ArticlesProgress towards Millennium Development Goals 4 and 5 on maternal and child mortality: an updated systematic analysis
Introduction
In 2000, 189 heads of state signed the Millennium Declaration committing themselves to achieve eight goals for development.1 The target for Millennium Development Goal (MDG) 4 was to reduce the under-5 mortality rate by two-thirds between 1990 and 2015 and the target for MDG 5 was to reduce the maternal mortality ratio by three-quarters during the same period.2 Progress on reducing child and maternal mortality has been substantially slower than the target annual rates of decline of 4·4% and 5·5% for children and mothers respectively.3, 4 In response to slow progress and the moral urgency of reinvigorating efforts to tackle child and maternal mortality, the UN Secretary-General launched the Global Strategy for Women's and Children's Health in September, 2010.5 Donor nations and other organisations committed US$40 billion to this effort to accelerate progress for MDGs 4 and 5.6
To be effective, increased investment to accelerate declines in maternal and child mortality will need intense monitoring of progress over the next 4 years. Understanding who has made progress in the recent past provides opportunities for shared learning on what policies can be the most effective. Tracking progress is crucial to sustaining increased resource mobilisation. In an era of slower growth in development assistance for health, showing the effectiveness of aid is essential.7 Evidence of effectiveness requires robust data on recent trends as well as accounting for broader drivers of these trends. Perhaps most importantly, data on trends are essential for prioritising where global and national resources should go to achieve an accelerated effect. The importance of good evidence and clear accountability for progress has been recognised by the UN Secretary-General Commission on Information and Accountability for Women's and Children's Health.3, 8, 9
In 2010, several analyses were published tracking trends in maternal and child mortality.3, 4, 8, 10 Differences between these analyses for children were mostly focused on 32 countries where differences were greater than 20% on average from 1990 to 2010. Nevertheless, there has been debate on datasets and methods.11, 12 For maternal mortality, there were more substantial differences between estimates for many countries. New data on maternal mortality, particularly the finding that there had been substantial progress in some countries, generated great interest.13, 14, 15, 16 Vigorous debate from academics, government officials, and other analysts on a country-by-country basis has been concentrated on data, HIV-related deaths during pregnancy, and estimation approaches.17, 18, 19, 20, 21, 22, 23, 24 First, many data sources were not included in published analyses such as vital registration, national surveys, censuses, and especially surveillance systems of maternal mortality.25, 26 Second, there has been substantial confusion around the MDG27 and International Classification of Diseases (ICD)28 recommendation that all deaths due to HIV during pregnancy or within 42 days of the termination of pregnancy be included in the computation of the maternal mortality ratio. In fact, the UN group chose to include only half the HIV-related deaths during pregnancy in their estimation.8 Many users would prefer to sharply distinguish obstetric causes of maternal mortality, including direct and indirect causes, from those related to HIV or other causes.29 Third, several aspects of the estimation of maternal mortality have been discussed including corrections for misclassification, model specification, and uncertainty analysis.24, 30, 31 The debate around these three main issues has resulted in many avenues for refining the estimation of child and especially maternal mortality.
In our report, we update the studies of Rajaratnam and colleagues3 and Hogan and colleagues4 to produce new estimates for under-5 mortality and maternal mortality from 1990 to 2011. Although we use their same general approach, we incorporate into this cycle of estimation important insights that have emerged in the past year from widespread debate. We take advantage of the many data sources revealed during the debate since the 2010 publications that were not previously included. For maternal mortality, we include in our predictive validity testing the modelling strategy used by the UN in 2010. By assessing evidence on both MDG 4 and MDG 5 in the same study, we are able to compare progress on the two goals country-by-country.
