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

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

Approximately 287,000 maternal deaths occurred in 2020 (MMEIG, 20231). In 2021, 1.9 million babies were stillborn, 2.3 million babies died during the first month of life, and 2.7 million children that survived the newborn period died before they reached five years of age (UNIGME 20232, UNIGME 20222).

Critical to reducing these largely preventable and treatable deaths and achieving universal health coverage is determining where and why they are occurring through:

  • Regular monitoring of the coverage of effective interventions.
  • Disaggregating data to identify populations falling behind.
  • Tracking key health system factors such as financial flows, the health workforce, and the readiness of health facilities to provide high quality, equitable services to all women and children.

Another important component to reaching global and national goals on maternal, newborn, and child health is improving the quality of the care provided. The GFF is supporting countries to move from measuring and monitoring simple contact or crude coverage of interventions (e.g. percentage of pregnant women who delivered in a health facility) to measuring service quality and effective coverage of essential interventions (e.g. percentage of pregnant women who gave birth in a health facility where care was respectful, provided by competent staff who had access to all necessary supplies, and with a functional referral system in the event of a complication and who received the expected health benefit from the service). The GFF works with countries to determine the most relevant MNCH indicators to track to ensure women and children are receiving life-saving care provided according to standards.

Partnership with Countdown to 2030: Progress along the continuum of care

GFF collaborates with the Countdown to 2030 initiative (Countdown) to produce annual analytical assessments of progress on women’s, children’s, and adolescents’ health in GFF priority countries. The 2023 progress report focuses upon select health impact and intervention coverage indicators from the GFF results framework. The analysis is primarily based on global estimates and the most recent available household surveys and covers the topic areas of maternal and newborn health, child health and nutrition, and adolescent fertility and family planning.

GFF also partners with Countdown on country collaborations aimed at generating evidence and strengthening country capacity to measure progress and performance of RMNCAH-N programs (More information on the country collaborations is available here). A key focus of the collaborations is to inform annual and mid-term reviews of country 5-year national health plans and GFF investment cases. Currently the country collaborations support 25 GFF partner countries in Africa and South Asia through two funding mechanisms, and Exemplars in Global Health. Country collaborations involve national academic and public health institutions working closely with ministries of health and national statistical offices. Technical assistance is provided by Countdown academic and United Nations partners as well as by GFF staff.

A flagship event for the Countdown country collaborations are multi-country workshops held annually to support country teams in generating a robust progress report on women’s, children’s, and adolescents’ health that can inform national review processes. The first two workshops were held in 2022 in Nairobi, and in 2023 in Dakar.

Specific objectives of the workshops are to:

  1. Support country analysts to prepare a clean data set and produce a set of national and subnational estimates for key RMNCAH-N indicators, including gender and equity.
  2. Strengthen skills of the country teams in the analysis of health facility and related national and subnational data.
  3. Support each country to prepare posters summarizing the most interesting findings from the analysis plus a first draft of a country report on progress on RMNCAH-N.
  4. Present additional methods and tools the country teams can use to finalize their country reports or for other analyses on RMNCAH-N.
  5. Discuss opportunities for the country teams to disseminate their findings through national fora.

Each country team finalizes the country progress report after the workshop and other related products for dissemination through country convenings and events.

To learn more, watch the video on the Countdown multi-country workshops here.

Summary Findings on Mortality and Service Coverage

Latest evidence on trends in maternal, newborn, and child health

Maternal mortality: latest estimates and trends

The global SDG target 3.1 is to reduce the global maternal mortality ratio to less than 70 maternal deaths per 100,000 live births by 2030. The Ending Preventable Maternal Mortality (EPMM) initiative includes an additional target of no country having a maternal mortality ratio (MMR) exceeding 140 in 20301. Major findings of the United Nations (UN) maternal mortality estimates (2023 release)2 included:

  • In 2020, the MMR was 430 per 100,000 live births (80% uncertainty interval (UI)3 : 378-505) in the low-income country group and 255 (80% UI: 223-313) in the lower- and middle-income country group.
  • During 2010-2020, the MMR declined by 24% in the low-income countries and by 17% in the lower-middle income countries, which was faster than the global decline (12%).
  • In 2020, sub-Saharan Africa was the only region with an MMR above 140 per 100,000 live births: 536 (80% UI 470-640). South Asia was the second highest mortality region at 138 per 100,000 live births (80% UI: 122-160). About 70% of the estimated 287,000 maternal deaths in the world occurred in sub-Saharan Africa (with 30% of livebirths in the world in 2020).

The median MMR based on the UN estimates for the 36 GFF supported countries, all of which are either low or lower-middle income countries, was 354 per 100,000 live births in 2020, down from 492 in 2010 and 391 in 2015. The top five countries with highest MMR in the 36 countries were Chad (1063), Nigeria (1047), Central African Republic (835), Somalia (621) and Liberia (620). All GFF supported countries except Cambodia and Vietnam had lower mortality estimates in 2020 than in 2015, though uncertainty intervals were overlapping for all countries suggesting that the measured declines were not statistically significant. The pace of decline was faster during 2015-2020 than 2010-2015 in just 13 of the 36 countries. Click here to compare mortality rates across the GFF partner countries.

