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Women, children, and global public health: beyond the millennium development goals

BMJ 2015; 350 doi: https://doi.org/10.1136/bmj.h1755 (Published 21 April 2015) Cite this as: BMJ 2015;350:h1755

This article has a correction. Please see:

  1. Nick J Brown, associate editor,
  2. Martin P Ward Platt, senior editor,
  3. R Mark Beattie, editor in chief
  1. 1Archives of Disease in Childhood, BMJ Publishing, BMA House, London WC1H 9JR, UK
  1. Correspondence to: R M Beattie mark.beattie{at}uhs.nhs.uk
  • Accepted 25 March 2015

As the deadline approaches for the millennium development goals, Nick Brown, Martin Ward Platt, and Mark Beattie discuss the sustainable development goals and the potential barriers to achieving them

The eight millennium development goals were a breakthrough. Together we created a blueprint for ending extreme poverty. We defined achievable targets and timetables. We have more development success stories than ever before. The transformative impact of the MDGs [millennium development goals] is undeniable. This is an achievement we can be proud of. But the clock is ticking, with much more to do. There is more to do for the mother who watches her children go to bed hungry—a scandal played out a billion times each and every night. There is more to do for the young girl weighed down with wood or water, when instead she should be in school. There is no global project more worthwhile. Let us keep the promise—Ban Ki-moon, in his opening remarks to the millennium development goal summit, 20 September 2010.

The millennium development goals were aspirational targets set by the United Nations in New York in September 2000.1 At the time governmental foreign aid was falling worldwide and the financing of major projects was dominated by the World Bank and International Monetary Fund. The goals were the result of concern at stagnation in mortality rates and social inequity and were based on what might be achievable by the end of 2015. The eight goals were:

  • Eradication of extreme poverty and hunger

  • Universal primary education

  • Promotion of gender equality and the empowerment of women

  • Reduction of child mortality

  • Improvement of adolescent and maternal health

  • Combat HIV/AIDS, malaria, and other diseases

  • Ensure environmental sustainability

  • Development of a global partnership for development

Each goal had specific targets, some of which were quantified—for example, goals three and four aimed for reductions in maternal and child mortality of three quarters and two thirds, respectively, from their rates in 1990.

The goals were adopted by all 189 member countries of the UN at the time.2 Crucially, they take a life cycle approach, recognising that children’s survival, health, and education are central to achieving all the targets. As we approach the deadline, a supplement in Archives of Disease in Childhood takes stock of the successes, failures, and oversights of the millennium development goals and considers the next phase—the sustainable development goals.3 Here we review some of the topics raised in the supplement, particularly with respect to how we move forward to the sustainable development goals and the potential barriers to achieving them.

Remarkable progress

Many of the goals were thought to be aspirational. However, the progress made towards mortality reduction, HIV infection, and education has been remarkable.4 5 Child mortality has effectively halved worldwide, from 90 per 1000 births in 1990 to 46 in 2013, equivalent to 17 000 fewer children dying each day.2 However, there are still many causes of child mortality that we need to work on to achieve further reductions (fig 1). For example, preventable infectious diseases, prematurity, and congenital malformation contribute to both neonatal and postneonatal mortality. Maternal mortality has fallen by 45% over the same period, from 380 to 210 per 100 000 live births, but this is some way short of the hoped for 75% reduction.6

Figure1

Global causes of child mortality in 2013. Group 1 conditions are any that feature in the neonatal section and can affect babies beyond 28 days (tetanus, intrapartum related complications, and sepsis). Source: WHO

Perinatal HIV infection is now considered both preventable, as a result of the hugely successful mother to child transmission programmes, and treatable, owing to the development and refinement of highly active antiretroviral drugs. This was inconceivable when the goals were launched and has been catalysed by the philanthropy of drug companies manufacturing antiretroviral drugs.7

The Global Alliance for Vaccines Initiative, which is a public-private collaboration between the vaccine industry, governments, and UN agencies supported by the Gates Foundation, has immunised an additional 440 million children and prevented an estimated six million deaths since its inception in 2000.8 9

