chapter one mothers and children matter so does their health The healthy future of society depends on the health of the children of today and their mothers, who are guardians of that future However, despite much good work over the years, 10.6 million children and 529 000 mothers are still dying each year, mostly from avoidable causes. This chapter assesses the current status of maternal and child health programmes against their historical background. It then goes on to examine in more detail the patchwork of progress, stagnation and reversals in the health of mothers and children worldwide and draws attention to the previously underestimated burden of newborn mortality. Most pregnant women hope to give birth safely to a baby that is alive with noticeable results. However, the countries with the and well and to see it grow up in good health Their chances of doing highest burden of mortality and ill-health to start with so are better in 2005 than ever before- not least because they are made little progress during the 1990s. In some, the situ- becoming aware of their rights. With today 's knowledge and technol- ation has actually worsened in recent years. Progress gy, the vast majority of the problems that threaten the world's moth- has therefore been patchy and unless it is accelerated rs and children can be prevented or treated. Most of the millions of significantly, there is little hope of reducing maternal untimely deaths that occur are avoidable, as is much of the suffering mortality by three quarters and child mortality by two that comes with ill-health. a mother's death is a tragedy unlike others, thirds by the target date of 2015-the targets set by the because of the deeply held feeling that no one should die in the course Millennium Declaration (2, 3) of the normal process of reproduction and because of the devasta- In too many countries the health of mothers and chil ting effects on her family (1). In all cultures, families and communities dren is not making the progress it should. The reasons acknowledge the need to care for mothers and children and try to do for this are complex and vary from one country to an- so to the best of their ability other. They include the familiar, persistent enemies of An increasing number of countries have succeeded in improving the health-poverty, inequality, war and civil unrest, and the health and well-being of mothers, babies and children in recent years, destructive influence of HIV/AIDS-but also the failure t
1 chapter one mothers and children matter – so does their health The healthy future of society depends on the health of the children of today and their mothers, who are guardians of that future. However, despite much good work over the years, 10.6 million children and 529 000 mothers are still dying each year, mostly from avoidable causes. This chapter assesses the current status of maternal and child health programmes against their historical background. It then goes on to examine in more detail the patchwork of progress, stagnation and reversals in the health of mothers and children worldwide and draws attention to the previously underestimated burden of newborn mortality. Most pregnant women hope to give birth safely to a baby that is alive and well and to see it grow up in good health. Their chances of doing so are better in 2005 than ever before – not least because they are becoming aware of their rights. With today’s knowledge and technology, the vast majority of the problems that threaten the world’s mothers and children can be prevented or treated. Most of the millions of untimely deaths that occur are avoidable, as is much of the suffering that comes with ill-health. A mother’s death is a tragedy unlike others, because of the deeply held feeling that no one should die in the course of the normal process of reproduction and because of the devastating effects on her family (1). In all cultures, families and communities acknowledge the need to care for mothers and children and try to do so to the best of their ability. An increasing number of countries have succeeded in improving the health and well-being of mothers, babies and children in recent years, with noticeable results. However, the countries with the highest burden of mortality and ill-health to start with made little progress during the 1990s. In some, the situation has actually worsened in recent years. Progress has therefore been patchy and unless it is accelerated significantly, there is little hope of reducing maternal mortality by three quarters and child mortality by two thirds by the target date of 2015 – the targets set by the Millennium Declaration (2, 3). In too many countries the health of mothers and children is not making the progress it should. The reasons for this are complex and vary from one country to another. They include the familiar, persistent enemies of health – poverty, inequality, war and civil unrest, and the destructive influence of HIV/AIDS – but also the failure to
2 The World Health Report 2005 translate life-saving knowledge into effective action and to invest adequately in public health and a safe environment. This leaves many mothers and children, particularly he poorest among them, excluded from access to the affordable, effective and re- sponsive care to which they are entitled For centuries, care for childbirth and young children was regarded as a domestic affair, the realm of mothers and midwives. In the 20th century, the health of mothers and children was transformed from a purely domestic concern into a public hea priority with corresponding responsibilities for the state. In the opening years of the 21st century, the Millennium Development Goals place it at the core of the struggle against poverty and inequality, as a matter of human rights. This shift in emphasis has far-reaching consequences for the way the world responds to the very uneven progress in different countries THE EARLY YEARS OF MATERNAL AND CHILD HEALTH The creation of public health programmes to improve the health of women and chil dren has its origins in Europe at the end of the nineteenth century. With hindsight, the reasons for this concern look cynical: healthy mothers and children were seen by governments at that time to be a resource for economic and political ambitions. Many of Europe's politicians shared a perception that the ill-health of the nation,s children threatened their cultural and military aspirations (4). This feeling was particularly strong in France and Britain, which had experienced difficulties in recruiting soldiers fit enough for war. Governments saw a possible solution in the pioneering French experiments of the 1890s, such as Leon Dufour's Goutte de lait (drop of milk) clinics and Pierre Budin's Consultations de noumssons(infant welfare clinics)(5). These programmes offered a scientific and convincing way to produce healthy children who would become productive workers and robust soldiers. The programmes also increas- ingly found support in the emerging social reform and charitable movements of the time. As a result, all industrialized countries and their colonies, as well as thailand and many Latin American countries, had instituted at least an embryonic form of maternal and infant health services by the onset of the 20th century(6). The First World War ac- celerated the movement. Josephine Baker, then Chief of the Division of Child Hygiene of New York, summed it up as follows: One of the first matemal and child health clinics, in the late 19th century, was L'OEuvre de la goutte de lait: Dr Variot's consultation at the Belleville Dispensary, Paris
