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Saving the lives of mothers and children

The urgency of scaling up action on maternal and child health

When the Millennium Development Goals (MDGs) were formulated in the year 2000, 2 of the 8 goals directly related to maternal and child health, highlighting the importance of reducing the unacceptable levels of maternal and child deaths globally. Countries committed to working to achieve a 66% reduction in under-5 mortality (MDG 4) and a 75% reduction in the maternal mortality ratio (MDG 5) by 2015. But, so far progress in reducing mortality in developing countries has been slow.

Although the under-5 mortality rate in the WHO Eastern Mediterranean Region decreased by 45% between 1990 and 2012 and the maternal mortality ratio decreased by 50% between 1990 and 2013, these reductions fall short of meeting the targets of MDGs 4 and 5. It is estimated that 899 000 children under 5 years of age and around 26 000 women still die every year in the Region as a result of common childhood diseases and pregnancy-related complications respectively. That so many still die when simple, affordable interventions exist that could save the lives of mothers and children is disturbing.

With 2015 fast approaching, urgent measures were required to help countries meet the targets of MDGs 4 and 5, particularly the high-burden priority countries in the Region: Afghanistan, Djibouti, Egypt, Iraq, Morocco, Pakistan, Somalia, Sudan and Yemen.

“Saving the lives of mothers and children” initiative

In January 2013, under the patronage of HH Sheikh Mohammed Bin Rashid Al Maktoum, WHO together with UNICEF, UNFPA and other partners organized a high-level meeting in Dubai to accelerate progress towards achieving MDGs 4 and 5 in the Region. This initiative “Saving the lives of mothers and children” resulted in the Dubai declaration in which countries pledged to accelerate progress on maternal, newborn, child and adolescent health through national action and international cooperation.

Since then, with support from WHO, UNICEF, UNFPA and other partners, all the high-burden countries in the Region have developed maternal and child health acceleration plans. WHO and partners continue to provide technical assistance to support the implementation of national activities in line with the acceleration plans and help countries follow through on their commitment to accelerate progress on maternal and child health. In this regard, two important components of maternal and child care were addressed in meetings held by WHO in the past year: maternal death surveillance and response, and community-based child care.

Gathering evidence to save the lives of mother: why is maternal death surveillance important?

Most maternal deaths are preventable, but a key first step in developing evidence-based approaches for reducing maternal deaths is surveillance. Maternal death surveillance and response (MDSR) is an evolution of the traditional maternal death review process towards an active approach which aims to: identify all maternal deaths; make each one a notifiable event (surveillance); and take action (response) to learn and prevent deaths in the future1.

Action on MDSR in the Region

As MDSR is a vital element in efforts to accelerate progress on MDG5 in the Region, a meeting was held in Rabat, Morocco on 7–9 October 2013 to evaluate MDSR in the MDG5-priority countries. Specifically, the meeting aimed to: map current regional MDSR initiatives; review the current status of country MDSR processes and methodologies; identify major bottlenecks for implementing MDSR; identify specific country needs for scaling up MDSR; update information on tools for MDSR; and develop country plans for scaling up MDSR initiatives.

The meeting, jointly organized by the WHO Regional Office for the Eastern Mediterranean and the United Nations Population Fund Arab States Regional Office in collaboration with the Ministry of Health of Morocco, was attended by national maternal and reproductive health programme managers from Afghanistan, Djibouti, Egypt, Iraq, Morocco, Pakistan, Somalia, Sudan, Tunisia and Yemen.

Country plans of action and next steps

Working groups of the participants drew up recommendations on death reviews and drafted country workplans for scaling up MDSR, with focus on the key elements and in line with the existing roadmaps for information and accountability in the participating countries; these are summarized in Box 1.

Improving access to quality child care: community-based approaches are key

Some of the factors responsible for the slow progress towards MDG4 need to be tackled at the community level: inequities in access of the population to quality child care services, low coverage of cost-effective interventions and suboptimal child health-related practices in families and communities. Poor families are often unable to obtain even the most basic health care for their children; poor or delayed care-seeking contributes to up to 70% of all under-5 child deaths. Families and communities need to know how best to bring up their children healthily and deal with sickness when it occurs.

Most of the high-burden countries for MDG4 and MDG5 have included a community child care component in their maternal and child health acceleration plans. In Member States with lower child mortality, community-based approaches remain important to promote the health and well-being of children. To support work in this area, WHO has designed an approach to caring for children in the community which sets out a framework for planning and monitoring, and provides training and monitoring tools for health-care workers. The new approach complements the integrated management of child health (IMCI) strategy and aims to: bring quality child care closer to the community; strengthen the initiative on saving their lives; and improve family practices related to child health.

Reviewing community child care approaches

In this context, it was important to bring country child health and IMCI programme managers together with partners to review the community child care approach and plan for its implementation. The WHO Regional Office therefore held an intercountry meeting on care for children in the community in Alexandria, Egypt on 27–29 April 2014. The meeting aimed to: present the current situation of community child care in different countries in the Region and share country experiences; review the Regional framework and tools on community child care; and review the community component of the maternal and child health acceleration plans for the MDG-priority countries and the child health plans of other countries in order to plan the way forward for the community approach within the plans.

The meeting was attended by primary health care directors, ICMI/child health focal points from 10 countries in the Region (including 5 MDG-priority countries) and WHO partners, including Management Sciences for Health, UNICEF and the World Bank.

There was a consensus that community-based child care plays an important role in improving key child-health practices in families, improving access to child health care and increasing the coverage of effective interventions, and that community health workers are a way to improve access to child care in remote areas which have poor health indicators and limited access to health services.

Challenges to community child care approaches

Despite the clear benefits of community child care, there are challenges to this approach which were discussed with a view to reducing them. These include overburdening community health workers or volunteers with too many tasks and responsibilities, the high turnover of these trained staff, and support of community health workers in remote areas. Additionally, there is the problem of fragmentation of community child care which can lead to duplication of work and inconsistencies in care. Furthermore, weak links with health systems, in particular follow-up and supervision, adversely affect the quality and sustainability of implementation.

Another issue of sustainability is the inadequate and fragmented financial resources to support the initiative in the medium and long term. Currently, this initiative is mainly donor-dependent, which affects its sustainability beyond the time limits of specific projects. Weak follow-up, monitoring and supervision and lack of evaluation are other challenges. Country experiences and activities in community-based child care are not always shared with concerned stakeholders and related information is not disseminated.

Next steps for community-based child care

In light of the discussions, the country teams reviewed the community component of their maternal and child health acceleration and child health plans and identified the actions needed by the countries and WHO and partners to address the challenges, and implement and monitor the community child care initiative and maternal and child health acceleration plans (Box 2).

Under 500 days to go

Considerable action has been taken in the priority countries of Region to accelerate progress in maternal and child care in line with MDGs 4 and 5. However, with fewer than 500 days to the deadline of the MDGs, much still remains to be done. The countries must now concentrate all effort to meet the targets set by MDGs 4 and 5 as quickly as possible.