- Email: [email protected]
The child survival revolution: what next?
Comment
The child survival revolution: what next? A child born today has half the risk of dying before their fifth birthday compared with a child born in 1990, the baseline of the Millennium Development Goals (MDGs), when 12·2 million children died, now reduced to 6·3 million (95% uncertainty interval 6·0–6·6 million).1 In The Lancet, Haidong Wang and colleagues1 from the Institute of Health Metrics and Evaluation (IHME) present complex analyses, the most detailed attempt yet to attribute change and predict the future post-2015 for child survival. Wang and colleagues1 estimate that the under-5 mortality rate reduced from a global average of 83·1 per 1000 livebirths (95% uncertainty interval 68·9–98·2) in 1990, to 43·3 per 1000 (32·9–57·3) in 2013. This proportionate reduction is similar to UN estimates of a reduction from 90 per 1000 livebirths in 1990 to 48 per 1000 in 2012.2 Because inputs for two-thirds of deaths worldwide depend on household surveys with a 5-year time lag, major data gaps exist in recent years. Even countries with usable vital registration have not yet submitted 2013 data.3 However, despite uncertainties, enough data are available to show remarkable mortality risk reductions. Estimates from IHME and the UN have increased the frequency, complexity, and transparency of estimation with convergence worldwide, although differences remain between countries.1 Yet many national policy makers continue to use national household survey data and not global estimates.4 Progress in child survival has changed gear with a recent doubling of the average annual rate of reduction to 3·5% in 2005–13, coinciding with increased attention and funding.1 The mid-1990s marked the slowest progress with an average annual rate of change of –1·2, stagnating compared with average annual rates of reduction of between 2·5% and 3·0% in 1970–80s.1 Although other factors played a part in the 1990s, especially in Africa, notably structural adjustment and an unchecked HIV epidemic, there is recognition that the UN and global community lost focus during the 1990s. There is real concern among national and global health policymakers that recent remarkable progress might again stall after 2015. Outcome-focused targets are fundamental to maintaining attention and accountability, and yet these targets are still unclear in the post-2015 framework, despite being crucial in A Promise Renewed, the African www.thelancet.com Vol 384 September 13, 2014
Union’s Campaign for Reduction of Maternal Mortality, and the Muskoka initiative. An important gap is our understanding of the drivers of rapid mortality change, and conversely what has impeded progress in the 17 slowest progressing countries identified by Wang and colleagues (including the USA).1 IHME’s mixed-effects model explains a remarkable 94% of the mortality rate change since 1990. Investigators applied Shapley decomposition to 64 scenarios to attribute average changes for covariates assessed. The identified factors were secular trend, maternal education, and less progress explained by income.1 When considering numbers, Africa’s child survival progress has been curtailed by the continuing increase in births, and a smaller effect from increased HIV/AIDS.1 Hence, secular trend is the main explanatory variable in this model. What is this secular trend and how do we scale it up? Is this improved environment, or shifts in social norms? Or better transport or communications? Or can it be directly attributed to health-care technologies, some of which have had major changes in coverage (notably immunisation, HIV/AIDS, and malaria interventions)? Can modelling account for co-linearity of income, education, and reduced family size with other unnamed, more proximal health-care parameters?5 As well as complex modelling, we urgently need rigorous standardised assessments to assess success factors and get beyond statistical associations alone, or platitudes regarding governance and leadership, and more into the how to of national change (or lack of it). Some countries with poor governance and little economic growth have made remarkable progress for maternal mortality and child survival, notably Bangladesh.5–7 Are these paradoxes context-specific or would solutions transfer from Bangladesh to Nigeria, for example? Families in countries with the highest mortality risks cannot wait for perfect governance. What does this mean for the future? The MDG endline of 2015 is a moment to pause, look back, learn, and gather speed. Momentum cannot be lost as it was in the late 1990s (table). If optimistic mortality trends and fertility trends are achieved then, by 2030, 2·4 million children will die yearly,1 of which most would be neonatal deaths.2,5,8 We need to use data to drive
See Articles page 957 For the Campaign for Reduction of Maternal Mortality in Africa see http://www.carmma.org/ For A Promise Renewed see http://www.apromiserenewed. org/ For the Every Newborn Action Plan see http://www. everynewborn.org/ For the Muskoka Initiative http://www.acdi-cida.gc.ca/acdicida/acdi-cida.nsf/En/FRA119133138-PQT
931
Comment
