Addressing Critical Knowledge Gaps in Newborn Health

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By Melinda Gates on May 21, 2014
Africa, North America

This is the transcript of Melinda Gates' speech at the 67th World Health Assembly, 20 May 2014. 

Mr. President, Director-General Dr. Chan, First Lady Dr. Christine Kaseba-Sata, Excellencies, ladies, and gentlemen. 

Thank you for inviting me to speak to you today.

Global health is my second career. I wasn’t formally trained in the field, but I have spent the last 15 years learning about it from experts, many of you in this room. I have travelled to dozens of countries to see for myself how the right investments can help people tap into potential that has been buried under the burden of poverty and disease.

One thing I’ve learned during my apprenticeship in global health is how complex and how absolutely critical your work is, both as part of this assembly and in your ministries. Here, you debate what is possible, and encourage the world to see what we can accomplish together. Back home, you do the challenging  work of turning big plans into results.

Simply put, you have proved that your bold ambition is justified. The world is getting healthier—faster—than ever before. To me, the best measure of success is declining child mortality in the last 20 years. When you think about global health as a choice between saving more children or letting more children die, I think it is very clear what we want.

The world’s record on child mortality is strong. Since 1990, the baseline year for the Millennium Development Goals, the number of children dying has gone down by 47 percent. This improvement is even more impressive if you account for population growth. If the rate of death had remained constant since 1990, then 17 million children would have died last year. Instead, the number was 6.6 million. That is incredible progress, but still too many children dying.

That progress is stunning. And yet the fact that 6.6 million children still die—almost all of whom could have been saved—is just as stunning. It’s also an urgent call to action. Getting that number down as close to zero as possible is a cornerstone of your work.

My husband Bill has had the honor to address this assembly on two occasions. In 2005, when our foundation was still very young, he explained who we are, why we were getting involved in global health, and how we think about solving problems together with our partners.

He told the story of the newspaper article we read about rotavirus, which kills hundreds of thousands of children in poor countries but almost none in rich countries.

We were shocked by this glaring inequity, but we were also inspired by the world’s ability to address it. Innovations like oral rehydration therapy and rotavirus vaccines are making it possible to save those lives—and to live out the principle that all lives have equal value.In 2011, Bill talked specifically about our foundation’s work on vaccines. This body committed to make this the Decade of Vaccines, and you committed to reaching all children with the vaccines they need by 2020. The WHO regional committees are tracking progress against this Global Vaccine Action Plan.

The GAVI Alliance, which has worked with you to drive global immunization rates higher than ever before, is hosting a replenishment conference this year. The results of that process will have a major impact on the story of child survival in the coming years.

Bill also spoke about the world’s fight to eradicate polio. At the time, there were four polio-endemic countries in the world. Now, thanks to India’s heroic efforts, there are just three. We still face serious challenges, including outbreaks. But new partners are joining the initiative. And they are using innovative approaches, including creating a Global Islamic Advisory Group under the Grand Imam of Mecca to support vaccination. 

Since you first heard about our foundation, our core values haven’t changed—and they never will. We will always do this work because we despise inequity, and because we believe in the power of innovation to solve problems.

Today, I’d like to talk about the issue I spend the majority of my time thinking about: the health of women and children around the globe.

A few years ago, I visited a hospital in Lilongwe, Malawi. It was an excellent hospital, with a highly trained staff. As I was talking to a doctor in the neonatal unit, a nurse rushed in carrying a baby girl suffering from birth asphyxia. She was purple when she was born, and I watched as the staff used a bag-and-mask device to resuscitate her. The doctor told me they had intervened in time; the baby was unlikely to suffer any long-term consequences from the asphyxia.

Even though this was a top-of-the-line hospital, it was crowded. The girl whose life has just been saved was lying on a warmer right next to a boy with asphyxia. Except the boy hadn’t been as fortunate. He was born on the side of the road, where his mother was waiting for a ride to the hospital. By the time they got there, it was too late for her son. He was dying.

