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Surviving the First Day

State of the WorldS MotherS 2013


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ContentsF rew rd b Melinda Gates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2

Intr ducti n b Jasmine Whitbread . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Executi e Summar : Ke Findings and Rec mmendati ns . . . . . . . . . . . . . . . . . . . . . . 5

Tw Decades Pr gress, But Change Has Been T Sl w and Une en . . . . . . . 13

Wh D Newb rns Die? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .23

The M st Danger us Places t be B rn . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27

C ntinuum Care r M thers and Newb rns . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37

D n r Funding r Newb rn Sur i al D es N t Match Need . . . . . . . . . . . . . . . . . 51Sa ing Newb rn Li es in Industriali ed C untries . . . . . . . . . . . . . . . . . . . . . . . . . . . . .55

Take Acti n r Newb rns . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .59

Appendix: 14th Annual M thers Index & C untr Rankings . . . . . . . . . . . . . . . . . . . 65

Meth d l g and Research N tes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75

Endn tes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .79

o v

Harriet, r m Uganda, h lds her 6-da - ldbab Pius wh was n t breathing when he wasb rn. Midwi es trained b Sa e the Childrenhelped Pius t breathe using a gentletechni ue and a simple entilati n de ice.Since it was m rst child, I was a raid gi ing birth and that I w uld n t kn w h w ttake care m bab , said Harriet. But whenm bab was b rn, a ter the midwi es helpedhim t breath and he started nursing, I was

er , er happ . I c uldnt belie e that I wasthe real m ther this bab and I elt s muchhappiness.

Photo by Suzanna Klaucke

Sa e the Children, Ma 2013.All rights reser ed.

ISBN 1-888393-26-2

State o the Worlds Mothers 2013 waspublished with gener us supp rt r m theBill & Melinda Gates F undati n.


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Surviving the First Day

The birth a child sh uld be a time w nder and celebrati n.But r milli ns m thers and babies in de el ping c untries, it isa dance with death.

In h n r m thers e er where, Sa e the Children is publishingits 14th annual State o the Worlds Mothersrep rt. E er ear,nearl 3 milli n babies die within the rst m nth li e, m st

r m pre entable causes. M re than a third these babies dien their rst da li e making the birth da the riskiest da r

newb rns and m thers alm st e er where. This rep rt sh wswhich c untries are d ing the best and which are d ing thew rst at pre enting these deaths. It als examines the need t

strengthen health s stems, train and e uip m re health w rkersand make pr en, underused s luti ns a ailable t e er m therand newb rn wh needs them. Such e rts c uld help pre ent asman as 3 ut 4 newb rn deaths.

The rst-e er Birth Day Risk Index c mpares rst-da deathrates r babies in 186 c untries t identi the sa est and m stdanger us places t be b rn. The annual Mothers Index usesthe latest data n w mens health, childrens health, educati nalattainment, ec n mic well-being and emale p litical participati nt rank 176 c untries and sh w where m thers and children arebest and where the ace the greatest hardships.

Nepal


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2 SAvE THE CHI LDREN STATE oF THE WoRLDS MoTHERS 2013

Foreword

Any report on the state o the worlds mothers is by de ni-

o po o o wo , u op. Wo g y o , c u g o o v p ov u co o . W winvest in them, we invest in a power ul source o global

v op .One way to invest in women and girls is to invest in the

survival and well-being o their children, and the recentstory o child survival is terri c nearly any way you look

.Globally, since 1970, the number o children dying has

declined by more than hal , even though the population

has almost doubled. I the rate o death had stayed con-stant, more than 31 million children would have died in2011. I , u w 6.9 o .

In many individual countries, progress has beeneven more dramatic. Barely a decade ago, in 1999, 1 in 5Rwandan children died be ore turning 5. In 2011, the childmortality rate in Rwanda had allen to 1 in 20. Other low-

co cou , uc M w , B g N phave also made signi cant progress against enormous odds.It is now possible that all our countries will meet the 2015United Nations Millennium Development Goal (MDG

4) o uc g c y wo- c 1990. We can make sure these numbers keep going in the

right direction by investing in proven solutions such asvaccines, anti-malarial bed nets, vitamin A supplementsand rontline health workers to deliver these li esaving

v o .T o o v v u ow oc v o . C w y v

lives o newborn babies? Tis yearsState of the Worlds Mothers report shows that the answer is yes, i the partners who have done such excellent work on maternal and childhealth also turn their attention to newborn health, starting w y o c .

Each year, 3 million newborns die, making up nearly (43 p c ) o wo u -5 c . A

y o w o o g o p vand treatable causes: we already have the tools available to

v ou -qu o w o w o y c y .

Tis report reveals that we know how to stop this trend,because we understand the causes and solutions o new-born death like never be ore. Simple li esaving treatments

k c p c o c g u c co c

p v y c o . A o ture babies breathe. Kangaroo mother care keeps them warm, encourages breast eeding and protects them romin ection. Tese inexpensive interventions havent takenhold, but a new analysis in this report shows that our basic

o u o o cou v o 1 o wannually as soon as they do. Improvements in access tocontraceptives, maternal nutrition and breast eeding prac-

c wou v v o .Saving newborn lives will prevent incalculable su -

ering. It is also a vital piece o the global developmentagenda. Te long-term economic prospects o poor coun-tries depend on investments in the health, nutrition andeducation o the people, particularly the women andyou g c v g . C u v v g ing healthy means more children in school and able to

learn, which in turn means productive adults who canv u co o c g ow .

Tere are clear opportunities to have an immediateimpact with smart investments in newborn survival. Tereis also a power ul rationale or making these investments

p o y. A oo w o, w w w gchapter in the terri c story o child survival and o global

v op w g .

Melinda GatesCo-chair o the Bill & Melinda Gates Foundation


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Introduction

Ev y y , ouState o the Worlds Mothers po

us o the inextricable link between the well-being o moth-ers and their children. As any mother mysel included will tell you, our childrens health is the most impor-tant thing in our lives. And we know that a strong and

pow o c p o c w vhave. More than 90 years o experience have shown us thatw o v c , uc o co o coppo u , o y c v c c o u v v v .

But many are not so ortunate. In 2011, 287,000 womendied during pregnancy or childbirth, and 6.9 million chil-

dren died be ore reaching their th birthday. Almost allthese deaths occur in developing countries where mothers

c ck cc o c c . W cmortality rates have declined in recent decades, 19,000

o ou o o c c v y y an unthinkable number o heartbreaks. Tis is unaccept-

w o o p v .Tis years report looks at the critical rst day o li e,

when mothers and their newborns ace the greatest threatsto survival, and when there is tremendous opportunity to save lives. It highlights approaches that are working

to bring essential health care to the hard-to-reach places where most deaths occur. And it shows how millions morelives can be saved each year i we invest in proven solutionsand help mothers do whats best or their children. I wedont save lives on this critical rst day, we struggle to meetour commitment to achieve the Millennium DevelopmentGo o uc g c o y y wo y 2015.

S v C wo k g o ou o p o our global campaign to save childrens lives, EVERY ONE:

First, we are increasing awareness o the challenges and

o u o o , w o c u v v . Apart o our campaign, this report calls attention to areas where greater investments are needed and shows thate ective strategies are working, even in some o thepoo p c o .

S co , w cou g g c o y o z g c -zens around the world to call or policy and politicalchange to reduce maternal, newborn and child mortality,and to advocate or increased leadership, commitment

u g o p og w k ow wo k.

hird, working in partnership with governments,civil society and the private sector, we are supporting

o o v g qu y vout the developing world. By improving pregnancy anddelivery care, vaccinating children, treating diarrhea,

pneumonia and malaria, as well as improving nutrition, we have saved millions o lives. Many more could besaved, i only more resources were available to ensure

c c v y c .

Fou , w co o g w p to determine what tools and approaches work bestto save the lives o babies in the rst month o li e.Ou g ou - k g Saving Newborn Lives p og ,

u c 2000w g o B & MGates Foundation, has helped deliver better carepractices and improved health interventions to savenewborn lives in 18 countries. Te challenge now isto get governments to ensure these li esaving servicesand practices reach mothers and newborns everywhere.

Tis report contains our annual ranking o the best and worst places in the world or mothers but no matter i theyre in the United States or Malawi or India, all mothersare undamentally the same. Every night, millions o moth-ers around the world wish or their children to be sa e,

ppy y. I w w w o ou A c y o oo uc o k.

When a child is placed into his mothers arms orthe rst time, that womans li e is changed orever. Temoment is brie and precious. We must seize the opportu-nity to invest in this most basic, most enduring partnership between a mother and her child i we are to change

orever the course o history and end preventable childdeaths. Please read the ake Action section o this report

jo o g w y o wou o: pw - g o c .

Jasmine WhitbreadCEO, Save the Children International


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4 SAvE THE CHI LDREN STATE oF THE WoRLDS MoTHERS 2013India


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Executive Summary: Key Findingsand Recommendations

Mo 1 o o y o k g y

the most dangerous day or babies in nearly every country, rich and poor alike.Tis is one o the major ndings o Save the Childrens 14th annualState of the Worlds Mothers po . T g c , v o , p g

u v v y w k o p gremaining challenge in reducing child mortality and meeting the ambitiousMillennium Development Goal o reducing 1990 child mortality rates by two-

y 2015.Te world has made unprecedented progress since 1990 in reducing maternal

c . Wo k g og , gov , co u , o gov -mental organizations and amilies have reduced the annual number o childrenu 5 w o c y y ov 40 p c o 12 o o 6.9 o .

Progress or mothers has been even greater, with deaths declining almost 50p c c 1990 o 543,000 o 287,000 p y .

