The U.S. Government and Global Maternal, Newborn & Child Health
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, 3 Almost all maternal and child deaths (99%) occur in the developing world, with Africa being the hardest hit region.2, 3 Attention to maternal, newborn, and child health (MNCH) has been growing and improving MNCH is increasingly seen as critical to fostering economic development—two of the eight Millennium Development Goals (MDGs) address MNCH: MDG 4 (reduce child mortality) and MDG 5 (improve maternal health). Despite the availability of many effective interventions, however, lack of funding and limited access to services have hampered progress, particularly on maternal health. Of all eight MDGs, countries have made the least progress towards MDG 5.4
Maternal Health: The health of mothers during pregnancy, childbirth, and in the postpartum period.
Newborn Health: The health of babies from birth through the first 28 days of life.
Child Health: The health of children from birth through adolescence, with a focus on the health of children under the age of five.
The U.S. government is one of the largest donors to global MNCH efforts and has been engaged in activities to improve MNCH in developing countries for several decades.5, 6, 7 In recent years, a higher priority has been placed on MNCH and increased funding has been provided. The Obama Administration has highlighted MNCH as key part of its Global Health Initiative (GHI), a six-year (FY09-FY14), multi-billion dollar effort to develop and implement a comprehensive U.S. global health strategy. The GHI includes specific MNCH targets: to reduce maternal mortality by 30% and under-five mortality by 35% across assisted countries.8 Additionally, Secretary of State Clinton has elevated women’s rights, including reproductive rights, and women’s empowerment more broadly as part of U.S. foreign policy.9
Current Global Snapshot
Each year, more than 7 million children under age five – primarily infants – die from largely preventable or treatable causes.2 In addition, approximately 358,000 women die during pregnancy and childbirth each year, and millions more experience severe adverse consequences.3 These challenges are especially prevalent in developing countries (see Figure 1). Sub-Saharan Africa is hardest hit region in the world, followed by South Asia, and there are significant disparities in maternal and under five mortality between industrialized and developing countries.10
|Figure 1: MNCH Indicators by Region2, 3, 11|
|Region12||Maternal Mortality Ratio
(deaths/100,000 live births)
|Under-Five Mortality Rate
(deaths/1,000 live births)
|Skilled Attendant at Birth
|Middle East and North Africa||170||41||75|
|East Asia and Pacific||88||24||90|
|Latin America and Caribbean||85||23||90|
- Maternal mortality:13 More than one-third (35%) of all maternal deaths are due to severe bleeding, primarily during the postpartum period (postpartum hemorrhage). Sepsis (8%), unsafe abortion (9%), and hypertension (18%) are other major causes. Diseases that complicate pregnancy, including malaria, anemia, and HIV, account for 20% of maternal deaths. Inadequate care during pregnancy and high fertility rates, often due to a lack of access to contraception and other FP/RH services, increase the lifetime risk of maternal death.
- Newborn mortality: Premature births account for more than a quarter (29%) of newborn deaths, followed by asphyxia (22%), sepsis (15%), pneumonia (10%), congenital abnormalities (7%), diarrhea (2%), and tetanus (2%).14, 15 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 (41%), followed by diarrhea (14%), pneumonia (14%), malaria (8%), injuries (3%), HIV/AIDS (2%), and other infectious or non-communicable diseases (18%, including measles (1%)).14 Undernutrition significantly increases children’s vulnerability to these conditions, as does the lack of access to clean water and sanitation.2, 16
- 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 the newborn warm and dry, and treating severe newborn infection.5
- 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.4 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).5, 6
- Health Systems: Strengthening health systems and increasing access to services, including through community-based clinics, are also important and interventions have been found to work best when integrated within a comprehensive continuum of care.2, 17
The U.S. Government Response
- The first U.S. international efforts in the area of MNCH 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.7, 18
- The U.S. increased support for its child survival activities in FY 1985 when Congress provided $85 million for child survival activities, nearly doubling funding for this purpose.5, 6, 7
- In 1989, USAID developed its first maternal health project, and in 2001, it introduced a newborn survival strategy.5, 6, 7
- More recently, the U.S. has strengthened its MNCH efforts, with increased funding and highlighting MNCH as a core program area of the GHI. In addition, last year, the Obama Administration joined other donors to commit to the G-8 Muskoka Initiative, an international “comprehensive and integrated approach to accelerate progress towards MDGs 4 and 5.4, 19
- Under the GHI, USAID has placed an increased emphasis on efforts to reduce child mortality with the goal of saving the lives of 5 million children between 2010 and 2015.20
Structure and Approach
USAID serves as the lead U.S. implementing agency for MNCH activities, and several other agencies and cross-cutting initiatives also carry out MNCH activities.
- USAID operates programs with MNCH components in 58 countries (see Figure 2).21 Of these, 24 are designated as MNCH “priority countries,” which are primarily in Africa and receive the majority of funding.22 They are chosen based on need as reflected by maternal and child mortality burden, the presence of USAID Missions, and the capacity of those Missions and recipient countries to implement MNCH activities.5
- Outlined originally in 2008, USAID’s comprehensive MNCH strategy focuses on developing, introducing, and bringing “high impact interventions” to scale, and strengthening health systems (see Figure 3).5, 6
- Programs and interventions are supported through direct and indirect mechanisms, including: USAID field staff’s work with governments and other on-the-ground partners; financial and technical support provided to countries, facilities, implementing partners, and others who, in turn, provide direct services and programs; health workforce training efforts; procurement of medications and other supplies; and operational research.5, 6
- The Centers for Disease Control and Prevention (CDC) operate immunization programs, provide scientific and technical assistance, and work to build capacity in a broad array of MNCH and RH areas. CDC also serves as a WHO Collaborating Center on reproductive, maternal, perinatal, and child health.23 NIH addresses MNCH by carrying out basic science and implementation research, sometimes in cooperation with other countries.24, 25 The Peace Corps carries out MNCH-related volunteer projects around the world.26
- The U.S. government’s family planning and reproductive health (FP/RH) efforts are also critical to improving MNCH (the internationally agreed upon definition of reproductive health includes both FP and MNCH),27 although Congress directs funding to and USAID operates these programs separately. Other U.S. global health and related efforts addressing conditions that threaten the health of many pregnant women, new mothers, and children include PEPFAR, PMI, the USAID NTD Program, the Feed the Future Initiative, and the Water for the Poor Act.
