Millennium Development Goal 4: reducing perinatal andneonatal mortality in low-resource settingsAbi C Smith MBChB,a Wonderful Mutangiri MBChB,b Robert Fox MD MRCOG,c,* Joanna F Crofts MD MRCOG

d

aAcademic Clinical Fellow, Department of Women’s Health, Southmead Hospital, Bristol BS9 5NB, UKbObstetric and Gynaecology Trainee, Mpilo Central Hospital, Bulawayo, ZimbabwecConsultant Obstetrician and Gynaecologist, Musgrove Park Hospital, Taunton TA1 5DA, UKdNIHR Clinical Lecturer, School of Social and Community Medicine, University of Bristol, Southmead Hospital, Bristol BS10 5NB, UK

*Correspondence: Robert Fox. Email: indigofoxbat@hotmail.com

Accepted on 14 October 2013

Key content� Millennium Development Goal 4 (MDG4) set targets to reduce by

two-thirds the number of deaths of children aged <5 years by 2015

compared with 1990. In 2010, 7.7 million of these children died.

Progress is accelerating but many countries will not meet targets.� Stillbirths account for 2.65 million deaths but are not addressed in

international targets.� Possible solutions including ‘kangaroo mother care’, neonatal

resuscitation and breastfeeding are identified; a difference can be

made with basic training and resources.� Political leadership is required to make significant health gains.� The evidence for improving peri- and neonatal mortality exists.

The challenge is in the implementation.

Learning objectives� To understand MDG4 and the variation in pregnancy outcomes

for neonates globally.

� To increase knowledge of simple interventions and key barriers to

improve peri- and neonatal mortality.� To help UK doctors understand the health background of

inward migrants.

Ethical issues� The increasing divide in health outcomes between rich and poor,

both within and between countries.� Gender inequalities may contribute to poor access to care.� Resource limitations are compounded by external factors such as

the ‘brain drain’ of health workers.

Keywords: Millennium Development Goals / neonatal death /

quality improvement / stillbirth

Please cite this paper as: Smith AC, Mutangiri W, Fox R, Crofts JF. Millennium Development Goal 4: reducing perinatal and neonatal mortality in low-resource

settings. The Obstetrician & Gynaecologist 2014;16:1–5.

Introduction

The Millennium Declaration set out development aims

that the world would strive to meet by 2015.1 This

included a set of health-related aspirations, known as the

Millennium Development Goals (MDGs). They have focused

the global community’s attention and funding on specific

health-related issues.

MDG4 set out to reduce by two-thirds the death rate of

children aged <5 years (‘under-five mortality rate’—U5MR), between 1990 and 2015. This article explores the

impact of MDG4 on perinatal and infant death in the

developing world. As this article is targeted towards those

providing maternity care, much of the discussion focuses

on neonatal death: babies who die within the first 28 days

of life. There has been least progress regarding this element

of the U5MR: the proportion of U5MR accounted for in

the neonatal period had risen from 37% in 1990 to 42%

in 2010.2

It is important to note that there is no mention of stillbirth

within the MDGs, and there remains no global target for its

reduction. Every year 2.65 million babies are stillborn, with

98% of all stillbirths occurring in low- and middle-income

countries. It is estimated that 45% of stillbirths occur during

the intrapartum period, a rate much higher than for countries

with advanced healthcare systems.3 A reduction in stillbirths

in low-resource settings is achievable, and many of the

interventions discussed in this article have the potential to

reduce the incidence of stillbirth, as well as of neonatal

mortality. Any progress towards collecting similar data for

stillbirth is hampered by debates around definition of

stillbirth, difficulties of registration of stillbirth, and the issues

of distinguishing between antepartum and intrapartum

deaths. These data challenges compound the lack of

political visibility.4

ª 2013 Royal College of Obstetricians and Gynaecologists 1

DOI: 10.1111/tog.12074

The Obstetrician & Gynaecologist

http://onlinetog.org

2014;16:1–5 Review

Progress towards Millennium DevelopmentGoal 4 (MDG4)

