5

Investing in Women’s and Children’s Health

Significant and long-lasting benefits accrue from investing in the health, quality of life, productivity, and economic growth of women and children. Despite these benefits, glaring gaps must still be filled to reduce the mortality rate, provide equitable access to quality health care among women and children, and improve outcomes for children who survive past the age of 5. Because healthy women and children are the linchpin for healthy and thriving societies (see Figure 5-1), investing in the health of women and children is indispensable to achieving the new Sustainable Development Goals (SDGs) agenda. In low- and middle-income countries (LMICs), providing more education for children, especially girls, can result in greater accumulation of human capital, increased productivity, and increased income and economic development (UNICEF, 2015). In an analysis of multiple countries, a clear correlation was noted between average years of education and poverty rates: For each additional year of education among young adults ages 25–34, national poverty rates were 9 percent lower (UNICEF, 2015). Similarly, a study in Botswana found that each additional year of secondary schooling reduced cumulative human immunodeficiency virus (HIV) infection risk by 8.1 percent (De Neve et al., 2015). Based on such evidence for the connection between education and health, the Global Fund to Fight AIDS, Tuberculosis and Malaria and other HIV and acquired immunodeficiency syndrome (AIDS) organizations have even shown an interest in developing incentives to keep girls in school. The U.S. President’s Emergency Plan for AIDS Relief’s (PEPFAR’s) Determined, Resilient, Empowered, AIDS-free, Mentored, and Safe women (DREAMS) program,

explored in Chapter 4, highlights education key to reducing HIV infections in adolescent girls and young women.

In addition to the education benefits for young adults, children born to more educated mothers are better off financially and are more likely to receive vaccines and rehydration, sleep under insecticide-treated bed nets, and have other good health interventions available to them. Countries where women hold more than 30 percent of seats in political bodies are shown to be more inclusive, equitable, and democratic (USAID, 2015). The benefits of investment in women and children will extend beyond health and translate into increased economic prosperity, strengthened societal bonds, and improved community resilience. These benefits make it a wise investment opportunity for the United States.

This chapter begins by discussing the shift of the global development agenda related to women and children, from the unfinished Millennium Development Goals (MDGs) to the multidisciplinary SDGs, and the current state of their health with a focus on mortality rates. Next, it reviews the current efforts in this area, including those of the U.S. Agency for International Development (USAID), World Health Organization (WHO), and Global Financing Facility (GFF). The chapter then goes through the key themes of the WHO strategy, with a focus on “Survive, Thrive, and Transform,” and highlights where gaps still remain in addressing health issues for women and children, and what can be done to accomplish the related targets of the SDGs over the next 15 years.

GLOBAL DEVELOPMENT AGENDA SHIFT: WOMEN AND CHILDREN

The MDGs adopted by world leaders in 2000 set forth the first global goals for women’s and children’s health, calling for a two-thirds reduction in the mortality rate for children under age 5, a three-quarter reduction in the maternal mortality ratio, and universal access to reproductive health by 2015 (UN, 2015c,d). Much progress has been made on all three fronts. Global mortality rates for children under 5 years were cut by more than half, dropping from 87 to 41 deaths per 1,000 live births between 1990 and 2015 (UN, 2015c). Global rates of maternal mortality were also reduced by nearly 50 percent between 1990 and 2015, from 385 to 216 deaths per 100,000 live births, with most of the reduction happening since 2000 (Kassebaum et al., 2016). Part of this reduction can be attributed to the rise in skilled birth attendants: In 2014, skilled personnel assisted in 71 percent of births globally, which is an increase from 59 percent in 1990 (UN, 2015d).

In spite of this progress, none of the maternal and child health-related goals were met by the time the MDGs expired in 2015, and now the objec-

tives remain a critical unfinished agenda (UN, 2015c,d). The approach to global development has since evolved, shifting in focus to the more cross-sector SDGs. As discussed in Chapter 2, the SDGs were designed to cut across sectors to advance progress more quickly and achieve new global targets by 2030 by attacking issues comprehensively (UN, 2015a). SDG 3—ensure healthy lives and promote well-being for all at all ages—has three targets pertaining directly to women’s and children’s health:

1. Reduce the global maternal mortality ratio from the current rate, which is 216 maternal deaths for every 100,000 live births (UN, 2015a), to <70 maternal deaths per 100,000 live births.
2. End preventable deaths of newborns and children under 5 years of age in all countries (neonatal mortality: maximum 12/1,000 live births; under-5 mortality: maximum 25/1,000 live births) (UN, 2015a).
3. Ensure universal access to sexual and reproductive health care services, including family planning, information, and education, and the integration of reproductive health into national strategies and programs.

CURRENT STATE OF WOMEN’S AND CHILDREN’S HEALTH

Despite the tremendous strides made in reducing the deaths of women and children, 5.9 million children still die each year before their fifth birthday (WHO, 2016a), with 4.5 million of these dying in their first year of life (WHO, n.d.-a). The vast majority of these deaths are preventable as they are caused by preterm birth complications, pneumonia, and intrapartumrelated events (e.g., birth asphyxia) (Liu et al., 2016). Infants and young children who live in LMICs experience a greater risk of death than their peers in wealthier countries and children living in poverty experience a greater risk of poor development. At least 250 million children (43 percent) under 5 years of age in LMICs suffer from suboptimal development, which has substantial short- and long-term negative consequences. These consequences include poorer health in childhood and later in life, lower educational attainment, poorer school performance, less social integration, and lower earning power (estimates suggest that 25 percent of average adult income is lost per year) (Black et al., 2017). These consequences contribute to the perpetuation of poverty and can result in a country’s forfeiting up to twice its current gross domestic product (GDP) expenditure on health (Richter et al., 2017). In addition, more than 50 percent of the almost 60 million displaced people, or refugees, documented in 2014 were children—many under 5 years old (Edwards, 2016). The violent and austere environments in which these children live have grave effects on their developmental

trajectories and stress response systems, which in turn influence their physical, social, and emotional health.

Almost all (99 percent) of the 303,000 women who die annually from causes related to pregnancy and childbirth die in LMICs (WHO, 2016d). Most of these deaths are preventable with access to appropriate health care, a skilled birth attendant, and the availability of emergency obstetric care (USAID, 2016). The maternal mortality rate in LMICs is 14 times higher than in high-income countries, in part because only half the women in LMICs receive adequate health care (GFF, 2016). However, high maternal mortality is not a problem isolated to LMICs or countries receiving financial assistance. The rate of maternal deaths in the United States jumped from 17.5 per 100,000 live births in 2000 to 26.4 per 100,000 live births in 2015 (Kassebaum et al., 2016). Texas recorded an even higher jump, from 18 maternal deaths per 100,000 live births in 2000 to more than 30 deaths per 100,000 live births in 2014 (MacDorman et al., 2016). These maternal mortality rates put the United States squarely in line with middle-income countries such as Chile, Mexico, and Turkey—clearly highlighting pregnancy- and childbirth-related maternal deaths as an area that would benefit from shared investment with other countries to achieve common solutions for improvement.