Those two babies, side by side, one taking her first breaths, the other taking his last, are a symbol of what we are here to do. There are two versions of the future. One is full of promise. The other is a broken promise. How well we care for women and children will determine which future comes to pass.

To the global health community, newborns are part of a broader continuum. We talk about their lives in the context of five letters: RMNCH. Reproductive, Maternal, Newborn, and Child Health.

It’s a cumbersome acronym and a mouthful, but there are good reasons to link those letters together.

In people’s experience, they are inextricably linked. Newborns don’t undergo a transformation on the 29th day of their lives, regardless of the fact that we suddenly categorize them as children. As far as parents are concerned, there is no difference between the N and the C.

And each step along the continuum relies on the previous step that was before it.

 

  • If women can plan their families, they are more likely to space their pregnancies.
  • If they space their pregnancies, they are more likely to have healthy babies.
  • If their babies are healthy, they are more likely to flourish as children and later as adults.

When mothers have healthy pregnancies, and when children thrive, the positive benefits last a lifetime.

This isn’t true just in developing countries where maternal and child mortality is relatively high. It’s true everywhere. In fact, we keep seeing new evidence that links maternal and child health to non-communicable diseases like cardiovascular disease, diabetes, and obesity that increasingly plague all countries.

The data is convincing. If we want thriving societies tomorrow, we need healthier mothers and children today.

I have three children. When I travel, I find myself drawn to other mothers. Their stories—which are about their tenacious fight to give their children a better life than they had— ring in my ears and inspire me to do the work I do. When I look at the data about maternal and child mortality, I always try to remember that the numbers are telling their stories.

Women and children are a leading indicator of the health of the world. So the trend lines are encouraging. I already mentioned child mortality. And it’s not just that more children are surviving; it’s also that more children are developing cognitively and physically in ways that will help them lead productive lives.

The trajectory for maternal mortality is also similar. Between 1990 and 2010, the annual number of maternal deaths dropped from about 550,000 to fewer than 300,000. When you think of the ripple effect that 250,000 mothers who are alive and well have on their communities, the improvement is even more momentous.

However, the exciting child and maternal health data highlights the fact that the data for newborn health isn’t nearly as good. The world is saving newborns at a much slower rate than  children under five. Each year, 2.9 million children die within their first month of life.  One million of those newborns die on their first day of life.

The vast majority of newborn deaths are preventable. I want to be very clear about what I mean when I say preventable. I don’t mean theoretically preventable under ideal but unrealistic circumstances. I mean preventable with relatively simple and relatively inexpensive interventions. Preventable with systems and technology available we have now in almost every country.

Let me give five examples of these interventions, which you can read more about in the Lancet series on newborns published today.

 

These are best practices that work everywhere, but that aren’t being used optimally anywhere. The United States spends more than $10 billion a year to treat babies with conditions resulting from sub-optimal breastfeeding. And U.S. pediatricians only recently began to recommend skin-to-skin care over putting babies in incubators.

Resuscitation. Drying the baby. Chlorhexidine cord care. Immediate breastfeeding. Skin-to-skin contact.

If we could manage to get these five interventions scaled up around the world, we would save hundreds of thousands of newborns each year.

What’s more, these inexpensive measures can be incorporated into health systems already in place in countries throughout the world.

When it comes to managing serious complications, it’s best for mothers and newborns to be in health facilities, provided that the quality of care in those facilities is high.

However, the high-impact interventions I just mentioned can also be delivered by frontline health workers. For example, Ethiopia trained health extension workers in certain regions to provide improved maternal and newborn care, including the five interventions I just mentioned. The result was an impressive 28 percent reduction in newborn mortality.

The same frontline worker who manages sepsis can counsel women about contraceptives, conduct pre-natal visits, and give vaccines. Ultimately, it’s the combination of all these interventions that will help women and children lead healthy, productive lives. Even though I have been focusing on newborn health, I want to reiterate that the goal is not to prioritize newborns above the other priorities along the RMNCH continuum, but to keep them in their proper place alongside the other priorities.