Between 1990 and 2010 the U5MR fell by just 35%,5 but this

rate of decline is accelerating. In 2010 approximately 7.7

million children died before their fifth birthday.6 Some

regions (such as North Africa) have been successful at

reaching their MDG4 targets, but the U5MR in Sub-Saharan

Africa and Oceania had only fallen by 30% by 2010.5

Almost all regions have seen slower declines in their

neonatal mortality rate than U5MR.5 Annually there are

approximately 2.1 million neonatal deaths.6 One million of

these deaths occur as a consequence of premature birth.2

Although there has been substantial progress towards

MDG4, with 31 countries on target to reach their goals, 23

countries in Sub-Saharan Africa are unlikely to achieve

MDG4 targets before 2040.7 Where countries have progressed

rapidly, the common theme is a governmental commitment

to make the required improvements.8 The model of

improvement of U5MR in Nepal clearly demonstrates this

point, but also provides a useful short case study for potential

cross-sector interventions to improve neonatal health.

Progress towards targets in Nepal

Between 2001 and 2006 the perinatal mortality rate in Nepal

decreased from 47 to 4 per 1000 live births. A sector-wide

approach was introduced in 1991, and was subsequently

developed into a ‘Safe Motherhood and Neonatal Health

long-term Plan for 2006–17’. Nepal’s strategy includes:

� comprehensive antenatal care,

� training for birth attendants,

� increasing attended deliveries through the introduction of

Maternity Incentive Schemes (e.g. provision of money for

transport costs, payment for giving birth within a

healthcare facility) designed to encourage women to

deliver in a health institution,

� postnatal care promoting breastfeeding and immunisation,

� maternal and perinatal death review reports identifying

preventable factors.9

These measures have increased the attended delivery rate

in Nepal from 7% in 2001 to 31.6% in 2009, and increase the

institutional delivery rate from 9% in 2001 to 19% in 2009.

Interventions to improve perinatal andneonatal death

The causes of perinatal and neonatal death are multi-factorial

and include social factors. The interventions required to

reduce mortality are, therefore, not all directly related to

healthcare. Improved nutrition, education, sanitation and

access to healthcare are all required8 alongside a political will

to implement multi-sector solutions. This discussion is

limited to interventions directly related to health care.

Key healthcare interventions that reduce intrapartum,

perinatal and neonatal mortality are detailed below. These

interventions perform best as part of a continuum of care in a

functioning, integrated healthcare system. However, some

could be implemented even in fragile states.10

Community mobilisationCommunity mobilisation covers interventions ranging from

home visits to facilitation of local women’s groups to advocate

for the local health resources required. Community

mobilisation can strengthen facility-based interventions and

contribute to effective healthcare10 and has been shown to be

cost-effective.11When at least one-third of pregnant women in

a community participated in such an intervention, neonatal

mortality decreased by up to 33%.11

Skilled attendance at birthSkilled attendance at birth has the potential to improve

neonatal mortality, especially when coupled with good

referral systems.8,12 An attended, clean delivery with access

to antibiotics is important for the prevention of infection.

Currently 15% of newborn deaths are as a consequence

of infection.8

Neonatal resuscitation is lifesaving. Basic skills can enable

the 5–10% of babies who require assistance with breathing at

birth to survive. The equipment required is of low cost (bag

and mask), but training is crucial.4 All birth attendants

should be trained in neonatal resuscitation as it is not

possible to predict accurately which babies will need

intervention.4 Training is simple and feasible.10 A

meta-analysis of training for traditional birth attendants

demonstrated that neonatal training packages can reduce

perinatal and neonatal mortality with a relative risk reduction

in both the randomised and non-randomised trials of

24–30% and 21–39% respectively.12

Administration of corticosteroids in prematurityCorticosteroids for promotion of lung maturation in

preterm births to reduce respiratory distress syndrome is

supported by high-quality evidence.13 This intervention is

low cost (for example, a corticosteroid course in India costs

just US$0.51), and could save 340 000 newborn lives

annually.8 If preterm labour is identified in a timely

fashion, the administration of corticosteroids is relatively

simple and moderately effective.

