The State of The Worlds Children 2009

THE STATE OF THE WORLD’S CHILDREN 2009
Maternal and
Newborn Health
unite for
children
© United Nations Children’s Fund (UNICEF) United Nations Children’s Fund
December 2008 3 United Nations Plaza
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ISBN: 978-92-806-4318-3
Sales no.: E.09.XX.1
THE STATE OF THE
WORLD’S CHILDREN
2009
Acknowledgements
This report was made possible with the advice and contributions of many people, both inside and outside UNICEF.
Important contributions were received from the following UNICEF field offices: Afghanistan, Bangladesh, Benin, Brazil,
Burundi, Central African Republic, Chad, Côte d’Ivoire, Ghana, Guatemala, Haiti, India, Indonesia, Kenya, Lao
People’s Democratic Republic, Liberia, Madagascar, Mexico, Morocco, Mozambique, Nepal, Niger, Nigeria, Occupied
Palestinian Territory, Pakistan, Peru, Rwanda, Sierra Leone, Sri Lanka, Sudan, Togo, Tunisia and Uganda. Input was
also received from UNICEF regional offices and the Innocenti Research Centre.
Special thanks to H. M. Queen Rania Al Abdullah of Jordan, the Honourable Vabah Gayflor, Zulfiqar A. Bhutta,
Sarah Brown, Jennifer Harris Requejo, Joy Lawn, Mario Merialdi, Rosa Maria Nuñez-Urquiza and Cesar G. Victora.
EDITORIAL AND RESEARCH PROGRAMME AND POLICY GUIDANCE

Patricia Moccia, Editor-in-Chief; David Anthony, Editor; UNICEF Programme Division, the Division of Policy and
Chris Brazier; Marilia Di Noia; Hirut Gebre-Egziabher; Practice and Innocenti Research Centre, with particular
Emily Goodman; Yasmine Hage; Nelly Ingraham; thanks to Nicholas Alipui, Director, Programme
Pamela Knight; Amy Lai; Charlotte Maitre; Meedan Division; Dan Rohrmann, Deputy Director, Programme
Mekonnen; Gabrielle Mitchell-Marell; Kristin Division; Maniza Zaman, Deputy Director, Programme
Moehlmann; Michelle Risley; Catherine Rutgers; Division; Peter Salama, Associate Director, Health;
Karin Shankar; Shobana Shankar; Judith Yemane Jimmy Kolker, Associate Director, HIV and AIDS;
Clarissa Brocklehurst, Associate Director, Water,
STATISTICAL TABLES Sanitation and Hygiene; Werner Schultink, Associate
Tessa Wardlaw, Chief, Strategic Information, Division Director, Nutrition; Touria Barakat; Linda Bartlett;
of Policy and Practice; Priscilla Akwara; Danielle Burke; Wivina Belmonte; Robert Cohen; Robert Gass; Asha
Xiaodong Cai; Claudia Cappa; Ngagne Diakhate; George; Christine Jaulmes; Grace Kariwiga; Noreen
Archana Dwivedi; Friedrich Huebler; Rouslan Karimov; Khan; Patience Kuruneri; Nuné Mangasaryan; Mariana
Julia Krasevec; Edilberto Loaiza; Rolf Luyendijk; Nyein Muzzi; Robin Nandy; Shirin Nayernouri; Kayode
Nyein Lwin; Maryanne Neill; Holly Newby; Khin Oyegbite; David Parker; Luwei Pearson; Ian Pett; Bolor
Wityee Oo; Emily White Johansson; Danzhen You Purevdorj; Melanie Renshaw; Daniel Seymour; Fouzia
Shafique; Judith Standley; David Stewart; Abdelmajid
PRODUCTION AND DISTRIBUTION Tibouti; Mark Young; Alex Yuster
Jaclyn Tierney, Chief, Production and Translation; DESIGN AND PRE-PRESS PRODUCTION
Edward Ying, Jr.; Germain Ake; Fanuel Endalew;
Eki Kairupan; Farid Rashid; Elias Salem Prographics, Inc.
TRANSLATION PRINTING
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Spanish edition: Carlos Perellón
DEDICATION
The State of the World’s Children 2009 is dedicated to Allan Rosenfield, MD, Dean Emeritus, Mailman
School of Public Health, Columbia University, who passed away on 12 October 2008. A pioneer in the
field of public health, Dr. Rosenfield worked tirelessly to avert maternal deaths and provide care and
treatment for women and children affected by HIV and AIDS in resource-poor settings. He lent his
energy and intellect to numerous groundbreaking programmes and institutions, and his passion,
dedication, courage and commitment to bringing women’s health and human rights to the fore of
development remain a source of inspiration.
ii
Foreword
Niger has the highest lifetime risk of maternal mortality Premature pregnancy and motherhood pose consider-
of any country in the world, 1 in 7. The comparable risk able risks to the health of girls. The younger a girl is
in the developed world is 1 in 8,000. Since 1990, the base when she becomes pregnant, the greater the health
year for the Millennium Development Goals, an estimat- risks for herself and her baby. Maternal deaths related
ed 10 million women have died from complications to pregnancy and childbirth are an important cause of
related to pregnancy and childbirth, and some 4 million mortality for girls aged 15–19 worldwide, accounting
newborns have died each year within the first 28 days of for nearly 70,000 deaths each year.
life. Advances in maternal and neonatal health have not
matched those of child survival, which registered a 27 Early marriage and pregnancy, HIV and AIDS, sexual
per cent reduction in the global under-five mortality violence and other gender-related abuses also increase
rate between 1990 and 2007. the risk that adolescent girls
will drop out of school. This,
The State of the World’s Children in turn, entrenches the vicious
2009 focuses on maternal and cycle of gender discrimination,
neonatal health and identifies the poverty and high rates of mater-
interventions and actions that nal and neonatal mortality.
must be scaled up to save lives.
Most maternal and neonatal Educating girls and young
deaths can be averted through women is one of the most
proven interventions – including powerful ways of breaking
adequate nutrition, improved the poverty trap and creating
© UNICEF/HQ05-0653/Nicole Toutounji
hygiene practices, antenatal care, a supportive environment for
skilled health workers assisting maternal and newborn health.
at births, emergency obstetric Combining efforts to expand
and newborn care, and post-natal coverage of essential services
visits for both mothers and and strengthen health systems
newborns – delivered through a with actions to empower and
continuum of care linking house- protect girls and women has real
holds and communities to health potential to accelerate progress.
systems. Research indicates that around 80 per cent of
maternal deaths are preventable if women have access As the 2015 deadline for the Millennium Development
to essential maternity and basic health-care services. Goals draws closer, the challenge for improving mater-
nal and newborn health goes beyond meeting the goals;
A stronger focus on Africa and Asia is imperative to it lies in preventing needless human tragedy. Success
accelerate progress on maternal and newborn health. will be measured in terms of lives saved and lives
These two continents present the greatest challenges improved.
to the survival and health of women and newborns,
accounting for an estimated 95 per cent of maternal
deaths and around 90 per cent of neonatal deaths.
Two thirds of all maternal deaths occur in just 10

countries; India and Nigeria together account for one
third of maternal deaths worldwide. In 2008, UNICEF,
the World Health Organization, the United Nations
Population Fund and the World Bank agreed to work
together to help accelerate progress on maternal and Ann M. Veneman
newborn health in the 25 countries with the highest Executive Director
rates of mortality. United Nations Children’s Fund
iii
CONTENTS
Acknowledgements ......................................................................ii Adapting maternity services to the cultures of rural Peru........42

Dedication ......................................................................................ii Southern Sudan: After the peace, a new battle against
Foreword maternal mortality ........................................................................43
Ann M. Veneman
Executive Director, UNICEF ......................................................iii Figures
2.1 The continuum of care ........................................................27
2.2 Although improving, the educational status of young
1 Maternal and newborn health:

Where we stand ......................................................1
women is still low in several developing regions ............30
2.3 Gender parity in attendance has improved markedly,
but there are still slightly more girls than boys out of
Panels primary school ......................................................................33
Challenges in measuring maternal deaths ..................................7 2.4 Child marriage is highly prevalent in South Asia and
sub-Saharan Africa ..............................................................34
Creating a supportive environment for mothers and
newborns by H. M. Queen Rania Al Abdullah of Jordan, 2.5 Female genital mutilation/cutting, though in decline,
UNICEF’s Eminent Advocate for Children ..................................11 is still prevalent in many developing countries ................37
2.6 Mothers who received skilled attendance at delivery,
Maternal and newborn health in Nigeria: Developing
by wealth quintile and region ............................................38
strategies to accelerate progress ................................................19
2.7 Women in Mali receiving three or more antenatal
Expanding Millennium Development Goal 5: Universal care visits, before and after the implementation of
access to reproductive health by 2015 ......................................20 the Accelerated Child Survival and Development
Prioritizing maternal health in Sri Lanka ....................................21 (ACSD) initiative....................................................................39
The centrality of Africa and Asia in the global challenges 2.8 Many women in developing countries have no say
for children and women ..............................................................22 in their own health-care needs............................................40
The global food crisis and its potential impact on maternal

and newborn health ....................................................................24
Figures
1.1 Millennium Development Goals on maternal and child
3 The continuum of care across
time and location: Risks and
opportunities ............................................................45
health ......................................................................................3
1.2 Regional distribution of maternal deaths ............................6 Panels
1.3 Trends, levels and lifetime risk of maternal mortality ........8 Eliminating maternal and neonatal tetanus ..............................49
1.4 Regional rates of neonatal mortality ..................................10 Hypertensive disorders: Common yet complex ........................53
1.5 Direct causes of maternal deaths, 1997–2002....................14
The first 28 days of life by Zulfiqar A. Bhutta, Professor
1.6 Direct causes of neonatal deaths, 2000 ..............................15 and Chairman, Department of Paediatrics & Child Health,
1.7 Conceptual framework for maternal and neonatal Aga Khan University, Karachi, Pakistan......................................57
mortality and morbidity ......................................................17 Midwifery in Afghanistan ............................................................60
1.8 Food prices have risen sharply across the board..............24
Kangaroo mother care in Ghana ................................................62
HIV/malaria co-infection in pregnancy ......................................63
2 Creating a supportive environment

