Countdown to 2015 Maternal Newborn and Child Survival

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ISBN: 978-92-806-4644-3

World Health Organization and UNICEF 2012

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Printed in Washington, DC.

Photo credits: cover, 2002, Leela Khanal, Courtesy o Photoshare; page 3, 2012 Cassandra Mickish/CCP, Courtesy o Photoshare; page 4, Joshua Roberts/Save

the Children; page 12, 2009 Joydeep Mukherjee, Courtesy o Photoshare; page 21, 2007 WHO/Christopher Black; page 22, 2006 Salma Siddique, Courtesy o

Photoshare; page 30, UNICEF/NYHQ2002-0516/Vitale; page 41, UNICEF/NYHQ2009-0600/Noorani; page 50, Colin Crowley/Save the Children; page 200, 2007

Bonnie Gillespie, Courtesy o Photoshare.

Editing and layout by Communications Development Incorporated, Washington, DC.

Contributors

Lead writers: Jennier Requejo (PMNCH/Johns

Hopkins University), Jennier Bryce (Johns Hopkins

University), Cesar Victora (University o Pelotas)

Subeditors/writers: Aluisio Barros (University o

Pelotas), Peter Berman (Harvard School o Public

Health), Zulfqar Bhutta (Aga Khan University),

Ties Boerma (WHO), Bernadette Daelmans (WHO),

Adam Deixel (Family Care International), Joy Lawn

(Saving Newborn Lives), Elizabeth Mason (WHO),

Holly Newby (UNICEF), Ann Starrs (Family Care

International)

Profle team: Tessa Wardlaw (UNICEF), Archana

Dwivedi (UNICEF), Holly Newby (UNICEF)

Additional writing team: Andres de Francisco

(PMNCH), Carole Presern (PMNCH), Mickey Chopra(UNICEF), Blerta Maliqi (WHO), Giorgio Cometto

(Global Health Workorce Alliance), Justine Hsu

(LSHTM), Matthews Matthai (WHO), Priyanka

Saksena (WHO), Sennen Hounton (UNFPA)

Production team: Christopher Trott and

Elaine Wilson (Communications Development

Incorporated), Jennier Requejo (PMNCH/Johns

Hopkins University), Adam Deixel (Family Care

International), Dina El Husseiny (PMNCH)

Countdown Coordinating Committee: Mickey

Chopra (co-chair), Zulfqar Bhutta (co-chair),Jennier Bryce, Joy Lawn, Carole Presern, Elizabeth

Mason, Ann Starrs, Peter Berman, Bernadette

Daelmans, Tessa Wardlaw, Ties Boerma, Cesar

Victora, Flavia Bustreo, Andres de Francisco,

Jennier Requejo, Laura Laski, Nancy Terreri,

Holly Newby, Archana Dwivedi, Zoe Matthews,

Jacqueline Mahon, Lori McDougall

Technical Working Groups

Coverage:Jennier Bryce (co-chair), Tessa

Wardlaw (co-chair), Holly Newby, Archana

Dwivedi, Jennier Requejo, Alison Moran, Shams

El Arieen, Sennen Hounton, Steve Hodgins,

Angella Mtimumi, Blerta Maliqi, Lale Say, James

Tibenderana, Nancy Terreri

Equity:Cesar Victora (co-chair), Ties Boerma

(co-chair), Henrik Axelson, Aluisio Barros, CarineRonsmans, Wendy Graham, Betty Kirkwood,

Edilberto Loaiza, Zulfqar Bhutta, Kate Kerber,

Financing:Peter Berman (chair), Henrik Axelson,

Jacqueline Mahon, Lara Brearley, Justine Hsu,

Daniel Kraushaar, Ravi Rannan-Eliya, Anne Mills,

Karin Stenberg

Health systems and policies:Bernadette

Daelmans (co-chair), Zoe Matthews (co-chair),

Blerta Maliqi, Nancy Terreri, Giorgio Cometto,

Priyanka Saksena, Sennen Hounton, Amani Siyam,

Daniel Kraushaar, Eleonora Cavagnero, MarkYoung, Lara Brearley, Amani Siyam


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Building a Future for Women and Children The 2012 Reportii

Acknowledgements

Countdownwould like to thank the ollowing:

UNICEF/Statistics and Monitoring Section or use

o global databases, preparation o country proles

and inputs to, and review o, report text. Particular

recognition goes to David Brown, Danielle Burke,

Xiaodong Cai, Liliana Carvajal, Elizabeth Horn-

Phathanothai, Priscilla Idele, Rouslan Karimov,

Mengjia Liang, Rol Luyendijk, Colleen Murray,

Khin Wityee Oo, Chiho Suzuki and Danzhen You.

University o Pelotas colleagues Andrea Damaso

and Giovanny Frana or their inputs to the equity

analyses.

The PMNCH secretariat or convening meetingsand teleconerences or the Countdown and

PMNCH colleagues Dina El Husseiny or providing

administrative support and Henrik Axelson,

Lori McDougall and Shyama Kuruvilla or their

contributions to the report.

Amani Siyam rom WHO (HQ), Thomas H. H.

Walter rom the University o Technology Berlin,

Fekri Dureab rom the WHO Yemen country oce

and Carmen Dolea or their inputs to the health

systems and health policies analyses.

Steve Hodgins, Cindy Berg, Andre Lalonde, Cherrie

Evans, Wendy Graham and Claudia Hanson or

their inputs on the quality o care panel. The

PMNCH or convening a meeting on quality o care.

Robert E. Black at Johns Hopkins University or his

inputs into the nutrition and cause o child death

analyses.

Lale Saye and Iqbal Shah rom WHO or their

inputs to the maternal mortality and causes o

maternal death analyses.

Nancy Terreri or her contributions to the report.

Nuriye Ortayli rom UNFPA or inputs to the amily

planning analyses.

The Bill and Melinda Gates Foundation, the World

Bank and the Governments o Australia, Canada,

Norway, Sweden and the United Kingdom or their

support or Countdown to 2015.


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Building a Future for Women and Children The 2012 Report

Building a uture or women and children

In the ve minutes it takes to read this page,

3 women will lose their lives to complications

o pregnancy or childbirth, 60 others will suer

debilitating injuries and inection due to the

same causes, and 70 children will die, nearly 30

o them newborn babies. Countless other babies

will be stillborn or suer potentially long-term

consequences o being born prematurely. The

vast majority o these deaths and disabilities are

preventable.

During these same ve minutes, however,

countless lives will be saved. A baby, ed only

breastmilk or her rst six months o lie, will

avoid diarrhoeal disease. Another will survive

pneumonia because he received appropriateantibiotics. A child will avoid malaria because

she sleeps under an insecticide-treated net.

Another, exposed to measles, will not succumb

to disease because he has been vaccinated. An

adolescent, not yet physically, emotionally or

nancially ready to have a child, will receive

amily planning services, including counselling to

prevent unintended pregnancy; a new mother will

choose to delay her next pregnancy until a saer

time. A pregnant, HIV-positive woman will receive

treatment that protects her health and that o her

baby. An expectant mother, at a routine antenatal

care visit, will receive treatment or the high bloodpressure that can threaten her lie; another will

give birth at a health acility where skilled birth

attendants save her lie when she experiences

postpartum bleeding; yet another will receive

antenatal corticosteroids to develop her babys

lungs to ensure a better chance o survival. And

a newborn and her mother will receive liesaving

treatment or inection within the rst week ater

birth.

The countdown to the 2015 Millennium

Development Goal deadline is a race against

time, a race to add to the list o lives saved andsubtract rom the tally o maternal, newborn

and child deaths. Each lie saved creates innite

possibilitiesor a healthy, productive individual;

or a stable, thriving amily; or a stronger

community and nation; or a better world. And

interventions that improve maternal, newborn

and child health and nutrition contribute to a

uture generation o healthier, smarter and more

productive adults.

This report highlights country progressand

obstacles to progresstowards achieving

Millennium Development Goals 4 and 5 to reduce

child mortality and improve maternal health

(box 1). Countdown to 2015ocuses on evidence-

based solutionshealth interventions proven to

save livesand on the health systems, policies,

nancing and broader contextual actors that

aect the equitable delivery o these interventions

to women and children. Countdownocuses

on data, because building a better uture andprotecting the basic human right to lie require

understanding where things stand right now

and how they got to where they are today.

And Countdownocuses on what happens in

countrieswhere investments are made or

not made, policies are implemented or not

implemented, health services are received or not

received and women and children live or die.

Box 1

News in the 2012 report

Status reprt n mrtaity and nutritin.

Evidence n the scae preterm birth and

stibirths.

Changes in cverage interventins.

Detaied equity anaysis.

A cus n the determinants cverage.

Picy, nancia and systems inputs needed

r prgress.

Ppuatin grwth and pitica cnfict as key

chaenges.

Miestneswhat des success k ike?

Hw t read and use the cuntry pres.

Countdown mving rward t 2015.

Quaity care.

Cuntry-eve engagement.


