section ..........54

3.6 Early and exclusive breastfeeding........................................59


7/168

v


Maternal and Newborn Health

4 Strengthening health systemsto improve maternal andnewborn health ......................................................67

PanelsUsing critical link methodology in health-care systems toprevent maternal deaths by Rosa Maria Nuñez-Urquiza,National Institute of Public Health, Mexico ................................73

New directions in maternal health by Mario Merialdi,World Health Organization, and Jennifer Harris Requejo,Partnership for Maternal, Newborn and Child Health ..............75

Strengthening the health system in the Lao People’sDemocratic Republic ....................................................................76

Saving mothers and newborn lives – the crucial first daysafter birth by Joy Lawn, Senior Research and Policy Advisor,Saving Newborn Lives/Save the Children-US, South Africa ....80

Burundi: Government commitment to maternal and childhealth care ....................................................................................83

Integrating maternal and newborn health care in India ..........85

Figures4.1 Emergency obstetric care: United Nations process

indicators and recommended levels ..................................70

4.2 Distribution of key data sources used to derive the2005 maternal mortality estimates ....................................71

4.3 Skilled health workers are in short supply in Africaand South-East Asia in particular ......................................74

4.4 Uptake of key maternal, newborn and childhealth policies by the 68 Countdown to 2015

priority countries ..................................................................784.5 Asia has among the lowest levels of government

spending on health care as a share of overall publicexpenditure ..........................................................................79

4.6 Post-natal care strategies: Feasibility andimplementation challenges ................................................81

4.7 Lower-income countries pay most of their privatehealth-care spending out of pocket ....................................82

4.8 Low-income countries have only 10 hospital bedsper 10,000 people ................................................................84

5Working together for maternal and

newborn health ......................................................91PanelsWorking together for maternal and newborn health bySarah Brown, Patron of the White Ribbon Alliance for Safe Motherhood and wife of Gordon Brown, Prime Ministerof the Government of the United Kingdom ..............................94

Key global health partnerships for maternal andnewborn health ............................................................................96

Partnering for mothers and newborns in the CentralAfrican Republic............................................................................99

UN agencies strengthen their collaboration in supportof maternal and newborn health ..............................................102

Enhancing health information systems: The HealthMetrics Network..........................................................................105

Figures5.1 Key global health initiatives aimed at strengthening

health systems and scaling up essential interventions ....975.2 Official development assistance for maternal and

neonatal health has risen rapidly since 2004 ....................985.3 Nutrition, PMTCT and child health have seen

substantial rises in financing ............................................1005.4 Financing for maternal, newborn and child health

from global health initiatives has increased sharplyin recent years ....................................................................101

5.5 Focal and partner agencies for each component ofthe continuum of maternal and newborn care andrelated functions ................................................................103

References ..............................................................................106

Statistical Tables ........................................................113Under-five mortality rankings................................................117

Table 1. Basic indicators ........................................................118

Table 2. Nutrition ....................................................................122

Table 3. Health ........................................................................126

Table 4. HIV/AIDS....................................................................130

Table 5. Education ..................................................................134

Table 6. Demographic indicators ..........................................138Table 7. Economic indicators ................................................142

Table 8. Women ......................................................................146

Table 9. Child protection ........................................................150

Table 10. The rate of progress ..............................................154

Acronyms ................................................................................158


8/168


9/168

Maternal and newborn health:Where we stand1

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


10/168

Pregnancy and childbirth aregenerally times of joy for par-ents and families. Pregnancy,birth and motherhood, in anenvironment that respects women,can powerfully affirm women’s rightsand social status without jeopardiz-ing their health.

The enabling environment forsafe motherhood and childbirthdepends on the care and attentionprovided to pregnant women andnewborns by communities andfamilies, the acumen of skilledhealth personnel and the availabil-ity of adequate health-care facili-ties, equipment, and medicinesand emergency care when needed.Many women in the developingworld – and most women in theworld’s least developed countries –give birth at home without skilledattendants, yet their newborns areusually healthy and survive pasttheir first few weeks of life untiltheir fifth birthday and beyond.Despite the multitude of risksassociated with pregnancyand childbirth, the majorityof mothers also survive.

But the health risks associated withpregnancy and childbirth are fargreater in developing countries thanin industrialized ones. They areespecially prevalent in the leastdeveloped and lowest-income coun-tries, and among less affluent andmarginalized families and communi-ties everywhere. Globally, efforts toreduce deaths among women fromcomplications related to pregnancyand childbirth have been less suc-cessful than other areas of humandevelopment – with the result thathaving a child remains among themost serious health risks for women.On average, each day around 1,500women die from complicationsrelated to pregnancy and childbirth,most of them in sub-Saharan Africaand South Asia.

The divide between industrializedcountries and developing regions –particularly the least developed coun-tries – is perhaps greater on maternalmortality than on almost any otherissue. This claim is borne out by thenumbers: Based on 2005 data, theaverage lifetime risk of a woman in aleast developed country dying from

complications related to pregnancyor childbirth is more than 300 timesgreater than for a woman living inan industrialized country. No othermortality rate is so unequal.

Millions of women who survivechildbirth suffer from pregnancy-related injuries, infections, diseasesand disabilities, often with lifelongconsequences. The truth is thatmost of these deaths and conditionsare preventable – research hasshown that approximately 80per cent of maternal deaths couldbe averted if women had accessto essential maternity and basichealth-care services. 1

Deaths of newborns in developingcountries have also received fartoo little attention. Almost 40 percent of under-five deaths – or 3.7million in 2004, according to thelatest World Health Organizationestimates – occur in the first 28days of life. Three quarters of neonatal deaths take place in thefirst seven days, the early neonatalperiod; most of these are alsopreventable. 2

2 T H E S T AT E O F T H E W O R L D ’ S C H I L D R E N 2 0 0 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.


11/168

The divide in neonatal deathsbetween the industrialized countriesand developing regions is also wide.Based on 2004 data, a child bornin a least developed country isalmost 14 times more likely todie during the first 28 days of lifethan one born in an industrializedcountry.

The health of mothers and new-borns is intricately related, so pre-venting deaths requires, in manycases, implementing the same inter-ventions. These include such essen-tial measures as antenatal care,skilled attendance at birth, accessto emergency obstetric care whennecessary, adequate nutrition,post-partum care, newborn careand education to improve health,infant feeding and care, and hygienebehaviours. To be truly effective andsustainable, however, these interven-tions must take place within adevelopment framework that strivesto strengthen and integrate pro-grammes with health systems andan environment supportive of women’s rights.

A human rights-based approach toimproving maternal and neonatalhealth focuses on enhancing health-care provision, addressing gender dis-crimination and inequities in societythrough cultural, social and behav-ioural changes, among other means,and targeting those countries andcommunities most at risk.