accelerated change, and to do so we need to understand that change better. Where to focus? Africa’s share of both child and maternal deaths has increased—now with 12% of world population yet more than 50% of maternal and child deaths.2 According to Wang and colleagues, all eight countries predicted to have under-5 mortality of more than 70 per 1000 livebirths in 2030 are African.1 Many of these are affected by conflict. Pakistan and Afghanistan are highlighted in other analyses.2,5,8 When to focus? Wang and colleagues note the changing age structure of child deaths, with rising importance of the neonatal period (first 4 weeks) and indeed early neonatal period (first week). Both IHME and the UN have recently addressed previous simplistic assumptions where the under-5 mortality rate in high HIV countries inflated the neonatal mortality rate.9 However, IHME’s modelled proportion of under-5 mortality that is neonatal is now lower than the UN’s and remains virtually flat until 2030, when it is predicted to still be around 44%, which suggests that the IHME model does not capture neonatal mortality rate trends differentially to under-5 mortality rate trends.1 There is already a notable divergence for IHME neonatal mortality estimates in some countries with recent real data such as those from Pakistan.10 An elegant analysis in Brazil showed that the median day of infant death had shifted from day 30 in 1979 to day 3 in 2007.11 In
most world regions half or more of child deaths are in the neonatal period, with the hours around birth being those with the greatest risk of death and disability, and requiring more attention given feasible and costeffective interventions.8 What should the child survival revolution focus on next? The first revolution led by Jim Grant had a rallying call for growth, oral rehydration salts, breastfeeding, immunisation, food supplementation, fertility, and female education (GOBI–FFF; table).6 From GOBI-FFF, family planning and female education received less focus and yet, according to Wang and colleagues’ analysis,1 these are potentially the biggest drivers of child survival, also affecting women’s empowerment and human development. During the past decade, the second child survival revolution has been fragmented and driven by selective investments in immunisation, HIV/AIDS, and malaria, but has lacked broader preventive care such as breastfeeding, water, and sanitation and has only recently focused more on care of children with pneumonia, diarrhoea, and undernutrition.12 Care of newborn babies has been almost entirely neglected, but preterm birth complications alone account for as many deaths as pneumonia and 10-fold more than does AIDS in children.8 We are the first generation able to envision a grand convergence in survival, in which child and maternal mortality in the poorest countries reach the levels of the richest.13 To achieve this, present mortality reduction
Goals and targets
Programmatic focus
Leadership
Phase 1: 1980s–1990s
Targets set by 1990 World Summit for Children (precursor of MDGs)
Growth, oral rehydration salts, breastfeeding, immunisation, food supplementation, fertility, and female education (GOBI-FFF)
UNICEF and Jim Grant with high attention from heads of state in high burden countries; WHO focused on diarrhoea and pneumonia, then on integrated management of childhood illness
Phase 2: 2000s–2015
MDG 4 (assessed by under-5 mortality, infant mortality rate, and measles vaccination); MDG 1 (assessed by stunting)
Immunisation, HIV/AIDS, malaria, pneumonia, diarrhoea, and undernutrition
Mainly global funds, Global Alliance for Vaccines and Immunisation, and The Global Fund; UNICEF focused on rights, then turned again to survival from about 2004 and particular equity focus more recently; weak global accountability mechanisms, fragmented UN and donor mechanisms; major new funding streams especially from the Bill & Melinda Gates foundation
Phase 3: after 2015
Targets need to continue to focus on outcomes, notably: under-5 mortality, adding explicit tracking of neonatal mortality rate (as opposed to outdated focus on infant mortality rate); stunting; low birthweight (split by preterm and small for gestational age); crucial to include child development outcomes and to count stillbirths both with explicit targets; neonatal mortality rate target is also crucial
Unfinished child survival business for: pneumonia, diarrhoea, and other infections, including more attention to hospital care and preventive care; healthy start: newborn deaths, including stillbirths, with attention to unmet need for family planning, quality of care at birth, and improved care of small and sick newborn babies; human capital: stunting, undernutrition, small for gestational age, and preterm birth, counting child development outcomes and disability; other disorders (eg, injuries, congenital disorders, and childhood cancers) will be increasingly important, especially in middle-income countries
The vision is to have country leadership supported by the global community including the UN and donors in a more coordinated way, also with more integration of reproductive, maternal, and newborn health including funding streams, and stronger global accountability mechanisms; intentional linkages between sectors (eg, health, education, water, and sanitation) will also be important
Information taken from Rohde and colleagues,6 Lawn and colleagues,8 and Bryce and colleagues.12 MDG=Millennium Development Goal. UN=United Nations.
