The U.S. Government and Global Maternal & Child Health Efforts
- Millions of pregnant women, new mothers, and children experience severe illness or death each year, largely from preventable or treatable causes. Almost all maternal and child deaths (99%) occur in less developed regions, with Africa being the hardest hit region. There have been some gains: attention to maternal and child health (MCH) has been growing, and under-five and maternal mortality have fallen substantially since 1990.
- The U.S. government (U.S.) has been involved in supporting global MCH efforts for more than 50 years and is the largest donor government to MCH activities in the world, in addition to being the single largest donor to nutrition efforts in the world.
- In recent years, the U.S. has placed a higher priority on MCH and adopted “ending preventable child and maternal deaths” as one of its three main global health goals.
- Total U.S. funding for MCH and nutrition was $1.38 billion in FY 2020, up from $728 million in FY 2006. This includes the U.S. contributions to Gavi, the Vaccine Alliance, and the U.N. Children’s Fund (UNICEF) as well as support for polio activities. The current Administration, however, has proposed significantly reduced MCH and nutrition funding for FY 2021.
- Despite gains, there is growing concern about the potential impact of the COVID-19 pandemic on MCH.
The health of mothers and children is interrelated and affected by multiple factors.1 Millions of pregnant women, new mothers, and children experience severe illness or death each year, largely from preventable or treatable causes.2 Almost all maternal and child deaths (99%) occur in less developed countries, with Africa being the hardest hit region.3 Attention to maternal and child health (MCH) has been growing, under-five and maternal mortality have fallen substantially since 1990, and improving MCH is seen as critical to fostering economic development.
Maternal Health: The health of mothers during pregnancy, childbirth, and in the postpartum period.
Child Health: The health of children from birth through adolescence, with a focus on the health of children under the age of five. Newborn health is the health of babies from birth through the first 28 days of life.
Still, as efforts focus on achieving new global MCH goals such as ending preventable deaths among newborns and children under five and reducing global maternal mortality, significant challenges remain. Although effective interventions are available, lack of funding and limited access to services have hampered progress, particularly on maternal health.
Each year, an estimated 5.3 million children under age five – primarily infants – die from largely preventable or treatable causes.4 In addition, approximately 295,000 women die during pregnancy and childbirth each year, and millions more experience severe adverse consequences.5 These challenges are especially prevalent in developing countries (see Table 1). Furthermore, sub-Saharan Africa is the hardest hit region in the world, followed by Southern Asia and South-Eastern Asia; altogether they account for approximately 90% of maternal and under-five deaths.6
|Table 1: Maternal & Child Health Indicators by Region|
|Region#||Maternal Mortality Ratio (MMR)
|Under-Five Mortality Rate (U5MR)
|Children Under Five Moderately or Severely Underweight^
|Least Developed Countries||415||66||61||10.9|
|Latin America and the Caribbean||74||16||94||1.3|
|NOTES: # Country classifications are based on SDG regional designations. ^ indicator reflects % moderately or severely wasted. — data not available. * Oceania excluding Australia and New Zealand.
SOURCES: U.N., Report of the Secretary-General on SDG Progress 2019, 2019; WHO, Trends in maternal mortality: 2000 to 2017, 2019; U.N. IGME, Levels & Trends in Child Mortality Report 2019, 2019; UNICEF, WHO, World Bank Group, Joint Malnutrition Estimates, March 2020 Edition; EWEC, Global Strategy for Women’s, Children’s and Adolescents’ Health (2016–2030) 2018 monitoring report: current status and strategic priorities, 2018; UNICEF/WHO joint database on SDG 3.1.2 Skilled Attendance at Birth, March 2020.
