Countdown to 2015 for maternal, newborn, and child survival: the 2008 report on tracking coverage of interventions

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1 Countdown to 215 for maternal, newborn, and child survival: the 28 report on tracking coverage of interventions Countdown Coverage Writing Group,* on behalf of the Countdown to 215 Core Group Summary Background The Countdown to 215 for Maternal, Newborn, and Child Survival initiative monitors coverage of priority interventions to achieve the Millennium Development Goals (MDG) for reduction of maternal and child mortality. We aimed to report on 68 countries which have 97% of maternal and child deaths worldwide, and on 22 interventions that have been proven to improve maternal, newborn, and child survival. Methods We selected countries with high rates of maternal and child deaths, and interventions with the most potential to avert such deaths. We analysed country-specific data for maternal and child mortality and coverage of selected interventions. We also tracked cause-of-death profiles; indicators of nutritional status; the presence of supportive policies; financial flows to maternal, newborn, and child health; and equity in coverage of interventions. Lancet 28; 371: *Members listed at end of paper Correspondence to: Jennifer Bryce, 281 Danby Road, Ithaca, NY 1485, USA Findings Of the 68 priority countries, 16 were on track to meet MDG 4. Of these, seven had been on track in 25 when the Countdown initiative was launched, three (including China) moved into the on-track category in 28, and six were included in the Countdown process for the first time in 28. Trends in maternal mortality that would indicate progress towards MDG 5 were not available, but in most (56 of 68) countries, maternal mortality was high or very high. Coverage of different interventions varied widely both between and within countries. Interventions that can be routinely scheduled, such as immunisation and antenatal care, had much higher coverage than those that rely on functional health systems and 24-hour availability of clinical services, such as skilled or emergency care at birth and care of ill newborn babies and children. Data for postnatal care were either unavailable or showed poor coverage in almost all 68 countries. The most rapid increases in coverage were seen for immunisation, which also received significant investment during this period. Interpretation Rapid progress is possible, but much more can and must be done. Focused efforts will be needed to improve coverage, especially for priorities such as contraceptive services, care in childbirth, postnatal care, and clinical case management of illnesses in newborn babies and children. Funding Bill & Melinda Gates Foundation, UK Department for International Development, Norwegian Agency for Development Cooperation, Partnership for Maternal, Newborn and Child Health, Save the Children US and UK, United Nations Children s Fund, United Nations Population Fund, and World Health Organization. Introduction The Countdown to 215 collaboration aims to track coverage for interventions that are essential to attainment of Millennium Development Goals (MDG) 4 and 5 and elements of MDGs 1, 6, and 7. 1 Countdown to 215 represents a common evaluation framework 1 for tracking coverage of proven interventions and measures of mortality and nutrition in countries with the highest burden of mortality in mothers and children. 2 The first round of the Countdown, 3,4 in 25, reported on 6 countries and 17 interventions, and focused on child survival. The Countdown process has since evolved 4 from attention to the individual child or mother to focus on the continuum of care from before pregnancy, through to pregnancy, childbirth, and the postnatal period, and on to early childhood. 5 Tracking of single, biologically based interventions was complemented by inclusion of broader approaches or packages, such as antenatal or postnatal care, that can serve as platforms for delivery of multiple interventions. The list of priority countries was also expanded, from those with the highest burden of mortality in children to those with high burdens of either maternal or child mortality. The aim of Countdown has remained unchanged: to assess every 2 or 3 years until 215 the target date for the MDGs whether proven interventions and approaches are reaching more women, newborn babies, and children, and especially the poorest families. 3 The 28 Countdown meeting is in Cape Town, linked to the Inter-Parliamentary Union meeting. 6 Countdown is independent, but has a wide ownership, incorporating UN agencies and civil society, individual researchers, and development workers from the country, regional, and international levels. Its mechanisms are mainly international publications and conferences, linked to national action. Countdown is designed to be action-oriented, in that it amalgamates the information needed to assess progress and to work collectively to Vol 371 April 12,

2 Azerbaijan Turkmenistan Tajikistan North Korea Mexico Guatemala Haiti Peru Bolivia Brazil Senegal Gambia Guinea Bissau Guinea Sierra Leone Liberia Morocco Cote d Ivoire Ghana Togo Benin Equatorial Guinea Gabon Congo Egypt Mauritania Mali Niger Chad Burkina Faso Eritrea Yemen Sudan Djibouti Nigeria Central African Ethiopia Republic Cameroon Somalia Democratic Kenya Uganda Republic of Rwanda the Congo Burundi Angola Zambia Tanzania Zimbabwe Botswana Iraq Malawi Mozambique Madagascar Afghanistan Iran Pakistan China Nepal Bangladesh India Burma Laos Vietnam Cambodia Indonesia Philippines Papua New Guinea South Africa Swaziland Lesotho Priority countries in 25 and 28 Countries added in the Countdown 28 Figure 1: The 28 countdown priority countries accelerate gains and address shortcomings. An important outcome of Countdown is identification of gaps in data and evidence, to thereby catalyse development of methods and instruments to better assess coverage over time. The Countdown process builds on and complements other important efforts to track progress toward the MDGs. 3 It consists of individual country profiles, with selected information about the demographic and epidemiological contexts of coverage and the key determinants of coverage. We aimed to present the findings for progress in coverage in selected countries in the context of trends in mortality. Other papers in this special issue also relate to progress in health policy and the strengthening of health systems; 7 overseas development assistance for maternal, newborn, and child health and nutrition; 8 and inequities in coverage across multiple interventions. 