SJC Concepts of Childhood Paper


Part A. In your own words explain the Millennium Development Goals 4 and 5 (how they were developed and their targets). Describe the Sustainable Development Goals and how they can be seen as an extension of the Millenium Development Goals.Part B. What is the current state of global infant mortality? Using specific information from the Gaffey et al. reading, what progress has been made in terms of meeting the 2015 targets for Millenium Development Goals 4 and 5? What are the highest priority infant health concerns facing the world now? Part C. Gaffey et al. suggest several interventions and recommended actions to help reduce infant mortality and promote the health of mothers and babies. If you were able to convince a large philanthropic foundation to support one of these actions – which would you choose and why? Provide specific information from Gaffey at al. to support your choice.

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ChAD106 – Seminar 3B
Required Reading:
Shahar, S. (1992). Stages of childhood. In S. Shahar, Childhood in the Middle Ages (pp. 21-31).
New York: Routledge.
Gaffery, M. F., Das, J. K., & Bhutta, Z. A. (2015). Millenium Development Goals: Past and future
progress. Seminars in Fetal and Neonatal Medicine, 20, 285-292.
Smith, S. L. & Neupane, S. (2011). Factors in health initiative success: Learning from Nepal’s
newborn survival initiative. Social Science and Medicine, 72, 568-575.
Sterns, N. S. (2017). Childhood in postclassical world history: Impact of religious change. In
Childhood in World History (pp. 46-56). New York, NY: Routledge.
Module Leaning Outcomes:
Students will be able to:
1. Identify the major factors that influence child health outcomes globally
2. Compare and contrast the impact of those factors on developmental outcomes of
children from first world and developing nations.
3. Analyze how these global conditions reflect a concept of childhood in the specific
societies addressed
Discussion Question:
Read this online Forbes news article (Cohen, 2021) about the United States’ infant mortality
rate –
Do the findings in the Forbes news report surprise you? Explain why or why not. Compare the
problems of U.S. infant mortality with the health problems facing children in developing
countries. Are there similarities? Use specific information from the required reading on global
infant health in your response (e.g., the article by Gaffey et al., “Millenium Development Goals 4
& 5: Past and future progress”).
Your discussion posting should be at least 300 words (but you can write more if you feel that
you need to in order to answer the question). Post your response directly to the Discussion area
— don’t submit it as an attached file. Please see the schedule in the course syllabus for the due
date for this assignment.
Discussion postings will be scored for length, being posted on time, quality of the writing and
the use of thoughtful reflection. Remember that you will also need to submit your Discussion
area posting (but not your reply) to the corresponding folder in the Assignment area. This is
so your file can go through and so I can enter your grade.
Seminar Notes:
UN Millenium Development Goals (MDG) 1990-2015
Perhaps the clearest statement of the measures that the international community has taken in
the past to promote the well-being of children was the UN Millennium Development Goals
(MDG). These were internationally agreed-upon goals for improving the human condition and
were selected as the underpinnings of a global strategic plan to improve the status of
impoverished people. Although the Millennium Development Goals were adopted in 2000 with
the approval of all 192 UN member states and more than 20 additional non-members, the
benchmark for examining progress toward the eight goals reaches back to 1990 levels. The
goals are listed below so that you can see just how comprehensive they were:
Goal 1: Eradicate extreme poverty and hunger: Reduce by half the proportion of people living
on less than a dollar a day. Achieve full and productive employment and decent work for
all, including women and young people. Reduce by half the proportion of people who
suffer from hunger.
Goal 2: Achieve universal primary education: Ensure that all boys and girls complete a full
course of primary schooling.
Goal 3: Promote gender equality and empower women: Eliminate gender disparity in primary
and secondary education preferably by 2005, and at all levels by 2015.
Goal 4: Reduce child mortality: Reduce by two thirds the mortality rate among children under
Goal 5: Improve maternal health: Reduce by three quarters the maternal mortality ratio.
Achieve, by 2015, universal access to reproductive health.
Goal 6: Combat HIV/AIDS, malaria and other diseases: Halt and begin to reverse the spread of
HIV/AIDS. Achieve by 2010, universal access to treatment for HIV/AIDS for all those who
need it. Halt and begin to reverse the incidence of malaria and other major diseases.
Goal 7: Ensure environmental sustainability: Integrate the principles of sustainable
development into country policies and programs; reverse loss of environmental
resources. Reduce biodiversity loss, achieving, by 2010, a significant reduction in the
rate of loss. Reduce by half the proportion of people without sustainable access to safe
drinking water and basic sanitation. Achieve significant improvement in lives of at least
100 million slum dwellers, by 2020.
Goal 8: Develop a global partnership for development: Develop further an open, rule-based,
predictable, non-discriminatory trading and financial system Address the special needs
of the least developed countries. Address the special needs of landlocked developing
countries and small-island developing States. Deal comprehensively with the debt
problems of developing countries.
Of the eight goals, five (1, 4, 5, 6, and 7) had direct implications for global child health indicating
the degree to which the nations of the world regard the seriousness of threats to healthy
physical development and the implications of child development for global health and
economic development. Progress toward accomplishing these goals was regularly assessed and
reported to the international community.
The world has made significant progress. Results of MDG 4 shows that between 1990 and 2015,
the global under-five mortality rate has declined by more than half, dropping from 90 to 43
deaths for every 1000 live birth. During that same time period, the number of deaths of
children under five worldwide decreased from 12.7 million in 1990 to almost 6 million in 2015.
Still there is more to do. Children in rural areas are about 1.7 times more likely to die before
them their fifth birthday then those growing up in cities. And while maternal mortality (MDG 5)
has been cut almost in half since 1990, there were still an estimated 289,000 maternal deaths
in 2013.
UN Sustainable Development Goals (MDG) 2015-2030
In an effort to continue the progress of the Millennium Development Goals, on Sept. 25, 2015
the 193 countries of the United Nations General Assembly adopted the Sustainable
Development Goals as its 2030 Development Agenda. These 17 goals are described in the
following video, “We the People for the Global Goals” …

