Building upon the successes of Countdown to 2015, Countdown to 2030 aims to support the monitoring and measurement of women's, children's, and adolescents' health in the 81 countries that account for 95% of maternal and 90% of all child deaths worldwide. To achieve the Sustainable Development Goals by 2030, the rate of decline in prevalence of maternal and child mortality, stillbirths, and stunting among children younger than 5 years of age needs to accelerate considerably compared with progress since 2000. Such accelerations are only possible with a rapid scale-up of effective interventions to all population groups within countries (particularly in countries with the highest mortality and in those affected by conflict), supported by improvements in underlying socioeconomic conditions, including women's empowerment. Three main conclusions emerge from our analysis of intervention coverage, equity, and drivers of reproductive, maternal, newborn, and child health (RMNCH) in the 81 Countdown countries. First, even though strong progress was made in the coverage of many essential RMNCH interventions during the past decade, many countries are still a long way from universal coverage for most essential interventions. Furthermore, a growing body of evidence suggests that available services in many countries are of poor quality, limiting the potential effect on RMNCH outcomes. Second, within-country inequalities in intervention coverage are reducing in most countries (and are now almost non-existent in a few countries), but the pace is too slow. Third, health-sector (eg, weak country health systems) and non-health-sector drivers (eg, conflict settings) are major impediments to delivering high-quality services to all populations. Although more data for RMNCH interventions are available now, major data gaps still preclude the use of evidence to drive decision making and accountability. Countdown to 2030 is investing in improvements in measurement in several areas, such as quality of care and effective coverage, nutrition programmes, adolescent health, early childhood development, and evidence for conflict settings, and is prioritising its regional networks to enhance local analytic capacity and evidence for RMNCH.
Introduction
The Millennium Development Goals (MDGs) era was characterised by an unprecedented decline in child and maternal mortality during 2000–15, even though mortality targets were not met by most countries.1, 2, 3, 4 Concerted action around the MDGs—specific time-bound, measurable, and easy-to-communicate goals—plus major increases in funding for health, including for reproductive, maternal, newborn, and child health (RMNCH) and nutrition, and scale-up of existing and new interventions are crucial factors that contributed to this decline.5, 6, 7 Progress was also driven by reductions in fertility and substantial improvements in underlying determinants, such as poverty and education of adolescent girls.8, 9, 10, 11 Health was prominently featured in three MDGs, two of which were specific to RMNCH. The 2030 agenda for sustainable development, adopted by the UN General Assembly in September, 2015, is much broader than the MDG framework.12 RMNCH is addressed in three of the 13 targets of the Sustainable Development Goal (SDG) for health (SDG 3), and in several targets in the other 16 SDGs. The need to reduce persistent inequalities in RMNCH between and within countries is explicitly acknowledged, as is the aim of reaching all people with effective and affordable interventions.
The Global Strategy for Women's, Children's and Adolescents' Health (2016–30) was developed to translate the SDG agenda into a comprehensive “survive, thrive, transform” framework for improving women's, children's, and adolescents' health through an inclusive and multisectoral approach.13, 14 The Global Strategy provides a roadmap for the Every Woman Every Child movement, which mobilises and intensifies international and national action by governments, multilaterals, the private sector, and civil society to address the major health challenges facing women, children, and adolescents around the world. The Global Financing Facility for women, children, and adolescents was also launched in 2015 to ensure scaled and sustained financing through country-driven investment cases.15
Key messages
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The 81 Countdown countries have made progress, but are still a long way from universal coverage for most essential interventions for reproductive, maternal, newborn, and child health and nutrition.
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Major investments are needed to achieve Sustainable Development Goal (SDG) targets related to reproductive, maternal, newborn, and child health and nutrition. These investments should be guided by reliable data on intervention coverage and quality of care for all inequality dimensions and in conflict settings.
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To address the broader SDG agenda, measurement improvements should focus on strengthening of vital statistics, understanding drivers of coverage change, and obtaining better data on early childhood development and adolescent health.
