Dying: Millions of women in childbirth, newborns, and young children
Progress is possible in poorest countries
However, all the news is not bad
Nineteen of the 68 countries with high incidences of maternal, newborn and infant deaths are now moving forward, and experience in several countries that were lagging shows a quick turn-around is possible, even in the poorest countries.
India’s Janani Suraksha Yojana (Women's Protection Scheme) was launched in April 2005 under the Government of India's National Rural Health Mission. The program seeks to reduce maternal and neo-natal mortality by promoting institutional delivery and skilled attendance at birth by offering cash payments to women who fulfill the conditions of attending antenatal appointments and seeking skilled care at delivery. These payments are primarily to women below the poverty line.
These benefits reached only 700,000 women in 2005, increasing to 8,380,000 in 2008, more than a 10-fold increase in just a few years. The government realizes that quality of services now needs to be urgently addressed.
Nepal used national cause of death data to design programs that curb child and maternal deaths, developing innovative approaches to bring care closer to home that included community child pneumonia treatment programs and household visits to promote family planning and newborn care. The effort required recruiting and training additional community workers. Offering skilled birth care is a particular challenge with very low coverage (only 19 percent) and is now being addressed by new investments in training midwives.
Malawi, a low-income country with only four pediatricians, has been declared on track for child survival. The Ministry of Health identified the main causes of child death as pneumonia, diarrhea, malaria, HIV, and newborn problems and planned to address those problems with national scale-up of an essential health package, including programs for immunization, malaria control, prevention of mother-to-child HIV transmission, and improved water and sanitation services. In spite of these efforts, diarrhea, pneumonia, and maternal and newborn care remained problematic, so Malawi trained health surveillance assistants to deliver selected services closer to the community. Over 800 health assistants now offer malaria, diarrhea, and pneumonia treatment (using the latest malaria drugs, zinc for diarrhea, and appropriate antibiotics), and some are being trained to support home based newborn care. To overcome high maternal mortality, facilities are being improved and additional staff is being hired and trained, including non-physicians to undertake emergency cesarean sections. Death rates for children and women are now declining.
Brazil’s success in reducing the under 5 death rate by 4.8 percent each year since 1990 is attributed to a sharp decline in inequalities in access to health care. This decline was done through a nationwide, tax-based Unified Health System with no user fees and specific geographical targeting of family health teams to attend the poorest areas of the country. Reducing regional and socioeconomic disparities in health and development have been a central element in Brazil’s political agenda for the last 20 years. As a result, primary healthcare coverage is universal, primary care is free for everyone, and even the poorest Brazilians now have access to skilled attendance at birth.
Rwanda has introduced health reforms, which expand coverage across all areas of health care. One approach gives “performance bonuses” for health facilities and hospitals, based on provision of high quality, priority services. From 2005 to 2008, births in health facilities have increased from 39 to 52 percent, the use of insecticide treated bed nets for children under 5 has risen from 4 to 67 percent, and modern contraceptive use has increased from 10 to 28 percent, contributing to a decline in under-5 mortality from 152 to 103 deaths per 100,000 live births.
“We know this global problem can be solved even in the poorest countries,” says Dr. Bustreo. “It will take commitment of donors and recipient countries, and considerable ingenuity. We are seeing that Malawi, Nepal, Brazil, and Rwanda are making progress in saving the lives of women and children.”