1. Poverty – End poverty in all its forms everywhere
2. Food – End hunger, achieve food security and improved nutrition and promote
sustainable agriculture
3. Health – Ensure healthy lives and promote well-being for all at all ages
4. Education – Ensure inclusive and equitable quality education and promote lifelong
learning opportunities for all
5. Women – Achieve gender equality and empower all women and girls
6. Water – Ensure availability and sustainable management of water and sanitation for all
7. Energy – Ensure access to affordable, reliable, sustainable and clean energy for all
8. Economy – Promote sustained, inclusive and sustainable economic growth, full and
productive employment and decent work for all
9. Infrastructure – Build resilient infrastructure, promote inclusive and sustainable
industrialization and foster innovation
10. Inequality – Reduce inequality within and among countries
11. Habitation – Make cities and human settlements inclusive, safe, resilient and sustainable
12. Consumption – Ensure sustainable consumption and production patterns
13. Climate – Take urgent action to combat climate change and its impacts
14. Marine-ecosystems – Conserve and sustainably use the oceans, seas and marine
resources for sustainable development
15. Ecosystems – Protect, restore and promote sustainable use of terrestrial ecosystems,
sustainably manage forests, combat desertification, and halt and reverse land
degradation and halt biodiversity loss
16. Institutions – Promote peaceful and inclusive societies for sustainable development,
provide access to justice for all and build effective, accountable and inclusive institutions
at all levels[35]
17. Sustainability – Strengthen the means of implementation and revitalize the global
partnership for sustainable development[36]
If you go to the UN link for the Sustainable Development Goals at … — you can click on each of the goals to
see what specific targets the world hopes to meet by 2030. As an example for the SDG 3 of
Good Health and Well-Bring, target 3.2 states that “by 2030, end preventable deaths of
newborns and children under 5 years of age, with all countries aiming to reduce neonatal
mortality to at least as low as 12 per 1,000 live births and under-5 mortality to at least as low as
25 per 1,000 live births.”
Clearly the world has a lot to do, but also record of progress over the past few decades.
Let’s examine some of the key threats to healthy child development . . .
Malnutrition and Under-Nutrition
What do you suppose is the full calorie count for a meal consisting of a Big Mac, medium fries
(no catsup), and a medium coke? According to a Mac Donald’s website, this meal totals 1130
calories. This one, fairly common U.S. meal turns out to contain more calories than the average
caloric intake per day available across all people (children and adults) in a large number of
countries, Rwanda, Cambodia, Zambia, Haiti, Vietnam, Ethiopia, Somalia, and Burundi, to name
just a few.
Often when we think about malnutrition what comes to mind is the total number of calories
available to fuel the body. Actually, optimal nutrition is more complicated than that. You can
think of malnutrition as taking several forms. There are two basic concerns related to
malnutrition, and both have serious implications for child health and developmental outcome.
Perhaps the more familiar form occurs when there not enough calories and protein-rich foods
available to be consumed. Diets deficient in sources of protein and/or deficient in sufficient
calories to meet the body’s daily energy needs limit children’s full physical growth potential as
well as their general health and cognitive development.
Although the world currently produces enough food to ensure all humans a diet of
approximately 2700 calories per day, large numbers of people do not have enough food to
meet even their basic needs. The problem is that many of the world’s people either lack the
money or the land to secure food sufficient to sustain life at a sustainable daily intake level.
International statistics on the rates of worldwide malnutrition are inconsistent but it appears
that about 850 million people are undernourished (energy/protein); fully 12% of the world’s
Overall, it is estimated that about 30% of the children living in developing countries do not have
enough to eat nor do they have access to important nutrients. Worldwide, undernourished
women during pregnancy and inappropriate feeding practices for infants and very young
children comprise about a third of all cases of childhood malnutrition. The World Health
Organization reports that about 168 million children younger than five years of age are
underweight. About 70% of the children with protein-energy malnutrition live in Asia; 26% live
in Africa; and about 4% live in Latin America and the Caribbean. The risk factors associated with
this form of malnutrition include all aspects of cognitive development, short physical
stature/stunting, vulnerability to disease, and the like.
What percent of all deaths among children less than five-years-old do you suppose are
associated with malnutrition? In a country as rich as ours, it’s hard to imagine that the World
Health Organization estimates that just over 50% of all early childhood deaths from infectious
diseases (e.g., respiratory, measles, malaria, HIV/AIDS, diarrhea) can be attributed directly to
In addition to caloric malnutrition, a critical form of dietary impact that does not readily come
to mind when we think of malnutrition is diets that are deficient in the micronutrients. For the
children of the world, adequate levels of micronutrients are another serious threat to wellbeing. The three most common vitamin and mineral deficiencies worldwide that impact child
health and development are:
• Iron: anemia can result in elevated infection rates and decreases in cognitive