CURRENT EFFORTS TO PROMOTE WOMEN’S AND CHILDREN’S HEALTH

The concept of investing in the well-being of women and children is not new, and many organizations have already begun tailoring their programs to specifically address the health needs of women and children based on the evidence and successes of others. Below is a brief review of the women’s and children’s health activities of a few key organizations engaged in global efforts to promote women’s and children’s health.

U.S. Agency for International Development

In 2014, USAID’s report Acting on the Call: Ending Preventable Maternal and Child Deaths operationalized the U.S. government strategy on maternal and child health (USAID, 2016). The aim of USAID’s Ending Preventable Maternal and Child Deaths (EPMCD) program is to save the lives of 15 million children and 600,000 mothers by 2020 in 24 priority countries (USAID, 2016). To reach this goal, USAID’s investments focus on the provision of routine immunizations; equity of care for childhood illnesses such as malaria, pneumonia, and diarrhea; family planning; maternal and newborn health; nutrition; and water, sanitation, and hygiene. Scaling up coverage of 11 of these innovations was projected to prevent up to

6 million maternal and child deaths (PATH, 2016). In 2016, total funding for the EPMCD program was $2.4 billion (USAID, 2016). Between 2012 and 2015, the average annual rate of reduction of under-5 deaths was 3.6 percent, which is short of the 4.1 percent required to meet the original MDG target. Furthermore, as of 2016, only 19 countries were on track to achieve the SDG’s under-5 mortality target by 2030 (USAID, 2016). Given these findings, the committee sees an opportunity for USAID to accelerate implementation of the EPMCD program to achieve unfinished maternal and child health MDG targets by 2020 and under-5 targets by 2030. Strategies should focus on ensuring the highest impact through scaling innovative approaches, with rigorous monitoring and evaluation, with a focus on immunization; integrated management of child illness, nutrition, and prenatal care; and increasing access to contraceptives, including family planning.

World Health Organization

A new global agenda, WHO’s Global Strategy for Women’s, Children’s, and Adolescents’ Health (2016–2030), aims to support countries in finishing the unfinished MDG targets (WHO, 2016b). WHO’s Global Strategy adopts a life-course perspective guided by a cross-cutting three-part framework: survive, thrive, and transform.¹ Several of the Global Strategy goals overlap with the SDGs’ health-related targets (WHO, 2016b). In the survive domain, for example, targeted reductions in global rates of maternal, newborn, and under-5 mortality are aligned with SDG Goal 3. The thrive domain calls for ending all forms of malnutrition and addressing the nutritional needs of children, adolescent girls, and pregnant and lactating women (which is aligned with SDG Goal 2); ensuring universal access to sexual and reproductive health care services; substantially reducing pollution-related deaths and illnesses; and achieving universal health coverage. In the transform domain, the target of achieving universal and equitable access to safe drinking water, sanitation, and hygiene is aligned with SDG Goal 6.

Global Financing Facility

Achieving the SDG targets will require closing the $33.3 billion funding gap for reproductive, maternal, newborn, child, and adolescent health in high-burden LMICs (GFF, 2016). The GFF, the financing arm of Every

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¹ The framework spans health-related domains as well as other areas such as promoting education for women, establishing legal identities, and eliminating gender-based discrimination and violence.

Woman Every Child,² was launched in 2015 and it seeks to address this funding gap in 63 target countries by supporting country-led efforts to build equitable and resilient health systems and promote long-term sustainable financing (Claeson, 2017). Furthermore, GFF establishes high-impact, evidence-based interventions unique to each country that have measurable results (Claeson, 2017). To help countries implement these interventions, GFF serves as an innovative financing pathfinder, shifting the focus from traditional development assistance toward four strategies: improving efficiency, increasing domestic resource mobilization, increasing and better aligning external financing, and leveraging private-sector resources (Claeson, 2017). Establishing GFF platforms in all high-burden countries by 2030 has the potential to prevent up to 3.8 million maternal deaths, 101 million child deaths, and 21 million stillbirths (GFF, 2016). This program has been met with optimism and excitement for the progress it can induce, but because it is so new, it is too difficult to assess yet, though the committee also remains hopeful for its success.

Opportunities for Investment and Intervention

Although gaps still exist in spite of widespread investments by various stakeholders, simple interventions without a large increase in cost can be implemented to address mother and child health issues. A strong evidence base supports the choice of interventions for the prevention of maternal and child deaths, with the current challenge found in the implementation and scaling up of these interventions. The programs described above largely continue to exclude adolescent girls, except when they are pregnant. A more effective strategy would be to focus on the life course, encouraging nutrition and health promotion for infants, children, adolescent girls, and women throughout adulthood, whether or not they are pregnant. In the sections below, the committee reviews the three key elements of WHO’s Global Strategy’s framework—survive, thrive, and transform—and offers potential investment and intervention strategies.

SURVIVE: CONTINUING TO DECREASE MORTALITY RATES

To continue the forward progress of the MDGs and address the weaknesses that prevent the elimination of preventable maternal and child

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² Every Woman Every Child is a global movement that puts into action WHO’s Global Strategy for Women’s, Children’s, and Adolescent’s Health. Launched by the UN Secretary-General in 2010, Every Woman Every Child aims to mobilize national governments, international organizations, the private sector, and civil society to solve the health issues that women, children, and adolescents face around the world (Every Woman Every Child, 2016).

deaths, it is important to understand the remaining barriers in the current burden of disease in children and women. During the past 15 years, the most important successes in reducing child and maternal mortality have been through immunizations; improved sanitation; and social changes, such as improved access to voluntary family planning methods, that allow women to thrive and take charge of their own decision making (Bustreo and Mpanju-Shumusho, 2016).