An integrated assessment of progress in maternal, stillbirth and neonatal mortality: The MNH transition model

Maternal mortality, stillbirths, and neonatal mortality are highly correlated, reflecting the interconnectedness of maternal and newborn health. Countdown to 2030 colleagues developed an approach for combining these three mortality statistics to better describe their interrelationships and trends over time4. They combined stillbirth and neonatal mortality into one measure: stillbirth + neonatal deaths per 1,000 births and then examined maternal mortality and stillbirth + neonatal mortality together. Figure 1 shows the maternal mortality ratio in 2020 by the stillbirths + neonatal mortality in 2021 for the 36 countries, as part of an integrated mortality transition model. The model has five transition phases, from high mortality to low mortality (phases I to V). The global SDG targets for 2030 are in phase IV, based on global maternal mortality ratio target of 70 and a stillbirth + neonatal death rate of 24 (resulting from summing the 12 deaths per 1,000 live births SDG3.2 target for neonatal mortality and the ENAP stillbirth target of 12 stillbirths per 1,000 births). The transition phases can be characterized by typical patterns, based on country evidence during 2000-2020. These typical patterns include changes in cause of death distribution, fertility, health service coverage, inequalities, and health system characteristics, as well as socioeconomic changes. Figure 1 shows the country situation of maternal, stillbirth, and neonatal mortality for the 36 GFF supported countries according to the latest UN estimates for the year 2020.

Figure 1. Maternal mortality per 100,000 live births by stillbirths and neonatal mortality per 1,000 births, mortality transition model with 5 phases, 2020

 

Data sources: World Health Organization. Trends in maternal mortality 2000 to 2020: estimates by WHO, UNICEF, UNFPA, World Bank Group and UNDESA/Population Division. February 2023. United Nations Inter-agency Group for Child Mortality Estimation (UNIGME), Levels & Trends in Child Mortality: Report 2022, Estimates developed the United Nations Inter-agency Group for Child Mortality Estimation, United Nations Children’s Fund, New York, 2023. Never forgotten: the situation of stillbirth around the world. Report of the Interagency-Group for Child Mortality Estimation (IGME). UNICEF, 2023.

Child health and nutrition

Child mortality trends

The global SDG target 3.2 is to end preventable deaths of newborns and children under 5 years of age, with all countries aiming to reduce neonatal mortality to at least as low as 12 per 1,000 live births and under 5 mortality to at least as low as 25 per 1,000 live births.

Major findings from the UN IGME levels and trends report, launched December 20225 include:

  • In 2021, 5 million children died before reaching their fifth birthday. Of these, 2.3 million (47%) occurred during the first month of life.
  • By 2021, under-five mortality was 67 deaths per 1,000 live births (90% UI: 62-80) in the low-income countries, and 44 deaths per 1,000 live births (90% UI (40-49) in the lower-middle income countries.
  • During 2010-2021, under-five mortality declined by 29% in low-income countries and by 31% in lower-middle income countries. There was little evidence of a slower pace of decline during 2015-2021 compared to 2010-2015.
  • In sub-Saharan Africa, under-five mortality declined by 28% during 2010-2021, from 102 to 74 deaths per 1,000 live births. However, 2.9 million or 58% of the total number of deaths in children under the age of five occurred in sub-Saharan Africa.

The median under-five mortality in the 36 GFF supported countries in 2021 was 57 deaths per 1,000 live births according to the UN-IGME estimates, down from around 67 in 2015 and 85 in 2010. Declines occurred in all but one of the GFF countries in the past five years. Only Madagascar’s mortality rate stayed roughly the same. However, the average annual pace of reduction slowed during 2015-2021 compared to 2010-2015 (2.8% per year and 4.6%, respectively): in 25 of the 36 countries the pace of decline was slower in the more recent time period.

In 2021, five of the 36 countries still had estimated levels of under-five mortality exceeding 100 per 1,000 live births, including Niger, Somalia, Nigeria, Chad, and Sierra Leone. Three countries had mortality levels approximating 100 (Central Africa Republic, Guinea, and Mali). On the positive side, four countries reached the SDG 3.2 target of 25 child deaths per 1,000 live births (Viet Nam, Indonesia, Guatemala, and Cambodia). Bangladesh almost achieved the target at 27 per 1,000 live births in 2021.

Focusing on mortality among children ages 1-59 months, major reductions occurred in almost all 36 countries between 2015 and 2021. UN estimates show continuing declines in mortality rates at 1-59 months during 2015-2020, and more than half of these country estimates include results from recent surveys (Figure 2). The median average annual rate of mortality decline was 4.1% per year, which was more than two times faster than neonatal mortality. Therefore, the trend of increased concentration of under-five deaths in the neonatal period is continuing. In 2010, 35% of all under-five deaths occurred in the neonatal period in the 36 countries, increasing to 40% in 2015 and 43% in 2020. This percent distribution, however, indicates that more than half of child deaths are still occurring after the neonatal period. Most of these deaths are from preventable and treatable causes such as pneumonia, diarrhea, and malaria.

Figure 2. Child mortality trends under-5 years

 

Stunting among children under 5 years

UN estimates for 2015 and 2020, which are generally based on national surveys, such as DHS, MICS, nutrition surveys and socioeconomic surveys, were used to ascertain trends in stunting. In 2020, the median estimated prevalence of stunting in children under five years of age was 30% for 35 GFF-supported countries (no estimates for Tajikistan), ranging from 15% in Ghana to 47% in Niger. All countries reduced stunting prevalence, with a median absolute reduction of 3.4 percentage points during 2015-2020 (Figure 3).

Figure 3. Percent of children under-5 years who are stunted (below -2 SD height for age), global estimates for 2015 and 2020, GFF-supported countries (countries ordered by 2020 stunting prevalence how to low)

 

Data source: Joint child malnutrition estimates (WHO, UNICEF, World Bank Group), 2023. https://www.who.int/publications/i/item/9789240073791

Additional analyses on MNCH coverage indicators are available in the Countdown GFF progress report available here.

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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 4).

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 4). 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 4. Number of GFF-supported countries with defined stillbirth targets and stillbirth data collection systems

Note: The values provided in Figure 4 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.