Vitamin A: approximately one sixth of the world’s 600 million children are deficient in
vitamin A, a nutrient that increases the body’s ability to fight infection. Vitamin A
deficiency is also related to stunted growth and to loss of vision. Approximately 250,000
to 500,000 vitamin A-deficient children become blind each year. About half of these
children die within 12 months or so of the onset of blindness; and
Iodine: this nutrient has a significant impact on fetal development and the incidence of
congenital abnormalities and on the development of irreversible mental retardation.
The World Health Organization (WHO) estimates that about 50 million people suffer
from some degree of mental impairment that was caused by iodine deficiencies
sometime in their early development.
Malnutrition can also result when diseases prevent the body from absorbing calories and
nutrients. For example, diarrhea, one of the three leading causes of child deaths worldwide,
often results from ingesting unclean drinking water or from poor hygiene. Take a look at a
UNICEF photo essay on issues of children and water:
Finally, malnutrition can be the result of over-nutrition, the consumption of too many calories,
a situation that we are becoming acutely aware of in the U.S. but one that is also rapidly
spreading throughout the world.
Lack of Immunization
In its 2009 report of the state of the world vaccines and immunization the WHO noted that
“With the exception of safe water, no other modality, not even antibiotics, has had such a
major effect on mortality reduction…” Clearly, access to immunization is directly related to the
achievement of MDG4. Take a few minutes to read some basic facts about the efficacy of
international immunization programs. Go to: (Click on ‘Read 10 facts on
immunization’ to get to a photo slideshow which presents ten facts about global
Although there are some variations in the immunization rate of US children that are related to
type of vaccine, race, and ethnicity, overall about 80% of all children in the US receive the major
childhood immunizations. Worldwide, the improvement in rates of immunization in some
regions is making good progress but in other areas coverage is stagnating at 50% – 70%. The
vaccination rate in Nigeria, for example, is less than 50%. In India and Pakistan the rate is about
64%. Millions of children – some 20% of all children born each year –do not have access to
immunizations. Globally, hundreds of thousands of children die annually from preventable
diseases: measles, pneumococcal diseases, whopping cough, and tetanus.
Maternal Health
To reach the MDG goal of improving maternal health, three key strategies appear crucial to
achieving success. They were:
• All women must have access to reproductive health care, including contraception, to
enable them to control the number and spacing of their children;