Mortality Among Children Under 5 Years of Age

Immunizations alone are estimated to save 2 to 3 million lives per year (Bustreo and Mpanju-Shumusho, 2016). These advancements have, to a degree, shifted some of the causes of under-5 deaths globally since 1990, so that death rates caused by diseases such as measles have dropped by 65.5 percent (Wang et al., 2016). However, many of the causes of under-5 mortality remain the same. Preterm birth, neonatal encephalopathy, and lower respiratory infections remain in the top five causes of death in children globally, with preterm birth being the leading cause in 2015³ (Wang et al., 2016). Additionally, environmental hazards such as air pollution, unsafe water, poor sanitation, and secondhand smoke are now found to be responsible for 26 percent of the nearly 6 million deaths each year of children under 5 years of age (WHO, 2017b). Undernutrition is linked to nearly half of all under-5 deaths (Black et al., 2017). Many of these deaths occur in regions nearly untouched by the lifesaving interventions and societal changes that have allowed such robust progress in other parts of the world. Children in rural areas are still 1.7 times more likely to die before their fifth birthday than children in urban areas, and children of mothers with no education are three times more likely to die than children with mothers who have a secondary or higher education (UN, 2015c).

Examining preterm birth as one of the top causes of death and disability in children highlights a need for an improvement in health care services for babies and their mothers, especially in LMICs, and also explains the important interplay between women’s health and children’s health. Preventing preterm birth requires both antenatal and postnatal care systems. Preterm birth complications can be prevented and addressed with cost-effective strategies provided by adequately trained midwives; these strategies can reduce prematurity by 24 percent (WHO, 2016e). Additionally, the healthy

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³ The top 20 causes of death for children under-5 are preterm birth, neonatal encephalopathy, lower respiratory infections, diarrheal diseases, congenital anomalies, malaria, neonatal sepsis, other neonatal disorders, protein-energy malnutrition, meningitis, sexually transmitted diseases, HIV/AIDS, hemoglobinopathies, measles, drowning, whooping cough, road injuries, neonatal hemolytic disease, encephalitis, and intestinal infections.

spacing of children plays an important role in the reduction of neonatal and under-5 deaths. Among the urban poor in LMICs, children born within 18 months of an older sibling are two times as likely to die, and children born between 18 and 23 months after an older sibling are 18 percent more likely to die as compared to children born 36 months after an older sibling (Fotso et al., 2013). Ensuring that mothers have access to modern contraceptives and birth spacing information will help to alleviate the burden of infant and under-5 deaths and increase the chance of childhood survival because the child does not have to compete for scarce resources, and also may reduce the likelihood of maternal depletion⁴ (Fotso et al., 2013).

Maternal Mortality and Morbidity

Although unsafe abortion and hemorrhage remain among the most frequent causes of maternal mortality in low-income countries (Say et al., 2014), the underlying causes of maternal mortality worldwide have become more complex. Almost one-third of global maternal deaths now result from causes not directly related to pregnancy, including HIV/AIDS, malaria, cardiovascular disease, diabetes, and obesity. In the modern context of this disease burden, midwives and other deliverers of health care services face the additional task of addressing the health needs of pregnant women with chronic illnesses. In addition to causing greater risks for mothers, noncommunicable diseases (NCDs) or unhealthy lifestyles cause significant risks for the newborn. Mothers who smoke, for example, are likely to breastfeed for shorter periods of time, have less milk, and produce milk that is less nutritious; additionally, their secondhand tobacco smoke increases the risk of respiratory infections, sudden infant death syndrome, and asthma in their children (WHO, 2010). The goal of allowing more children to survive is contingent on having adequate health care systems for mothers that can provide care and support for routine pregnancies as well as high-risk ones.

Although the world has not yet reached the MDG 5—A goal of reducing maternal mortality by 75 percent (achieving fewer than 70 deaths per 100,000 live births), the gains that have been made allowed for women to have greater access to trained health care workers during pregnancy. As the world transitions to the SDGs, the improvement in access can provide an entry point for an integration of primary care services for reproductive-aged women. Just as many women in the United States ask their obstetricians questions relating to primary care, women in LMICs can likewise benefit from receiving primary care services during antenatal visits. This integra-

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⁴ Maternal depletion syndrome (MDS) is defined as poor maternal health and infant health in LMICs encompassing successive pregnancies, suggesting that short interbirth intervals create poor maternal health and pregnancy outcomes (Winkvist et al., 1992).

tion will be particularly important as the burden of disease in women shifts to NCDs, because women who are sick are more likely to give birth to babies who are sick: For example, babies born from diabetic mothers are more likely to develop respiratory problems than babies born from non-diabetic mothers (Lee, 2017). An integrated health care system that lowers the incidence of NCDs in reproductive-aged women will improve women’s health overall and will allow women to give birth to healthier babies.

In addition to the management of physical health, ensuring the availability of mental health services is of utmost importance to ensure the health and safety of women and their babies; integrating these services in the primary care setting will increase the likelihood that women will take advantage of and benefit from them. It is known that prenatal depression in women is a major risk factor for postnatal depression, which has significant negative effects on the functioning of the mother and health of her baby. Prenatal and postnatal depression in mothers is linked to a higher risk of preterm birth, low birth weight, infant undernutrition, and increased disease incidence in their children (Shidhaye and Giri, 2014). Living in resource-poor areas and receiving poor family support exacerbates these risks (Shidhaye and Giri, 2014). Offering mental health services to women as they receive antenatal visits will help women avoid incurring extra costs to reach a specialized facility (Honikman et al., 2012). One study in South Africa revealed that among 5,407 women who received a mental health screening in a primary care setting during an antenatal visit, 32 percent were referred to an on-site counselor, and 62 percent of those who were referred agreed to receive services (Honikman et al., 2012). In a followup, 87.8 percent of women who received counseling services reported an improvement in their presenting problem, and 97.1 percent reported the experience as positive (Honikman et al., 2012). Treatment for maternal depression is feasible and provides significant benefits to the entire family. Offering these services at the primary-care level will decrease the barriers to receiving care and can promote healthier pregnancies in women.

Targeting Interventions to Maximize Survival

Although the scope of challenges across the entire sector of women’s and children’s health is extremely broad, many evidence-based practices and interventions can have a high level of impact in a cost-effective manner. The committee has selected five key areas (described in the sections below) in which it suggests investment and attention in order to maximize rates of survival for pregnant women and children: immunizations; integrated management of childhood illness; nutrition for pregnant women, newborns, infants, and children; keeping pregnant women safe; and access to contraceptives.

Immunizations

Immunizations are recognized as a “best buy” for global health, estimated to save 2 to 3 million lives each year. In one case—smallpox—vaccination led to disease eradication. Increased coverage of the measles vaccination alone is estimated to have saved 14 million lives since 2000 (Bustreo and Mpanju-Shumusho, 2016). However, infections leading to pneumonia and diarrhea—that could be prevented through immunization—are still some of the top contributors to mortality for children under 5. WHO estimates there are 1.5 million vaccine-preventable child deaths every year, 75 percent of which result from pneumococcus, Haemophilus influenzae serotype b (Hib), and rotavirus diarrhea (Gavi, 2015).