for maternal and newborn health ..........25
The challenges faced by adolescent girls in Liberia by the
Honourable Vabah Gayflor, Minister of Gender and
Development, Liberia ..................................................................64
Panels Figures
Promoting healthy behaviours for mothers, newborns 3.1 Protection against neonatal tetanus ....................................48
and children: The Facts for Life guide ........................................29
3.2 Antiretroviral prophylaxis for HIV-positive mothers to
Primary health care: 30 years since Alma-Ata ..........................31 prevent mother-to-child transmission of HIV ....................50
Addressing the health worker shortage: A critical action 3.3 Antenatal care coverage ........................................................51
for improving maternal and newborn health ............................35 3.4 Delivery care coverage ..........................................................52
Towards greater equity in health for mothers and 3.5 Emergency obstetric care: Rural Caesarean section ..........54
newborns by Cesar G. Victora, Professor of Epidemiology, 3.6 Early and exclusive breastfeeding ........................................59
Universidade Federal de Pelotas, Brazil ....................................38
iv
THE STATE OF THE WORLD’S CHILDREN 2009
Maternal and Newborn Health
4 Strengthening health systems Partnering for mothers and newborns in the Central
African Republic............................................................................99
to improve maternal and
UN agencies strengthen their collaboration in support
newborn health ......................................................67 of maternal and newborn health ..............................................102
Panels Enhancing health information systems: The Health
Using critical link methodology in health-care systems to Metrics Network..........................................................................105
prevent maternal deaths by Rosa Maria Nuñez-Urquiza,
National Institute of Public Health, Mexico ................................73 Figures
5.1 Key global health initiatives aimed at strengthening
New directions in maternal health by Mario Merialdi,
health systems and scaling up essential interventions ....97
World Health Organization, and Jennifer Harris Requejo,
5.2 Official development assistance for maternal and
Partnership for Maternal, Newborn and Child Health ..............75
neonatal health has risen rapidly since 2004 ....................98
Strengthening the health system in the Lao People’s 5.3 Nutrition, PMTCT and child health have seen
Democratic Republic ....................................................................76 substantial rises in financing ............................................100
5.4 Financing for maternal, newborn and child health
Saving mothers and newborn lives – the crucial first days
from global health initiatives has increased sharply
after birth by Joy Lawn, Senior Research and Policy Advisor,
in recent years ....................................................................101
Saving Newborn Lives/Save the Children-US, South Africa ....80
5.5 Focal and partner agencies for each component of
Burundi: Government commitment to maternal and child the continuum of maternal and newborn care and
health care ....................................................................................83 related functions ................................................................103
Integrating maternal and newborn health care in India ..........85
References ..............................................................................106
Figures
4.1 Emergency obstetric care: United Nations process Statistical Tables ........................................................113
indicators and recommended levels ..................................70 Under-five mortality rankings................................................117
4.2 Distribution of key data sources used to derive the Table 1. Basic indicators ........................................................118
2005 maternal mortality estimates ....................................71
Table 2. Nutrition ....................................................................122
4.3 Skilled health workers are in short supply in Africa
Table 3. Health ........................................................................126
and South-East Asia in particular ......................................74
Table 4. HIV/AIDS....................................................................130
4.4 Uptake of key maternal, newborn and child
health policies by the 68 Countdown to 2015 Table 5. Education ..................................................................134
priority countries ..................................................................78 Table 6. Demographic indicators ..........................................138
4.5 Asia has among the lowest levels of government Table 7. Economic indicators ................................................142
spending on health care as a share of overall public Table 8. Women ......................................................................146
expenditure ..........................................................................79
Table 9. Child protection ........................................................150
4.6 Post-natal care strategies: Feasibility and
Table 10. The rate of progress ..............................................154
implementation challenges ................................................81
4.7 Lower-income countries pay most of their private Acronyms ................................................................................158
health-care spending out of pocket ....................................82
4.8 Low-income countries have only 10 hospital beds
per 10,000 people ................................................................84
5 Working together for maternal and

newborn health ......................................................91
Panels
Working together for maternal and newborn health by
Sarah Brown, Patron of the White Ribbon Alliance for Safe
Motherhood and wife of Gordon Brown, Prime Minister
of the Government of the United Kingdom ..............................94
Key global health partnerships for maternal and
newborn health ............................................................................96
v
T H E S TAT E O F T H E W O R L D ’ S C H I L D R E N 2 0 0 9
1 Maternal and newborn health:

Where we stand
© UNICEF/HQ06-2706/Shehzad Noorani
Each year, more than half a million women die from causes related to pregnancy and childbirth, and
nearly 4 million newborns die within 28 days of birth. Millions more suffer from disability, disease,
infection and injury. Cost-effective solutions are available that could bring rapid improvements, but
urgency and commitment are required to implement them and to meet the Millennium Development
Goals related to maternal and child health. The first chapter of The State of the World’s Children 2009
examines trends and levels of maternal and neonatal health in each of the major regions, using
mortality ratios as benchmark indicators. It briefly explores the main proximal and underlying causes of
maternal and neonatal mortality and morbidity, and outlines a framework for accelerating progress.
P
regnancy and childbirth are But the health risks associated with complications related to pregnancy
generally times of joy for par- pregnancy and childbirth are far or childbirth is more than 300 times
ents and families. Pregnancy, greater in developing countries than greater than for a woman living in
birth and motherhood, in an in industrialized ones. They are an industrialized country. No other
environment that respects women, especially prevalent in the least mortality rate is so unequal.
can powerfully affirm women’s rights developed and lowest-income coun-
and social status without jeopardiz- tries, and among less affluent and Millions of women who survive
ing their health. marginalized families and communi- childbirth suffer from pregnancy-
ties everywhere. Globally, efforts to related injuries, infections, diseases
The enabling environment for reduce deaths among women from and disabilities, often with lifelong
safe motherhood and childbirth complications related to pregnancy consequences. The truth is that
depends on the care and attention and childbirth have been less suc- most of these deaths and conditions
provided to pregnant women and cessful than other areas of human are preventable – research has
newborns by communities and development – with the result that shown that approximately 80
families, the acumen of skilled having a child remains among the per cent of maternal deaths could
health personnel and the availabil- most serious health risks for women. be averted if women had access
ity of adequate health-care facili- On average, each day around 1,500 to essential maternity and basic
ties, equipment, and medicines women die from complications health-care services.1
and emergency care when needed. related to pregnancy and childbirth,
Many women in the developing most of them in sub-Saharan Africa Deaths of newborns in developing
world – and most women in the and South Asia. countries have also received far
world’s least developed countries – too little attention. Almost 40 per
give birth at home without skilled The divide between industrialized cent of under-five deaths – or 3.7
attendants, yet their newborns are countries and developing regions – million in 2004, according to the
usually healthy and survive past particularly the least developed coun- latest World Health Organization
their first few weeks of life until tries – is perhaps greater on maternal estimates – occur in the first 28
their fifth birthday and beyond. mortality than on almost any other days of life. Three quarters of
Despite the multitude of risks issue. This claim is borne out by the neonatal deaths take place in the
associated with pregnancy numbers: Based on 2005 data, the first seven days, the early neonatal
and childbirth, the majority average lifetime risk of a woman in a period; most of these are also
of mothers also survive. least developed country dying from preventable.2
2 T H E S TAT E O F T H E W O R L D ’ S C H I L D R E N 2 0 0 9
The gap in risk of maternal death between the industrialized world and
many developing countries, particularly the least developed, is often
termed the ‘greatest health divide in the world’.
The divide in neonatal deaths born health across the world, and in and newborn health based on respect
between the industrialized countries the developing world in particular, for women’s rights, and the need to
and developing regions is also wide. complementing last year’s report on establish a continuum of care for
Based on 2004 data, a child born child survival. While the emphasis of mothers, newborns and children that
in a least developed country is the report remains firmly on health integrate programmes for reproduc-
almost 14 times more likely to and nutrition, mortality rates are tive health, safe motherhood, new-
die during the first 28 days of life employed as benchmark indicators. born care and child survival, growth
than one born in an industrialized Sub-Saharan Africa and South Asia, and development. The report exam-
country. the regions with the highest numbers ines the latest paradigms, policies and
and rates of maternal and newborn programmes and describes key initia-
The health of mothers and new- mortality, are principal focuses. Key tives and partnerships that are striv-
borns is intricately related, so pre- threads running through the report ing to accelerate progress. A series of
venting deaths requires, in many are the imperative of creating a sup- panels, several of which have been
cases, implementing the same inter- portive environment for maternal contributed by guest collaborators,
ventions. These include such essen-
tial measures as antenatal care, Figure 1.1
skilled attendance at birth, access
Millennium Development Goals on maternal
to emergency obstetric care when
and child health
necessary, adequate nutrition,
post-partum care, newborn care Millennium Development Goal 4: Reduce child mortality
and education to improve health, Targets Indicators
infant feeding and care, and hygiene 4.1 Under-five mortality rate
behaviours. To be truly effective and 4.A: Reduce by two thirds, between 4.2 Infant mortality rate
sustainable, however, these interven- 1990 and 2015, the under-five
tions must take place within a mortality rate 4.3 Proportion of 1-year-old children
immunized against measles
development framework that strives
to strengthen and integrate pro- Millennium Development Goal 5: Improve maternal health*
grammes with health systems and Targets Indicators
an environment supportive of
5.A: Reduce by three quarters, between 5.1 Maternal mortality ratio
women’s rights.
1990 and 2015, the maternal
5.2 Proportion of births attended by
mortality ratio
skilled health personnel
A human rights-based approach to
improving maternal and neonatal 5.3 Contraceptive prevalence rate
health focuses on enhancing health- 5.4 Adolescent birth rate
care provision, addressing gender dis- 5.B: Achieve, by 2015, universal
access to reproductive health 5.5 Antenatal care coverage (at least
crimination and inequities in society one visit and at least four visits)
through cultural, social and behav-
5.6 Unmet need for family planning
ioural changes, among other means,
and targeting those countries and * The revised Millennium Development Goals framework agreed by the United Nations General
Assembly at the 2005 World Summit, with the new official list of indicators effective as of 15
communities most at risk. January 2008, has added a new target (5.B) and four new indicators for monitoring Millennium
Development Goal 5.
The State of the World’s Children Source: United Nations, Millennium Development Goals Indicators: The official United Nations site for
the MDG indicators, <http://mdgs.un.org/unsd/mdg/Host.aspx?Content=Indicators/OfficialList.htm>,
2009 examines maternal and new- accessed 1 August 2008.
M AT E R N A L A N D N E W B O R N H E A LT H : W H E R E W E S TA N D 3
address some of the critical issues in and affordable basic health care they “ensure to women appropriate
maternal and newborn health and would lower mortality rates further services in connection with pregnan-
nutrition today. still. These are not impossible, imprac- cy, confinement and the post-natal
tical actions, but proven, cost-effective period, granting free services where
The current situation of provisions that women of reproduc- necessary, as well as adequate nutri-
maternal and neonatal health tive age have a right to expect. tion during pregnancy and lactation”
(article 12.2). Furthermore, the
Since 1990, the estimate of the Maternal health, however, goes Convention on the Rights of the
global annual number of maternal beyond the survival of pregnant Child also commits States Parties to
deaths has exceeded 500,000. women and mothers. For every “ensure appropriate pre-natal and
Although the number of under-five woman who dies from causes related post-natal health care for mothers”
deaths worldwide has fallen consis- to pregnancy or childbirth, it is esti- and to “develop preventive health
tently – from around 13 million in mated that there are 20 others who care, guidance for parents and family
1990 to 9.2 million in 2007 – mater- suffer pregnancy-related illness or planning education and services”
nal deaths have remained stubbornly experience other severe consequences. (article 24). The available evidence
intractable. Limited gains have been The number is striking: An estimated suggests that many countries are fail-
made worldwide towards the first 10 million women annually who sur- ing to deliver on these commitments.
target of Millennium Development vive their pregnancies experience
Goal (MDG) 5, which aims to such adverse outcomes.4 Improving women’s health is pivotal
reduce the 1990 maternal mortality to fulfilling the rights of girls and
ratio by three quarters by 2015; and That maternal health – as epitomized women under CEDAW and the
progress on diminishing maternal by the risk of death or disability Convention on the Rights of the
mortality ratios has been virtually from causes related to pregnancy and Child and achieving the Millennium
non-existent in sub-Saharan Africa.3 childbirth – has scarcely advanced in Development Goals. In addition to
decades is the result of multiple under- meeting MDG 5, enhancing reproduc-
Maternal mortality ratios strongly lying causes. The root cause may lie tive and maternal health and services
reflect the overall effectiveness of in women’s disadvantaged position will also directly contribute to attain-
health systems, which in many low- in many countries and cultures, and in ing MDG 4, which seeks to reduce
income developing countries suffer the lack of attention to, and accounta- the under-five mortality rate by two
from weak administrative, technical bility for, women’s rights. thirds between 1990 and 2015.
and logistical capacity, inadequate
financial investment and a lack of The 1979 Convention on the Enhancing maternal nutrition will
skilled health personnel. Scaling up Elimination of All Forms of also bring benefits for the achieve-
key interventions – for example, ante- Discrimination against Women ment of Millennium Development
natal HIV testing, increasing the num- (CEDAW), currently ratified by Goal 1, which seeks to eradicate
ber of births attended by skilled health 185 countries, requires signatories extreme poverty and hunger by
personnel, providing access to emer- to “eliminate discrimination against 2015. Undernutrition is a process
gency obstetric care when necessary women in the field of health care which often starts in utero and
and providing post-natal care for in order to ensure, on a basis of may last, particularly for girls and
mothers and babies – could sharply equality of men and women, access women, throughout the life cycle:
reduce both maternal and neonatal to health care services, including A stunted girl is likely to become a
deaths. Enhancing women’s access to those related to family planning” stunted adolescent and later a stunt-
family planning, adequate nutrition (article 12.1). It also stipulates that ed woman. Besides posing threats to
The lifetime risk of maternal death for a woman in
a least developed country is more than 300 times greater
than for a woman living in an industrialized country.
required data are not routinely