9 Methods Selection of priority countries and interventions We focused on 68 priority countries that together had 97% of maternal and child deaths in 25 (figure 1). Details on the inclusion criteria for countries are in our technical report. 1 Inclusion criteria for interventions were (1) internationally accepted peer-reviewed evidence of mortality reduction in mothers, newborn babies, or children younger than 5 years of age, or evidence of use in most priority countries as a package or platform for providing at least one intervention (eg, antenatal care, package can deliver tetanus toxoid immunisation and identification and management of sexually transmitted diseases); (2) feasibility for implementation to universal coverage levels in low-income countries; and (3) availability (or expected availability within 3 years) of nationally representative data based on a standard indicator for coverage in most priority countries. We convened a working group on indicators and coverage data, which reviewed new evidence about the interventions that were included in the 25 Countdown to decide whether any additional interventions or delivery platforms should be included in We focused on interventions that have the potential to avert the greatest number of deaths in mothers, newborn babies, and children. Interventions and definitions of the coverage indicators for the 28 Countdown are in the technical report. 1 We defined coverage as the proportion of people in a population who need a service and receive it. 3 We defined women as those aged years; mothers as pregnant women or those who had given birth; children as those from birth until 59 months (ie, younger than 5 years of age); and newborn babies as infants aged 28 days. 1 Data sources and analysis None of the 68 priority countries had health-information systems that were able to produce coverage estimates for Vol 371 April 12, 28

3 all the standard indicators. 1 We used country-specific estimates of mortality in children younger than 5 years from tables prepared by UNICEF. 11 The methods and limitations associated with these estimates are described elsewhere. 12 We assessed progress toward MDG 4 by determining whether the average annual rate of reduction in mortality in children younger than 5 years between 199 and 26 was greater than or equal to the rate that would be needed between 27 and 215 to achieve the MDG. 11 We obtained country-specific cause-of-death profiles for children from WHO databases, 13,14 with updated neonatal cause-of-death estimates for 25 based on methods used in We assessed indicators of nutritional status, and adjusted country-specific estimates to incorporate WHO s new growth standards. 16 Estimates of the prevalence of low birthweight were adjusted for high levels of under-reporting, especially in sub-saharan Africa. 17 We used 25 data for country-specific estimates of maternal mortality per 1 livebirths. 18 Because the large margins of uncertainty around these estimates precluded trend analysis, 19 maternal mortality ratios were classified as either very high (55 or more); high (3 549); moderate (1 299); or low (below 1). 2 We used regional estimates from WHO s systematic review for maternal cause-of-death profiles. 2 With few exceptions, we obtained country-specific indicators for coverage of the Countdown interventions from population-based surveys in the 68 priority countries usually either the UNICEF-supported multiple-indicator cluster surveys (MICS) 21 or the USAID-supported demographic and health surveys (DHS). 22 These data were available in global databases maintained by UNICEF. 23 The exceptions were interventions for which data collection and analysis of coverage indicators were not yet routine or harmonised eg, special analyses for postnatal visits within 2 days of birth were undertaken by Save the Children, and unmet need for family planning by the United Nations Population Fund (UNFPA). In addition, coverage estimates for vaccinations, vitamin A supplementation, and prevention of mother-to-child transmission of HIV were obtained from routine programme data and data collected through household surveys. We summarised indicators of coverage for countries in which they were relevant (eg, only 45 of the 68 countries had endemic malaria, defined here as documented risk of Plasmodium falciparum transmission nationwide and throughout the year). 24 The country profiles in the Countdown report 1 present coverage for countries with malaria risk in defined geographic areas. We assumed that antiretroviral treatment for pregnant women with HIV, to prevent mother-to-child transmission of the virus, was needed in all Countdown priority countries. The latest available coverage data and methods for estimating coverage for the use of antiretroviral treatment for the prevention of mother-to-child transmission of HIV were based on harmonised estimates developed by UNAIDS, UNICEF, and WHO. These data were based on denominators derived from unpublished HIV estimates for 27 by UNAIDS and WHO, and are more recent than those in the State of the World s Children Report Data for the prevalence of caesarean sections were from analysis of demographic and health surveys. 22 To construct summary estimates for each of the coverage indicators, we included point estimates from data collected between 2 and 26. Exceptions were estimates for coverage for vitamin A supplementation (which were based on estimates for 25) and coverage of vaccines for measles; diptheria, pertussis, and tetanus (DPT3); Haemophilus Influenzae (Hib3); and neonatal tetanus protection (which refer to estimates for 26). 1 Role of the funding source Some of the funding for this work came from the regular budgets of the authors institutions, primarily in the form of in-kind contributions of staff time. These sponsors were therefore involved through their staff in the analysis and interpretation of the data contained in the country profiles, in the writing of the report, and in the decision to submit the paper for publication. However, the views expressed in this report are those of the authors and do not necessarily represent the policies or views of their institutions. Results The most important Countdown findings are presented as country profiles. Figure 2 shows the country profile from Benin to illustrate how the coverage data are complemented by information that is useful for their interpretation, such as policy and financial flows. We selected Benin as an example because it was the first country profile (in alphabetical order) in the report for which data were available for all major indicator categories such as malaria and HIV. The full 28 Countdown report 1 provides information for the 68 countries and a detailed analysis of the main trends and issues. These can be summarised as five themes (panel), all of which have implications for continuing efforts to accelerate progress towards the health MDGs. The first theme was the inadequate progress towards reduction of maternal and child mortality. Table 1 shows UNICEF s analysis of trends in mortality in the 68 Countdown priority countries and their progress towards the MDG 4 target, which is to reduce mortality in children younger than 5 years by two-thirds between 199 and 215. The number of child deaths worldwide has been reduced to fewer than 1 million per year, although the relative proportion in Africa (now over 5%) continued to rise. 11 Data for the 28 Countdown cycle showed that 16 of 68 countries (24%) were on track to meet MDG 4. These included seven countries (Bangladesh, Brazil, Egypt, Indonesia, Mexico, Nepal, and the Philippines) that had Vol 371 April 12,