Table: Child survival revolution, past and future
932
www.thelancet.com Vol 384 September 13, 2014
Comment
trends need to be doubled and intentional investment must reach the poorest with the highest effect of care. In addition to completion of the unfinished business for pneumonia, diarrhoea, malaria, and HIV, a major shift needs to prioritise a healthy start, through quality of care at birth for every woman, and improved care of small and sick newborn babies. The Lancet Every Newborn series8 details the evidence, and the Every Newborn Action Plan is gaining momentum. This healthy start also improves human capital, targeting disability, preterm birth, small for gestational age, and stunting. The next child survival revolution has to go beyond survival alone to counting child development outcomes. The post-2015 framework needs explicit targets for maternal mortality, under-5 mortality, and neonatal mortality, but also for stillbirths and development outcomes. However a gap remains for effective accountability mechanisms and leadership for national change (table). Finally, clever modelling is no panacea for poor input data. Counting births and deaths is not just about a piece of paper, but a shift in norms to show that every birth and every death counts and that millions of newborn and child deaths are not inevitable.8
I am an unpaid member of both the IHME Global Burden of Disease Scientific Review Group and WHO’s Global Statistics Advisory Board. 1
2
3
4 5
6 7
8
9
10
11
12
Joy E Lawn London School Hygiene & Tropical Medicine, London WC1E 7HT, UK [email protected]
13
Wang H, Liddell CA, Coates MM, et al. Global, regional, and national levels of neonatal, infant, and under-5 mortality during 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet 2014; 384: 957–79. UNICEF. Levels and trends in child mortality. New York: United Nations, 2013. http://www.childinfo.org/files/Child_Mortality_Report_2013.pdf (accessed May 24, 2014). Oestergaard MZ, Alkema L, Lawn JE. Millennium Development Goals national targets are moving targets and the results will not be known until well after the deadline of 2015. Int J Epidemiol 2013; 42: 645–47. Byass P. The imperfect world of global health estimates. PLoS Med 2010; 7: e1001006. Lawn JE, Kinney M, Black RE, et al. A decade of change for newborn survival, policy and programmes: a multi-country analysis. Health Policy Plan 2012; 27 (suppl 3): 6–28. Rohde J, Cousens S, Chopra M, et al. 30 years after Alma-Ata: has primary health care worked in countries? Lancet 2008; 372: 950–61. Adams AM, Rabbani A, Ahmed S, et al. Explaining equity gains in child survival in Bangladesh: scale, speed, and selectivity in health and development. Lancet 2013; 382: 2027–37. Lawn JE, Blencowe H, Oza S, et al. Every Newborn: progress, priorities, potential beyond survival. Lancet 2014; published online May 19. http:// dx.doi.org/10.1016/S0140-6736(14)60496-7. Kerber KJ, Lawn JE, Johnson LF, et al. South African child deaths 1990–2011: have HIV services reversed the trend enough to meet Millennium Development Goal 4? AIDS 2013; 27: 2637–48. National Institute of Population Studies. Pakistan Demographic and Health Survey 2012–13. Preliminary report. December, 2013. http://dhsprogram. com/publications/publication-FR290-DHS-Final-Reports.cfm (accessed July 7, 2014). Victora CG, Aquino EM, do Carmo Leal M, Monteiro CA, Barros FC, Szwarcwald CL. Maternal and child health in Brazil: progress and challenges. Lancet 2011; 377: 1863–76. Bryce J, Victora CG, Black RE. The unfinished agenda in child survival. Lancet 2013; 382: 1049–59. Stenberg K, Axelson H, Sheehan P, et al. Advancing social and economic development by investing in women’s and children’s health: a new Global Investment Framework. Lancet 2014; 383: 1333–54.
