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With only six years to go before the 2015 deadline to achieve the Millennium Development Goals (MDGs) to reduce child mortality and improve maternal health, some countries have made encouraging progress, while many have stagnated, or worse, slipped backwards since the Millennium Declaration was adopted in 2000.

Although the greater picture of overwhelming challenge remains, there are many glimmers of hope around the world. Communities across Africa and Asia have involved both families and caregivers in formulating solutions to their local challenges. They have succeeded in making essential care available to many, if not all, mothers and newborns. Governments have pledged money and other resources, while international aid organizations have developed programmes with local groups to drive change from the ground up.

Magnitude of the problem
Despite current programmes to improve the health of mothers and newborn babies, most recent figures show that one woman dies every minute due to pregnancy, childbirth or soon after giving childbirth. The figure is so staggering that seven newborns die each minute. The main causes of maternal deaths are severe bleeding, eclampsia, infections and obstructed labour. Just three causes -- infection, asphyxia and preterm birth -- together account for nearly 80 per cent of newborn deaths.

The "Countdown to 2015", a multi-partner initiative to track progress towards MDGs 4 (to reduce child mortality) and 5 (improve maternal health), estimated in its 2008 report that 68 countries worldwide account for 97 per cent of maternal and newborn deaths. The report focused on the coverage of essential interventions for maternal, newborn and child health. Annually, maternal deaths are estimated at 536,000 and some 3.7 million babies die within the first 28 days of life, while at least 3.3 million are stillborn. Almost all (98 per cent) of these deaths occur in developing countries, with rates highest in sub-Saharan Africa and in South-East Asia.

In addition to the women who die as a result of pregnancy or childbirth, about 10 million to 20 million worldwide are left each year with physical and mental disabilities. Furthermore, millions of newborns who survive fail to reach their full potential due to complications during birth and the early newborn period.

A joint statement issued in September 2008 by the World Health Organization (WHO), the United Nations Children's Fund (UNICEF), the United Nations Population Fund and the World Bank stated that "maternal mortality has root causes in gender inequality, limited access to education -- especially for girls, early marriage, adolescent pregnancy, low access to sexual and reproductive health (including for adolescents) and other social determinants".

Although there has been some improvement in the global maternal mortality ratio since 1990, progress is limited and too slow. An annual decline of 5.5 per cent in maternal mortality is required to reach MDG 5 by 2015; the actual average annual rate of decline is less than 1 per cent. Sub-Saharan Africa remains the most dangerous region in the world in which to give birth, with a negligible annual decrease in maternal and newborn deaths. Newborn deaths and stillbirths are strongly related to the availability and quality of care provided to mothers -- and unless maternal health improves, there is little chance of progress in the health of newborn babies.

Adolescent pregnancy poses a particular challenge. About 16 million girls aged 15 to 19 give birth every year. Worldwide, one in ten babies is born to an adolescent mother. These infants and their mothers need special protection since they are at a higher risk of disease and death, as well as social exclusion. Almost 95 per cent of adolescent mothers live in developing countries, with the highest levels of adolescent pregnancy in sub-Saharan Africa, where every second a woman gives birth to a child before her 20th birthday. There are also high rates in Asian countries like Bangladesh and India, in Latin America and the Caribbean and in the United States.

In general, early pregnancies mean an increased risk to the life of the mother and her baby. In many countries the risk of death in pregnancy or childbirth is twice as high for mothers aged 15 to 19 compared to mothers in their twenties, and the situation is even worse for girls under 15. Babies of adolescent mothers are also more likely to die. Stillbirth and death in the first week of life are 50 per cent higher among babies born to women under the age of 20 than to older mothers. Moreover, many girls who become pregnant end their schooling, limiting their potential for themselves as well as their families.