4 Demographics Total population 8 76 (26) Total population younger than 5 years (26) Births 358 (26) Birth registration 7% (26) Child mortality rate (per 1 livebirths) 148 (26) Infant mortality rate (per 1 livebirths) 88 (26) Neonatal mortality rate (per 1 live births) 38 (2) Deaths in children younger than 5 years 53 (26) Maternal mortality ratio (per 1 livebirths) 84 (25) Lifetime risk of maternal death 1 in 2 (25) Total maternal deaths 29 (25) Deaths per 1 livebirths Child mortality rate MDG target Causes of deaths in children Globally more than a third of child deaths are attributable to undernutrition Causes of neonatal deaths Measles 5% Other Injuries % Malaria 2% 27% HIV/AIDS 2% Diarrhoea 17% Pneumonia 21% Neonatal 25% Diarrhoea 2% Tetanus 4% Other 5% Congenital 8% Asphyxia 19% Preterm birth 28% Infection 34% Intervention coverage for mothers, newborn babies, and children Nutrition Underweight children younger than 5 years Stunting prevalence (moderate and severe) Wasting prevalence (moderate and severe) Prevalence of underweight children 22% 21 2% 44% (26) 9% (26) Exclusively breastfed infants younger than 6 months (%) Complementary feeding rate (6 9 months) Low birthweight incidence Exclusive breastfeeding % (26) 16% (21) 2 1% % 7% 56 Children aged 6 59 months who received vitamin A (%) Vitamin A supplementation 98% 94% 94% 1% 85% 96% 95% 95% 89% 92% At least one dose Two doses Child health Children immunised (%) Immunisation 93% 93% 89% 4 Measles vaccine 2 Three doses DPT vaccine Three doses Hib vaccine Children younger than 1 years who had insecticide-treated nets (%) Malaria prevention 2% 7% HIV-positive pregnant women who received antiretroviral drugs (%) Prevention of mother-to-child transmission of HIV 27% 25 53% 26 Children younger than 5 years with diarrhoea who had oral rehydration treatment or increased fluids (%) Diarrhoeal disease treatment 23% 42% Febrile children younger than 1 years who received antimalarial drugs (%) Malaria treatment 6% 21 54% 26 Children younger than 5 years with suspected pneumonia (%) Pneumonia treatment Children taken to appropriate health provider Children given antibiotics (data not available) 32% 35% Figure 2: Country profile for Benin The profiles for all 68 priority countries are in the Countdown report, with details of sources and methods for each data type. 1 DPT=diphtheria, pertussis, and tetanus toxoid. HiB=Haemophilus influenzae type B Vol 371 April 12, 28

5 Maternal and newborn health Causes of maternal deaths Coverage along the continuum of care Unmet need for family planning 27% (21) Antenatal visits for woman (four or more visits) 62% (21) Intermittent preventive treatment for malaria 3% (26) Rate of caesarean section (total*) 3% (21) Rate of caesarean section (urban) 6% (21) Rate of caesarean section (rural) 2% (21) Early initiation of breastfeeding (within 1 hour of birth) 49% (21) Postnatal visit for baby (within 2 days for home births).. *Target is a minimium of 5% and maximum of 15% Regional estimates for Africa, Obstructed labour 4% Abortion 4% Anaemia 4% Hypertensive Disorders 9% Sepsis or infections, Including AIDS 16% Haemorrhage 34% Contraceptive prevalence rate Antenatal visit (one or more) Skilled attendant at birth Postnatal care Exclusive breastfeeding Measles 17% 88% 78% 7% 89% Pre-pregnancy Pregnancy Birth Neonatal period Infancy Other causes3% Women aged years attended at least once by a skilled health provider during pregnancy (%) Antenatal care 8% 81% 66 88% Livebirths attended by skilled health personnel (%) Skilled attendant at delivery 6% 66% 78% Newborn babies protected against tetanus (%) Neonatal tetanus protection 94% Water and sanitation Water Sanitation Proportion of population using improved drinking water sources (%) % 57% 63% 57% 78% 67% Proportion of population using improved sanitation facilities (%) % 32% 33% 12% 11% 2% Rural Urban Total Rural Urban Total Equity Policies Systems Coverage gap by wealth quintile Poorest Second poorest Third poorest Coverage gap Ratio (poorest/wealthiest) Difference (poorest wealthiest) Fourth Wealthiest poorest % % % % International Code of Marketing of Breastmilk Substitutes New formula for oral rehydration salts and zinc for management of diarrhoea Community treatment of pneumonia with antibiotics Integrated Management of Childhood Illnesses adapted to cover newborn babies ( 1 week of age) Costed implementation plan or plans for maternal, newborn, and child health available Midwives be authorised to administer a core set of lifesaving interventions Maternity protection in accordance with International Labour Organisation Convention 183 Specific notification of maternal deaths Yes Yes Partial Yes Yes Partial No Yes Financial flows and human resources Expenditure on health per person Proportion of total government expenditure spent on health Out-of-pocket expenditure as proportion of total expenditure on health Density of health workers (per 1 population) Official Development Assistance to child health (per child) Official Development Assistance to maternal and neonatal health (per livebirth) National availability of Emergency Obstetric Care services (proportion of recommended minimum) US$4 (27) 1% (27) 49% (27) 9 (24) US$7 (25) US$4 (25) 66% (22) Vol 371 April 12,