Kangaroo care of the newbornKangaroo mother care (KMC) for preterm babies (weighing

<2000 g) comprises three components: (i) thermal care; (ii)

exclusive breastfeeding; and (iii) early recognition/response

to illness.14 In premature babies who are stable, KMC is more

2 ª 2013 Royal College of Obstetricians and Gynaecologists

Millennium Development Goal 4

effective than nursing in an incubator.8 A meta-analysis of

randomised controlled trials of KMC starting in the first

week of life demonstrated a reduction in mortality of >50%,

together with a reduction in serious morbidity of >60%.14

KMC is low cost and easy to implement.

Promotion of breastfeedingExclusive breastfeeding can prevent sepsis (gastrointestinal

diseases and respiratory infection) and offers the opportunity

to gain immunity and prevent hypoglycaemia.15 In most

regions, fewer than half of newborns are breastfed within

an hour of birth.8 Furthermore, exclusive breastfeed-

ing contributes to birth spacing through prolonged

lactational amenorrhea.16

Birth spacingBirth spacing improves pregnancy outcomes. Preterm birth

and low birthweight are associated with either short

(<18 months) or long (>59 months) intervals between

pregnancies. Enabling women to optimally space their

children can reduce poor perinatal outcomes.17 Education

and access to family planning methods is crucial,8 and can

reduce up to 40% of unplanned pregnancies.

Immunisation programmeImmunisation is effective at reducing mortality. For example,

offering two doses of an antenatal tetanus vaccine costs

approximately US$0.40 and could prevent the death of

58 000 newborns annually.8 Postnatally childhood morbidity

and mortality has been reduced with the implementation of a

vaccine schedule including measles and haemophilius

influenza vaccination.15

Malaria reductionMalaria is a risk factor for low birthweight and contributes to

approximately 100 000 deaths annually.18 There are

cost-effective proven interventions to prevent malarial

infection, which include intermittent preventive treatment

(IPT), antimalarial prophylaxis and insecticide-treated

bed-nets. These measures could reduce perinatal mortality

due to malaria by 27% in affected areas.18

Emergency obstetric careAccess to emergency obstetric care is necessary.10 Whereas

many interventions can be carried out in the community

there still needs to be a strong link to facility-based care.11

Caesarean section is indicated in 5–15% of births and could

go some way to preventing the 30% of intrapartum

stillbirths.4 Moreover, if a mother dies as a result of

childbirth, the risk of her children dying before they reach

the age of 5 years more than doubles.8,19 Improving

antenatal, intrapartum and postnatal care is vital for the

health of the mother, baby and wider family.

Continuum of careThe continuum of care is crucial; effective care for mothers

must have a pregnancy-course approach. Antenatal care must

run seamlessly into intrapartum and postnatal care. Postnatal

care should facilitate the integration of community and

outreach interventions with facility-based care where

necessary.20 It can enable promotion of healthy practices

such as breastfeeding, nutrition and immunisation while

facilitating the early identification of illnesses and access to

curative care.10,20

Barriers to the implementation of evidenceinto practice

Much of the evidence on mortality reduction has now existed

for well over a decade but implementation is patchy; the

challenge remains how to implement evidence into practice

consistently. The overarching barrier to achieving MDG4 is

that of political will. If the government of a country does not

commit to improving perinatal and neonatal mortality, then

very few gains will be made. Some of the other main barriers

to success include paucity of health workers and training,

cultural issues, and inability to access services. These are

discussed below.

Lack of healthcare workersLack of healthcare workers to deliver services leads to

increased challenges.19 Skilled care at birth can decrease

intrapartum death and birth asphyxia, but worldwide there

remains a shortage of 5 million health workers with 350 000

more midwives required alone.8 A lack of update training of

existing health workers further compounds this problem; it is

estimated that 50% of health workers in low-resource settings

have not received enough training to be able to adequately

perform basic neonatal resuscitation.4 Various methods have

been considered to combat this problem. Many countries are

moving to develop a new cadre of health professionals with

shorter training who are now undertaking roles which were

previously only performed by qualified staff. There have been

successful examples of this in Mozambique and the

Democratic Republic of Congo.