More than a quarter (27%) of all maternal deaths are due to severe bleeding, mostly after childbirth (postpartum hemorrhage). Sepsis (11%), unsafe abortion (8%), and hypertension (14%) are other major causes. Diseases that complicate pregnancy, including malaria, anemia, and HIV, account for about 28% of maternal deaths.8 Inadequate care during pregnancy and high fertility rates, often due to a lack of access to contraception and other family planning/reproductive health (FP/RH) services, increase the lifetime risk of maternal death.9 While the percentage of pregnant women receiving the recommended minimum number of four antenatal care visits has been on the rise, it is 52% in developing countries and lower still in sub-Saharan Africa and Southern Asia.10
Newborn and Under-Five Mortality
Complications due to premature births account for more than a third (35%) of newborn deaths, followed by delivery-related complications (24%), sepsis (15%), congenital abnormalities (11%), pneumonia (6%), tetanus (1%), diarrhea (1%), and other causes of death (7%).11 Low birth weight is a major risk factor and indirect cause of newborn death.12
Newborn deaths account for most child deaths (47%), followed by pneumonia (12%), diarrhea (8%), injuries (6%), malaria (5%), measles (2%), HIV/AIDS (1%), and other causes of death (21%).13 Undernutrition significantly increases children’s vulnerability to these conditions, as does the lack of access to clean water and sanitation.14
Key interventions that reduce the risk of maternal mortality include skilled care at birth and emergency obstetric care. Newborn deaths may be substantially reduced through increased use of simple, low-cost interventions, such as breastfeeding, keeping newborns warm and dry, and treating severe newborn infections. When scaled-up, interventions such as immunizations, oral rehydration therapy (ORT), and insecticide-treated mosquito nets (ITNs) have contributed to significant reductions in child morbidity and mortality over the last two decades. Other effective child health interventions include improved access to and use of clean water, sanitation, and hygiene practices like handwashing; improved nutrition; and the treatment of neglected tropical diseases (NTDs). Strengthening health systems and increasing access to services, including through community-based clinics, are also important, and interventions have been found to be more effective when integrated within a comprehensive continuum of care.16
There are several key global goals for expanding access to and improving MCH services, including:
SDGs 2 & 3: Save Mothers and Children’s Lives and End All Forms of Malnutrition
Global MCH targets were adopted in 2015 as part of Sustainable Development Goals (SDGs) 2 and 3 and are to, by 2030:
- reduce the global MMR17 and end preventable deaths of newborns and under-five children18 (as targets under SDG 3, which is “ensure healthy lives and promote well-being for all at all ages”); and
- end all forms of malnutrition (as a target under SDG 2, which is “end hunger, achieve food security and improved nutrition, and promote sustainable agriculture”).19
The SDGs are the successor to the Millennium Development Goals (MDGs), which also included MCH targets under MDGs 4 (reduce child mortality) and 5 (improve maternal health).20
Among the global efforts designed to support countries’ progress toward meeting these goals is the Every Woman, Every Child (EWEC) movement and the Scaling Up Nutrition (SUN) movement, which were both launched in 2010. The U.N.-led EWEC movement aims to operationalize the 2015 Global Strategy for Women’s, Children’s, and Adolescents’ Health by combining the efforts of partners who commit to advancing MCH and related efforts with the goal of ending preventable maternal, newborn, child, and adolescent deaths and stillbirths by 2030, among other goals.21 The SUN movement is an initiative that aims to bring together partner efforts to support households and women, in particular, and which recognizes that nutrition, maternal health, and child survival are closely linked.22
Global Nutrition for Growth Compact
The Global Nutrition for Growth Compact includes a goal of reducing stunting in children and nutrient deficiencies in women and children. Endorsed in 2013 by more than 40 developing country and donor governments, including the U.S., as well as other stakeholders, it commits them to, by 2020:23
- ensuring that at least 500 million pregnant women and children under two are reached with effective nutrition interventions;
- reducing the number of children under five stunted by at least 20 million; and
- saving at least 1.7 million under-fives by preventing stunting and increasing breastfeeding and treatment of severe acute malnutrition.
U.S. Government Efforts
The U.S. has been involved in global MCH efforts for more than 50 years. The first U.S. international efforts in the area of MCH began in the 1960s and focused on child survival research, including pioneering research on ORT conducted by the U.S. military, the U.S. Agency for International Development (USAID), and the National Institutes of Health (NIH). Early programs included fortifying international food aid with vitamin A (deficiency of which can cause blindness, compromise immune system function, and retard growth among young children) and efforts to control malaria. The U.S. increased support for its child health efforts in FY 1985 when Congress provided $85 million for child survival activities, nearly doubling funding for this purpose. USAID then developed its first maternal health project in 1989 and introduced a newborn survival strategy in 2001.24 More recently, Congress has increased MCH funding, and the U.S. government has adopted a longer-term goal of ending preventable child and maternal deaths by 2035.