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Contents

Countdownheadlines or 2012: saving the lives o

the worlds women, newborns and children 1

Countdown to 2015: tracking progress, ostering

accountability 5

The Countdowncountry prole: a tool or

action 10

Progress towards Millennium Development Goals

4 and 5 13

Coverage along the continuum o care 23

Determinants o coverage 32

Milestones o progress on the path to success 42

Accountability now or Millennium Development

Goals 4 and 5 48

Country proles 51

Annex A Country prole indicators and data

sources 203

Annex B Denitions oCountdown

indicators 206

Annex C Denitions o policy and health systems

indicators 208

Annex D Essential interventions or reproductive,

maternal, newborn and child health 210

Annex E Countdown priority countries

considered to be malaria endemic 211

Annex F Details on estimates rom the Inter-agency Group or Child Mortality Estimation used

in the Countdownreport 212

Notes 213

Reerences 214


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Countdownheadlinesfor 2012: saving the livesof the worlds women,

newborns and children

Maternal and child survival: progress, but not

enough . . .

Maternalmortalityhasdeclineddramatically,

butfasterprogressisneeded.

Maternaldeathshavedroppedfrom543,000

ayearin1990to287,000in2010.

Only9Countdowncountriesareontrackto

achieveMillenniumDevelopmentGoal5;25

havemadeinsufcientornoprogress.

MaternalmortalityisconcentratedinSub-

SaharanAfricanandSouthAsiancountries:

anAfricanwomanslifetimeriskofdying

frompregnancy-relatedcausesis100times

higherthanthatofawomaninadeveloped

country.

Childmortalityisdownsharply,butmoreneeds

tobedone.

Deathsamongchildrenunderage5

worldwidehavedeclinedfrom12milliona

yearin1990to7.6millionin2010.

Only23Countdowncountriesareontrackto

achieveMillenniumDevelopmentGoal4;13

havemadelittleornoprogress.

Despiterecentimprovements,pneumonia

anddiarrhoeastillcausemorethantwo

milliondeathsayearthatcouldbeavoided

byavailablepreventivemeasuresandprompt

treatment.

Newbornsurvivalisimprovingtooslowly,and

stillbirths,especiallyintrapartumstillbirths,and

pretermbirthsneedurgentattention.

40%ofchilddeathsoccurduringtherst

monthoflife.

Morethan10%ofbabiesarebornpreterm,

agurethatisrising,andcomplications

duetopretermbirtharetheleadingcause

ofnewborndeathsandthesecondleading

causeofchilddeaths.

Countdowncountriesthathavesuccessfully

reducedneonatalmortalitysuchas

Bangladesh,NepalandRwandaoffermodelsforimprovingnewbornsurvival.

MostCountdowncountriesfaceasevere

nutritioncrisis.

Undernutri tioncontributestomorethana

thirdofchilddeathsandtoatleastafthof

maternaldeaths.

Inthemajori tyofCountdowncountries,more

thanathirdofchildrenarestunted;stunting

ismostcommonamongpoorchildren.

Coverage: gains, gaps, inequities, challenges

Bangladesh,Cambodia,EthiopiaandRwanda,

countriesthathaverapidlyincreasedcoverage

formultipleinterventionsacrossthecontinuum

ofcare,offerlessonsforcountrieswithslower

ormoreunevenprogress.

Highcoveragelevelsforvaccines(over80%on

averageacrossallCountdowncountries)andrapid

progressindistributionofinsecticide-treatednets

showwhatispossiblewithhighlevelsofpolitical

commitmentandnancialresources.

Progressismuchslower,andinequitiesin

coveragemuchwider,forskilledattendant

atbirthandotherinterventionsthatrequire

astronghealthsystem.Newapproachesare

neededthatimprovethequalityofservices,

bringservicesclosertohomeandexpand

accesstoessentialcare.


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Building a Future for Women and Children The 2012 Report2

There are wide ranges in coverage across the

Countdowncountries or many interventions.

Coverage o demand or amily planning

satised, or example, ranges rom 17% in

ragile states such as Sierra Leone to 93% in

Vietnam and Brazil and 97% in China. Countries

with high coverage o specic interventions

show what can be achieved with the right

policies, adequate investments, appropriate

implementation strategies and strong demand.

To increase coverage, the volume o services

provided must grow at a aster pace than the

population. Nigeria, or example, has seen the

number o births grow rom 4.3 million in 1990

to 6.1 million in 2008, with 7 million projected

in 2015. Although the country has doubled

the number o births attended by a skilled

health care provider since 1990, coverage has

increased only 8%.

The Millennium Development Goal 7 target or

access to an improved drinking water source has

been achieved globally and in 23 Countdown

countries; progress in access to an improved

sanitation acility is lagging. For both interventions

the need is most pronounced in rural areas.

Poor people have less access to health services

than richer people, and geographic and urban-

rural inequities also exist in many countries,

highlighting the importance o digging deeper into

subnational data to support eective planning and

resource allocation according to need.

Context matters: supportive policies, adequate

fnancing, sufcient human resources and peace

Countries such as Ghana, Malawi, Lao Peoples

Democratic Republic and Tanzania have

achieved results through innovative human

resources policies such as task shiting. Other

countries need to ollow this lead.

Ocial development assistance or maternal,

newborn and child health in Countdowncountries has increased steadily over the

past decade, accounting or around 40% o

ocial development assistance or health that

Countdowncountries received in 2009, but the

rate o increase appears to be slowing.

Though domestic health unding is essential, 40

Countdowncountries devote less than 10% o

government spending to health.

In most countries a severe disease episode or

a major pregnancy or childbirth complication

can push amilies into nancial catastrophe: in

all but 5 Countdowncountries out-o-pocket

payments or health services account or 15% or

more o health expenditure.

53 Countdowncountries continue to experience

a severe shortage o health workers.

Countries with high-intensity conficts have lower

coverage and higher inequity and mortality.

Providing broader access to education,

expanding opportunities or girls and women,

reducing poverty and improving living

conditions, and respecting human rights,

including eliminating violence against women,

can improve health and reduce mortality.

Making good on commitments

Countries and their partners have pledged to work

together to meet Millennium Development Goals

4 and 5. There is still time. Countdowndata show

that by transorming commitment into action,

rapid progress is possible. To build a better uture

or women and children, we all must keep our

promises. Millions o womens and childrens lives

depend on it.

Countries must continue to:

Implement costed national health plans that

emphasize service integration and include

programmes or reproductive, maternal,

newborn and child health.

Strengthen health inormation systems,

including vital registration systems and national

health accounts, so that timely, accurate data

can inorm policies and programmes.

Increase domestic unding allocations or and

expenditures on health.

Build the numbers, motivation and skill mix o

the health workorce.

Analyse subnational data to identiy gaps

and inequities and to monitor and evaluate

programmes and policies.

Develop strategies to rapidly address nutrition

shortalls and increase coverage o essential


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health interventions across the ull continuum o

care, especially or the poor.

All stakeholders must continue to:

Advocate or sucient unding or reproductive,

maternal, newborn and child health.

Undertake research to develop the evidence on

eective interventions and innovative strategies

or service delivery.

Support country eorts to implement innovative

strategies that increase access to timely,

equitable and high-quality care.

Together we can:

Demand accountability and act accountably.

Build a better uture or millions o women and

children.


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Countdown to 2015:tracking progress,ostering accountability

Countdown to 2015is a global movement to

track, stimulate and support country progress

towards achieving the health-related Millennium

Development Goals, particularly goals 4 (reduce

child mortality) and 5 (improve maternal health;

box 2). Since 2005 Countdownhas produced

periodic reports and country proles on key

aspects o reproductive, maternal, newborn and

child health, achieving global impact with its ocuson accountability and use o available data to hold

stakeholders to account or global and national

action.

Countdown to 2015:

Focuses on coverage levels and trends o

interventions proven to improve reproductive,

maternal, newborn and child health as well

as critical determinants o coverage: health

systems unctionality, health policies and

nancing.

Examines equity in coverage across dierent

population groups within and across Countdown

countries.

Uses these data to hold countries and their

international partners accountable or progress

in reproductive, maternal, newborn and child

health (box 3).

Supports country-level countdowns to promote

evidence-based accountability (see concluding

section or a description o country-level

Countdownactivities).

Countdownincludes academics, governments,

international agencies, proessional associations,

donors and nongovernmental organizations, with

The Lancetas a key partner.

Countdown ocuses on countries

Countdowntracks progress in the 75 countries

where more than 95% o all maternal and

child deaths occur (map 1) and produces

country proles and reports to be used by all

stakeholdersinternationally and at the country

levelto advocate or action on reproductive,

maternal, newborn, and child health.

The number oCountdowncountries has

increased, refecting an evolution rom a child

survival initiative to a movement supportive o thecontinuum o care and responsive to the global

accountability agenda. Countdowncountries

are selected primarily based on burden o

maternal, newborn and child mortality, taking into

consideration both numbers and rates o death.

Details on the country selection process or this

and previous Countdowncycles are available at

www.countdown2015mnch.org.

Countdown is more than tracking coverage ointerventions!

Countdowngathers and synthesizes data oncoverage o liesaving interventions across

the continuum o care rom pre-pregnancy

and childbirth through childhood up to age 5,

highlighting progress and missed opportunities.

Coverage is dened as the proportion o

individuals needing a health service or intervention

who actually receive it. Countdownalso tracks

key determinants o coverage in countriesequity

patterns across population groups, health system

unctionality and capacity, supportive health

policies and nancial resources or maternal,

newborn and child health.

