Original Article

Obstetric Medicine
2017, Vol. 10(1) 21–25
! The Author(s) 2017
Global initiatives in maternal Reprints and permissions:
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and newborn health DOI: 10.1177/1753495X16684987
journals.sagepub.com/home/obm

Vanessa Brizuela1 and Özge Tunçalp2

Abstract
In 2015, 17 sustainable development goals were established for 2030. These global goals aim to ensure healthy lives and promote wellbeing for all.
In support of the sustainable development goals, the World Health Organization proposed a new global strategy for women’s, children’s, and adolescents’
health in 2016 with three overarching objectives: to survive, to thrive, and to transform. We are now globally seeking not only to end preventable deaths
but also to ensure health and wellbeing, and expand enabling environments. This strategy builds on several prior initiatives in maternal and newborn health,
such as the Every Woman, Every Child initiative, and the strategy to end preventable maternal mortality and implementation of an action plan to end
preventable newborn death. This confluence of initiatives, strategies, and novel financing mechanisms under the umbrella of the sustainable development
goals and the global strategy pave the way for a global agenda in which securing women’s health is critical.

Keywords
Maternal mortality, neonatal medicine, perinatal medicine

Date received: 7 October 2016; accepted: 9 November 2016

Introduction By 2010, in light of the challenges being faced with some of the
MDGs, the UN Secretary General launched the first Global Strategy
In 2015, at the United Nations General Assembly, sustainable devel- for Women’s and Children’s Health as a way to catalyze interventions
opment goals (SDGs) were established to continue the work started aimed at improving maternal and child health.5 In recognition that
through the millennium development goals (MDGs) 15 years prior. many of the obstacles in attaining these goals were related to accessing
The MDGs were a set of eight global development goals signed essential commodities, ten recommendations were made to overcome
in the year 2000 by all member states of the United Nations aimed such barriers.6 These focused on quality, financing, supply, and access.
at addressing some of the most pressing needs among the world’s This slow progress revealed overarching difficulties in improving
poorest.1 Three of the MDGs related specifically to health: to reduce maternal health. Essentially these related to disparities in access
child mortality (MDG 4), to improve maternal health (MDG 5), and to to health care—within and across regions—and inequalities faced by
combat HIV/AIDS, malaria, and other diseases (MDG 6). MDG 5 specific vulnerable populations. The latter are often determined by
was operationalized through a two-part goal of reducing maternal education, residence, economic status, and/or age, as well as race
mortality ratio (MMR) by 75% and achieving universal access to and ethnicity.4,7 In addition, the quality of maternal and newborn
reproductive health.1 (MDG 5.b was added in 2007, meaning it was care has not always been optimal or evidence-based.8–10 Poor quality
not part of the initial goal.2) of care is associated with increased health risks and poor health out-
The MDGs were an unprecedented initiative resulting in over- comes, including higher maternal and newborn mortality.11
whelming progress in reducing poverty and improving lives of people
around the globe. This success was also seen in maternal and newborn
health. Global maternal mortality declined significantly (45%) since The post-2015 agenda
1990, most births were assisted by skilled personnel by 2015, and
contraceptive prevalence also increased in this period.3 The SDGs now propose a much broader agenda that goes well beyond
However, the progress in maternal health was far from the what had been established for the MDGs, not only through its pro-
expected. Despite the improvements in maternal survival and access posed 17 goals and 169 targets but through its aim to ‘‘ensure healthy
to family planning and contraception, most regions did not achieve lives and promote well-being for all at all ages’’ by 2030.12 At the
their MMR reduction goal.4 While MMR was reduced 64% moment, the focus is on improving the overall wellbeing, and not
in Southern Asia and 65% in Eastern Asia, it only declined 40% in merely reducing mortality, morbidity, and burden of disease. Several
Latin America and 36% in the Caribbean. The proportion of births targets refer to maternal and neonatal health, either directly or indir-
attended by skilled personnel increased in all world regions, from ectly, such as: to reduce global maternal mortality ratio, to end pre-
59% in 1990 to 71% in 2015; however, this still means that, on average, ventable deaths of newborns and children under 5 years of age, to
one in four babies are being delivered without skilled care. Only half ensure universal access to sexual and reproductive health care services,
of pregnant women in developing regions receive the recommended
four antenatal visits, and there is still a significant proportion of
women with unmet need for contraception.4 Declines in adolescent 1
Harvard T. H. Chan School of Public Health, Boston, MA, USA
2
fertility have been seen across the globe but still remain worryingly Department of Reproductive Health and Research including UNDP/
high, especially in some regions; in sub-Saharan Africa there were UNFPA/UNICEF/WHO/World Bank Special Programme of Research,
116 births per 1000 15–19 year olds in 2015, compared to 51/1000 Development and Research Training in Human Reproduction (HRP),
globally and 17/1000 in the developed regions.4 Furthermore, aside World Health Organization, Geneva, Switzerland
from these regional differences, there are significant inequalities
within regional, national, and sub-national levels. These differences Corresponding author:
speak of inequities where many national averages hide great levels of Vanessa Brizuela, Harvard T. H. Chan School of Public Health,
inequalities with regards to access to care, and the quality of the care 677 Huntington Avenue, Boston, MA 02115, USA.
received.4 Email: [email protected]
22 Obstetric Medicine 10(1)