USAID serves as the lead U.S. implementing agency for MCH activities, and its efforts are complemented by those of the Centers for Disease Control and Prevention (CDC), NIH, and the Peace Corps. Collectively, U.S. activities reach nearly 40 countries.25
USAID funds a range of MCH interventions (see Table 20,26 and its MCH efforts focus on 25 “priority countries” that are mostly in Africa and Southern Asia.27 With a strategic emphasis on reaching the most vulnerable populations and improving access to and the quality of care and services for mothers and children across U.S. global health efforts, the agency’s near-term goal is to save 15 million child lives and 600,000 women’s lives from 2012 through 2020 in priority countries, which account for about 70% of the global maternal and child deaths.28 Additionally, in 2014, USAID released, for the first time, a multisectoral nutrition strategy that focuses on improving linkages among its humanitarian, global health, and development efforts to better address both the direct and underlying causes of malnutrition and to build resilience and food security in vulnerable communities.29
|Table 2: U.S. Government-Funded Maternal & Child Health (MCH) Interventions|
|Newborns and Children||Women|
|Essential newborn care||Skilled care at birth|
|Postnatal visits||Emergency obstetric care|
|Prevention and treatment of severe childhood diseases||Improved access to FP/RH and birth spacing|
|Immunizations, including those for polio, measles, and tetanus||Antenatal care, including aseptic techniques to prevent sepsis|
|Malaria prevention (including ITNs) and, for mothers, intermittent preventive treatment during pregnancy (IPTp)|
|HIV prevention/treatment/care, including prevention of mother-to-child-transmission (PMTCT) of HIV|
|Clean water, sanitation, and hygiene efforts|
|Health systems strengthening (health workforce, information systems, pharmaceutical management, infrastructure development)|
|Implementation science and operational research|
Other U.S. MCH Efforts
CDC operates immunization programs, provides scientific and technical assistance, and works to build capacity in a broad array of MCH (and related RH) areas. It also serves as a World Health Organization Collaborating Center on reproductive, maternal, perinatal, and child health.30 NIH addresses MCH by carrying out basic science and implementation research, sometimes in cooperation with other countries.31 The Peace Corps carries out MCH-related volunteer projects around the world.32
Additionally, U.S. global FP/RH efforts are also critical to improving MCH (the internationally agreed upon definition of reproductive health includes both FP and MCH), although Congress directs funding to and USAID operates these programs separately.33 See the KFF fact sheet on U.S. international FP/RH efforts.
Other U.S. global health and related efforts addressing conditions that threaten the health of many pregnant women, new mothers, and children include the President’s Emergency Plan for AIDS Relief (PEPFAR), the President’s Malaria Initiative (PMI), USAID’s NTD Program, Feed the Future, and clean water efforts under the Water for the Poor and Water for the World Acts. See the KFF fact sheets on U.S. PEPFAR efforts, U.S. global malaria efforts, and U.S. global NTD efforts.
The U.S. government partners with several international institutions and supports global MCH funding mechanisms. Among them are:
- Gavi, the Vaccine Alliance (a multilateral financing mechanism aiming to increase access to immunization in poor countries to which the U.S. is one of the largest donors; see the KFF fact sheet on the U.S. and Gavi);34
- the Global Financing Facility (GFF, a partnership to improve the health of women, children, and adolescents through innovative financing in which the U.S. is an investor);35
- the Global Polio Eradication Initiative (GPEI, a public-private partnership aiming to advance efforts to eradicate polio to which the U.S. is the second largest donor; see the KFF fact sheet on U.S. global polio efforts);36
- the Partnership for Maternal, Newborn, and Child Health (PMNCH, an alliance aiming to “provide a platform for organizations to align objectives, strategies and resources, and agree on interventions to improve maternal, newborn, child and adolescent health” in which the U.S. participates);37 and
- the United Nations Children’s Fund (UNICEF, a U.N. agency aiming to improve the lives of children, particularly the most disadvantaged children, to which the U.S. is the largest donor; UNICEF is one of the largest purchasers of vaccines worldwide).38
Total U.S. funding for MCH and nutrition, which includes the U.S. contributions to Gavi and UNICEF as well as support for polio activities, has increased from $728 million in FY 2006 to $1.38 billion in FY 2020 (see Figure 1).40 However, the current Administration has proposed significantly reduced MCH and nutrition funding for FY 2021.