Figure 1 shows the overarching conceptual

ramework oCountdown, illustrating the links

between coverage and its determinants as well

as the broader contextual actors that aect

maternal, newborn and child survival. Countdown

is engaging in cross-cutting research to answer

questions rom countries and their partners in

response to previous Countdownreports and

proles about the ingredients needed or success

in achieving high, sustained and equitable


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Equity in coverage, a central component o the

Countdownconceptual ramework, is highlighted

throughout this report. The Commission on

Accountability or Womens and Childrens

Healths Keeping Promises, Measuring Results,1

emphasizes disaggregating all coverage data by

key equity considerations to assess progress.

National-level aggregate statistics oten hide

important within-country inequities that

countries must address to achieve the health

intervention coverage. This research aims to

expand the evidence base on eective delivery

strategies or increasing coverage that take into

consideration critical health policy and systems,

political, economic, nancial, environmental

and social actors. Recognizing that eective

coverage depends on service quality, Countdown

is expanding eorts to examine barriers and

acilitating actors to improving the quality o

care.

Box 2

Countdown and the accountability agenda

At a September 2010 UN Genera Assemby summit

t assess prgress n the Miennium Devepment

Gas, Secretary-Genera Ban Ki-mn aunched the

Gba Strategy r Wmens and Chidrens Heath,

an unprecedented pan t save the ives 16 miin

wmen and chidren by 2015.1 This was wed by

the estabishment the Cmmissin n Inrmatin

and Accuntabiity r Wmens and Chidrens Heath,

which was charged with deveping an accuntabiity

ramewrk t mnitr and track cmmitments made

t the Gba Strategy. In May 2011 the Cmmissin

reeased Keeping Promises, Measuring Results,2 which

drew n advice rm Countdown members and ther

technica eperts t identiy a set cre indicatrs3

that enabe stakehders t track prgress in imprving

cverage interventins acrss the cntinuum care

and resurces r wmens and chidrens heath. Thereprt urged that a cverage data be disaggregated

by key equity cnsideratins. In September 2011 the

UN Secretary-Genera appinted the independent

Epert Review Grup t reprt annuay n prgress

in impementing the Cmmissins recmmendatins

n reprting, versight and accuntabiity in the 75

pririty cuntries.

Countdown to 2015has cntributed signicanty t

this accuntabiity ramewrk. In Nvember 2011

Countdown cabrated with the Heath Metrics

Netwrk in deveping Monitoring Maternal, Newborn

and Child Health: Understanding Key ProgressIndicators,4 which summarizes the key pprtunities

r and chaenges t eective mnitring the

cre indicatrs identied by the Cmmissin. In

March 2012 Countdown pubished Accountability or

Maternal, Newborn and Child Survival: An Update o

Progress in Priority Countries,5 which eatured cuntry

pres custmized t shwcase the cmmissin

indicatrs. That pubicatin was aunched at the

126th Assemby the Inter-Pariamentary Unin,

in Kampaa, Uganda, where a histric resutin n

the re pariaments in addressing key chaenges

t securing the heath wmen and chidren was

unanimusy adpted.6Countdown partners have

as cabrated with a wide range ther gba

heath initiativesincuding the Internatina Heath

Partnership,7 the GAVI Aiance8 and the Gba Fund t

Fight AIDS, Tubercusis and Maaria, amng thers

n deveping a cmmn, harmnized cnceptua

ramewrk9 r mnitring and evauating resuts.

Countdown is cmmitted t deepening its

engagement in the accuntabiity agenda thrugh:

Countdown pres cused n the Cmmissin

indicatrs, updated annuay with new data and

resuts.

Specia anayses t address accuntabiityquestins and inrm the independent Epert

Review Grup.

Cuntry-eve Countdown prcesses that incude

natina cnsutatins, wrkshps r pubicatins

and use Countdown data and methdgica

appraches (see cncuding sectin).

Notes

1. See www.everywmaneverychid.rg r up-t-date inrmatin

n cmmitments t the Gba Strategy.

2. Cmmissin n Inrmatin and Accuntabiity r Wmens and

Chidrens Heath 2011.

3. The cre Cmmissin indicatrs r resuts are a subset the

Countdown indicatrs and are incuded in the cuntry pres; see

annees A and B r denitins.

4. Cuntdwn t 2015, Heath Metrics Netwrk, UNICEF and WHo

2011.

5. Cuntdwn t 2015 2012.

6. IPU 2012.

7. Berma and thers 2010.

8. GAVI Aiance 2010.

9. Bryce and thers 2011.


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Millennium Development Goals and universal

coverage.

Countdownreviews, analyses and compiles

statistics on reproductive, maternal, newborn and

child health by child gender, household wealth

quintile, maternal education, urban-rural residence

and region o the country and produces scientic

publications with these results.2 Detailed equityproles or each country are available at www.

countdown2015mnch.org.

Countdown data sources and methods

Building on others work, Countdownaims

to make data on coverage levels and trends,

equity, health policies and systems, and nancial

resources or maternal, newborn and child health

readily accessible. The data or the coverage

indicators, publicly available at www.childino.

org, come mostly rom household surveys (box 4).

The two main surveys used to collect nationally

representative data or reproductive, maternal,

newborn and child health in the Countdown

countries are U.S. Agency or International

Developmentsupported Demographic and Health

Surveys and United Nations Childrens Fund

(UNICEF)supported Multiple Indicator Cluster

Surveys. These surveys also provide estimates

o coverage by household wealth, urban-rural

residence, gender, educational attainment and

geographic location.

The Countdownproles refect the estimates

available or each country. Missing values

and data that are more than ve years old

indicate an urgent need or concerted action to

increase data collection eorts so that timely

evidence is available or policy and programme

development.

The most important criterion or including

an intervention or approach in Countdownis

internationally accepted (peer-reviewed) evidence

demonstrating that it can reduce mortality

among mothers, newborns or children underage 5. Countdowncoverage indicators must also

produce results that are nationally representative,

Box 3

Countdownaddresses multiple MillenniumDevelopment Goals

Miennium Devepment Ga 4 t reduce chid

mrtaity.

Miennium Devepment Ga 5 t imprve

materna heath.

Miennium Devepment Ga 1 t eradicate

etreme pverty and hunger, specicay by

addressing nutritin with a cus n inant and

yung chid eeding.

Miennium Devepment Ga 6 t cmbat

HIV/AIDS, maaria and ther diseases.

Miennium Devepment Ga 7 t ensure

envirnmenta sustainabiity, thrugh tracking

access t an imprved water surce and an

imprved sanitatin aciity.

See www.un.rg/mienniumgas/ r mre

inrmatin n the Miennium Devepment

Gas.

MAP 1

The 75 CountdownPriority countries


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reliable and comparable across countries and time,

clear and easily interpreted by policymakers and

programme managers, and available regularly

in most Countdowncountries. The ull list o

Countdownindicators, data sources and methods

used to select the indicators, collect the health

policy and health systems data, and calculate the

equity and nancing measures are available at

www.countdown2015mnch.org.

Data quality control is a critical component o

Countdowntechnical output. Countdownworks

closely with UNICEF and many other groups

responsible or maintaining global databases

and conducts additional quality checks to

ensure consistency and reliability. Countdowns

technical tasks are carried out by working

groups in our areascoverage, equity, health

systems and policies, and nancingand by an

overarching scientic review group. They work

together to ensure data quality and analytic

rigour. A detailed description oCountdowns

organizational structure is available at www.

countdown2015mnch.org.

Supportive policies

For example, maternal protection,community health workers andmidwives authorized to provideessential services, vital registration,adoption of new interventions

Health systems and financing

For example, human resources, functioningemergency obstetric care, referral andsupply chain systems, quality of healthservices, financial resources forreproductive, maternal, newborn andchild health, user fees

Increased survival and improved health and nutrition for women and children

Political, economic, social, technological and environmental factors

Increased and equitable intervention coverage

Pre-pregnancy Pregnancy Birth Postnatal Childhood

Family planningWomens nutrition

Antenatal careIntermittent preventive

treatment for malariaPrevention of mother-to-child

transmission of HIVTetanus vaccines

Skilled attendantat birth

Caesarean sectionand emergency

obstetric care

Postnatal care formother and baby

Infant and youngchild feeding

Case managementof childhood illness

VaccinesMalaria prevention

(insecticide-treatednets and indoorresidual spraying)

FIGURE 1

Summary impact model guiding Countdown work


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Box 4

Sources of country-level Countdowndata

Natinal health inrmatin systems encmpass a

brad range data surces essential r planning

and r rutine mnitring and evaluatin, including

censuses, husehld surveys, health acility reprting

systems, health acility assessments, vital registratin

systems, ther administrative data systems and

surveillance. Cncerted erts are needed t

strengthen health inrmatin systems acrss the 75

Countdown cuntries t increase the availability

reliable and timely data (see table).1

The preerred surce r mrtality data is high-quality

vital registratin with cmplete reprting deaths

and accurate attributin cause death. Hwever,

nly arund a third Countdown cuntries have birth

registratin cverage ver 75%, and arund 14% have

death registratin cverage ver 50%. Since 2000nly 16% cuntries have been able t generate

cause death inrmatin rm a civil registratin

system r mre than 50% deaths, well belw the

level required r prducing reliable cause death

inrmatin. Mrtality data in Countdown cuntries are

als cllected thrugh surveys r censuses. Mre than

hal Countdown cuntries cnducted such surveys

r child mrtality during 2000 06 and 200711, but

less than a fth did s r maternal mrtality (see

table), hampering cuntry ability t assess mrtality

levels and trends.