Figure 1. Health in the SDG era.

Source: WHO.13

and to achieve universal health coverage (UHC).12 Moreover, SDG 3 initiatives include the first Global Strategy and the Every Woman Every
and all its sub-goals are also closely linked with other inter-sectoral Child movement launched in 2010, followed by A Promise Renewed
goals. For example, SDG 5 calls for the elimination of gender inequi- (a commitment towards newborn health) in 2012, Every Newborn:
ties, including violence against women, and SDG 6 seeks to prevent An Action Plan to End Preventable Deaths (ENAP) in 2014, and
disease through access to safe water and sanitation12 (Figure 1). Strategies for Ending Preventable Maternal Mortality (EPMM) in
What these goals reflect is a global recognition of the great progress 2015.5,19–22 In 2015, a Lancet Commission highlighted the importance
achieved through the MDGs, while pointing to the many unfinished of women in the global health agenda, and in making progress towards
agenda items still remaining. The SDGs are based on an understanding these commitments. This commission recommended valuing women,
of the need to move towards more equitable health systems that pro- compensating them equitably for their work and contributions, count-
vide the highest possible quality of care. They present, therefore, a ing them appropriately, and being accountable to them.23
renewed agenda with regards to inequality, in service provision and The ENAP and EPMM put forth five strategic objectives each to
access and in health system response, and a focus on quality of life, end preventable maternal and newborn mortality. These have been
especially with regards to noncommunicable diseases (NCDs) and synthesized by Chou et al.11 as follows:
maternal morbidity.14,15
Among the important pillars in the SGDs is the commitment to 1. Strengthening care around time of birth: this highlights the need to
achieving UHC around the globe where quality of care is at the heart improve quality of care making it safe, effective, timely, efficient,
of it.16 Ensuring that all people have access to quality health without equitable, people centered, and respectful.
suffering financial hardship has been one of the flagships of the SGDs, 2. Strengthening health systems: from the perspectives of infrastruc-
and it is an important factor in improving overall health, including ture and commodities, to leadership and governance, including
maternal health.17 In order to achieve UHC, several actions need to optimal referral systems.
be taken, among which are expanding priority services, including more 3. Reaching every woman and newborn: this means equity, not only in
personnel, and reducing out-of-pocket payments.18 access to services but also in access to high quality care.
4. Harnessing the power of parents, families, and communities: includ-
ing participatory learning, especially in rural and hard-to-reach
The road towards a new global era areas and communities.
5. Improving data for decision making and accountability: such as
The SDGs provide an overarching umbrella under which decades of establishing national registration and vital statistics systems in
work in maternal and newborn health come together. Previous guiding every country.
Brizuela and Tunçalp 23

Table 1. Seventeen targets in the global strategy for women’s, children’s, and adolescents’ health.
Survive Thrive Transform
End preventable deaths Ensure health and wellbeing Expand enabling environments

