i Index 221 Figures Figure 1.1 Slowing progress in child mortality:how Africa is faring worst 8 Figure 1.2 Neonatal and maternal mortality are related to the absence of a skilled birth attendant 10 Figure 1.3 Changes in under-5 mortality rates,1990-2003: countries showing progress,stagnation or reversal 14 Figure 1.4 Patterns of reduction of under-5 mortality rates,1990-2003 14 Figure 1.5 Maternal mortality ratio per 100 000 live births in 2000 15 Figure 1.6 Neonatal mortality rate per 1000 live births in 2000 15 Figure 2.1 A temporary reversal in maternal mortality: Mongolia in the early 1990s 23 Fiqure 2.2 Levelling off after remarkable progress: DTP3 vaccine coverage since 1980 26 Figure 2.3 Different patterns of exclusion:massive deprivation at low levels of coverage and marginalization of the poorest at high levels 29 Figure 2.4 From massive deprivation to marginal exclusion: moving up the coverage ladder 30 Figure 2.5 Survival gap between rich and poor:widening in some countries narrowing in others Figure 3.1 Coverage of antenatal care is rising 42 Figure 3.2 The outcomes of a year's pregnancies 49 Figure 3.3 Grounds on which abortion is permitted around the world 52 Figure 4.1 Causes of maternal death 62 Figure 4.2 Maternal mortality since the 1960s in Malaysia,Sri Lanka and Thailand 66 Figure 4.3 Number of years to halve materal mortality,selected countries 68 Figure 5.1 Deaths before five years of age,2000 80 Figure 5.2 Number of neonatal deaths by cause,2000-2003 80
vi Index 221 Figures Figure 1.1 Slowing progress in child mortality: how Africa is faring worst 8 Figure 1.2 Neonatal and maternal mortality are related to the absence of a skilled birth attendant 10 Figure 1.3 Changes in under-5 mortality rates, 1990–2003: countries showing progress, stagnation or reversal 14 Figure 1.4 Patterns of reduction of under-5 mortality rates, 1990–2003 14 Figure 1.5 Maternal mortality ratio per 100 000 live births in 2000 15 Figure 1.6 Neonatal mortality rate per 1000 live births in 2000 15 Figure 2.1 A temporary reversal in maternal mortality: Mongolia in the early 1990s 23 Figure 2.2 Levelling off after remarkable progress: DTP3 vaccine coverage since 1980 26 Figure 2.3 Different patterns of exclusion: massive deprivation at low levels of coverage and marginalization of the poorest at high levels 29 Figure 2.4 From massive deprivation to marginal exclusion: moving up the coverage ladder 30 Figure 2.5 Survival gap between rich and poor: widening in some countries, narrowing in others 31 Figure 3.1 Coverage of antenatal care is rising 42 Figure 3.2 The outcomes of a year’s pregnancies 49 Figure 3.3 Grounds on which abortion is permitted around the world 52 Figure 4.1 Causes of maternal death 62 Figure 4.2 Maternal mortality since the 1960s in Malaysia, Sri Lanka and Thailand 66 Figure 4.3 Number of years to halve maternal mortality, selected countries 68 Figure 5.1 Deaths before five years of age, 2000 80 Figure 5.2 Number of neonatal deaths by cause, 2000–2003 80 The World Health Report 2005
vii Figure 5.3 Changes in neonatal mortality rates between 1995 and 2000 81 Figure 5.4 Neonatal mortality in African countries shows stagnation and some unusual reversals 82 Figure 5.5 Neonatal mortality is lower when mothers have received professional care 88 Figure 5.6 The proportion of births in health facilities and those attended by medical doctors is increasing 92 Figure 5.7 The human resource gap in Benin,Burkina Faso,Mali and Niger,2001 95 Figure 5.8 Cost of scaling up maternal and newborn care,additional to current expenditure % Figure 6.1 An integrated approach to child health 111 Figure 6.2 Proportion of districts where training and system strengthening for IMCI had been started by 2003 114 Figure 6.3 Cost of scaling up child health interventions,additional to current expenditure 116 Boxes Box 1.1 Milestones in the establishment of the rights of women and children 5 B0x1.2 Why invest public money in health care for mothers and children? B0x1.3 A reversal of maternal mortality in Malaw 11 B0x1.4 Counting births and deaths 12 B0X2.1 Economic crisis and health system meltdown:a fatal cascade of events 22 Box 2.2 How HIV/AIDS affects the health of women and children 23 B0x2.3 Health districts can make progress,even in adverse circumstances 25 B0X2.4 Mapping exclusion from life-saving obstetric care 27 B0x2.5 Building functional health districts:sustainable results require a long-term commitment 34 B0x3.1 Reducing the burden of malaria in pregnant women and their children 44 Box3.2 Anaemia-the silent killer 45