It is possible to reduce maternal and newborn mortality

There are many reasons to be optimistic about the possibility of reducing maternal and newborn mortality. Some recent key advances include: the discovery of magnesium sulphate for treating eclampsia and severe pre-eclampsia; the ability to control heavy bleeding after birth through active management of the third stage of labour; care for infections with antibiotics; post-abortion care using manual vacuum aspiration by trained nurses and midwives; treatment of malaria and HIV in pregnancy and prevention of mother-to-child transmission of HIV; quality antenatal care; maternal death reviews as a means for improving quality of care; and an improved range of methods to measure progress.

Two thirds of newborn deaths could be prevented if all mothers and newborns had access to essential interventions that are well-known, feasible and deliverable without complex technology. These include tetanus immunization as part of antenatal care, skilled care during childbirth, early and exclusive breastfeeding, keeping the baby warm and timely management of life-threatening newborn conditions.

Actions to improve maternal and newborn health must be guided by what we call the "continuum of care". This term has two meanings. Firstly, it means that care is provided continuously over different life stages -- beginning at the time of adolescence and pre-pregnancy, through pregnancy and birth, and into the newborn period. Secondly, it also refers to the continuum of care that must be provided at all levels of the health system -- in the home and community health centre and hospital.

Some developing countries, including Egypt, Honduras, Malaysia, Sri Lanka and Thailand, have dramatically reduced maternal mortality since 1987. They rapidly increased the access of a skilled attendant to childbirth and, when required, timely emergency obstetric care. They recognized that provision of services for mothers and newborns are at the centre of a strong health care system, and the resulting reduction in maternal and newborn mortality is a measure of the success of that health system.

Four priority actions

We propose four priority actions for improving the health of mothers and newborns that will contribute to the achievement of MDGs 4 and 5, as well as MDG 6 (combat HIV/AIDS, malaria and other diseases):
(1) access to family planning services;
(2) skilled care during pregnancy and childbirth, including access to emergency obstetric and newborn care;
(3) essential care for mothers and newborns in the days following birth;
(4) prevention and management of HIV and malaria in pregnancy and following birth.

1. Access to family planning services
By far, the most important way of reducing maternal deaths is simply by reducing the number of pregnancies. Family planning is a critical element for improving maternal and child health. Studies have shown that family planning has immediate benefits for the lives and health of mothers and their infants. Ensuring basic access to contraception could reduce maternal deaths by one third and child deaths by as much as 20 per cent.

While contraceptive use has grown enormously since it became available in the 1960s, there is still a significant need for family planning services, in particular among adolescents. A recent study of married women in 53 countries found that the unmet need for contraceptives was highest among women aged 15 to 24 years. Some 4 million adolescents become pregnant unintentionally every year; however, the majority of adolescent mothers are married and most of their babies are wanted. In the developing world, about 90 per cent of births to adolescents occur in marriage.

In addition to making pregnancy and delivery safer, it is essential to reduce the number of unintended pregnancies through access to contraception. Family planning improves maternal health and reduces maternal mortality in several ways:

Effective use of contraception reduces the number of unintended and unwanted pregnancies;
At the individual level, family planning reduces the number of times a woman becomes pregnant and prolongs birth spacing, thus reducing her overall risk of death;

At the national level, family planning reduces the number of pregnancies and births; and

Family planning can be targeted to reduce the number of pregnancies to women in groups at increased risk of maternal death.

2. Skilled care during pregnancy and childbirth, including access to emergency obstetric and newborn care

For optimum safety, every woman, without exception, needs skilled care given in an appropriate environment (usually in decentralized, first-level facilities) close to her home, in a way that respects her culture. This can avert, contain or solve many of the life-threatening problems, particularly the complications that may arise during childbirth. It can also reduce maternal and newborn mortality and stillbirth to surprisingly low levels.