Most U.S. funding for MCH and nutrition is provided through the Global Health Programs account at USAID, with additional funding provided through the Economic Support Fund account. MCH funding is also provided through the International Organizations & Programs account at the State Department for the U.S. contribution to UNICEF and through CDC’s global immunization programs.41
Key Issues for the U.S.
Recent international and U.S. activities have brought new attention to and funding for MCH efforts. As the global community endeavors to support and fund efforts to achieve SDGs 2 and 3’s MCH and nutrition targets, perhaps two of the main questions are about the extent to which the current Administration will support MCH efforts, in light of its proposal to reduce MCH funding, and the strength of bipartisan support in Congress for MCH. Additionally, there is growing concern about the potential impact of COVID-19 on MCH and MCH programming, including on services and disruptions in immunization campaigns. Other key issues and challenges for U.S. efforts include:
- continuing to expand access to and ensure the quality of MCH services, while building local capacity, in the current restrained funding environment;
- reaching the most vulnerable, including adolescent girls and young women;
- supporting advances in research and uptake of new technologies and vaccines;
- further integration of MCH efforts with other U.S. global health programs (such as family planning and reproductive health as well as global HIV under PEPFAR) and broader U.S. development efforts (including education and food security); and
- coordinating these efforts with the activities of other donors and partner countries in order to maximize the impact of available resources.
George Schmid, et al., “The Lancet's neonatal survival series,” The Lancet, Vol. 365, Issue 9474, p. 1845, May 28, 2005.
U.N. Interagency Group on Child Mortality Estimates (IGME), Levels and Trends in Child Mortality Report 2019, 2019; WHO, Trends in maternal mortality: 1990 to 2017, 2019.
U.N. IGME, Levels and Trends in Child Mortality Report 2019, 2019; WHO, Trends in maternal mortality: 1990 to 2017, 2019.
U.N. IGME, Levels and Trends in Child Mortality Report 2019, 2019.
WHO, Trends in maternal mortality: 2000 to 2017, 2019; WHO/UNICEF, Countdown to 2015 Report, 2012.
U.N. IGME, Levels and Trends in Child Mortality Report 2019, 2019; WHO, Trends in maternal mortality: 2000 to 2017, 2019.
Percent of births attended by a skilled birth attendant, which is defined as an accredited health professional - such as a midwife, doctor, or nurse - who has been educated and trained to proficiency in the skills needed to manage normal (uncomplicated) pregnancies, childbirth, and the immediate postnatal period, and in the identification, management, and referral of complications in women and newborns.
L. Say, et al., “Global causes of maternal death: a WHO systematic analysis,” The Lancet Global Health, Vol. 2, no. 6, pp. 323-333, June 2014.
WHO and UNICEF, Countdown to 2015 Report, 2012.
WHO, World Health Statistics 2014, 2014; UN, The Millennium Development Goals Report 2015, 2015.
U.N. IGME, Levels and Trends in Child Mortality Report 2019, 2019.
Black, et al., for the Child Health Epidemiology Reference Group of WHO and UNICEF, “Global, Regional, and National Causes of Child Mortality in 2008: A Systematic Analysis,” The Lancet, Vol. 375, Issue 9730, pp. 1969–87, 2010.
Does not sum to 100 due to rounding. UN IGME, Levels and Trends in Child Mortality Report 2019, 2019.