2 The World Health Report 2005 translate life-saving knowledge into effective action and to invest adequately in public health and a safe environment. This leaves many mothers and children, particularly the poorest among them, excluded from access to the affordable, effective and responsive care to which they are entitled. For centuries, care for childbirth and young children was regarded as a domestic affair, the realm of mothers and midwives. In the 20th century, the health of mothers and children was transformed from a purely domestic concern into a public health priority with corresponding responsibilities for the state. In the opening years of the 21st century, the Millennium Development Goals place it at the core of the struggle against poverty and inequality, as a matter of human rights. This shift in emphasis has far-reaching consequences for the way the world responds to the very uneven progress in different countries. THE EARLY YEARS OF MATERNAL AND CHILD HEALTH The creation of public health programmes to improve the health of women and children has its origins in Europe at the end of the nineteenth century. With hindsight, the reasons for this concern look cynical: healthy mothers and children were seen by governments at that time to be a resource for economic and political ambitions. Many of Europe’s politicians shared a perception that the ill-health of the nation’s children threatened their cultural and military aspirations (4). This feeling was particularly strong in France and Britain, which had experienced difficulties in recruiting soldiers fit enough for war. Governments saw a possible solution in the pioneering French experiments of the 1890s, such as Léon Dufour’s Goutte de lait (drop of milk) clinics and Pierre Budin’s Consultations de nourrissons (infant welfare clinics) (5). These programmes offered a scientific and convincing way to produce healthy children who would become productive workers and robust soldiers. The programmes also increasingly found support in the emerging social reform and charitable movements of the time. As a result, all industrialized countries and their colonies, as well as Thailand and many Latin American countries, had instituted at least an embryonic form of maternal and infant health services by the onset of the 20th century (6). The First World War accelerated the movement. Josephine Baker, then Chief of the Division of Child Hygiene of New York, summed it up as follows: One of the first maternal and child health clinics, in the late 19th century, was ‘L’Œuvre de la goutte de lait’: Dr Variot’s consultation at the Belleville Dispensary, Paris
mothers and children matter - so does their health 3 It may seem like a cold-blooded thing to say, but someone ought to point out that the Word War was a back-handed break for children . As more and more thousands of men were slaughtered every day, the belligerent nations, on whatever side, began to ee that new human lives, which could grow up to replace brutally extinguished adult lives, were extremely valuable national assets. The children took the spotlight as the hope of the nation. That is the handsomest way to put it The ugliest way-and, I suspect, the truer- is to say flatly that it was the military usefulness of human life that wrought the change. When a nation is fighting a war or preparing for another. it must look to its future supplies of cannon fodder"(7) Caring for the health of mothers and children soon gained a legitimacy of its own beyond military and economic calculations. The increasing involvement of a variety of authorities-medical and lay, charitable and governmental-resonated with the rising expectations and political activism of civil society (1 ). Workers'movements, women's groups, charities and professional organizations took up the cause of the health of women and children in many different ways. For example, the International Labour Organization proposed legal standards for the protection of maternity at work in 1919 the New York Times published articles on maternal mortality in the early 1930s; and in 1938 the Mothers Charter was proclaimed by 60 local associations in the United King dom. Backed by large numbers of official reports, maternal and child health became a priority for ministries of health. Matemal and child health programmes became a public health paradigm alongside that of the battle against infectious diseases (8) These programmes really started to gain ground after the Second World War. Global events precipitated public interest in the roles and responsibilities of governments, and the Universal Declaration of Human Rights in 1948 by the newly formed United Nations secured their obligation to provide"special care and assistance"for mothers and children (9). This added an international and moral dimension to the issue of the health of mothers and children, representing a huge step forward from the political and economic concerns of 50 years earlier. One of the core functions assigned to the World Health Organization(WHO)in its Constitution of 1948 was"to promote maternal and child health and welfare"(10 ) By the 1950s, national health plans and policy documents from development agencies invariably stressed that mothers and children were vulnerable groups and therefore priority"targets" for public health action. The notion of mothers and children as vul- nerable groups was also central to the primary health care movement launched at Alma-Ata(now Almaty, Kazakhstan)in 1978. This first major attempt at massive scal- ing up of health care coverage in rural areas boosted maternal and child health pro grammes by its focus on initiatives to increase immunization coverage and to tackle malnutrition, diarrhoea and respiratory diseases. In practice, child health programmes were usually the central-often the only- programmatic content of early attempts to implement primary health care(11) WHERE WE ARE NOW: A MORAL AND POLITICAL IMPERATIVE The early implementation of primary health care often had a narrow focus, but among 秀858卫 its merits was the fact that it laid the groundwork for linking health to development and to a wider civil society debate on inequalities. The plight of mothers and children soon came to be seen as much more than a problem of biological vulnerability. The 1987 Call to Action for Safe Motherhood explicitly framed it as "deeply rooted in the adverse social, cultural and economic environments of society, and especially the environment