Antenatal consultations are the ideal location to establish birth plans which can ensure that childbirth takes place in safe circumstances with a skilled attendant who can detect problems, such as anaemia, and who can promote the mother's healthy nutrition, helping to prepare her in caring for her newborn, particularly with breastfeeding. Improving the nutrition status of women and tackling micronutrient deficiencies, particularly during pregnancy, is equally important. Management of health conditions like anaemia will reduce the probability of women dying due to post-partum haemorrhage. The golden opportunity for nutrition intervention extends from pregnancy to two years of age. If under-nutrition is not addressed during these crucial years, it may cause irreversible damage for future development towards adulthood, thus increasing the risk of girls becoming malnourished mothers and having low-birth-weight babies.

Adolescents tend to seek antenatal care later than other mothers. There are manifold reasons why, among which is that they may not be aware of their pregnancy. Furthermore, the decision to seek care may not always be made by the girl, but rather by her husband or mother-in-law. Also, the cost involved may present another obstacle that restrains adolescents from using available health services. It is important to overcome those barriers. Families and communities have to be involved, as well as systematic actions at district and national levels, to improve adolescents' access to skilled care services.

As previously stated, a strong health system is critical to the health of mothers and newborns. However, countries are at different stages of health system development and access to facility care. Improving the quality and availability of facilities for childbirth and increasing the number of midwives and health professionals with obstetric skills is essential. Alongside this, community mobilization is vital to ensure that all pregnant women are making use of skilled childbirth services. This dual strategy is targeted at achieving universal coverage of skilled attendance at childbirth, within the context of the primary health care approach.

The advantages of facility-based deliveries -- from both a technical perspective and a systematic analysis of mothers' experiences -- are many. They enable teamwork so that midwives can attend to far more births than would be possible in home deliveries. They also enable non-professionals, such as assistants and auxiliaries, to help, making care more cost-effective. This allows a single midwife to attend up to 175 to 220 deliveries per year, compared to about 50 for a single-handed midwife visiting mothers at home. In addition, the mixture of professionals in a facility means that life-saving emergency care can be given quickly. Skilled care at facilities not only ensures safety, cleanliness and the availability of supplies and equipment, but also makes management and supervision easier. Other work can also be performed and referrals are easier, as is emergency transport. Wherever childbirth takes place, it is essential that the person who helps has the core competencies for safe delivery, the necessary equipment and supplies, and the option to refer to a functioning facility offering emergency obstetric and newborn care. 3. Essential care for mothers and newborns in the days following birth

As mentioned, two-thirds of newborn deaths can be prevented if mothers and their babies receive known, effective interventions. However, the current coverage of care in the first hours and days after birth in most developing countries is low. Several studies have shown that home-based newborn-care interventions can prevent 30 to 60 per cent of newborn deaths in high-mortality developing country settings. They have also been shown to improve coverage of key newborn-care practices, such as early initiation of breastfeeding, exclusive breastfeeding, skin-to-skin contact, delayed bathing and attention to hygiene, such as washing hands with soap and, water and clean umbilical cord care. Therefore, as a complementary strategy to facility-based post-natal care, WHO and UNICEF now recommend home visits during the baby's first week of life to improve newborn survival. Home visits providing basic care for all newborns should include promoting and supporting early and exclusive breastfeeding, keeping the baby warm, increasing hand washing and providing hygienic umbilical cord and skin care, identifying conditions requiring additional care and counselling on when to take a newborn to a health facility.

The mother also requires care in the days following birth. During home visits following birth, the health worker should be concerned with the well-being of the mother, checking if she has signs of infection, such as fever, foul discharge or painful urination. The mother should be provided with support for breastfeeding and counselled about the danger signs, as well as be encouraged to seek care early if needed. In addition, she should be provided with counselling on birth spacing and nutrition. If a home visit is made by a midwife or a skilled professional, care for the mother could include more interventions, such as observing blood flow, measuring temperature and providing iron-folic acid supplementation and contraceptive methods.