vii Figure 5.3 Changes in neonatal mortality rates between 1995 and 2000 81 Figure 5.4 Neonatal mortality in African countries shows stagnation and some unusual reversals 82 Figure 5.5 Neonatal mortality is lower when mothers have received professional care 88 Figure 5.6 The proportion of births in health facilities and those attended by medical doctors is increasing 92 Figure 5.7 The human resource gap in Benin, Burkina Faso, Mali and Niger, 2001 95 Figure 5.8 Cost of scaling up maternal and newborn care, additional to current expenditure 96 Figure 6.1 An integrated approach to child health 111 Figure 6.2 Proportion of districts where training and system strengthening for IMCI had been started by 2003 114 Figure 6.3 Cost of scaling up child health interventions, additional to current expenditure 116 Boxes Box 1.1 Milestones in the establishment of the rights of women and children 5 Box 1.2 Why invest public money in health care for mothers and children? 6 Box 1.3 A reversal of maternal mortality in Malawi 11 Box 1.4 Counting births and deaths 12 Box 2.1 Economic crisis and health system meltdown: a fatal cascade of events 22 Box 2.2 How HIV/AIDS affects the health of women and children 23 Box 2.3 Health districts can make progress, even in adverse circumstances 25 Box 2.4 Mapping exclusion from life-saving obstetric care 27 Box 2.5 Building functional health districts: sustainable results require a long-term commitment 34 Box 3.1 Reducing the burden of malaria in pregnant women and their children 44 Box 3.2 Anaemia – the silent killer 45 overview
viii B0X3.3 Violence against women 47 B0X4.1 Obstetric fistula:surviving with dignity 64 B0X4.2 Maternal depression affects both mothers and children 65 B0x4.3 Screening for high-risk childbirth:a disappointment 69 B0x4.4 Traditional birth attendants:another disappointment 70 B0x4.5 Preparing practitioners for safe and effective practice 72 B0x5.1 Explaining variations in maternal,neonatal and child mortality: care or context? 83 B0x5.2 Sex selection 85 B0x5.3 Overmedicalization 94 B0x5.4 A breakdown of the projected costs of extending the coverage of maternal and newborn care 97 Box 6.1 What do children die of today? 106 Box6.2 How households can make a difference 110 B0x6.3 A breakdown of the projected cost of scaling up 118 Box 7.1 International funds for maternal,newborn and child health 126 B0x7.2 Building pressure:the partnerships for maternal,newborn and child health 127 B0x7.3 MNCH,poverty and the need for strategic information 128 B0X7.4 Sector-wide approaches 129 B0x7.5 Rebuilding health systems in post-crisis situations 133 B0X7.6 Civil society involvement requires support 142
viii Box 3.3 Violence against women 47 Box 4.1 Obstetric fistula: surviving with dignity 64 Box 4.2 Maternal depression affects both mothers and children 65 Box 4.3 Screening for high-risk childbirth: a disappointment 69 Box 4.4 Traditional birth attendants: another disappointment 70 Box 4.5 Preparing practitioners for safe and effective practice 72 Box 5.1 Explaining variations in maternal, neonatal and child mortality: care or context? 83 Box 5.2 Sex selection 85 Box 5.3 Overmedicalization 94 Box 5.4 A breakdown of the projected costs of extending the coverage of maternal and newborn care 97 Box 6.1 What do children die of today? 106 Box 6.2 How households can make a difference 110 Box 6.3 A breakdown of the projected cost of scaling up 118 Box 7.1 International funds for maternal, newborn and child health 126 Box 7.2 Building pressure: the partnerships for maternal, newborn and child health 127 Box 7.3 MNCH, poverty and the need for strategic information 128 Box 7.4 Sector-wide approaches 129 Box 7.5 Rebuilding health systems in post-crisis situations 133 Box 7.6 Civil society involvement requires support 142 The World Health Report 2005
x Tables Table 1.1 Neonatal and maternal mortality in countries where the decline in child mortality has stagnated or reversed 16 Table 2.1 Factors hindering progress 22 Table 4.1 Incidence of major complications of childbirth,worldwide 63 Table 4.2 Key features of first-level and back-up maternal and newborn care 71 Table 5.1 Filling the supply gap to scale up first-level and back-up maternal and newborn care in 75 countries(from the current 43%to 73% coverage by 2015 and full coverage in 2030) 96 Table 6.1 Core interventions to improve child survival 115
ix Tables Table 1.1 Neonatal and maternal mortality in countries where the decline in child mortality has stagnated or reversed 16 Table 2.1 Factors hindering progress 22 Table 4.1 Incidence of major complications of childbirth, worldwide 63 Table 4.2 Key features of first-level and back-up maternal and newborn care 71 Table 5.1 Filling the supply gap to scale up first-level and back-up maternal and newborn care in 75 countries (from the current 43% to 73% coverage by 2015 and full coverage in 2030) 96 Table 6.1 Core interventions to improve child survival 115 overview