Given weak vital registratin systems and the lack ther natinally representative surces mrtality

data, mrtality levels in mst Countdown cuntries

are derived rm mdel-based estimates that use

data rm several surces, including vital registratin,

husehld surveys, censuses, and ther studies.

Cuntry-specifc estimates nenatal and under-fve

mrtality are prduced by the United Natins Inter-

agency Grup r Child Mrtality Estimatin.2 Cuntry-

specifc causes nenatal and child death prfles are

rm natinal estimates calculated by the Child Health

Epidemilgy Reerence Grup with the Wrld Health

organizatin (WHo). Maternal mrtality ratis are rm

the Maternal Mrtality Estimatin Inter-agency Grup.3

Glbal and reginal cause maternal death prfles are

prduced thrugh a WHo systematic review prcess.

Interventin cverage respnds mre quickly t

prgrammatic changes than des mrtality and shuld

be measured mre requently t prmte evidence-

based decisinmaking. only 29 Countdown cuntries

(39%) cnducted a husehld survey during 200911,

and 21 them (28%) had als cnducted a previus

survey during 200608. Facility reprts can prvide

estimates r sme cverage indicatrs, but data

quality is ten a prblem in Countdown cuntries, and

these estimates are nt natinally representative.

Data availability in Countdown countries

Topic PeriodNumber ofcountries

Share ofCountdown

countries (%)

Coverage of civil registration

Births (more than 75%) 200510 23 31

Deaths (more than 50%) 200510 10 14

Cause-of-death (morethan 50%) 200010 12 16

Data collection (at least one in period)

Child mortality200711 43 58

And during 200006 41 55

Maternal mortality200711 12 16

And during 200006 8 11

Reproductive, maternal,newborn and child healthintervention coverage

200911 29 39

And during 200608 21 28

Accurate, timely and cnsistent data are crucial r

cuntries t eectively manage their health systems,

allcate resurces accrding t need and ensure

accuntability r delivering n cmmitments t wmen,

newbrns and children. Enhancing cuntry capacity

t mnitr and evaluate results is a cre Countdownprinciple and central t the accuntability agenda.

Achieving this gal requires a lng-term apprach with

shrt-term milestnes. Recmmended actins include4:

Develping a harmnized prgramme husehld

health surveys.

Investing in vital registratin systems and rutine

inrmatin systems.

Evaluating inrmatin and cmmunicatin

technlgies t imprve data cllectin.

Building cuntry capacity t mnitr, review and act

n available data.

Cuntry-level cuntdwn prcesses can cntribute t

building this capacity (see cncluding sectin).

Notes

1. Health Metrics Netwrk and WHo 2011.

2. UNICEF, WHo, Wrld Bank, UNDESA 2011.

3. UNICEF, WHo, Wrld Bank, UNDESA 2012.

4. Cuntdwn t 2015, Health Metrics Netwrk, UNICEF, WHo 2011.


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The Countdowncountryprole: a tool or action

Countdowncountry proles present in one place

the best and latest evidence to assess country

progress in improving reproductive, maternal,

newborn and child health (gure 2). The two-page

proles in this report are updated every two years

with new data and analyses. Countdownhas also

committed to annually updating the core indicators

selected by the Commission on Inormation and

Accountability or Womens and Childrens Health.

Reviewing the inormation

The rst step in using the country proles is to explore

the range o data presented: demographics, mortality,

coverage o evidence-based interventions, nutritional

status and socioeconomic equity in coverage. Key

questions in reviewing the data include:

Are trends in mortality and nutritional status

moving in the right direction? Is the country

on track to achieve the health Millennium

Development Goals?

How high is coverage or each intervention? Are

trends moving in the right direction towards

universal coverage? Are there gaps in coverage

or specic interventions?

How equitable is coverage? Are certain

interventions particularly inaccessible or the

poorest segment o the population?

Identiying areas to accelerate progress

The second step in using the country proles is toidentiy opportunities to address coverage gaps

and accelerate progress in improving coverage

and health outcomes across the continuum o care.

Questions to ask include:

Are the coverage data consistent with the

epidemiological situation? For example:

I pneumonia deaths are high, are policies

in place to support community case

management o pneumonia? Are coverage

levels low or careseeking and antibiotic

treatment or pneumonia, and what can be

done to reach universal coverage? Are the

rates o deaths due to diarrhoea consistent

with the coverage levels and trends o

improved water sources and sanitationacilities?

In priority countries or eliminating mother-

to-child transmission o HIV, are sucient

resources being targeted to preventing

mother-to-child transmission?

Does lagging progress on reducing maternal

mortality or high newborn mortality refect

low coverage o amily planning, antenatal

care, skilled attendance at birth and postnatal

care?

Do any patterns in the coverage data suggest

clear action steps? For example, coverage or

interventions involving treatment o an acute

need (such as treatment o childhood diseases

and childbirth services) is oten lower than

coverage or interventions delivered routinely

through outreach or scheduled in advance (such

as vaccinations). This gap suggests that health

systems need to be strengthened, or example

by training and deploying skilled health workers

to increase access to care.

Do the gaps and inequities in coverage alongthe continuum o care suggest prioritizing

specic interventions and increasing unding

or reproductive, maternal, newborn and child

health? For example, is universal access to

labour, delivery and immediate postnatal care

being prioritized in countries with gaps in

interventions delivered around the time o birth?


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Progress towardsMillennium DevelopmentGoals 4 and 5

Improving maternal, newborn and child survival

across Countdowncountries depends on each

countrys ability to reach women, newborns

and children with eective interventions along

the continuum o care. Reproductive, maternal,

newborn and child health is inextricably

interconnected: improving maternal health and

nutrition will reduce newborn and young child

deaths. In turn, reducing stunting, improving childhealth and lowering adolescent and total ertility

rates will reduce the risk o a maternal death

among the next generation o women.

Under-ve mortality is declining! A huge

reduction in global deaths among children

under age 5 has been achieved, rom more

than 12 million in 1990 to 7.6 million in 2010, the

latest year or which estimates are available.3

Countdowncountries account or over 95% o

these deaths. The decline has accelerated in the

past decaderom 1.9% a year in the 1990s to

2.5% a year over 200010showing that ocusedgoals and attention make a dierence. Despite

the remarkable progress, much work remains.

The majority o the 7.6 million unacceptable child

deaths that occur each year could be prevented

using eective and aordable interventions.

Mortality is not being reduced uniormly, and

reductions in neonatal mortality lag behind

survival gains among older children. As a result,

the share o neonatal deaths in all deaths among

children under age 5 has increased rom 36%

to 40% over the past decade.4 Faster reductions

in neonatal mortality are critical or achieving

Millennium Development Goal 4. Lessons canbe taken rom Bangladesh, Nepal and Rwanda,

Countdowncountries that have reduced their

neonatal mortality rate by more than 30% in the

last decade.

Modelled estimates o maternal mortality or 2010

based on socioeconomic determinants5 show a

substantial decline in maternal deaths over the

last two decades. The number o women who

die during pregnancy or childbirth has decreased

nearly 50% globally since 1990rom 543,000

deaths to around 287,000 in 2010.6 The majority o

maternal deaths are concentrated in Countdown

countries in Sub-Saharan Arica and South Asia, an

indication o global disparities in womens access

to needed obstetrical care and other services,

including amily planning and quality antenatal and

postnatal care. Data on a womans lietime risk o

a maternal death accentuate these disparitiesorexample, a woman in Chad has a 1 in 15 chance

o dying rom a maternal cause during her lie

time and a woman rom Aghanistan has a 1 in 32

chance, compared with 1 in 3,800 or a woman in a

developed country.

The maternal mortality ratio and lietime risk

o a maternal death are important measures o

health system unctionality. For every woman

who dies due to a pregnancy or childbirth

complication, approximately 20 others suer

injuries, inection and disabilities. The millions o

women experiencing adverse pregnancy outcomesare a critical marker o the worlds commitment

to improving maternal health and achieving

Millennium Development Goal 5.

Table 1 shows country specic progress towards

Millennium Development Goals 4 and 5, including

estimated under-ve mortality rates and maternal

mortality ratios or 1990, 2000 and 2010; the

average annual rate o reduction or 19902010 or

the two measures; and a summary assessment

o progress. Criteria or judging which countries

are on track to achieve Millennium Development

Goal 4 were developed by the Inter-agencyReerence Group on Child Mortality Estimation

and include three categories (on track, insucient

progress and no progress); criteria or judging

which countries are on track to achieve Millennium

Development Goal 5 were developed by the

Maternal Mortality Estimation Inter-agency Group

and include our categories (on track, making

progress, insucient progress and no progress).

See the ootnote to table 1 or more details on

these criteria.


