The promise: In 2000, the world made a promise to children: to reduce by two-thirds between 1990 and 2015, the rate of under-five mortality. In 2012, world leaders renewed the promise. Since the global launch of Committing to Child Survival: A Promise Renewed in June 2012, nearly 180 governments have pledged to scale up efforts to accelerate declines in preventable maternal, newborn and child deaths.
An overview of child survival: good news and bad
Globally, major progress has been made in improving child survival. The under-five mortality rate has declined by almost half since 1990, dropping from 90 to 46 deaths per 1,000 live births in 2013. The absolute number of under-five deaths was cut in half during the same period, from 12.7 million to 6.3 million, saving 17,000 lives every day.
The under-five mortality is falling faster than at any other time during the past two decades. Globally, the annual rate of reduction has more than tripled since the early 1990s. Eastern and Southern Africa currently has highest annual rate of reduction in the world with the exception of East Asia and the Pacific. Thanks to this accelerated progress, almost 100 million children have been saved over the past two decades – including 24 million newborns. These are babies who would have died had mortality remained at 1990 rates.
Under-five mortality is falling among the poorest children in all regions. Moreover, greater gains have been made among the poorest households than among the richest in all regions except sub-Saharan Africa. Between 1990 and 2010, the gap between the richest and poorest households fell in all regions except sub-Saharan Africa. However, substantial disparities remain in all regions.
But despite these advances, the toll of under-five deaths over the past two decades is staggering: between 1990 and 2013, 223 million children worldwide died before their fifth birthday.
Progress is insufficient to meet MDG 4. If current trends continue in all countries, the target will only be reached globally by 2026, 11 years behind schedule.
Sub-Saharan Africa and South Asia, together account for 4 out of 5 under-five deaths globally. Sub-Saharan Africa continues to shoulder the greatest burden: 1 in 11 children born there still die before age 5, nearly 15 times the average in high-income countries (1 in 159). The recent momentum achieved in Sub-Saharan Africa needs to be sustained and accelerated.
Although child deaths from leading infectious diseases have declined significantly, pneumonia, diarrhoea and malaria are still the main killers of children. Pneumonia, diarrhoea or malaria make up about one third of all under five deaths in 2013. Importantly, neonatal deaths account for 44% of all under-five deaths.
The first 28 days of life – the neonatal period – is the most vulnerable time for a child’s survival.The good news is that neonatal mortality is declining globally. The worldwide neonatal mortality rate fell by 40 per cent between 1990 and 2013 from 33 to 20 deaths per 1,000 live births.
The lives of 24 million newborns have been saved since 1990.Yet despite the availability of effective, proven strategies to prevent newborn deaths, 2.8 million babies still died in the first month of life in 2013, largely of preventable causes. Neonatal health must be prioritized to sustain the rapid progress on overall child mortality.
Mortality during the neonatal period is falling slower than during other age groups. As a result, the proportion of under-five deaths during the neonatal period has gone up in every region. Globally, it increased from 37 to 44 per cent between 1990 and 2013.
For 1 million babies every year, their day of birth is also their day of death, accounting for more than a third of neonatal deaths. Close to 2 million newborns die in the first week of life. Investments in maternal care, specifically labour and delivery care and other high-impact interventions focused on the 24 hours around the time of birth, hold the greatest potential for reducing neonatal mortality.
- Many deaths in the first month of life result from diseases and conditions that are readily preventable or treatable with proven, cost-effective interventions. Globally, preterm birth complications and complications during labour and delivery (intrapartum-related complications) account for nearly 60 per cent of neonatal deaths. The focus clearly needs to be on preventing these deaths by providing high-quality care for both the mother and the baby around the time of birth.
Educating women is crucial for reducing neonatal mortality. Neonatal mortality rates among mothers with no education are nearly twice as high as for mothers with secondary education or higher. The family’s wealth and geographic location (urban/rural) also remain powerful determinants of inequities in neonatal mortality.
