ReviewReproductive, maternal, newborn, and child health: key messages from Disease Control Priorities 3rd Edition
Introduction
In September, 2000, 189 world leaders signed a declaration on eight Millennium Development Goals (MDGs) to improve the lives of women, men, and children in their respective countries.1 Goal 4 called for a reduction in child mortality by 67% and Goal 5 for an improvement to maternal health, with target 5a referring to a reduction of maternal mortality by 75% between 1990 and 2015 and 5b to achievement of universal access to reproductive health.
For several decades, reproductive, maternal, newborn, and child health (RMNCH) has been a priority for most governments in low-income and middle-income countries (LMICs) and for donors and non-governmental agencies. For example, recent analyses by the Partnership for Maternal, Newborn and Child Health2, 3 showed that annual official development assistance for RMNCH to the 75 highest-burden countries increased from US$3·5 billion in 2006 to $8·7 billion in 2012. Since 1990, and notably after the MDG declaration, substantial progress has been made in improving RMNCH outcomes, with accelerated progress since 2005 that shows in particular the increased attention paid by the global community to improving the health of women and children. The UN Secretary General's Global Strategy for Women's and Children's Health, launched in 2010 and recast as the Global Strategy for Women's, Children's and Adolescents' Health in 2015, is an indication of the continued global commitment to the survival and wellbeing of women and children.4
However, a substantial burden of disease still remains in LMICs from unwanted pregnancies; high maternal, neonatal, and child mortality; prevalent malnutrition; frequent communicable and non-communicable diseases; and loss of human capacity to contribute to society. Cost-effective interventions that can be implemented widely in LMICs could greatly reduce these problems at an affordable cost, with substantial societal benefits.
RMNCH encompasses health concerns across the life course, from adolescent girls and women before and during pregnancy and delivery, to newborn babies (ie, in the first month of life) and to children. An important organisational framework is the continuum of care approach, which recognises the links from mother to child and the need for health services across the life course. This approach includes integrated preventive and therapeutic health interventions delivered through service platforms ranging from the community to the primary health centre (PHC) and to the hospital.
The RMNCH volume is part of the Disease Control Priorities 3rd Edition (DCP3), a nine-volume compendium that details the most up-to-date evidence on intervention efficacy and programme effectiveness for the leading causes of global disease burden (panel 1). Other volumes in the DCP3 series also cover topics of importance to women and children, including disorders requiring surgery, cancer, mental disorders, HIV/AIDS and other sexually transmitted infections, tuberculosis, and malaria, as well as the health and development of children older than 5 years. The RMNCH volume and this Review present the amount and trends of RMNCH indicators, proven interventions for prevention of mortality, the potential effects and costs of these interventions, and potential health service delivery platforms and system innovations in different World Bank regions and globally.
Section snippets
Reproductive health
Poor reproductive health outcomes for women and their children are related to a broad spectrum of adverse circumstances and risk factors, such as unsafe sex leading to unwanted pregnancies and sexually transmitted infections, as well as violence against women and girls. Because these are sensitive matters and often associated with cultural and social context, measurement and quantification of the burden of these circumstances and risk factors remains a challenge. The DCP3 volume focuses on four
Maternal, fetal, and child malnutrition and early childhood development
Malnutrition in women and in children under age 5 years includes both undernutrition and the increasing problem of overweight. One important measure of malnutrition in women of reproductive age (20–49 years) is body-mass index (BMI). A BMI of less than 18·5 kg/m2 is defined as undernutrition or excessive thinness and a BMI of at least 25 kg/m2 is classed as overweight. In 1980, the prevalence of maternal undernutrition was almost 20% in Asia and Africa, but it has fallen since then.23
Interventions to reduce maternal and child morbidity and mortality
The RMNCH volume identifies essential interventions, based on their efficacy and appropriateness to address important health conditions. In Figure 4, Figure 5, Figure 6, these interventions are listed according to the least advanced service platform where their delivery is possible. The three platforms represent services that can be provided by (1) community health workers or health posts, (2) PHCs, or (3) hospitals, both community and referral. The interventions are grouped by which stage they
Effect of essential interventions on stillbirths and maternal, neonatal, and child deaths
In this analysis, we estimated the deaths averted by essential interventions individually and grouped into three packages: (1) Reproductive Health, (2) Maternal and Newborn Health, and (3) Child (1–59 months) Health. We report the estimated effect on maternal, newborn, and child deaths and stillbirths in 75 countries in which over 95% of the world's maternal and child deaths occur.34 Estimates are derived using the Lives Saved Tool (LiST; panel 2)35, 36, 37, 38, 39, 40, 41, 42, 43, 44 by
Cost of scaling up essential interventions for RMNCH
The cost-effectiveness of individual RMNCH interventions, summarised in panel 3, is well established.49 In the RMNCH volume, we have estimated the cost of scaling up the Reproductive Health (family planning only), Maternal and Newborn Health, and Child Health packages in 74 of the 75 countries (Sudan excluded because of absence of data) that account for more than 95% of the world's maternal and child deaths. The estimated annual incremental costs are based on per-capita costs from an investment
Role of health-care delivery mechanisms
Many gaps exist in access to services, resulting in essential interventions not reaching the high coverage and quality needed to prevent more deaths. To help address these gaps, there has been great interest in task shifting, an innovative approach to delivery of more RMNCH services through reassignment of part or all of some tasks to other groups of workers. Lay community health workers (eg, health extension workers in Ethiopia) are being increasingly used to classify and treat childhood
Conclusions
Despite sizable recent reductions in child and maternal mortality, the speed of reduction in mortality has been too slow to achieve MDGs 4 and 5 globally. Particular world regions, especially sub-Saharan Africa, have high prevalence of fertility, maternal mortality, and under-5 mortality, providing a compelling case for accelerated implementation of integrated RMNCH interventions.
Most deaths from RMNCH conditions could be greatly reduced by scaling up packages of integrated interventions across
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