Elsevier

The Lancet

Volume 388, Issue 10061, 3–9 December 2016, Pages 2811-2824
The Lancet

Review
Reproductive, maternal, newborn, and child health: key messages from Disease Control Priorities 3rd Edition

https://doi.org/10.1016/S0140-6736(16)00738-8Get rights and content

Summary

As part of Disease Control Priorities 3rd Edition, the World Bank will publish a volume on Reproductive, Maternal, Newborn, and Child Health that identifies essential cost-effective health interventions that can be scaled up to reduce maternal, newborn, and child deaths, and stillbirths. This Review summarises the volume's key findings and estimates the effect and cost of expanded implementation of these interventions. Recognising that a continuum of care from the adolescent girl, woman, or mother to child is needed, the volume includes details of preventive and therapeutic health interventions in integrated packages: Maternal and Newborn Health and Child Health (along with folic acid supplementation, a key reproductive health intervention). Scaling up all interventions in these packages from coverage in 2015 to hypothetically immediately achieve 90% coverage would avert 149 000 maternal deaths, 849 000 stillbirths, 1 498 000 neonatal deaths, and 1 515 000 additional child deaths. In alternative calculations that consider only the effects of reducing the number of pregnancies by provision of contraceptive services as part of a Reproductive Health package, meeting 90% of the unmet need for contraception would reduce global births by almost 28 million and consequently avert deaths that could have occurred at 2015 rates of fertility and mortality. Thus, 67 000 maternal deaths, 440 000 neonatal deaths, 473 000 child deaths, and 564 000 stillbirths could be averted from avoided pregnancies. Particularly effective interventions in the Maternal and Newborn Health and Child Health packages would be management of labour and delivery, care of preterm births, and treatment of serious infectious diseases and acute malnutrition. Nearly all of these essential interventions can be delivered by health workers in the community or in primary health centres, which can increase population access to needed services. The annual incremental cost of immediately scaling up these essential interventions would be US$6·2 billion in low-income countries, $12·4 billion in lower-middle-income countries, and $8·0 billion in upper-middle-income countries. With the additional funding, greater focus on high-effect integrated interventions and innovations in service delivery, such as task shifting to other groups of health workers and supply and demand incentives, can help rectify major gaps in accessibility and quality of care. In recent decades, reduction of avoidable maternal and child deaths has been a global priority. With continued priority and expansion of essential reproductive, maternal, newborn, and child health interventions to high coverage, equity, and quality, as well as interventions to address underlying problems such as women's low status in society and violence against women, these deaths and substantial morbidity can be largely eliminated in another generation.

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

References (66)

  • DR Singla et al.

    Effects of a parenting intervention to address both maternal psychological wellbeing and child development and growth in rural Uganda: a community-based, cluster randomised trial

    Lancet Glob Health

    (2015)
  • SP Walker et al.

    Child development: risk factors for adverse outcomes in developing countries

    Lancet

    (2007)
  • JH Requejo et al.

    Countdown to 2015 and beyond: fulfilling the health agenda for women and children

    Lancet

    (2015)
  • S Venis

    Child survival

    Lancet

    (2003)
  • G Jones et al.

    How many child deaths can we prevent this year?

    Lancet

    (2003)
  • R Pattinson et al.

    Stillbirths: how can health systems deliver for mothers and babies?

    Lancet

    (2011)
  • ZA Bhutta et al.

    Interventions to address diarrhoea and pneumonia deaths equitably: what works and at what cost?

    Lancet

    (2013)
  • GP Garnett et al.

    Mathematical models in the evaluation of health programmes

    Lancet

    (2011)
  • S Verguet et al.

    Health gains and financial risk protection afforded by public financing of selected interventions in Ethiopia: an extended cost-effectiveness analysis

    Lancet Glob Health

    (2015)
  • CG Victora et al.

    Maternal and child undernutrition: consequences for adult health and human capital

    Lancet

    (2008)
  • K Stenberg et al.

    Advancing social and economic development by investing in women's and children's health: a new Global Investment Framework

    Lancet

    (2014)
  • A Prost et al.

    Women's groups practising participatory learning and action to improve maternal and newborn health in low-resource settings: a systematic review and meta-analysis

    Lancet

    (2013)
  • P Basinga et al.

    Effect on maternal and child health services in Rwanda of payment to primary health-care providers for performance: an impact evaluation

    Lancet

    (2011)
  • H Schmidt et al.

    Public health, universal health coverage, and Sustainable Development Goals: can they coexist?

    Lancet

    (2015)
  • United Nations millennium declaration

    (2000)
  • The PMNCH progress report 2013

    (2013)
  • The PMNCH 2014 accountability report. Tracking financial commitments to the global strategy for women's and children's health

    (2014)
  • Global strategy for women's and children's health

    (2010)
  • Millennium Development Goals report 2015

    (2015)
  • G Sedgh et al.

    Intended and unintended pregnancies worldwide in 2012 and recent trends

    Stud Fam Plann

    (2014)
  • S Singh et al.

    Unintended pregnancy: worldwide levels, trends, and outcomes

    Stud Fam Plann

    (2010)
  • S Singh et al.

    Adding it up: the costs and benefits of investing in sexual and reproductive health 2014

    (2014)
  • W Cui

    Mother or nothing: the agony of infertility

    Bull World Health Organ

    (2010)
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