mothers and children matter – so does their health 3 “It may seem like a cold-blooded thing to say, but someone ought to point out that the World War was a back-handed break for children ... As more and more thousands of men were slaughtered every day, the belligerent nations, on whatever side, began to see that new human lives, which could grow up to replace brutally extinguished adult lives, were extremely valuable national assets. [The children] took the spotlight as the hope of the nation. That is the handsomest way to put it. The ugliest way – and, I suspect, the truer – is to say flatly that it was the military usefulness of human life that wrought the change. When a nation is fighting a war or preparing for another ... it must look to its future supplies of cannon fodder” (7). Caring for the health of mothers and children soon gained a legitimacy of its own, beyond military and economic calculations. The increasing involvement of a variety of authorities – medical and lay, charitable and governmental – resonated with the rising expectations and political activism of civil society (1). Workers’ movements, women’s groups, charities and professional organizations took up the cause of the health of women and children in many different ways. For example, the International Labour Organization proposed legal standards for the protection of maternity at work in 1919; the New York Times published articles on maternal mortality in the early 1930s; and in 1938 the Mothers’ Charter was proclaimed by 60 local associations in the United Kingdom. Backed by large numbers of official reports, maternal and child health became a priority for ministries of health. Maternal and child health programmes became a public health paradigm alongside that of the battle against infectious diseases (8). These programmes really started to gain ground after the Second World War. Global events precipitated public interest in the roles and responsibilities of governments, and the Universal Declaration of Human Rights in 1948 by the newly formed United Nations secured their obligation to provide “special care and assistance” for mothers and children (9). This added an international and moral dimension to the issue of the health of mothers and children, representing a huge step forward from the political and economic concerns of 50 years earlier. One of the core functions assigned to the World Health Organization (WHO) in its Constitution of 1948 was “to promote maternal and child health and welfare” (10). By the 1950s, national health plans and policy documents from development agencies invariably stressed that mothers and children were vulnerable groups and therefore priority “targets” for public health action. The notion of mothers and children as vulnerable groups was also central to the primary health care movement launched at Alma-Ata (now Almaty, Kazakhstan) in 1978. This first major attempt at massive scaling up of health care coverage in rural areas boosted maternal and child health programmes by its focus on initiatives to increase immunization coverage and to tackle malnutrition, diarrhoea and respiratory diseases. In practice, child health programmes were usually the central – often the only – programmatic content of early attempts to implement primary health care (11). WHERE WE ARE NOW: A MORAL AND POLITICAL IMPERATIVE The early implementation of primary health care often had a narrow focus, but among its merits was the fact that it laid the groundwork for linking health to development and to a wider civil society debate on inequalities. The plight of mothers and children soon came to be seen as much more than a problem of biological vulnerability. The 1987 Call to Action for Safe Motherhood explicitly framed it as “deeply rooted in the adverse social, cultural and economic environments of society, and especially the environment © Archives de l’Assistance Publique – Hôpitaux de Paris
4 The World Health Report 2005 that societies create for women"(12). Box 1.1 recalls some important milestones in establishing the rights of women and children In this more politicized view, womens relative lack of decision-making power and their unequal access to employment, finances, education, basic health care and other resources are considered to be the root causes of their ill-health and that of their chil- dren. Poor nutrition in girls, early onset of sexual activity and adolescent pregnancy all have consequences for well-being during and after pregnancy for both mothers and children. millions of women and their families live in a social environment that works against seeking and enjoying good health. Women often have limited exposure to the education, information and new ideas that could spare them from repeated childbearing and save their lives during childbirth. They may have no say in decisions on whether to use contraception or where to give birth. They may be reluctant to use health services where they feel threatened and humiliated by the staff, or pressured to ot treatments that conflict with their own values and customs(13). Poverty, cul- ditions and legal barriers restrict their access to financial resources, making it re difficult to seek health care for themselves or for their children the unfair- ness of this situation has made it obvious that the health of mothers and children is an issue of rights, entitlements and day-to-day struggle to secure these entitlements The shift to a concern for the rights of women and children was accelerated by the International Conference on Population and Development, held in Cairo, Egypt, in Child health programmes were central to early attempts to implement primary health care Here a community nurse in Thailand watches as a mother weighs her baby
4 The World Health Report 2005 that societies create for women” (12). Box 1.1 recalls some important milestones in establishing the rights of women and children. In this more politicized view, women’s relative lack of decision-making power and their unequal access to employment, finances, education, basic health care and other resources are considered to be the root causes of their ill-health and that of their children. Poor nutrition in girls, early onset of sexual activity and adolescent pregnancy all have consequences for well-being during and after pregnancy for both mothers and children. Millions of women and their families live in a social environment that works against seeking and enjoying good health. Women often have limited exposure to the education, information and new ideas that could spare them from repeated childbearing and save their lives during childbirth. They may have no say in decisions on whether to use contraception or where to give birth. They may be reluctant to use health services where they feel threatened and humiliated by the staff, or pressured to accept treatments that conflict with their own values and customs (13). Poverty, cultural traditions and legal barriers restrict their access to financial resources, making it even more difficult to seek health care for themselves or for their children. The unfairness of this situation has made it obvious that the health of mothers and children is an issue of rights, entitlements and day-to-day struggle to secure these entitlements. The shift to a concern for the rights of women and children was accelerated by the International Conference on Population and Development, held in Cairo, Egypt, in Child health programmes were central to early attempts to implement primary health care. Here a community nurse in Thailand watches as a mother weighs her baby. WHO Archives: WHO12, SEARO 211