6 Mortality in children younger than 5 years Panel: Countdown to 215 themes from the data 1 Progress towards the Millennium Development Goals for maternal and child survival has been inadequate in the 68 priority countries, despite some hopeful signs 2 Coverage was uneven between countries and between interventions: interventions delivered through a scheduled approach had greater coverage than clinical-care interventions, which progressed more slowly and had higher levels of inequity 3 Coverage varied along the continuum of care, with especially low coverage for family planning, care in childbirth, postnatal care, and case management of illnesses in newborn babies and children 4 Opportunities have been missed to increase coverage by combined delivery of interventions throughout the continuum of care 5 The effectiveness of Countdown depends on the availability of reliable and timely data to guide decision making in countries MDG 4 target for 215 Average annual rate of reduction (199 26) Rate of reduction needed to meet MDG 4 (27 15) Progress towards the MDG 4 target Afghanistan % 12 1% No progress Angola % 12 2% No progress Azerbaijan % 1 2% Insufficient Bangladesh % 3 6% On track Benin % 9 7% Insufficient Bolivia % 4 2% On track Botswana % 2 7% No progress Brazil % 6% On track Burkina Faso % 12 1% No progress Burma % 9 7% Insufficient Burundi % 11 7% No progress Cambodia % 8 3% Insufficient Cameroon % 13 % No progress Central African % 12 3% No progress Republic Chad % 12 6% No progress China % 5 2% On track Congo % 14 5% No progress Congo, Democratic % 12 2% No progress Republic Côte d Ivoire % 1 1% Insufficient Djibouti % 8 9% Insufficient Egypt % 1 6% On track Equatorial Guinea % 14 3% No progress Eritrea % 4 6% On track Ethiopia % 6 6% Insufficient Gabon % 12 1% No progress Gambia % 8 8% Insufficient Ghana % 12 2% No progress (Continues on next page) been included in the 25 Countdown report and were judged to be on track for reduction of child mortality at that time. 4 Six of the remaining nine countries were included in the Countdown process for the first time in 28 (Bolivia, Eritrea, Guatemala, Laos, Morocco, and Peru). The other three countries (China, Haiti, and Turkmenistan) had been assessed at the time of the 25 Countdown and were not on track; therefore they had made demonstrable progress toward MDG 4 between 25 and 28. The achievement of China, as the world s largest country, is important, as are encouraging signs that several countries, many of which are in east Africa, have reduced mortality in children younger than 5 years since 25. Although these countries have not yet made enough progress to be on track to meet MDG 4, strategic rapid action could bring these countries on track. Table 2 presents the best available estimates of maternal mortality for the 68 countries, and therefore shows progress towards the MDG 5 target, which is to reduce the maternal mortality ratio by three-quarters between 199 and 215. However, we did not have sufficient data to assess trends in maternal mortality over time. Of the 68 priority countries, 56 (82%) had either high or very high rates of maternal mortality. Only three (Azerbaijan, China, and Mexico) had low maternal mortality. Lifetime risks for maternal death ranged from one in seven (in Niger) to one in 13 (in China). Sub-Saharan Africa as a whole accounted for 5% of the world s maternal deaths, and south Asia for another 45%. 2 In all the 41 countries in sub-saharan Africa that were priority countries in the 28 Countdown, maternal mortality was very high (32 countries) or high (nine countries). Tables 3 and 4 show the ten countries that made the greatest and the least progress toward MDG 4 and had the lowest and highest maternal mortality as a proxy for progress towards MDG 5. Of 26 countries with no reduction of mortality in children younger than 5 years, all had high or very high maternal mortality. None of the ten countries with either most progress in mortality in children younger than 5 years or lowest maternal mortality were in sub-saharan Africa. All ten with the least reduction in mortality in children younger than 5 years and nine of the ten countries with the highest maternal mortality were in this region. However, some countries had made progress towards reduction of child mortality but still had high maternal mortality; other countries had fairly low maternal mortality but had not made progress in reducing child mortality. Many of the countries in which mortality in children younger than 5 years increased between 199 and 26 had high HIV prevalence (eg, Botswana, Swaziland, Lesotho, South Africa, and Zimbabwe). HIV was also a factor in the countries with the highest absolute mortality in children younger than 5 years and in the 26 countries with no progress on mortality. 1 Ten of the 26 countries with no progress towards reduction of child mortality Vol 371 April 12, 28

7 were countries in conflict or post-conflict situations (eg, Chad and Congo). The second theme was that coverage of interventions was uneven between countries and between interventions (panel). Table 5 shows the average change in coverage of selected interventions in 68 countries that had at least two comparable data points since 2. The wide ranges in table 5 show differences in coverage for each intervention in the 68 countries that can also be seen from a comparison of coverage between individual country profiles. 1 Skilled attendance, oral rehydration therapy, and care-seeking for pneumonia increased by 2% or less compared with increases of 4 7% for tetanus immunisation in pregnancy, antenatal care (at least one visit), and insecticide-treated bednets. The third theme was that coverage varied across the continuum of care (panel). Figure 3 shows the median coverages for a selection of Countdown interventions along the continuum of care from before pregnancy to early childhood. 5 Services that can be scheduled notably antenatal care and immunisation had high coverage. Figure 3 emphasises three priority gaps in the continuum of care: contraceptive prevalence, skilled attendance at birth, and clinical case management of newborn and child illnesses. Contraceptive prevalence differs from other interventions in that the target coverage is not 1%, but varies according to desired family size. However, coverage was low, for both demand and supply reasons. Cultural and social factors inhibit use, but investment in family-planning programmes has declined, related to global policy swings. Reinvigoration of family planning is a highly cost-effective approach for reduction of maternal and child deaths. Skilled attendance at birth only reached half of women and babies in these 68 countries, and is affected by logistical factors (such as long distances to health facilities and high transport costs), and by supply factors, including non-existent or poor-quality services. The importance of postnatal care for both mothers and newborn babies has only recently been recognised fully. 