International Journal of Gynecology and Obstetrics 119 (2012) S13–S17

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International Journal of Gynecology and Obstetrics

journal homepage: www.elsevier.com/locate/ijgo

IMPROVING MATERNAL HEALTH

Reducing maternal, newborn, and infant mortality globally: An integrated

action agenda
Zulfiqar A. Bhutta ⁎, Sergio Cabral, Chok-wan Chan, William J. Keenan
International Pediatric Association, Geneva, Switzerland

a r t i c l e i n f o a b s t r a c t

Keywords: There has been increasing awareness over recent years of the persisting burden of worldwide maternal, new-
Child mortality born, and child mortality. The majority of maternal deaths occur during labor, delivery, and the immediate
Maternal mortality postpartum period, with obstetric hemorrhage as the primary medical cause of death. Other causes of mater-
Newborn mortality
nal mortality include hypertensive diseases, sepsis/infections, obstructed labor, and abortion-related compli-
Integrated strategies
cations. Recent estimates indicate that in 2009 an estimated 3.3 million babies died in the first month of life
Interventions
and that overall, 7.3 million children under 5 die each year. Recent data also suggest that sufficient evidence-
and consensus-based interventions exist to address reproductive, maternal, newborn, and child health
globally, and if implemented at scale, these have the potential to reduce morbidity and mortality. There is
an urgent need to put elements in place to promote integrated interventions among healthcare professionals
and their associations. What is needed is the political will and partnerships to implement evidence-based
interventions at scale.
© 2012 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.

1. Why do maternal and newborn deaths matter? from delivering single interventions to delivering packaged treatment
strategies that have high coverage. Considering the epidemiology of
There has been increasing awareness over recent years of the maternal deaths, a health center intrapartum care strategy can be justi-
persisting burden of worldwide maternal, newborn, and child mor- fied as the best way to reduce high rates of maternal mortality [5].
tality. Although estimates differ, approximately 300 000 women die The importance of newborn, especially early newborn, survival
each year globally, while over 15 million suffer long-term illness or to achieving the targets of Millennium Development Goal (MDG) 4 is
disability due to complications of pregnancy and childbirth [1–3]. The recognized by evaluating trends in the reduction of child mortality
risks of adverse pregnancy outcomes are much higher in low-income globally (Fig. 1). While there have been steady reductions in late
countries compared with high-income countries. In Northern Europe, neonatal mortality (7–28 days after delivery) and postneonatal mortali-
the risk of pregnancy-related maternal mortality is 1 in 30 000 com- ty, the corresponding reduction in early neonatal mortality (less than
pared with 1 in 6 in low-resource regions. The majority of maternal 7 days after delivery) is much slower. This is understandable given
deaths occur during labor, delivery, and the immediate postpartum pe- that the coverage of many interventions that relate to care immediately
riod, with obstetric hemorrhage as the primary medical cause of death. prior and during childbirth remains poor. There were an estimated
Other causes of maternal mortality include hypertensive diseases, 4 million neonatal deaths for the year 2000 [6] and recent estimates
sepsis/infections, obstructed labor, and abortion-related complications. indicate that in 2009 an estimated 3.3 million babies died in the first
In Sub-Saharan Africa, the combined maternal mortality ratio for severe month of life—a reduction from an estimated 4.6 million neonatal
bleeding, hypertensive diseases, and infections is almost 500 deaths deaths in 1990 [7]. More than half of all neonatal deaths occurred in
per 100 000 live births compared with fewer than 300 per 100 000 in 5 countries (44% of global live births): 27.8% in India (19.6%), 7.2% in
South Asia and 4 per 100 000 in high-income nations [4]. Nigeria (4.5%), 6.9% in Pakistan (4.0%), 6.4% in China (13.4%), and 4.6%
The Lancet Maternal Survival Series, published in 2006, emphasized in Democratic Republic of the Congo (2.1%) [7]. Between 1990 and
that although there are numerous outcomes for maternal health, it is 2009, the global neonatal mortality rate (NMR) declined by 28%, from
most important to focus on the outcome of maternal mortality, espe- 33.2 deaths per 1000 live births to 23.9 deaths per 1000 live births [7].
cially in areas with a high burden. In recent years the focus has shifted The proportion of child deaths in the neonatal period increased in all
regions of the world, and globally it is now 41%. While NMRs were
halved in some regions, Africa's NMR only reduced by 17.6% (from
⁎ Corresponding author at: Division of Women & Child Health, The Aga Khan University,
43.6% to 35.9%). Of these mortalities, maternal health complications
Karachi 74800, Pakistan. Tel.: +92 21 34930051; fax: +92 21 34934294. contribute to 1.5 million neonatal deaths during the first week of life
E-mail address: zulfi[email protected] (Z.A. Bhutta). and 1.4 million stillborn babies [8].