recorded. Beyond the estimation of
maternal mortality, determining and
recording the causes of death is a
complex process. For a death to be
conclusively established as related to
pregnancy or childbirth, both the
cause of mortality and the pregnan-
cy status and the timing of death in
© UNICEF/HQ06-2055/Pablo Bartholomew
relation to that pregnancy must be

accurately noted. This level of detail
is sometimes missing in the statisti-
cal reporting systems of industrial-
ized countries, and its absence is
commonplace in many developing
countries, particularly the poorest.7
A strong referral system, skilled health workers and well equipped facilities are pivotal to
reducing maternal and newborn deaths resulting from complications during childbirth. Efforts to improve data collection on
Health workers treat babies in the Sick Newborn Care Unit, India. maternal mortality have been ongoing
for the past two decades, initially
her own health and productivity, mothers who died of maternal involving the World Health
poor nutrition that contributes causes also subsequently died.6 Organization (WHO), UNICEF and
to stunting and underweight Moreover, maternal complications the United Nations Population Fund
increases a woman’s likelihood of in labour heighten the risk of (UNFPA), later joined by the World
adverse pregnancy and birth out- neonatal deaths, which are rapidly Bank. This inter-agency collaboration
comes. Undernourished mothers becoming a key focus of child pools resources and reviews method-
also have a far higher risk of deliv- survival efforts as overall rates ologies to arrive at more precise and
ering babies with low birthweight – of under-five mortality decline comprehensive global estimates of
a condition that gravely heightens in most developing countries. maternal mortality. The figures for
the baby’s risk of death.5 2005 are the most accurate yet and
Trends in maternal and the first to estimate maternal mortali-
Lowering a mother’s risk of newborn health ty trends by an inter-agency process.
mortality and morbidity directly (Further details on the estimation of
improves a child’s prospects for Maternal mortality maternal mortality ratios and levels
survival. Research has shown can be found in the Panel on page 7.)
that in developing countries, The most recent UN inter-agency
babies whose mothers die during estimates suggest that in 2005, In recent years, new methodologies
the first six weeks of their lives 536,000 women died from causes to calculate maternal and neonatal
are far more likely to die in the related to pregnancy and childbirth. health status, service needs and mor-
first two years of life than babies This figure may be far from precise, tality have been developed by the
whose mothers survive. In a study however, as measuring maternal research community. These efforts
conducted in Afghanistan, 74 mortality is challenging, and in are ongoing, enriching the process
per cent of infants born alive to many developing countries the of arriving at more precise estimates
Africa and Asia account for 95 per cent of the world's maternal
deaths, with particularly high burdens in sub-Saharan Africa
(50 per cent of the global total) and South Asia (35 per cent).
and causes of mortality and morbidity. improvements by increasing access to resulted in higher numbers of maternal
In turn, better data and analysis on basic maternity services. In the indus- deaths over the 15-year period. This
health status and health services are trialized countries, the maternal mor- lack of progress is particularly worry-
helping enhance the strategies and tality ratio remained broadly static ing, since the region has by far the
frameworks, programmes, policies between 1990 and 2005, at a low rate highest ratios and lifetime risk of
and partnerships – including those of 8 per 100,000 live births. Near maternal mortality and the greatest
that support gender mainstreaming – universal access to skilled care during number of maternal deaths. In West
that are striving to improve maternal delivery and emergency obstetric care and Central Africa, the regional mater-
and newborn health. when necessary have contributed to nal mortality ratio stands at a stagger-
these diminished levels of maternal ing 1,100 per 100,000 live births,
One issue in the estimation of mortality; no industrialized countries compared to the average for develop-
maternal mortality appears beyond with data have skilled attendance at ing countries and territories of 450
contention: The vast majority of birth of less than 98 per cent, and per 100,000 live births. This region
maternal deaths – more than 99 most have universal coverage. includes the country with the highest
per cent, according to the 2005 UN rate of maternal death in the world:
inter-agency estimates – occurred in In all of the developing regions outside Sierra Leone, with 2,100 maternal
developing countries. Half of these sub-Saharan Africa, both the absolute deaths per 100,000 live births.
(265,000) took place in sub-Saharan numbers of maternal deaths and
Africa and another third (187,000) maternal mortality ratios declined The West and Central Africa region
in South Asia. Between them, these between 1990 and 2005. In sub- also has the highest total fertility rate,
two regions accounted for 85 per cent Saharan Africa, maternal mortality at 5.5 children in 2007. (The total fer-
of the world’s pregnancy-related ratios remained largely unchanged tility rate measures the number of chil-
deaths in 2005. India alone had over the same period. Given the dren who would be born per woman if
22 per cent of the global total. region’s high fertility rates, this has she lived to the end of her childbearing
The trend estimates available for mater- Figure 1.2

nal mortality indicates the lack of suf-
Regional distribution of maternal deaths*
ficient progress towards Target A of
MDG 5, which seeks a 75 per cent Maternal deaths, 2005
East Asia/Pacific
reduction in the maternal mortality 45,000 (8%)
ratio between 1990 and 2015. Given South Asia
Latin America/Caribbean
that the global maternal mortality ratio 187,000 (35%)
15,000 (3%)
stood at 430 per 100,000 live births in Industrialized countries 830 (<1%)
1990, and at 400 deaths per 100,000
CEE/CIS, 2,600 (<1%)
live births in 2005, meeting the target
will require more than a 70 per cent Eastern/Southern Africa
103,000 (19%)
reduction between 2005 and 2015. Middle East/
North Africa
21,000 (4%)
Global trends can obscure the wide West/Central Africa