5 Technical issues related to the programmatic aspects of postnatal care (timing, and provision at home and in facility settings) need further research and translation into guidelines and protocols. Clinical case management of child illnesses was another gap in coverage; these interventions reached only about a third of ill children. Coverage of care for illnesses in newborn babies was not routinely tracked. According to updated financial tracking analysis, Integrated Management of Childhood Illness (IMCI) continues to receive less than 1% of investment in maternal, newborn, and child health, so it is not surprising that progress is slow. 8 The fourth theme was that opportunities to increase coverage through combined delivery of interventions have been missed (panel). The Countdown process tracks progress in coverage of single interventions (eg, immunisation) and in coverage of platforms or packages Mortality in children younger than 5 years MDG 4 target for 215 Average annual rate of reduction (199 26) (eg, antenatal care, skilled attendance at birth, and postnatal care) that can be used to deliver many interventions. Separate tracking of single interventions has shown that coverage rates sometimes vary within Rate of reduction needed to meet MDG 4 (27 15) Progress towards the MDG 4 target (Continued from previous page) Guatemala % 4 5% On track Guinea % 8 % Insufficient Guinea-Bissau % 1 2% Insufficient Haiti % 5 1% On track India % 7 6% Insufficient Indonesia % 1 3% On track Iraq % 1 6% No progress Kenya % 14 7% No progress Laos % 3 6% On track Lesotho % 15 2% No progress Liberia % 12 2% No progress Madagascar % 8 % Insufficient Malawi % 5 4% Insufficient Mali % 1 6% No progress Mauritania % 11 5% No progress Mexico % 7 6% On track Morocco % 2 4% On track Mozambique % 6 3% Insufficient Nepal % 2 5% On track Niger % 9 6% Insufficient Nigeria % 1 1% Insufficient North Korea % 12 2% No progress Pakistan % 9 % Insufficient Papua New Guinea % 9 4% Insufficient Peru % 4% On track Philippines % 4 8% On track Rwanda % 11 1% No progress Senegal % 9 4% Insufficient Sierra Leone % 11 4% No progress Somalia % 8 5% Insufficient South Africa % 13 8% No progress Sudan % 8 9% Insufficient Swaziland % 16 6% No progress Tajikistan % 6 4% Insufficient Tanzania % 8 7% Insufficient Togo % 8 6% Insufficient Turkmenistan % 4 8% On track Uganda % 1 2% Insufficient Yemen % 8 6% Insufficient Zambia % 12 3% No progress Zimbabwe % 15 8% No progress Data are deaths per 1 livebirths, unless otherwise specified. MDG=millennium development goal. Data from UNICEF. 1 Table 1: Progress toward the MDG 4 target for reduction of child mortality in 68 priority countries Vol 371 April 12,

8 Maternal mortality ratio (25, adjusted) Lifetime risk of maternal death (25) Maternal mortality Afghanistan 18 1 in 8 Very high Angola 14 1 in 12 Very high Azerbaijan 82 1 in 67 Low Bangladesh 57 1 in 51 Very high Benin 84 1 in 2 Very high Bolivia 29 1 in 89 Moderate Botswana 38 1 in 13 High Brazil 11 1 in 37 Moderate Burkina Faso 7 1 in 22 Very high Burundi 11 1 in 16 Very high Burma 38 1 in 11 High Cambodia 54 1 in 48 High Cameroon 1 1 in 24 Very high Central African 98 1 in 25 Very high Republic Chad 15 1 in 11 Very high China 45 1 in 13 Low Congo 74 1 in 22 Very high Congo, Democratic 11 1 in 13 Very high Republic Côte d Ivoire 81 1 in 27 Very high Djibouti 65 1 in 35 Very high Egypt 13 1 in 23 Moderate Equatorial Guinea 68 1 in 28 Very high Eritrea 45 1 in 44 High Ethiopia 72 1 in 27 Very high Gabon 52 1 in 53 High Gambia 69 1 in 32 Very high Ghana 56 1 in 45 Very high Guatemala 29 1 in 71 Moderate Guinea 91 1 in 19 Very high Guinea-Bissau 11 1 in 13 Very high Haiti 67 1 in 44 Very high India 45 1 in 7 High Indonesia 42 1 in 97 High Iraq 3 1 in 72 High Kenya 56 1 in 39 Very high (Continues in next column) Maternal mortality ratio (25, adjusted) Lifetime risk of maternal death (25) Maternal mortality (Continued from previous column) Laos 66 1 in 33 Very high Lesotho 96 1 in 45 Very high Liberia 12 1 in 12 Very high Madagascar 51 1 in 38 High Malawi 11 1 in 18 Very high Mali 97 1 in 15 Very high Mauritania 82 1 in 22 Very high Mexico 6 1 in 67 Low Morocco 24 1 in 15 Moderate Mozambique 52 1 in 45 High Nepal 83 1 in 31 Very high Niger 18 1 in 7 Very high Nigeria 11 1 in 18 Very high North Korea 37 1 in 14 High Pakistan 32 1 in 74 High Papua New Guinea 47 1 in 55 High Peru 24 1 in 14 Moderate Philippines 23 1 in 14 Moderate Rwanda 13 1 in 16 Very high Senegal 98 1 in 21 Very high Sierra Leone 21 1 in 8 Very high Somalia 14 1 in 12 Very high South Africa 4 1 in 11 High Sudan 45 1 in 53 High Swaziland 39 1 in 12 High Tajikistan 17 1 in 16 Moderate Tanzania 95 1 in 24 Very high Togo 51 1 in 38 High Turkmenistan 13 1 in 29 Moderate Uganda 55 1 in 25 Very high Yemen 43 1 in 39 High Zambia 83 1 in 27 Very high Zimbabwe 88 1 in 43 Very high Data are deaths per 1 livebirths, unless otherwise specified. MDG=millennium development goal. Data from UNICEF. 1 Table 2: Progress toward the MDG 5 target for maternal mortality in 68 priority Countdown countries these packages. For example, median coverage of interventions for prevention of mother-to-child transmission of HIV and intermittent preventive treatment of malaria in pregnancy, both of which should be delivered during antenatal care visits, was much lower than that for antenatal care, indicating that opportunities to integrate these interventions with antenatal care are being missed. 25 Countdown does not monitor indicators of the quality or content of service packages such as antenatal care, skilled birth attendance, or postnatal care. The effectiveness of such packages depends on whether they include proven interventions, such as use of a partograph in labour or active management of the third stage of labour. Similarly, programmatic links between different elements of the continuum of care for maternal, newborn, and child health are often not being promoted or provided. For example, immunisation visits offer an opportunity to counsel women on feeding of babies and children or on family planning, and to provide vitamin A supplementation and insecticide-treated nets. Another missed opportunity relates to maternal and child undernutrition. Undernutrition has been shown to be underlying cause of 3 5 million child deaths every year, and at least 35% of the disease burden in children younger than 5 years. 26 Maternal undernutrition increases the risk of death of the mother at birth, and might be Vol 371 April 12, 28