0020-7292/$ – see front matter © 2012 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.
doi:10.1016/j.ijgo.2012.04.001
 18793479, 2012, S1, Downloaded from https://obgyn.onlinelibrary.wiley.com/doi/10.1016/j.ijgo.2012.04.001 by Cochrane Romania, Wiley Online Library on [08/08/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
S14 Z.A. Bhutta et al. / International Journal of Gynecology and Obstetrics 119 (2012) S13–S17

4 regions (Africa, Asia, the western Pacific, and the Middle East).
These should be the priority regions for targeting packaged interven-
tions across the continuum of maternal, newborn, and child care.
Undernutrition is also an important area of concern for women of
reproductive age living in these regions. Maternal short stature and
iron deficiency anemia increase the risk of maternal death at delivery,
and account for at least 20% of maternal mortality. Maximum benefits
for the child can be achieved via interventions that are targeted
toward undernutrition from pregnancy through the first 2 years of
the child's life. After the age of 2, undernutrition would have caused
irreversible damage for future development [10].
Keeping this global picture in view, several efforts have been made
to identify interventions and strategies to improve maternal and neo-
natal health indicators and to bridge the gap between the high- and
Fig. 1. Worldwide early neonatal, late neonatal, postneonatal, and childhood mortality, low-income nations of the world. Much of the global burden of
1990–2011. Reproduced with permission granted by Elsevier from Lozano et al. [3]. maternal mortality is among women who are poor, uneducated, of in-
digenous origin, and from marginalized or rural populations. These
deaths have enormous social, economic, and emotional repercussions
A limited number of conditions affect neonatal survival globally. for families and communities, and are a major factor in the inter-
The leading causes of neonatal death are estimated to be preterm generational transmission of poverty and persistent inequity in the
birth, severe infections, and asphyxia. Low birth weight and maternal burden of disease and ill health. Therefore, when considering integra-
complications also carry a high risk of neonatal death. The intercon- tion and delivery of interventions in health systems, it is important
nections between maternal and newborn deaths can be gauged from to address the determinants mentioned previously, even though this
the associations between several proximal and distal determinants may require long-term investments.
of maternal and newborn mortality and morbidity [9] (Table 1).
3. Defining evidence-based interventions for maternal, newborn,
2. Addressing determinants and child survival

A major cause of concern is child undernutrition, which is an Following the successful elucidation of evidence-based interven-
underlying determinant of mortality. Major manifestations of under- tions to address child survival globally [11], there have been many
nutrition include stunting, severe wasting, and intrauterine growth efforts to explain key interventions that could make a difference
restriction [10]. It is estimated that the combination of these manifes- if implemented at scale. This section summarizes some of the key
tations is responsible for 2·2 million deaths and 21% of disability- developments and benchmarks for progress.
adjusted life years (DALYs) for children younger than 5 years [10]. In the 2005 Lancet Neonatal Survival Series, 16 interventions with
Suboptimum breastfeeding practices contribute to about 1.4 million proven efficacy for neonatal survival were identified [12]. These inter-
deaths and 10% of disease burden in children younger than 5 years. ventions were combined into packages according to 3 service delivery
Vitamin A and zinc deficiencies also have significant impact. As a result models (outreach, family–community, and facility-based clinical care)
of previously established intervention programs, iodine and iron defi- [13]. These packages were targeted at different points along the con-
ciencies have small disease burdens. This suggests that such programs tinuum of care (preconception, prenatal, intrapartum, postnatal care,
have the potential to substantially improve undernutrition. Once etc.). This series revealed that interventions can be bundled in cost-
again, the burden of malnutrition is greatest in 20 countries across effective packages for delivery in health systems through outreach,

Table 1
Link between maternal and newborn deaths and cause of death pathways.

