The U.S. Government and Global Maternal & Child Health Efforts
The health of mothers and children is interrelated and affected by multiple factors.1 Millions of pregnant women, new mothers, and children experience severe illness or death each year, largely from preventable or treatable causes.2 Almost all maternal and child deaths (99%) occur in the developing world, with Africa being the hardest hit region.3 Attention to maternal and child health (MCH) has been growing, under-five and maternal mortality have fallen substantially since 1990, and improving MCH is seen as critical to fostering economic development. Still, as efforts focus on achieving new global MCH goals such as ending preventable deaths among newborns and children under five and reducing global maternal mortality, significant challenges remain. Despite the availability of effective interventions, lack of funding and limited access to services have hampered progress, particularly on maternal health.
Maternal Health: The health of mothers during pregnancy, childbirth, and in the postpartum period.
Child Health: The health of children from birth through adolescence, with a focus on the health of children under the age of five. Newborn health is the health of babies from birth through the first 28 days of life.
The U.S. government (USG) has a long history of supporting global MCH efforts and is the largest donor government to MCH activities in the world, in addition to being the single largest donor to nutrition efforts in the world. In recent years, the USG has placed a higher priority on MCH within the USG global health agenda (particularly since the USG adopted ending preventable child and maternal deaths as one of its three main global health goals) and increased funding has been provided to support MCH and related efforts.
Current Global Snapshot
Each year, an estimated 5.9 million children under age five – primarily infants – die from largely preventable or treatable causes.4 In addition, approximately 303,000 women die during pregnancy and childbirth each year, and millions more experience severe adverse consequences.5 These challenges are especially prevalent in developing countries, with significant disparities between developing and developed regions in maternal and under-five mortality (see Table 1). Furthermore, sub-Saharan Africa is the hardest hit region in the world, followed by Southern Asia; together they account for more than 80% of maternal and under-five deaths.6
|Table 1: Maternal & Child Health (MCH) Indicators by Region7|
|Region8||Maternal Mortality Ratio (MMR) (deaths/100,000
|Under-Five Mortality Rate (U5MR)
|Skilled Attendant at Birth9
|Children Under Five Moderately or Severely Underweight
|Caucasus and Central Asia||33||32||96||4|
|Latin America and the Caribbean||67||18||92||2|
|NOTES: — indicates data not available.|
Maternal mortality: More than a quarter (27%) of all maternal deaths are due to severe bleeding, mostly after childbirth (postpartum hemorrhage). Sepsis (11%), unsafe abortion (8%), and hypertension (14%) are other major causes. Diseases that complicate pregnancy, including malaria, anemia, and HIV, account for about 28% of maternal deaths.10 Inadequate care during pregnancy and high fertility rates, often due to a lack of access to contraception and other family planning/reproductive health (FP/RH) services, increase the lifetime risk of maternal death.11
Newborn mortality: Complications due to premature births account for more than a quarter (35%) of newborn deaths, followed by delivery-related complications (24%), sepsis (15%), congenital abnormalities (11%), pneumonia (6%), tetanus (1%), diarrhea (1%), and other causes of death (7%).12 Low birth weight is a major risk factor and indirect cause of newborn death.13
Under-five mortality: Newborn deaths account for most child deaths (45%), followed by pneumonia (13%), diarrhea (9%), injuries (6%), malaria (5%), HIV/AIDS (1%), measles (1%), and other causes of death (20%).14 Undernutrition significantly increases children’s vulnerability to these conditions, as does the lack of access to clean water and sanitation.15
Mothers and Newborns: Key interventions that reduce the risk of maternal mortality include access to skilled care at birth and emergency obstetric care. Newborn deaths may be substantially reduced through increased use of simple, low-cost interventions, such as breastfeeding, keeping newborns warm and dry, and treating severe newborn infections.
