Extreme Risk for Pregnant Women and Newborn Babies in Developing Countries – UNICEF Report

Each year, more than half a million women die from causes related to pregnancy and childbirth, and nearly 4 million newborns die within twenty-eight days of birth. Millions more suffer from disability, disease, infections and injury. Cost-effective solutions are available that could bring rapid improvements, but urgency and commitment are required to implement them and to meet the Millennium Development Goals related to maternal and child health. The first chapter of the state of the world’s children 2009 examines trends and levels of maternal and neonatal health in each of the major regions using mortality ratios as benchmark indicators.

UNICEF this year has narrowed the reasons behind children’s deaths, and has gone deep to the core of the problem in order to help reduce the number of newborns who die soon after birth.

Women in the world’s least developed countries are 300 times more likely to die during childbirth, or from pregnancy-related complications than women in developed countries, according to UNICEF’s latest State of the World’s Children report, released today.

At the same time, a child born in a developing country is almost 14 times more likely to die during the first month of life than a child born in a developed one. The health and survival of mothers and their newborns are linked, and many of the interventions that save new mothers’ lives also benefit their infants. The 2009 edition of UNICEF’s flagship publication, The State of the World’s Children, highlights the link between maternal and neonatal survival, and suggests opportunities to close the gap between rich and poor countries.

“Every year, more than half a million women die as a result of pregnancy or childbirth complications, including about 70,000 girls and young women aged 15 to 19,” said Ann M. Veneman, UNICEF Executive Director, at the Johannesburg launch. “Since 1990, complications related to pregnancy and childbirth have killed an estimated 10 million women.”

Both mothers and infants are vulnerable in the days and weeks after birth – a critical time for life-saving interventions, such as post-natal visits, proper hygiene, and counseling about the danger signs of maternal and newborn health.

While many developing countries have made excellent progress improving their child survival rate in recent years, there has been less headway in reducing maternal mortality.

Niger and Malawi, for example, nearly cut their under-five death rates in half between 1990 and 2007, and in Angola the child mortality rate fell from 258 to 158 per 100,000 live births in the same time period. In Indonesia, under-five death rates fell to nearly a third of what they were in 1990, and in Bangladesh they fell by more than a half.

The same progress has not been made in addressing health risks for mothers, who are most vulnerable during delivery and in the first days after birth. And while the rate of survival for children less than five years of age is improving globally, the risks faced by infants in the first 28 days remain at unacceptably high levels in many countries.

In the developing world, a woman has a 1 in 76 lifetime risk of maternal death, compared with a probability of 1 in 8,000 for women in developed countries. Approximately 99 percent of global deaths arising from pregnancy and complications occur in the developing world, where having a child remains among the most serious health risks for women. The vast majority occur in Africa and Asia, where high fertility rates, a shortage of trained personnel and weak health systems spell tragedy for many young women.

The ten countries with the highest lifetime risk of maternal death are Niger, Afghanistan, Sierra Leone, Chad, Angola, Liberia, Somalia, the Democratic Republic of Congo, Guinea-Bissau, and Mali. A woman’s lifetime risk of maternal death in these countries ranges from 1 in 7 in Niger to 1 in 15 in Mali. And for every woman who dies, another 20 suffer illnesses or injury, often with severe and lasting consequences.

To lower maternal and infant mortality, the report recommends essential services be provided through health systems that integrate a continuum of home, community, outreach and facility-based care.

This continuum of care concept transcends the traditional emphasis on single, disease-specific interventions, calling instead for a model of primary health care that embraces every stage of maternal, newborn and child health.

“Saving the lives of mothers and their newborns requires more than just medical intervention,” said Veneman. “Educating girls is pivotal to improving maternal and neonatal health and also benefits families and societies.”

The report finds that health services are most effective in an environment supportive of women’s empowerment, protection, and education.

The Over all State of the World’s Children’s messages are to save children’s lives, we need to address the health of their mothers; there is an inextricable link between maternal and infant survival; women in developing countries are 300 times more likely to die from pregnancy and childbirth complications than women living in the industrialized world. Progress in maternal and neonatal health has fallen far behind advances in child survival; maternal mortality ratios mirror the overall effectiveness of health systems; to thrive, women and their children must have access to essential timely services at home, in the community, and at health facilities. Saving the lives of mothers and their newborns requires more than just medical intervention; it requires an environment that empowers women and respects their rights.

According to the report, what is needed to prevent maternal and neonatal deaths is rapid progress through sound strategies, political commitment, adequate resources and collaborative efforts, applied in support of the health of both mothers and newborns.