But we have made much less progress or the children who are the mostvulnerable o all newborns. In 2011, 3 million babies died in their rst montho li e. Tis is 43 percent o all deaths o children under age 5 worldwide. Tree-qu o o w o w k o v , o -

o u v v y o . Why such slow progress in reducing newborn deaths? One reason is that

until recently many believed incorrectly that little could be done to savenewborn lives in the poorest countries. We now know that newborn deaths are

o v ow- co cou c k g c p og reducing newborn mortality. We have identi ed the three major causes o thesedeaths complications during birth, prematurity and in ections and we have

v op o v o c p v o c o c u .Tese proven interventions coupled with stronger health systems and

sufcient health care workers who are trained, deployed and supported totackle the key causes o child mortality have the potential to reduce newborndeaths by as much as 75 percent. Tis would save more than 2 million newborn

v c y . E g p v w g o w qu increased ocus on the steps needed to reduce newborn mortality. What is lack-ing is the political will and unding to deliver these solutions to all the mothers

w o .Tis years State of the Worlds Mothers report shows which countries are

succeeding and which are ailing in saving the lives o mothers and theirnewborn babies. It examines the ways investments in health care, nutritionand education can make a di erence or newborns, mothers, communities and

oc y w o . I o po o p ov , ow-co o u o cou vo o v u y o w o .

MotherS and neWbornS:Vital StatiSticS

E er ear, 40 milli n w men gi ebirth at h me with ut the help askilled birth attendant.

E er da , 800 w men die duringpregnanc r childbirth and 8,000newb rn babies die during their rstm nth li e.

Newb rn deaths acc unt r 43percent all deaths am ng children

under age 5.3 milli n newb rn babies diee er ear m stl due t easilpre entable r treatable causes suchas in ecti ns, c mplicati ns at birthand c mplicati ns prematurit .

60 percent in ant deaths ccur inthe rst m nth li e. Am ng th se,nearl three- urths (2 milli n per

ear) die in their rst week. Andm re than a third (1 milli n per ear)die n their da birth.

Nearl all newb rn and maternaldeaths (98 and 99 percent, respec-ti el ) ccur in de el ping c untrieswhere pregnant w men and newb rnbabies lack access t basic health careser ices be re, during and a terdeli er .


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Key Findings

1) Te frst day o li e is the most dangerous day or mothers and babies. Worldwide, the day a child is born is by ar the most dangerous day in a childsli e. Save the Childrens rst-everBirth Day Risk Index compares rst-day death

o 186 cou o cou , cest risk on the day they are born. Babies in Somalia have the highest risk o

dying on their birth day. First-day death rates are almost as high in DemocraticRepublic o the Congo, Mali, and Sierra Leone. Mothers in these our countries

o g k o y. Mo So Sco g k o v y.( o read more, turn to pages 27-35.)

2) Te frst day is also a day o unequaled opportunity to save lives and set the stage or a healthy uture.Most newborn and maternal deaths could beprevented by ensuring that mothers and newborns have access to low-cost,

v g v o oug p ov xp Ensuring access to well-trained and equipped health care workers during child-birth is part o the solution. According to the United Nations, our productscou g y wo k v g y w o vanalysis by Save the Children estimates that within the rst month o li e, morethan 1 million babies could be saved each year with universal access to thesep o uc , w c co w 13 c US$6 c

c -up ow. T p o uc : steroid injections or women in preterm labor (to reduce deaths due to

p u g p o ); u c o v c ( o v w o o o c o x co c g ( o p v u c co j c o c ( o w o p p u o

Other low-cost interventions such as kangaroo mother care and early andexclusive breast eeding would save many more babies. Such interventions, aspart o strengthened health care systems, not only can dramatically reducematernal and newborn deaths, but also can prevent a li etime o negativehealth consequences such as long-term disabilities, intellectual impairment and

c vu y o . Poo o o y coand their amilies, it can also impede a nations e orts toward economic growth. ( o read more, turn to pages 37-49.)

3) Mothers and babies in sub-Saharan A rica ace the greatest risks.Maternal,child and newborn death rates have declined across the developing world since1990, u p og ow u -S A c . S v annual Mothers Index assesses the well-being o mothers and children in 176countries. Te bottom 10 countries on the Mothers Index are all in sub-Saharan A rica. Not surprisingly, many o these same countries also have very high rateso - y , u -S A c o occup 10 wthe Birth Day Risk Index . Seven countries Central A rican Republic, Chad,Cte dIvoire, Democratic Republic o the Congo, Mali, Sierra Leone andSo co o o 10 o o c . W o struggle or survival in much o sub-Saharan A rica, a number o countries havedemonstrated that progress is possible despite great challenges. For example,Mali


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M w uc w o o y y 44 p c c 1990. AM , z Ug v po po cy c g o p ovtheir readiness to expand newborn health programs. (To read more, turn to pages

27-35 and 65-74.)4) In South Asia, mothers and babies die in great numbers. An estimated423,000 babies die each year in South Asia on the day they are born, more than

y o g o . Sou A ccou o 24 p c o wo popu -o 40 p c o wo - y . I I w co o c

growth has been impressive but the bene ts have been shared unequally 309,000 babies die each year on the day they are born (29 percent o the globaltotal). Bangladesh and Pakistan also have very large numbers o rst-day deaths(28,000 and 60,000 per year, respectively.) Mothers in South Asia also die in

g u . E c y , 83,000 wo Sou A u g p g cy

or childbirth. India has more maternal deaths than any other country in the world (56,000 per year). Pakistan also has a large number o maternal deaths(12,000).( o read more, turn to pages 27-35 and 65-74.)

5) Babies born to mothers living in the greatest poverty ace the greatest challenges to survival. At the heart o the newborn survival problem is the widening gap between the health o the worlds rich and poor. Virtually all (98percent) newborn deaths occur in developing countries, and within many o these countries, babies born to the poorest amilies have a much higher risk o death compared to babies rom the richest amilies. A new analysis o 50

v op g cou ou o o o poo o population were on average 40 percent more likely to die compared to thosein the richest th. Disparities within countries like Bolivia, Cambodia, India,

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Morocco, Mozambique and the Philippines are especially dramatic. Many newborn lives could be saved by ensuring services reach the poorest amiliesin developing countries. For example: I all newborns in India experienced thesame survival rates as newborns rom the richest Indian amilies, nearly 360,000

o wou u v v c y . C o g qu y g p Democratic Republic o the Congo would similarly save the lives o 48,000and 45,000 newborns each year, respectively.(To read more, turn to pages 15-21.)

6) Funding or newborn survival programs does not match the need. Temajority o health unding in most developing countries is rom domestic

ou c . M y v op g o cog z p y oor the health o mothers and newborns and the importance o eliminating nancial barriers that limit access to care. Within this context, development

assistance can play an important role in helping to improve newborn health. W g o uppo o , w o c

c 2000, v y ow o o c g vlion newborn deaths and 2.6 million stillbirths that occur worldwide every year. More speci cally, donor unding or newborn care is extremely smallco p o u , p o w g o o .( o read more, turn

to pages 51-53.)7) In the industrialized world, the United States has by ar the most frst-day deaths. Only 1 percent o the worlds newborn deaths occur in industrializedcou , u w o p o k ,

y o , w y g k o countries. Te United States has the highest rst-day death rate in the industri-

z wo . A 11,300 w o c y

Ethi pia


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States on the day they are born. Tis is 50 percent more rst-day deaths than allo u z cou co . W - y UStates are compared to those in the 27 countries making up the EuropeanUnion, the ndings show that European Union countries, taken together, have1 million more births each year (4.3 million vs. 5.3 million, respectively), butonly about hal as many rst-day deaths as the United States( 11,300 in the U.S.vs. 5,800 in EU member countries). In Australia, Austria, Canada, Switzerlandand the United States, 60 percent or more o babies who die in their rst month

o y. Cu o o ow o y o - y rates among disadvantaged groups in wealthy countries, but newborn andin ant mortality are o ten higher among the poor and racial/ethnic minorities,and populations with high newborn mortality rates also tend to have high

rst-day death rates. Poor and minority groups also su er higher burdens o prematurity and low birthweight, which likely lead to rst-day deaths in theU.S. w .( o read more, turn to pages 55-57.)

2013 MotherS index rankingS

t p 10 b m 10

RANK CoUNTRy RANK CoUNTRy

1 Finland 167 Cte d'I ire

2 Sweden 168 Chad

3 N rwa 169 Nigeria

4 Iceland 170 Gambia

5 Netherlands 171 Central A rican Republic

6 Denmark 172 Niger

7 Spain 173 Mali

8 Belgium 174 Sierra Le ne9 German 175 S malia

10 Australia 176 DR C ng

Sa e the Childrens 14th annual Mothers Index assesses the well-being m thers and children in 176 c untries m re c untries than in an pre i us

ear. Finland, Sweden and N rwa t p the rankings this ear. The t p 10c untries, in general, attain er high sc res r m thers and childrens health,educati nal, ec n mic and p litical status. Dem cratic Republic the C ngranks last am ng the c untries sur e ed. The 10 b tt m-ranked c untries all r m sub-Saharan A rica are a re erse image the t p 10, per rmingp rl n all indicat rs. The United States places 30th this ear. C nditi ns

r m thers and their children in the b tt m c untries are grim. on a erage,1 w man in 30 dies r m pregnanc -related causes and 1 child in 7 dies be rehis r her th bir thda . These statistics g ar be nd mere numbers. Thehuman despair, l st pp rtunities and impaired ec n mic gr wth representedin these numbers demand m thers, amilies and c mmunities e er where begi en the basic t ls the need t break the c cle p ert and impr e the

ualit li e r themsel es, their children, and r generati ns t c me.See the Appendix or the Complete Mothers Index, Country Rankings and an expla-

nation o the methodology.

Finland

I l cu , a I c iv tupp t I , s k

S v w s v

P v h sp .