These interventions have to be integrated, and, with your leadership, they can be.

This week, you will consider the Every Newborn Action Plan. If you endorse the plan, I encourage you to use the full power of this assembly, as well as the regional committees and national engagements of the WHO, to track its progress in detail. We will be tracking along with you at our foundation, where aligning our investments to help newborns thrive. It is one of our top priorities.

You will be the ones responsible for translating the plan into action when you go back home. No public health intervention, no matter how successful it seems to be in the laboratory, can succeed without your leadership and management on the ground. The clinical science is one thing. The complex process of making sure that women and children in your countries benefit from the science is something else.

I don’t claim to understand the competing pressures that cross your desk every day. But I know that no health minister can drive change alone. Progress requires working with other government officials, not to mention the private sector, civil society, religious organizations, and community leaders. And winning allies requires making a case that newborn health is more than just one priority among many.

Saving newborns is a tender-hearted act of love that also makes hard-headed business sense. The Lancet recently published the most advanced analysis to date of the links between public health and economic growth. The report finds that lower mortality by itself has accounted for about 11 percent of economic growth in low- and middle-income countries. And that’s not counting the enormous economic advantages of a healthier, more productive labor force. The report modelled a package of health interventions focused on RMNCH and found that every dollar invested yields at least $9 in economic benefits.

At the Gates Foundation, we’re committed to supporting your leadership. That’s why we’re working with you to generate the evidence you need to strengthen your case that investments in women and children’s health provide value for money. For example, based on requests from you, we funded research into the demographic dividend that shows the connection between family planning, maternal and newborn mortality, child survival, nutrition, and economic growth. We will continue to gather the evidence you need to advocate for your priorities. Your priorities are our priorities.

Another way we can help is by supporting additional clinical and operational research. Which interventions are most effective? Can they be cheaper? Can they be adapted so that they’re easier to use? Can they be implemented more efficiently? The answers to these questions will help you get more impact per dollar, and we are investing with you to find those answers.

Finally, we will always advocate for these issues—and for the women and children who are fighting for a better life.

As you define your national priorities and draw up your national plans, we will work with global donors, both private and public, to align around shared priorities. We will explain why we are investing our money in these issues, and we will try to persuade donors that they should, too.

For most of human history, we have been resigned to the fact that women and children die.

But you and I are fortunate to be living at a time when we don’t have to be resigned any more. The facts are clear: When we invest in health, we get results. That’s a paradigm shift, the notion that we have the power to prevent sickness and promote better health. That exists in front of us today.

But there are other perceptions that still need to change. There is still a sense that cutting-edge health care requires expensive technology. There is still a sense that improving health is a nice thing to do, but not a smart way for a country to invest money.

That is why this assembly is so important.

You are representing the nations of the world at a historic moment—at the moment when we have solid proof that investing in health is the best use of our collective resources. People still say that caring for women and children is too big an investment for too uncertain a return. You and I get to be the ones who present powerful evidence to the contrary.

And we can use that evidence to insist to the world that—from this day forward—every baby born will be a promise kept. Thank you.

Watch Melinda gates give her speech by clicking the video below:

By Pragya Vats on May 20, 2014
India
Asia


Photo: Prashanth Vishwanathan/Save the Children

This blog was originally published by the EVERY ONE Campaign. Written by Pragya Vats.  

Even in the midst of madness over the election outcomes, India hasn’t forgotten its commitment towards its country’s children.

As the global leaders set out for the 67th World Health Assembly,  the office of the Indian delegate to the forum is a buzz with an army of technical experts, senior bureaucrats, technocrats preparing with their mission.

Leading among nations India has already sets its pen to paper – drawing the roadmap for India newborn action plan.