Distal determinants Proximal determinants Maternal morbidity and risk of mortality Associated newborn morbidity and risk of mortality

Poverty Maternal undernutrition Maternal anemia and risk of death due to Low birth weight,
Maternal infections hemorrhage or severe anemia SGA, prematurity, IUGR
Maternal tetanus, STIs, HIV/AIDS, malaria Neonatal infection
Poor access to services Late identification and referral Maternal pre-eclampsia, eclampsia, IUGR/prematurity, birth asphyxia
for high-risk pregnancies postpartum hemorrhage
Environment Indoor air pollution High risk of fetal morbidity, IUGR, and stillbirths Increased risk of birth asphyxia , newborn infections,
pneumonia, and other respiratory disorders
Sociocultural Women's empowerment Female genital mutilation Mother-to-child transmission, birth asphyxia
Lack of social support system STIs, HIV/AIDS, stillbirths, spontaneous
Cultural taboos abortions, abortions, postpartum complications
Unsafe/unprotected sex
Drug abuse
Domestic violence
Illiteracy/lack of education Maternal infections Mother-to-child transmission
Political instability Health program sustainability, Maternal morbidity and mortality risks Neonatal morbidity and mortality risks
health policy
Economic instability Lack of resources to provide Risk for maternal depression Low birth weight, undernutrition, infections,
optimal services Failure to thrive
Unemployment
Lack of program planning Untrained healthcare workers Mismanagement of high-risk pregnancy, Birth and newborn complications
(TBA, CHW, Lay Health Workers etc.) maternal morbidity and mortality
Genetic susceptibility Chronic morbidities Congenital malformations, thalassemia prevention, etc.

Abbreviations: SGA, small for gestational age; IUGR, intrauterine growth restriction; STIs, sexually transmitted infections; TBA, traditional birth attendant; CHW, community health
worker.
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Z.A. Bhutta et al. / International Journal of Gynecology and Obstetrics 119 (2012) S13–S17 S15

family–community care, and facility-based clinical care. However, maternal infections, as well as detection and management of diabetes,
current coverage rates for many of these interventions are extremely hypertension, and intrauterine growth restriction, the reviews once
low. It was estimated that in countries with high mortality and again underscore the need to improve infrastructure for comprehen-
poor health systems, outreach and health education of families and sive essential and emergency obstetric care. It has been shown that
communities could have a significant impact on preventing neonatal the provision of cesarean delivery and timely induction of labor have
deaths, with universal implementation of these packages of interven- considerable potential to reduce maternal and newborn deaths, as
tions potentially averting up to approximately 72% of neonatal deaths well as stillbirths, in low-resource settings [18].
in 75 countries [12]. Although some reviews in the past have evaluated the cost-
The Lancet Maternal and Child Undernutrition Series, published in effectiveness of individual interventions [12,19,20] and intervention
2008, focused on interventions such as promotion of breastfeeding, packages such as community-based newborn care packages, prenatal
strategies to promote complementary feeding, micronutrient inter- care (tetanus toxoid, screening for pre-eclampsia, screening and treat-
ventions, general supportive strategies to improve family and com- ment of asymptomatic bacteriuria and syphilis), skilled attendance at
munity nutrition, and strategies to reduce the burden of infections birth, and emergency obstetric and neonatal care, much more work is
such as malaria in pregnancy [14]. In the 2007 Lancet series based on needed to identify “best buys” in low-resource settings. Similarly, the
continuum of care for maternal, neonatal, and child health (MNCH), importance of going beyond survival to also address issues of quality
a case was made for providing some 190 interventions through of life and human development is just being appreciated [21].
8 packages that could be delivered at various levels of the health sys- This evidence has been vetted recently by a wide range of stake-
tem [15]. As a further step toward integrating interventions, the 2008 holders, including healthcare professionals, academics, and develop-
Lancet Alma-Ata series emphasized skilled care at facility levels for ment partners to develop consensus-based interventions to address
saving maternal lives and scaling up of community and household reproductive, maternal, newborn, and child health globally, and pub-
care for improving newborn and child survival. The series identified lished with the requisite key commodities, care providers at various
37 key promotional, preventive, and treatment interventions and strat- levels of care, and key training guidelines [22] (Table 2). The key chal-
egies for delivery in primary health care [16]. This review reaffirmed lenge remains delivering these interventions in an integrated manner
that primary healthcare interventions could make a significant differ- at scale and to those hardest to reach.
ence to MNCH outcomes and could be packaged for delivery across
the continuum of care (Fig. 2). It was noted that substantial gains can 4. Delivering integrated MNCH interventions in primary
be made for maternal and newborn outcomes by focusing on packages care settings
that relate to outcomes for both.
More recently, in an update of past reviews of interventions to Based on the potential health benefits of providing packaged inter-
address the orphan area of stillbirths [17], key interventions were ventions, focused and rapid actions are needed if significant progress is
identified that can be used to scale-up care for reducing intrapartum to be made toward MDGs 4 and 5. Reductions in maternal and neonatal/
stillbirths [18]. In addition to identifying interventions to address infant mortality can be achieved through various approaches, such as

Fig. 2. Integrated maternal, newborn, and child health packages of care. Source: Modified from Kerber et al. [15].
 18793479, 2012, S1, Downloaded from https://obgyn.onlinelibrary.wiley.com/doi/10.1016/j.ijgo.2012.04.001 by Cochrane Romania, Wiley Online Library on [08/08/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
S16 Z.A. Bhutta et al. / International Journal of Gynecology and Obstetrics 119 (2012) S13–S17

Table 2
Maternal, stillbirth, and newborn interventions that relate to each other and make a difference.