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(continued)

Countries and territories

Under-fve mortality rate Maternal mortality ratio, modelled

Deaths per 1,000live births

Averageannual rate oreduction (%) Assessment

o progressa



o progressb1990 2000 2010 19902010 1990 2000 2010 19902010

Aghanistan 209 151 149 1.7 Insufcient progress 1,300 1,000 460 5.1 Making progressAngola 243 200 161 2.1 Insufcient progress 1,200 890 450 4.7 Making progress

Azerbaijan 93 67 46 3.5 Insufcient progress 56 65 43 1.3 Insufcient progress

Bangladesh 143 86 48 5.5 On track 800 400 240 5.9 On track

Benin 178 143 115 2.2 Insufcient progress 770 530 350 3.9 Making progress

Bolivia (Plurinational State o) 121 82 54 4.0 On track 450 280 190 4.1 Making progress

Botswana 59 96 48 1.0 Insufcient progress 140 350 160 0.7 No progress

Brazil 59 36 19 5.7 On track 120 81 56 3.5 Making progress

Burkina Faso 205 191 176 0.8 No progress 700 450 300 4.1 Making progress

Burundi 183 164 142 1.3 Insufcient progress 1,100 1,000 800 1.5 Insufcient progress

Cambodia 121 103 51 4.3 On track 830 510 250 5.8 On track

Cameroon 137 148 136 0.0 No progress 670 730 690 0.2 No progress

Central Arican Republic 165 176 159 0.2 No progress 930 1,000 890 0.2 Insufcient progress

Chad 207 190 173 0.9 No progress 920 1,100 1,100 0.7 No progress

China 48 33 18 4.9 On track 120 61 37 5.9 On track

Comoros 125 104 86 1.9 Insufcient progress 440 340 280 2.2 Making progress

Congo 116 104 93 1.1 Insufcient progress 420 540 560 1.5 No progress

Congo, Democratic Republic 181 181 170 0.3 No progress 930 770 540 2.7 Making progress

Cte dIvoire 151 148 123 1.0 Insufcient progress 710 590 400 2.8 Making progress

Djibouti 123 106 91 1.5 Insufcient progress 290 290 200 1.9 Insufcient progress

Egypt 94 47 22 7.3 On track 230 100 66 6.0 On track

Equatorial Guinea 190 152 121 2.3 Insufcient progress 1,200 450 240 7.9 On track

Eritrea 141 93 61 4.2 On track 880 390 240 6.3 On track

Ethiopia 184 141 106 2.8 Insufcient progress 950 700 350 4.9 Making progress

Gabon 93 88 74 1.1 Insufcient progress 270 270 230 0.8 Insufcient progress

Gambia 165 128 98 2.6 Insufcient progress 700 520 360 3.4 Making progress

Ghana 122 99 74 2.5 Insufcient progress 580 550 350 2.6 Making progress

Guatemala 78 49 32 4.5 On track 160 130 120 1.5 Insufcient progressGuinea 229 175 130 2.8 Insufcient progress 1,200 970 610 3.4 Making progress

Guinea-Bissau 210 177 150 1.7 Insufcient progress 1,100 970 790 1.7 Insufcient progress

Haiti 151 109 165 0.4 No progress 620 460 350 2.7 Making progress

India 115 86 63 3.0 Insufcient progress 600 390 200 5.2 Making progress

Indonesia 85 54 35 4.4 On track 600 340 220 4.9 Making progress

Iraq 46 43 39 0.8 On track 89 78 63 1.7 Insufcient progress

Kenya 99 111 85 0.8 No progress 400 490 360 0.5 Insufcient progress

Korea, Democratic Peoples Republic 45 58 33 1.6 On track 97 120 81 0.9 Insufcient progress

Kyrgyzstan 72 52 38 3.2 On track 73 82 71 0.2 Insufcient progress

Lao Peoples Democratic Republic 145 88 54 4.9 On track 1,600 870 470 5.9 On track

Lesotho 89 127 85 0.2 No progress 520 690 620 0.9 No progress

Liberia 227 169 103 4.0 On track 1,200 1,300 770 2.4 Making progress

Madagascar 159 102 62 4.7 On track 640 400 240 4.7 Making progress

Malawi 222 167 92 4.4 On track 1,100 840 460 4.4 Making progress

Mali 255 213 178 1.8 Insufcient progress 1,100 740 540 3.5 Making progress

Mauritania 124 116 111 0.6 No progress 760 630 510 2.0 Making progress

Mexico 49 29 17 5.3 On track 92 82 50 3.0 Making progress

Morocco 86 55 36 4.4 On track 300 170 100 5.1 Making progress

Mozambique 219 177 135 2.4 Insufcient progress 910 710 490 3.1 Making progress

Myanmar 112 87 66 2.6 Insufcient progress 520 300 200 4.8 Making progress

Nepal 141 84 50 5.2 On track 770 360 170 7.3 On track

Table 1

Country progress towards Millennium Development Goals 4 and 5


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Of74Countdowncountrieswithavailable

data,23areontracktoachieveMillennium

DevelopmentGoal4(gure3).Bangladesh,

Brazil,EgyptandPerureducedtheunder-ve

mortalityrate66%ormore,andChina,Lao

PeoplesDemocraticRepublic,Madagascar,

MexicoandNepalreducedit60%65%.But

muchremainstobedone:13countriesmade

noprogress,and38madeinsufcientprogress.

Countriesandtheirdevelopmentpartnersmust

continueprioritizingchildsurvivaleffortsto

maintainforwardmomentumbeyond2015andto

preventreversals.

Only9of74Countdowncountrieswithavailable

dataareontracktoachieveMillennium

DevelopmentGoal5(gure4).Eightofthem

(Bangladesh,Cambodia,China,Egypt,Eritrea,

LaoPeoplesDemocraticRepublic,Nepaland

Vietnam)arealsoontracktoachieveMillennium

Source:Unde-fve motaity, UNICEF, WHO, Wod Bank and UNDESA 2011; matena motaity, WHO, UNICEF, UNFPA and Wod Bank 2012.

Countries and territories

Under-fve mortality rate Maternal mortality ratio, modelled



o progressa



o progressb1990 2000 2010 19902010 1990 2000 2010 19902010

Niger 311 218 143 3.9 Insufcient progress 1,200 870 590 3.6 Making progressNigeria 213 186 143 2.0 Insufcient progress 1,100 970 630 2.6 Making progress

Pakistan 124 101 87 1.8 Insufcient progress 490 380 260 3.0 Making progress

Papua New Guinea 90 74 61 1.9 Insufcient progress 390 310 230 2.6 Making progress

Peru 78 41 19 7.1 On track 200 120 67 5.2 Making progress

Philippines 59 40 29 3.6 On track 170 120 99 2.8 Making progress

Rwanda 163 177 91 2.9 Insufcient progress 910 840 340 4.9 Making progress

So Tom and Prncipe 94 87 80 0.8 No progress 150 110 70 3.8 Making progress

Senegal 139 119 75 3.1 Insufcient progress 670 500 370 3.0 Making progress

Sierra Leone 276 233 174 2.3 Insufcient progress 1,300 1,300 890 1.8 Insufcient progress

Solomon Islands 45 35 27 2.6 On track 150 120 93 2.2 Making progress

Somalia 180 180 180 0.0 No progress 890 1,000 1,000 0.7 No progress

South Arica 60 78 57 0.3 No progress 250 330 300 0.9 No progress

Sudanc 125 114 103 1.0 Insufcient progress 1,000 870 730 1.6 Insufcient progress

Swaziland 96 114 78 1.0 Insufcient progress 300 360 320 0.3 No progress

Tajikistan 116 93 63 3.1 Insufcient progress 94 120 65 1.8 Insufcient progress

Tanzania, United Republic o 155 130 76 3.6 Insufcient progress 870 730 460 3.2 Making progress

Togo 147 124 103 1.8 Insufcient progress 620 440 300 3.5 Making progress

Turkmenistan 98 74 56 2.8 Insufcient progress 82 91 67 1.0 Insufcient progress

Uganda 175 144 99 2.8 Insufcient progress 600 530 310 3.2 Making progress

Uzbekistan 77 63 52 2.0 Insufcient progress 59 33 28 3.7 Making progress

Viet Nam 51 35 23 4.0 On track 240 100 59 6.9 On track

Yemen 128 100 77 2.5 Insufcient progress 610 380 200 5.3 Making progress

Zambia 183 157 111 2.5 Insufcient progress 470 540 440 0.4 Insufcient progress

Zimbabwe 78 115 80 0.1 No progress 450 640 570 1.2 No progress

a. On tack indicates that the unde-fve motaity ate o 2010 is ess than 40 deaths pe 1,000 ive biths o that it is 40 o moe with an aveage annua ate

o eduction o 4% o highe o 19902010; insufcient pogess indicates that the unde-fve motaity ate o 2010 is 40 deaths pe 1,000 ive biths o

moe with an aveage annua ate o eduction o 1%3.9% o 19902010; no pogess indicates that the unde-fve motaity ate o 2010 is 40 deaths pe

1,000 ive biths o moe with an aveage annua ate o eduction o ess than 1% o 19902010.

b. On tack indicates that the aveage annua ate o eduction o the matena motaity atio o 19902010 is 5.5% o moe; making pogess indicates

that the aveage annua ate o eduction o the matena motaity atio o 19902010 is between 2% and 5.5%; insufcient pogess indicates that the

aveage annua ate o eduction o the matena motaity atio o 19902010 is ess than 2%; no pogess indicates that the aveage annua ate o eduction

o the matena motaity atio o 1990 2010 is negativethat is, that the matena motaity atio has inceased. Counties with a matena motaity atio

beow 100 deaths pe 100,00 0 ive biths in 1990 ae not categoized by the Matena Motait y Estimation Inte-agency Goup. Countdown to 2015cacuated

the assessment o pogess o Countdown counties that a into this goup.

c. Data ee to Sudan as it was constituted in 2010, beoe South Sudan seceded. Data o South Sudan and Sudan as sepaate states ae not avaiabe.