9 associated with at least 2% of maternal mortality. 26 In 33 of the 68 priority countries, at least 2% of children were moderately or severely underweight, and in 62 countries, stunting prevalence was greater than 2%. Although the prevalence of exclusive breastfeeding has shown some improvement, the median coverage in the priority countries was low (28%, range 1 88%). Low prevalences of timely initiation of breastfeeding 1 also show a need for continued efforts to promote breastfeeding and improve the delivery of essential nutrition interventions. The fifth theme is that the effectiveness of the Countdown depends on the availability of reliable and timely data to guide decision making in countries (panel). Since the first Countdown report in 25, an unprecedented number of household surveys have been undertaken, with new MICS data from 54 countries, new DHS data for 35 countries, and recent surveys for AIDS indicators and prevention of mother-to-child transmission of HIV. Although a large amount of coverage data was compiled for the 68 countries, other than data for immunisation, nearly a third of all data were either lacking, did not use comparable definitions, were not nationally representative, or were from before 2. Of this missing third, more than half was from 19 countries and pertained to data for postnatal care, childhood treatment for pneumonia, intermittent presumptive treatment of malaria in pregnancy, antenatal care visits (four or more), and caesarean sections. Given the preponderance of maternal and newborn deaths at birth and within the first few days after birth, filling the data gaps for maternal care and for postnatal care should be a top priority, and would be achievable with fairly minor changes to field survey questionnaires. Trends in coverage in the 68 priority countries could not be calculated for 4% of country-specific estimates for the nine interventions being tracked, which limited our ability to assess the effectiveness of programmes. Although many trend data were missing because of recent initiation of country-wide programmes (such as insecticide-treated nets and case management for pneumonia), about 6% were missing because national data for established programmes (such as exclusive breastfeeding, contraception, antenatal care, and skilled attendance at birth) had been assessed only infrequently. Of the 45 countries with endemic malaria that were included in the Countdown study, a third of data for coverage of preventive and curative treatment for malaria and for use of insecticide-treated nets were unavailable. Rank Mortality in children younger than 5 years (199) Mortality in children younger than 5 years (26) Change (199 26) Ten with most progress Peru % Brazil % Indonesia % Egypt % Nepal % Morocco % Laos % Bangladesh % Bolivia % Guatemala % Ten with least progress Chad % Cameroon % South Africa % Equatorial Guinea % Congo % Kenya % Lesotho % Zimbabwe % Swaziland % Botswana % Data are rank or deaths per 1 livebirths, unless otherwise specified. MDG=millennium development goal. Table 3: Ten best and ten worst performing countries on progress towards MDG 4 since 199 Rank Ten with lowest mortality China 1 45 Mexico 2 6 Azerbaijan 3 82 Brazil 4 11 Egypt 5 13 Turkmenistan 6 13 Tajikistan 7 17 Philippines 8 23 Peru 9 24 Morocco with highest mortality Congo, Democratic Republic 56= 11 Malawi 56= 11 Nigeria 56= 11 Guinea-Bissau 56= 11 Burundi 56= 11 Liberia Rwanda Somalia 63= 14 Angola 63= 14 Chad Niger 66= 18 Afghanistan 66= 18 Sierra Leone Maternal mortality Data are rank or deaths per 1 livebirths. MDG=millennium development goal. Table 4: Ranking of selected countries for maternal mortality as a proxy for progress towards MDG 5 Vol 371 April 12,

10 Coverage (%) Contraceptive prevalence One or more antenatal visits Skilled attendant at delivery Postnatal visit within 2 days Number of countries Exclusive breastfeeding Pre-pregnancy Pregnancy Birth Postnatal Childhood Average 3-year change in percentage points Nutrition Exclusive breastfeeding ( 5 months) 36 3 ( 11 to 29) Maternal and newborn health Antenatal care coverage (at least one visit to skilled provider) 42 4 ( 21 to 19) Births attended by skilled health personnel 45 2 ( 5 to 12) Neonatal tetanus protection 64 5 ( 11 to 31) Contraceptive prevalence 39 2 ( 7 to 1) Child health Care seeking for pneumonia 33 1 ( 1 to 18) Oral rehydration therapy (oral rehydration salts or recommended 31 2 ( 17 to 23) home fluids) or increased fluids, with continued feeding Children sleeping under insecticide-treated nets 19 7 (2 to 18) Data are number of countries or median (range). Vitamin A is not included because changes in definitions affected comparability. Table 5: Changes for selected interventions since 2 for Countdown countries with at least two measurements Case Measles management immunisation of pneumonia Figure 3: Coverage estimates for interventions across the continuum of care in the 68 priority countries (2 6) This gap is already being addressed with increased investment in tracking coverage of treated bednets. Other gaps in data that have been emphasised by the Countdown process include the need for improved tracking of deaths, especially regular comparable data for maternal and newborn deaths. Despite over 3 2 million stillbirths every year, these deaths remain invisible on the global agenda, even though several of the Countdown interventions could reduce such deaths. 27 Insufficient data for the prevalence of preterm births also reduce their visibility, despite at least 1 million deaths every year and associated risks from neonatal infections. 28 Data about quality of care are also needed, because high coverage of care that is low quality might not be effective in saving lives. The 28 report has included policy tracking, but many gaps remain in these data. Work on financial tracking is still largely limited to donor flows, yet in many cases country governments are investing more, requiring more analysis and attention. Discussion Progress towards MDGs 4 and 5 varies between countries. Important positive milestones include China s progress; it is now on track to meet MDG 4. High mortality in many countries provides a continuing and urgent rationale for the Countdown effort. The interventions and approaches included in Countdown are those with proven effectiveness for reduction of mortality. Factors such as human resources for health, armed conflict, and high HIV burden have prevented implementation of these interventions, and contributed to stagnating or deteriorating progress towards reduction of mortality in women, newborn babies, and children. The Countdown results indicated that inequities (both between and within countries) and insufficient or unreliable financial resources were important underlying constraints to progress. 