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Moving forward
1
Partnership for Maternal, ABSTRACT
Newborn & Child Health, In this article, we draw on available evidence from Key messages
Geneva, Switzerland
2
Institute for International Countdown to 2015 and other sources to make the case
Programs, Johns Hopkins for keeping women and children at the heart of the next
▸ Maternal and child mortality has dropped
Bloomberg School of Public development agenda that will replace the Millennium
Health, Baltimore, Maryland, nearly 50% since the 1990s. However, 17,000
Development Goal (MDG) framework after 2015. We
USA children are still dying every day from
3 provide a status update on global progress in achieving
Center for Global Child preventable causes, stillbirth rates have not
Health, Hospital for Sick MDGs 4 and 5, reduce child mortality and improve
measurably changed, and numerous women
Children, Toronto, Ontario, maternal health, respectively – showing that although
are dying or suffering from acute or chronic
Canada considerable mortality reductions have been achieved,
4
Center of Excellence in illnesses due to childbirth.
many more women’s and children’s lives can be saved
Women and Child Health, Aga ▸ Malnutrition accounts for nearly half of all
Khan University, Karachi, every day through available, cost effective interventions.
child deaths, and places children at risk of both
Pakistan We describe key underlying determinants of poor
short and long term negative developmental
maternal and child health outcomes and the need for
Correspondence to and health outcomes. Poor nutrition prior to
well-coordinated, comprehensive approaches for
Professor Zulfiqar A Bhutta, and during pregnancy is detrimental to a
addressing them such as introducing a combination of
Robert Harding Chair in Global woman’s own health and increases her risk of
Child Health & Policy, Center nutrition specific and sensitive interventions to reduce
delivering a low birth weight baby.
for Global Child Health, pervasive malnutrition, targeting interventions to the
Hospital for Sick Children,
▸ Effective preventive and treatment interventions
underserved to reduce inequities in access to care, and
Toronto, Ontario, Canada M5G across the continuum of care for reproductive,
increasing women’s social status through improved
0A4; maternal, newborn and child health and
zulfiqar.bhutta@sickkids.ca access to education and income-earning opportunities.
nutrition are available, and, if implemented at
In the wake of population momentum and emergencies
scale, could save thousands of women’s and
Received 18 November 2014 such as the recent ebola outbreak and other
Revised 9 December 2014 children’s lives including the poorest.
humanitarian crises, health systems must be
Accepted 10 December 2014 ▸ During this final year of the MDGs and the
strengthened to be able to respond to these pressures.
transition period to the SDG era, it is
In conclusion, we underscore that the unfinished
imperative that we stay the course on maternal
business of women’s and children’s health must be
and child survival so that the momentum
prioritized in the days ahead, and that ending
gained is not lost. This includes a continued
preventable maternal and child deaths is not only a
emphasis on supporting the continuum of care
moral obligation but is achievable and essential to
through effective policies and programs that
sustainable development moving forward.
create a supportive environment enabling
families to be able to access needed care
without risking financial catastrophe and for
children to develop into healthy, productive
The end of the period of the Millennium
adults.
Development Goals (MDGs) is fast approaching,
▸ The RMNCH community must effectively
with only a little more than 1 year to go. In 2015,
articulate how the well-being of women and
the world will take stock of what has been
children rests at the nexus of all the proposed
achieved, and a new global framework to reduce
SDGs, and to push for the adoption in the next
extreme poverty will be introduced building on the
global framework of feasible targets for ending
lessons learned from the past 15 years. The current
preventable maternal, newborn and child
MDGs will be replaced by a set of sustainable devel-
deaths. Our future depends on it.