Maternal interventions Newborn interventions Impacts

Micronutrient supplementation, Periconceptual Reduction in maternal undernutrition, reduced SGA,

folic acid supplementation LBW, prematurity, IUGR
Family planning/birth spacing, teenage pregnancy Reduction in high-risk pregnancy and complications
prevention
PMTCT Vaccination and ART Prevention of infection transmission
Smoking and alcohol cessation Reduction in maternal undernutrition, reduced SGA,
LBW, prematurity, IUGR
Prevention of intimate partner violence Spontaneous abortions, abortions
ITN/IPTp ITN/ IPTp Infection prevention, anemia prevention
Emergency obstetric care, intervention to prevent Community-based packages for birth and Prevention and management of birth complications
and manage hypertension, birth preparedness, newborn care preparedness
social support during childbirth, basic bkilled
obstetric care at birth
Antiplatelet agents for high-risk pregnancy, Preventing delivery complications, maternal morbidity
Antibiotics for premature rupture of membranes and mortality
Postpartum care Immediate thermal care, Kangaroo mother care, Maternal infections, postpartum complications
Hygiene care and cord care, care of preterm babies prevention, neonatal infection prevention
chlorhexidine, breast feeding
Women's groups, home visits, vaccinations, Care of preterm babies, emollients, vaccinations, Management of neonatal infection and associated
education programs, nutrition counseling presumptive antibiotics, case management of morbidity and mortality, prevention of maternal
neonatal sepsis, meningitis and pneumonia and child undernutrition

Abbreviations: SGA, small for gestational age; LBW, low birth weight; IUGR, intrauterine growth restriction; PMTCT, prevention of mother-to-child transmission; ART, antiretroviral
therapy; ITN/IPTp, insecticide-treated bed nets/intermittent preventive treatment for malaria in pregnancy.

the confidential review of maternal deaths, the use of evidence-based trials have been of sufficient scale to merit inclusion in this review
treatments and interventions, using a health systems approach, the and most have been undertaken in representative population settings
use of information technology and global and regional partnerships, with robust cluster randomized designs, thus making direct meta-
and making pregnancy safer through initiatives that increase the focus analysis of impact easier to assess. In addition, many intervention
on human rights. However, only a few systematic efforts have been packages were implemented in a way that made it possible to evaluate
attempted to take advantage of potential synergies in defining key process indicators as well as hard morbidity and mortality outcomes
interventions that integrate maternal and newborn health. across the continuum of MNCH. Such community-based strategies
Maternal, newborn, and child health lies at the center of primary focusing on healthcare providers and domiciliary care can be coupled
health care. It cannot be effectively improved and sustained by vertical with additional strategies to address financial barriers such as con-
programs alone. An integrated health system is potentially better able ditional cash transfers [26], especially those providing support for
to deal with the challenges of addressing health care and allocating maternal and newborn services [27] and innovative public–private
resources for the needs of mothers, newborns, infants, and children. partnerships [28].
Therefore, it is important to recognize that the mother is not a lone The bottom line is that all of this can be done. What we need is the
entity, and that when she seeks medical attention at the primary political will and partnerships to implement evidence-based inter-
care level, or goes for a prenatal visit, any opportunity to gain informa- ventions at scale, frequently within the resources available in low-
tion regarding the health status of her children should not be missed. and middle-income countries. The MDG 4 and 5 targets are upon us
For example, an unimmunized child can be screened and vaccinated and may not be met, and this should reenergize our efforts to work
appropriately, growth parameters can be assessed, and cases of mal- together to achieve these goals.
nutrition can be addressed. In this way, health intervention packages
can be delivered to the whole family, across population groups. Conflict of interest
Although primary healthcare strategies might be most appropriate
to address these issues and offer solutions, they might only be helpful Z. Bhutta is Treasurer of the International Pediatric Association
if the focus is on investments and actions to increase coverage with (IPA); S. Cabral is IPA President; Chok-wan Chan is a member of the
equitable access and empowerment of communities to make healthy IPA Executive Committee; and W. Keenan is IPA Executive Director.
choices for themselves. It has also been stated that health sector inter- The authors have no conflicts of interest to declare.
ventions alone may be insufficient and community development and
intersectoral collaboration, community empowerment, and poverty
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