The State of the World’s Children2009 examines maternal and new-

born health across the world, and inthe developing world in particular,complementing last year’s report onchild survival. While the emphasis of the report remains firmly on healthand nutrition, mortality rates areemployed as benchmark indicators.Sub-Saharan Africa and South Asia,the regions with the highest numbers

and rates of maternal and newbornmortality, are principal focuses. Keythreads running through the reportare the imperative of creating a sup-portive environment for maternal

and newborn health based on respectfor women’s rights, and the need toestablish a continuum of care formothers, newborns and children thatintegrate programmes for reproduc-tive health, safe motherhood, new-born care and child survival, growthand development. The report exam-ines the latest paradigms, policies and

programmes and describes key initia-tives and partnerships that are striv-ing to accelerate progress. A series of panels, several of which have beencontributed by guest collaborators,

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

Millennium Development Goals on maternaland child health

Figure 1.1

Millennium Development Goal 4: Reduce child mortality

Targets Indicators

4.A: Reduce by two thirds, between1990 and 2015, the under-fivemortality rate

4.1 Under-five mortality rate

4.2 Infant mortality rate

4.3 Proportion of 1-year-old childrenimmunized against measles

Millennium Development Goal 5: Improve maternal health*

Targets Indicators

5.A: Reduce by three quarters, between1990 and 2015, the maternalmortality ratio

5.1 Maternal mortality ratio

5.2 Proportion of births attended byskilled health personnel

5.B: Achieve, by 2015, universalaccess to reproductive health

5.3 Contraceptive prevalence rate

5.4 Adolescent birth rate

5.5 Antenatal care coverage (at leastone visit and at least four visits)

5.6 Unmet need for family planning

* The revised Millennium Development Goals framework agreed by the United Nations GeneralAssembly at the 2005 World Summit, with the new official list of indicators effective as of 15January 2008, has added a new target (5.B) and four new indicators for monitoring MillenniumDevelopment Goal 5.Source: United Nations, Millennium Development Goals Indicators: The official United Nations site forthe MDG indicators, ,accessed 1 August 2008.

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’.


12/168

address some of the critical issues inmaternal and newborn health andnutrition today.

The current situation ofmaternal and neonatal health

Since 1990, the estimate of theglobal annual number of maternal

deaths has exceeded 500,000.Although the number of under-fivedeaths worldwide has fallen consis-tently – from around 13 million in1990 to 9.2 million in 2007 – mater-nal deaths have remained stubbornlyintractable. Limited gains have beenmade worldwide towards the firsttarget of Millennium DevelopmentGoal (MDG) 5, which aims toreduce the 1990 maternal mortalityratio by three quarters by 2015; andprogress on diminishing maternalmortality ratios has been virtuallynon-existent in sub-Saharan Africa. 3

Maternal mortality ratios stronglyreflect the overall effectiveness of health systems, which in many low-income developing countries sufferfrom weak administrative, technicaland logistical capacity, inadequatefinancial investment and a lack of skilled health personnel. Scaling upkey interventions – for example, ante-natal HIV testing, increasing the num-ber of births attended by skilled healthpersonnel, providing access to emer-gency obstetric care when necessaryand providing post-natal care formothers and babies – could sharplyreduce both maternal and neonataldeaths. Enhancing women’s access tofamily planning, adequate nutrition

and affordable basic health carewould lower mortality rates furtherstill. These are not impossible, imprac-tical actions, but proven, cost-effectiveprovisions that women of reproduc-tive age have a right to expect.

Maternal health, however, goesbeyond the survival of pregnant

women and mothers. For everywoman who dies from causes relatedto pregnancy or childbirth, it is esti-mated that there are 20 others whosuffer pregnancy-related illness orexperience other severe consequences.The number is striking: An estimated10 million women annually who sur-vive their pregnancies experiencesuch adverse outcomes. 4

That maternal health – as epitomizedby the risk of death or disabilityfrom causes related to pregnancy andchildbirth – has scarcely advanced indecades is the result of multiple under-lying causes. The root cause may liein women’s disadvantaged positionin many countries and cultures, and inthe lack of attention to, and accounta-bility for, women’s rights.

The 1979 Convention on theElimination of All Forms of Discrimination against Women(CEDAW), currently ratified by185 countries, requires signatoriesto “eliminate discrimination againstwomen in the field of health carein order to ensure, on a basis of equality of men and women, accessto health care services, includingthose related to family planning”(article 12.1). It also stipulates that

they “ensure to women appropriateservices in connection with pregnan-cy, confinement and the post-natalperiod, granting free services wherenecessary, as well as adequate nutri-tion during pregnancy and lactation”(article 12.2). Furthermore, theConvention on the Rights of theChild also commits States Parties to

“ensure appropriate pre-natal andpost-natal health care for mothers”and to “develop preventive healthcare, guidance for parents and familyplanning education and services”(article 24). The available evidencesuggests that many countries are fail-ing to deliver on these commitments.

Improving women’s health is pivotalto fulfilling the rights of girls andwomen under CEDAW and theConvention on the Rights of theChild and achieving the MillenniumDevelopment Goals. In addition tomeeting MDG 5, enhancing reproduc-tive and maternal health and serviceswill also directly contribute to attain-ing MDG 4, which seeks to reducethe under-five mortality rate by twothirds between 1990 and 2015.

Enhancing maternal nutrition willalso bring benefits for the achieve-ment of Millennium DevelopmentGoal 1, which seeks to eradicateextreme poverty and hunger by2015. Undernutrition is a processwhich often starts in utero andmay last, particularly for girls andwomen, throughout the life cycle:A stunted girl is likely to become astunted adolescent and later a stunt-ed woman. Besides posing threats to



13/168

her own health and productivity,poor nutrition that contributesto stunting and underweightincreases a woman’s likelihood of adverse pregnancy and birth out-comes. Undernourished mothersalso have a far higher risk of deliv-ering babies with low birthweight –a condition that gravely heightensthe baby’s risk of death. 5

Lowering a mother’s risk ofmortality and morbidity directlyimproves a child’s prospects forsurvival. Research has shownthat in developing countries,babies whose mothers die duringthe first six weeks of their livesare far more likely to die in thefirst two years of life than babieswhose mothers survive. In a studyconducted in Afghanistan, 74per cent of infants born alive to

mothers who died of maternalcauses also subsequently died. 6Moreover, maternal complicationsin labour heighten the risk of neonatal deaths, which are rapidlybecoming a key focus of childsurvival efforts as overall ratesof under-five mortality declinein most developing countries.

Trends in maternal andnewborn health

Maternal mortality

The most recent UN inter-agencyestimates suggest that in 2005,536,000 women died from causesrelated to pregnancy and childbirth.This figure may be far from precise,however, as measuring maternalmortality is challenging, and inmany developing countries the

required data are not routinelyrecorded. Beyond the estimation of maternal mortality, determining andrecording the causes of death is acomplex process. For a death to beconclusively established as related topregnancy or childbirth, both thecause of mortality and the pregnan-cy status and the timing of death in

relation to that pregnancy must beaccurately noted. This level of detailis sometimes missing in the statisti-cal reporting systems of industrial-ized countries, and its absence iscommonplace in many developingcountries, particularly the poorest. 7

Efforts to improve data collection onmaternal mortality have been ongoingfor the past two decades, initiallyinvolving the World HealthOrganization (WHO), UNICEF andthe United Nations Population Fund(UNFPA), later joined by the WorldBank. This inter-agency collaborationpools resources and reviews method-ologies to arrive at more precise andcomprehensive global estimates of maternal mortality. The figures for2005 are the most accurate yet andthe first to estimate maternal mortali-ty trends by an inter-agency process.(Further details on the estimation of maternal mortality ratios and levelscan be found in the Panel on page 7. )

In recent years, new methodologiesto calculate maternal and neonatalhealth status, service needs and mor-tality have been developed by theresearch community. These effortsare ongoing, enriching the processof arriving at more precise estimates


A strong referral system, skilled health workers and well equipped facilities are pivotal toreducing maternal and newborn deaths resulting from complications during childbirth.Health workers treat babies in the Sick Newborn Care Unit, India.