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Recommendations

1) Address the underlying causes o newborn mortality, especially gender inequality. When mothers are strong and stable physically, nancially andsocially their children are more likely to survive and thrive. Educated girls

o y g c g , wmore ully developed. Tey are also more likely to make healthy choices or

v . W - ou g o g ow umothers who are less at risk or many health problems, including pretermbirth. And amily planning saves the lives o mothers and babies by enabling wo o vo p g cy w y oo you g o oo o ,

y v . M u o g g c o y uppo y c o c

o .( o read more, turn to pages 37-38.)

2) Invest in health workers especially those working on the ront lines toreach the most vulnerable mothers and babies. T wo c o g o 5 o wo k o yp cu ohealth workers, including 350,000 with midwi ery skills. New rontline health workers need to be recruited and trained, and those who are already practicing need opportunities to update and improve their skills. Tese health workers

u p o u c o g y , p oy o ties where they are most needed. Midwives and birth attendants need training,supplies and appropriate acilities to prevent and respond to birth complica-

o . I ou o c c c u p o g v g co co o o o p o , w c c

lungs develop so that they can breathe when they are born. Birth attendants also g o p w o u v v go u

moment a ter birth when, i a baby is not breathing spontaneously, a simplev o c v .( o read more, turn to pages 38-48.)

3) Invest in low-cost, low-tech solutions which health workers can use tosave lives during pregnancy, at birth and immediately a ter birth.Mo w-

o cou p v y u g cc o vapproaches, including: treatment o in ections in pregnant women; accessto low-tech equipment that can help babies breathe; clean cord care using c o x ; p o p o w o c o ;

o o ou po c o p op yg , w ing or newborns. Increasing the use o these services and these practices canp v up o 3 ou o 4 w o .( o read more, turn to pages 38-48.)

4) Strengthen health systems and address demand-related barriers to accessand use o health services.Investing in skilled birth attendants and other ront-line health workers is a critical piece o a broader movement to ensure UniversalHealth Coverage so that everyone starting with the most vulnerable receivesessential, high-quality care without nancial hardship. Developing nations needsupport in building strong, ully unctioning health systems and removing

c o p v o w othe care they need. Te success o Universal Health Coverage should be judgedby its success in delivering health outcomes, including reducing newborn,maternal and child mortality. Tousands die every day in developing countries

c u y g o y u u ck

upp o v v . T wo o uthe social, cultural and nancial barriers that prevent amilies rom receiving

Pakistan


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quality health care. More unding is needed or better acilities, or logisticsystems that reliably provide drugs and commodities, to ensure that services areaccessible to the most vulnerable, and or national and local monitoring thatincludes indicators o the coverage and e ectiveness o basic components o

w o c , o cou k o c p og g . ( o read more, turn to pages 46-49.)

5) Increase commitments and unding to save the lives o mothers and new-

borns. In order to meet internationally agreed-upon development goals toreduce child and maternal deaths, li esaving services must be increased or women and newborns. In most countries the majority o health nancing co o o c ou c . I y c , cou o c public investment in health especially investments in maternal, newborn andc k p o u c p y o c not a barrier to survival. Developing countries should develop their own undedroad maps to identi y and implement solutions that work best within their exist-

g y o p v w o . A go stakeholders, including donor countries, developing countries, internationalagencies, nongovernmental organizations (NGOs) and the private sector all

have separate roles to play in helping improve and expand e ective health carecoverage so even the poorest mothers and their newborns have access to quality care. NGOs, in particular, can help monitor progress and make sure stakehold-

ccou .( o read more, turn to pages 59-63.)

Uganda


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12 SAvE THE CHI LDREN STATE oF THE WoRLDS MoTHERS 2013Bangladesh


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Two Decades of Progress,But Change Has Been Too Slowand Uneven

Every year since 1990, the number o children under age 5 dying around the world has allen. Five million ewer children died in 2011 than in 1990. Te world is nearing a tipping point, where we see the real possibility o ending p v c ou .

Tis dramatic progress has been encouraging, and it shows that when ami-lies, communities, governments and NGOs work together, millions o lives can

v p ov . Bu w o c u v v g o g 5, p og-ress has been slower or survival during the rst month o li e the newbornperiod. Some 43 percent o under-5 deaths now occur among newborns, andthis percentage is rising. In all regions but A rica, that proportion is roughly 50

p c o o . I wo o c v go o c g p vc , w u ocu o o c g o w o u v v .

MillenniuM deVeloPMent goalS

The Millennium De el pment G als (MDGs) are eightgl ball agreed up n targets t reduce extreme p ertand pr m te human rights underpinned b measurabletimeb und targets. The target r MDG 4 is t reduce thew rlds under-5 m rtalit rate b tw -thirds between1990 and 2015. The target r MDG 5 is t reduce thematernal m rtalit rati b three- uarters er thesame peri d.

Man MDG targets ha e alread been reached ahead the 2015 deadline: extreme p ert has been reducedb hal ; the pr p rti n pe ple wh lack dependableaccess t impr ed s urces drinking water has beenhal ed; c nditi ns r m re than 200 milli n pe ple li ingin slums ha e been impr ed d uble the target andprimar sch l enr llment girls n w e uals that b s.1 These results represent tremend us pr gress, butmuch remains t be d ne.

Substantial pr gress has been made in reducing childm rtalit (d wn 41 percent r m 1990 t 2011), but thesegains are still insu cient t achie e the targeted tw -thirds reducti n. Similarl , maternal m rtalit has beencut nearl in hal since 1990, but this alls sh rt thetargeted three- uarters reducti n. 2 Se ent - e pri ritc untries ha e been identi ed which t gether acc unt

r m re than 95 percent maternal, newb rn and childdeaths each ear. These are kn wn as the C untd wnc untries. With the 2015 deadline ast appr aching, nl28 these c untries are n track t achie e the childsur i al g al3 and ar ewer nl 9 ( the 74 c untries

with a ailable data) are n track t achie e the maternalsur i al g al.4

While it will be a challenge t meet MDGs 4 and 5, as wellas ther remaining g als, success is still p ssible but nli g ernments d n t wai er r m their c mmitmentsmade er a decade ag .

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Te good news is that we have proven solutions to this problem. Many developing countries have made remarkable progress in reducing newbornmortality. Teir experiences show the way orward. Bangladesh, Cambodia and Nepal to name a ew have demonstrated that e ective solutions to thisc g x o , v poo cou

How have developing countries saved newborn lives? Tey have ocused onhigh-impact interventions and made sure these interventions reach many moth-ers and babies. With help rom the international community, they have trainedand deployed more health workers, removed nancial and other barriers to care,strengthened their health systems and increased equity. Tese investments pay o not only in lives saved, but also in better long-term health and economic

potential.5

In addition, many o the same interventions that save newborns alsov o p v , p ov g p uCompared to 10 years ago, many governments o low-income countries

ow p y g uc o g o p o o g v g ppcountry-wide basis. For example: Malawi is championing the use o breast eed-ing at birth and skin-to-skin care or warmth as e ective practices every mothercan and should undertake a ter the birth o her child. Nepal and Nigeria areusing an inexpensive gel called chlorhexidine to prevent in ections o babiesumbilical cords. Uganda is pioneering greater use o antenatal steroids to reducedeaths among premature babies. And Ethiopia has announced a country-wideprogram that will involve thousands o health care workers in the ght against

w o c o .

Major gainS for MotherS and older children, but SloWer ProgreSS for neWbornS

Rates child and maternal m rtal-

it are declining aster than e erbe re. Since 1990, maternal deathsand child deaths a ter the rst m nth

li e ha e been cut alm st in hal (b th b 47 percent). But newb rnm rtalit has nl dr pped 32percent. All regi ns the w rldare experiencing sl wer declines innewb rn m rtalit than in lder childm rtalit . Because this sl werdecline, newb rn deaths n w acc unt

r a higher pr p rti n under-5deaths: 43 percent in 2011, up r m

36 percent in 1990. Data s urces: UNICEF Gl bal Databases;Data c mpiled r A Decade o Change or Newborn Survival, Policy and Programmes (2000-2010): A Multi- Country Evaluation o ProgressTowards Scale. Health Policy and Planning,andUNICEF, Levels and Trends in Child Mortality:2012 Report .

* Den tes children 1-59 m nths age(i.e., all children under age 5 wh sur i e the newb rn peri d)

N e w

b o r n

& c h

i l d * m o r t a l

i t y r a t e s

( d e a t

h s p e r

1 , 0 0 0 l i v e

b i r t h s )

M a t er n

a l m

or t a l i t y r a t i o

( d e a t h s p er 1

0 0 , 0 0 0 l i v e

b i r t h

s ) 1990 1995 2000 2005 2010

Child deaths*

Maternal deaths

Newb rn deaths

60

50

40

30

20

10

0

500

400

300

200

100

0


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15

Growing Gaps Between Rich and Poor W cou , o o p o p ou g o oc y v the greatest reductions in preventable newborn deaths. Not surprisingly, thebetter-o amilies everywhere tend to have better nutrition, better sanitation

cc o v g c . T w o y g to be rom amilies with the lowest incomes in the most remote areas. Tey livein communities where there are ew health clinics and ew health personnel, orw uc v c o x u ou o c u o c pervasive poverty. Tey o ten belong to ethnic or religious minority groups that

v c g o o g c c o .Te majority o babies whose lives have been saved were o ten the ones who

w o c . wo c o p og , p g cco p ,have le t large gaps between rich and poor. Te challenge now is to deliverp ov o u o o g co u jo .

While dozens o countries mostly middle-income countries in EasternEurope and Latin America have halved newborn mortality in the last decade,countries in sub-Saharan A rica, on average, have seen no statistically signi cantc g .6 W ou c c g j c o y o A c ,

w k ov 150 y o A c w o o v c co u v v o o Eu op o No A c .7 P og Sou A ,w g c , o gg o wo .