Reduce global maternal mortality to less End all forms of malnutrition and address the Eradicate extreme poverty
than 70 per 100,000 live births nutritional needs of children, adolescent
girls, and pregnant and lactating women
Reduce newborn mortality to at least as Ensure universal access to sexual and Ensure that all boys and girls complete
low as 12 per 1,000 live births in reproductive health care services free, equitable and good-quality pri-
every country (including for family planning) and rights mary and secondary education
Reduce under-5 mortality to at least as Ensure that all boys and girls have access to Eliminate all harmful practices and all
low as 25 per 1,000 live births in good-quality early childhood discrimination and violence against
every country development women and girls
End epidemics of HIV, tuberculosis, mal- Substantially reduce pollution-related deaths Achieve universal and equitable access to
aria, neglected tropical diseases and and illnesses safe and affordable drinking water and
other communicable diseases to adequate and equitable sanitation
and hygiene
Reduce by one-third premature mortal- Achieve universal health coverage, including Enhance scientific research, upgrade
ity from noncommunicable diseases financial risk protection and access to technological capabilities and encour-
and promote mental health and quality essential services, medicines and age innovation
wellbeing vaccines
Provide legal identity for all, including
birth registration
Enhance the global partnership for sus-
tainable development

Source: WHO.25

In sum, provision of healthcare needs to go beyond essential inter- . Health system resilience: providing good quality care in all settings,
ventions, especially in light of the disappointing decline in maternal preparing for emergencies, and ensuring universal health coverage.
mortality and morbidity despite the increase in facility-based births.8,24 . Individual potential: investing in development of individuals, sup-
In fact, at the 2012 World Health Assembly, Director General porting people as agents of change and in overcoming legal barriers.
Margaret Chan openly expressed: ‘‘What good does it do to offer . Community engagement: promoting enabling laws, policies and
free maternal care and have a high proportion of babies delivered in norms, and ensuring inclusive participation.
health facilities if the quality of care is sub-standard or even danger- . Multi-sector action: adopting a multi-sector approach that facili-
ous?’’ Good quality of care refers not only to the provision of care tates cross-sector collaboration.
through evidence-based practices, actionable information systems, and . Humanitarian and fragile settings: supporting the use of human
functional referral systems but it also refers to the patients’ experience rights and gender-based programming to better protect women,
of care. This includes effective communication, respect and dignity, children, and adolescents in humanitarian settings, including the
and emotional support. Additionally, it is important to have competent integration of emergency response into health plans, and addressing
and motivated human resources, and to have essential physical the gaps in the transition from these settings to sustainable ones.
resources available.8 . Research and innovation: investing in research and development,
testing and scaling up innovations.
. Accountability: harmonizing monitoring and reporting, and
A strategy towards 2030 improving civil registration and vital statistics.

It is within this purview that the 2016 Global Strategy for Women’s,
Children’s and Adolescent’s Health (2016-2030) emerges as a new road- Additionally, this new strategy includes adolescents, and places an
map towards ending preventable deaths, ensuring health and well- important focus on emergency and humanitarian settings. This
being, and expanding enabling environments for women, children, increases attention on equity where all people (hard to reach, vulner-
and adolescents.25 It does this by aligning itself to the SDGs with a able, in crisis situations) are accessed and provided with the highest
specific focus on 17 targets. The vision of this strategy is to ensure that level of care possible. The inclusion of adolescents also speaks to a
‘‘every woman, child and adolescent in every setting realizes their rights realization that young people are at the center of the post-2015 era,
to physical and mental health and well-being, has social and economic and ensuring their livelihood and attainment of their full potential, is
opportunities, and is able to participate fully in shaping prosperous critical in assuring wellbeing in 2030.
and sustainable societies’’ (p. 6).25 This new Global Strategy provides a blueprint to ensuring these
There are several novelties and goals for this new strategy that goals are attained through 60 indicators, of which 16 are key in assess-
promise to render better results than the previous one. For one, it ing progress. Most of these indicators are in line with the SDGs, while
has expanded its focus to go beyond just survival to include thrive others have been constructed from other global initiatives in maternal,
and transform, as well as an additional nine action areas. The targets child, and adolescent health26 (Appendix). They seek to ensure that the
are described in Table 1, and the action areas relate to the following: second goal of thrive by including indicators that measure access and
use of contraception, NCDs, mental health, and UHC.26
. Country leadership: reinforcing leadership and management at all This expanded strategy, if followed, promises to end preventable
levels and promoting collective action. deaths among mothers, newborns, children, and adolescents by 2030.
. Financing for health: mobilizing resources, ensuring value for It will also render a 10-fold return on investment in health and nutri-
money, and integrating innovative approaches. tion through improved education, participation in the workforce, and
24 Obstetric Medicine 10(1)

