High-level meeting on Saving the Lives of Mothers and Children: Rising to the Challenge
29–30 January 2013, Dubai, United Arab Emirates
Background
The Eastern Mediterranean Region is a young region where children up to 18 years old constitute more than 40% of the population (244 million children). Under-five children represent 12% (73 million children) of the regional population and women of childbearing age 29%. Both children under five and women are highly vulnerable groups for which two specific Millennium Development Goals (MDGs), 4 and 5 respectively, and indicators under other MDGs have been set to highlight their role in country development.
Maternal and child health are at the core of the Alma-Ata Declaration on Primary Health Care that has been reaffirmed by the World Health Organization (WHO), the United Nations Children’s Fund (UNICEF) and the United Nations Population Fund (UNFPA). Both are the subject of the United Nations Global Strategy for Women’s and Children’s Health. They are also the focus of recommendations of the United Nations Commission on Information and Accountability for Women’s and Children’s Health, and UNICEF’s commitment to child survival in ‘A Promise Renewed,’ [1] and several resolutions of the World Health Assembly and WHO Regional Committee for the Eastern Mediterranean.
What is the problem?
It is estimated that 923 000 children under five years of age die every year in the Region. Under-five mortality has decreased by only 41% since 1990, from 99 deaths per 1000 live births to 58 per 1000 live births in 2011. Of the total under-five deaths, 82% occur in six countries (Afghanistan, Pakistan, Somalia, South Sudan, Sudan and Yemen). [2]
According to one set of estimates, six countries in the Region have already achieved reductions in under-five mortality rate beyond the targets of MDG 4; i.e. beyond two-thirds reduction in under-five mortality rate. [3] Four of these countries (Lebanon, Oman, Saudi Arabia and United Arab Emirates) as well as Bahrain and Qatar have under-five mortality rates at or below 10 per 1000 live births. Another five countries are on track to reach MDG 4, including Egypt and Morocco. Some countries (Iraq and Afghanistan) seem to be accelerating their progress while others are at halt (Somalia). [4] The highest decrease in under-five mortality in the world between 1990 and 2010 (72%) occurred in the North African countries of the Region, associated with economic development, investments in education and scale up of evidence-based interventions.
Significant reduction in measles mortality was achieved and eight countries are close to measles elimination. The regional EPI target of 90% DTP3 coverage has been met in 16 out of the 23 countries. Vaccines against the major childhood killers, namely Hib, pneumococcal and rotavirus vaccines are being introduced in an increasing number of countries of the Region.
Despite these achievements, they are overshadowed by slow progress and high burden of mortality among a few countries. Given the population and birth cohort size, and if current trends continue, the Region as a whole is unlikely to achieve MDG 4 on reduction of under-five mortality by two thirds by 2015.
Around 39 000 women of childbearing age still die every year in the Eastern Mediterranean Region as a result of pregnancy-related complications. Mortality rates are particularly high among pregnant adolescents. Over 90% of the burden of maternal deaths in the Region is shared by seven countries: Afghanistan, Iraq, Morocco, Pakistan, Somalia, Sudan and Yemen. In terms of MDG 5, only two countries (Egypt and Morocco) are “on-track” to achieve reduction in maternal mortality by three-quarters.4 According to one set of estimates, six countries are not on track to achieve their targets: Djibouti, Iraq, Libya, Pakistan, Somalia and Tunisia. Skilled maternal health care and family planning are recognized as most cost effective interventions that can prevent 80% and 30% of maternal deaths, respectively. Only 31% of married women in the Region are using modern contraceptives; this proportion ranges from 1% in Somalia to 60% in the Islamic Republic of Iran. Meanwhile, 35% of women and newborn babies are left unattended at childbirth.
In summary, of the twenty-three countries of the Region, only one country (Egypt) will achieve MDGs 4 and 5. [4] The regional average of annual reduction rates of maternal and child mortality between 1990 and 2010 (2% for under-five mortality rate and 2.6% for maternal mortality ratio) are among the lowest in the world, together with those of sub-Saharan Africa. The Region is unlikely to achieve the targets of MDGs 4 and 5 by 2015 unless intensive and accelerated progress is made, especially in those countries contributing to the bulk of under-five deaths.
Regional challenges and opportunities
The Eastern Mediterranean Region has unique challenges impacting health, nutrition and development outcomes. A large number of countries, especially the four major countries with the highest burden of maternal and child mortality, are also in the throes of armed conflict and insurgency and significant population displacement at different times. Some have also experienced major humanitarian emergencies in recent years. There are signs that donor and country financial commitments are declining because of the global financial crisis [4]. There are also challenges that relate to issues that may be unique for the Region. These include the disproportionate number of consanguineous families and genetic disorders. In addition, the Region has a high burden of maternal and child undernutrition that is coupled, in many instances, with the rapidly developing challenge of obesity and noncommunicable diseases.