India steps up effort

Today the world and India is on the brink of a major breakthrough to ensure newborns everywhere survive. If there is one place to trace the seeds of this brewing revolution, it’s India. In the last few years India has begun a major political movement to systematically take on the complex and large scale problem of newborn and child mortality. India has also made dramatic progress in reducing the under-five mortality to more than 50 percent since 1990 – at a much faster rate than the world put together, but newborn survival is critical to reach the last mile on the goal. While progress on newborn survival may not have been as fast in the last two years newborn mortality has declined at the rate of 6 percent annually.

India is fully committed to accelerating progress on material newborn and child health and comprehensive package of intervention through RMNCH+A (Reproductive Maternal Newborn Child Health + Adolescent) strategy following India Call to Action Summit on child survival.

From pledges to action

In this India has already initiated a nationwide momentum to scale up services to reach every mother and newborn by addressing demand-and-supply-related bottlenecks integrating maternal and newborn care into health systems and the RMNCH+A continuum of care in a life cycle approach than just looking at the singular vertical and segregated approach.

In a series of steps the national level plans and strategies are speedily being rolled out across the high priorities states in the country. Building on partnerships and forging new ones, the strategy aims at bringing together various sectors – businesses and private sector, training institutions, civil society and faith based organisations to deliver unprecedented breakthrough in newborn and child survival.

Can India surprise the world?

We know that curbing child mortality levels in India could dramatically bend the curve for child mortality levels globally, and the world is looking to India to turn our pledges into reality.

If statistics are to be believed India is on track to meet MDG5 target by reducing Maternal Mortality Rate (MMR) from 327 in 1999-2001 to 178 per 100,000 in 2010-2012.  It is noteworthy that India’s decline between 1990  and 2012 has been an impressive 70 percent, while global decline in the same period has been just 48 percent.

In a historic achievement, this year, India has been officially declared polio-free clocking three full years after its last polio case was reported in 2011. It is a healthcare landmark for a country of 1.3 billion people to be proclaimed free of the disease by the World Health Organization

Today we are at a critical juncture towards the achievement of Millenium Development Goals 4 and 5 and success seems within grasp. 

Launching Save the Children’s report  ‘Ending Newborn Deaths’ earlier this year,  Ms. Anuradha Gupta, AS MD National Health Mission said, “India likes to surprise the world, we are on track to meet MDG 5 targets and we are confident that we will sure achieve the  reduction in child mortality too.”

For the world to crack the breakthrough, India must lead the way. Will India surprise the world? Promises to keep. 

By Pancho Kaslam on May 19, 2014
Indonesia
Asia

Photo: David Wardell/Save the Children

This blog was originally published by the EVERY ONE Campaign. Written by Dr. Pancho Kaslam.  

In Indonesia, the number of newborns that die annually from preventable causes stands at 48,000.  Despite making great progress in the last decade by cutting child mortality by 40%, Indonesia’s newborn mortality figures are stagnant and are slowing the effort to reach the global target of reducing child mortality rates by two thirds by 2015 as set out in the Millenium Development Goals.

To overcome these newborn deaths, the government of Indonesia has developed its version of the Every Newborn Action Plan - a joint action platform to help galvanize national commitments to reducing newborn mortality, and hold governments accountable for progress.  Indonesia still struggles with a neonatal mortality rate of 19 out of 1,000 live births.  Many of these deaths are caused by infections, complications during labour and birth such as asphyxia, prematurity and low birth weight, and pneumonia and diarrhoea.   However most of these deaths can be prevented through relatively low-cost solutions, including improving nutrition and giving antenatal corticosteroid for preterm labour during antenatal care, safe and clean delivery, immediate and exclusive breastfeeding practices, infection prevention practice and antibiotics for infections, and “kangaroo mother care” or —keeping newborn babies warm through continuous skin-to-skin contact with the mother. Ensuring that skilled birth attendants are present to provide immediate care to mothers, and that health workers are accessible to mothers and newborn babies before, during and after child birth, is critical to delivering these life-saving services.