Some newborns are particularly vulnerable – those born to the youngest and oldest mothers, as well as mothers living in rural areas. Children born shortly after another sibling are also at greater risk of dying than those born after longer intervals between births. Therefore, ending child marriage, reducing adolescent pregnancy and extending birth intervals are crucial to reducing the risk of newborn mortality.
The Promise: Reaching every newborn with quality care
- Too many mothers and newborns miss out on key interventions that can save their lives. Pregnant mothers and their babies require access to high-quality services along a continuum of care from pregnancy through childbirth and the postnatal period. There is substantial variation in access to and use of these services and in the quality of care across countries.
Newborns are most vulnerable during the first hours and days of life, yet this critical window of opportunity is being missed.
- Evidence shows that initiating breastfeeding within one hour of birth reduces the risk of neonatal death by 44 per cent. Yet fewer than half of newborn babies (43 per cent) worldwide receive the benefits of immediate breastfeeding.
In the regions with the highest neonatal mortality rates, access to postnatal care is abysmally low. In the majority of countries with data in sub-Saharan African and South Asia, fewer than half of mothers and babies receive a postnatal health check.
- Complications during labour and delivery are responsible for approximately a quarter of all neonatal deaths worldwide. Yet in 2012, one in three babies – an estimated 44 million – entered the world without the help of a skilled health care provider, putting them at even greater risk during this most vulnerable time.
Coverage of key maternal and newborn interventions is too low. Only about half of women worldwide receive the recommended minimum of four antenatal care visits. Global progress has been modest since 1990, increasing on average only by 15 percentage points, from 37 to 52 per cent of women.
- One third of women globally deliver their baby without the help of a doctor, nurse or midwife. The global rate of women delivering with skilled attendance has risen by a mere 12 percentage points since 1990– from 57 to 69 per cent.
Quality of care is grossly lacking even for babies and mothers who have contact with the health system. A 10 countries analysis suggests that less than 10 per cent of mothers who saw a skilled provider during pregnancy received a set of eight key interventions. Similarly, less than 10 per cent of babies who were delivered by a skilled health professional went on to receive seven needed interventions, including early initiation of breastfeeding and postnatal care.
In the least developed countries, women in the richest households are almost three times as likely to give birth with a skilled attendant as women in the poorest. The poorest are worst off in the countries with the lowest coverage. Not only are poor mothers and babies less likely to have contact with the health system, but when they do they are less likely to receive high-quality care.
Globally, only 59 per cent of children under age 1 have had their birth registered at birth. In the high-mortality regions of South Asia and sub-Saharan Africa, only about one third of infants are registered. Children must be registered at birth if they are to have assured access to services, such as to health care and education.
Better data are needed to help guide programmes. Although information on use of basic services increased greatly over the past decade, more effort is needed to understand the quality of care available to women across the continuum of pregnancy, delivery and the postnatal period. Expanding the availability and quality of population and health facility data must include a concerted effort to register every newborn and count the deaths of every mother and newborn, including stillbirths. Global commitment and priorities for action
Since the global launch of A Promise Renewed in June 2012, nearly 180 governments have pledged to scale up efforts to accelerate declines in preventable maternal, newborn and child deaths.
Under the banner of A Promise Renewed, nearly 20 of these are turning their pledges into practical action by sharpening national strategies for reproductive, maternal, newborn and child health, setting costed targets and monitoring progress. More countries need to do the same. By scaling-up progress for women and children, governments are positioning countries to close the gap on MDG 4 and sustain the progress well after 2015.
With millions of women and children still at risk of dying of preventable causes, maternal, newborn and child survival must remain at the heart of the post-2015 global development agenda. The world cannot abandon its promise to women and children.
Now is the time to scale-up progress. The Every Newborn Action Plan represents a global consensus on the actions that need to be taken to scale up progress on newborn survival.
The world has the knowledge and solutions to save ever more women, newborns and children from dying of causes that are easily avoidable.