June 2012 Number 177 www.worldbank.org/enbreve A regular series of notes highlighting recent lessons emerging from the operational and analytical program of the World Bank‘s Latin America and Caribbean Region (LAC). MDGs 4 and 5: Maternal and Child Health/Reproductive Health in LAC by Amparo Gordillo-Tobar 72687 1. The Latin America and Caribbean (LAC) region fares well two decades between 1990 and 2010. Similarly, the infant on achievement of the MDG targets when compared with mortality rate (IMR) in the region declined 58 percent in other regions, but the region has great disparities between the same period.4 and within countries on these goals.1,2,3 The region is also performing better than the rest of the developing world 3. The new challenge for the region is neonatal mortality. in relation to child mortality, having achieved more than In most LAC countries, neonatal mortality rate (NNR)5 70% of the progress needed to reduce under-five mortality accounts for about half of the IMR (Graph 1). Efforts to by two-thirds. However LAC still faces serious challenges improve access to opportune and quality neonatal care regarding maternal mortality, achieving good public and are in the agenda for many countries in the region. individual health and alleviating poverty. For LAC, the MDGs are a historic opportunity to address all forms of inequality 4. Undoubtedly, many of these deaths are related to the and attain the political will needed to achieve these goals. lack of prompt and effective health care. Strategies to reach MDG 4 are: (i) appropriate home care and timely treatment of complications for newborns; (ii) integrated management of illnesses for those under five; and (iii) MDG 4: Reducing Under-Five Mortality by expanded immunization and nutrition programs. These Two-Thirds in 1990-2015 strategies need to be complemented by interventions for 2. The LAC region is on track to achieving MDG 4, according maternal health that involve access to skilled and quality to the Inter-Agency Group for Child Mortality Estimation. care during pregnancy, childbirth and the postpartum LAC experienced a 57 percent decline in under five mortality, period. at an average annual rate of reduction of 4.3 percent in the For more information contact Amparo Gordillo-Tobar, Reproductive Health Focal Point, LCSHH, agordillotobar@worldbank.org 1 The Millennium Declaration is the political manifestation of 189 countries’ commitment to development based on values that will promote freedom, equality, solidarity, tolerance, respect for nature, and common responsibilities. The specific objectives, known as the Millennium Development Goals, are a “road map towards the implementation of the Millennium Declaration� which include eight goals, 18 targets and 48 indicators. 1990 was established as the baseline, with the aim of reaching the targets in 25 years. 2 WB Global Monitoring Report 2012: http://siteresources.worldbank.org/INTPROSPECTS/ Resources/334934-1327948020811/8401693-1327957211156/8402494-1334239337250/GMR-2012-LAC-Brief.pdf 3 According to the World Bank’s Global Monitoring Report 2012: Food Prices, Nutrition, and the Millennium Development Goals, the LAC region has already reached the targets on extreme poverty, primary completion, gender equality and access to safe water. 4 Under-5 mortality rate is measured as the number of deaths of children under 5 per 1,000 live births; and infant mortality rate as the number of deaths of babies under one year of age per 1,000 live births. According to the 2011 report by the UN Inter-agency Group for Child Mortality Estimation, a country or region is on track to achieve MDG 4 if its under-five mortality rate is less than 40 deaths per 1,000 live births in 2010 or the average annual rate of reduction of under-five mortality is at least 4 percent over 1990–2010. 5 Neonatal mortality rate is the number of deaths during the first 28 completed days of life per 1,000 live births in a given year or period. 1 MDG 5: Improve Maternal Health in 1990- 7. Rates of teen pregnancy range from less than five to 20156 over 20 percent of total birth deliveries in the Americas. 