Notwithstanding the above challenges, there are huge opportunities for accelerating progress. There is evidence on what should be done, i.e. implementing country-tailored cost effective interventions for reproductive, maternal, newborn and child health, and on why investments in such interventions are important, i.e. impact of the interventions on maternal and child health.
There are important country success stories in the Region in implementing these interventions and delivery strategies. For example, Egypt has achieved universal coverage with the integrated management of childhood illnesses and high coverage of maternal health interventions. The Islamic Republic of Iran has scaled up primary care for maternal, newborn and child health building on the success of community health workers. Yet in some countries, especially those with high mortality rates, implementation strategies remain limited and ineffective due, in part, to inadequate political support and leadership, restricted and unequal access to care, weak health systems, low workforce capacities and inadequate ability to monitor progress and track results and resources. The challenge now facing the high-burden countries of the Region is how to achieve universal coverage of effective interventions while optimizing investments and enhancing accountability to improve the health of women and children.
It must also be pointed out that the changes in maternal and child survival over time reflect investments across sectors in many countries, requiring interventions across a range of social determinants of health, such as female education, empowerment, poverty alleviation, investments in health systems and good governance. These investments are crucial in the context of addressing the range of social sector policies and the human development agenda for the Region.
Commitments
There are unprecedented opportunities to accelerate progress in improving the health of women and children. Leaders in the Region from Afghanistan, Djibouti, South Sudan, Sudan and Yemen have made commitments to the implementation of the United Nations Global Strategy for Women’s and Children’s Health. The United Nations agencies represented by WHO, UNICEF, UNFPA, UNAIDS and UN Women and the World Bank (H4+) are working together to support the implementation of these commitments. The United Nations Commission on Life-Saving Commodities for Women and Children has made recommendations to improve access to essential medicines and commodities for mothers and children. More recently, over 150 countries pledged – ‘A Promise Renewed’ to take action to accelerate progress on newborn, child and maternal survival and to reduce child mortality to 20 per thousand live births by 2035 (Washington, June 2012), and to increase access to family planning services for women and girls (London, July 2012). [5]
There is clear recognition that gains in child survival over time in several countries depend upon provision of equitable access to populations in greatest need. The recent call for provision of universal health care is an important step in this direction and represents a huge opportunity for change. The report of the ‘Commission for Information and Accountability for Women’s and Children’s Health’ provides a framework for action for Member States. These opportunities will only bear fruit if there is a high level engagement by all leaders and if this engagement is translated into action. Too many women and children are losing their lives from preventable conditions. The target date for reaching the MDGs is fast approaching. The know-how for action is available. Now, there is a need for urgent action to fulfil commitments to mothers and children and work together to ensure that every mother and child count.
Next steps
Recognizing the pressing need for action, the WHO Regional Office for the Eastern Mediterranean has prioritized the health of women and children and has called for hosting a high-level meeting on maternal, newborn and child health, working jointly with partners. During the meeting, progress will be reviewed, barriers and bottlenecks identified, future directions shaped and commitments made, including support with the necessary investment. This two-day event will be organized by WHO, UNICEF, UNFPA and partners and will follow some targeted preparatory work in countries. The event will provide a platform for a leadership dialogue to:
- Increase the profile and commitment to maternal, adolescent, and child health (including newborns) with a focus on equity;
- Facilitate policy dialogue for accelerated action towards the achievement of universal access to maternal, adolescent, newborn and child health services in the Region;
- Discuss and agree on evidence-based packages for care and implementation strategies across the continuum of care;
- Establish a high level regional commission for women and children. The commission will track progress in implementation, advocate and mobilize resources, and hold countries accountable for improving the lives of women and children.
Expected outcomes
- Increased commitments of leaders in the Region to improving maternal and child health (including newborns) in the foreseeable future and in agreement with emerging global targets.
- A regional declaration on maternal and child health with defined commitments.
- Establishment of a regional commission on maternal and child health.
- Agreement on practical coordination mechanisms to accelerate progress towards MDGs 4 and 5 in countries of the Eastern Mediterranean Region.
- Increased commitment of partners to support accelerated action for maternal and child health in the Region.
Participants
Leading figures, including high-level officials from Member States and key partners, Parliamentarians, Ministers of Health, Higher Education and Planning, representatives of regional bodies and stakeholders, will participate in the meeting.
[1] Committing to Child Survival: A Promise Renewed, UNICEF 2012.
[2] Based on estimates of the United Nations Inter-agency Group for Child Mortality Estimation, Levels and trends in child mortality. Report of 2011.
[3] Egypt, Lebanon, Oman, Saudi Arabia, Tunisia and United Arab Emirates.
[4] The Every woman, every child: from commitments to action: the first report of the independent Expert Review Group (iERG) on Information and Accountability for Women’s and Children’s Health. WHO 2012.
[5] The conference on Child Survival: A Call to Action, held in Washington DC on 14–15 June 2012, during which pledges were made by leaders from Afghanistan, Djibouti, Egypt, Iraq, Kurdistan Regional Government, Pakistan and Yemen, and the Family Planning Summit, held in London on 11 July 2012.