162,000 (30%)
variations between regions, many of
* Percentages may not total 100% because of rounding.
which have made appreciable progress
in reducing maternal mortality and Source: World Health Organization, United Nations Children’s Fund, United Nations Population
Fund and the World Bank, Maternal Mortality in 2005: Estimates developed by WHO, UNICEF,
are laying the foundations for further UNFPA and the World Bank, WHO, Geneva, 2007, p. 35.
Challenges in measuring maternal deaths
Maternal mortality is defined as the death of a woman while mortality rate by three quarters between 1990 and 2015. The
pregnant or within 42 days of termination of pregnancy, Maternal Mortality Working Group, which originally comprised
regardless of the site or duration of pregnancy, from any the World Health Organization, UNICEF and the United Nations
cause related to or aggravated by the pregnancy or its man- Population Fund, developed internationally comparable global
agement. Causes of deaths can be divided into direct causes estimates of maternal mortality for 1990, 1995 and 2000.
that are related to obstetric complications during pregnancy,
labour or the post-partum period, and indirect causes. There In 2006, the World Bank, United Nations Population Division
are five direct causes: haemorrhage (usually occurring post- and several outside technical experts joined the group, which
partum), sepsis, eclampsia, obstructed labour and complica- subsequently developed a new set of globally comparable
tions of abortion. Indirect obstetric deaths occur from either maternal mortality estimates for 2005, building on previous
previously existing conditions or from conditions arising in methodology and new data. The process generated estimates
pregnancy which are not related to direct obstetric causes but for countries with no national data, and adjusted available
may be aggravated by the physiological effects of pregnancy. country data to correct for under-reporting and misclassifica-
These include such conditions as HIV and AIDS, malaria, tion. Of the 171 countries reviewed by the Maternal Mortality
anaemia and cardiovascular diseases. Simply because a Working Group for the 2005 estimations, appropriate national-
woman develops a complication does not mean that death level data were unavailable for 61 countries, representing one
is inevitable; inappropriate or incorrect treatment or lack of quarter of global births. For these countries, models were
appropriate, timely interventions underlie most maternal deaths. used to estimate maternal mortality.
Accurate classification of the causes of maternal death, For the 2005 estimates, data were drawn from eight cate-
whether direct or indirect, accidental or incidental, is challeng- gories of sources: complete civil registration systems with
ing. To accurately categorize a death as maternal, information good attribution of data, complete civil registration systems
is needed on the cause of death as well as pregnancy status, with uncertain or poor attribution of data, direct sisterhood
or the time of death in relation to the pregnancy. This infor- methods, reproductive-age mortality studies, disease surveil-
mation may be missing, misclassified or under-reported even lance or sample registration, census, special studies and no
in industrialized countries with fully functioning vital registra- national data. Estimates for each source were calculated
tion systems, as well as in developing countries facing high according to a different formula, taking into account factors
burdens of maternal mortality. There are several reasons for such as correcting for known bias and determining realistic
this: First, many deliveries take place at home, particularly in uncertainty bounds.
the least developed countries and in rural areas, complicating
efforts to establish cause of death. Second, civil registration Measures of maternal mortality are prepared with a margin of
systems may be incomplete or, even if deemed complete, uncertainty, highlighting the fact that while they are the best
attribution of causes of death may be inadequate. Third, estimates available, the actual rate may be higher or lower
modern medicine may delay a women’s death beyond the than the average. Although this is true of any statistic, the
42-day post-partum period. For these reasons, in some cases high degree of uncertainty for maternal mortality ratios indi-
alternative definitions of maternal mortality are used. One cates that all data points should be interpreted cautiously.
concept refers to any cause of death during pregnancy or
the post-partum period. Another concept takes into account Notwithstanding the challenges of data collection and meas-
deaths from direct or indirect causes that occur after the urement, the 2005 inter-agency estimates for maternal mortal-
post-partum period up to one year following pregnancy. ity were sufficiently rigorous to produce trend analysis,
assessing progress from the 1990 baseline date of MDG 5 to
The main measure of mortality risk is the maternal mortality 2005. The lack of improvement in reducing maternal mortality
ratio, which is identified as the number of maternal deaths identified in many developing countries has helped bring
during a given period of time per 100,000 live births during greater attention to achieving MDG 5.
the same period, which is generally a year. Another key meas-
ure is the lifetime risk of maternal death, which reflects the The 2005 maternal mortality estimates are far from perfect,
probability of becoming pregnant and the probability of dying and much work is still required to refine the processes of data
from a maternal cause during a women’s reproductive lifespan. collection and estimation. But they reflect a strong commit-
In other words, the risk of maternal death is related to two ment on the part of the international community to continual-
main factors: mortality risk associated with a single pregnancy ly strive for greater accuracy and precision. These ongoing
or live birth; and the number of pregnancies that women have efforts will support and guide actions to improve maternal
during their reproductive years. health and ensure that women count.
Working together to improve estimations See References, page 107.

of maternal deaths
Several agencies are collaborating to establish more accurate
measurements of maternal mortality rates and levels world-
wide, and assess progress towards Target A of Millennium
Development Goal 5, which seeks to reduce the maternal
Although the number of under-five deaths worldwide has fallen consistently –
from around 13 million in 1990 to 9.2 million in 2007 – the toll of maternal
mortality has remained stubbornly intractable above 500,000.
Figure 1.3 years and bore children at each age in

Trends, levels and lifetime risk of maternal mortality accordance with prevailing age-specific
fertility rates.) High fertility rates
increase the risk that a woman will die
from maternal causes. While mortality
Maternal mortality ratios, 1990 and 2005 risks are associated with all pregnan-
West/Central Africa 1,100 cies, these risks rise the more times a
1,100
Eastern/Southern Africa 790 woman gives birth.

760
South Asia 500
650
Middle East/North Africa 270

1990 Elevated fertility rates, combined
210 2005
East Asia/Pacific 220 with weak access to basic health-care
150
Latin America/Caribbean 180 and maternity services, can have life-

130
CEE/CIS 63 long implications for women’s sur-

46
8
vival. In the developing world as a
Industrialized countries 8
whole, a woman has a 1 in 76 life-
430
World 400 time risk of maternal death, com-
Sub-Saharan Africa* 940
920 pared with a probability of just 1 in
480
Developing countries 450 8,000 for women in industrialized
Least developed countries 900
870 countries. By way of comparison, the
0 200 400 600 800 1000 1200 lifetime risk of maternal mortality
Maternal deaths per 100,000 live births ranges from just 1 in 47,600 for a
mother in Ireland, to 1 in every 7 in
Niger, the country with the highest
Lifetime risk of maternal death, 2005
lifetime risk of maternal death.8
West/Central Africa 5.9
Eastern/Southern Africa 3.4 Neonatal mortality

South Asia 1.7
Neonatal mortality is the probability
Middle East/North Africa 0.7
of a newborn dying between birth
East Asia/Pacific 0.3
Latin America/Caribbean 0.4

and the first 28 completed days of
CEE/CIS 0.1
life. The latest estimates from the
Industrialized countries 0.01
World Health Organization, which
date from 2004, indicate that around
World 1.1 3.7 million children died within the
Sub-Saharan Africa* 4.5 first 28 days of life in that year.
Developing countries 1.3 Within the neonatal period, however,
Least developed countries 4.2
there is wide variation in mortality
0 1 2 3 4 5 6 7
risk. The greatest risk is during the
Probability that a women will die from causes related to pregnancy
cumulative across her reproductive years (%) first day after birth, when it is esti-
mated that between 25 and 45 per
*Sub-Saharan Africa comprises the regions of Eastern/Southern Africa and West/Central Africa.
cent of neonatal deaths occur. Around
three quarters of newborn deaths, or
Source: World Health Organization, United Nations Children’s Fund, United Nations Population
Fund and the World Bank, Maternal Mortality in 2005: Estimates developed by WHO, UNICEF,
2.8 million in 2004, occur within the
UNFPA and the World Bank, WHO, Geneva, 2007, p. 35. first week – the early neonatal period.
© UNICEF Mozambique/Emidio Machiana
Expanded distribution of insecticide-treated mosquito nets to help prevent malaria and rapid scaling up of programmes to prevent and treat
HIV infection are helping to save maternal and newborn lives. An HIV-positive mother and her newborn son under an insecticide-treated
mosquito net are assisted by a nurse in a health centre, Mozambique.
Like maternal deaths, almost all (98 particular, deaths in the first week prisingly, are found in industrialized
per cent in 2004) neonatal deaths of life have risen from 23 per cent countries, where the neonatal mortal-
occur in low- and middle-income of under-five deaths in 1980 to 28 ity rate in 2004 was just 3 per 1,000
countries. The total number of peri- per cent in 2000.10 live births. The highest rates of
natal deaths, which groups stillbirths neonatal death in 2004 were found
with early neonatal deaths owing to In part, the rising proportion of in South Asia (41 per 100,000 live
the fact that they have similar obstet- neonatal deaths reflects two key fac- births) and West and Central Africa
ric causes, was 5.9 million deaths in tors: the difficulty of reaching many (44 per 100,000). Owing to a higher
2004. Stillborns accounted for around babies who are born at home with number of births, South Asia has the
3 million perinatal deaths that year.9 effective and timely neonatal interven- highest number of neonatal deaths
tions, and the success of many coun- among the world’s regions.11
Until the mid-to-late 1990s, neonatal tries in implementing interventions
mortality figures were estimated from such as immunization that have The main causes of maternal
rough historical data. But as more reli- markedly reduced post-neonatal and neonatal mortality and
able data emerged from household deaths in the developing world as a morbidity
surveys, it became evident that previ- whole. This has led in part to a rela-
ous estimates had significantly under- tive neglect of cost-effective, simple Maternal mortality
estimated the incidence of newborn neonatal survival interventions.
deaths. The global neonatal mortality Reducing neonatal deaths therefore Direct causes
rate declined by one quarter between has become a major component of
1980 and 2000, but its rate of reduc- new paradigms and strategies for The timing and causes of maternal
tion was much slower than that of the diminishing child mortality and reach- and newborn deaths are well known.
overall under-five mortality rate, which ing Millennium Development Goal 4. Maternal deaths mostly occur from
fell by one third. As a consequence, the third trimester to the first week
neonatal deaths currently constitute a Regional patterns of neonatal death after birth (with the exception of
much higher proportion of under-five correlate closely to those for mater- deaths due to complications of abor-
deaths than in previous years. In nal death. The lowest rates, unsur- tion). Studies show that mortality
The latest inter-agency estimates suggest that 536,000 women died in
2005 from causes related to pregnancy and childbirth.
risks for mothers are particularly to pregnancy but may be exacer- Maternal anaemia affects about half
elevated within the first two days bated by pregnancy and childbirth. of all pregnant women. Pregnant
after birth. Most maternal deaths are Attributing these causes to preg- adolescents are more prone to
related to obstetric complications – nancy is difficult owing to the poor anaemia than older women, and they
including post-partum haemorrhage, diagnostic capacity of many coun- often receive less care. Infectious dis-
infections, eclampsia and prolonged tries’ health information systems. eases such as malaria, which affects
or obstructed labour – and complica- Nonetheless, assessing the indirect around 50 million pregnant women
tions of abortion. Most of these direct causes of maternal deaths helps living in malaria-endemic countries
causes of maternal mortality can be determine the most appropriate inter- every year, and intestinal parasites
readily addressed if skilled health per- vention strategies for maternal and can exacerbate anaemia, as can poor-
sonnel are on hand and key drugs, child health. Collaboration between quality diets – all of which heighten
equipment and referral facilities are condition-specific programmes – such vulnerability to maternal death.
available.12 (For further details on as those to address malaria or AIDS – Severe anaemia contributes to the risk
birth complications and emergency and maternal health initiatives may of death in cases of haemorrhage.14
obstetric care, see Chapter 3.) often be the most effective way to
address some of these indirect causes, Anaemia is highly treatable with
Indirect causes including those that are highly pre- iron supplements offered through
Many factors contributing to a ventable or treatable, such as maternal health programmes. This
mother’s risk of dying are not unique anaemia.13 intervention, however, remains limit-
Figure 1.4
Regional rates of neonatal mortality
West/Central Africa 44
Eastern/Southern Africa 36
South Asia 41
East Asia/Pacific 18
Latin America/Caribbean 13
CEE/CIS 15
Industrialized countries 3
World 29
Developing countries 31
0 5 10 15 20 25 30 35 40 45 50
Neonatal deaths (0–28 days) per 1,000 live births, 2004