5. Maternal mortality is a key health indicator that shows Central America is particularly affected with Nicaragua the widest gaps between rich and poor, both between (25.2%) and El Salvador (22.8 %) having the highest rates countries and within them. Among the 13 LAC countries of the Sub-region. The risk of death and complications that had a maternal mortality ratio (MMR) higher than from pregnancies and deliveries is greater among young 100 per 100,000 live births in 1990, progress on maternal women, so it is crucial for the region to prevent unintended mortality between 1990 and 2010 is mixed. MMR declined pregnancies and delay second or third pregnancies. The 41% in the region between 1990 and 2010, from 140 to challenge is ahead for the region - prevention, appropriate 81 per 100,000 live births. However, MMR ranged from health care and support needs to be in place to face this 25 in Chile to 350 in Haiti in 2010, and the lifetime risk of social problem. The use of all types of contraceptives maternal death (the probability that a woman will die from among women of reproductive age ranges from 87% in complications of pregnancy and childbirth) was estimated Brazil to 25% in Bolivia. Marital status plays an important at 1 in 520, compared to the 1 in 4200 estimate for high role on the access to contraceptive methods among income countries. Similarly, Chile MMR, the lowest in the young women, particularly among 15 to 19-year olds region, still lags behind compared to the estimated 14 per unmarried women who are sexually active. They are less 1,000 live births in high income countries (Graph2). likely to access/use contraceptive methods. 6. Obtaining maternal mortality data continues to be a 8. Reducing maternal and child mortality requires challenge in LAC; as a result, official estimates still observe a comprehensive approach to health care for women important differences (Graph 3). Accurate measurements during their reproductive years, starting with access require complete and accurate civil registration systems to contraception, birth deliveries and the secondary with good attribution of cause of death. Indeed, several prevention of cervical and breast cancer. LAC needs to countries’ civil vital registration systems still need major provide universal maternal and child health coverage adjustments. with effective and affordable interventions, such as care Graph 1. Infant and Neonatal Mortality in Selected LAC Countries Source: Estimations by the UN Inter-agency Group on Child Mortality Estimation 2011. The group is led by UNICEF and the WHO; also includes World Bank and the United Nation Population Division of the Department of Economic and Social Affairs as full members.   6 The maternal health goals are to (a) reduce the mortality ratio by three quarters from 1990-2015, and (b) achieve universal access to reproductive health care by 2015. The maternal mortality ratio (MMR) is the number of maternal deaths per 100 000 live births during a 2 specified time period, usually 1 year. for newborns and mothers, nutrition services for infants and child mortality. Some projects focus entirely on MCH and young children, vaccination, and prevention and interventions, as in Guatemala, while others include MCH management of diarrhea, pneumonia, sepsis, HIV/AIDS as part of the support to the achievement of broader and malaria. The health system and quality of care —from health goals in the country. Most projects implement public health and primary to tertiary health care—plays activities related to the strengthening of the MCH care a key role in preventing maternal mortality. This strongly delivery, while others provide incentives for the demand suggests that quality of reproductive health and delivery of such services. Some of the most successful country care as well as health care network response, also have to initiatives supported by the Bank in LAC have been in be developed and measured. place for over a decade, such as Plan Nacer in Argentina, which supports capitation payments for MCH. More recent initiatives promote management and quality of maternal LAC Reproductive Health and Maternal care to adolescents with payment for results in Brazil and and Child Health Action prevention of teen pregnancy assessments in Ecuador, El Salvador and Nicaragua. 