Global coverage for pneumococcal vaccine has reached only 35 percent of children under 5, and even that number is sometimes reduced because of supply issues (Gavi, 2015). Rotavirus coverage numbers are slightly lower with just 23 percent coverage (WHO, 2016c), also due to supply concerns and ill-equipped immunization systems in some countries. Although global coverage of three doses of Hib vaccine is estimated to be 64 percent, there is great variability across regions. In the Americas this number is as high as 90 percent, yet the Western Pacific only has 25 percent coverage (WHO, 2016c). To reach child mortality targets, it will be critical to scale up coverage for these three vaccines. Since its establishment in 2000, Gavi, the Vaccine Alliance (Gavi), has employed innovative mechanisms (discussed further in Chapter 8) to increase vaccination coverage and subsidize the costs of new vaccines that lack a commercial market. Additionally, it has established groups focused on pneumococcus, Hib, and rotavirus—the top three most frequent causes of pneumonia and diarrhea (Greenwood, 2014). As a result of these groups partnering with country governments, ministries of health and finance, and nongovernmental organizations (NGOs), there has been rapid introduction of the Hib and pneumococcal vaccines (Greenwood, 2014). As barriers to vaccination are better understood, strategies will be needed to address the inequities that contribute to disparities in access for vulnerable populations.

Integrated Management of Childhood Illness

Historically, treatment of the top causes of death among children (e.g., neonatal causes, diarrhea, pneumonia, AIDS, and malaria) occurred within vertical programs. In the 1990s, there was a push for integrated management of the sick child. Integrated Management of Childhood Illness (IMCI) was developed in 1995 by WHO and the United Nations Children’s Fund to promote health and provide preventive and curative services for children under 5 in countries with high child mortality rates (WHO, 2016f). The

approach focused on three key components of improving case management skills of health care staff, overall health systems, and family and community health practices. IMCI was expected to increase the probability that children would receive treatment for all major diseases and decrease the possibility that children would receive correct treatment for one disease and die from another unrecognized illness (Victora et al., 2006). In this integrated system, children are screened for risk factors, signs, and symptoms of the key diseases listed previously and treated based on needs. For proper management, children should be assessed for malnutrition, anemia, and vaccination status. Parents and caregivers of low-weight children receive nutrition counseling. Varying levels of classification are assigned based on needs, and children are discharged as those classifications designate. Evaluations of this approach have shown some reductions in child mortality and improved quality of care, but IMCI needs to be complemented with efforts to redesign and strengthen the health system, and significant reductions in mortality will not be realized until widespread intervention coverage is achieved (WHO, 2016f). Additionally, childhood mortality reductions were found to be limited when a country’s approach lacked an emphasis on equity, community engagement, and linkages across sectors (e.g., water and sanitation or education).

Nutrition for Pregnant Women, Newborns, Infants, and Children

Children who survive undernutrition have diminished wellness and productivity trajectories, contributing up to a 12 percent reduction in a country’s GDP (Soe-Lin et al., 2016). Because a child’s nutrition starts in utero, maternal undernutrition has significant consequences for that child’s future growth, health, and development (Black et al., 2013). The threat of stunting as a result of undernutrition is most serious in the 1,000 days from conception until the age of 2; this window is vital because the negative effects of undernutrition on the brain and on future development cannot be remediated (USAID, 2014). Consequently, the committee has identified nutritional interventions as possessing great potential not only for continuing to decrease the mortality rates of infants and young children, but for improving their developmental trajectories. Among many successful programs is USAID’s Multi-Sectoral Nutrition Strategy, which targets its nutritional interventions to pregnant women and their children during the first 1,000 days (USAID, 2014). Through their interventions at several levels, the committee encourages the continuation of these cross-cutting efforts.

Ensuring babies are born at adequate birth weight starts with the mother’s nutrition, even before she gets pregnant. Making certain that pregnant women have access to adequate food will ensure that the baby has nutrients to grow and develop in utero (USAID, 2014). The Multi-

Sectoral Nutrition Strategy addresses women’s nutritional needs by increasing women’s access to high-quality nutrition services to ensure they gain adequate weight during pregnancy, avoid anemia, and, for women with HIV, safely breastfeed after the baby is born (USAID, 2014).

One of the most widely supported interventions for nutrition after the baby is born is exclusive breastfeeding, including the provision of colostrum in the first few hours and days of a baby’s life (Black et al., 2008; WHO, 2017a). In the 2016 Lancet series Breastfeeding, researchers found that the deaths of 823,000 children and 20,000 mothers each year could be averted through universal breastfeeding (Victora et al., 2016). Breastfeeding is essential to child survival in part because of its unique biological contribution to the child’s immune response (Victora et al., 2016). Similar to the added benefits of sufficient nutrition for young children, breastfeeding can contribute to long-term positive effects such as reduction of the risk of diabetes and obesity later in life, as well as higher cognitive performance. A study in Brazil that followed participants for 30 years found a positive association with breastfeeding and adult earnings—roughly 20 percent of the average income level (Victora et al., 2015). The majority of this effect (72 percent) was explained by the direct benefits of breastfeeding on intelligence. The benefits of breastfeeding also extend to the mothers, and include a reduction in incidence of breast cancer, improvement in birth spacing, and possible reductions in women’s risk of diabetes and ovarian cancer (Victora et al., 2016).

In addition to breastfeeding, micronutrient supplementation is a key intervention to improve maternal, infant, and child health. Ensuring mothers and children receive adequate nutrients will help them stay healthy, which has lasting effects on development. Iron and folate deficiencies, for example, which are two of the most common causes of anemia during pregnancy, can lead to pregnancy complications as well as poor development consequences for the baby (Darnton-Hill and Mkparu, 2015). Children need diversity as well as adequate amounts of nutrient-rich foods after the breastfeeding stage (USAID, 2014). Vitamin A, for example, is extremely important for the eyesight of mothers and children, as well as the immune system development of young children (WHO, n.d.-b). However, it is estimated that 250 million preschool children will be vitamin A deficient, leading to about 250,000 to 500,000 children losing their eyesight every year (WHO, n.d.-b). Supplementation with vitamin A keeps children healthy and is known to significantly reduce mortality for children under 5 years (USAID, 2014), and it keeps women healthy in the final trimester, when the demand for vitamin A is highest for the mother and unborn child (WHO, n.d.-b). USAID’s Multi-Sectoral Nutrition Strategy seeks to improve intake of micronutrients, including vitamin A, by increasing the availability and quality of nutrient-rich foods for women, who in many contexts receive less food than other members of the family (USAID, 2014).