*Sub-Saharan Africa comprises the regions of Eastern/Southern Africa and West/Central Africa.
Source: World Health Organization, using vital registration systems and household surveys.
Creating a supportive environment for mothers and newborns
by H. M. Queen Rania Al Abdullah of Jordan, UNICEF’s Eminent Advocate for Children*
In 1631, a beautiful empress, Mumtaz Mahal, died while women who die in childbirth each year. Why are maternal
giving birth to her 14th child. Overwhelmed by grief, her deaths only partially enumerated? One possible reason is
husband constructed a monument in her honour: the Taj that, in too many places, women’s lives do not fully count.
Mahal, today one of the best-known buildings in the world.
And as long as women remain disadvantaged in their soci-
And yet, while the Taj Mahal’s domes and spires are instantly eties, maternal and newborn health will suffer as well. But
recognizable, there is far less global awareness of the tragedy if we can empower women with the tools to take control of
that inspired its creation. their lives, we can create a more supportive environment
for women and children alike.
Nearly 400 years after Mumtaz Mahal lost her life in child-
birth, a woman still dies from causes related to pregnancy or Empowerment begins with education, the best development
childbirth every minute of every day – more than 500,000 investment we can make – from ensuring that girls as well as
women each year, 10 million per generation. How can it be boys are able to attend primary school to teaching women to
that in our age of modern advances and medical miracles we read and write, and providing public health education. Although
are still failing to safeguard women as they perpetuate the much remains to be done, many countries are beginning to
human race itself? make strides in this direction. In Jordan, for example, nursing
students from the University of Jordan are volunteering to
The answer, of course, is that public health has made breath- educate girls in public schools about women’s health issues.
taking strides, but those benefits have not been equally shared,
either among countries or between the geographical areas and Study after study shows that educated women are better
social groups within them. Even though the causes of pregnan- equipped to earn income to support their families, more
cy and childbirth complications are the same around the world, likely to invest in their children’s health care, nutrition and
their consequences vary dramatically from country to country education, and more inclined to participate in civic life and
and region to region. Today, a young woman in Sweden has a to advocate for community improvements.
1 in 17,400 lifetime risk of dying of pregnancy-related causes.
In Sierra Leone, her risk soars to 1 in 8. Educated mothers are also more likely to seek proper health
care for themselves; according to the 2007 Millennium
And for every woman who dies, another 20 are afflicted with Development Goals Report, “84 per cent of women who have
serious infections or injuries. An estimated 75,000 women each completed secondary or higher education are attended by
year become victims of obstetric fistula, a physically and psycho- skilled personnel during childbirth, more than twice the rate
logically devastating condition that can result in social exclusion. of mothers with no formal education.”
The toll in women’s lives is enormous. But they are not the Children of educated mothers are 50 per cent more likely to
only ones who suffer. As a group of experts stated during a survive until the age of five and beyond than those whose
global conference on women’s health in 2007: “In their prime mothers did not receive or complete schooling. For girls in par-
reproductive years, women ‘deliver’ for their societies in ticular, education can make the difference between hope and
multiple ways: They bear and raise the next generation, and despair. Research shows that young people who complete pri-
they are critical actors for progress as workers, leaders, and mary school are less likely to be infected by HIV than those
activists.” When women’s lives are cut short or incapacitated who never managed to graduate from primary school.
as a result of pregnancy or childbirth, the tragedy cascades.
Children lose a parent. Spouses lose a partner. And societies Educated girls are also more likely to delay marriage and less
lose productive contributors. likely to get pregnant while very young, reducing the risk of
dying in childbirth while they are still children themselves. As
Our world cannot afford to keep sacrificing so many people girls continue their education, their earning potential increas-
and so much potential. We know what it takes to prevent and es, enabling them to break the bonds of poverty too often
treat the vast majority of pregnancy-related difficulties, from passed down through the generations.
eclampsia and haemorrhage to sepsis, obstructed labour and
anaemia. Indeed, the World Bank estimates that such basic Put simply, changing the trajectory for girls can change the
interventions as antenatal care, attendance at delivery by course of the future. And if these girls grow into women who
skilled health personnel, and accessible emergency treatment choose to become mothers themselves, they will view preg-
for women and newborns could avert almost three quarters nancy and childbirth as something to celebrate, not fear.
of maternal deaths.
See References, page 107.
But expanding medical interventions is just one part of
improving maternal and newborn health. More fundamentally, *Her Majesty Queen Rania Al Abdullah of Jordan is UNICEF’s Eminent
we need to boost women’s empowerment around the world. Advocate for Children and a tireless global advocate for child protec-
Consider that in a century increasingly defined by information, tion, early childhood development, gender parity in education and
we still do not have precise data regarding the numbers of women's empowerment.
ed in both coverage and effective- The precise contribution of HIV and are ensuing. For example, coverage
ness in some developing countries, AIDS to maternal deaths is difficult of antiretroviral prophylaxis for
mostly as a result of low access to to assess since, despite the expansion HIV-positive mothers to prevent
basic health care and, more specifi- of programmes to prevent mother-to- mother-to-child transmission rose
cally, to quality antenatal care and child transmission of HIV, the HIV from 10 per cent of HIV-infected
support. Encouragingly, there are status of many pregnant women is pregnant women in low- and
signs that efforts to address anaemia still unknown. HIV and pregnancy middle-income countries in 2004
by fortifying staple foods like flour might interact in several ways. The to 33 per cent in 2007. Despite this
are beginning to accelerate at the virus may heighten the risk of such appreciable progress, much more
national level in a number of devel- obstetric complications as haemor- needs to be done to provide women
oping countries.15 rhage, sepsis and complications of with interventions for HIV preven-
Caesarean section. Pregnancy, in tion, care and therapy – including
Maternal iodine deficiency during turn, may raise the risk of HIV-related testing and counselling, and quality
pregnancy is associated with a higher illnesses such as anaemia and tuber- sexual and reproductive health serv-
incidence of stillbirths, miscarriage culosis, or accelerate HIV progres- ices in addition to medicines.18
and congenital abnormalities. These sion. Current research findings are
risks can be reduced and prevented indicative rather than conclusive, Although the consequences of
by ensuring optimal maternal iodine and more research is needed to clar- co-infection with HIV and malaria
status before or during pregnancy. ify the degree of causality in both parasites are not fully understood,
Universal salt iodization and, in directions. It is believed that in available evidence suggests that the
some cases, iodine supplementation countries with high prevalence of infections act synergistically and
are essential to ensure optimum HIV, the AIDS epidemic may have result in adverse outcomes. Recent
iodine intake during pregnancy reversed previous advances in evidence suggests that HIV-positive
and childhood.16 maternal mortality. What can be women with placental malaria are
assessed with greater certainty, at more likely to give birth to low-
Malaria is another deadly risk for least partially, is the number of birthweight infants. Research also
mothers and babies. In malaria- women identified as living with suggests that low-birthweight
endemic areas, the disease con- HIV who gave birth – around infants are more susceptible to HIV
tributes to around one quarter of 1.5 million in 108 low- and infection as a result of mother-to-
severe maternal anaemia cases, middle-income countries in 2006. child transmission of the virus
heightens the risk of stillbirth and than infants of normal birthweight.
miscarriage, and contributes to low Efforts to address the AIDS epidem- Antiretroviral treatment for HIV-
birthweight and neonatal deaths. ic and its impact on maternal and positive women and children and the
Prevention of malaria through the newborn health are intensifying in use of insecticide-treated mosquito
use of insecticide-treated mosquito four key areas: prevention of infec- nets can reduce the risk of malaria
nets is therefore vital to reduce its tion among adolescents and young still further.19 (For further details on
impact on pregnant women and people; antiretroviral treatment for HIV and malaria co-infection, see
newborns. In addition, intermittent HIV-positive women and mothers the Panel in Chapter 3, page 63.)
preventive treatment of malaria for who require antiretroviral therapy;
pregnant women in the second and prevention of mother-to-child trans- For every woman who dies from
third trimesters is increasingly used mission; and paediatric treatment of pregnancy-related complications,
in sub-Saharan Africa to avert HIV. Advances are being made in all around 20 more incur injuries, infec-
anaemia and placental malaria.17 four areas and encouraging results tions and disabilities – approximately
and other routine tasks. A number
of factors can cause uterine pro-
lapse, including prolonged labour,
difficult delivery, frequent pregnan-
cies, inadequate obstetric care and
heavy manual labour.
Other forms of maternal morbidity

include anaemia, infertility, chronic
infection, depression and incontinence
– all of which may result in domestic
problems including physical and psy-
chological abuse, household dissolu-
tion and social exclusion.20
Neonatal mortality
Some 86 per cent of newborn deaths
UNICEF/HQ05-1222/Roger LeMoyne
globally are the direct result of three