opment goals (SDGs) with a more limited focus on
health. The exact nature of global ambition captured
in the SDGs and accompanying targets will become
apparent by September 2015. It is imperative that which focuses on improvement of maternal health
the global community maintains the momentum for through a reduction of maternal mortality by three-
women’s and children’s health moving forward to quarters and universal access to reproductive
2015 and beyond, placing women and children health.1 Although substantial progress has been
firmly where they belong at the centre of the next, achieved in reducing maternal and child mortality,
more expansive development agenda. the world is off track for reaching MDGs 4 and 5
The MDGs, established in 2000, committed the and the rates of reduction for both in many coun-
global community to achieve a set of targets by tries is much slower than anticipated with some
To cite: Requejo JH, 2015, relative to a baseline of 1990. At the core of remarkable exceptions. The number of deaths in
Bhutta ZA. Arch Dis Child the MDGs are MDG 4, which calls for a reduction children under 5 years of age has declined from
2015;100(Suppl 1):s76–s81. of child mortality by two-thirds, and MDG5, around 12.7 million in 1990 to around 6.3 million
s76 Requejo JH, et al. Arch Dis Child 2015;100(Suppl 1):s76–s81. doi:10.1136/archdischild-2013-305737
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Moving forward
Requejo JH, et al. Arch Dis Child 2015;100(Suppl 1):s76–s81. doi:10.1136/archdischild-2013-305737 s77
Downloaded from http://adc.bmj.com/ on September 14, 2016 - Published by group.bmj.com
Moving forward
‡Note that these are AARI estimated by the writing team based on the last two available estimates for exclusive breastfeeding in the Unicef Global database. Formal AARIs from Unicef/WHO are not available at this time.
higher-order and other high-risk pregnancies.18 19 The
Countdown equity analyses (figure 4) send a clear message that
required‡
coverage levels for a set of proven interventions among the
wealthiest often far exceeds coverage among the poor.4 17
Looked at more positively, the attainment of high levels of
37% in 2000, 41% in 2012
No progress (globally, 8%
Current pace projects 130
No
No
No
No
No
middle-income countries.
Required average annual rate
2.11% AARI
5.2% AARR
JMC, the Joint Child Malnutrition data set from UNICEF, World Bank and WHO; WHA, World Health Assembly.
10%
50%
7%
15%
38%
7%
8%
2008–12
2008–12
(years)
2011
2012
2012
Wasting
Moving forward
Figure 3 The graph showing continuum of care for RMNCH (source: Countdown 2014 report).
refugee populations and turns back the clock on progress in Numerous reports indicate that many high burden countries
improving maternal and child health.4 22 23 We may also are suffering from health workforce crises and decrepit supply
require strategies for action to support and protect RMNCH chain systems that result in chronic stock-outs of essential drugs,
activities in conflict zones and fragile health systems, natural making it impossible for available staff to provide quality care.24
disasters as well as outbreaks. Innovations such as cell phones, task shifting practices and
expansion of community outreach services are promising
approaches to helping countries overcome these challenges, but
more investment by governments and their partners is needed
to make sure countries are able to provide the basic packages of
services needed across the RMNCH continuum of care.22 23 25
Financial schemes such as cash transfers and the removal of user
fees are also essential for increasing the ability of all families to
afford care.
According to the WHO, ‘Social determinants of health are
the conditions in which people are born, grow, live, work and
age; these circumstances are shaped by the distribution of
money, power and resources at global, national, and local
levels’.26 The poorest populations tend to be the ones with the
least access to care and the highest exposure to infectious dis-
eases and harmful environmental conditions such as overcrowd-
ing, air pollution and unimproved water and sanitation facilities.
These inequalities are likely to worsen in the wake of population
pressures and the havoc produced by climate change. Pervasive
gender inequalities and violence against women inhibit women’s
life opportunities and ability to best care for themselves and
their families. Addressing such deep rooted issues requires
greater incorporation of human rights and social protection
measures into national legal frameworks, specific policies and
plans, and long-term investments in girls’ education. Gender
mainstreaming is another approach that has been used by policy
Figure 4 Graph for Composite Coverage Index by wealth quintile makers when developing budgets and national plans to improve
(source: Countdown 2014 report). women’s social status.
