In September 2000, the largest-ever gathering of Heads of State and Government ushered in the new millennium by adopting the United Nations Millennium Declaration. The Declaration was endorsed by 189 countries and was translated into eight Millennium Development Goals (MDGs) to be achieved by 2015. The Goals include eradicating extreme poverty and hunger, improving education, promoting gender equality, improving health and combating disease, ensuring environmental sustainability and building a global partnership for development.
MDG 5 focuses on improving maternal health. Progress towards achieving the MDGs is monitored with a framework of measurable targets and indicators for each MDG that was defined in 2001. The monitoring framework for MDG 5 was revised following the review of progress at the 2005 World Summit, with one new target and four new indicators . The current situation on the range of indicators defined to monitor progress shows that accelerated action is needed to achieve MDG 5.
The eight Millennium Development Goals
* MDG 1: To eradicate extreme poverty and hunger
* MDG 2: To achieve universal primary education
* MDG 3: To promote gender equality and empower women
* MDG 4: To reduce child mortality
* MDG 5: To improve maternal health
* MDG 6: To combat HIV/AIDS, malaria, and other diseases
* MDG 7: To ensure environmental sustainability
* MDG 8: To develop a global partnership for development
MDG 5 aims to improve maternal health. This goal was translated into two targets:
* to reduce maternal mortality by three quarters between 1990 and 2015, and
* to achieve universal access to reproductive health by 2015.
The two key indicators for monitoring the progress towards the first target are the maternal mortality ratio and the proportion of births attended by skilled health personnel.
What progress has been made on MDG 5?
According to the 2005 data, few low- and middle-income countries are on track to achieve the first target of MDG 5. In 56 of the 68 priority countries where 98% of maternal deaths occur, mortality ratios are still high, exceeding 300 maternal deaths per 100 000 live births (1). The global maternal mortality ratio is 400 maternal deaths per 100 000 live births versus 430 in 1990. This average annual decrease of less than 1% is far below the 5.5% annual decline that is required to achieve MDG 5. At the regional level, none of the MDG priority regions have achieved a 5.5% annual decline, although eastern Asia comes close with a 4.2% average annual decline. In sub-Saharan Africa, where maternal mortality is highest, the annual decline has been 0.1%. However, given the high uncertainty margins for the maternal mortality ratio, determining whether there is any real decline at all is difficult.
Nevertheless, there is a sense of progress, backed by an increase in the uptake of care during pregnancy and childbirth. The proportion of births in low- and middle-income countries assisted by a skilled birth attendant increased from 47% in 1990 to 61% in 2006. However, coverage is far lower than the global targets set at a special session of the United Nations General Assembly in 1999 to follow up the 1994 International Conference on Population and Development: 80% by 2005, 85% by 2010 and 90% by 2015. The regions with the lowest proportions of skilled health attendants at birth were eastern Africa (34%), western Africa (41%) and south-central Asia (47%), which also had the highest numbers of maternal deaths (3).
The second target of MDG 5 constitutes the main goal of the International Conference on Population and Development: “Achieve, by 2015, universal access to reproductive health”. This was incorporated within the MDG monitoring framework under MDG 5 based on the recommendations of world leaders at the 2005 World Summit(4) Universal access to reproductive health refers to the ability to achieve sexual and reproductive health (including maternal health) through health care, as defined within the Programme of Action of the International Conference on Population and Development (the constellation of methods, techniques and services that contribute to health and well-being by preventing and solving reproductive health problems)(5). It implies “equitable access”, in which individuals with equal need have equal access to relevant health care.
The use of contraception has improved impressively during the past two decades in many regions. However, the unmet need for family planning is still unacceptably high in low- and middle-income countries. In sub-Saharan Africa, 24% of women who want to delay or stop childbearing have no access to family planning. This figure varies between 10–15% in the other world regions and further varies across population groups. For example, in Latin America and the Caribbean, an average of 27% of the poorest households have an unmet need for family planning versus 12% of the wealthiest group.
Antenatal care is a crucial service for healthy motherhood and childbirth by monitoring the well-being of both the woman and her baby. The proportion of pregnant women in low- and middleincome countries who had at least one antenatal care visit increased from less than 55% in the early 1990s to almost 75% in a decade. Although this is an improvement, the recommended norm of four antenatal visits is still not accessible to many pregnant women worldwide: for example, 55% of those in sub-Saharan Africa.
Pregnancy in adolescence contributes to the cycle of maternal deaths and indicates limited access to reproductive health services. Adolescent fertility declined in almost all low- and middle-income countries between 1990 and 2000 but either remained stagnant or increased marginally between 2000 and 2005.