main causes: severe infections –
including sepsis/pneumonia, tetanus
and diarrhoea – asphyxia and
preterm births. Severe infections are
estimated to account for 36 per cent
Exclusive breastfeeding for the first six months of life helps protect newborns and infants of all newborn deaths. They can
from disease, reduces the risk of mortality and encourages healthy child development. occur at any point during the first
A woman breastfeeds her newborn at the Uskudar Ana ve Cocuk Sagligi Klinigi, a clinic
operated by the Ministry of Health in Istanbul, Turkey. month of life but are the main cause
of neonatal death after the first week.
10 million women each year. Among cal discomfort and emotional distress Clean delivery practices are clearly
the most distressing conditions is of the condition, they also may risk important in preventing infection,
obstetric fistula, which occurs when being shunned by their husbands but maternal infections also need to
prolonged pressure from the baby’s and families. be identified and treated during preg-
head during extended, problematic nancy. Infections in newborns require
labour causes tissue damage in the Another debilitating condition is rapid identification and treatment as
birth canal. In the period following uterine prolapse, which occurs soon as possible following childbirth.
the birth, holes open up and there is when the muscles, ligaments and
leakage from the bladder and/or the tissue supporting the pelvic struc- Asphyxia (difficulty in breathing after
rectum into the vagina. Fistula can ture give way, causing the uterus to birth) causes 23 per cent of newborn
be easily treated by health workers fall into the vaginal canal. Limited deaths and can largely be prevented
with appropriate surgical skills, but mobility, chronic back pains and by improved care during labour and
many of the estimated 75,000 women urinary incontinence are three con- delivery. The condition can be alleviat-
afflicted by this condition each year sequences of prolapse, which, if ed by a trained health worker who
never receive treatment. Instead, they severe, can also make it impossible is able to detect its signs and resusci-
not only have to cope with the physi- for women to undertake household tate the newborn. Preterm birth (deliv-
Pregnancy- and childbirth-related complications are an important
cause of mortality for girls aged 15–19 years worldwide, accounting
for 70,000 deaths every year.
ery at less than 37 weeks of completed Saharan Africa, the regions with the health is not simply a practical mat-
gestation) directly causes 27 per cent highest rates of undernutrition among ter of making available better and
of newborn deaths. Infants born girls and women. Maternal undernu- more extensive maternal health serv-
prematurely find it more difficult trition is correlated with a higher inci- ices. It also involves tackling head
than full-term babies to feed, maintain dence of low birthweight in infants.22 on the neglect of women’s basic
normal body temperature and with- rights in many societies.
stand infection. Preventing malaria in Intrauterine growth restriction, which
pregnant women can have a positive refers to restricted growth of the fetus In addition to adequate nutrition
impact on the incidence of premature during pregnancy, is a leading risk for for women, birth spacing is also
births in malaria-endemic areas.21 perinatal deaths. Like low birthweight, central to avoiding preterm births,
it is also associated with maternal low birthweight in infants and
According to the latest international undernutrition and ill health, among neonatal deaths; studies show
estimates, which cover the period other factors. With correct identifica- that birth intervals of less than
2000–2007, 15 per cent of all new- tion and proper management, includ- 24 months significantly increase
borns are born with low birthweight ing early treatment of maternal dis- these risks. It is also imperative
(defined as infants weighing less than eases and good nutrition, the condition to secure girls’ access to proper
2,500 grams at birth). Low birth- can be contained and need not result nutrition and health care from
weight, which is caused by preterm in lifelong consequences.23 birth through childhood and into
birth or intrauterine growth restric- adolescence, womanhood and their
tion, is an underlying factor in 60–80 The intergenerational nature of the potential childbearing years.24
per cent of neonatal deaths. The solution to intrauterine growth
majority of such cases occur in South restriction underlines the fact that For every newborn baby who dies,
Asia in particular, and also in sub- improving maternal and newborn another 20 suffer birth injury, com-
Figure 1.5
Direct causes of maternal deaths, 1997–2002*
Complications of abortion
4%
Other causes
30%
Obstructed labour Other causes Other causes Haemorrhage
4% 21% 21%
Haemorrhage 21%
Anaemia 31%
4%
Complications Sepsis/
of abortion Complications infections
HIV/AIDS 6% of abortion 8%
6% 12%
Obstructed
Hypertensive
Haemorrhage labour
disorders Sepsis/
34% 9% Obstructed Hypertensive
9% infections
Sepsis/ labour disorders
Anaemia 12%
infections 13% 26%
10% 13%
Hypertensive
disorders
9%
Africa Asia Latin America/Caribbean
* Data refer to the most recent year available during the period specified. Percentages may not total 100% because of rounding.
Source: Khan, Khalid S., et al., 'WHO Analysis of Causes of Maternal Death: A systematic review', The Lancet, vol. 367, no. 9516, 1 April 2006, p.1069.
For every woman who dies from a pregnancy-related cause, another
20 more incur injuries, infections and disabilities – around 10 million
women each year.
plications arising from preterm birth to nutritious food and essential survival. Studies show that women’s
or other neonatal conditions. More micronutrients, poor environmental health throughout the life cycle,
than 1 million children who survive health facilities and inadequate basic from childhood through adolescence
birth asphyxia each year, for exam- health-care services and limited and into adulthood, is critical in
ple, end up suffering disabilities access to maternity services – includ- determining maternal and neonatal
such as cerebral palsy or learning ing emergency obstetric and newborn health outcomes. Access to institu-
difficulties.25 care. There are also basic factors, tional facilities and skilled health
such as poverty, social exclusion and personnel at birth are also important
Underlying and basic causes gender discrimination that underpin factors; it should come as no sur-
of maternal and neonatal both the direct and underlying causes prise that the countries with the
mortality and morbidity of maternal and newborn mortality highest rates of neonatal mortality
and morbidity. (For a fuller outline of have among the lowest rates of
In addition to the direct causes of how these factors interact, see Figure skilled attendants at birth and
maternal and newborn mortality and 1.7 on page 17.) institutional deliveries.26
morbidity, there are a number of
underlying factors at the household, Of particular importance is the Poverty undermines maternal and
community and district levels that restricted access to quality health neonatal health in several ways. It
also serve to undermine the health care services that many women face. can heighten the incidence of direct
and survival of mothers and new- Maternal health and access to quali- causes of mortality, such as maternal
borns. They include lack of education ty contraception and reproductive infections and undernutrition, and
and knowledge, inadequate maternal health services save women’s lives discourage care seeking or reduce
and newborn health practices and and are also important factors access to health-care services. It can
care seeking, insufficient access underlying newborn health and also undermine the quality of the
Figure 1.6
Direct causes of neonatal deaths, 2000*
Low birthweight, which is related to maternal malnutrition, is a causal factor
in 60–80 per cent of neonatal deaths.
Tetanus (7%) Congenital (7%)
Sepsis/pneumonia (26%) Diarrhoea (3%) Preterm (27%) Asphyxia (23%) Other (7%)
0 20 40 60 80 100
* Percentages may not total 100% because of rounding.

Source: Lawn, Joy E., Simon Cousens and Jelka Zupan, ‘4 million neonatal deaths; When? Where? Why?', The Lancet, vol. 365, no. 9462,
5 March 2005, p. 895.
services provided even when they
© UNICEF/HQ08-0302/Susan Markisz
are available. Information from 50
Demographic and Health Surveys
from 1995 to 2002 reveals that with-
in regions, neonatal mortality rates
are around 20–50 per cent higher for
the poorest 20 per cent of households
than for the richest quintile. Similar
Improving maternity services is essential to enhancing maternal and newborn health and
inequities are also prevalent for survival. A nurse examines a six-week-old baby during a check-up at a community health
maternal mortality.27 centre, Jamaica.
Providing a supportive social con- certainly know enough to implement • Access to skilled health personnel –
text for the rights of women and interventions that could save millions a doctor, nurse or midwife – at
girls is also critical to reducing of lives. The main methods of redu- delivery.
maternal and neonatal mortality cing maternal and newborn mortality
and morbidity. Efforts to increase and morbidity are well established • Basic emergency obstetric care at
health interventions to address the and understood. These include: a minimum of four facilities per
proximate causes of maternal and 500,000 population – adapted to
neonatal deaths and ill health, and • Promoting access to family plan- each country’s circumstances –
to ameliorate maternal undernutri- ning services, based on individual for women who experience some
tion, curb infectious diseases and country policies. complication.
improve hygiene facilities and prac-
tices will be only partly successful • Quality antenatal care providing a • Comprehensive emergency
unless the social context in which comprehensive package of health obstetric care at a minimum of
women and girls reside respects their and nutrition services. one facility in every district or
rights. As Chapter 2 shows, expand- one per 500,000 population.
ing service delivery may prove insuf- • Preventing mother-to-child transmis-
ficient if women and girls are denied sion of HIV and offering antiretro- • A post-natal visit for every
access to essential commodities or viral treatment for women in need. mother and newborn as soon
services because of cultural, social, as possible after delivery, ideally
or familial impediments. • Basic preventive and curative inter- within 24 hours, with additional
ventions, including immunization visits towards the end of the
Accelerating progress on against neonatal tetanus for preg- first week and at four to
maternal and newborn health nant women, routine immuniza- six weeks.
tion, distribution of insecticide-
Many of the causal factors responsi- treated mosquito nets and oral • Knowledge and life skills for
ble for maternal and neonatal mor- rehydration salts, among others. pregnant women and families
bidity and mortality are well known on the danger signs of maternal
and interrelated, as illustrated in the • Access to improved water and sani- and newborn health and about
conceptual framework in Figure 1.7. tation, and adoption of improved referral systems.
While there are still many gaps in our hygiene practices, especially at deliv-
knowledge of the extent and causes ery. Clean water for hygiene and • Maternal nutrition counselling and
of maternal and newborn deaths, we drinking is essential for safe delivery. supplementation as needed as part of
The burden of neonatal deaths is also high, as each year almost
4 million newborns die within the first 28 days of life.
Figure 1.7
Conceptual framework for maternal and neonatal mortality and morbidity
This conceptual framework on the causes of maternal and newborn deaths illustrates that health outcomes are determined by interrelated fac-
tors, encompassing nutrition, water, sanitation and hygiene, health-care services and healthy behaviours, and disease control, among others.
These factors are defined as proximate (individual), underlying (household, community and district) and basic (societal). Factors at one level
influence other levels. The framework is devised to be useful in assessing and analysing the causes of maternal and newborn mortality and
morbidity, and in planning effective actions to enhance maternal and neonatal health.
Maternal and neonatal Outcomes

mortality and morbidity
Obstetric risks
Congenital Diseases and Inadequate Direct causes
incl. complications
factors infections dietary intake
of abortion
Lack of education, Insufficient Inadequate Insufficient access Poor water/

health information, access to maternal and to nutritious food sanitation
and life skills maternity newborn health and essential and hygiene, Underlying causes at the
services – practices and micronutrients and inadequate household/community
including care seeking including early basic health-care and district levels
emergency and exclusive services
obstetric and breastfeeding
newborn care
Quantity and quality of actual

resources for maternal health —
human, economic and organizational —
Inadequate and/or inappropriate and the way they are controlled
knowledge, discriminating attitudes
limit household access to actual resources Basic causes at
societal level
Potential resources: environment, technology, people