© U N I C E F / H Q 0 6 - 2

0 5 5 / P a b

l o B a r

t h o l o m e w

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.


14/168

and causes of mortality and morbidity.In turn, better data and analysis onhealth status and health services arehelping enhance the strategies andframeworks, programmes, policiesand partnerships – including thosethat support gender mainstreaming –that are striving to improve maternaland newborn health.

One issue in the estimation of maternal mortality appears beyondcontention: The vast majority of maternal deaths – more than 99per cent, according to the 2005 UNinter-agency estimates – occurred indeveloping countries. Half of these(265,000) took place in sub-SaharanAfrica and another third (187,000)in South Asia. Between them, thesetwo regions accounted for 85 per centof the world’s pregnancy-relateddeaths in 2005. India alone had22 per cent of the global total.

The trend estimates available for mater-nal mortality indicates the lack of suf-ficient progress towards Target A of MDG 5, which seeks a 75 per centreduction in the maternal mortalityratio between 1990 and 2015. Giventhat the global maternal mortality ratiostood at 430 per 100,000 live births in1990, and at 400 deaths per 100,000live births in 2005, meeting the targetwill require more than a 70 per centreduction between 2005 and 2015.

Global trends can obscure the widevariations between regions, many of which have made appreciable progressin reducing maternal mortality andare laying the foundations for further

improvements by increasing access tobasic maternity services. In the indus-trialized countries, the maternal mor-tality ratio remained broadly staticbetween 1990 and 2005, at a low rateof 8 per 100,000 live births. Nearuniversal access to skilled care duringdelivery and emergency obstetric carewhen necessary have contributed to

these diminished levels of maternalmortality; no industrialized countrieswith data have skilled attendance atbirth of less than 98 per cent, andmost have universal coverage.

In all of the developing regions outsidesub-Saharan Africa, both the absolutenumbers of maternal deaths andmaternal mortality ratios declinedbetween 1990 and 2005. In sub-Saharan Africa, maternal mortalityratios remained largely unchangedover the same period. Given theregion’s high fertility rates, this has

resulted in higher numbers of maternaldeaths over the 15-year period. Thislack of progress is particularly worry-ing, since the region has by far thehighest ratios and lifetime risk of maternal mortality and the greatestnumber of maternal deaths. In Westand Central Africa, the regional mater-nal mortality ratio stands at a stagger-

ing 1,100 per 100,000 live births,compared to the average for develop-ing countries and territories of 450per 100,000 live births. This regionincludes the country with the highestrate of maternal death in the world:Sierra Leone, with 2,100 maternaldeaths per 100,000 live births.

The West and Central Africa regionalso has the highest total fertility rate,at 5.5 children in 2007. (The total fer-tility rate measures the number of chil-dren who would be born per woman if she lived to the end of her childbearing


Maternal deaths, 2005

Eastern/Southern Africa103,000 (19%)Middle East/

North Africa21,000 (4%)

South Asia187,000 (35%)

East Asia/Pacific45,000 (8%)

Latin America/Caribbean15,000 (3%)

West/Central Africa162,000 (30%)

Industrialized countries 830 (


15/168


Maternal mortality is defined as the death of a woman whilepregnant or within 42 days of termination of pregnancy,regardless of the site or duration of pregnancy, from anycause related to or aggravated by the pregnancy or its man-agement. Causes of deaths can be divided into direct causesthat are related to obstetric complications during pregnancy,labour or the post-partum period, and indirect causes. Thereare five direct causes: haemorrhage (usually occurring post-partum), sepsis, eclampsia, obstructed labour and complica-tions of abortion. Indirect obstetric deaths occur from eitherpreviously existing conditions or from conditions arising inpregnancy which are not related to direct obstetric causes butmay be aggravated by the physiological effects of pregnancy.These include such conditions as HIV and AIDS, malaria,anaemia and cardiovascular diseases. Simply because awoman develops a complication does not mean that deathis inevitable; inappropriate or incorrect treatment or lack of appropriate, timely interventions underlie most maternal deaths.

Accurate classification of the causes of maternal death,whether direct or indirect, accidental or incidental, is challeng-ing. To accurately categorize a death as maternal, informationis needed on the cause of death as well as pregnancy status,or the time of death in relation to the pregnancy. This infor-mation may be missing, misclassified or under-reported evenin industrialized countries with fully functioning vital registra-tion systems, as well as in developing countries facing highburdens of maternal mortality. There are several reasons forthis: First, many deliveries take place at home, particularly inthe least developed countries and in rural areas, complicatingefforts to establish cause of death. Second, civil registrationsystems may be incomplete or, even if deemed complete,attribution of causes of death may be inadequate. Third,

modern medicine may delay a women’s death beyond the42-day post-partum period. For these reasons, in some casesalternative definitions of maternal mortality are used. Oneconcept refers to any cause of death during pregnancy orthe post-partum period. Another concept takes into accountdeaths from direct or indirect causes that occur after thepost-partum period up to one year following pregnancy.

The main measure of mortality risk is the maternal mortality ratio , which is identified as the number of maternal deathsduring a given period of time per 100,000 live births duringthe same period, which is generally a year. Another key meas-ure is the lifetime risk of maternal death , which reflects theprobability of becoming pregnant and the probability of dyingfrom a maternal cause during a women’s reproductive lifespan.In other words, the risk of maternal death is related to twomain factors: mortality risk associated with a single pregnancyor live birth; and the number of pregnancies that women haveduring their reproductive years.

Working together to improve estimationsof maternal deathsSeveral agencies are collaborating to establish more accuratemeasurements of maternal mortality rates and levels world-wide, and assess progress towards Target A of MillenniumDevelopment Goal 5, which seeks to reduce the maternal

mortality rate by three quarters between 1990 and 2015. TheMaternal Mortality Working Group, which originally comprisedthe World Health Organization, UNICEF and the United NationsPopulation Fund, developed internationally comparable globalestimates of maternal mortality for 1990, 1995 and 2000.

In 2006, the World Bank, United Nations Population Divisionand several outside technical experts joined the group, whichsubsequently developed a new set of globally comparablematernal mortality estimates for 2005, building on previousmethodology and new data. The process generated estimatesfor countries with no national data, and adjusted availablecountry data to correct for under-reporting and misclassifica-tion. Of the 171 countries reviewed by the Maternal MortalityWorking Group for the 2005 estimations, appropriate national-level data were unavailable for 61 countries, representing onequarter of global births. For these countries, models wereused to estimate maternal mortality.