Access to and distribution of health services is a major issue in Indonesia. In a country of over 240 million, there are only 25,000 registered OBGYN’s--9,000 of those registered are in Jakarta alone.  Children in the poorest 20% are more than twice as likely to die as children born into the wealthiest 20%. These inequalities will need to be addressed if we are make real progress in reducing preventable newborn deaths. 

COLLABORATION OF ‘PONED-PONEK’ IN REFERRAL SYSTEM

Central to Indonesia’s Newborn Action Plan has been the need to strengthen the health system for emergency response and operationalized referral, such as  Basic Emergency Obstetric Neonatal Care-BEONC or PONED and Comprehensive Emergency Obstetric Neonatal Care-CEONC or PONEK.

From the community perspective that lack of trained staff performance, poor sanitation and hygiene practice and a shortage of basic equipment meant women and their families did not feel confident going to a health centre or Puskesmas PONED even though it was usually the closest facility to them. Instead they would risk the longer journey to a hospital PONEK which was further away and usually overloaded and unable to take them in.  So the mother would then make the long journey back to her village and instead of returning to the Puskesmas PONED, she would make the dangerous decision of giving birth at home, without the help of a skilled health worker.  If a woman were to develop any complications with her pregnancy, that journey to the hospital PONEK would become  life threatening for both her unborn child. 

In response to this problem, the government recognised the need to invest heavily to improve the quality of care mothers received at the PONED and PONEK which in turn would play a critical role in reducing the mortality rates of mothers and newborns in Indonesia. 

Health workers were given emergency obstetric training and facilities began receiving better equipment.  The most recent data shows that this investment is working, as more women are now beginning to go to their local Puskesmas PONED to give birth instead of making the long trip to the hospital PONEK. Therefore to avoid preventable maternal and neonatal death, the delivery should be conducted by skill birth attendant at health facility which provide emergency for stabilization and pre-referral services.

INDONESIA’S NEWBORN ACTION PLAN:

Indonesia has not only developed its newborn action plan, it has already begun the process or rolling out and implementing the plan across the country by getting ownership and commitment from local districts.  Between April and June 2014, Indonesia’s Newborn Action Plan, or Rencana Aksi Nasional tentang Neonatus-RAN as it’s called here, is being rolled out in six of its most populous provinces which contribute the highest rates of newborn mortality:  North Sumatra, South Sulawesi, Banten, Central, East & West Java.  Under USAID-EMAS funded program, Save the Children with its consortium members led by Jhpiego has been facilitating a collaboration between the Ministry of Health Indonesia, the Indonesian Paediatrician Association, and Indonesian Ob-gyn Society with representatives at the provincial and district level to roll out and implementation of INAP which aims to reduce maternal and newborn mortality rates by 25% by 2035. 

With a decentralised government, much of the implementation work around INAP is done at the district level, so a three day workshop was developed in each province to bring together civil society leaders, professional organizations, health workers, representatives from the provincial and district legislature.  Participants received an updated situation of the newborn health in their own province, an overview of the national newborn action plan, and were then asked to adapt the national plan into a localized blueprint that could be implemented at the district level.  Feedback from the first four provinces where the national plan has been unveiled will been incorporated into the final draft of the Indonesia Newborn Action Plan, which will be presented to the World Health Assembly next week by the Minister of Health.

The government of Indonesia has made a concerted effort to address the need to improve the health of its mothers and provide better care to newborns in their first day of life.    If successful, the Indonesia Newborn Action Plan will result in a strengthened health system supported by fully trained and skilled health workers with an adequately serviced health facility which can save the lives of millions of newborns and their mothers.

By Nick Pearson on May 16, 2014
Kenya
Africa

This blog was originally published by Grand Challenges Canada. Written by Nick Pearson and Allison Ettenger.  

“Since you came home from Jacaranda Maternity, have you had fever or chills?” asks Sharon, a Jacaranda Community Health Worker (CHW).