This is in addition to the continuum of care, which embraces every stage of maternal, newborn and child health, and which differs from the traditional disease-specific approach. These essential services for mothers, newborns and children are most effective when they are delivered in a timely fashion at critical points in the life cycle of mothers and children: adolescence, pre-pregnancy, pregnancy, birth, post-partum, neonatal, infancy and childhood. Post-natal care urgently needs to be expanded during the first 24-48 hours after birth, when the risks of maternal and newborn death are greatest.

The interrelated health needs of women, newborns and children require integrated solutions. Essential services must be provided at key points in the life cycle through dynamic health systems that integrate a continuum of home, community, outreach and facility-based care. An integrated approach reaps more dividends than myriad separate initiatives. Linking interventions in packages not only increases their efficiency and cost-effectiveness, but it provides greater incentive for people to use them and greater opportunity to extend and enhance coverage.

The essential services required to support a Continuum of Maternal and Neonatal Care include: enhanced nutrition, safe water, sanitation and hygiene practices, disease prevention and treatment; quality reproductive health services; adequate antenatal care; skilled attendance at delivery, emergency obstetric and newborn care; post-natal care; neonatal care; and Integrated Management of Neonatal and Childhood Illness.

The report states the main causes of maternal and neonatal mortality, dividing them into direct medical causes, reproductive health and family planning, indirect factors influencing maternal and neonatal health, weak health systems and lack of access to facility-based care.

Three quarters of all maternal deaths occur from complications either during delivery or in the immediate post-partum period. These complications include: hemorrhaging, (25 percent of maternal deaths); infections (15%); unsafe abortion (13 %); eclampsia or hypertensive disorders (12 %); and obstructed labour (8%). Mortality risks for mothers and newborns are particularly elevated within the first two days after birth.

Studies show that involuntary pregnancies carry a greater risk than those that are wanted; women with unwanted pregnancies are less likely to receive early antenatal care or give birth under medical supervision. Such pregnancies may also risk unsafe abortions – a significant cause of maternal death.

There is growing consensus that improving access to reproductive health – especially among young people – can have a positive impact on maternal and newborn health. In 2005, the United Nations added universal access to reproductive health as a specific target of the Millennium Development Goal on maternal health.

Linking Maternal and Newborn Health:
The health and survival of mothers and their newborns are intrinsically linked, and many of the same interventions that save maternal lives also benefit their infants.

Regions with high maternal death rates show correspondingly high rates of neonatal mortality. Lowering a mother’s risk of mortality directly improves a child’s prospects for survival. Babies whose mothers die during the first six weeks of their lives are far more likely to die before their second birthday than babies whose mothers survive. Like maternal deaths, the vast majority of neonatal deaths occur in the developing world, and have received far too little attention. A child born in a poor country is almost 14 times more likely to die during the first 28 days of life than one born in an industrialized country. Almost 40 percent of all under 5 deaths occur in the first 28 days of life, three-quarters of which take place in the first seven days. During this early neonatal period, babies and mothers are most vulnerable.

II) Maternal Mortality: The General Picture
While many developing countries and several regions have managed to make significant advances in child survival, several of these same countries have failed to make any serious progress in reducing maternal mortality rates. At the same time, the proportion of under-five deaths occurring in the early neonatal period have risen dramatically. Between 1980 and 2000, deaths in the first week of life have risen from 23 to 28 per cent of overall under-five mortality rates.

Millions of women who survive childbirth suffer from pregnancy-related injuries, infections, diseases and disabilities. For every maternal death, some 20 women – or 10 million a year – suffer complications with severe consequences.

If women had access to essential maternity and basic health-care services, up to eighty percent of all maternal deaths and injuries could be avoided.

Progress on diminishing maternal mortality ratios has been virtually non-existent in sub-Saharan Africa, where half of all maternal deaths take place.

Maternal mortality ratios are particularly staggering in sub-Saharan Africa. Within this region, Sierra Leone – with 2100 maternal deaths per 100,000 live births – has the highest maternal mortality ratio in the world, followed closely by Niger, with an MMR of 1800 deaths per 100,000 live births. In comparison, Tunisia and Egypt have maternal mortality ratios of 100 and 130, respectively.

India accounts for 22 per cent of the global total of maternal deaths; an estimated 117,000 women died from maternal causes in 2005.

Elevated fertility rates, combined with weak access to basic health care and maternity services can have life-long implications for women’s survival. In the developing world as a whole, a woman has a 1 in 76 lifetime risk of maternal death, compared with a probability of just 1 in 8000 for women in industrialized countries. In Niger, the country with the highest lifetime risk, her chance of dying skyrockets to 1 in 7, in contrast to 1 in 47,600 in Ireland.

With the exception of sub-Saharan Africa, all regions have made progress improving access to life-saving maternity services, particularly in regard to skilled attendance at delivery. Yet the global community is not on target to reach the Millennium Development Goal on maternal mortality, which will require a 70 percent reduction in maternal deaths between 2005 and 2015.


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