Children of mothers with primary education have a better chance of survival than those born to illiterate mothers, and some would argue that, of all the goals, this is the most important.4

Sobering stagnation

However, satisfaction with the progress made in these areas must be tempered by the reality of sobering stagnation on others.3 Rates of perinatal mortality and stillbirth remain stubbornly static. Given that these deaths are the biggest contributor to young child mortality, one can appreciate the need in this area for new collaborative efforts, such as the Every Newborn Action Plan.10 Similarly, the progress made in vaccination is tempered by the overall inconsistent cover in bare minimum drug availability as delineated by the World Health Organization’s list of essential medicines.5

Another crucial area that continues to frustrate is that of child nutrition, the failure of which is the result of a complex pathway involving political will and expenditure, warfare, family planning, recognition of education, early treatment, and infectious disease burden.11 The World Health Assembly has adopted a set of six key malnutrition targets to be met by 2025—stunting and wasting (chronic and acute under nutrition, respectively), anaemia, low birth weight, exclusive breast feeding, and, in transitional populations, under 5 overweight.12 13 Little to no progress has been made in all of these parameters since the targets were set in 2012, and in many cases the average annual rates of change have fallen rather than risen (table).

Areas of underachievement

View this table:

Identification and management of severe acute malnutrition have improved in the past 20 years, but nearly half of all childhood deaths (3.1 million) a year are still attributable in part to malnutrition. Up to 10% of all preschool deaths are a direct result of marasmus or kwashiorkor, and this rises to 45% if indirect mechanisms of malnutrition are included. Moreover, stunting and micronutrient deficiencies, especially iron and iodine, constrain children’s developmental potential, with consequent reductions in educational attainment and earning power. Early undernutrition is also associated with late childhood and adult obesity leading to chronic poor health from non-communicable diseases in later life.14 15

Paradoxically, if the world’s food supply was equitably distributed hunger would be abolished. Yet even countries with recently acquired wealth seem unable to distribute food supplies evenly to their own population. Nevertheless, there are modifiable factors, such as education, maternal nutrition, sanitation, and effective school nutrition, that can be tackled. Ultimately, however, political will, peace, and adequate funding are crucial and have proved to be stumbling blocks to progress in many countries. It is perhaps the main reason that sub-Saharan Africa and South Asia still lag far behind other areas.16

The concept of “the first 1000 days”—that nutrition is most important between conception and the second birthday—is well established. It highlights the impact of maternal nutrition, breast feeding, and appropriate nutrition soon after weaning in terms of lifelong health.11

Positive consequences

With some justification the millennium development goals have been regarded as over-ambitious, and they have been criticised for important omissions, notably non-communicable diseases, early child development, mental health, and the neglected tropical diseases. In addition, some argue that substantial changes would have occurred in the absence of the goals. But in a recent economic analysis, based on extrapolation of trends in the 1990s and adjusted for expected temporal change, Baker estimated that 13.6 million extra children’s lives have been saved since 2001.17 Data from the Global Burden of Disease study support this finding.18

An indirect benefit of the goals has been the establishment of a number of alliances, such as the Global Alliance for Vaccines Initiative and Roll back Malaria, which provide a new philosophical approach to international collaboration. The Global Action Plan for Pneumonia and Diarrhoea is a new programme built on the recognition that both illnesses share risk factors including inadequate breast feeding, poor sanitation, and incomplete vaccination. This global action plan was the culmination of a joint initiative by WHO and Unicef, which included a series of workshops aimed at assessing the evidence base for shared predictors of disease and their most appropriate interventions.19

Sustainable development goals

As 2015 approached it became clear that with shortfalls in so many areas, the project could not simply stop. So the UN organised a summit in Rio in 2012 and a working group that led to the development of the sustainable development goals. These 17 new goals, with 169 associated targets, have built and expanded on the millennium development goals with a greater emphasis on environmental matters. They will replace the millennium development goals in late 2015 (box).20