Ruth (*) came to Jacaranda Health three days ago to deliver her healthy baby girl. When it was time to leave the hospital, Jacaranda nurses counseled Ruth –  as they do for all of our mothers – to make sure she and her newborn had the best opportunity to stay healthy once they returned home to Kasarani, just outside Nairobi.

But this is just the beginning of Jacaranda’s commitment to Ruth and her baby. Sharon’s question comes from Jacaranda’s Postpartum Home Follow-Up Checklist, a series of screening questions Jacaranda’s Community Health Workers (CHWs) ask once our mothers are leaving for home. This is part of an innovative strategy to ensure that mothers and babies delivered at a Jacaranda hospital safely transition from hospital to home. Our project was awarded a seed grant in 2012 by Saving Lives at Birth, a partnership between Grand Challenges Canada, the U.S. Agency for International Development (USAID), the U.K. Department for International Development (DFID), the Government of Norway and the Bill & Melinda Gates Foundation.


Photo: Jacaranda Health

Jacaranda’s trained CHWs use the checklists to conduct a comprehensive follow-up to reduce risk in the potentially dangerous time after delivery. The checklists guide CHWs to identify and refer danger signs early, and to provide reminders for essential counseling on topics like breastfeeding and cord care. Community Health Workers counsel the new mothers on the importance of seeking timely care and troubleshoot common barriers low-income women face when seeking care, such as lack of transport, hospital fees, and decision-making with their husband around postpartum family planning.

Jacaranda’s collaboration with researchers at the Harvard School of Public Health ensures that we rigorously evaluate these innovative delivery approaches. The evaluation of this program is currently underway, but we are excited to share four early insights from our pilot:

  • Reduce health risks through early detection and action. Good news: when potential risks were detected by the CHW, nearly 70 percent of women followed through with our referral and sought the recommended care. What are some of those risks? Newborn jaundice, infection and breast issues were among the most common complications we identified.
  • Promote Healthy Postpartum Behaviour. Here’s what we already know: less-educated and poor women are less likely to receive postnatal care than their wealthier and more educated counterparts in Kenya. Contact and follow-up shortly after delivery could reduce this disparity for Jacaranda’s low-income clients. We find that women who received a call or visit returned to our facility between 50% and 74% more frequently for postnatal care, family planning or child wellness services, as compared to delivery clients who did not receive a visit or a call.
  • Promote timely postpartum family planning. Home visits and calls also provide a unique opportunity for counseling around postpartum family planning decision-making. As a part of our strategy integrating family planning education across the continuum, CHWs conduct structured health education (adapted from Population Council's great Balanced Counseling Strategy) to help women (and partners) decide on the family planning method that is right for them. During the follow-up, 76% of participating women are selected a specific method of family planning to be started at their six-week postnatal clinic visit.
  • Importance of a multi-level care team. There has been a global call promoting task-shifting, particularly to CHWs, to combat health-worker shortages in low-resource settings such as Kenya. Yet, too frequently, the lifeline to expert trainers and clinicians is cut after the conclusion of a short training. We're taking a different approach by strengthening the facility-community link through teams of CHWs and nurses. This supprt is essential: they know why they have the nurses and, more importantly, the hospital behind them.

When providing this care Jacaranda mothers and their newborns, our preliminary findings show that we're able to reduce health risks, promote healthy behaviour postpartum and ensure a safe transition home in these critical few days after delivery. 

(*) Name changed for privacy 

By Ray Chambers on May 12, 2014
Syria
Middle East

This blog was originally published in the Huffington Post Global Motherhood. Written by Ray Chambers

The birth of a child should be a day of celebration and awe. But for millions of women around the world it can be the most dangerous -- and too often the last -- day of her life. Save the Children, with its release this week of the 2014 report on the "State of the World's Mothers," reminds us of how far we have come in keeping mothers and their babies healthy and safe, but also how much more we need to do. A special focus of this year's "State of the World's Mothers" report is the dire situation faced by expectant mothers who are caught in humanitarian crises. In fact more than half of all maternal and child deaths worldwide occur in crisis-affected places. 