Counting what counts for maternal mortality More than half a century ago, Dugald Baird1 wrote the public health classic about the application of a preventive outlook to obstetrics. This paper challenged the dominant curative model by acknowledging the broader determinants of pregnancy outcomes, and led to the emergence of social obstetrics. Baird’s message remains very relevant today. A social perspective is clearly relevant to all areas of health care, but it is vulnerable groups who suffer the most from its absence, especially children and women.2 The latest estimates of maternal mortality from Nicholas Kassebaum and colleagues3 published in The Lancet are a reminder of the need to apply a social lens to assessing improvements in health outcomes. The usual metrics of numbers and ratios show decreases since 1990 at global, regional, and national levels, with, for example, a worldwide estimate of 283 maternal deaths www.thelancet.com Vol 384 September 13, 2014
per 100 000 livebirths in 1990 (95% uncertainty interval 259–307), and 209 (186–234) in 2013. However, little is learnt from these figures in terms of the fundamental question of who has benefitted from this progress: have social gradients in the risk of preventable maternal death been narrowed? This question needs to be a focus as the Millennium Development Goal deadline approaches, and as the future world we want is debated.4 Evidence of marked differences in the burden of maternal mortality goes back centuries,5 both for individual-level characteristics, such as age or parity, and for aggregate-level factors, such as regions or rural versus urban areas. Although such a long-term view of differentials is restricted to what are now highincome countries with advanced vital registration systems, evidence of patterns of maternal mortality
See Articles page 980
933
The child survival revolution: what next? A child born today has half the risk of dying before their fifth birthday compared with a child born in 1990, the baseline of the Millennium Development Goals (MDGs), when 12·2 million children died, now reduced to 6·3 million (95% uncertainty interval 6·0–6·6 million).1 In The Lancet, Haidong Wang and colleagues1 from the Institute of Health Metrics and Evaluation (IHME) present complex analyses, the most detailed attempt yet to attribute change and predict the future post-2015 for child survival. Wang and colleagues1 estimate that the under-5 mortality rate reduced from a global average of 83·1 per 1000 livebirths (95% uncertainty interval 68·9–98·2) in 1990, to 43·3 per 1000 (32·9–57·3) in 2013. This proportionate reduction is similar to UN estimates of a reduction from 90 per 1000 livebirths in 1990 to 48 per 1000 in 2012.2 Because inputs for two-thirds of deaths worldwide depend on household surveys with a 5-year time lag, major data gaps exist in recent years. Even countries with usable vital registration have not yet submitted 2013 data.3 However, despite uncertainties, enough data are available to show remarkable mortality risk reductions. Estimates from IHME and the UN have increased the frequency, complexity, and transparency of estimation with convergence worldwide, although differences remain between countries.1 Yet many national policy makers continue to use national household survey data and not global estimates.4 Progress in child survival has changed gear with a recent doubling of the average annual rate of reduction to 3·5% in 2005–13, coinciding with increased attention and funding.1 The mid-1990s marked the slowest progress with an average annual rate of change of –1·2, stagnating compared with average annual rates of reduction of between 2·5% and 3·0% in 1970–80s.1 Although other factors played a part in the 1990s, especially in Africa, notably structural adjustment and an unchecked HIV epidemic, there is recognition that the UN and global community lost focus during the 1990s. There is real concern among national and global health policymakers that recent remarkable progress might again stall after 2015. Outcome-focused targets are fundamental to maintaining attention and accountability, and yet these targets are still unclear in the post-2015 framework, despite being crucial in A Promise Renewed, the African www.thelancet.com Vol 384 September 13, 2014