Nutrition interventions delivered via community health workers can be a key resource for reducing nutrition-related maternal, infant, and child mortality. For example, community health workers in rural Uganda decreased nutrition-related morbidity and mortality simply by offering health information to families with children under 5 years and encouraging families to attend health outreach activities (USAID, 2014). The community health worker, then, has the opportunity to build trust with mothers during pregnancy and immediately after birth to ensure a mother is empowered to make proper nutritional decisions for herself and her child, and can then follow the mother as the child grows and develops.

Keeping Pregnant Women Safe: Prenatal Care, Safe Delivery, and Access to Emergency Obstetrical Care

Although the number of women who die each year from pregnancy and childbirth complications has fallen by nearly half in the past 20 years, 303,000 women still die every year from these causes (WHO, 2016d). Almost all these deaths could be prevented if these women had access to skilled care, good hygiene, and available drugs to manage conditions (such as preeclampsia) caused by high-risk pregnancies (Bustreo and Mpanju-Shumusho, 2016). Various interventions during the prenatal period are relatively simple, such as the provision of supplements like iron and folic acid; exercising safely during pregnancy; and, more recently, a booster vaccine to protect against pertussis⁵ to give protective benefits to the unborn child. With so many comorbidities contributing to more complex pregnancies, expanding the scope of training and skills for midwives and skilled birth attendants to include knowledge about hypertension, healthy nutrition, and other lifestyle factors can enhance the delivery of simple, life-saving interventions to women at risk of complex pregnancy and delivery.

Worldwide, at least 15 percent of pregnancies result in complications that require emergency obstetric care, including surgical management, and an estimated 951 million women are without access to this type of care (Meara et al., 2015). In 2010, the collective disability for all measured maternal disorders reached 16 million disability-adjusted life years, of which 3.3 million were attributed to maternal hemorrhage, 1.8 million to complications of obstructed labor, and 1.3 million to maternal sepsis (Murray et al., 2012). These numbers indicate the tremendous morbidity associated with surgically preventable obstetric complications that can be targeted worldwide.

Two interventions will have a major impact in reducing the toll of maternal death and disability: the presence of a trained attendant at every

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⁵ This vaccine (Tdap) provides protection against tetanus, diphtheria, and pertussis (CDC, 2016).

birth and access to urgent obstetric care at every birth. Increasing the number of women giving birth in a facility or with a skilled attendant has been challenging, but rates are on the rise. One study in Tanzania showed that using simplified ultrasound scanning at the lowest levels of care led to mothers’ increased attendance for future antenatal care and increased chances of a facility delivery (Mbuyita et al., 2015). This finding was reinforced with the finding that paraprofessionals with minimal training can perform sonographic procedures on rural pregnant women in Tanzania with consequent beneficial effects (Bellagio Study Group on Child Survival, 2003). A report from the Lancet Commission on Global Surgery determined that all people should have timely access to emergency surgical services, which includes the ability to “access, within 2 [hours], a facility that can do caesarean delivery. . . . 2 [hours] is a threshold of death from complications of childbirth” (Meara et al., 2015, p. 608). Several studies have shown that with the exception of very few countries, devoting appropriate financial resources to cesarean delivery, for example, could combat the catastrophic health consequences to mothers in an economically favorable fashion (Meara et al., 2015).

A combined set of relatively simple interventions integrated with appropriate task shifting and work force training within a functioning health system may have a tremendous effect on the overall well-being of any LMIC. Interventions should be aimed at streamlining care so that women in need of an emergent cesarean delivery are aware of facilities available, are properly diagnosed, can be transported to a referral hospital within a reasonable amount of time, and undergo safe cesarean delivery in a capable facility.

Access to Contraceptives

Access to modern contraceptives is a critical foundation for maternal and child health, according to the Lancet series Maternal Health (Ceschia and Horton, 2016). Preventing unwanted pregnancy, family planning, and delaying of pregnancy through healthy birth spacing are critical actions to reduce both maternal and infant death, as well as provide other health benefits to women (Ahmed et al., 2012). An analysis of 172 countries showed that family planning prevents approximately 272,000 maternal deaths worldwide each year (Ahmed et al., 2012). Countries with the highest maternal mortality burden also have low contraceptive prevalence rates. In many of these countries, the unmet need for contraception is even higher than the prevalence of contraceptive use (Ahmed et al., 2012). The London Summit on Family Planning (the FP2020 initiative) in 2012 committed countries to providing access to contraceptives to an additional 120 million women by 2020, requiring 15 million to gain access each year (Ceschia and

Horton, 2016). As of October 2016, 8 million additional women are accessing modern contraceptive methods each year. Though they are off track for achieving the goal, the FP2020 initiative has increased contraceptive users by 30.2 million since 2012, putting the total at 300 million in the world’s 69 poorest countries, a huge milestone. As a result of this increase in contraceptive use, between July 2015 and July 2016, the FP2020 initiative estimated that globally, 82 million unintended pregnancies were prevented, 25 million unsafe abortions were averted, and 124,000 maternal deaths were averted (FP2020, 2016).

At a more granular level, when contraceptive prevalence in Kazakhstan increased by 50 percent between 1990 and 2000, abortion rates decreased by 50 percent in the same time frame (Westoff, 2000). More recently, a study in Ghana found that lack of access to contraceptives likely caused the observed 12 percent increase in rural pregnancies, leading to 200,000 additional abortions and more than 500,000 additional unwanted births (Jones, 2011). The researchers also found the unwanted children were less likely to have proper nutrition and development (Jones, 2011). Moving forward, the challenge will be examining country-level inequities and issues and understanding why some countries have been quick to implement this commitment to contraception access, while others lag behind.

The United States has long supported international family planning and population issues, and it is the largest donor to global family planning and reproductive health efforts. The Senate Appropriations Committee, with bipartisan support, recently approved its version of a fiscal year (FY) 2017 U.S. Department of State foreign operations appropriations bill that funds the operations of the U.S. government’s foreign assistance program, including international family planning and reproductive health (PAI, 2016). This continued support will be critical to achieve the maternal and child health-related SDG targets.