In anticipation of Mother's Day this weekend, I reached out to maternal and newborn health advocate Princess Sarah Zeid to discuss how we can focus our efforts to save the 800 women who die every day during pregnancy or childbirth, and to explain her reasons for getting involved in this important effort.

You had a near death experience delivering your third baby, a girl, here in the United States. Can you tell us a little bit about that experience and how it changed you and inspired you to become an advocate for the estimated 289,000 women who do not survive childbirth each year?

My life-threatening experience occurred four years ago, at the birth of my third child. Immediately after delivery I suffered an amniotic fluid embolism, which is a rare obstetric emergency. There was very little chance that I would survive the experience, but under the exceptional care available to me, my life was saved. The reality that my three children came so close to being motherless literally catapulted me to becoming an advocate for maternal health. Mothers are the heart of every family, and crucial to the survival, well-being and happiness of newborns and children.

Just imagine: If the low-cost medicines oxytocin and misoprostol were available to all women giving birth, we could prevent 41 million cases of postpartum hemorrhage -- the leading cause of maternal mortality-and save the lives of 1.4 million women over 10 years. That represents 1.4 million more women who could continue to be the glue for their families and communities; to safeguard their children's health, education, and security; and to inspire their offspring to seek bold and successful futures.

In addition to the women who die in childbirth, so many babies still do not survive the first month of life -- 2.8 million each year -- with most of those deaths occurring on the day of birth and the days immediately following. A further 2.6 million babies are stillborn every year. What are some of the ways we can prevent maternal and newborn deaths and stillbirths in this critical 48 hours around birth?

The world has come to recognize that newborn survival must be addressed, and in June this year we will see the launch of Every Newborn: An Action Plan To End Preventable Deaths. The plan is part of the UN Secretary General's maternal and child survival movement Every Woman, Every Child. This plan sets the first-ever target to reduce not just newborn deaths, but stillbirths -- and that new goal is 10 deaths per 1,000 live births by 2035 for both stillbirths and newborn deaths. Newborn survival and health are intrinsically linked with the survival, health and nutrition of women before conception and during and between pregnancies. The periods of greatest risk for mortality for woman and child -- and the focus of the Every Newborn action plan -- are when the woman is in labor, giving birth and during the first days of life. Intervention during this critical time period provides the greatest potential for ending preventable neonatal deaths.

Introducing high-quality care with high-impact, cost-effective interventions for mother and baby together -- delivered, in most cases, by the same health providers with midwifery skills at the same time -- is the key to improving the quality of care.

Save the Children just launched its State of the World's Mothers 2014 report, with a special focus on saving mothers and children in humanitarian crises. We won't meet Millennium Development Goal 5 and our maternal health goals by 2015 unless we can deliver health services to the most vulnerable women and children in crises. How can we ensure that humanitarian interventions prioritize maternal health?

Save the Children's excellent and crucial report draws attention to the extraordinarily difficult situation faced by mothers and children in crisis settings. Of the 80 million people projected to need humanitarian aid in 2014, more than three-quarters are women and children. The report shows that in the most challenging places to be a mother, 1 in 27 is likely to die from a pregnancy-related cause, and 1 in 7 children die before their 5th birthday. These are shocking figures and an absolute tragedy, especially because the majority of these deaths are preventable.

We must ensure that mothers their newborns and children living in crisis situations are put at the center of national and international processes when we provide humanitarian support in these challenging situations.

Despite more women delivering their babies in facilities that have skilled birth attendants, in many places we are not seeing the expected decline in maternal and newborn deaths, so something is not right with the quality of care being provided in facilities. As the world gets closer to the 2015 end of the Millennium Development Goals, how can we get real improvements in the quality of care at the large maternity facilities in the countries where most maternal and newborn deaths are concentrated?

