The GFF Approach to Maternal and Newborn Child Health (MNCH)

MNCHThe GFF supports countries to provide complete and timely data for monitoring maternal, newborn, child health and stillbirths, a fundamental requirement to achieve the Sustainable Development Goals.

Of the estimated 300,000 maternal deaths, 2 million stillbirths, 2.45 million newborn deaths that occur each year, half happen around the time of birth.  An additional 2.8 million deaths in children between one month and five years.  The COVID-19 pandemic has seen an increase in stillbirth and maternal deaths across the GFF supported countries and risks reversing the gains made in the past decade.

Critical to understanding what can reduce these deaths is understanding where and why deaths are occurring through better disaggregated data; the coverage data of known interventions that can prevent known causes of death; and the health system requirements to ensure that services are reaching everyone, through data tracking of health financing, the health workforce and service delivery systems.

The other important component is the quality of the care provided. The GFF is supporting countries to move from simple contact or crude coverage of interventions (e.g. how many women gave birth in a facility) to defining quality and measuring the effective coverage (e.g. how many women gave birth in a facility where care was respectful, provided by competent staff who had access to all necessary supplies and with a timely referral system available for referral in the event of a complication within the woman or newborn). Moving to quality adjusted measures is not straightforward and requires revision of current health information systems and measures. The GFF works with countries to determine the most relevant MNCH indicators to support measures of quality coverage.

In collaboration with Countdown to 2030 the GFF seeks to examine national-level progress in reproductive maternal newborn and child health and nutrition in the 36 GFF-supported countries. The following progress report focuses upon selected indicators related to the impact indicators of the GFF results framework. The analysis is primarily based on global estimates and the most recent available household surveys.

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Summary Findings on Mortality and Service Coverage

Neonatal Mortality

The neonatal mortality picture in most countries is sobering (Figure 1). The median neonatal mortality for the 19 countries increased from 29 to 30 per 1,000 live births between the last two surveys. Positive changes were observed in Viet Nam, Pakistan, Afghanistan, Sierra Leone, and Senegal, where neonatal mortality declined at least 2.0 percentage points per year. At the other end, neonatal mortality increased at least 2.0 percentage points per year between the surveys in Liberia, Zimbabwe, and Zambia. 

Figure 1: Recent survey data on neonatal mortality per 1,000 live births for the five years preceding the survey, GFF countries with a national survey that ended in 2018-2020

Under Five Mortality

The median under-five mortality in the 36 countries in 2020 was 59 per 1,000 live births according to the UN-IGME estimates, down from 69 in 2015 and 88 in 2010. A decline occurred in all countries and the average annual pace of reduction during 2015-20 was 3.0% per year, compared to 4.6% during 2010-15. 

The differences between West and Central Africa and the other subregions are large (Figure 2). By 2020, five countries still had estimated levels of under-five mortality exceeding 100 per 1,000 live births, including Central African Republic, Chad, Guinea, Nigeria, Sierra Leone, and Somalia. Three countries had already reached the 2030 target of the SDGs (25 per 1,000 live births), including Viet Nam, Indonesia and Guatemala, while Cambodia and Bangladesh were close to the target. In 2010, 35% of all under-five deaths occurred during the neonatal period in the 36 countries, increasing to 40% in 2015 and 43% in 2020.  Therefore, the trend of increased concentration of under-five deaths in the neonatal period is continuing.

Figure 2: Under-five mortality per 1,000 live births, country medians by subregion (in parentheses the number of countries in subregion), UN IGME estimates, 2010-2020

Figure 3: Mortality at 1-59 months per 1,000 children (after the neonatal period and before the fifth birthday) per 1,000 live births by country, 2000 and 2020, UN IGME estimates, GFF-supported countries

 

RMNCAH Coverage Inequities

The overall picture until the end of the MDGs was one of slowly declining inequalities between the poorest and richest households. Historical trends in the Composite Coverage Index (CCI) show an average absolute increase of about 1% per year, although some countries, especially those in post-conflict situations, have succeeded in achieving increases as large as 2% per year over considerable stretches of time. A gap in the CCI of 10%, therefore, implies that it could take the poorest 10 years to reach the current level of coverage of the richest quintile at the average past pace of decline.

Figure 4: Equiplot of the RMNCH composite coverage index (CCI) among the poorest (Q1) and richest (Q5) wealth quintiles and for the national population in countries with a survey since 2017

Household surveys provide information on inequalities between regions, provinces, or states within countries. A recent Countdown analysis of inequalities in sub-Saharan Africa showed the variation in subnational gaps in the coverage index between countries.1 Figure 5 shows that provinces/regions with capital cities tend to have higher coverage but the extent to which there are advantaged differs greatly between countries. Central Africa Republic, Guinea and Mali are examples of low-coverage countries with major gaps between the capital city and the other provinces or regions (top inequality pattern). Other countries are characterized by a widespread in coverage, such Cameroon and Madagascar, but no capital advantage. In the countries with the highest coverage, the subnational gaps have reduced to about 10% or less. 

Figure 5: RMNCH composite coverage index (CCI) in sub-Saharan Africa, most recent survey.

Focus on Stillbirths: Why is Counting Stillbirths Important for GFF-Supported Countries?

Each year, globally, nearly 2 million babies are stillborn. The COVID-19 pandemic has led to a significant increase in stillbirths, estimated from 3.2 to 11.1% of global births1. The Every Newborn Action Plan (ENAP), led by the World Health Organization (WHO) and UNICEF and endorsed by 194 WHO member states, calls for each country to achieve a rate of 12 stillbirths or fewer per 1,000 total births by 20302. Almost all 37 GFF-supported countries are off track to reaching their stillbirth targets of 12 stillbirths or fewer per 1,000 total births, translating into millions of lives lost (Figure 6).

Most stillbirths are preventable, and high stillbirth rates are a marker of low access to and coverage of antenatal and intrapartum care quality. Notably, 42% of stillbirths occur between the onset of labor and birth. This percentage is even higher in sub-Saharan Africa and Central and Southern Asia, where about half of all stillbirths occur during the intrapartum period1 . Intrapartum stillbirth is a tragedy since timely interventions could have virtually prevented these deaths.

What is the Current State of Stillbirth Reporting in GFF-Supported Countries?

Across the 37 GFF-supported countries3, only a fifth have defined stillbirth targets in their national newborn or reproductive, maternal, newborn, child, adolescent health, and nutrition (RMNCAH-N) plans, and fewer than a third are required by law to register stillbirths in their CRVS systems (Figure 6). Around 40% do not currently report stillbirths in their HMIS4. Fewer than 40% have a perinatal death review system2. Though this analysis is only limited to those countries currently supported by the GFF, these shortfalls are likely to be typical of other LMIC as well. 

Figure 6. Number of GFF-supported countries with defined stillbirth targets and stillbirth data collection systems

Note: The values provided in Figure 6 are based on the most recent secondary data sources and, therefore, may not be completely up to date. 

Beginning in the fall of 2022, the GFF will include GFF partner country stillbirth results as part of the routine reporting included in the GFF Annual Report and GFF Data Portal.  Additional information will be shared on the portal to show the ways in which GFF-supported countries are mobilizing to improve the prevention and reporting of stillbirths.