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Strengthening of countries' analytic capacity, a priority for the Countdown to 2030, is crucial to improve monitoring and accountability for women's, children's, and adolescents' health.
Countdown to 2030 for Women's, Children's and Adolescents' Health (referred to simply as Countdown) is a multi-institutional network of academics from institutions around the world and representatives from UN agencies and civil society that builds upon the successes of Countdown to 2015.6, 16 A key output of Countdown is a regular review of progress towards RMNCH targets in the 81 countries with the highest burden of maternal, neonatal, and child mortality. According to global estimates for population and mortality, the 81 countries accounted for 47% of the world's population, but 64% of all births, 90% of all child deaths, and 95% of all maternal deaths in 2015.1, 2, 17 The Countdown list of priority countries, core indicators, and equity dimensions were revised to address the SDG agenda, and to take into account country progress during the MDG era (appendix). Areas of expansion from Countdown to 2015 include nutrition, quality of care, adolescent girls' reproductive health, and RMNCH in conflict settings.
In this paper, we analyse progress towards improvement of intervention coverage, equity, and drivers of RMNCH in the Countdown countries, summarise key gains, highlight areas for further action, and show how Countdown priorities are evolving in response to the SDGs and universal health coverage (UHC) challenge.
Section snippets
Maternal, neonatal, and child survival
From 2000 to 2015, under-5 and neonatal mortality in the 81 Countdown countries fell rapidly, to country averages of 59 and 24 per 1000 livebirths, respectively, in 2015.18 However, a major acceleration of this mortality decline is required for countries to reach the SDG under-5 and neonatal mortality targets of 25 and 12 per 1000 livebirths, respectively, especially among the countries with the highest mortality. The average annual rates of decline in the 50 Countdown countries with the
Nutritional status
Undernutrition—including fetal growth restriction, stunting and wasting, and deficiencies in micronutrients such as vitamin A, iodine, iron, and zinc—along with suboptimal breastfeeding has been estimated to contribute to 45% of deaths in children younger than 5 years in 2011, and to poor childhood development.25, 26 Levels of stunting in under-5s have dropped substantially in the past decade,27 but 31 of the 59 Countdown countries with available data from 2012 still have a national prevalence
Coverage
Household surveys are the main source of data used to compare coverage trends and inequalities between and within countries. We have previously reported on Countdown's data sources and methods (appendix).6 Data availability for Countdown coverage indicators has improved considerably since 2005, partly because of the increased frequency of surveys done in the context of international household survey programmes—such as the USAID-supported Demographic and Health Surveys and UNICEF-supported
Equity
Progress towards universal coverage should be assessed in terms of not only national averages, but also how well such gains benefit all population groups. Survey data were used to classify households into wealth quintiles on the basis of ownership of household assets and housing characteristics.33 We use the slope index of inequality, which measures the difference in coverage between the richest and poorest extremes of the wealth scale and takes into account the full wealth distribution, to
Drivers
The SDGs stress the need to address the drivers or determinants of women's, children's, and adolescents' health, including health system, socioeconomic, cultural, political, and environmental factors. For some key drivers, such as women's empowerment, a positive association with coverage of RMNCH interventions has been shown.35 The effect of conflict, both during and after, on women's and children's health can be devastating (panel).