Many countries are now encouraging women to deliver their babies in facilities and not at home, where there is no access to skilled care. This is the right policy. But to really reduce maternal and child deaths, policy makers must focus on what happens when women get to the facilities. We know that too many of the facilities are not able to provide quality care. They don't have the right equipment, they don't have the trained staff, and too often they just don't create a supportive environment for women -- a respectful environment so that pregnant women and new mothers are treated with dignity and compassion. Not surprisingly, women don't want to deliver their babies in facilities that can't offer a quality experience. Partners like the World Bank and Merck for Mothers, I know, are committed supporting countries with this critical quality issue.

The strong relationship between contraceptive use and maternal and newborn survival is not well known. I was surprised to learn that if all of the women who wanted to use modern contraception did, we would have 600,000 fewer newborn deaths each year and 80,000 fewer maternal deaths. Can you talk about the role of contraception in maternal and newborn health and survival, particularly for adolescent girls who are most at risk of death in childbirth and whose babies are at higher risk for newborn complications?

Contraceptive use is inextricably linked to maternal and newborn survival, as it decreases the risk of both maternal and newborn deaths among women most at risk -- adolescent girls, women who have had a very recent pregnancy, older women who have already had many pregnancies -- and it also reduces the need for unsafe abortions, which are now the third leading cause of maternal deaths. The United Nations Population Fund (UNFPA) -- the lead UN agency for delivering a world where every pregnancy is wanted, every birth is safe, and every young person's potential is fulfilled -- estimates that one in three deaths related to pregnancy and childbirth could be avoided if all women had access to contraception. The fact that more than 200 million women in the world today want to use modern contraception and can't get it is one of the most shameful statistics in global health. We all know the strong relationship between contraceptive use and women's empowerment and economic and social development, so reducing the unmet need for modern contraception must go right to the top of our global development priorities. We can't afford not to confront this issue, as many countries are still struggling with fertility rates above 5 children per woman, and this massive population growth is making to harder for women, for families, for communities and for entire nations to achieve their full potential.

Finally, I know that the Syrian conflict is one that is of particular concern to you. How is this grave crisis specifically impacting the health of mothers and children?

The current situation in Syria is both horrific and heartbreaking. Every day this brutal civil war continues, the resilience of Syria's women and children is further eroded, as they are weakened by malnutrition, disease, untreated aliments and injuries. Today, as a result of the conflict, the public health system has broken down and almost half of the Syrian population is on the move. Children under the age of five are at greater risk of dying from treatable and vaccine-preventable illness such as diarrhea, respiratory illness, measles and meningitis. Polio, once eradicated in Syria, has re-emerged and is putting the lives of children, both in Syria and in the region, at risk. Already, UNFPA estimates that there are over 2.8 million Syrian women and girls of reproductive age in need of support inside and outside the country. That number is expected to grow to 5 million in the next eight months. This means thousands of women bearing and delivering babies under the most perilous circumstances.

For families, dwindling resources keep women, babies and children away from seeking medical care often until problems have become critical. As in many middle-income countries, Syrian women had moved away from the practice of exclusive breastfeeding, a trend that has continued throughout the conflict. Newborns are therefore not getting the critical protection and nutrients provided by breast milk, but the lack of availability of formula, or the expense of it, means that mothers are using water and sugar to feed their small ones. Newborn babies are surely the most innocent and helpless victims of war. In Syria, less than half of the remaining functioning public hospitals have the equipment and staff to treat newborns. Prenatal, delivery and postnatal care, which are vital for a healthy mother and baby, are often impossible to access because of checkpoints and roadblocks, lack of security, lack of ambulances and lack trained health workers. We urgently need to increase the number of skilled and female health workers in crisis situations through improved access to training. We must ensure that every mother and newborn living in crises has access to high quality health care -- a goal expressed in the forthcoming Every Newborn Action Plan, which I urge governments to support and adopt at the World Health Assembly.

To learn more about the work of the UN Special Envoy for Financing the Health Millennium Development Goals and for Malaria, visit www.mdghealthenvoy.org