contributions to society. Additionally, it is estimated that there will be with scenario-based projections to 2030: A systematic analysis by
at least US$100 billion more in demographic dividends from these the UN Maternal Mortality Estimation Inter-Agency Group.
investments. The convergence of these three objectives will allow all Lancet 2016; 387: 462–474.
women, children, and adolescents equal chances to survive, thrive, and 4. United Nations. The Millennium Development Goals Report 2015
transform their lives.27 In addition, and through the leadership of the [Internet]. United Nations; 2015, http://www.un.org/millennium-
World Bank, a global financing facility (GFF) was introduced in mid goals/2015_MDG_Report/pdf/MDG%202015%20rev%20
2015 as a multi-stakeholder partnership to support country-led efforts (July%201).pdf (accessed 6 June 2016).
to improve the health of women, children, and adolescents.28 The GFF 5. Ki-Moon B. Global strategy for women’s and children’s health. N
has the potential to financially support 63 high-burden countries (low- Y U N, http://www.un.org/en/mdg/summit2010/pdf/Global%
and middle-income) to bridge the US$33 billion gap in required 20Strategy.pdf (accessed 16 June 2016).
investments. 6. Jonathan HGE, Stoltenberg RHJ. UN Commission on Life-
Saving Commodities for Women and Children, http://ww.state
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order to ascertain that no women, children or adolescents die from Health Care. A Shadow Report for the UN Committee on the
preventable diseases by 2030. The SDGs provide a framework under Elimination of Racial Discrimination. Center for Reproductive
which to guide actions for the upcoming 15 years. Initiatives such as Rights; 2014, http://www.reproductiverights.org/sites/crr.civicac-
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translates into an understanding of the current need to focus on a pregnant women and newborns-the WHO vision. Int J Obstet
life-course approach to women’s health within an agenda that includes
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10. Bohren MA, Hunter EC, Munthe-Kaas HM, et al. Facilitators
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GOAL 3: Transform (Expand Enabling Environments)

13. Proportion of children under 5 years of age whose births have

been registered with a civil authority (SDG 16.9.1)
Appendix: Sixteen key indicators for the 14. Proportion of children and young people (in schools): (a) in grades
global strategy for women’s, children’s, and 2/3; (b) at the end of primary; and (c) at the end of lower second-
adolescents’ health ary achieving at least a minimum proficiency level in (i) reading
and (ii) mathematics, by sex (SDG 4.1.1)
GOAL 1: Survive (End Preventable Mortality) 15. Proportion of ever-partnered women and girls aged 15 and older
subjected to physical, sexual or psychological violence by a current
1. Maternal mortality ratio (SDG 3.1.1) or former intimate partner in the previous 12 months (SDG 5.2.1)
2. Under-5 mortality rate (SDG 3.2.1) and proportion of young women and men aged 18–29 who experi-
3. Neonatal mortality rate (SDG 3.2.2) enced sexual violence by age 18 (SDG 16.2.3)
4. Stillbirth rate 16. Percentage of population using safely managed sanitation services
5. Adolescent mortality rate including a hand-washing facility with soap and water (SDG
6.2.1)
GOAL 2: Thrive (Promote Health and Wellbeing)
Note: Equity is a cross-cutting consideration aligned with SDG
6. Prevalence of stunting among children under 5 years of age (SDG 17.18.1.
2.2.1)
7. Adolescent birth rate (10–14, 15–19) per 1,000 women in that age
group (SDG 3.7.2)