Children: When scaled-up, interventions such as immunizations, oral rehydration therapy (ORT), and insecticide-treated mosquito nets (ITNs) have contributed to significant reductions in child morbidity and mortality over the last two decades. Other effective child health interventions include improved access to and use of clean water, sanitation, and hygiene practices like handwashing; improved nutrition; and the treatment of neglected tropical diseases (NTDs).
Health Systems: Strengthening health systems and increasing access to services, including through community-based clinics, are also important and interventions have been found to be more effective when integrated within a comprehensive continuum of care.17
Increased attention to MCH since 2000 has been supported by new financing mechanisms and initiatives, like Gavi, the Vaccine Alliance (a multilateral financing mechanism that aims to increase access to immunization in poor countries) and the Scaling Up Nutrition movement (an initiative that aims to bring together partner efforts to support households and women, in particular, and which recognizes that nutrition, maternal health, and child survival are closely linked).18 These and other efforts work toward achieving major global MCH goals that have been set through:
- The Millennium Development Goals (MDGs), adopted in 2000 by all member-states of the United Nations, and their successor, the Sustainable Development Goals (SDGs), adopted in 2015. The MDGs included MCH targets under MDGs 4 (reduce child mortality) and 5 (improve maternal health); the world missed these targets in 2015, but substantial progress was made, with under-five mortality having fallen by 53% and maternal mortality by 45% compared to 1990 levels.19 The SDGs included MCH targets for achievement by 2030 under SDG 3 (“ensure healthy lives and promote well-being for all at all ages”), aiming to reduce the global MMR20 and end preventable deaths of newborns and under-five children,21 and under SDG 2 (“end hunger, achieve food security and improved nutrition, and promote sustainable agriculture”), aiming to end all forms of malnutrition.22 Among the global efforts designed to support countries’ progress toward meeting these goals is the Every Woman, Every Child (EWEC) movement, which launched in 2010. The UN-led EWEC movement aims to put into action the 2015 Global Strategy for Women’s, Children’s, and Adolescents’ Health by combining the efforts of partners who commit to advancing MCH and related efforts with the goal of ending preventable maternal, newborn, child, and adolescent deaths and stillbirths by 2030, among other goals.23
- The A Promise Renewed initiative, which has a goal of ending preventable child deaths by 2035. In 2012, a global summit was convened by the USG and other governments and partners. Known as the Call to Action for Child Survival, it aimed to focus political will and resources on eliminating deaths from preventable causes among children under-five by 2035 and led to the establishment of the “A Promise Renewed” initiative, bringing together partner efforts around this goal.
- The Global Nutrition for Growth Compact, which includes a goal of reducing stunting in children and nutrient deficiencies in women and children. Endorsed in 2013 by governments and other stakeholders, it commits them to, by 2020: ensuring that at least 500 million pregnant women and children under two are reached with effective nutrition interventions; reducing the number of children under five stunted by at least 20 million; and saving at least 1.7 million under-fives by preventing stunting and increasing breastfeeding and treatment of severe acute malnutrition.24
The U.S. Government Response
The first USG international efforts in the area of MCH began in the 1960s and focused on child survival research, including pioneering research on ORT conducted by the U.S. military, the U.S. Agency for International Development (USAID), and the National Institutes of Health (NIH). Early programs included fortifying international food aid with vitamin A (deficiency of which can cause blindness, compromise immune system function, and retard growth among young children) and efforts to control malaria. The USG increased support for its child health efforts in FY 1985 when Congress provided $85 million for child survival activities, nearly doubling funding for this purpose. USAID then developed its first maternal health project in 1989 and introduced a newborn survival strategy in 2001.25 More recently, Congress has increased MCH funding, and the USG has adopted a longer-term goal of ending preventable child and maternal deaths by 2035.