|Figure 3: U.S. Government-Funded MNCH Interventions5, 6|
|Newborns and Children||Women|
|Essential newborn care||Skilled care at birth, including attendants|
|Postnatal visits||Emergency obstetric care|
|Prevention and treatment of severe childhood diseases||Antenatal care, including aseptic techniques to prevent sepsis|
|Immunizations, including those for polio, measles, and tetanus||Improved access to FP/RH and birth spacing|
|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 efforts|
|Health systems strengthening (health workforce, information systems, pharmaceutical management, infrastructure development)|
|Implementation science and operational research|
U.S. Government Funding
- Most U.S. government funding for MNCH is specified by Congress in annual appropriations bills and is part of the Global Health Programs (GHP) account (formerly the Global Health and Child Survival account) at USAID; all GHP funding for MNCH is counted as part of the GHI. Additional funding is provided through other accounts, such as the Economic Support Fund (ESF), and for programs operated by the CDC, although this funding is not currently counted as part of the GHI.
- Funding appropriated by Congress for MNCH, including nutrition, within the GHP account increased from $328 million in FY 2004 to $701 million in FY 2012.21 The FY 2013 budget request for MNCH and nutrition is $668 million, which would represent a decrease of $33 million (5%) below FY 2012; with additional funding through other accounts and agencies, the total requested amount would reach $1.2 billion (see Figure 4).21, 28
The Obama Administration has highlighted the importance of MNCH within the U.S. global health portfolio as part of the GHI, and Congress has also expressed continued interest in funding MNCH efforts. However, given current budget constraints a key question facing policymakers is the appropriate distribution of funding across U.S. global health efforts, including MNCH, as well as the potential impact of funding levels on achieving the GHI’s targets. Other questions include the whether and how effectively MNCH programs, goals, and activities are coordinated and integrated with other U.S. global health programs, such as FP/RH and PEPFAR, with broader U.S. development efforts, including education and food security; and with other donors and partner countries.
George Schmid, et al. “The Lancet's neonatal survival series,” Lancet 365, no. 9474 (May 28, 2005): 1845.
UNICEF. Levels and Trends in Child Mortality, 2011.
WHO. Trends in maternal mortality: 1990 to 2008, 2010.
UN. The Millennium Development Goals Report 2009, 2009; The Millennium Development Goals Report 2010, 2010; and The Millennium Development Goals Report 2011, 2011.
USAID. Working Toward the Goal of Reducing Maternal and Child Mortality: USAID Programming and Response to FY08 Appropriations (Report to Congress), July 2008.
USAID. Two Decades of Progress: USAID’s Child Survival and Maternal Health Program, June 2009.
USAID Reports to Congress, 1985, 1987, 1990.
GHI. The United States Government Global Health Initiative: Strategy Document, March 2011.
State Department. Remarks on the 15th Anniversary of the International Conference on Population and Development, January 2010: http://www.state.gov/secretary/rm/2010/01/135001.htm.
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. Data are from the most recent year available.
UNICEF. The State of the World’s Children 2012, February 2012.
Country classifications are based on UNICEF regional designations. For a list of countries in each region, see UNICEF, The State of the World’s Children 2011, February 2011.
WHO and UNICEF. Countdown to 2015 Decade Report; 2010.
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,” Lancet 375, no. 9730 (2010): 1969–87.
Calculated by KFF based on Black, et al., data. The remaining 13% is due to other causes.
CRS. Child Survival and Maternal Health: U.S. Agency for International Development Programs, FY2001-FY2008, July 2008.
Partnership for Maternal, Newborn & Child Health. Strategic Framework 2012-2015, November 2011.
USAID. Child Health [website]: www.usaid.gov/our_work/global_health/mch/ch/index.html.
White House. The G-8 Muskoka Summit: Saving Lives Through the New G-8 Maternal and Child Health Initiative, June 25, 2010.
USAID. "Saving 5 Million Children by 2015," infographic: http://50.usaid.gov/infographic-saving-5-million-children-by-2015/.
KFF analysis of data from the Office of Management and Budget (OMB), Agency Congressional Budget Justifications, Congressional Appropriations Bills, U.S. Foreign Assistance Dashboard [website]: www.foreignassistance.gov, and personal communications with OMB and USAID.
KFF personal communication with USAID, February 2011.
CDC. Global Reproductive Health [website]: www.cdc.gov/reproductivehealth/Global/index.htm.
NIH. "NIH Newborn Screening Research Program Named in Memory of Hunter Kelly," news release, October 19, 2009: http://www.nih.gov/news/health/oct2009/nichd-19.htm.
NIH. "Focus on NICHD International Health Activities," news release, October 6, 2006: http://www.nichd.nih.gov/news/resources/spotlight/100606_international_activities_p2.cfm.
Peace Corps. Health [website]: http://www.peacecorps.gov/learn/whatvol/health/.
International Conference on Population and Development (ICPD). Programme of Action, Cairo, 1994: http://www.un.org/ecosocdev/geninfo/populatin/icpd.htm#intro.
CDC also provides some funding for MNCH, which is not included here.