Countdown reports on a set of 17 indicators related to four
Progress towards universal coverage: still much to do
Three main conclusions emerge from our analysis of coverage, equity, and drivers of RMNCH in the 81 Countdown countries. First, strong progress in the coverage of many essential RMNCH interventions was made during the past decade, but many countries are still a long way from universal coverage for most essential interventions. Furthermore, there is growing evidence of the low quality of services because of a lack of basic inputs, such as medicines and trained health workers, which limits the
Measurement and monitoring gaps
An important limitation of our analysis of progress was the poor availability of empirical data in the past 5 years (and especially since 2015) for key indicators and inequality dimensions. Despite major improvements in data collection, there are not enough datapoints to assess whether the rate of improvement in survival or programme performance noted during the MDG era is accelerating or not. Countdown makes only limited use of predictions and aims as much as possible, to allow country data to
Transformation of the Countdown
The SDGs call for a comprehensive and integrated health agenda, with UHC at the centre of the health goal. The Every Woman Every Child Global Strategy for Women's, Children's and Adolescents' Health translates the SDG framework into a comprehensive “survive—thrive—transform” framework that goes well beyond RMNCH.13 Countdown is responding to this new agenda in several ways, while preserving its core features. Countdown will continue to publish independent comprehensive analyses of progress
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Klebsiella pneumoniae is an important cause of nosocomial and community-acquired pneumonia and sepsis in children, and antibiotic-resistant K pneumoniae is a growing public health threat. We aimed to characterise child mortality associated with this pathogen in seven high-mortality settings.
We analysed Child Health and Mortality Prevention Surveillance (CHAMPS) data on the causes of deaths in children younger than 5 years and stillbirths in sites located in seven countries across sub-Saharan Africa (Ethiopia, Kenya, Mali, Mozambique, Sierra Leone, and South Africa) and south Asia (Bangladesh) from Dec 9, 2016, to Dec 31, 2021. CHAMPS sites conduct active surveillance for deaths in catchment populations and following reporting of an eligible death or stillbirth seek consent for minimally invasive tissue sampling followed by extensive aetiological testing (microbiological, molecular, and pathological); cases are reviewed by expert panels to assign immediate, intermediate, and underlying causes of death. We reported on susceptibility to antibiotics for which at least 30 isolates had been tested, and excluded data on antibiotics for which susceptibility testing is not recommended for Klebsiella spp due to lack of clinical activity (eg, penicillin and ampicillin).
Among 2352 child deaths with cause of death assigned, 497 (21%, 95% CI 20–23) had K pneumoniae in the causal chain of death; 100 (20%, 17–24) had K pneumoniae as the underlying cause. The frequency of K pneumoniae in the causal chain was highest in children aged 1–11 months (30%, 95% CI 26–34; 144 of 485 deaths) and 12–23 months (28%, 22–34; 63 of 225 deaths); frequency by site ranged from 6% (95% CI 3–11; 11 of 184 deaths) in Bangladesh to 52% (44–61; 71 of 136 deaths) in Ethiopia. K pneumoniae was in the causal chain for 450 (22%, 95% CI 20–24) of 2023 deaths that occurred in health facilities and 47 (14%, 11–19) of 329 deaths in the community. The most common clinical syndromes among deaths with K pneumoniae in the causal chain were sepsis (44%, 95% CI 40–49; 221 of 2352 deaths), sepsis in conjunction with pneumonia (19%, 16–23; 94 of 2352 deaths), and pneumonia (16%, 13–20; 80 of 2352 deaths). Among K pneumoniae isolates tested, 121 (84%) of 144 were resistant to ceftriaxone and 80 (75%) of 106 to gentamicin.
K pneumoniae substantially contributed to deaths in the first 2 years of life across multiple high-mortality settings, and resistance to antibiotics used for sepsis treatment was common. Improved strategies are needed to rapidly identify and appropriately treat children who might be infected with this pathogen. These data suggest a potential impact of developing and using effective K pneumoniae vaccines in reducing neonatal, infant, and child deaths globally.
2024, American Journal of Obstetrics and Gynecology MFM
The introduction of assisted reproductive technology and the trend of increasing maternal age at conception have contributed to a significant rise in the incidence of multiple pregnancies. Multiple pregnancies bear several inherent risks for both mother and child. These risks increase with plurality and type of chorionicity. Multifetal pregnancy reduction is the selective abortion of ≥1 fetuses to improve the outcome of the remaining fetus(es) by decreasing the risk of premature birth and other complications.