Structure and Approach
USAID serves as the lead U.S. implementing agency for MCH activities, and its efforts are complemented by those of the Centers for Disease Control and Prevention (CDC), NIH, and the Peace Corps. Collectively, USG activities reach at least 40 countries.26
|Table 2: U.S. Government-Funded Maternal & Child Health (MCH) Interventions30|
|Newborns and Children||Women|
|Essential newborn care||Skilled care at birth|
|Postnatal visits||Emergency obstetric care|
|Prevention and treatment of severe childhood diseases||Improved access to FP/RH and birth spacing|
|Immunizations, including those for polio, measles, and tetanus||Antenatal care, including aseptic techniques to prevent sepsis|
|Malaria prevention (including ITNs) and, for mothers, intermittent preventive treatment during pregnancy (IPTp)|
|HIV prevention/treatment/care, including prevention of mother-to-child-transmission (PMTCT) of HIV|
|Clean water, sanitation, and hygiene efforts|
|Health systems strengthening (health workforce, information systems, pharmaceutical management, infrastructure development)|
|Implementation science and operational research|
Other USG MCH and Related Global Health Efforts. CDC operates immunization programs, provides scientific and technical assistance, and works to build capacity in a broad array of MCH (and related RH) areas. It also serves as a WHO Collaborating Center on reproductive, maternal, perinatal, and child health.31 NIH addresses MCH by carrying out basic science and implementation research, sometimes in cooperation with other countries.32 The Peace Corps carries out MCH-related volunteer projects around the world.33 Additionally, USG FP/RH efforts are also critical to improving MCH (the internationally agreed upon definition of reproductive health includes both FP and MCH), although Congress directs funding to and USAID operates these programs separately.34 Other USG global health and related efforts addressing conditions that threaten the health of many pregnant women, new mothers, and children include: the President’s Emergency Plan for AIDS Relief (PEPFAR), the President’s Malaria Initiative (PMI), USAID’s NTD Program, Feed the Future, and clean water efforts under the Water for the Poor and Water for the World Acts.
Multilateral Efforts. The USG partners with international institutions and supports global MCH funding mechanisms. Key partners include the United Nations Children’s Fund (UNICEF); the Partnership for Maternal, Newborn, and Child Health (PMNCH); Gavi, the Vaccine Alliance; and the Global Polio Eradication Initiative (GPEI). The USG is one of the largest donors to Gavi, which has provided over $9 billion for vaccination programs worldwide,35 and the largest donor to the GPEI,36 which has invested $14.3 billion in efforts to eradicate polio globally.37
U.S. Government Funding38
Total USG funding for MCH and nutrition, which includes the U.S. contributions to Gavi and UNICEF as well as support for polio activities, has increased from $730 million in FY 2006 to $1.37 billion in FY 2016 (see Figure 2).39 The President’s FY 2017 budget request for MCH and nutrition totaled $1.43 billion. If approved by Congress, this would be an increase of $65 million (5%) over the FY 2016 enacted level. Most USG funding for MCH and nutrition is provided through the Global Health Programs (GHP) account at USAID, with additional funding provided through the Economic Support Fund (ESF) account. MCH funding is also provided through the International Organizations & Programs (IO&P) account at the State Department for the U.S. contribution to UNICEF, and for global immunization programs at CDC.40
Recent international and USG activities have brought new attention to and funding for MCH efforts. As the global community endeavors to support and fund efforts to achieve SDGs 2 and 3’s MCH and nutrition targets, key issues and challenges for USG efforts include: continuing to expand access to and ensure the quality of MCH services, while building local capacity, in the current restrained funding environment; reaching the most vulnerable; supporting advances in research and uptake of new technologies and vaccines; further integration of MCH efforts with other U.S. global health programs (such as FP/RH and PEPFAR) and broader U.S. development efforts (including education and food security); and coordinating these efforts with the activities of other donors and partner countries in order to maximize the impact of available resources.
George Schmid, et al., “The Lancet's neonatal survival series,” The Lancet, Vol. 365, Issue 9474, p. 1845, May 28, 2005.