For the 2005 estimates, data were drawn from eight cate-gories of sources: complete civil registration systems withgood attribution of data, complete civil registration systemswith uncertain or poor attribution of data, direct sisterhoodmethods, reproductive-age mortality studies, disease surveil-lance or sample registration, census, special studies and nonational data. Estimates for each source were calculatedaccording to a different formula, taking into account factorssuch as correcting for known bias and determining realisticuncertainty bounds.

Measures of maternal mortality are prepared with a margin of uncertainty, highlighting the fact that while they are the bestestimates available, the actual rate may be higher or lower

than the average. Although this is true of any statistic, thehigh degree of uncertainty for maternal mortality ratios indi-cates that all data points should be interpreted cautiously.

Notwithstanding the challenges of data collection and meas-urement, the 2005 inter-agency estimates for maternal mortal-ity were sufficiently rigorous to produce trend analysis,assessing progress from the 1990 baseline date of MDG 5 to2005. The lack of improvement in reducing maternal mortalityidentified in many developing countries has helped bringgreater attention to achieving MDG 5.

The 2005 maternal mortality estimates are far from perfect,and much work is still required to refine the processes of datacollection and estimation. But they reflect a strong commit-ment on the part of the international community to continual-ly strive for greater accuracy and precision. These ongoingefforts will support and guide actions to improve maternalhealth and ensure that women count.

See References, page 107.

Challenges in measuring maternal deaths


16/168

years and bore children at each age inaccordance with prevailing age-specificfertility rates.) High fertility ratesincrease the risk that a woman will diefrom maternal causes. While mortalityrisks are associated with all pregnan-cies, these risks rise the more times awoman gives birth.

Elevated fertility rates, combinedwith weak access to basic health-careand maternity services, can have life-long implications for women’s sur-vival. In the developing world as awhole, a woman has a 1 in 76 life-time risk of maternal death, com-pared with a probability of just 1 in8,000 for women in industrializedcountries. By way of comparison, thelifetime risk of maternal mortalityranges from just 1 in 47,600 for amother in Ireland, to 1 in every 7 inNiger, the country with the highestlifetime risk of maternal death. 8

Neonatal mortality

Neonatal mortality is the probabilityof a newborn dying between birthand the first 28 completed days of life. The latest estimates from theWorld Health Organization, whichdate from 2004, indicate that around3.7 million children died within thefirst 28 days of life in that year.Within the neonatal period, however,there is wide variation in mortalityrisk. The greatest risk is during thefirst day after birth, when it is esti-mated that between 25 and 45 percent of neonatal deaths occur. Aroundthree quarters of newborn deaths, or2.8 million in 2004, occur within thefirst week – the early neonatal period.


Trends, levels and lifetime risk of maternal mortality

Figure 1.3

Source: World Health Organization, United Nations Children’s Fund, United Nations PopulationFund and the World Bank, Maternal Mortality in 2005: Estimates developed by WHO, UNICEF,UNFPA and the World Bank, WHO, Geneva, 2007, p. 35.

Lifetime risk of maternal death, 2005

West/Central Africa

Sub-Saharan Africa*

Eastern/Southern Africa

South Asia

Middle East/North Africa

East Asia/Pacific

Latin America/Caribbean

CEE/CIS

Industrialized countries

0 1 2 3 4 5 6 7

World

Least developed countries

Developing countries

5.9

3.4

1.7

0.7

0.3

0.4

0.1

0.01

1.1

4.5

1.3

4.2

Probability that a women will die from causes related to pregnancycumulative across her reproductive years (%)

*Sub-Saharan Africa comprises the regions of Eastern/Southern Africa and West/Central Africa.

West/Central Africa

World

Sub-Saharan Africa*




South Asia

Middle East/North AfricaEast Asia/Pacific


CEE/CIS


Maternal mortality ratios, 1990 and 2005

1,1001,100

1990

2005

0 200 400 600 800 1000 1200

790760

650500

270210

220150

180130

6346

88

430400

940920

480450

900870

Maternal deaths per 100,000 live births

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.


17/168

Like maternal deaths, almost all (98per cent in 2004) neonatal deathsoccur in low- and middle-incomecountries. The total number of peri-natal deaths, which groups stillbirthswith early neonatal deaths owing tothe fact that they have similar obstet-ric causes, was 5.9 million deaths in2004. Stillborns accounted for around3 million perinatal deaths that year. 9

Until the mid-to-late 1990s, neonatalmortality figures were estimated fromrough historical data. But as more reli-able data emerged from householdsurveys, it became evident that previ-ous estimates had significantly under-estimated the incidence of newborndeaths. The global neonatal mortalityrate declined by one quarter between1980 and 2000, but its rate of reduc-tion was much slower than that of theoverall under-five mortality rate, whichfell by one third. As a consequence,neonatal deaths currently constitute amuch higher proportion of under-fivedeaths than in previous years. In

prisingly, are found in industrializedcountries, where the neonatal mortal-ity rate in 2004 was just 3 per 1,000live births. The highest rates of neonatal death in 2004 were foundin South Asia (41 per 1,000 livebirths) and West and Central Africa(45 per 1,000). Owing to a highernumber of births, South Asia has thehighest number of neonatal deathsamong the world’s regions. 11

The main causes of maternaland neonatal mortality andmorbidity

Maternal mortality

Direct causes

The timing and causes of maternaland newborn deaths are well known.Maternal deaths mostly occur fromthe third trimester to the first weekafter birth (with the exception of deaths due to complications of abor-tion). Studies show that mortality

M A T E R N A L A N D N E W B O R N H E A L T H : W H E R E W E S T A N D 9

particular, deaths in the first weekof life have risen from 23 per centof under-five deaths in 1980 to 28per cent in 2000. 10

In part, the rising proportion of neonatal deaths reflects two key fac-tors: the difficulty of reaching manybabies who are born at home witheffective and timely neonatal interven-tions, and the success of many coun-tries in implementing interventionssuch as immunization that havemarkedly reduced post-neonataldeaths in the developing world as awhole. This has led in part to a rela-tive neglect of cost-effective, simpleneonatal survival interventions.Reducing neonatal deaths thereforehas become a major component of new paradigms and strategies fordiminishing child mortality and reach-ing Millennium Development Goal 4.

Regional patterns of neonatal deathcorrelate closely to those for mater-nal death. The lowest rates, unsur-

Expanded distribution of insecticide-treated mosquito nets to help prevent malaria and rapid scaling up of programmes to prevent and treatHIV 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.