All pregnant women must have access to skilled care at the time of birth, including
timely access to quality emergency obstetric care if needed; and

All women and newborns must have access to postnatal care soon after delivery.
An examination of the causes of maternal deaths indicates that the majority of the deaths can
be attributed to hemorrhaging, infection, extremely high blood pressure (eclampsia), and
unsafe abortions. While these are the physical conditions leading to deaths, it is also clear that
the underlying threat to maternal and, therefore, neonatal health is a lack of systems of health
care for women and children. The availability of clinics and/or trained health-care providers is a
key component to improving the outcomes of pregnancies.
Environmental Factors
There are a large number of environmental factors that impact the health status of children.
Three of these are described briefly below:
1. Contaminated sources of drinking water – waterborne diseases, especially diarrhea, kill large
numbers of children each year. Globally, about 2.4 billion of the world’s people still do not have
access to safe sources of drinking water.
2. Chemicals – children are particularly vulnerable to neuro-toxins such as lead and chemicals
found in pesticides. That’s why in the US a major public health effort has been to remove lead
from a wide range of exposure sources in the environment – for example, from paint, from
manufacturing emissions, from gasoline products, and from ceramic and glass items used for
3. Air pollution – this is a risk factor in particular for children who have respiratory diseases such
as asthma and pneumonia. Human sources of air pollution are a growing problem particularly in
the developing world where, in addition to petro-fuels, much of industrial production is fueled
by coal. As noted above, pneumonia is one of the top three killers of children worldwide.
We know that a significant percentage of all child deaths are preventable. And, it is apparent
that interventions to reduce the rate of child deaths internationally are not the stuff of rocket
science. There are a number of factors that could impact mortality rates. Recall, for example
that one of the MDG 5 was the improvement of maternal health. It is the case that about a
third of all infant deaths occur in the first four weeks of life. What would it take to improve on
these statistics? UNICEF recommends several types of services and practices:

skilled attendants at delivery and newborn care;
care of low birth weight infants;
hygiene promotion;
prevention of mother-to-child transmission of HIV and pediatric treatment of AIDS;
adequate nutrition, particularly in the form of early and exclusive breastfeeding during
the first six months of life;
complementary feeding combined with continued breastfeeding for at least two more
micronutrient supplementation to boost immune systems;
immunization to protect children against the six major vaccine-preventable diseases;
oral rehydration therapy and zinc to combat diarrhea-related diseases;
antibiotics to fight pneumonia; and
insecticide-treated mosquito nets and effective medicines to prevent and treat malaria.
What are other interventions to reduce or prevent the major causes of child deaths
internationally? The table below suggests that by US standards, the costs per child of many
immunizations are, for the most part, pocket change, substantially less than the cost of a
double shot mocha latte vente, hold the whipped cream. Have a look:
Recall that the SDGs were established at the end of 2015 with a 15 year window in which to
achieve most of the goals. However each day in 2015, 16,000 children under five died
worldwide, mostly from preventable causes. How many minutes has it taken you to read these
lecture notes? On average, 11 children die every minute from causes that modern medicine and
basic care can prevent.
We have a lot of work ahead of us if we want to make positive changes in our world. This
website shows some of the projects going on across the globe for each of the SDGs and how
individuals can help and raise awareness …
Selected References:
Black, R. E., Morris, S. S., & Bryce, J. (2003). Where and why are 10 million children dying every
year? The Lancet, 361, 2226–2234.
UNICEF, (2008). State of the world’s children 2008, executive summary. Retrieved May 13, 2011
Seminars in Fetal & Neonatal Medicine 20 (2015) 285e292
Contents lists available at ScienceDirect
Seminars in Fetal & Neonatal Medicine
journal homepage:
Millennium Development Goals 4 and 5: Past and future progress
Michelle F. Gaffey a, b, Jai K. Das c, Zulfiqar A. Bhutta a, b, c, *
Centre for Global Child Health, The Hospital for Sick Children, Toronto, ON, Canada
Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
Division of Women and Child Health, Aga Khan University, Karachi, Pakistan
s u m m a r y
Maternal health
Millennium Development Goals
Newborn and child health
Sustainable Development Goals
We review global and regional progress towards Millennium Development Goals (MDGs) 4 and 5 with
respect to their indicators, drawing on the latest data available from the relevant United Nations interagency groups responsible for maternal and child mortality estimation, as well as recent reports from
individual UN agencies and external monitoring groups reporting on MDG progress. We also draw on
recent, comprehensive evidence syntheses to present an overview of a selection of existing effective
interventions that, if collectively implemented at scale, would reduce maternal and child deaths well
beyond the MDG target levels. We conclude with a summary of why and how a focus on maternal and
child health in the post-2015 era should be maintained, as the global development agenda transitions
from the MDGs to the Sustainable Development Goals.
© 2015 Published by Elsevier Ltd.
1. Introduction
Emerging from the United Nations Millennium Declaration
adopted by 189 countries in September 2000, the Millennium
Development Goals (MDGs) articulated an ambitious set of aims to
motivate and accelerate global progress in economic and social
development and environmental sustainability. Including 21 targets measured through 60 indicators, the eight MDGs focus on
ending poverty and hunger; achieving universal primary education; promoting gender equality; improving child survival and
maternal health, and reducing HIV/AIDS, tuberculosis and malaria;
ensuring environmental sustainability; and promoting a global
enabling environment for development with respect to international economic, financial and commercial relations.
MDGs 4 and 5 are concerned with improving child survival and
maternal health, respectively. MDG 4 targets a two-thirds reduction
in the global under-five mortality rate (U5MR) between 1990 and
2015, with the U5MR defined as the number of under-five deaths
per 1000 live births. The additional indicators used to track progress toward MDG 4 are the infant mortality rate (i.e. number of
deaths in the first year of life per 1000 live births) and the proportion of one-year-old children immunized against measles.
* Corresponding author. Address: Centre for Global Child Health, The Hospital for
Sick Children, 686 Bay St, Toronto, ON, Canada M5G 0A4. Tel.: þ1 416 813 7654.
E-mail address: (Z.A. Bhutta).
1744-165X/© 2015 Published by Elsevier Ltd.
MDG 5 includes two targets for improving maternal health. The
first is a three-quarters reduction in the maternal mortality ratio
(MMR) between 1990 and 2015, with the MMR defined as the
number of maternal deaths per 100,000 live births. The proportion
of births attended by skilled health personnel is an additional indicator of progress towards MMR reduction. The second target of
MDG 5 is the achievement of universal access to reproductive
health by 2015. Progress toward this target is measured through
four indicators: the contraceptive prevalence rate, the proportion of
the demand for family planning that is unmet, the adolescent birth
rate, and the proportion of pregnant women receiving antenatal
In this paper we review global and regional progress towards
MDGs 4 and 5, drawing heavily on the latest data available from the
relevant United Nations inter-agency groups responsible for
maternal and child mortality estimation, as well as recent reports
from individual UN agencies and external monitoring groups
reporting on MDG progress. We also draw on recent, comprehensive evidence syntheses to present an overview of a selection of
existing effective and cost-effective interventions that, if collectively implemented at scale, would reduce maternal and child
deaths well beyond the MDG target levels. We conclude with a
summary of why and how a focus on maternal and child health in
the post-2015 era should be maintained, as the global development
agenda transitions from the MDGs to the Sustainable Development