Union’s Campaign for Reduction of Maternal Mortality, and the Muskoka initiative. An important gap is our understanding of the drivers of rapid mortality change, and conversely what has impeded progress in the 17 slowest progressing countries identified by Wang and colleagues (including the USA).1 IHME’s mixed-effects model explains a remarkable 94% of the mortality rate change since 1990. Investigators applied Shapley decomposition to 64 scenarios to attribute average changes for covariates assessed. The identified factors were secular trend, maternal education, and less progress explained by income.1 When considering numbers, Africa’s child survival progress has been curtailed by the continuing increase in births, and a smaller effect from increased HIV/AIDS.1 Hence, secular trend is the main explanatory variable in this model. What is this secular trend and how do we scale it up? Is this improved environment, or shifts in social norms? Or better transport or communications? Or can it be directly attributed to health-care technologies, some of which have had major changes in coverage (notably immunisation, HIV/AIDS, and malaria interventions)? Can modelling account for co-linearity of income, education, and reduced family size with other unnamed, more proximal health-care parameters?5 As well as complex modelling, we urgently need rigorous standardised assessments to assess success factors and get beyond statistical associations alone, or platitudes regarding governance and leadership, and more into the how to of national change (or lack of it). Some countries with poor governance and little economic growth have made remarkable progress for maternal mortality and child survival, notably Bangladesh.5–7 Are these paradoxes context-specific or would solutions transfer from Bangladesh to Nigeria, for example? Families in countries with the highest mortality risks cannot wait for perfect governance. What does this mean for the future? The MDG endline of 2015 is a moment to pause, look back, learn, and gather speed. Momentum cannot be lost as it was in the late 1990s (table). If optimistic mortality trends and fertility trends are achieved then, by 2030, 2·4 million children will die yearly,1 of which most would be neonatal deaths.2,5,8 We need to use data to drive
See Articles page 957 For the Campaign for Reduction of Maternal Mortality in Africa see http://www.carmma.org/ For A Promise Renewed see http://www.apromiserenewed. org/ For the Every Newborn Action Plan see http://www. everynewborn.org/ For the Muskoka Initiative http://www.acdi-cida.gc.ca/acdicida/acdi-cida.nsf/En/FRA119133138-PQT
931
Comment
accelerated change, and to do so we need to understand that change better. Where to focus? Africa’s share of both child and maternal deaths has increased—now with 12% of world population yet more than 50% of maternal and child deaths.2 According to Wang and colleagues, all eight countries predicted to have under-5 mortality of more than 70 per 1000 livebirths in 2030 are African.1 Many of these are affected by conflict. Pakistan and Afghanistan are highlighted in other analyses.2,5,8 When to focus? Wang and colleagues note the changing age structure of child deaths, with rising importance of the neonatal period (first 4 weeks) and indeed early neonatal period (first week). Both IHME and the UN have recently addressed previous simplistic assumptions where the under-5 mortality rate in high HIV countries inflated the neonatal mortality rate.9 However, IHME’s modelled proportion of under-5 mortality that is neonatal is now lower than the UN’s and remains virtually flat until 2030, when it is predicted to still be around 44%, which suggests that the IHME model does not capture neonatal mortality rate trends differentially to under-5 mortality rate trends.1 There is already a notable divergence for IHME neonatal mortality estimates in some countries with recent real data such as those from Pakistan.10 An elegant analysis in Brazil showed that the median day of infant death had shifted from day 30 in 1979 to day 3 in 2007.11 In