Political, economic, cultural, religious and
social systems, including women’s status,
limit the utilization of potential resources
Source: UNICEF.
A child born in a least developed country is almost 14 times
more likely to die during the first 28 days of life than one born
in an industrialized country.
routine antenatal, post-natal and skilled professionals throughout preg- and infrastructure services and offer
neonatal care. nancy, birth, post-partum and neona- security to citizens. Fragile states
tal care, supported by referrals to hold around 8 per cent of the world’s
• Essential care for all newborns, adequately staffed facilities equipped population, but they account for
including initiation of breastfeeding to manage emergencies. The emerging 35 per cent of global maternal
within the first hour of birth, role of mid-level providers such as deaths and comprise 8 of the 10
exclusive breastfeeding, infection nurses and midwives in broadening countries with the highest maternal
control, warmth provision and access to emergency obstetric care is mortality ratios. These countries also
avoidance of bathing during the also showing promising potential in account for 21 per cent of global
first 24 hours. the developing world. neonatal deaths, and comprise 9 of
the 10 countries with the most ele-
• Extra care for small babies, multi- In particular, given that the risks of vated rates of neonatal mortality.29
ple births and severe congenital maternal and newborn death are
abnormalities. greatest during the first 24–48 hours Strengthening governance and the rule
after birth, post-natal care urgently of law and restoring peace and security
• Integrated Management of needs to be expanded during this are requisites for accelerating progress
Neonatal and Childhood Illness, or period, and greater emphasis needs on improving maternal and newborn
the equivalent, in health facilities to be placed on follow-up visits for health. Donors and international agen-
that provide care to women and babies and mothers. Visits shortly cies also face the challenge of moving
children.28 after birth are vital for new mothers, beyond short-term humanitarian
who may remain at higher risk of response to long-term development
For these interventions to work, mortality and morbidity for up to a assistance, and ensuring that maternal,
however, it is increasingly recognized year after birth. This is usually not child and newborn health and women’s
that essential services must be provid- possible, however, as maternal and rights are among the key issues in
ed, at key points in the life cycle, newborn services are often sorely negotiations and programmes aimed at
through dynamic health systems that lacking in the poorest countries and improving governance, resolving con-
integrate a continuum of home, com- communities where the most deaths flict and strengthening institutions.30
munity, outreach and facility-based occur. Particularly in sub-Saharan
care. This concept of a continuum of Africa, factors such as distance, In the least developed countries, insuf-
care for maternal, neonatal and child migration, urbanization, armed con- ficient resources have been dedicated
health has arisen in recent years from flict, disease and lack of investment to maternal and neonatal health, with
the recognition that an integrated in public health have left severe the result that the poor have been
approach reaps more dividends than shortages of skilled health effectively denied access to clinics and
myriad separate initiatives. The con- professionals. hospitals, especially in rural areas.
tinuum must exist, however, in a sup- This may be due to the absence of
portive environment that safeguards Women and newborns in fragile such a facility, the poor quality and
women’s rights and prioritizes mater- states – countries that experience condition of health centres and hospi-
nal and newborn health. Chapter 2 weak institutional policy, poor gov- tals, the lack of skilled health person-
explores the elements required to cre- ernance, political instability and nel or personnel with low skills levels,
ate and sustain such an environment. weak rule of law – require particular or the existence of user fees and other
attention. Often these states lack the costs that the poor cannot afford. The
Among the most vital elements in the institutional capacity and adequate continuum of care concept refers not
continuum of care is the presence of resources to deliver basic social only to the needs of mothers and
Focus On Maternal and newborn health in Nigeria:
Developing strategies to accelerate progress
Nigeria is Africa’s most populous country, with 148 million largest ethnic group in northern Nigeria and are therefore
inhabitants in 2007, 25 million of them under age five. With critically affected by this region’s higher poverty rates.
almost 6 million births in 2007 – the third highest number in
the world behind India and China – and a total fertility rate Cultural attitudes and practices that discriminate against
of 5.4, Nigeria’s population growth continues to be rapid in women and girls contribute to maternal mortality and mor-
absolute terms. bidity. Child marriage and high rates of adolescent births
are commonplace across Nigeria, exposing girls and
In addition to its sizeable population, Nigeria is known for women of reproductive age to numerous health risks.
its vast oil wealth. Nonetheless, poverty is widespread;
according to the latest World Development Indicators 2007, Given these complex realities, developing strategies to
published by the World Bank, more than 70 per cent of accelerate progress on maternal and newborn health
Nigerians live on less than US$1 per day, impairing their remains a considerable challenge. But the Government of
ability to afford health care. Nigeria, together with international partners, is attempting
to meet the challenge. In 2007, it began to implement a
Poverty, demographic pressures and insufficient investment national Integrated Maternal, Newborn and Child Health
in public health care, to name but three factors, inflate lev- (IMNCH) Strategy to fast-track high-impact intervention
els and ratios of maternal and neonatal mortality. The latest packages that include nutritional supplements, immuniza-
United Nations inter-agency estimates place the 2005 aver- tion, insecticide-treated mosquito nets and prevention
age national maternal mortality ratio at 1,100 deaths per of mother-to-child transmission of HIV.
100,000 live births and the lifetime risk of maternal death at
1 in 18. When viewed in global terms, the burden of mater- The strategy is to be rolled out in three phases, each lasting
nal death is brought into stark relief: Approximately 1 in three years, and has been designed along the continuum of
every 9 maternal deaths occurs in Nigeria alone. care model to strengthen Nigeria’s decentralized health sys-
tem, which operates at the federal, state and local levels. In
The women who survive pregnancy and childbirth may face the initial phase, covering 2007–2009, the key focus will be
compromised health; studies suggest that between 100,000 identifying and removing bottlenecks, while delivering a
and 1 million women in Nigeria may be suffering from basic package of services using community-based and
obstetric fistula. Neonatal deaths in 2004 stood at 249,000, family-care strategies. A sizeable proportion of expenditure
according to the latest World Health Organization figures, will go towards artemisinin-based combination therapy to
with 76 per cent taking place in the early neonatal period combat malaria in women, children and newly recruited
(first week of life). Inadequate health facilities, lack of trans- and trained health workers, particularly in rural areas. As
portation to institutional care, inability to pay for services basic healthcare improves, it is anticipated that the demand
and resistance among some populations to modern health for clinical services will increase.
care are key factors behind the country’s high rates of
maternal, newborn and child mortality and morbidity. The second and third phases of the IMNCH will place
greater emphasis on building health infrastructure. Over
Disparities in poverty and health among Nigeria’s nine years, the strategy aims to revitalize existing facilities,
numerous ethnolinguistic groups and between its states construct clinics and hospitals, and create incentives –
are marked. Poverty rates in rural areas, estimated at such as dependable salaries, hardship allowances and
64 per cent in 2004, are roughly 1.5 times higher than the performance-based bonuses – that will help retain skilled
urban-area rate of 43 per cent. Moreover, the poverty rate health professionals in Nigeria’s health system.
in the north-east region, which stands at 67 per cent,
is almost twice the level of 34 per cent in the more The IMNCH strategy, if implemented in full and on time,
prosperous south-east. can markedly improve maternal and newborn health.
Together with this package, the country has recently passed
Low levels of education, especially among women, and the National Health Insurance Scheme, which integrates
discriminatory cultural attitudes and practices are barriers the public and private health sectors to make health care
to reducing high maternal mortality rates. A study at the more affordable for Nigerians. If the government passes
Jos University Teaching Hospital in the north-central region the National Health Bill, which is currently before the legis-
shows that nearly three quarters of maternal deaths in 2005 lature, a direct funding line for primary health care will
occurred among illiterate women. The mortality rate among become available. These health-system improvements have
women who did not receive antenatal care was about 20 the potential to set a new course for meeting Millennium
times higher than among those who did. Of the several eth- Development Goals 4 and 5 in Africa’s largest nation.
nic groups represented among the patients, Hausa-Fulani
women accounted for 22 per cent of all deliveries and 44
per cent of all deaths. The Hausa-Fulani represent the See References, page 107.
For every newborn baby who dies, another 20 suffer birth injury,
complications arising from preterm birth or other neonatal conditions.
children across time, but also to grating and scaling up a range of Development Goal to reduce child
increasing access to health services by actions. Chapter 4 examines the key mortality (MDG 4) and even further
linking households and communities, paradigms, policies, and programmes behind on the goal to improve mater-
clinics and hospitals. Chapter 3 looks that are driving the process forward. nal health (MDG 5). It is clear that
in more depth at how to integrate and progress has to be significantly acceler-
strengthen the services available to The final chapter of The State of the ated. The experiences of several devel-
mothers and newborns and deliver World’s Children 2009 calls for con- oping countries, explored in depth in
them at key points in the life cycle certed action and strong, cohesive subsequent chapters, have proved that
and at key locations. partnerships to improve maternal and rapid progress is possible when sound
neonatal survival and health. The strategies, political commitment, ade-
Implementing and extending contin- goals are already clear – and it is also quate resources and collaborative
ua of care for mothers, newborns evident that the world as a whole has efforts are applied in support of the
and children will require both inte- fallen behind on the Millennium health of both mothers and newborns.
Expanding Millennium Development Goal 5: Universal access to

