Sub-Saharan Africa's mothers, newborns, and children: where and why do they die?

Abstract

In the first article in a series on maternal, newborn, and child health in sub-Saharan Africa, Joy Lawn and colleagues outline where and why deaths among mothers and children occur and what known interventions can be employed to prevent these deaths.

Figure 1. Progress towards Millennium Development Goal 4 for newborn and child survival in sub-Saharan Africa.

U5MR has declined since 1990 in sub-Saharan Africa in relation to the MDG 4 target for child survival, a reduction of the U5MR by two-thirds by 2015. Although some reduction in the U5MR has been achieved, particularly since 2000, on average, the pace of the decline across the region has been too slow to meet the MDG 4 target. The figure also shows the regional trend for the NMR since 1995. Newborn deaths account for over a quarter of under-5 deaths and there has been little decline. Figure adapted from Kinney et al. 2009 and Lawn and Kerber 2006 . Data from http://www.childmortality.org and updated for 2008 using data from Countdown to 2015 for Maternal, Newborn and Child Health and State of the World's Children 2010 . The second line on the graph uses data generated by IHME from Rajaratnam et al. 2010 .

Figure 2. Progress towards Millennium Development Goal 5 for maternal survival in sub-Saharan Africa.

MMR has remained practically unchanged since 1990 in sub-Saharan Africa in relation to the MDG 5 target for maternal survival, a reduction of the MMR by three quarters by 2015. However, the confidence intervals are extremely wide and trend comparison is uncertain as methodology has changed over time. Data for 1990 from WHO, UNICEF, UNFPA, and The World Bank 2007 ; data for 1995 are from WHO, UNICEF, and UNFPA 2001 ; data for 2000 are from WHO, UNICEF, UNFPA 2004 ; and data for 2005 are from Hill et al. 2007 . The second line on the graph uses data generated by IHME from Hogan et al. 2010 .

Figure 3. Regional distribution of the global burden for maternal mortality, child mortality, and HIV.

Sub-Saharan Africa carries a high proportion of the global disease burden for maternal and child health, and HIV/AIDS. The region accounts for half of the world's maternal, newborn, and child deaths and two-thirds of people living with HIV/AIDS. Figure adapted from Kinney et al. 2009 ; data for maternal deaths in 2005 from Hill et al. 2007 ; data for under-5 child deaths in 2008 from State of the World's Children 2010 ; data for number of adults and children living with HIV in 2007 from UNAIDS, Report on the Global AIDS Epidemic, 2008 .

Figure 4. Causes of maternal, newborn, and child deaths in sub-Saharan Africa.

More than half of maternal deaths in Africa are due to direct obstetric complications, with hemorrhage being the leading cause. Maternal sepsis and hypertensive disorders are important and preventable causes of maternal mortality. Newborn deaths account for more than one quarter of under-5 deaths in Africa. Infections are the biggest cause of newborn death yet the most feasible causes to prevent and treat. The two other major causes of newborn deaths are preterm birth complications and intrapartum-related (previously called “birth asphyxia”), which are closely linked to maternal health. Main causes of under-5 deaths include pneumonia, diarrhea, and malaria. Globally more than one-third of postneonatal child deaths are attributable to undernutrition. The cause-of-death profile varies between and within countries, with HIV/AIDS contributing to more deaths in southern African countries. Figure adapted from Kinney et al. 2009 using data sources for maternal (Khan et al. 2006 [28]) and newborn and child (Black et al. 2010 [34]) causes of death.

Figure 5. Integrated maternal, newborn and child health packages.

Eight integrated packages for MNCH, with evidence-based interventions along the continuum of care, organized by lifecycle and place of service delivery. Figure from Kinney et al. 2009 adapted from Kerber et al. 2007 with permission .

Figure 6. Coverage at critical time points along the continuum of care in sub-Saharan Africa, around the year 2008.

The regional average coverage varies along the continuum of care for MNCH in sub-Saharan Africa. Currently, there are data available for six of the eight basic service delivery packages. The reproductive health packages delivered through outpatient/outreach services is represented by contraceptive prevalence rate. ANC package delivered through outpatient/outreach service is represented by one ANC visit. Childbirth clinical care package is represented by skilled attendant at birth. Postnatal care package delivered through outpatient/outreach service is represented by a postnatal check on the mother's health within 2 days of childbirth. Newborn baby and child clinical care package is represented by under-5 children with suspected pneumonia receiving antibiotics. Child health package delivered through outpatient or outreach service is represented by three doses of DPT vaccine. The reproductive health clinical care package and family and community care package have no routine indicator data available. *Postnatal care data from 12 countries. ⁺Under-5 children with suspected pneumonia receiving antibiotics data from 20 countries. Figure adapted from Kinney et al. 2009 with data from a new analysis of Demographic and Health Surveys (2005–2008) and State of the World's Children 2010 .

Figure 7. Quality gap for antenatal care in sub-Saharan Africa, around the year 2008.

There is a substantial quality gap in ANC services in sub-Saharan Africa. While coverage of at least one ANC visit is relatively high at 71% compared to other MNCH services (see Figure 6), many women attending ANC do not receive the full range of evidence-based components during pregnancy. This quality gap demonstrates key missed opportunities within health systems. Tetanus vaccine coverage is higher because of outreach campaigns. Figure adapted from Kinney et al. 2009 with a new analysis of data from Demographic and Health Surveys (2005–2008) and the UNAIDS Report on the Global AIDS Epidemic, 2008 , and State of the World's Children 2010 .