Knowledge Summary 1: Understand the burden
Where do we stand now?Progress on MDG 4 – Reduce under-five child mortality by two thirds between 1990 and 2015
Globally, under-five mortality has reduced by 35% (1990 – 2010). More children survive today than they did a decade ago. In 1990, there were more than 12 million under-five deaths globally, but in 2010, this had reduced to 7.6 million. Child mortality rate dropped from 88 deaths per 1000 live births, in 1990, to 57 in 2010. Although the rate of decline at 2.5% per year between 2000 and 2010, was an improvement from the 1.9% year between 1990 and 2000, it is still insufficient to meet the MDG 4.
Newborn deaths (41%) form the single largest category of deaths amongst under-fives. Preterm complications and birth asphyxia are the major causes for newborn deaths. Pneumonia, diarrhoea, malaria and other infections such as tuberculosis, measles, etc. cause more than half the deaths in under-fives. Although not included in this category, as they are not counted as child deaths, there were 2.6 million stillbirths in 2008.
Under-five deaths have declined by at least 50% in some countries, but continue to be particularly high in sub-Saharan Africa. About 1 in 8 under-five children continue to die in sub-Saharan Africa, and 1 in 15 underfives die in Southern Asia. Sub-Saharan Africa, with 121 deaths per 1000 live births, has nearly twice the averagerate seen in low- and middle-income countries. But some large reductions have also been seen here between 1990 and 2010, as four sub-Saharan countries recorded the largest absolute reductions. India, Nigeria, Democratic Republic of Congo, Pakistan and China account for half the under-five deaths.
Children in rural areas and from the poorest households are vulnerable. Even in areas where child mortality rates could be generally low, poor children under-five years in rural areas are 1.7 times more likely to die than those in urban areas. Children from the poorest 20% of households face more than twice the risk of dying as children in the richest 20% of households.
Children of mothers with secondary or higher education face less risk of dying. Basic primary education among mothers brings down child mortality rates, but with secondary or higher education, the reductions are much more significant. The chances of survival are almost two-fold higher if a child’s mother has secondary education. For example, in Latin America and the Caribbean, the ratio of under-five mortality amongst children who had mothers with no education to that of those with primary education is 1.6. This ratio increases to 3.1 between mothers with no education and those with secondary education, implying that higher educational levels bring larger benefits.
Progress on MDG 5 (target 1) – Reduce maternal mortality rates by three quarters between 1990 and 2015
Maternal mortality rates in low- and middle-income countries dropped by 34% (1990 to 2008). Despite a significant drop from 440 maternal deaths per 100,000 live births in 1990, to 290 deaths in 2008, the progress in low- and middle- income countries is not at a rate that can achieve the MDG. The progress has been uneven across regions with some regions such as Eastern Asia, Northern Africa, South-Eastern Asia and Southern Asia reporting reductions of 40% or more, while others such as sub-Saharan showing only a 26% reduction.
About 87% of maternal deaths happen in South Asia and sub-Saharan Africa (2008). South Asia has shown a 53% reduction (1990 to 2008), but is still host to a large number of maternal deaths. With maternal mortality rates of 280 deaths per 100,000 live births and 640 deaths per 100,000 live births, South Asia and sub-Saharan Africa respectively bear the largest burden of maternal deaths in the world.
More than 50% of maternal deaths are due to haemorrhage and hypertension. This high proportion of deaths due to haemorrhage and hypertension reflects the poor access to basic as well as emergency obstetric care. Unsafe abortions, which are also preventable, account for 9% of maternal deaths. About a fifth of the maternal deaths are due to indirect causes such as cardiac diseases, malaria, HIV/AIDS, etc.
Skilled birth attendance in low- and middle- income countries increased from 55 to 65% (1990 to 2009). There has been significant progress in many regions, but that is not enough yet. For example, in South Asia, skilled birth attendance improved from 32 to 50% (1990 to 2009), but coverage is still low here as well as in sub-Saharan Africa (46%).
Progress on MDG 5 (target 2) – Achieve universal access to reproductive health, by 2015
Proportion of women who received care from a skilled health worker at least once during pregnancy increased from 64 to 81% (1990 to 2009), but the proportion of those who had the recommended four contacts is only 51%. South Asia and followed by sub-Saharan Africa have the lowest ante-natal coverage. In South Asia the coverage for at least one contact is 70%, whilst that for four contacts is 44%. If India is excluded, the proportion of women having four contacts goes down to 26% in this region.
Childbearing among teenagers in low- and middleincome countries continues to be high at 54% (2008). Overall, teenage childbearing decreased between 1990 and 2000. But the rate of decline slowed down between 2000 and 2008, and in some places childbearing in this age group has actually increased. In sub-Saharan Africa, however, there has been little change in the past two decades and it still records the highest rate (122 births per 1000 women aged 15 to 19 years).
Although 61% of all married women or those with a partner (15 to 49 years) use contraception (2008), unmet need is high in some areas. In sub-Saharan Africa in 2008, only 22% of women in the above category used any contraception. And the proportion of women in sub-Saharan Africa who wished to delay or avoid pregnancy but did not use any contraception was 25%. These facts point to the low contraceptive prevalence in this region. Donor aid for family planning services as a proportion of total health care aid decreased from 8.2 to 2.6% between 2000 and 2009.
The sub-Saharan region is home to the highest maternal mortality rates and teenage pregnancy rates, lowest rates of skilled birth attendance, and contraception prevalence, making it the most unsafe place for a woman to become pregnant. With a growing population in the childbearing age group in low- and middle-income countries, the pressure on reproductive and maternal health services is set to increase. If the current trend of dwindling funds to reproductive health and family services continues, it could exacerbate the high rates of teenage pregnancies and low contraceptive use/prevalence – potentially leading to unsafe abortions and maternal deaths.
Poverty and lack of education are key determinants of under-five mortality rates, high rate of teenage pregnancies, low contraceptive use, lack of access to skilled birth attendance, undernourishment among children, lack of access to clean drinking water and proper sanitation. Improvements in these two key determinants can help accelerate progress in other areas.