Less than 1000 days to go for MDGs 4 and 5: where are we and what needs to be done?

The Millennium Development Goals (MDGs) 4 and 5 called for reducing the mortality of under-5-year-olds by two-thirds between 1990 and 2015, and reducing maternal mortality by three-quarters over the same period. Substantial progress towards this has been made worldwide. The global maternal mortality ratio fell by 47% between 1990 and 2010 and the under-5 mortality rate also fell by 47% between 1990 and 2012 [1,2]. However, there has been insufficient progress and there is a risk that the global targets will not be met. Still every year 6.6 million children die before their 5th birthday, of whom 2.9 million are newborn babies in the first month of life. An estimated 287 000 women die due to the complications of pregnancy and childbirth, and the annual 2.6 million stillbirths are silent tragedies that have to be prevented. The leading causes of maternal mortality—obstetric haemorrhage, hypertensive disorders of pregnancy, sepsis and unsafe abortion—are to a large extent preventable in most highburden countries. Certain services are key to preventing maternal deaths, such as contraception, antenatal care, skilled attendance at birth and postnatal care. Likewise, many children still die from easily preventable diseases. Deaths in the newborn period are mostly due to prematurity, sepsis and intrapartum causes, while in the 1–59-month age group it is pneumonia and diarrhoea and high rates of malnutrition which underlie over 45% of all under-5 deaths. In addition, malaria and HIV and AIDS cause significant numbers of deaths in some countries. For those children who survive, malnutrition may jeopardize their potential for optimal growth and development, with significant consequences later in life. Proven effective interventions exist to further reduce maternal and child mortality [3], and the scaling up of these interventions is critical. However, coverage remains low for many of these interventions and is often not evenly distributed within countries. Recognizing that progress in maternal, newborn and child survival requires reaching all population subgroups with essential health services, health-equity dimensions such as wealth, sex, age, maternal education, ethnicity and urban/rural residence are critical factors to take into account. Analysis of data in the latest Countdown to 2015 report showed pronounced inequities in coverage for many essential interventions, with women and children from richer households much more likely to receive care than those from poorer households [4]. This pattern is particularly evident for interventions that require a fully functional health system, such as having a skilled attendant at the birth. Multiple global efforts are being made to support countries to accelerate progress and address the “unfinished business” of reducing maternal and child mortality. The United Nations Secretary-General’s Global Strategy for Women’s and Children’s Health, launched in 2010, is an unprecedented plan to save the lives of 16 million women and children by 2015. Under this umbrella, the Commission on Information and Accountability for Women’s and Children’s Health developed a framework to monitor and track commitments made to the Global Strategy, and an independent Expert Review Group (iERG) reports annually on progress towards implementation of the Commission’s recommendations in 75 high-burden countries regarding reporting, oversight and accountability. More recently, a number of initiatives have been launched with the aim of accelerating progress towards MDGs 4 and 5, and to end preventable maternal and child mortality in a generation. The Commitment to Child Survival: A Promise Renewed sets out targets for reduction of child mortality to 20 child deaths or less per 1000 live births by 2035. In support of this target, the Global Action Plan for the Prevention and Control of Pneumonia and Diarrhoea (GAPPD) provides directions for ending preventable child deaths due to pneumonia and diarrhoea through a combination of interventions, such as exclusive breastfeeding and good nutrition, hand-washing, safe drinking-water, improved cooking stoves, zinc supplements and oral rehydration solution, amoxicillin, vitamin A supplements and new vaccines. Likewise, a plan for reducing newborn deaths—Every Newborn: an Action to End Preventable Newborn deaths—is in preparation to address this increasingly important issue. Finally, the Family Planning 2020 (FP2020) initiative at the London Family Planning Summit in 2012 set an ambitious goal to provide an additional