12 deVeloPing countrieS Making the greateSt StrideS to SaVe neWborn liVeS

Newb rn deaths per 1,000 li e births

These 12 c untries ha e cut theirnewb rn m rtalit rates signi cantlsince 1990. B lstered b this pr gressin sa ing newb rn li es, all are ntrack t achie e MDG 4.

N te: Anal sis was limited t the 75

pri rit (i.e., C untd wn) c un-tries r maternal and child sur i al. Data s urces: Data c mpiled r A Decadeo Change or Newborn Survival, Policy and Programmes (2000-2010): A Multi-Country Evaluation o Progress Towards Scale; WHo andUNICEF. Countdown to 2015 Building a uture

or Women and Children: The 2012 Report.

0 20 40 60

Peru

Bra il

Eg pt

China

Mexic

La PDR

Bangladesh

Guatemala

Ind nesia

vietnam

Camb diaNepal

19902011

26

27

20

23

17

38

52

28

29

22

37

51

9 65% decline

10 64% decline

7 63% decline

9 62% decline

7 59% decline

18 54% decline

26 49% decline

15 48% decline

15 48% decline

12 47% decline

19 47% decline

27 47% decline


18/88


High-income countries have the lowest newborn mortality rates and ewestnewborn deaths compared to the rest o the world, and they have also madesome o the astest reductions in newborn mortality. While newborn mortality

v c g o o wo , p og slowest regions with the highest rates, especially sub-Saharan A rica. Because o this,

g p w c poo cou co u o c. A w o , v op wo 2.7 p c uc

in newborn mortality. Tis is twice the reduction seen in sub-Saharan A rica (1.3 percent per year) and 50 percent higher than that seen in South Asia (1.9percent per year) rom 1990-2011. Moreover, o the 10 countries with the greatestrelative reductions in newborn mortality (all achieved reductions o more than70 p c ), u z o g - co cou (CRepublic, Estonia, Lithuania, Oman, Portugal, San Marino, Saudi Arabia andS ov ) o Sou A upp - - co cou y (M

National averages o ten hide important disparities within countries. In many countries, the newborn mortality gap between rich and poor has widened

despite alling national rates overall. When progress dis avors those who need ito , c o o v qu y cto-reach amilies. In Cambodia, or example, the newborn mortality rate among the poorest th o the population has declined by only 5 percent over the past10 years, but among the wealthiest th the rate has allen by nearly 40 percent.Similarly, in Nepal, declines were 35 percent among the poorest and 60 percentamong the richest between 1996 and 2011. In Peru and the Philippines, survivalg o pp o v p opo o y 8

On the positive side, several countries have shown that it is possible to makep og v g w o v w ou c g qu y.

x p , v y v g uc g w o o

all income groups, which means it has neither increased nor decreased inequity.I Egyp , p og pp o v c u y vo poo

Sub-Saharan A rica has sh wn theleast pr gress an regi n in c m-bating newb rn deaths er the lasttw decades. In act, due t sl wldeclining m rtalit rates and risingp pulati n er the peri d 1990-2011, the number newb rns whdied in sub-Saharan A rica actuallwent up ( r m 1.0 t 1.1 milli n)e en th ugh newb rn m rtalit rates

ell erall.

Data s urce: UNICEF Gl balDatabases.

neWborn deathS haVe declined eVeryWhere but africa

N e w

b o r n

d e a t

h s

( m i l l i o n s )

1990 1995 2000 2005 2010

5

4

3

2

1

0

Change 1990-2011

East Asia & Paci c 65%

CEE/CIS 58%

Latin America 58% & Caribbean

Middle East 35% & N rth A rica

S uth Asia 33%

Sub-Saharan A rica 10%


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17

neWborn SurViVal gainS are SloWeSt in the PooreSt countrieS

C untries acr ss all inc me le elcateg ries ha e made pr gressin reducing newb rn m rtalit .H we er, the gap between rich andp r has widened as high-inc mec untries maintain the l west ratesand achie e the astest reducti ns.

Data s urce: UNICEF. Levels and Trends inChild Mortality: 2012 Report.

Philippines

50

45

40

35

30

25

20

15

10

5

0

High Middle L w

Inc me gr up

50%Decline

31%Decline

30%Decline

N e w

b o r n

d e a t

h s

( p e r

1 , 0 0 0 l i v e

b i r t h s )

1990 2011


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qu y g p. B w 1995 2008, w o o y o o w Egyp y 38 p c ,

poo Egyp 60 p c .9

Where Are Babies Most at Risk? At the heart o the newborn survival problem is a stubborn and widening

g p w o wo c poo . V u y o w o occu v op g cou .

A o u -S A c , o x p , 30 o o u z cou y o o w o y

her li e.10 On average, 1 in 6 A rican mothers is likely to lose a newborn baby a co o p c u g y u o o g .

Te newborn mortality rate (34 per 1,000 live births) is highest in sub-S A c , g o w c A c (

). Sou A g y ow w o (32because o that regions higher population density, it accounts or 41 percent o

wo w o o o y g o . I o 30 p c o wo w o .11

Especially high newborn mortality rates are seen in countries with recent wars or civil unrest, such as Angola, Central A rican Republic, Cte dIvoire,D oc c R pu c o Co go, M , S L o So

Nigeria


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19

B o o poo o u c g c g o u v v . While many countries have achieved some success in increasing the numbero o w o g v c c , y poo wo u

g v o , w ou y co c w y . Tmother might be aided at delivery by a neighbor or amily member or by no oneat all. In sub-Saharan A rica, or example, only 46 percent o women deliver in

c y. T gu v ow Sou A (43 p c ).12I ocommunities, such as certain rural areas o India, a woman gives birth in the

o ou , w o p c o foo y a ter birth, and breast eeding is discouraged or several days. In Bangladesh,Ethiopia and India, the mother and her newborn are o ten kept in isolation ortwo weeks or more, or the purpose o ending o evil spirits.13 Tese are just

wo x p o cu u p c c u o w o . An analysis o 50 developing countries ound babies born to mothers in the

poorest th o the population were on average 40 percent more likely to diecompared to those in the richest th.14 A similar analysis o 38 countries in A rica and Asia ound babies born in rural areas were 20 percent more likely to

co p o o u .15 D p w o cou p c y c. Fo x p ,

Bolivia, babies born to the poorest 20 percent o mothers die at nearly threetimes the rate o babies born to the richest 20 percent o mothers. Similarly,

MoSt neWborn deathS occur in juSt 10 countrieS

Nearl tw -thirds all newb rn deaths (2 milli n ut 3 milli n each ear) ccur in just 10 c untries. Man these c untries ha e er large p pulati ns (such as

China and Ind nesia) and thers ha e high percentages newb rns d ing (A ghanistan, DR C ng , Ethi pia and

Tan ania). Se eral ha e b th large p pulati ns and highnewb rn m rtalit rates (Bangladesh, India, Nigeria andPakistan). These are places where m thers are als at high

risk death during pregnanc and childbirth 59 percent maternal deaths ccur in these same 10 c untries.

Data s urces: Health Newb rn Netw rk (data c mpiled r ADecade o Change or Newborn Survival, Policy and Programmes (2000-2010): A Multi- Country Evaluation o Progress Towards Scale) and UNICEFGl bal Databases.

Nigeria

254,100

DR C ng

137,100

A ghanistan

51,000

65 % ws

Ind nesia

66,300

Tan ania

48,100

Pakistan

169,400

India

876,200

Ethi pia

81,700

1

2

3

4

5

67

8

9

10

1 2 3 4 5 6 7 8 9 10

Bangladesh

79,700

China

143,400


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babies born to the poorest mothers in Cambodia, India, Morocco, Mozambique P pp w c o o o

On the other end o the equity spectrum, in Ghana, Uganda and Malawi thereis no measurable gap in newborn death rates across income groups. Notably,

cou v po c o p ov c 16Many newborn lives could be saved by targeting programs to reach the

poorest amilies in developing countries. For example: I all newborns in India experienced the same survival rates as newborns rom the richest 20 percent o I , y 360,000 o wou u v v c ythe equity gaps in Pakistan and Democratic Republic o the Congo would

y v v o 48,000 45,000 w o c y , And i newborns in all these 50 countries experienced the same chances o survival as babies born to the wealthiest amilies in the same country (i.e. i the poorest 80 percent o amilies had the same newborn mortality rates as the

c 20 p c o ), wou uc y 29 psaving 653,000 newborn babies lives every year. Te biggest e ect would beseen in Cambodia, where closing the equity gap would result in a 48 percent

uc o w o o y. I N p , w o o y uc y 46 p c .17

india VoWS to continue ProgreSS

T da , the w rld is n the brink a maj r breakthr ught ensure newb rn babies e er where sur i e. I theres

ne place t trace the seeds this brewing re luti n,its India. yet t da , India als aces s me the greatestchallenges in seeing this re luti n thr ugh. It has per-sistentl high rates newb rn m rtalit and acc unts

r 29 percent all rst-da deaths gl ball m re than

300,000 a ear.In 1993, Dr. Abha Bang, wh spent his earl childh din a Gandhi ashram and is n w an internist and a publichealth expert trained at J hns H pkins Uni ersit , set utt address the biggest challenge acing pregnant w men inrural India n access t health clinics r h spitals t gi ebirth. T gether with his wi e, Rani, Dr. Bang pi neered as stem training c mmunit lunteers in 39 illages a tribal, insurgent, rural and p r district Ghadhchir liin central India t pr ide h me-based newb rn care.This included essential newb rn care, management birth c mplicati ns and management newb rn sepsis.

Their e rts pr duced dramatic l cal impr ements tnewb rn sur i al.

Since then, s me the w rlds p rest c untries ha eadapted Dr. Bangs m del and achie ed remarkable results.o er the ears, health w rkers in Bangladesh, Malawiand Nepal ha e likel pre ented hundreds th usands newb rn deaths.