mothers and children matter - so does their health 5 Box 1.1 Milestones in the establishment of the rights of women and children In the 20th century several international treaties came into being, holding signatory countries accountable for the human rights of their citizens. Over the past two decades United Nations bodies, as well as international, regional and national courts, have increasingly focused on the human ights of mothers and children The Universal Declaration of Human Rights states that 1948- motherhood and childhood are entitled to special care and 1952 The General Conference of the International Labour Organi- assistance zation adopts the Maternity Protection Convention The Declaration of the Rights of the Child 1966 The International Covenant on Economic, Social and Cul tural Rights recognizes the right to the highest attainable stan dard of physical and mental health on on the Elimination of All Forms of Dis- 1981 Against Women enjoins States parties to ensure opropriate maternal health services. 1989 The Convention on the Rights of the child guarantees chil At the United Nations World Summit on Children govern- 1990 dren s right to health States commit themselves to ensuring ments declare their "joint commitment. to give every child a appropriate matemal health services. better future", and recognize the link between womens rights and children s well-being The United Nations Human Rights Committee expresses 1993 concern over high rates of maternal mortality 1994 The United Nations International Conference on Popula- 1995 tion and Development and the United Nations Fourth World The United Nations United Nations Human Rights Commit- 1996 Conference on Women affirm women's right of access to tee rules that, when abortion gives rise to a criminal penal appropriate health care services in pregnancy and childbirth even if a woman is pregnant as a result of rape, a womans ight to be free from inhuman and degrading treatment might 2000 The United Nations Committee on Economic Cultural Rights states that measures are required child and maternal health, sexual and reproductive = vIces The United Nations Committee on the Rights of the Child 2003-2003 The United Nations Commission on Human Rights, states states that adolescent girls should have access to informatio that sexual and reproductive health are integral elements of on the impact of early marriage and early pregnancy and have the right to health. The United Nations Committee on the Rights of the Child dopts its General Comment on HIV/AIDS and that on the Rights of the Child The United Nations Committee Against Torture calls for an 2004-2004 The United Nations Sub-Commission on the Promotion and traction of confessions for prosecution Protection of Human Rights adopts a resolution on"harmful from women seeking emergency medical care as a result of traditional practices affecting the health of women and the illegal abortion. The United Nations Special Rapporteur on the Right to Health reports that all forms of sexual violence are inconsistent with the right to heal
mothers and children matter – so does their health 5 Box 1.1 Milestones in the establishment of the rights of women and children In the 20th century several international treaties came into being, holding signatory countries accountable for the human rights of their citizens. Over the past two decades United Nations bodies, as well as international, regional and national courts, have increasingly focused on the human rights of mothers and children. The Universal Declaration of Human Rights states that “motherhood and childhood are entitled to special care and assistance”. The Declaration of the Rights of the Child. The Convention on the Elimination of All Forms of Discrimination Against Women enjoins States parties to ensure appropriate maternal health services. At the United Nations World Summit on Children governments declare their “joint commitment ... to give every child a better future”, and recognize the link between women’s rights and children’s well-being. The United Nations Human Rights Committee expresses concern over high rates of maternal mortality. The United Nations United Nations Human Rights Committee rules that, when abortion gives rise to a criminal penalty even if a woman is pregnant as a result of rape, a woman’s right to be free from inhuman and degrading treatment might be violated. The United Nations Committee on the Rights of the Child states that adolescent girls should have access to information on the impact of early marriage and early pregnancy and have access to health services sensitive to their needs and rights. The United Nations Committee on the Rights of the Child adopts its General Comment on HIV/AIDS and that on the Rights of the Child. The United Nations Committee Against Torture calls for an end to the extraction of confessions for prosecution purposes from women seeking emergency medical care as a result of illegal abortion. The United Nations Special Rapporteur on the Right to Health reports that all forms of sexual violence are inconsistent with the right to health. The General Conference of the International Labour Organization adopts the Maternity Protection Convention. The International Covenant on Economic, Social and Cultural Rights recognizes the right to the highest attainable standard of physical and mental health. The Convention on the Rights of the Child guarantees children’s right to health. States commit themselves to ensuring appropriate maternal health services. The United Nations International Conference on Population and Development and the United Nations Fourth World Conference on Women affirm women’s right of access to appropriate health care services in pregnancy and childbirth. The United Nations Committee on Economic, Social and Cultural Rights states that measures are required to “improve child and maternal health, sexual and reproductive health services”. The United Nations Commission on Human Rights, states that sexual and reproductive health are integral elements of the right to health. The United Nations Sub-Commission on the Promotion and Protection of Human Rights adopts a resolution on “harmful traditional practices affecting the health of women and the girl child”. 1948 1952 1959 1966 1981 1990 1993 1996 1994 2000 1995 2003 2003 2004 2004 1989
