Written by Countdown researchers Jennifer Requejo of Global Financing Facility and Johns Hopkins Bloomberg School of Public Health, Aluisio Barros of the International Center for Equity in Health, Federal University of Pelotas, and Cheikh Faye of the African Population and Health Research Center, Nairobi, Kenya
As global experts and leaders gather this May for the International Maternal Newborn Health Conference (IMNHC) in Cape Town, it is essential to shine a light on the urgent action required to improve maternal and newborn health. According to the latest United Nations estimates, progress in reducing maternal, stillbirth and neonatal mortality has stagnated in recent years (1, 2, 3). Approximately 4.5 million deaths occur every year around the time of childbirth (about 287,000 maternal deaths, 2.3 million newborn deaths, and 1.9 million stillbirths), and most happen in sub-Saharan Africa and conflicted affected contexts (1, (2, 3). The proportion of all births is also increasing in sub-Saharan Africa because it is the only region where fertility and population growth remain high (4).
The message is clear about prioritizing sub-Saharan Africa and fragile settings for action, but these statistics do not tell the whole story of progress and the interconnectedness between maternal, stillbirth, and neonatal mortality. We know that most maternal and neonatal deaths and over 45 percent of stillbirths occur between the start of labor and first 24 hours after childbirth (1, 2). Alignment of the Every Newborn Action Plan and Ending Preventable Maternal Mortality targets reflects increased awareness that progress assessments should be done using an integrated approach (5, 6). To this end, the new report Born Too Soon: Decade of Action on Preterm Birth highlights the need for stronger investments in the integration of high-quality maternal and newborn care, centered around women and families (7).
A mortality transition model developed by Countdown to 2030 – which includes five phases based on thresholds for maternal, stillbirth, and neonatal mortality – facilitates simultaneous examination of these three statistics and their comparison with drivers of maternal and newborn health (8). Analysis of data from 151 countries using the model found distinctive characteristics associated with each phase. Countries in the highest mortality phases typically have high burdens of death due to infectious diseases and peripartum causes, high fertility rates, and low coverage of health services. Countries in the lowest mortality phases are typified by below replacement fertility levels and universal coverage of hospital births (8). Country transition from higher to lower mortality phases tends to occur through equitable increases in intervention coverage, a shift from deliveries in lower-level facilities to hospitals, and fertility rate reductions.
The transition model is most useful for planning when accompanied by equity analyses. All pregnant women and their babies need high quality antenatal, skilled delivery, and postnatal care. Yet, many miss out on this care. Findings from an analysis of 43 countries with survey data since 2015 found wide ranges across countries in the percentage of mother-baby dyads who received all three of these interventions from a low of 17% in Niger to universal coverage in Belarus (9)(10). In almost all 43 countries, the wealthiest mother-baby dyads were more likely to have received all three interventions compared to the poorest (10).
Access to essential services is not enough. Positive birth experiences and healthy outcomes depend upon the quality of services received. Analysis of a composite antenatal care measure (11) on the timing of the first antenatal care visit, visit frequency, and content of care in 63 countries shows that, on average, the percentage of pregnant women receiving good quality care was around 57% with huge variation across countries (12). More than 95% of women received good care in Cuba, Dominican Republic, Maldives, and Thailand whereas only about 20% received good care in Afghanistan, Ethiopia, Niger, and Papua New Guinea (12).