In 2006, India went in a di erent directi n and beganering nancial incenti es r rural w men t gi e birth

in health acilities. Facilit births ha e b med, but new-b rn sur i al rates ha e n t reduced c mmensuratel ,because m st the acilities had neither the ualit care n r trained, m ti ated and e uipped health w rkersin place t handle the infux.

In the past ear, India has begun a maj r p litical m e-ment t s stematicall take n the c mplex and large-scalepr blem newb rn and child m rtalit in the w rldssec nd m st p pul us c untr . T gether with the UnitedStates and Ethi pia, India c -h sted a Child Sur i alCall t Acti n in Washingt n in June 2012 (A Pr miseRenewed). It has since rec mmitted itsel t a nati nalp lic g al ending child m rtalit in a generati n and

de el ped a clear r ad map r success.Man challenges remain, including a decentrali ed p liti-cal structure, health w rker sh rtages, rapid urbani ati nand p licies that currentl pr hibit the use s me the m st e ecti e inter enti ns t sa e babies, such aschl rhexidine and antenatal ster ids. But India has alreadm bili ed the m st imp rtant ingredient t achie e anlarge-scale change p litical will. And, r the rst time,newb rn sur i al is a central element a clear nati nalagenda r impr ing maternal and child health.


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21

SIzE oF THE EqUITy GAP EFFECT oF CLoSING THE GAP

NMR* am ngthe richest20%

NMR* am ngthe p rest20%

P rest'sele ated risk

death

% reducti nin newb rnm rtalit

Li es sa edper ear

Camb dia 16 39 144% 48 3,000

Nepal 19 37 95% 46 8,900

B li ia 17 50 194% 45 2,600

India 26 56 115% 41 358,400

Philippines 10 20 100% 41 11,800

Eritrea 18 24 33% 40 1,600

M ambi ue 29 59 103% 40 11,800

Namibia 16 29 81% 39 400

Haiti 19 24 26% 37 2,500

DR C ng 27 44 63% 33 44,600Niger 29 43 48% 33 8,000

* Newb rn m rtalit rate (per 1,000 li e births)

S urce: Anal sis DHS data r 50 de el ping c untries, 2000-2011.F r additi nal details, see Meth d l g and Research N tes.

10 countrieS that could SaVe the MoSt neWborn liVeS by cloSing the equity gaP

Ethi pia


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22 SAvE THE CHI LDREN STATE oF THE WoRLDS MoTHERS 2013S uth Sudan


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23

According to the most recent estimates, 35 percent o newborn deaths arecaused by complications o premature birth. Every year, about 15 million babies

o p c g o cou w data.19More than 1 million babies die each year due to complications o pretermbirth.20Survivors may ace a li etime o disability, including learning disabilitiesand visual and hearing problems.21Babies born be ore 37 weeks o pregnancy areat risk due to loss o body heat, inability to take enough nutrition, breathing di -

culties and in ections. Almost hal o all preterm babies are born at home, andv o o o c , c o ck g.22 P

c p v y v g o c o o o , u g

and a ter childbirth. Family planning and increased empowerment o women,especially adolescents, will also help to reduce preterm birth rates. More research

cauSeS of neWborn deathS

Why Do Newborns Die?

Researchers have made tremendous advances in recent years to pinpoint the

c u o w o o y. W ow po o v o o ge ective solutions to the problems that kill the most newborns and to saveo v . As recently as 2005, gaps in monitoring and reporting meant that the relative

importance o di erent causes o newborn deaths was unclear in many develop-g cou . T cu o g k o w o .Now we know that the three major causes o newborn mortality are pre-

term birth, severe in ections and complications during childbirth. Tesethree causes together account or more than 80 percent o all deaths among

w o .18

Prematurit is the single largest

cause newb rn deaths w rldwide.Preterm births, se ere in ecti nsand c mplicati ns during childbirtht gether acc unt r m re than80 percent all deaths am ngnewb rn babies.

S urce: Li Liu, et al. Gl bal, Regi naland Nati nal Causes Child M rtalit :An Updated S stematic Anal sis r 2010 withTime Trends Since 2000. The Lancet.

35%

2%

2%

23%

23%

13%

11%

6%9%

Birth c mplicati ns

C mplicati ns r mpreterm birth

Diarrhea

Pneum nia

Se erein ecti ns

Sepsis/Meningitis

Tetanus

other

C ngenital


26/88


is needed to link the multiple causes o preterm birth to e ective solutions. Butit is clear that hundreds o thousands o preterm babies lives could be savedeach year using inexpensive solutions that havent yet taken hold in developing countries. For example, corticosteroids a common anti-infammatory can be

g v o o p o o v op u o y c w y o .(See pages

38-46 or more about low-cost solutions.)T co o co o k o w o

tions, particularly sepsis (blood in ection), pneumonia (lung in ection) and meningitis (in ection o the lining o the brain). Tese deaths are the easiest to prevent andtreat, so rapid reductions in death rates are possible with

expanded care. Some in ections such as newborn tetanus almost exclusively a ect the poorest amilies.23 o prevent death, newborn in ections must be

y, u u y w o c . Cois also important, as the mothers milk contains important antibodies to protectthe baby. Promising innovations such as chlorhexidine an easy-to-use anti-

p c u g g o v w v ou uc o o o o pu p o uc o

health workers and mothers. (See pages 38-46 for more about low-cost solutions to ght in ections.)

T f t u a ay a baby li ap cially c itical. Ab ut t -qua t

all wb at ( v 2 milli ) tak plac wit i w k bi t . 36 p c t

wb at ( v 1 milli ) ccu tay a c il i b .

grieVing in Silence

L sing a bab is a de astating experience and e erm ther experiences grie in her wn wa . But the pain canbe especiall intense in cultures where a w mans status isde ned b her ertilit , where newb rn deaths are hidden

r m s ciet , and where utward expressi ns grie aredisc uraged.

Because a w mans alue in traditi nal cultures is usuallcl sel linked t her abilit t pr duce children, l sing abab ma se erel a ect her sel -esteem and the wa sheis treated b thers. A stud in rural India bser ed thatw men wh had su ered stillbir ths were at higher risk rmental health pr blems than their western c unterpartsbecause the s cial is lati n the experienced at a timewhen the were m st in need em ti nal supp rt. 24

W men in Mala sia wh had l st a newb rn rep rtedeelings emptiness, c n usi n, anger, anxiet and guilt.

I asked m sel , did I d s mething wr ng? said new man.25

In rural Tan ania, public grie ing a ter the l ss anewb rn is disc uraged in rder t pre ent g ssip andbewitchment. Female elders tell the m ther that suchm urning c uld lead t in ertili t and e en death uturechildren. The m ther is ad ised t suppress her em ti nsin rder t speed her healing and pre ent an ther l ss. Ine er cried when m babies died, n t e en r ne min-ute, said ne Tan anian w man. It is said it is rbiddent cr . y u cr nl silentl kimoyo moyo(in ur heart). 26

In Nigeria, w men are disc uraged r m seeing r h ldingthe b d their bab and it is ten buried uickl in anunmarked gra e. The bab is n t gi en a name and there is

n cial m urning pr cess. W men are t ld the sh uldn t talk ab ut the l ss. 27

W men in Bangladesh rep rted eelings guilt and expe-rienced high rates depressi n. The als experienceddeteri rati n relati nships with their husbands andhusbands amilies. The auth rs ne stud c ncludedthere is an urgent need t de el p mental health ser ices

r m thers wh ha e su ered perinatal l ss, a daunt-ing challenge in a c untr with nl ne ps chiatrist re er 2 milli n pe ple. Their rec mmendati n: A specialappr ach using c mmunit health w rkers with training inculturall appr priate mental health care. 28

Liberia


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25

the neglected tragedyof StillbirthS

E er da , m re than 7,300 babies arestillb rn. Like newb rn deaths, still-births ccur m stl am ng the p rin de el ping c untries, ten in ruralareas. 36 The l ss is e uall tragic,

and ten pre entable, et stillbirthsha e been largel neglected b thegl bal public health c mmunit untilrecentl . And pr gress in reducingstillbirths has been e en sl wer thanpr gress r newb rn sur i al.37

In man de el ping c untries,stillbirth deaths are n t c unted,but rates are th ught t be highestin Pakistan and Nigeria (47 and 42per 1,000 births, respecti el ). B thc untries l se m re than 264,000

stillb rn babies each ear.38

Stillbirthrates are l west in Finland andSingap re (2 per 1,000 bir ths).

Man the 2.6 milli n stillbirthseach ear c uld be pre ented withthe same s luti ns that sa e m thersand newb rns, such as ualit careat birth, emergenc bstetric care(including caesarean secti n) andprenatal care. 39

Stillbirths are n t menti ned inMDG 4 r MDG 5. And nl recentl

(2011) ha e United Nati ns datas stems included in rmati n nstillbirths. Failure t set gl bal p licg als and targets t reduce still-births suggests that these newb rnsare in particular need atten-ti n.40 The Lancet Stillbirth Seriesin2011 culminated in a call r acti nt the internati nal c mmunit ,indi idual c untries, pr essi n-al rgani ati ns, and amilies t takea stand r stillbirths and c mmit thal ing the number stillbirths b2020 r m the 2008 rate. 41

The Gl bal Alliance t Pre entPrematurit and Stillbirth (GAPPS)is a c llab rati e e rt t ad anceresearch, accelerate de el pment anddeli er c st-e ecti e s luti ns,and raise awareness ab ut theseneglected issues. Nearl 200 gl balstakeh lders ha e utlined whatneeds t be d ne in the 2015 Global

Action Agenda on Preterm Birth and Stillbirth(GAA).42

M ambi ue

Babies born in the worlds least developed countries have a particularly g k o c - co p c o (k ow p yx )

. Mo o wo k g qu po x g wo k o p v y p ov g

prenatal care, skilled care during birth and emergency obstetric care. Teseservices are also critical or saving mothers who su er with obstructed laboro o g . W u o , y w o o g oube ventilated with a bag and a mask. Up to 10 percent o newborns require

o c o g g.29 O y 3-6 p c qu c u c -o ( v w 1 p c x v u c o )30, u

co c c qu w v 4 ou o 5 w o .31Ev y k ou o u c o - g y. How v , y

acilities in developing countries lack even the most basic equipment or resus-c o , o w v , wo k y o co pin its use. (See pages 41-42 for more about simple resuscitation devices and their potential to save lives.)