This study aimed to compare birth outcomes of trichorionic triplets reduced to twins with those of trichorionic triplets and primary dichorionic twins. The added value of this study is the comparison with an additional control group, namely primary dichorionic twins.
This was a retrospective cohort study. Data from January 1990 to November 2016 were collected from the East Flanders Prospective Twin Survey, one of the largest European multiple birth registries. A total of 85 trichorionic triplet pregnancies (170 neonates) undergoing multifetal pregnancy reduction to twins were compared with 5093 primary dichorionic twin pregnancies (10,186 neonates) and 104 expectantly managed trichorionic triplet pregnancies (309 neonates). The assessed outcomes were gestational age at delivery, birthweight, and small for gestational age.
Pregnancy reduction from triplets to twins was associated with higher birthweight (+365.44 g; 95% confidence interval, 222.75–508.14 g; P<.0001) and higher gestational age (1.7 weeks; 95% confidence interval, 0.93–2.46; P<.0001) compared with ongoing trichorionic triplets after adjustment for sex, parity, method of conception, birth year, and maternal age. A trend toward lower risk of small for gestational age was observed. Reduced triplets had, on average, lower birthweight (−263.12 g; 95% confidence interval, −371.80 to −154.44 g; P<.0001) and lower gestational age (−1.13 weeks; 95% confidence interval, −1.70 to −0.56; P=.0001) compared with primary twins. No statistically significant difference was observed between primary twins and reduced triplets that reached 32 weeks of gestation.
Multifetal pregnancy reduction from trichorionic triplets to twins significantly improved birth outcomes. This suggests that multifetal pregnancy reduction of trichorionic triplets to twins is medically justifiable. However, the birth outcomes of primary twins before 32 weeks of gestation are still better than those of reduced triplets. The process of multifetal pregnancy reduction includes at least 1 fetal death by definition, and thus prevention of higher-order pregnancies is preferable.
Monitoring the progress in reproductive, maternal, newborn, and child health (RMNCH) using the composite coverage index (CCI) is crucial to evaluate the advancement of low-income and middle-income countries (LMICs) towards the attainment of Sustainable Development Goal target 3. We present current benchmarking for 70 LMICs, forecasting to 2030, and an analysis of inequities within and across countries.
In this cross-sectional secondary data analysis, we extracted 291 data points from the WHO Equity Monitor, and Demographic and Health Survey Statcompiler for 70 LMICs. We selected countries on the basis of whether they belonged to LMICs, had complete information about the predictors between 2000 and 2030, and had at least one data point related to CCI. CCI was calculated on the basis of eight types of RMNCH interventions in four domains, comprising family planning, antenatal care, immunisations, and management of childhood illnesses. This study examined CCI as the main outcome variable. Bayesian hierarchical models were used to estimate trends and projections of the CCI at regional and national levels, as well as the area of residence, educational level, and wealth quintile.
Despite progress, only 18 countries are projected to reach the 80% CCI target by 2030. Regionally, CCI is projected to increase in all regions of Asia (in southern Asia from 51·8% in 2000 to 89·2% in 2030; in southeastern Asia from 58·8% to 84·4%; in central Asia from 70·3% to 87·0%; in eastern Asia from 76·8% to 82·1%; and in western Asia from 56·5% to 72·1%), Africa (in sub-Saharan Africa from 46·3% in 2000 to 72·2% in 2030 and in northern Africa from 55·0% to 81·7%), and Latin America and the Caribbean (from 67·0% in 2000 to 83·4% in 2030). By contrast, southern Europe is predicted to experience a decline in CCI over the same period (70·1% in 2000 to 55·2% in 2030). Across LMICs, CCIs are higher in urban areas, in populations in which women have higher education levels, and in populations with a high income.
Governments of countries where the universal target of 80% CCI has not yet been reached must develop evidence-based policies aimed at enhancing RMNCH coverage. Additionally, they should focus on reducing the extent of existing inequalities within their populations to drive progress in RMNCH.
Hitotsubashi University and Japan Society for the Promotion of Science.