Sustainable development goals

  • End poverty in all its forms everywhere

  • End hunger, achieve food security and improved nutrition, and promote sustainable agriculture

  • Ensure healthy lives and promote wellbeing for all at all ages

  • Ensure inclusive and equitable quality education and promote lifelong learning opportunities for all

  • Achieve gender equality and empower all women and girls

  • Ensure availability and sustainable management of water and sanitation for all

  • Ensure access to affordable, reliable, sustainable, and modern energy for all

  • Promote sustained, inclusive, and sustainable economic growth; full and productive employment; and decent work for all

  • Build resilient infrastructure, promote inclusive and sustainable industrialisation, and foster innovation

  • Reduce inequality within and among countries

  • Make cities and human settlements inclusive, safe, resilient, and sustainable

  • Ensure sustainable consumption and production patterns

  • Take urgent action to combat climate change and its impacts (taking note of agreements made by the United Nations Framework Convention on Climate Change)

  • Conserve and sustainably use the oceans, seas, and marine resources for sustainable development

  • Protect, restore, and promote sustainable use of terrestrial ecosystems; sustainably manage forests; combat desertification and halt and reverse land degradation; and halt biodiversity loss

  • Promote peaceful and inclusive societies for sustainable development; provide access to justice for all; and build effective, accountable, and inclusive institutions at all levels

  • Strengthen the means of implementation and revitalise the global partnership for sustainable development

The absolute priorities are women’s education and empowerment, poverty, and the amelioration of armed conflict.21 The launch of the sustainable development goals provides a unique opportunity to intervene in these areas.

Women’s health

Women’s health, family planning, literacy, and empowerment are interlinked. Enrolment in primary school reached 90% in 2010 which, though impressive, still left 58 million children worldwide without even primary school education. Post primary education remains patchy and almost 800 million adults worldwide—60% of whom are women—have no basic literacy or numeracy skills.21 Gender inequality persists beyond school, including discrimination in employment opportunities, salaries, and governmental positions.

Almost half of the 125 million births worldwide each year are to women who have not received the minimum of four antenatal visits, and a third of women deliver in places other than health facilities. There are no facilities for the management of obstetric complications for 21 million women or neonatal care for 33 million babies.22 23 24 Deficiencies in antenatal and peripartum care are reflected in correspondingly high maternal mortality rates (fig 2).

Figure2

Maternal mortality rates (deaths per 100 000 deliveries). Source: WHO

Worldwide 22% of adolescents have a partner, whether married or not. They contribute 11% of the total pregnancies, and many of these relationships are coerced, either through abuse or in the context of child marriage. Adolescent mothers and their babies are at higher risk of morbidity and mortality for reasons that include poor antenatal care, poor nutrition, gynaecological immaturity, and inadequate pelvic growth. This is compounded in cultures that practise female genital mutilation.23 Women who reproduce as children are less likely to complete their education, which perpetuates the cycle.24

The importance of expanding family planning services and ensuring that they occupy a central position in the post 2015 agenda is beyond any doubt. The benefits extend far beyond child mortality to social and economic gains—two recent studies predicted the potential reduction in child and maternal mortality associated with scaled up family planning and estimated a demographic dividend of 8% of the gross domestic product in the 23 poorest of the 74 low and middle income countries studied.25 26

Violence against women continues to undermine efforts to reach the goals. An estimated 120 000 young girls worldwide are enlisted as soldiers, leaving them vulnerable to injury, chronic ill health, sexual exploitation, and sexually transmitted infections.27 A large proportion of female sex workers are minors (40% in some estimates) and are more likely to experience violation of their human rights, sexually transmitted infections, unwanted pregnancies, and suicide.28

The Global Fund to Fight AIDS, Tuberculosis, and Malaria has long recognised that without the reduction of gender inequality at social, cultural, and legal levels, population health cannot truly move forward. The Global Fund recently launched the Gender Equality Action Plan, which prioritises women’s rights and empowerment as part of its long term agenda.27 Similarly, the World Bank initiated the Global Financing Facility in Support of Every Woman and Every Child. It is too soon to judge any impact but we hope that these and other initiatives improve this overlooked area.29