most world regions half or more of child deaths are in the neonatal period, with the hours around birth being those with the greatest risk of death and disability, and requiring more attention given feasible and costeffective interventions.8 What should the child survival revolution focus on next? The first revolution led by Jim Grant had a rallying call for growth, oral rehydration salts, breastfeeding, immunisation, food supplementation, fertility, and female education (GOBI–FFF; table).6 From GOBI-FFF, family planning and female education received less focus and yet, according to Wang and colleagues’ analysis,1 these are potentially the biggest drivers of child survival, also affecting women’s empowerment and human development. During the past decade, the second child survival revolution has been fragmented and driven by selective investments in immunisation, HIV/AIDS, and malaria, but has lacked broader preventive care such as breastfeeding, water, and sanitation and has only recently focused more on care of children with pneumonia, diarrhoea, and undernutrition.12 Care of newborn babies has been almost entirely neglected, but preterm birth complications alone account for as many deaths as pneumonia and 10-fold more than does AIDS in children.8 We are the first generation able to envision a grand convergence in survival, in which child and maternal mortality in the poorest countries reach the levels of the richest.13 To achieve this, present mortality reduction
Goals and targets
Programmatic focus
Leadership
Phase 1: 1980s–1990s
Targets set by 1990 World Summit for Children (precursor of MDGs)
Growth, oral rehydration salts, breastfeeding, immunisation, food supplementation, fertility, and female education (GOBI-FFF)
UNICEF and Jim Grant with high attention from heads of state in high burden countries; WHO focused on diarrhoea and pneumonia, then on integrated management of childhood illness
Phase 2: 2000s–2015
MDG 4 (assessed by under-5 mortality, infant mortality rate, and measles vaccination); MDG 1 (assessed by stunting)
Immunisation, HIV/AIDS, malaria, pneumonia, diarrhoea, and undernutrition
Mainly global funds, Global Alliance for Vaccines and Immunisation, and The Global Fund; UNICEF focused on rights, then turned again to survival from about 2004 and particular equity focus more recently; weak global accountability mechanisms, fragmented UN and donor mechanisms; major new funding streams especially from the Bill & Melinda Gates foundation
Phase 3: after 2015
Targets need to continue to focus on outcomes, notably: under-5 mortality, adding explicit tracking of neonatal mortality rate (as opposed to outdated focus on infant mortality rate); stunting; low birthweight (split by preterm and small for gestational age); crucial to include child development outcomes and to count stillbirths both with explicit targets; neonatal mortality rate target is also crucial
Unfinished child survival business for: pneumonia, diarrhoea, and other infections, including more attention to hospital care and preventive care; healthy start: newborn deaths, including stillbirths, with attention to unmet need for family planning, quality of care at birth, and improved care of small and sick newborn babies; human capital: stunting, undernutrition, small for gestational age, and preterm birth, counting child development outcomes and disability; other disorders (eg, injuries, congenital disorders, and childhood cancers) will be increasingly important, especially in middle-income countries
The vision is to have country leadership supported by the global community including the UN and donors in a more coordinated way, also with more integration of reproductive, maternal, and newborn health including funding streams, and stronger global accountability mechanisms; intentional linkages between sectors (eg, health, education, water, and sanitation) will also be important
Information taken from Rohde and colleagues,6 Lawn and colleagues,8 and Bryce and colleagues.12 MDG=Millennium Development Goal. UN=United Nations.