TABlE 1 (CONTINUED)

Country progress towards Millennium Development Goals 4 and 5


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DevelopmentGoal4.Onlythreecountries

(EquatorialGuinea,NepalandVietnam)reduced

themodelledmaternalmortalityratio75%ormore

from1990to2010,thoughCambodia,Bangladesh,

Egypt,EritreaandLaoPeoplesDemocratic

Republiccameclose,reducingit70%74%.

Causes of child deaths

Newanalysesfor2010showthat64%ofchild

deathsareattributabletoinfectiousdiseasesin

newbornsandchildren,and40%occurduring

theneonatalperiod(gure5).Undernutrition

contributestooverathirdofchilddeaths.7The

leadingcausesofneonataldeathsarecomplications

ofpretermbirth(box 5),intrapartum-relatedevents,

andsepsisandmeningitis;theleadingcausesof

deathamongolderchildrenremainpneumonia,

diarrhoea(box6)andmalaria(31%).

Causes of maternal deaths

Haemorrhageandhypertensiontogetheraccount

formorethanhalfofmaternaldeathsdeaths

ofwomenwhilepregnantorwithin42daysof

terminationofpregnancy,regardlessofthesiteor

durationofpregnancy,fromanycauserelatedtoor

aggravatedbythepregnancyoritsmanagement

andsepsisandunsafeabortion(box7)combined

accountfor17%(gure6).Indirectcauses,

includingdeathsduetoconditionssuchasmalaria,

HIV/AIDSandcardiacdiseases,accountfor

about20%.Indirectmaternaldeathsattributable

toAIDSin15CountdowncountrieswithHIV

prevalenceabove5%rangesfrom8%to67%,

withamedianof27%.8Thecategoriesofmaternal

deathsarebasedonaWHOclassicationsystem

thatconsidersobstructedlabourandanaemia

tobecontributingconditionsratherthandirect

causes.Deathsrelatedtothesetwoconditions

areclassiedunderhaemorrhageorsepsis.Clear

programmaticactionslinkedtoobstructedlabour

FIGUrE 3

Progress towards Millennium DevelopmentGoal 4 in Countdowncountries

Source:Countdown to 2015anaysis based on UNICEF, WHO, Wod

Bank and UNDESA 2011.

0

10

20

30

40

Overall progress as of 2010

Number of Countdown countries

On track Insufficientprogress

No progress

FIGUrE 4

Progress towards Millennium DevelopmentGoal 5 in Countdowncountries

Source:Countdown to 2015anaysis based on WHO, UNICEF, UNFPA

and Wod Bank 2012.

0

10

20

30

40

Overall progress as of 2010

Number of Countdown countries

On track Makingprogress

Insufficientprogress

No progress

9

40

16

9

FIGUrE 5

Roughly 40% of child deaths occur duringthe neonatal period

Source:liu and othes othcoming.

Global causes of death among children ages 059 months, 2010

Diarrhoea

10%

Measles 1%

Diarrhoea, neonatal 1%

Tetanus 1%

Pneumonia 14%Preterm birth

complications 14%

Intrapartum-

related events9%

Other

non-neonatal18%

Malaria 7%

Sepsis and

meningitis 5%

Congenitalabnormalities 4%

Injury 5%

AIDS 2%

Meningitis 2%

Other neonatal 2%

Pneumonia, neonatal 4%

Neonatal

40%

Neonatal

40%


23/228


(continued)

Preterm births and stibirths have been verked

n the gba heath agenda. Countdown is reprting

preterm birth estimates and stibirth rates r the

rst time t raise their visibiity and prmte their

priritizatin r actin. Many the interventins r

preventing preterm births and stibirths are eective

in imprving ther materna and newbrn heath

utcmes.

15 million preterm births a year

Preterm birth cmpicatins are the eading cause

newbrn deaths and the secnd-eading cause

deaths in chidren under age 5. Mre than 1.1 miin

chidren a year die due t cmpicatins being brn

t sn,1 and many thers eperience a ietime

disabiity.2

Apprimatey 80% preterm births ccurbetween 32 and 37 weeks gestatins, and mst

these babies survive when they receive essentia

newbrn care; 75% deaths preterm babies can

be prevented withut intensive care.

Accrding t the rst natina estimates preterm

birth (bere 37 cmpeted weeks pregnancy),

apprimatey 14.9 miin babies a yearmre than

1 in 10are brn t sn.o the 65 cuntries in

the wrd with reiabe trend data, ny 3 have shwn

substantia reductins ver 19902010. Abut 84%

a preterm births ccur in Countdown cuntries. The

preterm birth rate in Countdown cuntries ranges rm7% in Papua New Guinea and Iraq t 18% in Maawi,

with a median 12%.

There is a stark surviva and care gap r premature

babies between w- and high-incme cuntries.

Yet many preterm babies can be saved thrugh

easibe, w-cst interventins such as breasteeding

supprt, therma care and basic care r inectins

and breathing dicuties. An anaysis using the lives

Saved T und that universa cverage kangar

mther care cud prevent 450,000 deaths a year

ane.3 Nurses, midwives and cmmunity-based

wrkers prviding pstnata care need training in

kangar mther care, breasteeding supprt and

ther preterm baby care skis as we as access t

reiabe suppies key cmmdities and equipment.

Eective care bere, during and between pregnancies

and chidbirth is as imprtant r preventing preterm

births and imprving the surviva chances preterm

babies. Antenata crticsterid injectins, a pririty

medicine the United Natins Cmmissin n

lie-Saving Cmmdities r Wmen and Chidren,

deivered t wmen in preterm abur, reduce the risk

death and respiratry distress in preterm babies.

Cverage antenata crticsterids is w in the ew

Countdown cuntries with estimates. Scaing up t

universa cverage acrss Countdown cuntries cud

save an estimated 400,000 preterm babies a year.

Investment in research is essentia r better

understanding the causes preterm birth in rder

t devep preventive interventins r universa

appicatin. Research t imprve impementatin

prven interventins in w-resurce settings

and n w-cst techngica sutins t address

cmpicatins prematurity is needed.

The May 2012 Born Too Soon: The Global Action

Report on Preterm Births3supprted by Countdown

and arund 50 rganizatinssets a new ga

having deaths due t preterm birth by 2025.

Almost 3 million stillbirths a year

An estimated 2.7 miin third-trimester stibirths ccur

every year, a drp 1.1% a year ver 1995-2009.

Countdown cuntries accunted r 93% stibirths

in the 193 cuntries with data r 2009, with rates

ranging rm 5 per 1,000 tta births in Meic t 47 in

Pakistan and a median 23.

Wrdwide, apprimatey 1.2 miin stibirths

ccur during abur; these are knwn as intrapartum

stibirths. The risk intrapartum stibirth is 24 times

higher r an Arican wman than r a wman in a

high-incme cuntry. Yet these deaths are argey

preventabe. The mst imprtant strategy t reduce

stibirths is imprved care at birth, which as saves

materna and newbrn ives, giving a tripe return

n investments in training skied birth attendants

and increasing the number unctina basic and

cmprehensive emergency bstetric care aciities.4

other interventins prven t reduce stibirths are

amiy panning, supprtive picies prtecting wmen

rm harmu wrking cnditins and epsure t

envirnmenta tins (such as indr air putin rm

ckstves and tbacc smke) and quaity antenata

care services (such as eary recgnitin and treatment

intrauterine grwth restrictin; prtectin rm maaria

Box 5

Preterm births and stillbirths: making them count


24/228


thrugh insecticide-treated net use and deivery

intermittent preventive treatment r pregnant wmen;

and identicatin and treatment hypertensin,

diabetes and seuay transmitted diseases, particuary

syphiis). Stibirths can as be reduced by inducing

pst-term pregnancies (at 41 weeks and ater) and

by cnducting newbrn resuscitatin. Scaing up

eective care, especiay quaity chidbirth services,

cud have stibirth rates by 2020.5

Notes

1. liu and thers rthcming.

2. Bencwe and thers rthcming.

3. March Dimes, PMNCH, Save the Chidren and WHo 2012.

4. lawn and thers 2011; Bhutta and thers 2011.

5. Pattinsn and thers 2011.

Box 5 (CoNTINUED)

Preterm births and stillbirths: making them count

Source:UNICEF rthcming.