© U N I C E F M o z a m

b i q u e /

E m

i d i o M a c

h i a n a


18/168

risks for mothers are particularlyelevated within the first two daysafter birth. Most maternal deaths arerelated to obstetric complications –including post-partum haemorrhage,infections, eclampsia and prolongedor obstructed labour – and complica-tions of abortion. Most of these directcauses of maternal mortality can be

readily addressed if skilled health per-sonnel are on hand and key drugs,equipment and referral facilities areavailable. 12 (For further details onbirth complications and emergencyobstetric care, see Chapter 3. )

Indirect causes

Many factors contributing to amother’s risk of dying are not unique

to pregnancy but may be exacer- bated by pregnancy and childbirth.Attributing these causes to preg-nancy is difficult owing to the poordiagnostic capacity of many coun-tries’ health information systems.Nonetheless, assessing the indirectcauses of maternal deaths helpsdetermine the most appropriate inter-

vention strategies for maternal andchild health. Collaboration betweencondition-specific programmes – suchas those to address malaria or AIDS –and maternal health initiatives mayoften be the most effective way toaddress some of these indirect causes,including those that are highly pre-ventable or treatable, such asanaemia. 13

Maternal anaemia affects about half of all pregnant women. Pregnantadolescents are more prone toanaemia than older women, and theyoften receive less care. Infectious dis-eases such as malaria, which affectsaround 50 million pregnant womenliving in malaria-endemic countriesevery year, and intestinal parasites

can exacerbate anaemia, as can poor-quality diets – all of which heightenvulnerability to maternal death.Severe anaemia contributes to the riskof death in cases of haemorrhage. 14

Anaemia is highly treatable withiron supplements offered throughmaternal health programmes. Thisintervention, however, remains limit-

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

West/Central Africa

South Asia

Sub-Saharan Africa*


Middle East/North Africa

East Asia/Pacific

CEE/CIS



World



0 5 10 15 20 25 30 35 40 45 50

45

36

41

25

18

16

13

3

28

41

40

31

Neonatal deaths (0–28 days) per 1,000 live births, 2004

Regional rates of neonatal mortality

Figure 1.4

Source: World Health Organization, using vital registration systems and household surveys.

The latest inter-agency estimates suggest that 536,000 women died in

2005 from causes related to pregnancy and childbirth.

*Sub-Saharan Africa comprises the regions of Eastern/Southern Africa and West/Central Africa.


19/168


In 1631, a beautiful empress, Mumtaz Mahal, died whilegiving birth to her 14th child. Overwhelmed by grief, herhusband constructed a monument in her honour: the TajMahal, today one of the best-known buildings in the world.

And yet, while the Taj Mahal’s domes and spires are instantlyrecognizable, there is far less global awareness of the tragedythat inspired its creation.

Nearly 400 years after Mumtaz Mahal lost her life in child-birth, a woman still dies from causes related to pregnancy orchildbirth every minute of every day – more than 500,000women each year, 10 million per generation. How can it bethat in our age of modern advances and medical miracles weare still failing to safeguard women as they perpetuate thehuman race itself?

The answer, of course, is that public health has made breath-

taking strides, but those benefits have not been equally shared,either among countries or between the geographical areas andsocial groups within them. Even though the causes of pregnan-cy and childbirth complications are the same around the world,their consequences vary dramatically from country to countryand region to region. Today, a young woman in Sweden has a1 in 17,400 lifetime risk of dying of pregnancy-related causes.In Sierra Leone, her risk soars to 1 in 8.

And for every woman who dies, another 20 are afflicted withserious infections or injuries. An estimated 75,000 women eachyear become victims of obstetric fistula, a physically and psycho-logically devastating condition that can result in social exclusion.

The toll in women’s lives is enormous. But they are not theonly ones who suffer. As a group of experts stated during aglobal conference on women’s health in 2007: “In their primereproductive years, women ‘deliver’ for their societies inmultiple ways: They bear and raise the next generation, andthey are critical actors for progress as workers, leaders, andactivists.” When women’s lives are cut short or incapacitatedas a result of pregnancy or childbirth, the tragedy cascades.Children lose a parent. Spouses lose a partner. And societieslose productive contributors.

Our world cannot afford to keep sacrificing so many peopleand so much potential. We know what it takes to prevent andtreat the vast majority of pregnancy-related difficulties, fromeclampsia and haemorrhage to sepsis, obstructed labour andanaemia. Indeed, the World Bank estimates that such basicinterventions as antenatal care, attendance at delivery byskilled health personnel, and accessible emergency treatmentfor women and newborns could avert almost three quartersof maternal deaths.

But expanding medical interventions is just one part of improving maternal and newborn health. More fundamentally,we need to boost women’s empowerment around the world.Consider that in a century increasingly defined by information,we still do not have precise data regarding the numbers of

women who die in childbirth each year. Why are maternaldeaths only partially enumerated? One possible reason isthat, in too many places, women’s lives do not fully count.

And as long as women remain disadvantaged in their soci-eties, maternal and newborn health will suffer as well. Butif we can empower women with the tools to take control of their lives, we can create a more supportive environmentfor women and children alike.

Empowerment begins with education, the best developmentinvestment we can make – from ensuring that girls as well asboys are able to attend primary school to teaching women toread and write, and providing public health education. Althoughmuch remains to be done, many countries are beginning tomake strides in this direction. In Jordan, for example, nursingstudents from the University of Jordan are volunteering toeducate girls in public schools about women’s health issues.

Study after study shows that educated women are betterequipped to earn income to support their families, morelikely to invest in their children’s health care, nutrition andeducation, and more inclined to participate in civic life andto advocate for community improvements.

Educated mothers are also more likely to seek proper healthcare for themselves; according to the 2007 MillenniumDevelopment Goals Report , “84 per cent of women who havecompleted secondary or higher education are attended byskilled personnel during childbirth, more than twice the rateof mothers with no formal education.”

Children of educated mothers are 50 per cent more likely tosurvive until the age of five and beyond than those whosemothers did not receive or complete schooling. For girls in par-ticular, education can make the difference between hope anddespair. Research shows that young people who complete pri-mary school are less likely to be infected by HIV than thosewho never managed to graduate from primary school.

Educated girls are also more likely to delay marriage and lesslikely to get pregnant while very young, reducing the risk of dying in childbirth while they are still children themselves. Asgirls continue their education, their earning potential increas-es, enabling them to break the bonds of poverty too oftenpassed down through the generations.

Put simply, changing the trajectory for girls can change thecourse of the future. And if these girls grow into women whochoose to become mothers themselves, they will view preg-nancy and childbirth as something to celebrate, not fear.

See References, page 107.

*Her Majesty Queen Rania Al Abdullah of Jordan is UNICEF’s Eminent Advocate for Children and a tireless global advocate for child protection, early childhood development, gender parity in education and women's empowerment.

Creating a supportive environment for mothers and newbornsby H. M. Queen Rania Al Abdullah of Jordan, UNICEF’s Eminent Advocate for Children*


20/168

are ensuing. For example, coverageof antiretroviral prophylaxis forHIV-positive mothers to preventmother-to-child transmission rosefrom 10 per cent of HIV-infectedpregnant women in low- andmiddle-income countries in 2004to 33 per cent in 2007. Despite thisappreciable progress, much more

needs to be done to provide womenwith interventions for HIV preven-tion, care and therapy – includingtesting and counselling, and qualitysexual and reproductive health serv-ices in addition to medicines. 18

Although the consequences ofco-infection with HIV and malariaparasites are not fully understood,available evidence suggests that theinfections act synergistically andresult in adverse outcomes. Recentevidence suggests that HIV-positivewomen with placental malaria aremore likely to give birth to low-birthweight infants. Research alsosuggests that low-birthweightinfants are more susceptible to HIVinfection as a result of mother-to-child transmission of the virusthan infants of normal birthweight.Antiretroviral treatment for HIV-positive women and children and theuse of insecticide-treated mosquitonets can reduce the risk of malariastill further. 19 (For further details onHIV and malaria co-infection, seethe Panel in Chapter 3, page 63. )