Goals (SDGs).
M.F. Gaffey et al. / Seminars in Fetal & Neonatal Medicine 20 (2015) 285e292
2. Progress on MDG 4: reducing child mortality
Global progress towards a two-thirds reduction in the global
U5MR since 1990 has been substantial, but insufficient. The latest
available estimates from the UN Inter-agency Group for Child
Mortality Estimation (IGME) suggest a 49% global reduction in the
U5MR between 1990 and 2013, from 90 to 46 under-five deaths per
1000 live births, with the absolute number of under-five deaths
declining from 12.7 to 6.3 million annually [1]. Alternate estimates
for the same period from the Global Burden of Disease Study are
similar, suggesting a 48% decline in the U5MR, from 85 to 44 underfive deaths per 1000 live births and reduction in the number of
annual under-five deaths from 12.2 to 6.3 million [2].
Whereas U5MR declined in all MDG regions between 1990 and
2013, there is substantial variation in both the levels and trends by
region. Eastern Asia, Latin America and the Caribbean, and Northern Africa had already met the MDG 4 two-thirds reduction target
by 2013, while Western Asia and Southeastern Asia each achieved
declines in U5MR of about 60% by 2013 [1]. In each of these five
regions, the U5MR had fallen to 500) in
about 20%, and very few will actually meet the MDG 5 target on
reducing maternal mortality.
Despite declines in maternal mortality in every region since
1990, there has been limited change in the distribution of major
causes of maternal death globally, with the most recent analysis
from the Global Burden of Disease Study suggesting that more than
half of maternal deaths still occur from unsafe abortion and preventable complications of pregnancy and delivery including hemorrhage, hypertension, and sepsis [7].
In addition to MMR, the percentage of births attended by
skilled health personnel is also used to track progress on
maternal mortality within the MDG framework. Globally, this
percentage increased from 57% in 1990 to only 69% in 2012, with
Southern Asia and Sub-Saharan Africa the two lowest coverage
regions in 1990, reaching just above 50% skilled birth attendance
by 2012 [5].
The second target of MDG 5 on improving maternal health
focuses on achieving universal access to reproductive health, with
progress measured through trends in contraceptive prevalence
and unmet need for family planning, adolescent fertility, and
coverage of antenatal care services. Contraceptive prevalence refers to the proportion of women using at least one method of
contraception; unmet need for family planning refers to the proportion of women who wish to avoid or delay pregnancy but who
are not currently using any method of contraception. A recent
systematic analysis of rates and trends in these indicators,
restricted to married or in-union women of reproductive age
(MWRA), estimated a global increase in contraceptive prevalence
from 55% in 1990 to 63% in 2010, driven mainly by increases in
Southern Asia and in the Eastern, Northern and Southern Africa
sub-regions [9]. Less than 20% of MWRA used any contraceptive
method in Central and Western Africa in 2010. During the same
period, unmet need for family planning decreased from 15% to
12%, with the greatest reductions seen in Central America and in
the Northern Africa sub-region. Unmet need remained 20% or
higher in Eastern, Central and Western Africa in 2010, with
virtually no change in Central or Western Africa since 1990. Contrary to the trends of maternal mortality, which show that rates of
change have accelerated more recently, increases in contraceptive
prevalence appear to have slowed since 2000, whereas the rate of
reduction in unmet need for family planning has been stable
across the MDG period [9].
Defined as the number of births to girls aged 15e19 years, per
1000 girls, the adolescent fertility rate declined in all regions between 1990 and 2011, and from 64 to 54 births per 1000 girls in
developing regions [5]. Southern Asia experienced the largest
decline, from 88 to 50 births per 1000 girls, whereas adolescent
fertility remained very high in Sub-Saharan Africa, at 117 compared
to 123 births per 1000 girls’ in 1990. Rates also remained high in
Latin America and the Caribbean, declining only from 86 to 76
births per 1000 girls.
Antenatal care (ANC) coverage is the fourth indicator used to
track progress on the MDG 5 target of universal access to reproductive health. In developing country regions, the proportion of
pregnant women reporting at least one ANC visit increased from
65% in 1990 to 83% in 2012, with the proportion reporting at least
four ANC visits increasing from 37% to 52% over the same period [5].
As with other indicators of MDG 5 progress, regional variation in
ANC coverage levels and trends are considerable, with little change
over time in Sub-Saharan Africa (from 48% of pregnant women
reporting at least four visits in 1990 to 50% in 2012) but significant
progress in South-Eastern Asia (from 45% to 80%) as well as in the
Caribbean (from 59% to 80%). In Southern Asia, the proportion of
pregnant women reporting at least four ANC visits increased from
24% in 1990 but remained low at 36% in 2012.
4. Proven interventions and recommended action to
accelerate progress in maternal, newborn, and child survival
and health
Several major evidence synthesis initiatives in recent years
[10e13] have systematically reviewed the landscape of proven interventions and intervention packages that, if collectively brought
to scale, would avert the majority of preventable maternal,
newborn and child deaths globally. With respect to maternal, fetal
and neonatal survival particularly, a recent analysis suggests that a
set of essential interventions reaching 90% of the target population
within the 75 Countdown countries would avert 51% (range:
44e53%) of maternal deaths, 33% (23e38%) of stillbirths, and 71%
(56e76) of neonatal deaths per year [13]. These interventions
during the preconception, pregnancy, delivery, and newborn periods include:
Preconception and antenatal nutrition care: folic acid supplementation/fortification, multiple micronutrient supplementation (including iron and folic acid), and balanced energy protein
Basic and advanced antenatal care: prevention of malaria with
insecticide-treated bed nets or intermittent preventive treatment with antimalarial drugs, syphilis detection and treatment,