Accrding t UNICEFs (rthcming) Pneumonia and

Diarrhoea: Tackling the Deadliest Diseases or the

Worlds Poorest Children, ewer chidren under age

5 are dying due t pneumnia and diarrhea than a

decade ag. Hwever, these tw diseases cmbined

sti accunt r cse t 2 miin deaths a year. o

the 7.6 miin deaths amng chidren under age 5 in

2010 (incuding nenata deaths), 18% were due t

pneumnia and 11% t diarrhea (see gure 5 in the

main tet). Apprimatey 90% these deaths were

in Sub-Saharan Arica and Suth Asia, and the ve

cuntries with the mst deaths are a Countdowncuntries: India, Pakistan, Nigeria, Demcratic Repubic

the Cng and Ethipia.

Preventive interventins, sme which reduce

the incidence bth diseases, incude ptima

breasteeding practices and adequate nutritin,

immunizatins, hand washing with sap and access

t imprved water and sanitatin aciities. liesaving

treatment ptins ater a chid gets sick incude

antibitics r bacteria pneumnia and ra rehydratin

sats and zinc r diarrhea. Hwever, cverage

these interventins remains w, particuary amng

the mst vunerabe.

In Countdown cuntries the median cverage

ecusive breasteeding (r the rst si mnths

ie), antibitic use r pneumnia and ra

rehydratin therapy with cntinued eeding are a

ess than 50% (see gure 9 in the main tet). ony

39 Countdown cuntries have picies r cmmunity

case management pneumnia that cud epand

treatment access t the underserved (see gure 15

in the main reprt). Athugh the number cuntries

adpting picies n w-smarity ra rehydratin

sats and zinc r managing diarrhea is increasing,

zinc treatment remains unavaiabe in neary a third

Countdown cuntries. Median cverage access

t an imprved water surce is 76% in Countdown

cuntries, but access t an imprved sanitatin aciityhvers at an unacceptabe 40%. Mst Countdown

cuntries reprt high cverage meases and

Haemophilus infuenzaetype b vaccines, but ny 9 are

impementing picies r rtavirus vaccine and 16 r

pneumccca cnjugate vaccines. Epanding vaccine

uptake is essentia t reaize the u ptentia these

interventins in reducing deaths due t pneumnia and

diarrhea, particuary as vaccines against rtavirus and

pneumcccus are being intrduced in mre cuntries.

A gba actin pan r pneumnia has been in pace

since 2009. A cnsrtium partners incuding

academic universities, UN agencies and the Cintn

Heath Access Initiative is deveping an integrated

gba actin pan r diarrhea and pneumnia t scae

up prven interventins and increase cmmitment t

addressing these tw eading kiers chidren.

Box 6

Pneumonia and diarrhoea: neglected killers


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(continued)

Wrdwide apprimatey 22 miin unsae abrtins,

ha a induced abrtins, ccur each year, resuting

in the deaths 47,000 wmen and temprary r

permanent disabiity amng an additina 5 miin

wmen. Amst a these deaths and disabiities

ccur in deveping cuntries.1 An abrtin is dened

as unsae when perrmed by an individua wh

acks the necessary skis r in an envirnment that

des nt meet minima medica standards. Deaths

due t unsae abrtin resut mainy rm severe

inectins, beeding and rgan damage caused by

the prcedure. Preventing unsae abrtins wud

cntribute substantiay twards achieving Miennium

Devepment Ga 5.

Countdown cuntries represent a wide spectrum

pubic heath cnsequences unsae abrtin,ranging rm itte r nne in sme cuntries (Centra

and Sutheast Asian cuntries and thse in Far East

Asia) t abut 1 in 5 materna deaths due t unsae

abrtin in Countdown cuntries in East Arica (see

map). In genera, materna deaths due t unsae

abrtins are high in Countdown cuntries with high

vera materna mrtaity.

Gbay the abrtin rate e between 1995 and 2003

rm 35 per 1,000 wmen reprductive age (ages

1544) t 29 but has since stagnated at 28 in 2008.

over 2003-2008 the tta number abrtins rse,

refecting increased gba ppuatin. The prprtin

abrtins that were unsae increased rm 44% in

1995 t 49% in 2008.2

Mre than 80% unintended pregnancies in

deveping cuntries ccur t wmen wh have an

unmet need r mdern cntraceptin. Given the

etent unintended pregnancy and the high eves

unsae abrtin arund the wrd, cntinuing

erts t prvide amiy panning services (see b

9), educatin and inrmatin t prevent unsae

abrtins are essentia pubic heath interventins.3

Eective, high-quaity amiy panning services arecharacterized by a variety ardabe cmmdities,

cmpete inrmatin r wmen abut ptentia

benets and side eects and attentin t scia

and cutura actrs t epand wmens access t

cntraceptin.4 WHo estimates that 75% unsae

abrtins cud be avided i the need r amiy

panning were uy met.5

Unsae abortions are concentrated in Latin America and the Caribbean and Central Arica

Unsafe abortions

per 1,000 women

ages 154430 or more

2029

1019

19

None or negligible

Source:WHo 2008.

Box 7

Unsae abortion: a preventable cause o maternal deaths


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and anaemia include increasing womens accessto comprehensive emergency obstetric care and

nutrition interventions, respectively.

Undernutrition: grave crisisa call or action

Undernutrition contributes to over a third o

child deaths globally.9 The result o inadequate

energy or micronutrient intake and oten rooted in

poverty, undernutrition increases the risk o death

and ill-health or both mother and baby during

pregnancy, childbirth and the postnatal period

through early childhood. Stunting prevalence is

a critical indicator o progress in child survival,

refecting long-term exposure to poor health and

nutrition, especially in the rst two years o lie.10

Children under age 5 around the world have the

same growth potential, and stunting prevalence

above 3% indicates the need or remedial actions.

a. Incudes deaths due t bstructed abur r anaemia.

b. Neary a (99%) abrtin deaths are due t unsae abrtin.

Source:Preiminary data rm the Wrd Heath organizatin.

Global estimates of the causes of maternal deaths, 19972007

Haemorrhagea

35%

Hypertension18%

Sepsisa

8%Unsafe

abortionb

9%

Embolism 1%

Other direct11%

Indirect18%

FIGURE 6

Haemorrhage and hypertension accountor more than hal o maternal deaths

As stated by the Inter-Agency Grup r Sae

Mtherhd, Unsae abrtin is the mst

negectedand mst preventabecause materna

death. These deaths can be signicanty reduced by

ensuring that [materna heath] prgrammes incude

cient-centered amiy panning services t prevent

unwanted pregnancy, cntraceptive cunseing r

wmen wh have had an induced abrtin, the use

apprpriate techngies r wmen wh eperience

abrtin cmpicatins, and, where nt against the

aw, sae services r pregnancy terminatin.6

Where unsae abrtins ccur, cmprehensive pst-

abrtin care r wmen is imprtant t address

cmpicatins and ensure access t cntraceptin.

Skied heath wrkers, apprpriate pain cntr

management, w-up care incuding identicatin

and treatment beeding r inectin, remving

heath wrker stigma r caring r wmen ater an

abrtin, and increasing and imprving amiy panning

cunseing and services are a necessary cmpnents.7

Notes

1. Wrd Heath organizatin 2011.

2. Sedgh and thers 2012.

3. WHo 2005.

4. WHo 2009.

5. WHo 2011.

6. Inter-Agency Grup r Sae Mtherhd 1998.

7. Singh and thers 2009.

Box 7 (CoNTINUED)

Unsae abortion: a preventable cause o maternal deaths

FIGURE 7

Two-thirds o Countdowncountries havestunting prevalence o 30% or more

Source:UNICEF gba databases, Apri 2012, based n Demgraphic

and Heath Surveys, Mutipe Indicatr Custer Surveys and ther

husehd surveys

0

5

10

15

20

25

50%

or more

40%

49%

30%

39%

20%

29%

5%

19%

Less

than 5%

Number of Countdown countries (n = 63)

Prevalence of stunting, 20062010


27/228


All 63 Countdowncountries with available data

since 2006 have stunting prevalence above this

threshold (gure 7). In the majority o these

countries more than a third o children are

stunted, a situation requiring urgent attention, and

prevalence is particularly high among the poorest

populations (gure 8). In a th o these countries

more than hal o children in the poorest 20% o

households are stunted. Multisectoral programmes

that emphasize reaching the poor must continue to

be a major priority in Countdowncountries.

Wasting, or low weight or height, in children

under age 5, is the most reliable indicator o

acute ood insecurity and signals an urgent need

or action. The short-term mortality risk is much

higher or a wasted child than or a stunted child.

In 62 Countdowncountries with available data

since 2006 the prevalence o wasting ranges rom

0.8% in Swaziland to 21% in the last survey in

pre-secession Sudan, with a median o 7%. Niger

(16%), Chad (16%), Bangladesh (18%) and India

(20%) also have high prevalence o wasting. The

median prevalence is 10% in the nine Countdown

countries in the Sahel region prone to severe

drought and amine.