SUMMARY AND RECOMMENDATION

Despite the tremendous strides made in reducing mortality among women and children, nearly 6 million children still die annually before their fifth birthday, and an estimated 303,000 women die each year from preventable pregnancy- and childbirth-related causes (WHO 2016a,d). Maternal mortality stands at 216 per 100,000 births, while child deaths are at 41 per 1,000 live births (Kassebaum et al., 2016; UN, 2015c). Investing in women and children yields proven short- and long-term benefits for a country’s economy. USAID has increased its investments in reducing maternal, newborn, and child deaths and recently launched the Ending Preventable Maternal and Child Death initiative, but gaps still exist with respect to subnational inequity in access to care. Many of the causes of death that still

plague both women and children are preventable; for example, undernutrition is linked to nearly half of all deaths of children under 5 (Black et al., 2017). Extremely strong evidence supports the most effective interventions for preventing maternal and child deaths, yet the remaining challenge is to implement and scale up these interventions in locations that have the highest level of need.

Recommendation 7: Improve Survival in Women and Children

THRIVE: MEETING DEVELOPMENT POTENTIAL AND BUILDING COUNTRY FUTURES

In LMICs, 250 million children (43 percent of the population) younger than 5 years do not reach their developmental potential because of extreme poverty and stunting (Black et al., 2017). Saving lives is critical, but simply keeping children from dying around the world is not enough. As child mortality declines, the focus correctly shifts to thriving, or maximizing the cognitive, language, and emotional development of children. In addition to developmental interventions, efforts must also include nurturing care, that is, the supportive environment in which a child grows and develops.

Nurturing care is a core principle underlying the support for children to thrive (Britto et al., 2017). This concept is realized by having a stable home environment that is sensitive to children’s health and nutritional needs, responsive, emotionally supportive, and developmentally stimulating and appropriate, with opportunities for play and exploration and protection from adversities (Britto et al., 2017). Such early child development practices translate into significant lifelong benefits in terms of labor market participation and earnings (Richter et al., 2017). Early and continued investments in children can help them grow and develop into healthy and productive adults, ultimately contributing to economic growth.

Links Between Adverse Childhood Experiences and Diminished Adult Outcomes

Children who live in poverty in LMICs and are exposed to negative stressors such as violence or abuse are subject to many repercussions into adulthood (Currie and Vogl, 2013). Research continues to emerge on the strong links between adverse childhood experiences and physical, emotional, and social outcomes in adulthood. When children are exposed to violence or abuse at a young age, their brains are physically altered by the stress, and their executive functioning is adversely affected (Hertzman and Boyce, 2010). Children with greater exposure to violence may grow up to become perpetrators of violence or revictimized in adulthood (Moylan et al., 2010; Widom et al., 2008). The documented associations between low socioeconomic status in early childhood and brain development (Noble et al., 2015) may explain the well-established associations between poverty and low cognitive, academic, and behavioral performance (Hair et al., 2015). These long-term effects of early life experiences make it critically important for service providers and stakeholders to change their thinking to accurately target interventions and services to prevent and mitigate those problems.

Scientific evidence supports the notion that the period from conception to age 3 years is a crucial time for interventions (Black et al., 2017). The early years in a child’s life are critical for investments for physical growth and cognitive and socioemotional development. For example, the association of linear growth and cognitive development is stronger for children under 2 than for older children, although the association appears to persist beyond the first 2 years of a child’s life (Sudfeld et al., 2015). Gearing assistance and evidence-based interventions for young children toward their physical, cognitive, and social-emotional development offers clear long-term returns on investment.

Fostering Positive Environments for Children and Families

The social, economic, political, climatic, and cultural context can provide broad support and guidance for the implementation of family-friendly systems that enable nurturing care to support children best (Britto et al., 2017). Positive and healthy environments for children and families should be prioritized. For example, social protection programs are designed to reduce poverty and provide opportunities to improve child development (Britto et al., 2017). Supportive environments are then likely to extend past the individual and immediate family and often create a ripple effect throughout the community. Previous attempts to create packages of effective interventions have focused either on grouping interventions because they should happen at the same time (e.g., packaging interventions that co-occur during the same age period of the child) or packaging interventions that are delivered through the same system (e.g., maternal health). The recent Lancet series Early Child Development proposed a set of packages that consider these factors while also incorporating nurturing care and protection and tailoring the packages to unique sets of risks and adversities that characterize complex environments (Britto et al., 2017). The packages proposed in the review are

• family support and strengthening (i.e., increasing access to quality care, building skills, and providing social-sector support);
• “caring for the caregiver” (i.e., caring for and protecting the parent’s physical and mental health with a life-cycle approach); and
• early learning and protection package (i.e., supporting parents, teachers, and caregivers in learning programs) (Britto et al., 2017).

Promoting positive environments for children and families often does not require new services or programs, but instead demands the integration of existing programs, structures, and systems of service delivery under a more holistic lens. This integration should be considered across health care and social services, nurturing care and parenting support, violence prevention and mitigation, poverty assistance, and early childhood education.

Health Care and Social Services

Maternal and newborn health programs should be designed and conducted as an integrated whole, rather than separate programs for two types of patients, as is currently the case in many places. The Lancet series Maternal Mortality recently found that linking health care for a mother and her baby not only promotes greater efficiency and lowers costs, but also maximizes the effect on their health and survival (Lassi et al., 2013). Hav-

ing a mother visit one clinic for her own maternal care and another clinic at a different time, and often in a separate location, for her newborn’s care is duplicative and inefficient. Such an arrangement creates an added burden and may make women more likely to miss appointments. For example, until recently, HIV/AIDS services and maternal and newborn health services were not available at the same service delivery points, making it difficult for women and their newborns to receive both types of necessary care (SMGL, 2014). Many opportunities for this type of packaging and collaboration can take place without new infrastructure or funding of new programs. However, success will require both teamwork among global health actors and alignment of efforts to achieve specific, country-appropriate goals. With a recent study finding depression as the largest contributor to disability globally for the 20- to 24-year-old age group (Vos et al., 2016), this imperative is clear to ensure all medical appointments are attended and that with each interaction, a trained provider is available to check on the mother’s well-being and mental health to ensure her safety and the safety of the baby.

Nurturing Care and Parenting Support

In addition to providing simple health-related services like immunizations and nutrition—both critical to encouraging a healthy life for a child—the health care delivery system is also an opportunity to integrate nonhealth services such as nurturing care and parenting support. Support for caregivers’ nutrition and mental and physical health provides secondary benefits in children’s growth and development and enhances caregiver receptiveness to parenting programs. Rahman and colleagues (2013) found the relationship between maternal mood and infant health and development is not unidirectional (Rahman et al., 2013). Interventions engaging mothers on how to improve infant development had positive impacts on maternal mood, and other interventions designed to improve maternal mood had positive effects on the infant’s development (Rahman et al., 2013). Studies from across the globe, including Jamaica (Gertler et al., 2014; Grantham-McGregor et al., 1997; Walker et al., 2005), Pakistan (Yousafzai et al., 2014), and Turkey (Kagitcibasi et al., 2009), illustrated by the Lancet series Early Childhood Development, have shown that incorporating nurturing care components into interventions significantly improved childhood development and even later adult outcomes (see Box 5-1). Additionally, members of the Lancet Commission on Early Childhood Development found that programs providing parental support for child development within the context of larger social protection efforts in Latin America have shown substantial benefits for child development (Fernald et al., 2017).