For every woman who dies frompregnancy-related complications,around 20 more incur injuries, infec-tions and disabilities – approximately


ed in both coverage and effective-ness in some developing countries,mostly as a result of low access tobasic health care and, more specifi-cally, to quality antenatal care andsupport. Encouragingly, there aresigns that efforts to address anaemiaby fortifying staple foods like flourare beginning to accelerate at the

national level in a number of devel-oping countries. 15

Maternal iodine deficiency duringpregnancy is associated with a higherincidence of stillbirths, miscarriageand congenital abnormalities. Theserisks can be reduced and preventedby ensuring optimal maternal iodinestatus before or during pregnancy.Universal salt iodization and, insome cases, iodine supplementationare essential to ensure optimumiodine intake during pregnancyand childhood. 16

Malaria is another deadly risk formothers and babies. In malaria-endemic areas, the disease con-tributes to around one quarter of severe maternal anaemia cases,heightens the risk of stillbirth andmiscarriage, and contributes to lowbirthweight and neonatal deaths.Prevention of malaria through theuse of insecticide-treated mosquitonets is therefore vital to reduce itsimpact on pregnant women andnewborns. In addition, intermittentpreventive treatment of malaria forpregnant women in the second andthird trimesters is increasingly usedin sub-Saharan Africa to avertanaemia and placental malaria. 17

The precise contribution of HIV andAIDS to maternal deaths is difficultto assess since, despite the expansionof programmes to prevent mother-to-child transmission of HIV, the HIVstatus of many pregnant women isstill unknown. HIV and pregnancymight interact in several ways. Thevirus may heighten the risk of such

obstetric complications as haemor-rhage, sepsis and complications of Caesarean section. Pregnancy, inturn, may raise the risk of HIV-relatedillnesses such as anaemia and tuber-culosis, or accelerate HIV progres-sion. Current research findings areindicative rather than conclusive,and more research is needed to clar-ify the degree of causality in bothdirections. It is believed that incountries with high prevalence of HIV, the AIDS epidemic may havereversed previous advances inmaternal mortality. What can beassessed with greater certainty, atleast partially, is the number of women identified as living withHIV who gave birth – around1.5 million in 108 low- andmiddle-income countries in 2006.

Efforts to address the AIDS epidem-ic and its impact on maternal andnewborn health are intensifying infour key areas: prevention of infec-tion among adolescents and youngpeople; antiretroviral treatment forHIV-positive women and motherswho require antiretroviral therapy;prevention of mother-to-child trans-mission; and paediatric treatment of HIV. Advances are being made in allfour areas and encouraging results


21/168


10 million women each year. Amongthe most distressing conditions isobstetric fistula, which occurs whenprolonged pressure from the baby’shead during extended, problematiclabour causes tissue damage in thebirth canal. In the period followingthe birth, holes open up and there isleakage from the bladder and/or therectum into the vagina. Fistula canbe easily treated by health workerswith appropriate surgical skills, butmany of the estimated 75,000 womenafflicted by this condition each yearnever receive treatment. Instead, theynot only have to cope with the physi-

cal discomfort and emotional distressof the condition, they also may riskbeing shunned by their husbandsand families.

Another debilitating condition isuterine prolapse, which occurswhen the muscles, ligaments andtissue supporting the pelvic struc-ture give way, causing the uterus tofall into the vaginal canal. Limitedmobility, chronic back pains andurinary incontinence are three con-sequences of prolapse, which, if severe, can also make it impossiblefor women to undertake household

and other routine tasks. A numberof factors can cause uterine pro-lapse, including prolonged labour,difficult delivery, frequent pregnan-cies, inadequate obstetric care andheavy manual labour.

Other forms of maternal morbidityinclude anaemia, infertility, chronic

infection, depression and incontinence– all of which may result in domesticproblems including physical and psy-chological abuse, household dissolu-tion and social exclusion. 20

Neonatal mortality

Some 86 per cent of newborn deathsglobally are the direct result of threemain causes: severe infections –including sepsis/pneumonia, tetanusand diarrhoea – asphyxia andpreterm births. Severe infections areestimated to account for 36 per centof all newborn deaths. They canoccur at any point during the firstmonth of life but are the main causeof neonatal death after the first week.Clean delivery practices are clearlyimportant in preventing infection,but maternal infections also need tobe identified and treated during preg-nancy. Infections in newborns requirerapid identification and treatment assoon as possible following childbirth.

Asphyxia (difficulty in breathing afterbirth) causes 23 per cent of newborndeaths and can largely be preventedby improved care during labour anddelivery. The condition can be alleviat-ed by a trained health worker whois able to detect its signs and resusci-tate the newborn. Preterm birth (deliv-

Exclusive breastfeeding for the first six months of life helps protect newborns and infantsfrom disease, reduces the risk of mortality and encourages healthy child development.A woman breastfeeds her newborn at the Uskudar Ana ve Cocuk Sagligi Klinigi, a clinic operated by the Ministry of Health in Istanbul, Turkey.

U N I C E F / H Q 0 5 - 1

2 2 2 / R o g e r

L e M o y n e


22/168

Saharan Africa, the regions with thehighest rates of undernutrition amonggirls and women. Maternal undernu-trition is correlated with a higher inci-dence of low birthweight in infants. 22

Intrauterine growth restriction, whichrefers to restricted growth of the fetusduring pregnancy, is a leading risk for

perinatal deaths. Like low birthweight,it is also associated with maternalundernutrition and ill health, amongother factors. With correct identifica-tion and proper management, includ-ing early treatment of maternal dis-eases and good nutrition, the conditioncan be contained and need not resultin lifelong consequences. 23

The intergenerational nature of thesolution to intrauterine growthrestriction underlines the fact thatimproving maternal and newborn

health is not simply a practical mat-ter of making available better andmore extensive maternal health serv-ices. It also involves tackling headon the neglect of women’s basicrights in many societies.

In addition to adequate nutritionfor women, birth spacing is also

central to avoiding preterm births,low birthweight in infants andneonatal deaths; studies showthat birth intervals of less than24 months significantly increasethese risks. It is also imperativeto secure girls’ access to propernutrition and health care frombirth through childhood and intoadolescence, womanhood and theirpotential childbearing years. 24

For every newborn baby who dies,another 20 suffer birth injury, com-

ery at less than 37 weeks of completedgestation) directly causes 27 per centof newborn deaths. Infants bornprematurely find it more difficultthan full-term babies to feed, maintainnormal body temperature and with-stand infection. Preventing malaria inpregnant women can have a positiveimpact on the incidence of premature

births in malaria-endemic areas.21

According to the latest internationalestimates, which cover the period2000–2007, 15 per cent of all new-borns are born with low birthweight(defined as infants weighing less than2,500 grams at birth). Low birth-weight, which is caused by pretermbirth or intrauterine growth restric-tion, is an underlying factor in 60–80per cent of neonatal deaths. Themajority of such cases occur in SouthAsia in particular, and also in sub-


Haemorrhage34%

Haemorrhage31%

Haemorrhage21%

Other causes30%

Other causes21%

Other causes21%

Complications of abortion4%

Complicationsof abortion6%

Obstructed labour4%

Obstructedlabour

9% Obstructedlabour

13%

Anaemia4%

Anaemia13%

HIV/AIDS6%

Hypertensivedisorders

9%


9%


26%Sepsis/

infections10%

Sepsis/ infections

12%

Sepsis/ infections

8%Complications

of abortion12%

Direct causes of maternal deaths, 1997–2002*

Figure 1.5

Latin America/CaribbeanAfrica Asia

Source: Khan, Khalid S., et al., 'WHO Analysis of Causes of Maternal Death: A systematic review', The Lancet , vol. 367, no. 9516, 1 April 2006, p.1069.