tetanus immunization, detection and management of hypertensive disease and diabetes, detection and management of fetal
growth restriction, and induction of labour for pregnancy >41
Labour and delivery care: skilled birth attendance, emergency
obstetric care, antenatal steroids for preterm labour, antibiotics
for premature rupture of membranes, active management of the
third stage of labour
Immediate newborn care and care of healthy newborns:
neonatal resuscitation, immediate assessment and stimulation
of the newborn, early and exclusive breastfeeding, antiseptic
cord care, and clean postnatal practices
Care of small and ill newborns: thermal care including kangaroo
mother care, full supportive care for sepsis and asphyxia and for
preterm newborns.
Despite their known efficacy, the availability and uptake of
many of these interventions in high burden settings remains far
from universal and well below the coverage levels needed to achieve substantial maternal and neonatal mortality impact (Fig. 4).
For example, from the latest data available in 2014, less than 50% of
pregnant women in the 75 Countdown countries made the recommended minimum four visits to an antenatal care provider, less
than 40% accessed malaria prevention interventions, and less than
25% were screened for syphilis. Coverage of interventions for the
care of small and ill newborns was even more limited, with only
25% of such newborns having access to full supportive care for infections, only 8% receiving oral antibiotics for infections and only
11% receiving simple thermal care. Continued emphasis on
increasing the availability and uptake of proven interventions is
clearly necessary to accelerate further progress toward improved
survival and health outcomes.
M.F. Gaffey et al. / Seminars in Fetal & Neonatal Medicine 20 (2015) 285e292
Fig. 4. Current coverage of essential interventions for maternal and newborn survival in 75 high burden countries. IPTp, intermittent preventive treatment during pregnancy; ITN,
insecticide-treated mosquito net; PPROM, preterm premature rupture of the membranes. (Source: Bhutta et al. [13].)
These focal interventions for maternal, fetal, and neonatal survival are presented in Box 1, along with a selection from a broader
set of key interventions for improving maternal, neonatal, and child
health, organized across the broad continuum of care. We discuss
several interventions from this broader set below.
4.1. Preconception reproductive health interventions for women
and adolescent girls
Effective interventions in the pre-pregnancy period to improve
maternal, fetal and neonatal outcomes include improving women’s
reproductive health through family planning to avoid unintended
pregnancy and optimize inter-pregnancy intervals, and through
management of sexually transmitted infections, including HIV [12].
The reproductive health of adolescent girls is of particular importance, given the increased risks of stillbirth, preterm birth, low birth
weight, asphyxia, and neonatal as well as maternal mortality
associated with adolescent pregnancy [13] along with its significant
social costs. While examples of successful adolescent pregnancy
prevention interventions exist, further research is needed to
identify the most effective school- and community-based strategies
for delivering education and family planning interventions to increase age at first pregnancy and to avoid repeat pregnancy in
adolescent girls [13]. In contexts where adolescent pregnancy
typically occurs within marriage, policy interventions and programming to prevent child marriage, promote girls’ education and
empowerment, and address sociocultural norms are needed in
addition to targeted reproductive health and antenatal care interventions for adolescents [14].
4.2. Nutrition interventions in women and children
The importance of nutrition throughout the life course and
especially for maternal, newborn and child health cannot be
overstated, with poor nutrition contributing significantly to
morbidity and mortality among both women and children, and
with an estimated 45% of global under-five deaths attributable to
undernutrition (i.e. to fetal growth restriction, suboptimal
breastfeeding, stunting, wasting, and micronutrient deficiencies)
[15]. Various strategies have been employed in different contexts
to address the persistent burden of maternal and child undernutrition, including nutrition education and diet modification
awareness campaigns, mass micronutrient fortification of staple
foods and targeted fortification of complementary and weaning
foods, micronutrient supplementation in pregnant women and
children, supplementary feeding to food-insecure and vulnerable
populations, and therapeutic feeding interventions to treat acute
and chronic malnutrition. The evidence base for effective nutrition
interventions and delivery strategies has expanded markedly, and
many interventions have now been successfully implemented at
scale [11]. Nonetheless, coverage rates for other key nutrition interventions remain low.
4.2.1. Micronutrient supplementation
Micronutrient supplementation is particularly important in
the preconception and prenatal periods, to avoid or mitigate a
range of maternal, fetal and newborn outcomes associated with
micronutrient deficiencies during pregnancy. Compared to no
supplementation, periconceptional folic acid supplementation is
associated with a 72% reduction in the incidence of neural tube
defects [16], and prenatal iron and folic acid supplementation is
associated with a 66% reduction in maternal anemia and an
average 58 g increase in birth weight [17]. When supplementation with multiple micronutrients (MMS) including iron and folic
acid is compared to supplementation with iron and folic acid
alone, MMS is associated with a 12% reduction in the risk of low
birth weight, a 13% reduction in the risk of small-for-gestational
age (SGA), and a 9% decrease in the stillbirth rate [18]. Calcium
supplementation during pregnancy is associated with a 52%
reduction in pre-eclampsia, a 24% reduction in preterm birth, and
an average 85 g increase in birth weight [19]. In addition to
micronutrient supplementation in pregnancy, the provision of
M.F. Gaffey et al. / Seminars in Fetal & Neonatal Medicine 20 (2015) 285e292
Box 1
Selected interventions across the continuum of care to improve
maternal, newborn, and child survival and health.
Adolescence and preconception