Section snippets
Child mortality
For our update of the trends in child mortality we use the previously published method.3 The webappendix (p 18) summarises the estimation process for child mortality beginning with data from vital registration systems, surveillance systems, complete birth histories, summary birth histories, and household recall of deaths through to the synthesis of many sources for a given country over time. The webappendix (pp 13–17) lists the number of data points used in the estimation by country. Compared
Results
The worldwide mortality rate for children younger than 5 years declined continuously from the MDG baseline in 1990 to present at an annualised rate of 2·2% (uncertainty interval 1·8–2·6). By 2011, there were 7·2 (6·6–7·8) million deaths in children younger than 5 years. The fraction of deaths in sub-Saharan Africa has increased from 33% (3·9 million of 11·6 million) in 1990 to 49% (3·5 million of 7·2 million) in 2011. The contribution of deaths in north Africa and the Middle East has declined
Discussion
Progress on reducing under-5 and maternal mortality is continuing. In much of sub-Saharan Africa, the pace of progress seems to be accelerating for under-5 mortality and maternal mortality. Substantial progress in the past 5 years in India in reducing maternal mortality is promising. Likewise, several countries in east and southern Africa have had substantial declines in HIV-related deaths during pregnancy because of the expansion of antiretroviral-drug programmes. Despite overall progress,
References (59)
- et al.
Neonatal, postneonatal, childhood, and under-5 mortality for 187 countries, 1970–2010: a systematic analysis of progress towards Millennium Development Goal 4
Lancet
(2010) - et al.
Maternal mortality for 181 countries, 1980–2008: a systematic analysis of progress towards Millennium Development Goal 5
Lancet
(2010) - et al.
Development assistance for health: trends and prospects
Lancet
(2011) - et al.
Levels and trends in child mortality, 1990–2009
Lancet
(2010) - et al.
Estimates of mortality in children younger than 5 years for Burkina Faso
Lancet
(2010) Maternal mortality: surprise, hope, and urgent action
Lancet
(2010)- et al.
Countdown to 2015 decade report (2000–10): taking stock of maternal, newborn, and child survival
Lancet
(2010) - et al.
New modelled estimates of maternal mortality
Lancet
(2010) - et al.
New modelled estimates of maternal mortality
Lancet
(2010) - et al.
Maternal mortality for 181 countries, 1980–2008
Lancet
(2010)
New modelled estimates of maternal mortality
Lancet
New modelled estimates of maternal mortality
Lancet
New modelled estimates of maternal mortality
Lancet
New modelled estimates of maternal mortality
Lancet
Maternal mortality for 181 countries, 1980–2008
Lancet
HIV and maternal mortality: turning the tide
Lancet
New modelled estimates of maternal mortality
Lancet
Epidemiologic transition in maternal mortality and morbidity: new challenges for Jamaica
Int J Gynaecol Obstet
Maternal mortality for 181 countries, 1980–2008
Lancet
New estimates of maternal mortality and how to interpret them: choice or confusion?
Reprod Health Matters
Worldwide mortality in men and women aged 15–59 years from 1970 to 2010: a systematic analysis
Lancet
Estimates of maternal mortality worldwide between 1990 and 2005: an assessment of available data
Lancet
Financing of global health: tracking development assistance for health from 1990 to 2007
Lancet
Countdown to 2015: assessment of donor assistance to maternal, newborn, and child health between 2003 and 2006
Lancet
Improvement of perinatal and newborn care in rural Pakistan through community-based strategies: a cluster-randomised effectiveness trial
Lancet
The check box: determining pregnancy status to improve maternal mortality surveillance
Am J Prev Med
Towards good practice for health statistics: lessons from the Millennium Development Goal health indicators
Lancet
United Nations Millennium Declaration
Road map towards the implementation of the United Nations Millennium Declaration: Report of the Secretary-General 2001
Cited by (685)
Protecting infants from natural disasters: The case of vitamin A supplementation and a tornado in Bangladesh
2022, Journal of Development EconomicsCancer in sub-Saharan Africa: a Lancet Oncology Commission
2022, The Lancet OncologyRule-in and rule-out of pre-eclampsia using DELFIA Xpress PlGF 1-2-3 and sFlt-1: PlGF ratio
2022, Pregnancy Hypertension