Contrary to a “grand convergence” – a theory proposed at the start of the Sustainable Development Goal era that anticipated rapid declines in maternal and child mortality and a closing in the mortality gap between rich and poor countries – the evidence shows persistent high mortality and coverage inequalities in some countries (13). Accelerated efforts are needed to combat this situation by improving health system capacity to provide high quality care for every mother-baby dyad. Specific strategies should be tailored to the status of each country’s health system, mortality levels, and available resources. These strategies should be informed by comprehensive examination of maternal, newborn, and stillbirth data at local and national levels. The mortality transition model, co-coverage indicator, and composite measure are examples of tools that can support integrated analyses. However, these tools depend upon availability of high-quality data and well-functioning country health information systems. More investments in civil and vital statistics registration systems, for example, are essential for countries to track trends in births and deaths. Efforts to shore-up routine health information systems, health workforce statistics, and logistics and supply chain systems are also critical for countries to have timely information for guiding policies and programs. And sufficient resources are needed for periodic household surveys and health facility assessments, so countries have reliable information on population-level coverage and facility-readiness to deliver quality care.
Improving maternal and newborn health will require attention to human rights and health system reforms that ensure where you live does not determine whether you live. Babies who survive childbirth will become the next generation of parents only if their health is protected throughout their lives. Achieving this goal entails designing health systems equipped to provide continuous care, inclusive strategies, and provisions that enable individuals to decide when or if they want to start a family and desired family size. These efforts hinge upon reliable data to inform their development. Strengthening country health information systems and capacity to use data is an imperative we cannot ignore.
Acknowledgements: We would like to thank Dr Ties Boerma and Dr Peter Hansen for their review and comments on this article.
- Maternal, Stillbirth and Neonatal Mortality Transition: Data Sheet
- Maternal and Newborn Health Co-Coverage: Data Sheet
- Composite Indicator of Antenatal Care: Data Sheet 20232023ancq
- Trends in maternal mortality 2000 to 20202: estimates by WHO, UNICEF, UNFPA, World Bank Group and UNDESA/Population Division. Geneva: World Health Organization, 2023. Licence: CC BY-NC-SA 3.0 IGO. https://www.who.int/publications/i/item/9789240068759
- United Nations Inter-Agency Group for Child Mortality Estimation (UNIGME), Never Forgotten: The situation of stillbirth around the globe, United Nations Children’s Fund, New York, 2023.
- United Nations Inter-agency Group for Child Mortality Estimation (UNIGME), Levels & Trends in Child Mortality: Report 2022, Estimates developed the United Nations Inter-agency Group for Child Mortality Estimation, United Nations Children’s Fund, New York, 2023.
- United Nations Population Division, World Population Prospects, the 2022 revision. https://www.un.org/development/desa/pd/sites/www.un.org.development.desa.pd/files/wpp2022_summary_of_results.pdf.
- Every Newborn Action Plan Initiative, https://www.who.int/initiatives/every-newborn-action-plan. Accessed April 14, 2023.
- Ending Preventable Maternal Mortality, https://www.who.int/initiatives/ending-preventable-maternal-mortality. Accessed April 14, 2023
- PMNCH, WHO, UNICEF, UNFPA. (2023). Born too soon: decade of action on preterm birth. World Health Organization. In press.
- Boerma T, Campbell O, Amouzou A, Blumenberg C, Blencowe H, Moran A, Lawn JE, Ikilezi G, Maternal mortality, stillbirths, and neonatal mortality: A transition model based on analyses of 151 countries. The Lancet Global Health (in press).
- Countdown to 2030, Maternal and newborn health in low- and middle-income countries: A brief assessment of mortality, coverage and policies. Prepared for the AlignMNH opening forum, 20-21 April 2021. https://www.countdown2030.org/wp-content/uploads/2021/04/Report-AlignMNH-Final-19Apr2021-1.pdf. Accessed April 14, 2023.
- Countdown data sheet: Maternal newborn health co-coverage (in press).
- Arroyave L, Saad GE, Victora CG, Barros AJD, A new content-qualified antenatal care coverage indicator: Development and validation of a score using national health surveys in low- and middle-income countries. J Glob Health, 2022;11:1-9. Doi:10.7189/jogh.11.04008.
- Countdown data sheet: Antenatal care quality index (in press)
- Jamison et al., Global Health 2035: a world converging within a generation. The Lancet, vol. 382, (9908), 1898-1955.