Although rates and numbers of maternal and child deaths have decreased substantially during the past two decades, few countries are on track to achieve the declines specified in the Millennium Development Goals, a recent analysis indicates.¹ Between 1990 and 2011, the global maternal mortality ratio declined by 1.9% per year and the child mortality rate by 2.2% per year—less than half the rates needed to reach the targets. At present, only 13 developing countries are on track to meet the maternal mortality goal, and just nine are expected to meet both goals.

Reductions in maternal and child mortality were among the eight goals cited in the United Nations Millennium Declaration of 2000. Specifically, the targets were for countries to reduce the mortality rate among children younger than five by two-thirds (goal 4) and the maternal mortality ratio by three-quarters (goal 5) from their 1990 levels by 2015. Two analyses published in 2010 concluded that annual declines in these outcomes were falling far short of the 4–5% needed to achieve the targets. However, the analyses were inconsistent in their classification of HIV-related maternal deaths, and did not have access to data that has since become available.

For the new analyses, investigators added 1,142 site-years of maternal mortality data, including new data from published reports and vital registration and surveillance systems; as a result, 138 of the 187 countries in the analysis have data that were unavailable for previous analyses, and the number of countries without data has been reduced from 21 to 15. In addition, unlike one of the 2010 reports, the researchers used the Millennium Development Goal definition of maternal mortality, which includes not only deaths during pregnancy or within 42 days of termination of pregnancy from direct and indirect causes, but also all HIV-related deaths that occur during pregnancy or within 42 days of termination. Moreover, the analyses on HIV-related maternal mortality used updated data on HIV prevalence, access to antiretroviral drugs and age-specific fertility from the United Nations and the World Health Organization.

Similarly, the researchers obtained new child mortality data for 163 countries. In addition to calculating numbers and rates for all deaths among children younger than five, they calculated estimates for four subcategories: neonatal mortality (within 0–6 days of birth), late neonatal mortality (7–28 days), postneonatal mortality (29–364 days) and childhood mortality (1–4 years).

Because accurate, up-to-date vital event data are unavailable for most countries, the researchers created models to fill gaps and correct for biases in event reporting. To obtain the most accurate estimates, the researchers created a range of regression models using 80% of available data; they then examined how well each model's predictions matched the remaining 20%, and used the most accurate models to make their estimates.

The analyses indicate that the annual number of maternal deaths worldwide declined from 409,000 in 1990 to 273,000 in 2011. Nearly half of the decrease occurred between 2005 and 2011, during which time India accounted for 29% of the decline. In 2011, the estimated maternal mortality ratio was 202 deaths per 100,000 live births; the ratio was highest in Eritrea, Liberia, Burundi and Afghanistan (881–1,081 per 100,000), and lowest in Austria and Iceland (four per 100,000 in both). About 56,000 maternal deaths were related to HIV during pregnancy.

Thirteen countries, representing 19% of births in the developing world, are on track to meet the Millennium Development Goal for reducing maternal mortality; the 13 include China, Egypt and Turkey, but no countries in Sub-Saharan Africa. Fifteen additional countries will meet the goal between 2015 and 2025 if the rate of decline they achieved between 1990 and 2011 continues; however, 96 others will not meet the goal until at least 2035 unless their rate of reduction increases. Twenty countries made no progress in reducing maternal mortality between 1990 and 2011.

The number of deaths among children younger than five declined by more than a third worldwide between 1990 and 2011, from 11.6 million to 7.2 million. The annual rate of decline was 2.2%; it was lowest for early neonatal mortality (1.7%), and higher for late neonatal (2.7%), postneonatal (2.5%) and childhood (2.4%) mortality. Sub-Saharan Africa accounted for 49% of child deaths in 2011 (an increase from 33% in 1990), while South Asia accounted for 33%. The rate of early neonatal mortality was 16.1 per 1,000 live births globally, and ranged from 0.8 per 1,000 in Japan to 36 per 1,000 in Equatorial Guinea; the rate of late neonatal mortality was 5.2 per 1,000 globally, and ranged from 0.4 in seven European countries to 15 in Equatorial Guinea (which also had the highest rates of postneonatal and child mortality).

Between 1990 and 2011, the number of developing countries whose mortality rate among children younger than five was lower than 20 per 1,000 increased from 20 to 41. Eighteen of the 41 were in Latin America; only two were in Sub-Saharan Africa, though 39 of the latter's 48 countries had greater declines in 2000–2011 than in 1990–1999, suggesting that the rate of progress has accelerated.

The investigators estimate that 31 countries (representing 27% of live births in developing countries) will meet the Millennium Development Goal for reducing child mortality. An additional 11 are predicted to meet the target by 2020, and all but three Latin American countries are on track to meet it by 2025. The picture is not as encouraging for Sub- Saharan Africa: Only Madagascar will likely meet the 2015 goal; eight other countries in the region are on track to make it by 2025, but 23 others, if past trends continue, will not meet the goal before 2040.

Countries with large declines in maternal mortality did not necessarily achieve similar declines in child mortality; the coefficient for the correlation between the rates of progress for the two measures was 0.42. Only 11 countries, and nine of 137 developing countries, are expected to make both goals: Albania, China, Egypt, Estonia, Iran, Libya, Maldives, Mongolia, Peru, Syria and Tunisia. Another 14 are on target to meet both goals by 2020.

The researchers note that their analyses have several limitations. All of the estimates encompass a degree of uncertainty; for ex-ample, the 95% uncertainty interval for the number of maternal deaths in 2011 was 256,000–292,000, and the range for the ?number of child deaths was 6.6–7.8 million. In addition, data were unavailable for 15 countries, and atypical events such as the 2009 H1N1 epidemic may have affected estimates for some years. Still, the findings indicate that progress in reducing maternal and child mortality "is continuing" in much of the world, and seems to be accelerating in Sub-Saharan Africa. Although most countries are unlikely to a-chieve either target, the investigators acknowledge, "it is perhaps more important to keep track of whether the pace of progress for children and mothers has improved. Accelerated progress should be viewed as an important indicator of success of programmes … even if the pace of the progress is below the [pace needed to reach the Millennium Development Goal] target."—P. Doskoch

REFERENCE

1. Lozano R et al., Progress toward Millennium Development Goals 4 and 5 on maternal and child mortality: an updated systemic analysis, Lancet, 2011, 378(9797):1139–1165.