UN Interagency Group on Child Mortality Estimates (IGME), Levels and Trends in Child Mortality Report 2015, 2015; WHO, Trends in maternal mortality: 1990 to 2015, 2015.
UN IGME, Levels and Trends in Child Mortality Report 2015, 2015; WHO, Trends in maternal mortality: 1990 to 2015, 2015.
UN IGME, Levels and Trends in Child Mortality Report 2015, 2015.
WHO, Trends in maternal mortality: 1990 to 2015, 2015; WHO/UNICEF, Countdown to 2015 Report, 2012.
UN IGME, Levels and Trends in Child Mortality Report 2015, 2015; WHO, Trends in maternal mortality: 1990 to 2015, 2015.
WHO, Trends in maternal mortality: 1990 to 2015, 2015; UN IGME, Levels and Trends in Child Mortality Report 2015, 2015; UN, The Millennium Development Goals [MDGs] Report 2015, 2015.
Country classifications are based on MDG regional designations.
Percent of births attended by a skilled birth attendant, which is defined as an accredited health professional - such as a midwife, doctor, or nurse - who has been educated and trained to proficiency in the skills needed to manage normal (uncomplicated) pregnancies, childbirth, and the immediate postnatal period, and in the identification, management, and referral of complications in women and newborns.
L. Say, et al., “Global causes of maternal death: a WHO systematic analysis,” The Lancet Global Health, Vol. 2, no. 6, pp. 323-333, June 2014.
WHO and UNICEF, Countdown to 2015 Report, 2012.
UNICEF, Committing to Child Survival: A Promise Renewed - Progress Report 2015, 2015.
Black, et al., for the Child Health Epidemiology Reference Group of WHO and UNICEF, “Global, Regional, and National Causes of Child Mortality in 2008: A Systematic Analysis,” The Lancet, Vol. 375, Issue 9730, pp. 1969–87, 2010.
UNICEF, Committing to Child Survival: A Promise Renewed - Progress Report 2015, 2015.
Robert E. Black, et al., “Maternal and child nutrition: building momentum for impact,” The Lancet, Vol. 382, Issue 9890, pp. 372-375, Aug. 3, 2013; CRS, Child Survival and Maternal Health: U.S. Agency for International Development Programs, FY2001-FY2008, July 2008.
USAID, Working Toward the Goal of Reducing Maternal and Child Mortality: USAID Programming and Response to FY08 Appropriations (Report to Congress), July 2008; UN, The Millennium Development Goals Report 2009, 2009; The Millennium Development Goals Report 2010, 2010; and The Millennium Development Goals Report 2011, 2011; USAID, Two Decades of Progress: USAID’s Child Survival and Maternal Health Program, June 2009; UN IGME, Levels and Trends in Child Mortality Report 2013, 2013.
Partnership for Maternal, Newborn & Child Health, Strategic Framework 2012-2015, November 2011.
UN, The Millennium Development Goals [MDGs] Report 2015, 2015.
To less than 70 per 100,000 live births.
For neonatal mortality, to at least as low as 12 per 1,000 live births, and for under-five mortality, to at least as low as 25 per 1,000 live births.
UN, Transforming our world: the 2030 Agenda for Sustainable Development, 2015.
The updated strategy succeeds the original Global Strategy for Women’s and Children’s Health, which was issued in 2010 and set the goal of saving the lives of 16 million women and children by 2015.
The Global Nutrition for Growth Compact, June 2013, http://www.who.int/pmnch/media/events/2013/nutritionforgrowth/en/.
USAID: MCH website, http://www.usaid.gov/what-we-do/global-health/maternal-and-child-health; Working Toward the Goal of Reducing Maternal and Child Mortality: USAID Programming and Response to FY08 Appropriations (Report to Congress), July 2008; Two Decades of Progress: USAID’s Child Survival and Maternal Health Program, June 2009; USAID Reports to Congress, 1985, 1987, 1990.