Robert E. Black, et al., “Maternal and child nutrition: building momentum for impact,” The Lancet, Vol. 382, Issue 9890, pp. 372-375, Aug. 3, 2013; CRS, Child Survival and Maternal Health: U.S. Agency for International Development Programs, FY2001-FY2008, July 2008. Per the UN IGME, Levels and Trends in Child Mortality Report 2017, 2017, “nearly half of all deaths in children under age 5 are attributable to undernutrition.”
USAID, Working Toward the Goal of Reducing Maternal and Child Mortality: USAID Programming and Response to FY08 Appropriations (Report to Congress), July 2008; UN, The Millennium Development Goals Report 2009, 2009; The Millennium Development Goals Report 2010, 2010; and The Millennium Development Goals Report 2011, 2011; USAID, Two Decades of Progress: USAID’s Child Survival and Maternal Health Program, June 2009; UN IGME, Levels and Trends in Child Mortality Report 2013, 2013.
Partnership for Maternal, Newborn & Child Health, Strategic Framework 2012-2015, November 2011.
To less than 70 per 100,000 live births.
For neonatal mortality, to at least as low as 12 per 1,000 live births, and for under-five mortality, to at least as low as 25 per 1,000 live births.
U.N., Transforming our world: the 2030 Agenda for Sustainable Development, 2015.
The world missed these targets in 2015, but substantial progress was made, with under-five mortality having fallen by 53% and maternal mortality by 45% compared to 1990 levels. UN, The Millennium Development Goals [MDGs] Report 2015, 2015.
The updated strategy succeeds the original Global Strategy for Women’s and Children’s Health, which was issued in 2010 and set the goal of saving the lives of 16 million women and children by 2015.
Its secretariat is located in the United Nations Office for Project Services. SUN, “The Vision and Principles of SUN,” webpage, http://scalingupnutrition.org/about-sun/the-vision-and-principles-of-sun/.
The Global Nutrition for Growth Compact, June 2013, http://www.who.int/pmnch/media/events/2013/nutritionforgrowth/en/. Progress toward the compact’s goals is tracked by, among others, the Nutrition for Growth partnership, which is led by the governments of the United Kingdom, Brazil, and Japan governments, and involves philanthropic foundations and civil society organizations; see Nutrition for Growth website, http://nutritionforgrowth.org/nutrition-growth/.
USAID: MCH website, http://www.usaid.gov/what-we-do/global-health/maternal-and-child-health; Working Toward the Goal of Reducing Maternal and Child Mortality: USAID Programming and Response to FY08 Appropriations (Report to Congress), July 2008; Two Decades of Progress: USAID’s Child Survival and Maternal Health Program, June 2009; USAID Reports to Congress, 1985, 1987, 1990.
KFF analysis of data from the U.S. Foreign Assistance Dashboard website, ForeignAssistance.gov. Additional countries may be reached through USAID regional programs and other efforts.
USAID: Acting on the Call: Ending Preventable Child and Maternal Deaths, June 2014; USAID Maternal Health Vision for Action, June 2014; “USAID’s Investments Save the Lives of Women and Children,” 2019.
According to USAID, Acting on the Call: Ending Preventable Child and Maternal Deaths, June 2014, priority countries are chosen based on need (as reflected by maternal and child mortality burden) and having: governments that have demonstrated a commitment to working with others to achieve accelerated reductions in maternal and under-five mortality; and opportunities to integrate/leverage other U.S. global health and development efforts as well as leverage USAID resources against those of the partner-country and other donors/organizations. Additional countries may be reached through other country and regional programs. USAID, “Maternal and Child Health Priority Countries,” webpage, https://www.usaid.gov/what-we-do/global-health/maternal-and-child-health/priority-countries; USAID, “Maternal and Child Health,” webpage, https://www.usaid.gov/what-we-do/global-health/maternal-and-child-health.
USAID: Acting on the Call: Ending Preventable Child and Maternal Deaths, June 2014; USAID Maternal Health Vision for Action, June 2014; “USAID Global Health Programs: FY 2016 President’s Budget Request, Ending Preventable Child and Maternal Deaths,” fact sheet, March 2015; “USAID Global Health Programs Ending Preventable Child and Maternal Deaths – FY 2017,” fact sheet, undated.