Poverty

There is a clear correlation between income per capita and health parameters (fig 3).30 However, the relation is complex and non-linear.31 Food security and basic health needs still need to be met, and favourable societal frameworks (such as equity) are needed.32

Figure3

Correlation between under 5 mortality rate and gross domestic product per capita. Source: World Bank30

The aim of millennium development goal one was to halve the number of people living in absolute poverty, defined as existing on less than $1.25 (£0.85; €1.15) a day. Although this seems to have been achieved,33 there are caveats. One is that the improvement in living standards in the huge population of South East Asia, particularly China, has masked stagnation elsewhere, such as parts of sub-Saharan Africa. Also, the reduction in poverty may have occurred as part of natural temporal changes uninfluenced by the goals.

Unsurprisingly, armed conflict consistently impedes progress, destroying infrastructure and worsening poverty. We may have become blasé through continued exposure, but it remains true that the world spends seven times as much on arms as on health. The cost of war is not only financial. In addition to the direct physical and psychological effects of trauma, there are indirect effects such as infectious diseases resulting from poor sanitation, overcrowding, and reduced public health activity, all of which are compounded by malnutrition.34

Perinatal mortality

Despite the strides made in reducing overall mortality for children under 5, further progress will not be possible until perinatal care is tackled more comprehensively. For years neonatal deaths have been a major contributor to under 5 mortality, but the relative proportion of these deaths has recently increased and now approaches 50% in several low and middle income countries. Perinatal conditions and their sequelae account for 8.1% of global disability adjusted life years—more than all cancers combined, three times that for HIV, and equal to cardiovascular disease.35 The main causes of death are prematurity and low birth weight, complications of delivery (such as obstructed labour and asphyxia), and infection.

Perinatal care has long been in the shadow of higher profile diseases and has attracted less funding. Yet simple, cheap, and evidence supported interventions and care packages do exist, including antenatal steroids in preterm labour, maintenance of general hygiene in the perinatal period, neonatal thermal care, kangaroo care, and breast feeding.36 37 Surveillance after delivery and early recognition of illness are essential.38

The Every Newborn Action Plan aims to eliminate avoidable deaths by strengthening the quality of care received during labour, childbirth, and the first days of life; reaching every woman and every newborn; empowering parents and communities; and improving measurement and accountability.39

Optimistic outlook

As the new era of the sustainable development goals dawns, there remains much unfinished business, including persistent and substantial variations between countries and regions. The open working group has suggested hugely ambitious targets for 2030, including the abolition of unnecessary neonatal deaths and ending AIDS, tuberculosis, malaria, and neglected tropical diseases. The three targets of greatest importance remain women’s education and empowerment, poverty, and warfare.

Left unattended, progress made in the millennium development era will certainly slow and in some parts of the world may even reverse. Despite this, there are reasons for optimism—the progress made in Rwanda in only 20 years after the genocide shows what can be achieved with political and social will.40

Key messages

  • The millennium development goals are eight aspirational targets set by the United Nations in New York in September 2000 to be achieved by the end of 2015

  • The progress made towards some of the goals has been remarkable—in particular, reduction of child mortality, HIV prevention and treatment, and improvements in education

  • In other areas, however, few inroads have been made—perinatal mortality, gender empowerment, and undernutrition lag behind for complex, interconnected reasons

  • The new sustainable developmental goals have built and expanded on the millennium development goals with ambitious targets for 2030

  • These include the abolition of unnecessary neonatal deaths and ending AIDS, tuberculosis, malaria, and neglected tropical diseases

Notes

Cite this as: BMJ 2015;350:h1755

Footnotes

  • Contributors and sources: NB and RMB conceived the article. All three authors contributed to the article. RMB is the guarantor.

  • Competing interests: We have read and understood BMJ policy on declaration of interests and have no relevant interests to declare.

  • Provenance and peer review: Not commissioned; externally peer reviewed.

References

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