In addition to inadequate care o the baby, another major cause o newborndeaths in developing countries is the poor health o mothers, especially during p g cy, v y y po p u p o . M y p g woare inadequately nourished, overworked and may still be recovering rom a p v ou p g cy. Fo y o , c u g c c p o particularly during and immediately a ter birth is virtually nonexistent. It isestimated that each year 40 million women in developing countries give birth athome with no pro essional health care whatsoever,32and about 287,000 women

c o o co p c o o p g cy.33A y w o o c y u v v .34 O u y o B g

k o o up o 10 g o w o o w x w k c .35

Cu u u p c c c g g wo

also signi cantly contribute to maternal and newborn deaths. For example,in many parts o A rica and South Asia, control o household nances andthe decision-making authority lies with the husband or other male relatives.U o u y, y wo v o v w w g oa decision to be made by such gatekeepers. Constraints placed on womensmovement outside the home also limit their access to health acilities. Tisco u o ow v o p c , ow o c ,

ow u o po v c w o u z o .Low v o uc o o g c g v y fu c

- k g v o , k o o c o oaccurate in ormation. In poor communities o developing countries, it is o ten

the practice to seek medical care only as a last resort, or a variety o cultural y o , o c u o co o c .


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26 SAvE THE CHI LDREN STATE oF THE WoRLDS MoTHERS 2013S malia


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27

The Most Dangerous Places to be Born

Worldwide, the day a child is born is by ar the most dangerous day in that

c . A 1,049,300 c c y o y o li e, representing 15 percent o all deaths o children under 5 each year. Tisstaggering death toll, which has been determined through new original research,is largely the result o prematurity and complications during childbirth. I nations are truly committed to progress in reducing child mortality, they mustco c o o ou c o v y c y.

Save the ChildrensBirth Day Risk Index compares rst-day deaths in 186cou . I ow v y y, v yw , g k o o day they are born. Tis is true in every country in the world rich and pooralike. Te birth day is a highly vulnerable time or mothers as well about hal o k p c w o y o c .43

Somalia has the worlds highest rst-day death rate (18 per 1,000 live births).First-day death rates are almost as high in Democratic Republic o the Congo,M S L o (17 p 1,000). T ou cou o c y risky places or mothers. Mothers in Somalia and Sierra Leone ace the secondand third highest li etime risk o death in the world, respectively.44 In Somalia,1 wo 16 k y o p g cy o c . I S L o , o 1 23. DR Co go M o o g k p c wo o o .

N w o ow p 43 p c o g o u -5 o y. Aestimated 36 percent o these newborn deaths occur on the day a child is born.I current trends are allowed to continue, both o these percentages are likely

o .Te worlds lowest rst-day mortality rates are ound in Cyprus, Estonia,

Iceland, Luxembourg, Singapore and Sweden. Tese six countries all have rateso less than 0.5 per 1,000 live births, meaning that less than 1 birth in every 2,000 results in the death o a baby on the day he or she is born. Industrializedcou o v ow o - y , u k up

v y g p c g o c o y, u o g c c o pbirths and ewer deaths later in childhood. Generally speaking, 30 percent o

u -5 u z cou occu o y.wo regions sub-Saharan A rica and South Asia together account or

y 80 p c o wo - y .

Sub-Saharan A rica Su -S A c y k g o o o . T 14 cou

with the highest rst-day death rates are all in sub-Saharan A rica. As a region,sub-Saharan A ricas rst-day mortality rate is 12 per 1,000 live births. Babiesborn in sub-Saharan A rica are more than 7 times as likely to die on the day

y o u z cou . An estimated 397,000 babies die each year in sub-Saharan A rica on the day

they are born. Te region accounts or 12 percent o the worlds population but38 p c o wo - y .

SaVing MotherSand babieS duringeMergencieS

Imagine being eight m nths pregnantwhen armed rebels attack ur

illage. y u fee ur h me in search sa et . y u l se amil members

and riends. The crisis has le t uwith ut the em ti nal supp rt andthe health care s stem u weredepending n. y u ha e n ch icebut t deli er ur bab al ne, r

i u are rtunate, in a m bile rtemp rar clinic.

In the p rest c untries, anemergenc e ent be it c nfict,earth uake r f d usuall leadst a humanitarian crisis that can bede astating r pregnant w men andtheir newb rn babies.

Eight the 10 c untries with thehighest maternal m rtalit rati s inthe w rld are in ragile circumstancesdue t current r recent c nfict. 45 Newb rn m rtalit rates are alshighest in areas a ected b humani-tarian emergencies. 46 H we er,repr ducti e health particularlensuring care during childbirth has

nl recentl been rec gni ed as ake gap and pri rit in these settings.

A gr up gl bal health experts ledb WHo recentl agreed n mini-mum standards r care m thersand babies during emergencies. Thestandards include pr iding kits t

acilitate clean and sa e deli eriesand establishing re erral s stems tmanage bstetric emergencies. 47 TheCenters r Disease C ntr l andSa e the Children ha e als createdan Emergency Health and NutritionToolkitwith best practices t sa e theli es w men and newb rns a terdisaster strikes. 48


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W y u -S A c uc g ou p c o o ?M y u -S A c cou v u u u y g

birth. For example, in Malawi, 18 percent o babies are born too early thehighest prevalence in the world.49 In Botswana, Mauritania, Mozambique,Z w v o A c cou , o 15 p care born prematurely.50 Even more A rican babies are born too small. InM u , 34 p c o o w ow w g51I N g , 27p c o v ow w g .52

Poor health among A rican mothers contributes to high rates o rst-day death or babies. Serious maternal undernutrition is common in the region, where 10-20 percent o women are underweight.53 Low body mass index and

o u po k c o o cow g w o o y. E p c y g u o

mothers are ound in Ethiopia (24 percent), Madagascar (28 percent) andE (38 p c ).54I S L o , 13 p c o wo u is nearly twice the rate ound in any other A rican country with available data.55

I co o o wo u -S A c o y g you g g , o o v u y u . C

Republic, Chad and Niger have the highest rates o child marriage in the world more than two-thirds o women in their early 20s were married by the ageo 18. C g ov 80 p c ou u N56A the Amhara region o Ethiopia, 50 percent o girls are married be ore the ageo 15.57R g o -w , 14.5 o you g wo w children.58 Not surprisingly, countries with high levels o child marriage tendto have high levels o early childbearing.59 In Chad and Niger, or example,

ou (48 51 p c , p c v y) o you g wo wy g o 18.60

Low contraceptive use, high ertility and poor newborn outcomes go hand-in-hand.61 Across the region, less than 16 percent o women use a modern

o o co c p o .62 Co c p v u ow So C at only 1 and 2 percent but rates are also below 5 percent in Angola andGuinea.63 Its not surprising, then, that women in the region have on average

ve children each. Mothers in Malawi, Mali, Somalia and Zambia have six children on average. And in Niger, where ertility rates are highest in the world,

c o o v c p wo .64 H c o o u -S A c wo u y

v g , o y wo g o c v k c65 In Ethiopia, Niger and South Sudan, more than hal o all women receive

o u y o k p c . I So , 74 p c o pgo without care during pregnancy the highest rate in the world. In Niger and

South Sudan, more than 80 percent o women are unattended during child-birth.66 And in Ethiopia, up to 90 percent o women give birth at home withoutk c .67I M N g , 13 17 p c o wo g v

A N g , y 1 wo 5 o o o v o o p u g c .68

A severe shortage o health workers in A rica explains many o these direc . T g o w o o y 11 oc o , u

10,000 p op c c o o 23 gnecessary to deliver essential health services.69 Te most severe shortages o health workers are ound in Guinea, Niger, Sierra Leone and Somalia, wherethere are ewer than two skilled health workers or every 10,000 people. Out

o 48 cou u -S A c w v , o yu o o u o wo k .70Niger


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29

South Asia South Asia is the second riskiest region to be born. First-day mortality rates

vary greatly across the region, ranging rom a high o almost 13 deaths per 1,000v A g P k o ou 2.5 p 1,000 M v

S L k . A w o , g o 11 p 1,000. An estimated 420,000 babies die each year in South Asia on the day they

o . Sou A ccou o 24 p c o wo popu o 40p c o wo - y .

W c o co u o g o - y ?Many babies in South Asia are born too early. Region-wide, an average

o 13.3 percent o all live births are preterm, the highest regional rate in the world.71 Especially high preterm birth rates are ound in Pakistan, where 16percent o babies are born too early and in Bangladesh and Nepal where the

14 p c. Low birthweight is also a serious public health problem in most South

Asian countries. An estimated 28 percent o in ants in South Asia are bornoo o ou ou y o g o o wo .