9. The region has demonstrated its commitment to the reduction of infant and maternal mortality with the 11. The World Bank Reproductive Health Action Plan approval of legislation to protect mothers and children, (WB-RHAP 2010-2015) provides the framework for as well as the establishment of several health insurances the development of efforts advocating for better RH schemes: Plan Nacer in Argentina, Universal Mother outcomes, particularly for the poor and the vulnerable, and Child Insurance in Bolivia, Bolsa Familia and Family in the context of the Bank’s overall strategy for poverty Health Program in Brazil, Mother and Child Social Health alleviation and health system strengthening. Protection Policy in Chile, Free Maternity and Child Care Law in Ecuador, Mother and Child Voucher in Honduras, 12. Bank Results-based financing approaches should Oportunidades and Seguro Popular in Mexico, and continue to be used in projects focusing on MCH/RH. Integrated Health Insurance in Peru, are some examples. Knowledge and convening services in LAC will continue Despite these efforts, the region has some work ahead on to focus on the main identified areas of need: Producing the improvement of quality and opportune health care more knowledge on prevention of neonatal mortality delivery to ensure infant and maternal health continue and teen pregnancy, development of quality maternal to improve, especially in countries unlikely to reach the and child health care networks; Sharing knowledge to MDGs. promote examples of success in the region on prevention and reduction of maternal mortality, teen pregnancy, 10. The Bank currently finances 21 projects in LAC and regulation and management of MCH; South-south that include maternal and child health/reproductive exchange programs and making sure the knowledge health components or activities. These projects aim to products and convening services are language accessible. contribute, directly or indirectly, to reducing maternal Graph 2. Progress in Maternal Mortality Ratio in Countries with a MMR >100 Progress   MMR  per   MMR  per   MMR  per   Average    Annual   towards   100,000   100,000   100,000   %  change  in   Country improving   l.b.in     l.b.in   l.b.in   MMR                             maternal  health 1990 2000 2010 (1990-­�2010) Bolivia making  progress 450 280 190 –4.1 Brazil making  progress 120 81 56 –3.5 Colombia making  progress 170 130 92 –2.9 Dominican  Rep. insufficient  progress 220 130 150 –1.9 Ecuador making  progress 180 130 110 –2.7 El  Salvador making  progress 150 110 81 –3.1 Guatemala insufficient  progress 160 130 120 –1.5 Source: WHO/UNICEF/UNFPA/The World Bank. “Trends in Guyana no  progress 180 220 280 2.1 maternal mortality: 1990 to 2010�. WHO, UNICEF, UNFPA and The Haiti making  progress 620 460 350 –2.7 World Bank estimates. Geneva, World Health Organization, 2012 Honduras making  progress 220 160 100 –3.7 Nicaragua making  progress 170 130 95 –2.9 Note: A country is considered “on track� to improve maternal Panama insufficient  progress 100 110 92 –0.5 health if its annual % decline in MMR is 5.5% or more as “making Paraguay insufficient  progress 120 110 99 –0.9 progress� if its annual % decline in MMR is between 2% and 5.5%, Peru making  progress 200 120 67 –5.2 and as having made “insufficient progress� if it annual decline in LAC making  progress 140 110 81 -­�2.6                              is Source:   WHO/UNICEF/UNFPA/The  World  Bank.  "Trends  in  maternal  mortality:  1990  to  2010".                      MMR           less than 2%.          of WHO,  UNICEF,  UNFPA  and  The  World  Bank  estimates.  Geneva,  World  Health  Organization,  2012 Note:    A  country  is  considered  "on  track"  to  improve  maternal  health  if  its  annual  %  decline  in  MMR  is  5.5%  or  more,  as                                                                                             "making  progress"  if  its  annual  %  decline  in  MMR  is  between  2%  and  5.5%,  and  as  having  made  ''insufficient  progress''  if                 it    annual  decline  in  MMR  is  of  less  than  2%. 3 Graph 3. Maternal Mortality Ratio (MMR) Estimates by Source in LAC 1. WHO/UNICEF/UNFPA/The World Bank 2012. “Trends in maternal mortality: 1990 to 2010.� WHO, UNICEF, UNFPA and The World Bank estimates. Geneva, World Health Organization, 2012�. 2. Pan American Health Organization. Health Situation in the Americas: Basic Indicators 2011. Data on the basis of technical reports from PAHO/WHO country offices and national authorities. 3. World Bank Development Indicators Database 2011 based on data from UNICEF, State of the World’s Children, Childinfo, and Demographic and Health Surveys by Macro International. Disclaimer: The findings, interpretations, and conclusions expressed herein are those of the author(s) and do not necessarily reflect the views of the Executive Directors of the International Bank for Reconstruction and Development / The World Bank or the governments they represent. The World Bank does not guarantee the accuracy of the data included in this work. 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