6 The World Health Report 2005 1994. The conference produced a 20-year plan of action that focused on universal access to reproductive health services(of which maternal and child health care be came a subset), which was grounded in individual choices and rights. This change in perspective is important, because it alters the rationale for investing in the health of mothers and children Today, more is known than ever before about what determines the health of women and children and about which interventions bring about improvements most cost effectively. This knowledge makes investment more successful, and withholding care even less acceptable. The health of mothers and children satisfies the classical criteria for setting public health priorities(see Box 1.2). Compelling as these arguments may be, however, they miss two vital points Box 1.2 Why invest public money in health care for mothers and children? Modern states guarantee health birth-weight children in turn are at greater risk maternal and child health interventions can be or mothers, newborns and children of dying and of suffering from infections and classified as private goods, a comprehensive grounded in human rights convention growth retardation(25), have lower scores programme also includes components such as ing them access to care has become on cognitive tests(26-28)and may be at information on contraception, on sexual health and political imperative, which also has a higher risk of developing chronic diseases in and rights, on breastfeeding and child care, that rong rational basis. are obvious public goods. Moreover, the rule of From a public health point of view a Healthy children are at the core of the rescue, which gives priority to interventions important criterion for priority setting and formation of human capital. Child illnesses that save lives, applies to many maternal and public funding is that cost-effective intervention and malnutrition reduce cognitive development child health interventions ckages exist Such packages are well and intellectual performance (31-33), school Finally, public funding for maternal and documented in the case of matemal and child enrolment and attendance (34, 35), which child health stified on grounds health(14, 15). But cost-effectiveness is only impairs final educational achievement. equity Motherhood and childhood are periods one of the criteria for public investment. Others Intrauterine growth retardation and malnutri- of particularly high vulnerability that require commonly used include: the generation of tion during early childhood have long-term special care and assistance"(19); they are sitive extemalities; the production of public effects on body size and strength(36, 37) with also periods of high vulnerability because oods and the rule of rescue; and the potential for productivity in adul women and children are more likely to be poor expenditure (16). Any of these criteria can be woman, society loses a member whose labour that they are overrepresented among the poor a sufficient condition for public investment on and activities are essential to the life and is scarce (46). women are more likely to be ten. l nen chore heant ie is westin she montershat a more me cnomaremors Heathly toemuplatyen to as owes ad es, r Ss acts. case for public funding is even stronger. for the social interaction and the creation of the decision-making power, all of which limit their Health care for mothers and children bonds that are the prerequisite of social capital. access to care. Public investment in maternal produces obvious positive externalities through They also play an important social role in caring and child health care is justified in order t accination or the treatment of the infectious for those who are ill diseases of childhood, and through the im- The economic costs of poor maternal and e women proved child health that follows improveme ild health are high (38), substantial savings represent a large proportion of the poor, of maternal health. There has been little in future expenditure are likely through family subsidizing health services for them can be systematic research on the human, social and planning programmes (39, 40) and interventions an effective strategy for income redistribution conomic capital generated by improving the that improve maternal and child health in the and poverty alleviation(14 ) Ill-health among health of mothers and children, but the negative long term. Consequent gains in human and mothers and children, and particularly the externalities of ill-health are clear ocial capital translate into long-term economic occurrence of major obstetric problems The health of mothers is a major determinant benefits (41). There is evidence of economic is largely unpredictable and can lead to of that of their children, and thus indirectly returns on investment in immunization (42), catastrophic expenditures(47)that may push affects the formation of human capital. nutrition programmes (41, 43), interventions households into poverty. The risk of catastrophic Motherless children die more frequently, are to reduce low birth weight ( 36), and integrated expenditures is often a deterrent for the timel more at risk of becoming malnourished and health and social development programmes uptake of care-a major argument, technically less likely to enrol at school(17, 18). The babies (44, 45) and politically, for public investmen f ill or undernourished pregnant women are Maternal and child health programmes ar more likely to have a low birth weight(19-21) also prime candidates for public funding because and impaired development(19, 22-24). Low- they produce public goods. Although many