R g P k , w 32 p c o o w ow w g I (28 p c ). Mo k y u , 2

ou o 3 w o g o o w g .72T o o y Sou A u g p o

poor nutritional status o mothers. Stunting among women (height o less than145 cm, or 4'7") is particularly severe in this region. For example, in Bangladesh,

Pakistan


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India and Nepal, 12 to 13 percent o women are stunted, which puts them at higher risk o complications during delivery and o having small babies. In these same coun-tries, 20 to 40 percent o women are excessively thin, whichco pou k o poo p g cy ou co .73

Early marriage and childbearing heighten the risksor both mothers and babies. According to UNICEFs

estimates, 34 million South Asian women aged 20-24 were married or in union be ore the age o 18 in 2009.74 C g y c g o pin Bangladesh, where 66 percent o young women weremarried75 and 40 percent had given birth76 by the timethey were 18. High rates o child marriage are also oundin India, where 47 percent o girls marry by the age o 18, although rates vary dramatically across income levels,

o ow o 16 p c o g g o wth o amilies to 75 percent among the poorest th.77

I A g N p , 40 p c o g o g o 18.78oo many women in South Asia give birth alone or

with only a riend or amily member helping, so many newborns die rom complications that could easily be pre-vented by a health worker with the right skills, the rightequipment and the right support. Region-wide, only 49percent o births are assisted by a skilled care provider.Coverage is lowest in Bangladesh, where 68 percent o women deliver their babies without skilled attendance.79 Birth attendance rates are similarly low in Nepal and A ghanistan, where more than 60 percent o women donot have skilled care during birth,80and among the women who do have skilled assistance, hal or more likely givebirth at home. 81 As a whole, South Asia has the lowest

c y o y g o o y 43 p ck p c c y.82

Although many countries in South Asia have madeg g c g cc o y p g, u in A ghanistan and Pakistan, where only 16 and 19 percent o women use mod-ern orms o contraception.83 Partly as a result, these countries have the highest

y g o , w c pu o o o death. In A ghanistan, women have six children on average. In Pakistan,

wo v c o v g .84

T o oug wo k Sou A o o mothers and babies. As a whole, the region has about 14 doctors, nurses andmidwives per 10,000 people (9 less than the recommended 23).85Health workershortages are most severe in A ghanistan, Bangladesh and Nepal (6 to 7 healthwo k p 10,000 p op ).86 O y M v S L k v oug oc

o , u w v o v v c

Which countrieS haVe the MoStfirSt-day deathS?

T p 10 c untrieswith the m st

rst-da deaths

Number rst-da

deaths

Share gl bal rst-da deaths

1 India 309,300 29%2 Nigeria 89,700 9%

3 Pakistan 59,800 6%

4 China 50,600 5%

5 DR C ng 48,400 5%

6 Ethi pia 28,800 3%

7 Bangladesh 28,100 3%

8 Ind nesia 23,400 2%

9 A ghanistan 18,000 2%

10 Tan ania 17,000 2%

t : 673,200* 64%*

*T tal di ers r m c lumn sum because r unding.

Nearl tw -thirds all rst-da deaths (673,000 ut 1 milli n in 2011) ccur in just 10 c untries. Man thesec untries ha e er large p pulati ns (such as China andInd nesia) and thers ha e relati el high percentages babies d ing n their birth da (A ghanistan, DR C ng ,Ethi pia, Pakistan and Tan ania). India with b th a largep pulati n and a high rst-da m rtalit rate is h met m re than 309,000 rst-da deaths (29 percent thegl bal t tal). Nigeria has the sec nd highest burden withnearl 90,000 rst-da deaths, r 9 percent the gl balt tal. S urce: Birth Day Risk Index , page 31.


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31

birth day riSk index

c

t

f s d * f s M * f s 5 y s*

First-daymortality rate(per 1,000 livebirths)

Number o irst-day deaths

Share o under-5 deathsthat are irst-day deaths**

Newbornmortality rate(per 1,000 livebirths)

Number o newborn deaths

Share o under-5deaths thatare newborndeaths**

Under-5mortality rate(per 1,000 livebirths)

Number o under-5 deaths

Somalia 18 7,400 10% 50 20,800 29% 180 71,100

Congo, Democratic Republic o the 17 48,400 10% 47 137,100 29% 168 465,100

Mali 17 12,600 10% 49 35,800 29% 176 121,500

Sierra Leone 17 4,000 9% 49 11,200 27% 185 42,100

Central A rican Republic 16 2,500 10% 46 7,200 29% 164 24,600

Angola 15 12,300 10% 43 34,800 29% 158 119,900

Cte d'Ivoire 15 9,900 13% 41 28,000 37% 115 75,500

Chad 15 7,600 10% 42 21,600 27% 169 79,300

Burundi 15 4,400 11% 43 12,400 32% 139 38,600Guinea-Bissau 15 910 10% 44 2,600 29% 161 9,000

Nigeria 14 89,700 12% 39 254,100 34% 124 755,700

Guinea 14 5,500 12% 39 15,500 33% 126 47,500

Mauritania 14 1,700 13% 40 4,800 37% 112 12,900

Lesotho 14 820 16% 39 2,300 46% 86 5,100

Pakistan 13 59,800 17% 36 169,400 48% 72 352,400

A ghanistan 13 18,000 14% 36 51,000 40% 101 128,400

South Sudan 13 4,400 10% 38 12,600 29% 121 43,400

Togo 13 2,500 12% 36 7,000 33% 110 20,900

Equatorial Guinea 13 350 12% 37 980 33% 118 2,900

Mozambique 12 10,600 12% 34 29,900 35% 103 86,000Burkina Faso 12 8,900 9% 34 25,100 25% 146 101,300

Cameroon 12 8,400 10% 33 23,900 27% 127 87,500

Gambia 12 810 13% 34 2,300 36% 101 6,400

Swaziland 12 430 12% 35 1,200 34% 104 3,600

Djibouti 12 300 13% 33 860 38% 90 2,200

India 11 309,300 19% 32 876,200 53% 61 1,655,400

Ethiopia 11 28,800 15% 31 81,700 42% 77 193,900

Sudan 11 12,200 13% 31 34,700 37% 86 94,700

Yemen 11 10,600 15% 32 30,000 43% 77 70,100

Myanmar 11 8,700 17% 30 24,600 47% 62 52,600

Niger 11 8,700 10% 32 24,700 28% 125 89,000Zimbabwe 11 4,000 16% 30 11,300 46% 67 24,300