x message from the director-general Parenthood brings with it the strong desire to see our children grow up happily and in good health.This is one of the few constants in life in all parts of the world.Yet,even in the 21st century,we still allow well over 10 million children and half a million moth- ers to die each year.although most of these deaths can be avoided.Seventy million mothers and their newborn babies,as well as countless children,are excluded from the health care to which they are entitled.Even more numerous are those who remain without protection against the poverty that ill-health can cause. Leaders readily agree that we cannot allow this to continue,but in many countries the situation is either improving too slowly or not improving at all,and in some it is getting worse.Mothers,the newborn and children represent the well-being of a society and its potential for the future.Their health needs cannot be left unmet without harming the whole of society. Families and communities themselves can do a great deal to change this situation. They can improve,for example,the position of women in society,parenting,disease prevention,care for the sick,and uptake of services.But this area of health is also a public responsibility. Public health programmes need to work together so that all families have access to a continuum of care that extends from pregnancy(and even before),through childbirth and on into childhood,instead of the often fragmented services available at present. It makes no sense to provide care for a child while ignoring the mother's health,or to assist a mother giving birth but not the newborn child. To ensure that all families have access to care.governments must accelerate the building up of coherent,integrated and effective health systems.This means tackling the health workforce crisis,which in turn calls for a much higher level of funding and better organization of it for these aspects of health.The objective must be health sys- tems that can respond to these needs,eliminate financial barriers to care,and protect people from the poverty that is both a cause and an effect of ill-health. The world needs to support countries striving to achieve universal access and finan- cial protection for all mothers and children.Only by doing so can we make sure that every mother,newborn baby and child in need of care can obtain it,and no one is driven into poverty by the cost of that care.In this way we can move not only towards the Millennium Development Goals but beyond them. LEE Jong-wook Director-General World Health Organization Geneva,April 2005
xi Parenthood brings with it the strong desire to see our children grow up happily and in good health. This is one of the few constants in life in all parts of the world. Yet, even in the 21st century, we still allow well over 10 million children and half a million mothers to die each year, although most of these deaths can be avoided. Seventy million mothers and their newborn babies, as well as countless children, are excluded from the health care to which they are entitled. Even more numerous are those who remain without protection against the poverty that ill-health can cause. Leaders readily agree that we cannot allow this to continue, but in many countries the situation is either improving too slowly or not improving at all, and in some it is getting worse. Mothers, the newborn and children represent the well-being of a society and its potential for the future. Their health needs cannot be left unmet without harming the whole of society. Families and communities themselves can do a great deal to change this situation. They can improve, for example, the position of women in society, parenting, disease prevention, care for the sick, and uptake of services. But this area of health is also a public responsibility. Public health programmes need to work together so that all families have access to a continuum of care that extends from pregnancy (and even before), through childbirth and on into childhood, instead of the often fragmented services available at present. It makes no sense to provide care for a child while ignoring the mother’s health, or to assist a mother giving birth but not the newborn child. To ensure that all families have access to care, governments must accelerate the building up of coherent, integrated and effective health systems. This means tackling the health workforce crisis, which in turn calls for a much higher level of funding and better organization of it for these aspects of health. The objective must be health systems that can respond to these needs, eliminate financial barriers to care, and protect people from the poverty that is both a cause and an effect of ill-health. The world needs to support countries striving to achieve universal access and financial protection for all mothers and children. Only by doing so can we make sure that every mother, newborn baby and child in need of care can obtain it, and no one is driven into poverty by the cost of that care. In this way we can move not only towards the Millennium Development Goals but beyond them. message from the director-general LEE Jong-wook Director-General World Health Organization Geneva, April 2005 overview