6 The World Health Report 2005 1994. The conference produced a 20-year plan of action that focused on universal access to reproductive health services (of which maternal and child health care became a subset), which was grounded in individual choices and rights. This change in perspective is important, because it alters the rationale for investing in the health of mothers and children. Today, more is known than ever before about what determines the health of women and children and about which interventions bring about improvements most costeffectively. This knowledge makes investment more successful, and withholding care even less acceptable. The health of mothers and children satisfies the classical criteria for setting public health priorities (see Box 1.2). Compelling as these arguments may be, however, they miss two vital points. birth-weight children in turn are at greater risk of dying and of suffering from infections and growth retardation(25), have lower scores on cognitive tests (26–28) and may be at higher risk of developing chronic diseases in adulthood(29, 30 ). Healthy children are at the core of the formation of human capital. Child illnesses and malnutrition reduce cognitive development and intellectual performance(31–33), school enrolment and attendance(34, 35), which impairs final educational achievement. Intrauterine growth retardation and malnutrition during early childhood have long-term effects on body size and strength(36, 37) with implications for productivity in adulthood. In addition, with the death or illness of a woman, society loses a member whose labour and activities are essential to the life and cohesion of families and communities. Healthy mothers have more time and are more available for the social interaction and the creation of the bonds that are the prerequisite of social capital. They also play an important social role in caring for those who are ill. The economic costs of poor maternal and child health are high (38); substantial savings in future expenditure are likely through family planning programmes (39, 40) and interventions that improve maternal and child health in the long term. Consequent gains in human and social capital translate into long-term economic benefits (41). There is evidence of economic returns on investment in immunization (42), nutrition programmes (41, 43), interventions to reduce low birth weight (36), and integrated health and social development programmes (44, 45). Maternal and child health programmes are also prime candidates for public funding because they produce public goods. Although many Modern states guarantee health entitlements for mothers, newborns and children that are grounded in human rights conventions. Ensuring them access to care has become a moral and political imperative, which also has a strong rational basis. From a public health point of view an important criterion for priority setting and public funding is that cost-effective intervention packages exist. Such packages are well documented in the case of maternal and child health (14, 15). But cost-effectiveness is only one of the criteria for public investment. Others commonly used include: the generation of positive externalities; the production of public goods and the rule of rescue; and the potential to increase equity and avoid catastrophic expenditure (16). Any of these criteria can be a sufficient condition for public investment on its own. When more than one is present, as in maternal and child health interventions, the case for public funding is even stronger. Health care for mothers and children produces obvious positive externalities through vaccination or the treatment of the infectious diseases of childhood, and through the improved child health that follows improvement of maternal health. There has been little systematic research on the human, social and economic capital generated by improving the health of mothers and children, but the negative externalities of ill-health are clear. The health of mothers is a major determinant of that of their children, and thus indirectly affects the formation of human capital. Motherless children die more frequently, are more at risk of becoming malnourished and less likely to enrol at school(17, 18). The babies of ill or undernourished pregnant women are more likely to have a low birth weight(19–21) and impaired development(19, 22–24). Lowmaternal and child health interventions can be classified as private goods, a comprehensive programme also includes components such as information on contraception, on sexual health and rights, on breastfeeding and child care, that are obvious public goods. Moreover, the rule of rescue, which gives priority to interventions that save lives, applies to many maternal and child health interventions. Finally, public funding for maternal and child health care is justified on grounds of equity. Motherhood and childhood are periods of particularly high vulnerability that require “special care and assistance” (19); they are also periods of high vulnerability because women and children are more likely to be poor. Although systematic documentation showing that they are overrepresented among the poor is scarce (46), women are more likely to be unemployed, to have lower wages, less access to education and resources and more restricted decision-making power, all of which limit their access to care. Public investment in maternal and child health care is justified in order to correct these inequities. In addition, where women and children represent a large proportion of the poor, subsidizing health services for them can be an effective strategy for income redistribution and poverty alleviation (14). Ill-health among mothers and children, and particularly the occurrence of major obstetric problems, is largely unpredictable and can lead to catastrophic expenditures (47) that may push households into poverty. The risk of catastrophic expenditures is often a deterrent for the timely uptake of care – a major argument, technically and politically, for public investment. Box 1.2 Why invest public money in health care for mothers and children?
mothers and children matter - so does their health 7 First, children are the future of society, and their mothers are guardians of that future. Mothers are much more than caregivers and homemakers, undervalued as these roles often are. They transmit the cultural history of families and communities along with social norms and traditions. Mothers influence early behaviour and estab- lish lifestyle patterns that not only determine their children 's future development and capacity for health, but shape societies. Because of this, society values the health of its mothers and children for its own sake and not merely as a contribution to the wealth of the nation (48) Second, few consequences of the inequities in society are as damaging as those that affect the health and survival of women and children. For governments that take their function of reducing inequality and redistributing wealth seriously, improving the living conditions and providing access to health care for mothers and children are good starting points. Improving their health is at the core of the world's push to reduce poverty and inequality MOTHERS. CHILDREN AND THE MILLENNIUM DEVELOPMENT GOALS In his report to the Millennium Summit, the Secretary-General of the United Nations, Kofi Annan, called on"the international community at the highest level - the Heads of State and Government convened at the Millennium Summit- to adopt the target of halving the proportion of people living in extreme poverty, and so lifting more than 1 billion people out of it, by 2015"(49 ) He further urged that no effort be spared to he health of mothers and children is now seen as an issue of rights, entitlements and day-to-day struggle to secure these entitlements
