The report also focuses on developing countries where progress in maternal and child health is slow, stagnating, or has even gone into reverse mode in recent years. Within such countries, less than half of mothers and newborns receive care, but by no means the full range of what they need. "Make every mother and child count" is a wide-ranging study of the obstacles to health facing women before and during pregnancy, in childbirth, and in the weeks, months, and years that follow for them and their children. It pays particular attention to the plight of newborns, whose specific needs have "fallen between the cracks" separating maternal and child-care programs.

    "There are half a million women who die during pregnancy or during childbirth. It's a scandal," said Marie-Paule Kieny, head of the WHO family-health department.

    Every year, about 530,000 women die in pregnancy or childbirth, more than three million babies are stillborn, more than four million newborns die within the first days or weeks of life, and altogether 10.6 million children die before their fifth birthday, according to the report.

    There are 136 million yearly births worldwide, and attending to them is one of the major challenges that face the world's health system. The WHO estimates that less than two-thirds of women in developing countries give birth with the help of a qualified health professional, a proportion that drops to less than one-third in the poorest countries.

    Nine out of 10 deaths among children under five result from just six conditions: acute neonatal conditions, mainly preterm birth, birth asphyxia, and infections (37 percent); lower-respiratory infections, mostly pneumonia (19 percent); diarrhea (18 percent); malaria (eight percent); measles (four percent); and HIV/AIDS (three percent).

    Most of those conditions could be easily treated with rehydration therapy, antibiotics, antimalarial drugs, vitamins or minerals, greater breast-feeding, immunization or skilled care during pregnancy and childbirth, the report said.

    "We know what needs to be done to avoid this massacre: action is simple and not so costly," Kieny said, noting that an uncontrolled two-hour postnatal hemorrhage is enough to kill a mother. Newborn deaths could be reduced substantially if all babies were washed, warmed, and fed within an hour of their birth, she added.

A continuum

    To reduce the deaths sharply, the WHO advocates a wider use of key interventions and a "continuum of care" approach for mother and child that begins before pregnancy and extends through childbirth and into the baby's childhood.

    "This approach has the potential to transform the lives of millions of people," said Dr. Lee Jong-wook, WHO director general. "Giving mothers, babies, and children the care they need is an absolute imperative."

    It, however, requires a massive investment in health systems, particularly the deployment of more health professionals, including doctors, midwives, and nurses.

    "For optimum safety, every woman, without exception, needs professional skilled care when giving birth," the report says, stressing that continuity of care for the newborn in the following weeks is vital. "Women risk death to give life, but with skilled and responsive care, at, and after birth, nearly all fatal outcomes and disabling sequelae can be averted…and much of the suffering can be eased," it adds.

Meeting millennium goals

    Under the United Nations' Millenium Development Goals, countries around the world are committed to cutting down maternal mortality by three-quarters and child mortality by two-thirds by 2015.

    "On current trends, some parts of the world won't reach the goals for 150 years. We must not let that happen," said Denis Aitken, a senior WHO official.

    The WHO estimates that an additional US$9 billion dollars a year should be invested over the next decade in the 75 countries most affected by maternal- and child-health problems to meet the goals. These countries already spend US$97 billion per year, but the WHO says it is not enough.

    Countries like Afghanistan, Angola, Burkina Faso and the Democratic Republic of Congo are at a standstill, according to the report. Kenya, Rwanda, Turkmenistan, Zambia, and Zimbabwe have dropped back after making progress recently.

    The WHO laid most of the blame for those setbacks on the collapse of basic health care, mainly due to conflicts or political strife.

    Exclusion from maternal, newborn, and child-health care is a key feature of inequity as well as a crucial obstacle to progress toward the MDGs, the report says. The health of mothers and children "is at the core of the struggle against poverty and inequality, as a matter of human rights."

    Lack of access to skilled care and to major obstetric interventions is the prime reason why large numbers of mothers in rural areas are excluded from life-saving care at childbirth. For example, in a study of 2.7 million deliveries in seven developing countries, only 32 percent of women WHO needed a major life-saving intervention received it.

    More than 18 million induced abortions each year are performed by people lacking the necessary skills or in an environinent lacking rudimentary medical standards, or both, and are therefore unsafe. As a consequence, 68 000 women a year die.

    In many countries, "numerous women and children are excluded from even the most basic health benefits: those that are important for mere survival," says the report. Some countries, often the poorest, show a pattern of massive deprivation, with only a small minority, usually the urban rich, enjoying reasonable access to health care, while an overwhelming majority is excluded.

    Among those left out, women and their children suffer most. Notes the report: "Being poor or being a woman is often a reason for being discriminated against, and may result in abuse, neglect and poor treatment, poorly explained reasons for procedures, compounded by views sometimes held by health workers that women are ignorant. The care that women are offered may be untimely, ineffective, unresponsive, or discriminatory."

    The report adds that putting in place the health workforce needed for scaling up maternal, newborn, and child-health services toward universal access is the first and most pressing task. Out of the US$9 billion additional funding needed, US$3.5 billion should go to additional human resources.

    Making up for the huge shortages and imbalances in the distribution of health workers in many countries will remain a major challenge for years to come. WHO is currently assessing the need for a massive scale-up in the numbers of health workers of all categories, not just maternal and child care, in the coming decade.

    The human-resources crisis relates not just to shortages of people but also to issues such as pay and working conditions. WHO is developing a series of policy actions for each of the areas covered in the report and is encouraging governments and other stakeholders to introduce recommended interventions and scale up maternal, newborn and child health programs. WHO will monitor and evaluate progress in these programs. With a report from AFP