Achieving MDG 5 requires reducing maternal mortality at a much faster rate in the future than it was reduced between 1990 and 2005. Greater attention to improving sexual and reproductive health care and universal access to all its aspects are required to prevent unintended pregnancies and unsafe abortions, to manage abortion complications, to prevent morbidity and mortality due to sexually transmitted infections (including HIV) and to provide high-quality pregnancy and delivery care, including essential obstetric care.
MDG 5 is related to other MDGs. As maternal mortality strongly affects newborn mortality, progress on MDG 5 will also influence the efforts to reduce child mortality (MDG 4). Progress on MDG 5 is also linked to MDG 6, which aims to combat HIV/AIDS and malaria, as these are important indirect causes of maternal death. Gender inequality is one of the social determinants at the heart of inequity in health. Progress in achieving MDG 3, promoting gender equality and women’s empowerment, will help in achieving MDG 5. Maternal mortality is a sensitive indicator of inequality, as current statistics show that the poorest and least educated women have the highest risk of death during pregnancy or childbirth. Increasing primary education (MDG 2) for girls and eradicating extreme poverty and hunger (MDG 1) are means to empower women and will positively influence the achievement of MDG 5.What does MPS do to achieve MDG 5?
What is WHO doing to achieve MDG 5?
WHO supports countries in improving maternal health and focuses on 75 priority countries that account for 97% of all maternal deaths worldwide. WHO aims to reduce maternal mortality by providing and promoting evidence-based clinical and programmatic guidance. The cornerstone of WHO’s efforts to make pregnancy safer is the integrated management of pregnancy and childbirth (IMPAC), which includes guidance and tools to increase pregnant women’s access to high-quality health services. In addition, WHO promotes skilled care at every birth. It has developed educational modules for midwifery training and offers training for trainers in midwifery education in the regions of WHO. Further, WHO promotes the approach of involving individuals, families and communities to increase access to quality care.
MPS vignette
The World Health Assembly adopted WHO’s global strategy to accelerate progress towards the achievement of international goals and targets in reproductive health (including the MDGs) in May 2004. Within this framework, WHO works to ensure that “by 2015 all primary health-care facilities are able to provide, directly or through referral, the widest achievable range of safe and effective family planning and contraceptive methods; essential obstetric care; prevention and management of reproductive tract infections, including sexually transmitted diseases; and barrier methods, such as male and female condoms and microbicides if available, to prevent infection” (based on a resolution adopted by the United Nations General Assembly). WHO’s work involves conducting and building capacity in research and research synthesis, developing international clinical standards through evidence-based guidelines and assisting countries in implementing such norms within health systems. WHO also monitors progress towards reaching MDG 5 in collaboration with other United Nations agencies and programmes at the global level.
MDG 5 focuses on improving maternal health. Progress towards achieving the MDGs is monitored with a framework of measurable targets and indicators for each MDG that was defined in 2001. The monitoring framework for MDG 5 was revised following the review of progress at the 2005 World Summit, with one new target and four new indicators . The current situation on the range of indicators defined to monitor progress shows that accelerated action is needed to achieve MDG 5.
The eight Millennium Development Goals
* MDG 1: To eradicate extreme poverty and hunger
* MDG 2: To achieve universal primary education
* MDG 3: To promote gender equality and empower women
* MDG 4: To reduce child mortality
* MDG 5: To improve maternal health
* MDG 6: To combat HIV/AIDS, malaria, and other diseases
* MDG 7: To ensure environmental sustainability
* MDG 8: To develop a global partnership for development
MDG 5 aims to improve maternal health. This goal was translated into two targets:
* to reduce maternal mortality by three quarters between 1990 and 2015, and
* to achieve universal access to reproductive health by 2015.
The two key indicators for monitoring the progress towards the first target are the maternal mortality ratio and the proportion of births attended by skilled health personnel.
What progress has been made on MDG 5?
According to the 2005 data, few low- and middle-income countries are on track to achieve the first target of MDG 5. In 56 of the 68 priority countries where 98% of maternal deaths occur, mortality ratios are still high, exceeding 300 maternal deaths per 100 000 live births (1). The global maternal mortality ratio is 400 maternal deaths per 100 000 live births versus 430 in 1990. This average annual decrease of less than 1% is far below the 5.5% annual decline that is required to achieve MDG 5. At the regional level, none of the MDG priority regions have achieved a 5.5% annual decline, although eastern Asia comes close with a 4.2% average annual decline. In sub-Saharan Africa, where maternal mortality is highest, the annual decline has been 0.1%. However, given the high uncertainty margins for the maternal mortality ratio, determining whether there is any real decline at all is difficult.