mothers and children matter – so does their health 7 First, children are the future of society, and their mothers are guardians of that future. Mothers are much more than caregivers and homemakers, undervalued as these roles often are. They transmit the cultural history of families and communities along with social norms and traditions. Mothers influence early behaviour and establish lifestyle patterns that not only determine their children’s future development and capacity for health, but shape societies. Because of this, society values the health of its mothers and children for its own sake and not merely as a contribution to the wealth of the nation (48). Second, few consequences of the inequities in society are as damaging as those that affect the health and survival of women and children. For governments that take their function of reducing inequality and redistributing wealth seriously, improving the living conditions and providing access to health care for mothers and children are good starting points. Improving their health is at the core of the world’s push to reduce poverty and inequality. MOTHERS, CHILDREN AND THE MILLENNIUM DEVELOPMENT GOALS In his report to the Millennium Summit, the Secretary-General of the United Nations, Kofi Annan, called on “the international community at the highest level – the Heads of State and Government convened at the Millennium Summit – to adopt the target of halving the proportion of people living in extreme poverty, and so lifting more than 1 billion people out of it, by 2015” (49). He further urged that no effort be spared to The health of mothers and children is now seen as an issue of rights, entitlements and day-to-day struggle to secure these entitlements. Rafiqur Rahman/Reuters
8 The World Health Report 2005 reach this target by that date in every region, and in every country. The Millennium Declaration (50), coming after a decade of"unprecedented stagnation and deteriora- tion"(51), set out eight specific Millennium Development Goals(MDGs), each with its numerical targets and indicators for monitoring progress. The MDGs galvanized coun tries and the international community in a global partnership that, for the first time, articulated a commitment by both rich and poor countries to tackle a whole range of dimensions of poverty and inequality in a concerted and integrated way The health agenda is very much in evidence in the MDGs: it is explicit in three of the eight goals, eight of the 18 targets, and 18 of the 48 indicators. This emphasis on health reflects a global consensus that ill-health is an important dimension of poverty in its own right. Il-health contributes to poverty. Improving health is a condition for poverty alleviation and for development Sustainable improvement of health depends on successful poverty alleviation and reduction of inequalities. It is no accident that the formulation of the MDG targets and indicators reveals the special priority given to the health and well-being of women, mothers and children Mother and child health is clearly on the international agenda even in the absence of iversal access to reproductive health services as a specific Millennium Develop ment Goal. Globally, we are making progress towards the MDGs in maternal and child health. Success is overshadowed, however, by the persistence of an unacceptably high mortality and the increasing inequity in maternal and child health and access to health care worldwide UNEVEN GAINS IN CHILD HEALTH Being healthy means much more than merely surviving. Nevertheless, the mortality rates of children under five years of age provide a good indicator of the progress made or the tragic lack of it. Under-five mortality rates fell worldwide throughout the latter part of the 20th century: from 146 per 1000 in 1970 to 79 per 1000 in 2003. Since 1990, this rate has dropped by about 15%, equating to more than two million lives Figure 1. 1 Slowing progress in child mortality: how Africa is faring worst 250 Eastem mediterranean South-East asia without india 0002003
8 The World Health Report 2005 reach this target by that date in every region, and in every country. The Millennium Declaration (50), coming after a decade of “unprecedented stagnation and deterioration” (51), set out eight specific Millennium Development Goals (MDGs), each with its numerical targets and indicators for monitoring progress. The MDGs galvanized countries and the international community in a global partnership that, for the first time, articulated a commitment by both rich and poor countries to tackle a whole range of dimensions of poverty and inequality in a concerted and integrated way. The health agenda is very much in evidence in the MDGs: it is explicit in three of the eight goals, eight of the 18 targets, and 18 of the 48 indicators. This emphasis on health reflects a global consensus that ill-health is an important dimension of poverty in its own right. Ill-health contributes to poverty. Improving health is a condition for poverty alleviation and for development. Sustainable improvement of health depends on successful poverty alleviation and reduction of inequalities. It is no accident that the formulation of the MDG targets and indicators reveals the special priority given to the health and well-being of women, mothers and children. Mother and child health is clearly on the international agenda even in the absence of universal access to reproductive health services as a specific Millennium Development Goal. Globally, we are making progress towards the MDGs in maternal and child health. Success is overshadowed, however, by the persistence of an unacceptably high mortality and the increasing inequity in maternal and child health and access to health care worldwide. UNEVEN GAINS IN CHILD HEALTH Being healthy means much more than merely surviving. Nevertheless, the mortality rates of children under five years of age provide a good indicator of the progress made – or the tragic lack of it. Under-five mortality rates fell worldwide throughout the latter part of the 20th century: from 146 per 1000 in 1970 to 79 per 1000 in 2003. Since 1990, this rate has dropped by about 15%, equating to more than two million lives Figure 1.1 Slowing progress in child mortality: how Africa is faring worst Mortality rate of children under 5 years of age per 1000 live births 0 50 100 150 200 250 1970 1980 1990 2000 2003 Africa Eastern Mediterranean World South-East Asia South-East Asia without India Western Pacific Western Pacific without China Americas Europe