Care in the immediate period after birth is particularly important for a first-time mother, especially if she is very young. Adolescent mothers often lack the knowledge, education, experience, income and power relative to older mothers. In some cultures, they may also have to bear the effects of many judgemental attitudes, making an already difficult situation even worse. Thus, the provision of the continuum of care through to the early days following delivery can provide the extra support needed for the mother and her newborn. 4. Preventing and managing HIV and malaria in pregnancy and following birth

Malaria infection during pregnancy, HIV in pregnancy, as well as transmission of HIV from mother to child pose substantial risks to the mother, her fetus and the newborn. About 90 per cent of clinical cases recorded worldwide occur in sub-Saharan Africa. Despite the toll that malaria exacts on pregnant women and their infants, until recently this was a relatively neglected problem. Less than 5 per cent of pregnant women have access to effective interventions. The HIV epidemic has also had a devastating impact on maternal, newborn and child health, undermining efforts to achieve the MDGs in those related areas. Effective interventions that are safe for the prevention and control of HIV/AIDS and malaria during pregnancy exist and must be deployed on a large-scale at the national level.

With 77 per cent of pregnant women (70 million) in low- and middle-income countries able to have at least one antenatal care visit, the opportunity exists for them to be tested for HIV and counselled on primary prevention, including the prevention of mother to child transmission, as well as the treatment and care of mothers and their newborns for those who test positive. Yet, in the 71 countries falling in this category in 2005, only 11 per cent of pregnant women (10.3 million) were actually counselled on prevention of mother to child transmission and 10 per cent (9.2 million) had an HIV test. The near universal acceptance of HIV testing among pregnant women who have received counselling for prevention of mother to child transmission illustrates that women desire this important bridge to HIV treatment and prevention services. The fact that the vast majority of pregnant women do not receive testing and counselling points to the many missed opportunities for ensuring the necessary services for healthy mothers and newborns.

Malarial infection during pregnancy is a major public health problem in tropical and subtropical regions throughout the world. In most endemic areas, pregnant women are the main adult-risk group for malaria. Malaria during pregnancy has been most widely evaluated in sub-Saharan Africa, where 90 per cent of the global malaria burden occurs. Every year, at least 30 million pregnancies occur among women in malarious areas of Africa, most of them residing in places with relatively stable malaria transmission.

Malaria prevention and control during pregnancy has a three-pronged approach: intermittent preventive treatment during pregnancy; sleeping under insecticide-treated nets; and case-management of malaria illness during pregnancy.

Conclusion

Women are the backbone of homes, families, communities and nations. They are central to the survival of cultures and often drive flourishing economies. But far too often they neither have equal rights nor receive equal treatment, especially in the delivery of health care.

The economic productivity of communities and nations is affected every time a woman or an infant dies. A mother's death has a grave impact on the children's long-term well-being, their education, growth and care. Without their mothers, infants have a lower chance of surviving their first year of life. A mother's income is most often used to pay for household, education, medical and family-related expenses, and its loss is the frequent factor that pushes a family into absolute poverty. Estimates show that the worldwide potential productivity loss due to maternal and infant deaths is $15 billion. The projected costs of providing first-level and back-up maternal and neonatal care to all are dwarfed by this potential loss in annual productivity.

The time for rhetoric is over and action is required now if countries are to reach MDGs 4 and 5. Governments must provide sustained funding and support for health initiatives and policies aimed at helping women and children. They need to ensure that their health systems provide a continuum of affordable, high-quality care from pre-pregnancy through the post-natal period. Health care must be equally accessible to all, and skilled health-care providers must have access to better training, improved facilities and functioning health infrastructure, supplies, equipment and logistics for timely referral. In addition, women and their families need to be educated. Women must be empowered to choose when to become pregnant and must have access to skilled care during pregnancy and childbirth. Women must also be empowered to make decisions for themselves on their sexual and reproductive health.

We know what needs to be done to save the lives of thousands of women and their newborns. Our commitments must now match our actions with investment.