Existing cultural practicesExisting cultural practices can contribute to poor neonatal

outcomes. For example, in rural India women give birth on

to a dirt floor and breastfeeding is discouraged for several

days. In Bangladesh and Ethiopia the mother and baby may

be isolated to fend off evil spirits.8,21 Other traditional

practices, such as not feeding the baby colostrum, are

prevalent.21 There may also be erroneous perceptions of

some interventions being inferior despite evidence to the

contrary; kangaroo care being viewed as a poor man’s

alternative to an incubator, or breastfeeding less good than

ª 2013 Royal College of Obstetricians and Gynaecologists 3

Smith et al.

the more modern formula feeding.4 Furthermore, issues of

gender roles can lead to men hindering access to care,

resulting in critical delays in receiving treatment.8,19

Access to servicesAccess to services is central to improving perinatal health. In

addition to the gender disparity, financial, geographical and

poor quality services affect the ability of women to access

healthcare services. The most obvious financial barrier is the

requirement to pay user fees (direct payment made by the

patient’s family for the care required); however, the cost

implications of seeking care aremuch broader.19 These include

time off work and costs of transport and accommodation.19

All of these factors can make the out-of-pocket costs

catastrophic for families. Solutions are being sought,

including investigation of conditional cash transfers to

improve care-seeking,9 and the abolition of user fees.19

Geographical variations are numerous, with a rural/urban

divide in access to care, with health facilities being

concentrated in urban, easy-to-reach areas. This is

compounded by poor infrastructure making it difficult for

the rural population to reach the health facility.19

Quality of servicesThe quality of services patients receive at a healthcare facility

affects health-seeking behaviour. Fewer women access

poor-quality services.4 Multiple problems can be responsible

for lack of quality of care, including absenteeism of staff and

lack of good management, training and equipment.4,21

Addressing health inequities

The MDGs were designed to address inequalities between

countries. We are quickly approaching their end, but

Sub-Saharan Africa and South Asia still continue to bear the

majority of the burden of disease. Sub-Saharan Africa has just

11% of the world’s population, but accounts for nearly half of

all newborn and child deaths.10 Eighty per cent of the babies

who die in their first day of life, live and die in Sub-Saharan

Africa and South Asia,8 illustrating the inequalities that have

continued despite the MDGs. Each country’s target does not

demand equity of services within the country. This has often

led to improvement in outcomes for those parts of the

population that are easy to reach, and with no improvement or

evenworsening outcomes in the harder-to-reach populations.8

There are many examples of health inequity. Babies born

to the poorest fifth of the population are 40% more likely to

die than those born to the richest fifth.8 Estimates from low-

and middle-income countries suggest a caesarean section rate

of approximately 12%; however, in 42 countries the

caesarean section rate is only 1% for the poorest fifth of

the population,4 and in Sub-Saharan Africa the coverage for

skilled birth attendance is five-times lower for the least poor

compared with most of the poor.10 Sophisticated solutions

are still required to ensure that the needs of the poorest, most

vulnerable members of society are not simply overlooked.

It is beyond the scope of this article to address many of the

important non-health sector interventions that could lead to

improved neonatal outcomes. Female education can lead to

later marriage and childbearing and it decreases chances of

dying in childbirth, in turn reducing child mortality.8,19

Poverty is associated with poor housing, undernutrition and

poor sanitation, which all impact on the ability of families to

make healthy choices.19 Addressing these issues concurrently

could result in significant health gains.

Conclusion

MDG4 has served to highlight the issue of child health

globally, and, despite a slow start, progress towards achieving

the goal has recently accelerated. Much evidence for effective,

affordable interventions that prevent neonatal and childhood

deaths already exists. The task now is to ensure that these are

implemented consistently and evenly, within and between

countries. It remains a role of individual countries to identify

and address local priorities, supported by the wider global

community. Looking beyond 2015, the development agenda

is unclear. However, the energy created through the MDGs

would be wasted if momentum for reducing neonatal deaths

were not maintained. Obstetricians have a vital role in

advocating for improvements in reproductive health—improvements that can save the lives of mothers, their

babies and their children.

AcknowledgementsNorth Bristol NHS Trust and Mpilo Central Hospital are

Health Partners. The Health Partnership Scheme is funded by

the UK Department for International Development (DFID)

and managed by the Tropical Health & Education

Trust (THET).

Disclosure of interestsDr Joanna Crofts is a member of the PROMPT Maternity

Foundation, a Registered Charity that enables maternity units

to run their own multi-professional obstetric emergencies

training. AS, WM and RF have no interests to disclose.

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