mothers and children matter -so does their health 9 saved in 2003 alone. Towards the turn of the millennium however, the overall down ward trend was showing signs of slowing. Between 1970 and 1990, the under-five mortality rate dropped by 20% every decade; between 1990 and 2000 it dropped by only 12%(see Figure 1. 1). The global averages also hide important regional differences. The slowing down of progress started in the 1980s in the WHO African and Western Pacific Regions, and during the 1990s in the Eastern Mediterranean Region. The African Region started out at the highest levels, saw the smallest reductions(around 5% by decade between 1980 and 2000)and the most marked slowing down. In contrast, progress continued or accelerated in the WHO Region of the Americas, and the South-East Asia and European Regions. he result is that the differences between regions are growing. The under-five mor- tality rate is now seven times higher in the African Region than in the European Region; the rate was " only"4.3 times higher in 1980 and 5. 4 times higher in 1990. Child deaths are increasingly concentrated in the African Region (43% of the global total in 2003, up from 30%in 1990). As 28% of child deaths still occur in South-East Asia, two of the six WHO regions-Africa and South-East Asia-account for more than 0% of all child deaths. Looking at it another way, more than 50% of all child deaths are concentrated in just six countries: China, the Democratic Republic of the Congo, Ethiopia, India, Nigeria and Pakistan The fortunes of the world 's children have also been mixed in terms of their nutritional status. Overall, children today are better nourished: between 1990 and 2000 the global prevalence of stunting and underweight declined by 20% and 18%, respec- tively. Nevertheless, children across southern and central Asia continue to suffer very high levels of malnutrition, and throughout sub-Saharan Africa the numbers of children who are stunted and underweight increased in this period (52) THE NEWBORN DEATHS THAT WENT UNNOTICED If further progress is to be made in reducing child mortality, increased efforts are needed to bring about a substantial reduction in deaths among newborns. The first global estimates of neonatal mortality, dating from 1983(53), were derived using historical data and are generally considered to give only a rough indication of the magnitude of the problem More rigorous estimates became available for 1995 and for 2000. These are based on national demographic surveys as well as on statistical models. The new estimates show that the burden of newborn mortality is considerably Each year, about four million newborns die before they are four weeks old 98%of these deaths occur in developing countries. Newborn deaths now contribute to about 0%of all deaths in children under five years of age globally, and more than half of infant mortality (54, 55). Rates are highest in sub-Saharan Africa and Asia. Two thirds of newborn deaths occur in the WHO Regions of Africa(28%)and South-East Asia (36%)(56). The gap between rich and poor countries is widening: neonatal mortal- ity is now 6.5 times lower in the high-income countries than in other countries. The lifetime risk for a woman to lose a newborn baby is now 1 in 5 in Africa, compared with 1 in 125 in more developed countries (57) do not include the 3. 3 million stillbirths per year. Data on stillbirths are even more scarce than those on newborn deaths. This is not surprising, as only 14% of births in the world are registered. Both live births and deaths of newborns go underreported; fetal deaths are even more likely to go unreported, particularly early fetal deaths
mothers and children matter – so does their health 9 saved in 2003 alone. Towards the turn of the millennium, however, the overall downward trend was showing signs of slowing. Between 1970 and 1990, the under-five mortality rate dropped by 20% every decade; between 1990 and 2000 it dropped by only 12% (see Figure 1.1). The global averages also hide important regional differences. The slowing down of progress started in the 1980s in the WHO African and Western Pacific Regions, and during the 1990s in the Eastern Mediterranean Region. The African Region started out at the highest levels, saw the smallest reductions (around 5% by decade between 1980 and 2000) and the most marked slowing down. In contrast, progress continued or accelerated in the WHO Region of the Americas, and the South-East Asia and European Regions. The result is that the differences between regions are growing. The under-five mortality rate is now seven times higher in the African Region than in the European Region; the rate was “only” 4.3 times higher in 1980 and 5.4 times higher in 1990. Child deaths are increasingly concentrated in the African Region (43% of the global total in 2003, up from 30% in 1990). As 28% of child deaths still occur in South-East Asia, two of the six WHO regions – Africa and South-East Asia – account for more than 70% of all child deaths. Looking at it another way, more than 50% of all child deaths are concentrated in just six countries: China, the Democratic Republic of the Congo, Ethiopia, India, Nigeria and Pakistan. The fortunes of the world’s children have also been mixed in terms of their nutritional status. Overall, children today are better nourished: between 1990 and 2000 the global prevalence of stunting and underweight declined by 20% and 18%, respectively. Nevertheless, children across southern and central Asia continue to suffer very high levels of malnutrition, and throughout sub-Saharan Africa the numbers of children who are stunted and underweight increased in this period (52). THE NEWBORN DEATHS THAT WENT UNNOTICED If further progress is to be made in reducing child mortality, increased efforts are needed to bring about a substantial reduction in deaths among newborns. The first global estimates of neonatal mortality, dating from 1983 (53), were derived using historical data and are generally considered to give only a rough indication of the magnitude of the problem. More rigorous estimates became available for 1995 and for 2000. These are based on national demographic surveys as well as on statistical models. The new estimates show that the burden of newborn mortality is considerably higher than many people realize. Each year, about four million newborns die before they are four weeks old: 98% of these deaths occur in developing countries. Newborn deaths now contribute to about 40% of all deaths in children under five years of age globally, and more than half of infant mortality (54, 55). Rates are highest in sub-Saharan Africa and Asia. Two thirds of newborn deaths occur in the WHO Regions of Africa (28%) and South-East Asia (36%) (56). The gap between rich and poor countries is widening: neonatal mortality is now 6.5 times lower in the high-income countries than in other countries. The lifetime risk for a woman to lose a newborn baby is now 1 in 5 in Africa, compared with 1 in 125 in more developed countries (57). The above figures do not include the 3.3 million stillbirths per year. Data on stillbirths are even more scarce than those on newborn deaths. This is not surprising, as only 14% of births in the world are registered. Both live births and deaths of newborns go underreported; fetal deaths are even more likely to go unreported, particularly early fetal deaths