Table: Child survival revolution, past and future
932
www.thelancet.com Vol 384 September 13, 2014
Comment
trends need to be doubled and intentional investment must reach the poorest with the highest effect of care. In addition to completion of the unfinished business for pneumonia, diarrhoea, malaria, and HIV, a major shift needs to prioritise a healthy start, through quality of care at birth for every woman, and improved care of small and sick newborn babies. The Lancet Every Newborn series8 details the evidence, and the Every Newborn Action Plan is gaining momentum. This healthy start also improves human capital, targeting disability, preterm birth, small for gestational age, and stunting. The next child survival revolution has to go beyond survival alone to counting child development outcomes. The post-2015 framework needs explicit targets for maternal mortality, under-5 mortality, and neonatal mortality, but also for stillbirths and development outcomes. However a gap remains for effective accountability mechanisms and leadership for national change (table). Finally, clever modelling is no panacea for poor input data. Counting births and deaths is not just about a piece of paper, but a shift in norms to show that every birth and every death counts and that millions of newborn and child deaths are not inevitable.8
I am an unpaid member of both the IHME Global Burden of Disease Scientific Review Group and WHO’s Global Statistics Advisory Board. 1
2
3
4 5
6 7
8
9
10
11
12
Joy E Lawn London School Hygiene & Tropical Medicine, London WC1E 7HT, UK [email protected]
13
Wang H, Liddell CA, Coates MM, et al. Global, regional, and national levels of neonatal, infant, and under-5 mortality during 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet 2014; 384: 957–79. UNICEF. Levels and trends in child mortality. New York: United Nations, 2013. http://www.childinfo.org/files/Child_Mortality_Report_2013.pdf (accessed May 24, 2014). Oestergaard MZ, Alkema L, Lawn JE. Millennium Development Goals national targets are moving targets and the results will not be known until well after the deadline of 2015. Int J Epidemiol 2013; 42: 645–47. Byass P. The imperfect world of global health estimates. PLoS Med 2010; 7: e1001006. Lawn JE, Kinney M, Black RE, et al. A decade of change for newborn survival, policy and programmes: a multi-country analysis. Health Policy Plan 2012; 27 (suppl 3): 6–28. Rohde J, Cousens S, Chopra M, et al. 30 years after Alma-Ata: has primary health care worked in countries? Lancet 2008; 372: 950–61. Adams AM, Rabbani A, Ahmed S, et al. Explaining equity gains in child survival in Bangladesh: scale, speed, and selectivity in health and development. Lancet 2013; 382: 2027–37. Lawn JE, Blencowe H, Oza S, et al. Every Newborn: progress, priorities, potential beyond survival. Lancet 2014; published online May 19. http:// dx.doi.org/10.1016/S0140-6736(14)60496-7. Kerber KJ, Lawn JE, Johnson LF, et al. South African child deaths 1990–2011: have HIV services reversed the trend enough to meet Millennium Development Goal 4? AIDS 2013; 27: 2637–48. National Institute of Population Studies. Pakistan Demographic and Health Survey 2012–13. Preliminary report. December, 2013. http://dhsprogram. com/publications/publication-FR290-DHS-Final-Reports.cfm (accessed July 7, 2014). Victora CG, Aquino EM, do Carmo Leal M, Monteiro CA, Barros FC, Szwarcwald CL. Maternal and child health in Brazil: progress and challenges. Lancet 2011; 377: 1863–76. Bryce J, Victora CG, Black RE. The unfinished agenda in child survival. Lancet 2013; 382: 1049–59. Stenberg K, Axelson H, Sheehan P, et al. Advancing social and economic development by investing in women’s and children’s health: a new Global Investment Framework. Lancet 2014; 383: 1333–54.
Counting what counts for maternal mortality More than half a century ago, Dugald Baird1 wrote the public health classic about the application of a preventive outlook to obstetrics. This paper challenged the dominant curative model by acknowledging the broader determinants of pregnancy outcomes, and led to the emergence of social obstetrics. Baird’s message remains very relevant today. A social perspective is clearly relevant to all areas of health care, but it is vulnerable groups who suffer the most from its absence, especially children and women.2 The latest estimates of maternal mortality from Nicholas Kassebaum and colleagues3 published in The Lancet are a reminder of the need to apply a social lens to assessing improvements in health outcomes. The usual metrics of numbers and ratios show decreases since 1990 at global, regional, and national levels, with, for example, a worldwide estimate of 283 maternal deaths www.thelancet.com Vol 384 September 13, 2014
per 100 000 livebirths in 1990 (95% uncertainty interval 259–307), and 209 (186–234) in 2013. However, little is learnt from these figures in terms of the fundamental question of who has benefitted from this progress: have social gradients in the risk of preventable maternal death been narrowed? This question needs to be a focus as the Millennium Development Goal deadline approaches, and as the future world we want is debated.4 Evidence of marked differences in the burden of maternal mortality goes back centuries,5 both for individual-level characteristics, such as age or parity, and for aggregate-level factors, such as regions or rural versus urban areas. Although such a long-term view of differentials is restricted to what are now highincome countries with advanced vital registration systems, evidence of patterns of maternal mortality
See Articles page 980
933