Benin 11 3,900 11% 31 11,000 30% 106 36,300

Congo 11 1,600 12% 32 4,600 33% 99 13,800

Comoros 11 310 15% 32 880 41% 79 2,100

Uganda 10 15,100 12% 28 42,700 33% 90 130,900

Ghana 10 8,100 14% 29 22,900 38% 78 59,700

Nepal 10 6,900 21% 27 19,500 58% 48 33,600

Zambia 10 6,000 13% 27 17,100 37% 83 46,300

Liberia 10 1,500 13% 27 4,300 36% 78 11,900

Sao Tome and Principe 10 50 12% 29 150 34% 89 450

Bangladesh 9 28,100 21% 26 79,700 60% 46 133,600


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c t

f s d * f s M * f s 5 y s*









Tanzania, United Republic o 9 17,000 14% 25 48,100 40% 68 121,700

Kenya 9 14,700 14% 27 41,700 39% 73 106,800

Malawi 9 6,500 13% 27 18,400 35% 83 51,800

Senegal 9 4,300 14% 26 12,200 41% 65 29,600

Haiti 9 2,400 13% 25 6,700 36% 70 18,500

Tajikistan 9 1,700 14% 25 4,800 40% 63 12,100

Gabon 9 360 14% 24 1,000 39% 66 2,600

Bhutan 9 130 17% 25 370 48% 54 770

Madagascar 8 6,100 14% 23 17,200 38% 62 44,700

Bolivia, Plurinational State o 8 2,100 16% 22 5,800 45% 51 12,900

Papua New Guinea 8 1,700 14% 23 4,700 39% 58 11,900

Eritrea 8 1,500 12% 21 4,100 33% 68 12,700

Turkmenistan 8 840 16% 22 2,400 44% 53 5,300

Timor-Leste 8 370 15% 24 1,100 43% 54 2,400

Iraq 7 8,000 19% 20 22,800 54% 38 42,400

South A rica 7 7,500 16% 19 20,200 43% 47 47,400

Morocco 7 4,100 20% 19 11,600 56% 33 20,800

Rwanda 7 3,400 15% 21 9,500 42% 54 22,800

Cambodia 7 2,200 16% 19 6,200 46% 43 13,400

Azerbaijan 7 1,200 15% 19 3,500 42% 45 8,400

Kyrgyzstan 7 940 22% 16 2,100 48% 31 4,300

Guyana 7 90 23% 20 260 65% 36 410

Kiribati 7 15 14% 19 40 41% 47 100

Algeria 6 4,200 20% 17 11,800 56% 30 21,100

Korea, Democratic People's Republic o 6 2,100 18% 17 6,100 52% 33 11,800

Paraguay 6 910 27% 13 2,000 59% 22 3,400

Lao People's Democratic Republic 6 870 15% 17 2,500 42% 42 5,900

Namibia 6 390 16% 18 1,100 44% 42 2,500

Suriname 6 50 20% 16 160 56% 30 280

Micronesia, Federated States o 6 15 15% 17 45 41% 42 110

Indonesia 5 23,400 17% 15 66,300 49% 32 134,400

Iran, Islamic Republic o 5 6,100 19% 14 17,300 53% 25 32,700

Uzbekistan 5 3,100 11% 15 8,800 30% 49 29,600

Guatemala 5 2,400 17% 15 6,900 49% 30 13,900

Kazakhstan 5 1,700 16% 14 5,000 47% 28 10,600

Dominican Republic 5 1,100 20% 14 3,000 57% 25 5,300

Occupied Palestinian Territory 5 630 21% 13 1,800 60% 22 3,000

Trinidad and Tobago 5 110 19% 18 360 66% 28 550

Saint Vincent and the Grenadines 5 10 21% 13 25 60% 21 40

Brazil 4 10,700 24% 10 29,100 66% 16 44,000

Philippines 4 10,100 18% 12 28,700 50% 25 57,300

Vietnam 4 6,100 19% 12 17,300 55% 22 31,500

Colombia 4 3,600 22% 11 10,200 63% 18 16,300

Ecuador 4 1,100 16% 10 3,000 45% 23 6,800

Honduras 4 770 18% 11 2,200 50% 21 4,300

Jordan 4 660 19% 12 1,900 54% 21 3,500

Nicaragua 4 610 17% 12 1,700 47% 26 3,600

Mongolia 4 270 12% 12 770 35% 31 2,200

Jamaica 4 200 20% 11 570 57% 18 1,000


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33

c t

f s d * f s M * f s 5 y s*









Georgia 4 200 19% 15 740 69% 21 1,100

Botswana 4 190 15% 11 540 43% 26 1,200

Armenia 4 180 24% 11 520 67% 18 780

Solomon Islands 4 60 18% 10 180 50% 22 370

Barbados 4 10 16% 10 30 46% 20 70

Dominica 4 5 43% 8 10 83% 12 10

Marshall Islands 4 < 5 16% 12 15 46% 26 30

China 3 50,600 20% 9 143,400 58% 15 248,600

United States 3 11,300 35% 4 18,400 57% 8 32,200

Egypt 3 4,900 12% 7 13,900 35% 21 39,600

Turkey 3 4,100 20% 9 11,500 57% 15 20,300

Thailand 3 2,200 22% 8 6,200 62% 12 10,100

Peru 3 1,900 18% 9 5,400 51% 18 10,700

Syrian Arab Republic 3 1,400 19% 9 4,000 55% 15 7,300

Sri Lanka 3 1,000 22% 8 2,900 63% 12 4,600

Tunisia 3 600 20% 9 1,700 57% 16 3,000

Romania 3 580 21% 8 1,700 58% 13 2,800

Libya 3 490 21% 10 1,400 60% 16 2,300

Panama 3 190 14% 9 620 46% 20 1,400

Albania 3 100 18% 7 290 50% 14 580

Fiji 3 50 16% 8 140 46% 16 310

Cape Verde 3 35 16% 10 100 46% 21 220

Bahamas 3 15 15% 7 40 41% 16 90

Saint Lucia 3 10 20% 9 30 57% 16 50

Tonga 3 10 18% 8 20 51% 15 45

Samoa 3 10 15% 8 35 43% 19 80

Seychelles 3 < 5 17% 9 10 47% 14 20

Mexico 2 5,000 15% 7 15,400 46% 16 33,800

Russian Federation 2 3,900 19% 6 10,900 54% 12 20,200

Argentina 2 1,600 16% 7 5,200 52% 14 10,000

Venezuela, Bolivarian Republic o 2 1,300 15% 8 5,000 56% 15 8,900

Saudi Arabia 2 1,100 19% 5 3,300 54% 9 6,000

Canada 2 960 43% 4 1,400 62% 6 2,200

Ukraine 2 820 16% 5 2,300 44% 10 5,300

Poland 2 670 27% 3 1,400 58% 6 2,500

Chile 2 590 28% 5 1,100 53% 9 2,100

Australia 2 480 34% 3 800 57% 5 1,400

El Salvador 2 280 14% 6 800 39% 15 2,100

Costa Rica 2 180 25% 6 450 62% 10 720

Switzerland 2 170 48% 3 240 68% 4 350

Serbia 2 170 23% 4 480 64% 7 750

Bulgaria 2 130 14% 7 490 52% 12 940

Lebanon 2 120 19% 5 340 53% 9 640

Austria 2 110 37% 2 180 59% 4 310

New Zealand 2 100 26% 3 180 47% 6 390

Moldova, Republic o 2 100 13% 8 340 44% 16 770

Oman 2 90 18% 5 250 51% 9 500

Croatia 2 70 30% 3 140 62% 5 230

Bosnia and Herzegovina 2 60 21% 5 160 60% 8 270


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c t

f s d * f s M * f s 5 y s*









Latvia 2 45 22% 5 120 63% 8 200

Mauritius 2 40 17% 9 150 67% 15 230

Macedonia, The ormerYugoslav Republic o

2 35 17% 6 140 66% 10 220

Maldives 2 15 23% 6 35 60% 11 60Montenegro 2 15 23% 5 35 64% 7 60

Vanuatu 2 15 19% 7 50 53% 13 90

Belize 2 15 12% 8 60 49% 17 130

Antigua and Barbuda 2 < 5 22% 4 5 64% 8 10

Grenada 2 < 5 17% 7 15 48% 13 25

United Kingdom 1 1,100 26% 3 2,300 56% 5 4,100

Germany 1 720 25% 2 1,600 55% 4 2,900

Malaysia 1 700 19% 3 2,000 55% 7 3,600

France 1 670 20% 2 1,800 55% 4 3,300

Japan 1 610 16% 1 1,200 33% 3 3,700

Italy 1 440 20% 2 1,300 59% 4 2,100Korea, Republic o 1 350 13% 2 990 38% 5 2,600

Spain 1 340 16% 3 1,300 59% 4 2,100

Netherlands 1 200 29% 3 480 69% 4 690

Hungary 1 130 20% 4 370 59% 6 620

United Arab Emirates 1 130 20% 4 370 58% 7 640

Israel 1 120 17% 2 330 50% 4 670

Cuba 1 110 18% 3 300 51% 6 600

Belarus 1 100 16% 3 280 46% 6 610

Ireland 1 90 29% 2 160 52% 4 310

Greece 1 90 17% 3 310 58% 4 540

Belgium 1 90 17% 2 290 54% 4 530Denmark 1 70 27% 2 150 63% 4 240

Slovakia 1 70 15% 4 240 54% 8 450

Uruguay 1 70 13% 5 270 53% 10 510

Kuwait 1 70 12% 5 270 44% 11 610

Portugal 1 60 19% 2 170 54% 3 320

Czech Republic 1 60 13% 2 270 58% 4 460

Finland 1 40 22% 2 100 55% 3 180

Norway 1 40 19% 2 110 54% 3 200

Qatar 1 30 19% 4 90 54% 8 160

Lithuania 1 30 14% 3 100 48% 6 210

Bahrain 1 30 13% 4 90 39% 10 230

Slovenia 1 15 24% 2 30 53% 3 60

Brunei Darussalam 1 10 20% 4 30 57% 7 50

Malta 1 < 5 20% 4 15 63% 6 25

Sweden < 0.5 50 18% 1 170 53% 3 310

Singapore < 0.5 20 15% 1 60 42% 3 130

Estonia < 0.5 10 13% 2 30 46% 4 60

Cyprus < 0.5 5 14% 1 20 44% 3 40

Iceland < 0.5 < 5 19% 1 5 42% 3 10

Luxembourg < 0.5 < 5 13% 1 10 47% 3 20


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35

S mm S s s f s d *+ f s M * f s 5 y s *









Sub-Saharan A rica 12 396,500 12% 34 1,122,200 33% 109 3,369,800

South Asia 11 423,300 18% 32 1,199,100 52% 62 2,308,800

Middle East and North A rica 6 55,800 16% 16 158,300 45% 36 351,400

East Asia and Pacifc 4 110,000 19% 11 311,500 53% 20 589,800

Latin America and Caribbean 3 37,400 18% 10 106,800 53% 19 202,500

CEE/CIS 3 20,100 16% 10 56,600 45% 21 125,100

Industrialized countries 2 18,800 30% 3 35,500 56% 6 63,700

World 8 1,049,300 15% 22 2,954,500 43% 51 6,914,300

*Estimates were r unded acc rding t thell wing schemes: M rt alit rates 0.5,

r unded t the nearest wh le number;Number deaths: 5 x < 50, r unded t thenearest 5, 50 x < 1,000, r unded t nearest10, x 1,000, r unded t the nearest 100.

** The share under-5 deaths that ccur nthe rst da and during the rst m nth arebased n unr unded estimates.

UNICEF regi ns. F r a c mplete list c untries and territ ries in these regi ns, see:UNICEF. The State o the Worlds Children 2012.(New y rk: 2012) p.124

+ First Da estimates are r the c untrieswithin each regi n included in this anal sis.Data is n t a ailable r e less-p pul usindustriali ed c untries, e small Paci cislands, and ne Caribbean island. The e ect

these missing alues n regi nal indicat rsis likel negligible as all missing c untries ha e

ewer than 1,000 annual li e births.

N te: Data estimates are r 2011.Data s urces: First Da data are theresult an riginal anal sis d ne r Sa ethe Children b She ali o a, Sim n C usensand J Lawn (The Risk o Dying on the Day o Birth: Estimates or 186 Countries.Submitted

manuscript, 2013). Findings are rep rted rall c untries with at least 1,000 li e births in2011. F r detailed meth d l g this anal -sis, see Meth d l g and Research N tes.Nati nal and regi nal estimates r the FirstM nth and First 5 years were s urced

r m UNICEF Gl bal Databases and theHealth Newb rn Netw rk (data c mpiled

r A Decade o Change or Newborn Survival ,Policy and Programmes (20002010): A Multi-Country Evaluation o Progress Towards Scale.Health Policy and Planning ).


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36 SAvE THE CHI LDREN STATE oF THE WoRLDS MoTHERS 2013 A ghanistan


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37

Continuum of Care for Mothersand Newborns

Research consistently shows that cost-e ective services to improve womens

overall health and nutrition, to make childbirth sa er, and to help mothersc o v w v g c u o o w o v .

Care o Future MothersTe three interventions that are most e ective in preventing high-risk preg-

nancies thus saving the lives o mothers and babies are emale education,u o y p g.

Female education One o the most e ective ways to reduce risks to moth-ers and newborns is to ensure that more girls enroll in school and stay inschool. Te more time girls spend in school, the later they marry and beginc g. E uc g o o k y o g ow up o o who are healthy, well-nourished, economically empowered and resource ulw co o c g o v . E uc wotend to have ewer children, healthier pregnancies and sa er deliveries. Teir

o k y o u v v c , vu ou days o li e, and the crit

lr-sowm13 whole report - africa cover (2)

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