* Data refer to the most recent year available during the period specified. Percentages may not total 100% because of rounding.

Pregnancy- and childbirth-related complications are an important

cause of mortality for girls aged 15–19 years worldwide, accounting

for 70,000 deaths every year.


23/168

plications arising from preterm birthor other neonatal conditions. Morethan 1 million children who survivebirth asphyxia each year, for exam-ple, end up suffering disabilitiessuch as cerebral palsy or learningdifficulties. 25

Underlying and basic causes

of maternal and neonatalmortality and morbidity

In addition to the direct causes of maternal and newborn mortality andmorbidity, there are a number of underlying factors at the household,community and district levels thatalso serve to undermine the healthand survival of mothers and new-borns. They include lack of educationand knowledge, inadequate maternaland newborn health practices andcare seeking, insufficient access

to nutritious food and essentialmicronutrients, poor environmentalhealth facilities and inadequate basichealth-care services and limitedaccess to maternity services – includ-ing emergency obstetric and newborncare. There are also basic factors,such as poverty, social exclusion andgender discrimination that underpin

both the direct and underlying causesof maternal and newborn mortalityand morbidity. ( For a fuller outline of how these factors interact, see Figure1.7 on page 17. )

Of particular importance is therestricted access to quality healthcare services that many women face.Maternal health and access to quali-ty contraception and reproductivehealth services save women’s livesand are also important factorsunderlying newborn health and

survival. Studies show that women’shealth throughout the life cycle,from childhood through adolescenceand into adulthood, is critical indetermining maternal and neonatalhealth outcomes. Access to institu-tional facilities and skilled healthpersonnel at birth are also importantfactors; it should come as no sur-

prise that the countries with thehighest rates of neonatal mortalityhave among the lowest rates of skilled attendants at birth andinstitutional deliveries. 26

Poverty undermines maternal andneonatal health in several ways. Itcan heighten the incidence of directcauses of mortality, such as maternalinfections and undernutrition, anddiscourage care seeking or reduceaccess to health-care services. It canalso undermine the quality of the


For every woman who dies from a pregnancy-related cause, another

20 more incur injuries, infections and disabilities – around 10 million

women each year.

0 20 40 60 80 100

Sepsis/pneumonia (26%)

Tetanus (7%)

Diarrhoea (3%) Preterm (27%) Asphyxia (23%)

Congenital (7%)

Other (7%)

Direct causes of neonatal deaths, 2000*

Figure 1.6

* Percentages may not total 100% because of rounding.

Source: Lawn, Joy E., Simon Cousens and Jelka Zupan, ‘4 million neonatal deaths; When? Where? Why?', The Lancet , vol. 365, no. 9462,5 March 2005, p. 895.

Low birthweight, which is related to maternal malnutrition, is a causal factor in 60–80 per cent of neonatal deaths.


24/168

services provided even when theyare available. Information from 50Demographic and Health Surveysfrom 1995 to 2002 reveals that with-in regions, neonatal mortality ratesare around 20–50 per cent higher forthe poorest 20 per cent of householdsthan for the richest quintile. Similarinequities are also prevalent for

maternal mortality.27

Providing a supportive social con-text for the rights of women andgirls is also critical to reducingmaternal and neonatal mortalityand morbidity. Efforts to increasehealth interventions to address theproximate causes of maternal andneonatal deaths and ill health, andto ameliorate maternal undernutri-tion, curb infectious diseases andimprove hygiene facilities and prac-tices will be only partly successfulunless the social context in whichwomen and girls reside respects theirrights. As Chapter 2 shows, expand-ing service delivery may prove insuf-ficient if women and girls are deniedaccess to essential commodities orservices because of cultural, social,or familial impediments.

Accelerating progress onmaternal and newborn health

Many of the causal factors responsi-ble for maternal and neonatal mor-bidity and mortality are well knownand interrelated, as illustrated in theconceptual framework in Figure 1.7.While there are still many gaps in ourknowledge of the extent and causesof maternal and newborn deaths, we

certainly know enough to implementinterventions that could save millionsof lives. The main methods of redu-cing maternal and newborn mortalityand morbidity are well establishedand understood. These include:

• Promoting access to family plan-ning services, based on individualcountry policies.

• Quality antenatal care providing acomprehensive package of healthand nutrition services.

• Preventing mother-to-child transmis-sion of HIV and offering antiretro-viral treatment for women in need.

• Basic preventive and curative inter-ventions, including immunizationagainst neonatal tetanus for preg-nant women, routine immuniza-tion, distribution of insecticide-treated mosquito nets and oralrehydration salts, among others.

• Access to improved water and sani-tation, and adoption of improvedhygiene practices, especially at deliv-ery. Clean water for hygiene anddrinking is essential for safe delivery.


• Access to skilled health personnel –a doctor, nurse or midwife – atdelivery.

• Basic emergency obstetric care ata minimum of four facilities per500,000 population – adapted toeach country’s circumstances –for women who experience somecomplication.

• Comprehensive emergencyobstetric care at a minimum ofone facility in every district orone per 500,000 population.

• A post-natal visit for everymother and newborn as soonas possible after delivery, ideallywithin 24 hours, with additionalvisits towards the end of thefirst week and at four tosix weeks.

• Knowledge and life skills forpregnant women and familieson the danger signs of maternaland newborn health and aboutreferral systems.

• Maternal nutrition counselling andsupplementation as needed as part of

Improving maternity services is essential to enhancing maternal and newborn health andsurvival.A nurse examines a six-week-old baby during a check-up at a community health

centre, Jamaica.

© U N I C E F / H Q 0 8 - 0

3 0 2 / S u s a n

M a r

k i s z


25/168


The burden of neonatal deaths is also high, as each year almost

4 million newborns die within the first 28 days of life.

Maternal and neonatalmortality and morbidity

Obstetric risksincl. complications

of abortion

Insufficientaccess tomaternityservices –including

emergencyobstetric andnewborn care

Inadequatematernal and

newborn healthpractices andcare seeking

Insufficient access to nutritious food

and essentialmicronutrientsincluding earlyand exclusivebreastfeeding

Quantity and quality of actualresources for maternal health —

human, economic and organizational —and the way they are controlled

Potential resources: environment, technology, people

Poor water/ sanitation

and hygiene,and inadequate

basic health-careservices

Diseases andinfections

Congenitalfactors

Inadequatedietary intake

Inadequate and/or inappropriateknowledge, discriminating attitudeslimit household access to actual resources

Outcomes

Direct causes

Basic causes atsocietal level

Underlying causes at thehousehold/communityand district levels

Political, economic, cultural, religious andsocial systems, including women’s status,limit the utilization of potential resources

Lack of education,health information,

and life skills

Conceptual framework for maternal and neonatal mortality and morbidityFigure 1.7

This conceptual framework on the causes of maternal and newborn deaths illustrates that health outcomes are determined by interrelated fac-tors, encompassing nutrition, water, sanitation and hygiene, health-care services and healthy behaviours, and disease control, among others.These factors are defined as proximate (individual), underlying (household, community and district) and basic (societal). Factors at one levelinfluence other levels. The framework is devised to be useful in assessing and analysing the causes of maternal and newborn mortality andmorbidity, and in planning effective actions to enhance maternal and neonatal health.