Nevertheless, there is a sense of progress, backed by an increase in the uptake of care during pregnancy and childbirth. The proportion of births in low- and middle-income countries assisted by a skilled birth attendant increased from 47% in 1990 to 61% in 2006. However, coverage is far lower than the global targets set at a special session of the United Nations General Assembly in 1999 to follow up the 1994 International Conference on Population and Development: 80% by 2005, 85% by 2010 and 90% by 2015. The regions with the lowest proportions of skilled health attendants at birth were eastern Africa (34%), western Africa (41%) and south-central Asia (47%), which also had the highest numbers of maternal deaths (3).
The second target of MDG 5 constitutes the main goal of the International Conference on Population and Development: “Achieve, by 2015, universal access to reproductive health”. This was incorporated within the MDG monitoring framework under MDG 5 based on the recommendations of world leaders at the 2005 World Summit(4) Universal access to reproductive health refers to the ability to achieve sexual and reproductive health (including maternal health) through health care, as defined within the Programme of Action of the International Conference on Population and Development (the constellation of methods, techniques and services that contribute to health and well-being by preventing and solving reproductive health problems)(5). It implies “equitable access”, in which individuals with equal need have equal access to relevant health care.
The use of contraception has improved impressively during the past two decades in many regions. However, the unmet need for family planning is still unacceptably high in low- and middle-income countries. In sub-Saharan Africa, 24% of women who want to delay or stop childbearing have no access to family planning. This figure varies between 10–15% in the other world regions and further varies across population groups. For example, in Latin America and the Caribbean, an average of 27% of the poorest households have an unmet need for family planning versus 12% of the wealthiest group.
Antenatal care is a crucial service for healthy motherhood and childbirth by monitoring the well-being of both the woman and her baby. The proportion of pregnant women in low- and middleincome countries who had at least one antenatal care visit increased from less than 55% in the early 1990s to almost 75% in a decade. Although this is an improvement, the recommended norm of four antenatal visits is still not accessible to many pregnant women worldwide: for example, 55% of those in sub-Saharan Africa.
Pregnancy in adolescence contributes to the cycle of maternal deaths and indicates limited access to reproductive health services. Adolescent fertility declined in almost all low- and middle-income countries between 1990 and 2000 but either remained stagnant or increased marginally between 2000 and 2005.
Achieving MDG 5 requires reducing maternal mortality at a much faster rate in the future than it was reduced between 1990 and 2005. Greater attention to improving sexual and reproductive health care and universal access to all its aspects are required to prevent unintended pregnancies and unsafe abortions, to manage abortion complications, to prevent morbidity and mortality due to sexually transmitted infections (including HIV) and to provide high-quality pregnancy and delivery care, including essential obstetric care.
MDG 5 is related to other MDGs. As maternal mortality strongly affects newborn mortality, progress on MDG 5 will also influence the efforts to reduce child mortality (MDG 4). Progress on MDG 5 is also linked to MDG 6, which aims to combat HIV/AIDS and malaria, as these are important indirect causes of maternal death. Gender inequality is one of the social determinants at the heart of inequity in health. Progress in achieving MDG 3, promoting gender equality and women’s empowerment, will help in achieving MDG 5. Maternal mortality is a sensitive indicator of inequality, as current statistics show that the poorest and least educated women have the highest risk of death during pregnancy or childbirth. Increasing primary education (MDG 2) for girls and eradicating extreme poverty and hunger (MDG 1) are means to empower women and will positively influence the achievement of MDG 5.What does MPS do to achieve MDG 5?
What is WHO doing to achieve MDG 5?
WHO supports countries in improving maternal health and focuses on 75 priority countries that account for 97% of all maternal deaths worldwide. WHO aims to reduce maternal mortality by providing and promoting evidence-based clinical and programmatic guidance. The cornerstone of WHO’s efforts to make pregnancy safer is the integrated management of pregnancy and childbirth (IMPAC), which includes guidance and tools to increase pregnant women’s access to high-quality health services. In addition, WHO promotes skilled care at every birth. It has developed educational modules for midwifery training and offers training for trainers in midwifery education in the regions of WHO. Further, WHO promotes the approach of involving individuals, families and communities to increase access to quality care.
MPS vignette
The World Health Assembly adopted WHO’s global strategy to accelerate progress towards the achievement of international goals and targets in reproductive health (including the MDGs) in May 2004. Within this framework, WHO works to ensure that “by 2015 all primary health-care facilities are able to provide, directly or through referral, the widest achievable range of safe and effective family planning and contraceptive methods; essential obstetric care; prevention and management of reproductive tract infections, including sexually transmitted diseases; and barrier methods, such as male and female condoms and microbicides if available, to prevent infection” (based on a resolution adopted by the United Nations General Assembly). WHO’s work involves conducting and building capacity in research and research synthesis, developing international clinical standards through evidence-based guidelines and assisting countries in implementing such norms within health systems. WHO also monitors progress towards reaching MDG 5 in collaboration with other United Nations agencies and programmes at the global level.
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