Prevention and Mitigation of Violence

The 2014 Global Status Report on Violence Prevention includes data from 133 countries on violence prevalence and prevention, including child abuse and neglect (WHO, 2014b). In spite of the (1) global acceptance of child rights, (2) recognition of the harmful effects of violence exposure and maltreatment on children, and (3) endorsement of home visiting and parent education as effective in reducing risk factors for child maltreat-

ment (Mikton and Butchart, 2009), there have been few evaluations of programs to protect children from violence and maltreatment in LMICs (Black et al., 2017). Given the lack of knowledge around risks children face in conflict and as refugees and the effectiveness of interventions in fragile countries and failed states, program evaluation is an area where more research is needed. The United Nations International Children’s Emergency Fund (UNICEF) recommends that efforts along six dimensions are needed as part of a global violence prevention strategy (UNICEF, 2014):

1. Support caregivers.
2. Help children manage risks.
3. Change attitudes and norms that encourage violence.
4. Provide support services for children.
5. Implement child protection laws.
6. Conduct data collection and research.

One intervention that can address some of these dimensions is registering births. In 2012, only 49 percent of births were registered in the first year of life worldwide. This percentage drops even lower for regions such as South Asia (37 percent) and sub-Saharan Africa (38 percent), although country rates within a region can vary greatly (Lawn et al., 2014). A birth certificate provides the child with an identity and nationality that will allow him or her to access fundamental social services, including medical care and education, as well as allowing the child to obtain a driver’s license or marriage license later in life. Possession of a birth certificate is linked to higher rates of finishing primary school (Corbacho et al., 2012), countering early marriage before girls are legally eligible, protecting children who are trafficked, ensuring children are enrolled in school, and providing access to immunization and health care (UNICEF, n.d.-a,-b). The biggest hindrance to obtaining birth certificates for children is that parents often need to present documentation such as a marriage license and visit multiple government agencies to obtain the certificate (Mailman School of Public Health, 2016). Ensuring that all births are registered is of critical importance to countries as they evaluate national priorities and international aid. Birth certificates allow countries to make policies based on facts as opposed to ideologies (Mikkelsen et al., 2015), and they help to better evaluate international aid needs (Mailman School of Public Health, 2016). Because the absence of this crucial information negatively affects policy making and development, it is a strategic objective of WHO’s Every Newborn Action Plan to End Preventable Deaths (WHO, 2014a).

Poverty Assistance and Cash Transfers

Social safety-net programs support vulnerable populations by distributing cash transfers to low-income households to prevent shocks, protect the chronically poor, promote capabilities and opportunities for vulnerable households, and transform systems of power that exclude certain marginalized groups (e.g., women, children, rural poor, indigenous). The economic rationale for cash transfer programs is that they can be an equitable and efficient way to address market failures and reach the most vulnerable populations (Fiszbein et al., 2009). Most LMICs spend 1–2 percent of their GDP on social transfer programs. Conditional cash transfer programs and microcredit usually target the transfer to mothers based on evidence that money controlled by mothers is spent on more child-centered goods and services than money controlled by fathers (Thomas, 1990). Social safety-net programs are hypothesized to improve outcomes via the family investment model (i.e., having more money to spend on inputs or more time to spend with children) and family stress model (i.e., decreased maternal depression due to increased household resources). A recent review shows mostly positive effects of cash transfer programs on some child outcomes, including birth weight; infant mortality; illness or morbidity; and cognitive, language, and behavioral development. Strong positive effects of cash transfers on promoting participation in prenatal care, giving birth in the presence of a skilled birth attendant, and growth monitoring have been reported (De Walque et al., 2017).

Early Childhood Education

For the post-2015 agenda, the SDGs call for all children by 2030 to “have access to quality early child development, care and preprimary education so that they are ready for primary education” (UN, 2015b). Achievement of this goal will require greater coordination of early child development programming within the broader education infrastructure, with attention to equity in both access and quality of services. Education and intellectual support of young children can take many forms. Low-cost activities such as storytelling, singing, and playing with household objects expose young children to a rich and varied social network that promotes early development (Black et al., 2017).

High-quality early child development programs and opportunities for early learning, such as day care, child care, and preschool, improve child outcomes during later schooling (Britto et al., 2017). The inclusion of early child development in the first of six Education for All goals recognizes early child development as an essential component of the broader educa-

tion agenda.⁶ Additionally, education has been found to have downstream health effects, especially when one considers female schooling. For example, a meta-analysis conducted by Schäferhoff and colleagues (2015) found that a 1-year increment in female schooling is associated with a 6.5 to 9.9 percent reduction in mortality for children under 5 in LMICs. Furthermore, 39.6 percent and 17.5 percent of child mortality reduction between 1990–2000 and 2000–2011, respectively, can be attributed to increases in female schooling (Schäferhoff et al., 2015). A challenge in most countries is the lack of a robust system for education for children before they enter primary school. In the United States, for example, there is little support for public-sector day care, and private day care is in short supply, high demand, and comes with extremely high out-of-pocket costs. Even for countries with early childhood programs, the variability of quality is such that it is difficult to measure effects and attribution across the board.

Despite the measured benefits of investment in early education for children, many reports still indicate that governments and private donors consider it a low priority (UNESCO, 2006, 2011). Another option for providing supportive early learning environments is through media. A meta-analysis representing more than 10,000 children from 15 countries⁷ found significant benefits in literacy and numeracy, health and safety, and social reasoning and attitudes toward others—all from watching Sesame Street (Mares et al., 2015). Although shows like Sesame Street are a relatively easy way to bring learning opportunities to children who cannot join formal learning environments before age 5, gaps remain that need to be addressed for children to be mentally and socially prepared to enter school.

SUMMARY AND RECOMMENDATION

In LMICs, 250 million children younger than age 5 (43 percent) fail to reach their developmental potential because of extreme poverty and stunting (Black et al., 2017). With the decline of nutrition- and infection-related child mortality and the push for universal primary school, the support and promotion of child development is crucially important. The SDGs call for all children to “have access to quality early child development, care, and preprimary education so that they are ready for primary education” by 2030 (UN, 2015b). Recent evidence indicates that there are significant long-term effects of early investments in child cognitive and language de-

___________________

⁶ Education for All is a global movement led by UNESCO (United Nation Educational, Scientific and Cultural Organization) that aims to meet the learning needs of all children, youth, and adults by 2015.