Requejo JH, et al. Arch Dis Child 2015;100(Suppl 1):s76–s81. doi:10.1136/archdischild-2013-305737 s79
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Moving forward
POST 2015—ACCELERATING THE AGENDA FOR WOMEN featured with associated indicators that promote increased
AND CHILDREN coverage of essential interventions across all population
The figures above are a stark reminder that the core business of groups. Such targets will help drive coordinated action and
the MDGs is unfinished and the health of women and children accountability for progress.
must remain at the heart of the post-2015 Development 3. Good nutrition across the life course and particularly during
Agenda. In this final year of the MDGs and during the transi- pregnancy and the first 2 years of life must be a priority
tion to the SDG era, we must continue working towards achiev- aspiration. Nutrition specific interventions need to be com-
ing high levels of equitable and effective coverage for proven plemented by nutrition-sensitive approaches that improve
interventions across the RMNCH continuum of care. This access to food, clean water and improved sanitation and
means pushing for integration of services (ie, HIV and malaria social protection measures so that children can survive and
services with maternal and child care services) to best leverage thrive.
resources and to maximise the impact, quality and efficiency of 4. Establish an independent accountability mechanism for
care provided. It also means developing policies and pro- women’s and children’s health that pushes the global com-
grammes that recognise the tight interlinkages between mater- munity and governments to improve data collection and the
nal, newborn and child survival and that are pro-poor, so use of evidence for decision making. Good data are central
inequities are steadily tackled as interventions are brought to to the efficient allocation of resources and for identifying
scale. Implementation of the Every Newborn Action Plan and and remedying where progress is lagging. Baseline data must
the Global Action Plan for the Prevention of Pneumonia and be collected now for the post-2015 era.
Diarrhoea is needed to strengthen country focus on the new 5. The international community must be poised to promptly
born within existing maternal, child and reproductive health respond to political and environmental crises such as negative
plans27 and on combatting these two diseases that exact a huge effects of climate change to mitigate steep reversals in survival
toll of child deaths every year. Support for family planning is and help countries rebuild. This includes emphasising good
essential for empowering women to have more control over governance and dialogue to reduce the risk of armed conflict
their own fertility and for improving maternal and newborn sur- and civil unrest leading to devastation of the healthcare and
vival—another strategy that embraces the principle of survival educational systems as well as basic infrastructure. Stability is
convergence and the integrity of the maternal–infant dyad. It the cornerstone of development, enabling countries to focus
will also be important to expand beyond survival to focusing resources on this and the next generation.
attention on enhancing child and adolescent development and We are at the cusp of finalising the SDGs post 2015 for which
reducing morbidity and the burden of poor mental health. an extensive and inclusive consultative process has been held for
There are still opportunities to influence the defining of the well over 2 years. It is quite likely that these goals, targets and
new goals and targets in the SDG framework. Although there indicators will include a broad range of aspirations for global
will likely be only one overarching health goal, it is critical that development and inclusion of hitherto neglected areas such as
targets for ending preventable maternal, newborn and child human rights, issues of environment and climate change and
deaths and stillbirths are included and clustered together so that non-communicable diseases. We sincerely hope that women and
the concept of the continuum of care remains intact. A method children will remain at the core of the SDGs; it is a global
and a process for disaggregating the data for the health-related agenda that is far from complete and we have a unique oppor-
targets need to be agreed upon so that the principle of equity is tunity to achieve reductions in preventable maternal and child
not lost. Feasible targets for mortality reduction are also critical mortality within a lifetime.
for holding countries to account for progress. Work is also
Acknowledgements We would like to thank members of the Countdown
essential in describing the pathways through which other
Scientific Review Group, Jennifer Bryce, Cesar Victora, Peter Berman, Joy Lawn, Holly
sectors, such as education and agriculture, ultimately impact the Newby, Andres de Francisco and Monica Fox, for their comments on the paper draft
health of women and children so that we can achieve each of and for giving us permission to use key figures and build on the messages from the
the stepping stones along these pathways and develop better latest Countdown to 2015 analyses.
coordinated multisectoral activities with clearly defined roles Competing interests None.
and responsibilities. Provenance and peer review Commissioned; internally peer reviewed.
Echoing the independent Expert Review Group recommenda-
tions in its latest report, an independent accountability mechan-
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Notes