Source: UNICEF.


26/168

routine antenatal, post-natal andneonatal care.

• Essential care for all newborns,including initiation of breastfeedingwithin the first hour of birth,exclusive breastfeeding, infectioncontrol, warmth provision andavoidance of bathing during the

first 24 hours.

• Extra care for small babies, multi-ple births and severe congenitalabnormalities.

• Integrated Management of Neonatal and Childhood Illness, orthe equivalent, in health facilitiesthat provide care to women andchildren. 28

For these interventions to work,however, it is increasingly recognizedthat essential services must be provid-ed, at key points in the life cycle,through dynamic health systems thatintegrate a continuum of home, com-munity, outreach and facility-basedcare. This concept of a continuum of care for maternal, neonatal and childhealth has arisen in recent years fromthe recognition that an integratedapproach reaps more dividends thanmyriad separate initiatives. The con-tinuum must exist, however, in a sup-portive environment that safeguardswomen’s rights and prioritizes mater-nal and newborn health. Chapter 2explores the elements required to cre-ate and sustain such an environment.

Among the most vital elements in thecontinuum of care is the presence of

skilled professionals throughout preg-nancy, birth, post-partum and neona-tal care, supported by referrals toadequately staffed facilities equippedto manage emergencies. The emergingrole of mid-level providers such asnurses and midwives in broadeningaccess to emergency obstetric care isalso showing promising potential in

the developing world.

In particular, given that the risks of maternal and newborn death aregreatest during the first 24–48 hoursafter birth, post-natal care urgentlyneeds to be expanded during thisperiod, and greater emphasis needsto be placed on follow-up visits forbabies and mothers. Visits shortlyafter birth are vital for new mothers,who may remain at higher risk of mortality and morbidity for up to ayear after birth. This is usually notpossible, however, as maternal andnewborn services are often sorelylacking in the poorest countries andcommunities where the most deathsoccur. Particularly in sub-SaharanAfrica, factors such as distance,migration, urbanization, armed con-flict, disease and lack of investmentin public health have left severeshortages of skilled healthprofessionals.

Women and newborns in fragilestates – countries that experienceweak institutional policy, poor gov-ernance, political instability andweak rule of law – require particularattention. Often these states lack theinstitutional capacity and adequateresources to deliver basic social

and infrastructure services and offersecurity to citizens. Fragile stateshold around 8 per cent of the world’spopulation, but they account for35 per cent of global maternaldeaths and comprise 8 of the 10countries with the highest maternalmortality ratios. These countries alsoaccount for 21 per cent of global

neonatal deaths, and comprise 9 of the 10 countries with the most ele-vated rates of neonatal mortality. 29

Strengthening governance and the ruleof law and restoring peace and securityare requisites for accelerating progresson improving maternal and newbornhealth. Donors and international agen-cies also face the challenge of movingbeyond short-term humanitarianresponse to long-term developmentassistance, and ensuring that maternal,child and newborn health and women’srights are among the key issues innegotiations and programmes aimed atimproving governance, resolving con-flict and strengthening institutions. 30

In the least developed countries, insuf-ficient resources have been dedicatedto maternal and neonatal health, withthe result that the poor have beeneffectively denied access to clinics andhospitals, especially in rural areas.This may be due to the absence of such a facility, the poor quality andcondition of health centres and hospi-tals, the lack of skilled health person-nel or personnel with low skills levels,or the existence of user fees and othercosts that the poor cannot afford. Thecontinuum of care concept refers notonly to the needs of mothers and


A child born in a least developed country is almost 14 times

more likely to die during the first 28 days of life than one born

in an industrialized country.


27/168


Nigeria is Africa’s most populous country, with 148 millioninhabitants in 2007, 25 million of them under age five. Withalmost 6 million births in 2007 – the third highest number inthe world behind India and China – and a total fertility rate

of 5.4, Nigeria’s population growth continues to be rapid inabsolute terms.

In addition to its sizeable population, Nigeria is known forits vast oil wealth. Nonetheless, poverty is widespread;according to the latest World Development Indicators 2007 ,published by the World Bank, more than 70 per cent of Nigerians live on less than US$1 per day, impairing theirability to afford health care.

Poverty, demographic pressures and insufficient investmentin public health care, to name but three factors, inflate lev-els and ratios of maternal and neonatal mortality. The latestUnited Nations inter-agency estimates place the 2005 aver-

age national maternal mortality ratio at 1,100 deaths per100,000 live births and the lifetime risk of maternal death at1 in 18. When viewed in global terms, the burden of mater-nal death is brought into stark relief: Approximately 1 inevery 9 maternal deaths occurs in Nigeria alone.

The women who survive pregnancy and childbirth may facecompromised health; studies suggest that between 100,000and 1 million women in Nigeria may be suffering fromobstetric fistula. Neonatal deaths in 2004 stood at 249,000,according to the latest World Health Organization figures,with 76 per cent taking place in the early neonatal period(first week of life). Inadequate health facilities, lack of trans-portation to institutional care, inability to pay for servicesand resistance among some populations to modern healthcare are key factors behind the country’s high rates of maternal, newborn and child mortality and morbidity.

Disparities in poverty and health among Nigeria’snumerous ethnolinguistic groups and between its statesare marked. Poverty rates in rural areas, estimated at64 per cent in 2004, are roughly 1.5 times higher than theurban-area rate of 43 per cent. Moreover, the poverty ratein the north-east region, which stands at 67 per cent,is almost twice the level of 34 per cent in the moreprosperous south-east.

Low levels of education, especially among women, anddiscriminatory cultural attitudes and practices are barriersto reducing high maternal mortality rates. A study at theJos University Teaching Hospital in the north-central regionshows that nearly three quarters of maternal deaths in 2005occurred among illiterate women. The mortality rate amongwomen who did not receive antenatal care was about 20times higher than among those who did. Of the several eth-nic groups represented among the patients, Hausa-Fulaniwomen accounted for 22 per cent of all deliveries and 44per cent of all deaths. The Hausa-Fulani represent the

largest ethnic group in northern Nigeria and are thereforecritically affected by this region’s higher poverty rates.

Cultural attitudes and practices that discriminate against

women and girls contribute to maternal mortality and mor-bidity. Child marriage and high rates of adolescent birthsare commonplace across Nigeria, exposing girls andwomen of reproductive age to numerous health risks.

Given these complex realities, developing strategies toaccelerate progress on maternal and newborn healthremains a considerable challenge. But the Government of Nigeria, together with international partners, is attemptingto meet the challenge. I

sowc09 fullreport en

Documents