⁷ Countries analyzed included Australia, Bangladesh, Canada, Egypt, India, Indonesia, Israel, Kosovo, Mexico, Nigeria, Northern Ireland, Palestine, South Africa, Tanzania, and Turkey (Mares and Pan, 2013).

velopment, which translate into lifelong benefits in terms of labor market participation, lifetime earnings, productivity, health, and economic growth (Gertler et al., 2014; Kagitcibasi et al., 2009; Yousafzai et al., 2014). Thus, a “thrive” agenda in addition to the existing “survival” agenda can be an important focal point for investment.

Recommendation 8: Ensure Healthy and Productive Lives for Women and Children

TRANSFORM: DEVELOPING WHOLE SYSTEMS OF CARE

Many of the strategies and opportunities for investments related to reducing maternal and child mortality described above do not necessarily require new and separate funding streams or a novel and dedicated workforce. Instead, a change of thinking is required that starts with an examination of all parts of the existing services delivery and support system to see what can be amended to maximize efficiency and effectiveness. The many opportunities for transformation are most easily and effectively pursued through broadening the delivery system to include social determinants (e.g.,

poverty and education), expanding the workforce skillsets, and bundling different types of services to optimize the interaction between patient and provider and improve adherence to treatments or behaviors.

Altering the Approach for Increased Survival

Shifting from a condition-based care and support model for a particular disease to a whole-person approach allows health care and social service workers to address risk and protective factors across the life span. For example, USAID’s AIDS, Population, and Health Integrated Assistance Plus program, which integrates family planning into PEPFAR-platform HIV/AIDS services for women in Kenya (Fleischman and Peck, 2015), has been commended as a game changer. Such a program could be used as a model for other approaches to integrate essential maternal and child services, such as breast and cervical cancer screening.

Program administration that permits funding flexibility and connectivity of U.S.-supported efforts will go a long way to ensure that integrative models are successful. However, the successful scaling, adoption, and sustainability of integrative models requires investments in workforce development. Training community health workers to share the tasks of physicians and nurses serves as an effective means to increase awareness in low-resource settings about NCDs (e.g., high blood pressure), and they can help to disseminate information about particular diseases with the community’s needs and culture in mind (Abrahams-Gessel et al., 2015). Skilled birth attendants and midwives can also be effectively used to increase their patients’ awareness of breast or cervical cancer screening programs.

Expanding the Effort to Strengthen Health Systems

In many countries, early child development services are delivered through a disconnected set of organizations, primarily NGOs, often with few regulatory guidelines and little coordination with other services or sectors (Black et al., 2017). As the emphasis on early childhood has increased over the past decade and governments look to increase access to early child development programs, finding effective ways to leverage the nongovernmental sector to increase access and ensure quality is critically important (Black et al., 2017). Platforms for early child development services include home visits, clinical contacts, and community-based group sessions as well as newer approaches, such as media (Black et al., 2017). Overall, successful programs are not universal and need more research and contextual understanding. The factors that influence health and development often go well beyond the health sector and include the nutrition, education, and social sectors (Britto et al., 2017). Thus, to truly improve the health and well-

being of populations, which is a desired outcome inherent in the design of the SDGs, policy and practice professionals need to go beyond the health sector to make the needed changes and integrate services across sectors. Integrated approaches should ideally include all sectors and share messages and opportunities for synergy. Several key improvements within the sector of women’s and children’s health would be relatively easy to implement and would result in multiple dividends, especially as such interventions often act synergistically with women and children. Consider the examples from Rahman and colleagues (2013) noted previously: Multiple studies show strong effects of improved maternal mood and infant health and development simply by having supervised, nonspecialist community health workers conduct culturally competent interventions (Rahman et al., 2013). Simple improvements to the health systems in countries could also include workforce development changes, mental health support for women and families, increased focus on nutrition to address remaining survival issues as well as enhanced thriving, and finally, increased cross-sector partnerships at the ground level to provide integrated services.

Within the category of workforce development, it is important to ensure that skilled birth attendants, community health workers, nurses, and primary care physicians have appropriate training in exclusive breastfeeding promotion and can ensure proper nutrition for newborns (WHO, 2017a). Refocusing the health system to include an emphasis on nutrition from pregnancy across the life cycle can ameliorate under-5 mortality and stunting and promote healthy growth as children grow into adolescents and adults. For women, this focus could translate to improved nutrition during pregnancy, ideally propagating the cycle of health and wellness (USAID, 2014). Moreover, because primary care health workers often do not possess the essential knowledge and skills to promote early child development, providing a basic training curriculum could assist in the identification of children who are at risk of delayed development at age-appropriate times. This approach would also enable providers to identify optimal opportunities to intervene to promote development.

Public–Private Partnerships with a Multisector Focus

Creating multisector partnerships with community organizations and the numerous NGOs throughout the global health community is another way to transform the system of care. As noted in Chapter 4, PEPFAR’s DREAMS partnership is still nascent, but its goals to address poverty, gender inequality, lack of education, and sexual violence—even with a bottom-line focus of reducing HIV infection rates—demonstrate a promising cross-sector example of this type of partnership. Saving Mothers, Giving Life is another public–private partnership. Launched in 2012, it partners

with donor and recipient governments, NGOs, the private sector, and representatives from provider associations to test an integrated approach to significantly reduce maternal deaths (SMGL, 2014). In its first year alone, the program upgraded 68 facilities in Zambia and 11 facilities in Uganda to provide basic emergency obstetric and newborn care (Kruk et al., 2014). Additionally, the program trained 1,010 health workers in Zambia and 4,004 in Uganda to promote delivery in facilities and in birth preparedness, and it trained 179 health workers in Zambia and 238 health workers in Uganda to provide emergency obstetric care, newborn resuscitation, or surgery (Kruk et al., 2014). Saving Mothers, Giving Life’s latest report showed a 55 percent reduction in maternal mortality in target facilities in Zambia as a result of its interventions, and target districts in Uganda saw a 44 percent reduction in maternal mortality (SMGL, 2016), showing the partnership is helping women from all over the community, not just those who make it to the facility (see Figure 5-2).

Among the successful private-sector partners in this partnership is Merck through its Merck for Mothers program. Merck for Mothers, part of the Saving Mothers, Giving Life initiative, supports on-the-ground program evaluation and program implementation (Merck for Mothers, 2013). More partnerships that pair the expertise of the public and private sectors are needed to take cross-sector intervention approaches, show results, and help to change the system.

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