USAID, USAID Multi-Sectoral Nutrition Strategy 2014-2025, 2014. USAID reports prioritizing nutrition efforts in 22 focus countries, which are mostly in Africa. 16 of these countries are also MCH priority countries. USAID, “Nutrition Countries,” webpage, https://www.usaid.gov/global-health/health-areas/nutrition/countries.
CDC, Global Reproductive Health website, www.cdc.gov/reproductivehealth/Global/index.htm; WHO Collaborating Centres Global Database, “WHO Collaborating Centre for Reproductive Health,” USA-374, webpage, https://apps.who.int/whocc/Detail.aspx?tBVp7HlRcT5vnFl/XfLrgw==. According to WHO, “WHO collaborating centres are institutions such as research institutes, parts of universities or academies, which are designated by the Director-General to carry out activities in support of the Organization's programmes.” See WHO, “WHO Collaborating Centres,” webpage, http://www.who.int/collaboratingcentres/en/, for more information.
NIH/NICHD Office of Global Health website, https://www.nichd.nih.gov/about/org/od/ogh; NIH Office of Research on Women’s Health, “Global Health Research,” webpage, https://orwh.od.nih.gov/research/funded-research-and-programs/co-funded-research/global-health-research; NIH/FIC, “Maternal and child health news, resources and funding for global health researchers,” webpage, https://www.fic.nih.gov/ResearchTopics/Pages/maternal-child-health.aspx.
Peace Corps, “What Volunteers Do: Health,” webpage, https://www.peacecorps.gov/volunteer/what-volunteers-do/#health.
International Conference on Population and Development (ICPD), Programme of Action, Cairo, 1994.
Gavi has provided over $13 billion for vaccination programs worldwide through Nov. 2018. Gavi, “Disbursements and commitments,” webpage, https://www.gavi.org/programmes-impact/our-impact/disbursements-and-commitments.
The GFF was launched in 2015 as “a multi-stakeholder partnership that supports country-led efforts to improve the health of women, children, and adolescents,” and the U.S. is as a member of the Investors Group that oversees the partnership’s overall activities; see https://www.globalfinancingfacility.org/introduction. See also USAID, “USAID’s Partnership with the Global Financing Facility,” fact sheet, Aug. 2019, https://www.usaid.gov/documents/1864/usaid%E2%80%99s-partnership-global-financing-facility.
GPEI has invested $16.6 billion in efforts to eradicate polio globally. KFF analysis of funding based on data in GPEI, “Contributions and Pledges to the GPEI, 1985-2019,” as of 31 December 2018, http://polioeradication.org/financing/donors/historical-contributions/ and data from the Office of Management and Budget, Agency Congressional Budget Justifications, Congressional Appropriations Bills, and U.S. Foreign Assistance Dashboard website, ForeignAssistance.gov.
PMNCH, “About the Partnership,” webpage, http://www.who.int/pmnch/about/en/.
UNICEF, “About UNICEF,” webpage, https://www.unicef.org/about-unicef; UNICEF, UNICEF Annual Report 2019, June 2020, https://www.unicef.org/reports/annual-report-2019; UNICEF, “Immunization,” webpage, https://www.unicef.org/immunization; UNICEF, “Infographic: Fast Facts on Immunization,” April 16, 2020, https://www.unicef.org/stories/infographic-fast-facts-immunization.
KFF analysis of data from the Office of Management and Budget, Agency Congressional Budget Justifications, Congressional Appropriations Bills, and the U.S. Foreign Assistance Dashboard website, ForeignAssistance.gov. See also KFF fact sheets U.S. Global Health Budget: Maternal & Child Health (MCH) and U.S. Global Health Budget: Nutrition.
Prior to FY 2009, nutrition funding was included as part of maternal and child health.
Represents specified funding for international MCH and nutrition programs in the President’s budget request, ForeignAssistance.gov, and Congressional appropriations bills. Additional support for international MCH and nutrition programs is provided through research activities at NIH.