8,9 Understanding the reasons for gaps in coverage of different interventions, and the factors associated with high and low coverage in specific country settings, will be imperative for future progress. Coverage of preventive interventions (such as insecticide-treated nets, vitamin A supplementation, and immunisation for measles, maternal and newborn tetanus, and H influenza) increased more than that for most curative interventions (treatment of pneumonia, diarrhoea, malaria, and neonatal illness) and those that depend on availability of 24-hour clinical care (skilled attendance at birth and caesarean section). Moreover, progress on interventions that require behavioural and social change, such as early initiation of breastfeeding and complementary feeding, was mixed and often insufficient to achieve the MDGs. Contraceptive prevalence was also lagging in coverage. For some interventions, such as protection against neonatal tetanus and insecticide-treated nets to prevent malaria, high levels of political commitment and investment seem to have contributed to substantial increases, which are perhaps also facilitated by the simplicity of these interventions and existing vertical systems for delivery. Our data also suggest that interventions that can be scheduled for delivery in advance and that are based on simple technologies, such as immunisation, have achieved and sustained higher rates of coverage than have those that require 24-hour on-demand availability, such as correct treatment of childhood illnesses or skilled attendance at birth. Urgent action and investment will be needed to accelerate progress for coverage of clinical-care interventions, which depend on adequate access, human resources, and essential supplies. Countries that scale up innovative delivery approaches can achieve Vol 371 April 12, 28

11 rapid progress; for example, case management of pneumonia in Nepal has increased through large-scale community-based management. Reductions in mortality in children younger than 5 years do not necessarily go hand in hand with reductions in maternal mortality. Examination of these variations in light of the coverage of interventions for maternal, newborn, and child health shows that some progress towards reduction of mortality in children younger than 5 years can generally be achieved through schedulable services that can be delivered through improved community-based and outreach approaches. Similarly, mortality in newborn babies can be reduced to some extent with schedulable services such as tetanus-toxoid immunisation and home preventive care. However, reductions in maternal mortality, and further reduction in child mortality and newborn deaths, will require 24-hour services. The priority gaps, in which interventions have low coverage and little progress, are contraceptive services, childbirth and postnatal care, and clinical case management of newborn and childhood illnesses. In some countries, HIV prevalence has peaked and is beginning to drop, 29 and rapid increases in coverage for effective HIV interventions in recent years might not yet have been fully captured in estimates of coverage and mortality in children younger than 5 years. 3 In southern Africa, however, HIV is still having a major effect on both maternal mortality and that in children younger than 5 years. Expanded and sustained efforts are needed to scale up comprehensive programmes for prevention of mother-to-child transmission of HIV, including treatment for pregnant women and those who have recently given birth 31 and care and treatment for paediatric HIV. Scale-up in these areas will require a functional continuum of care, especially during the critical childbirth and postnatal period. The full effect of conflict and transition occuring after conflict might not yet be captured by current mortality estimates. For example, in 26, Afghanistan had an official estimate of mortality in children younger than 5 years of 257 deaths per 1 livebirths, but research suggests that this might be decreasing rapidly. 32 Innovative programme models, such as performance-based contracting to accelerate implementation, are urgently required in such environments. An adequately functioning health system was crucial to progress towards the MDGs. Variations in coverage across the continuum of care showed where focused effort will be needed to meet the MDGs. Priority attention in health-system strengthening should be given to establishment of a functional continuum of care that encompasses women before pregnancy, pregnancy, childbirth, the postnatal period, and the first 24 months of a child s life. Countries need better data to assess progress and make results-based decisions. Donors also need such information, especially given recent unprecedented rises in global health investments. Despite recent increases in the availability of data on coverage of essential interventions, important gaps remain, and many countries still use data that are 5, 1, or even 15 years old. The Countdown process reinforce recommendations that national data collection needs to be done as part of routine activities, which will require investment in strengthening country-owned health-information systems. 33,34 More assessment of implementation will be needed to determine how interventions can be delivered in different settings to large populations but with high coverage and high quality. The 28 Countdown report suggests that many of the necessary ingredients are in place to accelerate progress towards achievement of the health-related MDGs. These factors include consensus on the priority interventions and countries, commitment from countries and donors, programmes in place, data for decision making, and some increases in funding. A framework for assessment of maternal, newborn, and child survival that is relevant to countries and accepted by all new global initiatives might help to cement agreement on priorities and processes, especially for results-based strengthening of health systems. In the 7 years until 215, the next 2 years before the next Countdown report will be the most crucial. With strategic decisions and investments, and a focus on partnerships for results, we have the opportunity to see unprecedented progress in these 68 countries. Or, will the 21 report show more of the same gaps and lives lost? Countdown Coverage Writing Group (alphabetical order) for the Countdown Core Group Jennifer Bryce (Johns Hopkins School of Public Health, USA); Bernadette Daelmans (WHO, Switzerland); Archana Dwivedi (UNICEF, New York, USA); Vincent Fauveau (UNFPA, Geneva, Switzerland); Joy E Lawn (Save the Children-US, Cape Town, South Africa); Elizabeth Mason (WHO, Switzerland); Holly Newby (UNICEF, New York, USA); Jennifer Requejo (PMNCH); Peter Salama (UNICEF, New