KFF analysis of data from the U.S. Foreign Assistance Dashboard website, ForeignAssistance.gov. Additional countries may be reached through USAID regional programs and other efforts.
According to USAID, Acting on the Call: Ending Preventable Child and Maternal Deaths, June 2014, priority countries are chosen based on need (as reflected by maternal and child mortality burden) and having: governments that have demonstrated a commitment to working with others to achieve accelerated reductions in maternal and under-five mortality; and opportunities to integrate/leverage other USG global health and development efforts as well as leverage USAID resources against those of the partner-country and other donors/organizations. USAID, “Maternal and Child Health Priority Countries,” webpage, https://www.usaid.gov/what-we-do/global-health/maternal-and-child-health/priority-countries. Burma may soon be added as the 25th priority country, per Ariel Pablos-Mendez, “Burma, the 25th Priority country for USAID’s Ending Preventable Child and Maternal Deaths,” email, May 3, 2016. Additional countries may be reached through other country and regional programs.
USAID: Acting on the Call: Ending Preventable Child and Maternal Deaths, June 2014; USAID Maternal Health Vision for Action, June 2014; “USAID Global Health Programs: FY 2016 President’s Budget Request, Ending Preventable Child and Maternal Deaths,” fact sheet, March 2015.
USAID, USAID Multi-Sectoral Nutrition Strategy 2014-2025, 2014. USAID reports prioritizing nutrition efforts in 19 focus countries, which are mostly in Africa. 15 of these countries are also MCH priority countries. USAID, “Nutrition Countries,” webpage, https://www.usaid.gov/what-we-do/global-health/nutrition/country-map.
USAID: Acting on the Call: Ending Preventable Child and Maternal Deaths, June 2014; USAID Maternal Health Vision for Action, June 2014.
CDC, Global Reproductive Health website, www.cdc.gov/reproductivehealth/Global/index.htm.
NIH/NICHD Office of Global Health website, http://www.nichd.nih.gov/about/org/od/ogh/Pages/index.aspx; NIH Office of Research on Women’s Health, “Global Health Research,” webpage, http://orwh.od.nih.gov/research/globalhealth/index.asp; NIH/FIC, “Maternal and child health information and resources,” webpage, http://www.fic.nih.gov/ResearchTopics/Pages/maternal-child-health.aspx.
Peace Corps, “Health,” webpage, http://www.peacecorps.gov/volunteer/learn/whatvol/health/.
International Conference on Population and Development (ICPD), Programme of Action, Cairo, 1994. See KFF fact sheet on global FP/RH.
Gavi, “Disbursements and commitments,” webpage, http://www.gavi.org/results/disbursements/ (through the end of April 2016).
KFF analysis of funding through 2015 based on data in GPEI, “Contributions and Pledges to the GPEI, 1985-2019,” as of 1 April 2016, www.polioeradication.org/Portals/0/Document/Financing/HistoricalContributions.pdf.
GPEI, “Contributions and Pledges to the GPEI, 1985-2019,” as of 1 April 2016, www.polioeradication.org/Portals/0/Document/Financing/HistoricalContributions.pdf.
KFF analysis of data from the Office of Management and Budget, Agency Congressional Budget Justifications, Congressional Appropriations Bills, and the U.S. Foreign Assistance Dashboard website, ForeignAssistance.gov. For an in-depth discussion of USG MCH funding, including trends, see KFF, U.S. Funding for International Maternal & Child Health, April 2016, and for similar discussion of USG nutrition funding, see KFF, U.S. Funding for International Nutrition Programs, April 2016.
Prior to FY 2009, nutrition funding was included as part of maternal and child health.
Represents specified funding for international MCH and nutrition programs in the President’s budget request, ForeignAssistance.gov, and Congressional appropriations bills. Additional support for international MCH and nutrition programs is provided through research activities at NIH.