Maternal undernutrition is a risk actor or poor

maternal, newborn and child health outcomes,

and interventions to improve womens nutritionalstatus beore, during, ater and between

pregnancies are essential (box 8). The Scale

Up Nutrition road map, the Global Alliance or

Improved Nutrition, the Renewed Eorts Against

Child Hunger, the U.S. and Irishled 1,000 days:

Change a Lie, Change the Future campaign

and similar initiatives are under way to address

maternal and child undernutrition;11 the challenge

is to ensure that these are ully integrated with

country-level reproductive, maternal, newborn and

child health programmes.12

FIGURE 8

Poorer children are more likely to be stunted

Source:Demgraphic and Heath Surveys and Mutipe Indicatr

Custer Surveys

0

10

20

30

40

50

Median prevlance of stunting by wealth quintile,Countdown countries with data (%)

Poorest Second Middle Fourth Richest

42 42

36

32

25


28/228


Key indicatrs materna nutritin are materna

stature, bdy mass inde and micrnutrient deciency.

Pr materna nutritin cntributes t at east 20%

materna deaths, and increases the prbabiity

ther pr pregnancy utcmes, incuding newbrn

deaths.1 Materna undernutritin is particuary severe

in Suth Asian Countdown cuntries. In Pakistan, r

eampe, mre than 25% wmen ages 1519 have

a w bdy mass inde (bew 18.5 kigrams per

square metre) and 10% had shrt stature (ess than

145 centimetres).2

In this reprt Countdown tracks r the rst time the

prevaence w bdy mass inde amng wmen

reprductive age, an imprtant risk actr r intrauterine

grwth restrictin, w birthweight and nenata

mrtaity. less data are avaiabe n the nutritina status wmen than n the nutritina status chidren. In

24 Countdown cuntries with a recent Demgraphic and

Heath Survey the median prevaence w bdy mass

inde amng wmen reprductive age is 11%, with

a w 0.7% in Egypt. Fur cuntries reprt etremey

high prevaence: Nepa (26%), Madagascar (28%),

Bangadesh (33%) and India (40%).

Shrt materna stature, ten a resut chidhd

stunting, is as a risk actr r bstructed abur and

caesarean deivery due t a disprprtin between

the babys head and the materna pevis. Prnged

bstructed abur cmbined with n r deayedaccess t caesarean deivery can resut in materna

mrtaity, debiitating ng-term heath cnsequences

such as bstetric stua and nenata mrtaity due

t birth asphyia. Many Countdown cuntries with

high materna undernutritin as ack readiy avaiabe

emergency caesarean sectins.

limited inrmatin is avaiabe n materna

micrnutrient deciencies. A WHo review natinay

representative surveys rm 1993 t 2005 und that

42% pregnant wmen wrdwide are anaemic,

mre than ha them due t irn deciency.2

Prenata ic acid deciency, as widespread, is

assciated with increased risk neura tube deects.

Further research is needed t understand the

reatinships between materna undernutritin

and shrt- and ng-term materna and chid heathutcmes. Mre and better data are as needed

n measures materna nutritina status and n

cverage evidence-based interventins, incuding

ic acid suppementatin in the pericnceptina

perid, irn and ic acid uptake amng wmen at risk

irn deciency anaemia and nutritin prgrammes

t address d insecurity and w materna bdy

mass inde.

Notes

1. Back and thers 2008; Sttzus, Muany and Back 2004.

2. Zugar A. Bhutta and thers, Aga Khan University, Natina

Nutritin Survey, Pakistan, 2011.

3. WHo and CDC 2008.

Box 8

A new ocus on maternal undernutrition


29/228


Coverage along thecontinuum of care

This section presents levels and trends in the

Countdowncoverage indicators, including

measures o equity in coverage. It reviews the

number o countries with coverage data available

or Countdownindicators, discusses new

indicators included or the rst time in 2012 and

summarizes coverage trends since 2000.

Figure 9 shows median coverage values basedon the latest available estimates since 2006 or

21 Countdown indicators. Table 2 shows the

number o countries with available data or

each Countdown indicator, the median coverage

values and the range in coverage across reporting

countries. Figure 9 and table 2 do not include the

caesarean section rate, prevention o mother-to-

child transmission o HIV and eligible HIV-positive

pregnant women receiving antiretroviral treatment

or their own health, which are reported on

separately.

New coverage indicators or 2012 refect

advancements in amily planning and inant

eeding: demand or amily planning satised (anindicator o met need or amily planning; box 9)

and introduction o solid or semisolid oods.

Coverage is reported both or the compound

measure o oral rehydration therapy with

continued eeding and or oral rehydration salts

alone. Inormation on oral rehydration salts use

Figure 9

Coverage of interventions varies across the continuum of care

a. Data a fo 2010.

b. Analyss s basd on conts wth 75% o mo of th poplaton at sk of p. falciparum tansmsson.

Source:immnzaton ats, WHO and uNiCeF; postnatal vst fo moth, Savn Nwbon Lvs analyss of Dmoaphc and Halth Svys;

mpovd wat and santaton, WHO and uNiCeF Jont Monton Poamm 2012; all oth ndcatos, uNiCeF lobal databass, Apl 2012, basd on

Dmoaphc and Halth Svys, Mltpl indcato Clst Svys and oth natonal svys.

0

25

50

75

100

Median national coverage of selected Countdown interventions, most recent year since 2006 (%)

Pregnancy Birth Postnatal Infancy Childhood Water and

sanitation

Pre-

pregnancy

Improvedsanitation

facilities

Improved

drinking

watersources

Oralrehydrationsalts

Malariatreatment

(first-lineantimalarial)b

Antibioticsforpn

eumonia

Careseekingforpn

eumonia

Childrensleepingunder

insecticide-treatednetsb

VitaminAsupplem

entation

(tw

odoses)

Haemophilusinfluenzaetypeb

immunization(threedoses)a

Measlesimmu

nizationa

DTP3immu

nizationa

Introduction

ofsolid,

semisolidors

oftfoods

Exclusivebrea

steeding

(forfirstsix

months)

Postnatalvisitfo

rmother

Early

initiation

ofbreastfeeding

Skilledattendan

tatbirth

Neonataltetanusp

rotection

Intermittentpreventive

treatmento

fmalaria

forpregnantwomen

Antenatalcare

(atleastfo

urvisits)

Antenatalcare

(atleastonevisit)

Demandforfamily

planning

satisfied


30/228


alone has considerable programme relevance but

is not captured in the oral rehydration therapy with

continued eeding measure.

These results demonstrate what is possible. All

our vaccines (neonatal tetanus protection, DTP3,

measles and Haemophilius infuenzaetype b

[three doses]) and vitamin A supplementation (two

doses) have median coverage o 80% or more in

Countdowncountries with available data. In most

Countdowncountries vaccines and vitamin A

are provided in health acilities as well as during

campaigns such as child health days, when outreach

teams can reach a high proportion o the population.

Median coverage o at least one antenatal visit is

also very high, at 88%, but coverage o our or more

antenatal visits is only 55%.

At least one country has achieved coverage

above 80% or each o 17 interventions, and

at least one country has reached coverage o

70%80% or each o our other interventions

(postnatal visit or baby, exclusive breasteeding,

children sleeping under insecticide-treated nets

and diarrhoea treatment with oral rehydration

salts). For intermittent preventive treatment o

malaria or pregnant women and oral rehydration

therapy with continued eeding coverage is

below 70% in the highest perorming country.

Substantial progress is still needed. The median

coverage o interventions related to case

management o childhood illnesses, demand

or amily planning satisfed, early initiation o

breasteeding and exclusive breasteeding hover

at or below 50%.

a. Numer o countries is ased on the 50 countries with 75% or more o the popuation at risk o p. aciparum transmission.

. Not isted in fgure 9.

Source:UNICEF goa dataases, Apri 2012, ased on Demographic and Heath Surveys, Mutipe Indicator Custer Surveys and other nationa surveys.

IndicatorNumber of countries

with dataMedian coverage

(%)Range

(%)

Pre-pregnancy

Demand or amily planning satisfed 46 56 1797

Pregnancy

Antenatal care (at least one visit) 69 88 26100Antenatal care (at least our visits) 49 55 697

Intermittent preventive treatment o malaria or pregnant womena 39 13 069

Neonatal tetanus protection 66 85 6094

Birth

Skilled attendant at birth 67 57 10100

Postnatal

Early initiation o breasteeding 55 46 1881

Postnatal visit or mother 22 41 2287

Postnatal visit or babyb 4 50 877

Inancy

Exclusive breasteeding 57 37 174

Introduction o solid, semisolid or sot oods 39 73 1694

Diphtheria-tetanus-pertussis (three doses) 74 85 3399

Measles immunization 73 84 4699

Haemophilius infuenzaetype b immunization (three doses) 58 83 4599

Vitamin A supplementation (two doses) 56 92 0100

Childhood

Children sleeping under insecticide-treated nets a 36 34 370

Careseeking or pneumonia 57 55 1383

Antibiotic treatment or pneumonia 45 39 388

Malaria treatment (frst-line antimalarial)a 31 25 091

Oral rehydration therapy with continued eedingb 53 45 768

Oral rehydration salts 57 33 1077

Water and sanitation

Improved drinking water sources (total) 70 76 2999

Improved sanitation acilities (total) 71 40 9100

TAblE 2

National coverage of Countdowninterventio

Countdown to 2015 Maternal Newborn and Child Survival

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