York, USA); Anuraj Shankar (WHO, Switzerland); Ann Starrs (Family Care International, New York, USA); Tessa Wardlaw (UNICEF, New York, USA). Contributors All authors designed the study in collaboration with the 28 Countdown Working Group. JB, JL, ASt, ASh, and PS drafted the manuscript, with review and revisions by other named authors. JR, JB, HN, AD, TW, JL, and ASh analysed the data. BD, VF, and EM reviewed and commented on drafts of the manuscript. All authors participated in the interpretation of the results and have seen and approved the final version. Conflict of interest statement AD, HN, PS, and TW are employees of UNICEF; BD, EM, and ASh are employees of WHO; and VF is an employee of UNFPA. JB has worked as a consultant to both UNICEF and WHO on this and related work in child survival; JR worked as a consultant for the Secretariat of the Partnership for Maternal, Newborn and Child Health in the preparation of this manuscript. Other authors declare that they have no conflict of interest. Acknowledgments The Countdown effort was funded by many partners, including the Bill & Melinda Gates Foundation, DFID, NORAD, PMNCH, Save the Children US and UK, UNICEF, UNFPA, and WHO. We thank all members of the Countdown Core Group, who are listed in the Vol 371 April 12,

12 Countdown report specifically Irene Deineko for administrative support; Christa Fischer Walker for preparation of the maps; Kate Kerber for analysis to provide the postnatal care data; and Monir Islam for helpful comments on the manuscript. We also thank the DevInfo intitiative for development of the database and production of the country profiles. References 1 Victora CG, Bryce J, Black RE. Learning from new initiatives in maternal and child health. Lancet 27; 37: UNICEF. Progress for children. A world fit for children: statistical review. New York, USA: UNICEF, progressforchildren/27n6/index_41854.htm (accessed Jan 4, 28). 3 Bryce J, Terreri N, Victora CG, et al. Countdown to 215: tracking intervention coverage for child survival. Lancet 26; 368: The Countdown Core Group. Tracking progress in child survival: the 25 report. New York, USA: UNICEF, countdown215mnch.org/reports (accessed March 28, 28). 5 Kerber K, de Graft-Johnson J, Bhutta Z, Okong P, Starrs A, Lawn J. Continuum of care for maternal, newborn, and child health: from slogan to service delivery. Lancet; 37: Bustreo F, Johnsson AB. Parliamentarians: leading the change for maternal, newborn, and child survival? Lancet 28; 371: Countdown Working Group on Health Policy and Health Systems. Assessment of the health system and policy environment as a critical complement to tracking intervention coverage for maternal, newborn, and child health. Lancet 28; 371: Greco G, Powell Jackson T, Borghi J, Mills A. Assessment of donor assistance to maternal, newborn, and child health between 23 and 26. Lancet 28; 371: Countdown 28 Equity Analysis Group. Mind the gap: equity and trends in coverage of maternal, newborn, and child health services in 54 Countdown countries. Lancet 28; Bryce J, Requejo J, and the 28 Countdown Working Group. Tracking progress in maternal, newborn, and child survival: the 28 report. (accessed April, 28). 11 UNICEF. The State of the World s Children, 28. New York, USA: UNICEF, UNICEF, WHO, World Bank, UNPD. Levels and trends of child mortality in 26: Estimates developed by the Inter-Agency Group for Child Mortality Estimation [Draft]. New York, USA: UNICEF (accessed February 8, 28). 13 WHO. World Health Statistics 27. Geneva, Switzerland: World Health Organization, Bryce J, Boschi-Pinto C, Shibuya K, Black RE; WHO Child Health Epidemiology Reference Group. WHO estimates of the causes of death in children. Lancet 25; 365: Lawn JE, Wilczynska-Ketende K, Cousens SN. Estimating the causes of 4 million neonatal deaths in the year 2. Int J Epidemiol 26; 35: WHO. WHO Child Growth Standards: Length/height-for-age, weight-for-age, weight-for-length, weight-for-height and body mass index-for-age: methods and development. Geneva, Switzerland: World Health Organization, childgrowth/publications/technical_report_pub/en/index.html (accessed Feb 19, 28). 17 Blanc A, Wardlaw T. Monitoring Low birthweight: an evaluation of international estimates and updated estimation procedure. Bull World Health Organ 25; 83: Hill, K, Thomas K, AbouZahr C, Walker N, Say L, Suzuki E; Maternal Mortality Working Group. Estimates of maternal mortality worldwide between 199 and 25: an assessment of available data. Lancet 27; 37: WHO, UNICEF, UNFPA, World Bank. Maternal mortality in 25: estimates developed by WHO, UNICEF, UNFPA and the World Bank. Geneva, Switzerland: World Health Organization, (accessed March 16, 28). 2 Khan KS, Wojdyla D, Say L, Gulmezoglu AM, Van Look PF. WHO analysis of causes of maternal death: a systematic review. Lancet 26; 367: UNICEF. Multiple indicator cluster surveys. New York, USA: UNICEF. (accessed Feb 8, 28). 22 Measure DHS, MACRO International. Demographic and health surveys. Calverton, MD, USA: Measure DHS, MACRO International. dhs/start.cfm (accessed Feb 8, 28). 23 UNICEF. Childinfo. New York, USA: UNICEF. (accessed March 19, 28). 24 WHO. International Travel and Health, 27. Geneva, Switzerland: World Health Organization, (accessed March 15, 28). 25 Lawn JE, Kerber K, eds. Opportunities for Africa s newborns: practical data, policy and programmatic support for newborn care in Africa. Cape Town, South Africa: PMNCH, Save the Children, UNFPA, UNICEF, USAID, WHO, Black RE, Allen LH, Bhutta ZA, et al; Maternal and Child Undernutrition Study Group. Maternal and child undernutrition: global and regional exposures and health consequences. Lancet 28; 371: Stanton C, Lawn JE, Rahman H, Wilczynska-Ketende K, Hill K. Stillbirth rates: delivering estimates in 19 countries. Lancet 26; 367: Lawn JE, Cousens S, Zupan J. 4 million neonatal deaths: when? Where? Why? Lancet 25; 365: UNAIDS. Report on the global AIDS epidemic. Geneva, Switzerland: Joint United Nations Programme on HIV/AIDS, McIntyre J. Maternal Health and HIV. Reprod Health Matters 24; 13: Eyakuze C, Jones D, Starrs A, Sorkin N. From PMTCT to a more comprehensive AIDS response for women: a much-needed shift. Dev World Bioeth 28; 8: John Hopkins, Indian Institute of Health Management Research and Afghanistan Ministry of Public Health. Afghanistan health survey 26: estimates of priority health indicators for rural Afghanistan. 33 Setel PW, Macfarlane SB, Szreter S, et al. A scandal of invisibility: making everyone count by counting everyone. Lancet 27; 37: AbouZahr C, Boerma T. Health information systems: the foundations of public health. Bull World Health Organ 25; 83: Vol 371 April 12, 28