Reducing adolescent marriage
Increasing age at first pregnancy
Optimizing inter-pregnancy interval
Micronutrient supplementation
Balanced energyeprotein supplementation
Folic acid supplementation/fortification
Multiple micronutrient supplementation (including iron
and folic acid)
Antenatal care with at least four antenatal visits,
e prevention of malaria
e syphilis detection and treatment
e tetanus toxoid immunization
e detection and management of hypertensive disease
and diabetes in pregnancy
e detection and management of fetal growth restriction
e identification and induction of mothers at 41 weeks of
Labour and birth

Skilled birth attendance
Emergency obstetric care
Antenatal steroids for preterm labor
Antibiotics for premature rupture of membranes
Active management of the third stage of labour
Neonatal resuscitation

Immediate assessment and stimulation of the newborn
Cord care including chlorhexidine application
Early initiation of breastfeeding
Thermal care including Kangaroo Mother Care
Full supportive care for sepsis, asphyxia and preterm
The pooled evidence from studies of micronutrient supplementation in children suggests that vitamin A supplementation in
children aged 6e59 months reduces all-cause mortality and
diarrhea-specific mortality by 24% and 28% respectively, and reduces diarrhea incidence by 15% and measles incidence by 50% [21].
Zinc supplementation in children under-five is associated with a
13% reduction in diarrhea incidence and a 19% reduction in pneumonia incidence [22]; it may also increase linear growth by an
average of 0.37 cm [23]. Intermittent iron supplementation in
children aged

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500 words

Concepts of Childhood

Millennium Development Goals

global infant mortality

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