reproductive health by 2015
In 2005, Heads of State meeting at the United Nations to Antenatal care coverage – Percentage of women aged 15–49
review commitments made in the Millennium Declaration – attended at least once during pregnancy by skilled health per-
the outcome document of the Millennium Summit of 2000 – sonnel (doctors, nurses or midwives) and the percentage
not only reaffirmed the development goals elaborated in 2000 attended by any provider at least four times.
and ever since known as the Millennium Development Goals
(MDGs), they also added four new targets to support them. Unmet need for family planning – Refers to women who are
fecund and sexually active but are not using any method of
One of the major changes to the MDG configuration is contraception and report not wanting any more children or
the inclusion of a specific target on reproductive health: wanting to delay the birth of the next child.
Millennium Development Goal 5, Target B, which seeks
to “Achieve, by 2015, universal access to reproductive The addition of the reproductive health target to the MDGs
health.” This new target falls within the goal’s overarching reflects a long process linking reproductive health issues to
objective of improving maternal health and complements development, human rights and gender equity, whose land-
its original target and associated indicators. The indicators mark event was the International Conference on Population
selected to monitor progress towards MDG 5, Target B, are and Development (ICPD) held in Cairo in 1994. Since then,
shown below: other important events, notably the Fourth World Conference
on Women (Beijing, 1995) and ICPD+5 – the UN General
Contraceptive prevalence rate – Percentage of women aged Assembly Special Session on the International Conference on
15–49 in union currently using contraception. Population and Development held in 1999 – have confirmed
and extended the recommendations of the original ICPD gath-
Adolescent birth rate – Annual number of births to women ering, including the goal of universal access to reproductive
aged 15–19 per 1,000 women in that age group. Alternatively, health services by 2015.
it is referred to as the age-specific fertility rate for women
aged 15–19. See References, page 107.
Focus On Prioritizing maternal health in Sri Lanka
Sri Lanka is a story of success against the odds. A lower- sionalize midwives, and a no-blame policy helped make
middle-income country – in 2006, Sri Lanka’s annual gross inquiries into maternal deaths routine.
national income per capita was less than US$1,500 – it has
also experienced a protracted civil conflict and the devas- The results were dramatic – maternal mortality was halved
tation of the 2004 Indian Ocean tsunami. Yet the country’s between 1947 and 1950. Thirteen years later, maternal mor-
progress in human development, particularly in maternal tality rates were cut in half again. Once health structures and
and child health and education, has been one of the key networks were in place, increasingly better organization
success stories among developing countries in recent and clinical management have allowed Sri Lanka to cut the
decades. Sri Lanka’s maternal mortality ratio declined from maternal mortality ratio by 50 per cent every 6 to 11 years.
340 per 100,000 live births in 1960 to 43 per 100,000 live In addition, women’s literacy rose from 44 to 71 per cent
births in 2005, and 98 per cent of births now take place in between 1946 and 1971. The rates of skilled attendance at
hospitals. Rates of antenatal care (at least one visit) and birth and institutional delivery also grew. The public health
skilled attendance at birth stand at 99 per cent. In 2007, the midwife’s role became more that of an institutional delivery
country had an overall fertility rate of 1.9 – compared to assistant, as home midwife-assisted deliveries declined from
3.0 for the South Asia region. These results have also had 9 per cent in 1970 to just 2 per cent in 1995. Beginning in
positive effects on child survival: The under-five mortality 1965, midwives also played a role in expanding government
rate has fallen from 32 per 1,000 live births in 1990 to 21 family planning services.
per 1,000 live births in 2007. The latest available data sug-
gest that the neonatal mortality rate has also fallen, to Sri Lanka’s development of its health system has long been
around 8 per 100,000 births in 2004. a model for other developing countries, demonstrating the
degree of success that can be achieved in maternal and
In basic education, too, Sri Lanka’s performance has been out- child health when sound strategies, sufficient resources
standing. According to the latest international estimates, net and political commitment are judiciously applied. Despite
primary school enrolment stands at more than 97 per cent its noteworthy advances in maternal and child health, chal-
for both girls and boys, while literacy rates among young lenges remain. In recent years, the country has faced a
people aged 15–24 are 97 per cent for males and 98 per cent shortage of health workers; according to the World Health
for females. Administrative data suggest that the comple- Statistics 2008, in the 2000–2006 period the country had
tion rate for primary school is 100 per cent. Given the posi- only 6 doctors and 17 nurses and midwives per 10,000
tive correlation between education and maternal and child inhabitants. In addition, services have deteriorated as
survival, these are the results of sustained investment in all financial resources have been squeezed, with health
three areas. spending at around 4 per cent of GDP in 2005. Private
spending on health, most of which is out-of-pocket,
The key to Sri Lanka’s outstanding improvements in mater- accounts for more than half of total health expenditure.
nal health was the expansion of a synergistic package of
health and social services to reach the poor. The country’s A further challenge for Sri Lanka will be to ensure food
health system, which dates back to the late 19th century, security, particularly if global food prices remain high. The
first targeted universal provision of improved health care, country still has marked levels of undernutrition among
sanitation and disease management. It subsequently added newborns and children under five. According to the latest
specific interventions to improve the health of women and international estimates, more than 1 in every 5 newborns
children. Over the years, successive governments have fol- are born with low birthweight, and 23 per cent of children
lowed a prudent approach of prioritizing health-care servi- under five are moderately or severely underweight.
ces to mothers and the poor while spending economic and Improving the level of exclusive breastfeeding for children
human resources judiciously. The resulting improvements less than six months old from its current level of 53 per cent
in women’s health are supported and strengthened by will be vital to sustaining Sri Lanka’s gains in neonatal and
measures to empower women socially and politically child mortality.
through education, employment and social engagement.
Sri Lanka’s early written records and colonial past give a
unique perspective of the evolution of maternal health in
the country, starting with 9th- and 10th-century medical
texts. Formal midwifery training was established under the
British colonial government in 1879, and the Registrar
General has recorded maternal mortality since 1902. This
wealth of information and knowledge makes it possible to
evaluate results of differing approaches to maternal health
over time. Clear mandatory competencies helped profes-
The centrality of Africa and Asia in the global
challenges for children and women
The continents of Africa and Asia* present the largest global challenges to the survival of children and
women. Their progress in such critical areas as child and maternal health, nutrition and education,
among others, is pivotal to achievement of the Millennium Development Goals.
Deaths of children under five, 2007 Maternal deaths, 2005

Rest of the world: Rest of the world:
0.7 million (8%) 28,000 (5%)
Africa: 276,000
Africa: 4.7 million (51%)
Asia: 232,000
Asia: 3.8 million (51%)
(43%)
(41%)
Source: UNICEF global databases. Source: UNICEF global databases.
Deaths among children Maternal deaths

under five • In 2005, the latest year for which firm estimates are
available, an estimated 536,000 women died from
• In 2007, 9.2 million children died before age five.
causes related to pregnancy and childbirth. Almost
Africa and Asia together accounted for 92 per cent
all – 95 per cent – of these maternal deaths occurred
of these deaths.
in Africa and Asia.
• Half of the world’s under-five deaths occurred in Africa,

• Africa is the continent with the highest rate of maternal
which remains the most difficult place in the world for a
mortality, estimated at 820 maternal deaths per 100,000
child to survive until age five.
live births in 2005. Asia’s rate of maternal death is 350
per 100,000 live births.
• Although Asia has seen a remarkable reduction in
the annual number of child deaths since 1970, it still
• In Africa, the lifetime risk of maternal death is 1 in 26,
accounted for 41 per cent of global under-five deaths
four times higher than in Asia and more than 300 times
in 2007.
higher than in the industrialized countries.
The full burden of maternal and child deaths in Africa and Asia – for each continent and for the two combined – is
frequently understated due to the lack of continent-wide estimates for key Millennium Development Goal indicators.
This panel presents a snapshot of key child and maternal indicators for Africa and Asia, and in their totality provides a
complementary perspective to the regional breakdown presented in the Statistical Tables, pages 113-157 of this report.
Aggregating the data on children from these two vast continents provides a stark reminder of the overwhelming
importance of making rapid progress across both Africa and Asia if global development goals are to be realized.
In the push to accelerate progress at the continental level, however, the often startling disparities in the status of
women and children and in rates of progress within countries and continents must not be forgotten. The issue
of disparities and inequalities affecting children will be examined in greater detail in future editions of The State
of the World’s Children.
Underweight children under five, 2007 Primary-school-age children out of school, 2007
Rest of the world: Rest of the world:
10 million (7%) 12 million (12%)
Africa: 39 million
(27%)
Africa: 49 million
(49%)
Asia: 40 million
Asia: 99 million (39%)
(67%)
Source: UNICEF global databases. Source: UNICEF global databases.
Nutritional status of young children Primary education

• In 2007, 148 million children under age five in the develop- • In 2007, 101 million children of primary school age were
ing world were underweight for their age. not in school.
• Two thirds of these children live in Asia, and just over one • Almost half of these children live in Africa, and 39 per cent
quarter live in Africa. live in Asia.
• Together, Africa and Asia account for 93 per cent of all under- • Across the two regions, approximately 20 per cent of
weight children under age five in the developing world. girls and 16 per cent of boys of primary school age are
either not enrolled or are not attending primary school.
* Africa includes all member states of the African Union. Asia includes the countries in the UNICEF regions of East Asia and the Pacific and
South Asia. Numbers may not always add up due to rounding.
The global food crisis and its potential impact on
maternal and newborn health
The recent, precipitous rise in global prices that began in 2006 however, it is the poorest sections of society – who spend
and continued in 2007–2008 has illustrated the vulnerability of the largest proportion of their disposable income on food –
millions to hunger and undernutrition, particularly those in that are likely to be hardest hit by the food crisis.
countries where food security is still a major concern. The
sharp increases involved such basic foodstuffs as vegetable Addressing the special nutritional needs of mothers
oils, grains, dairy products and rice. Although fluctuations in and newborns
the prices of commodities are common, what distinguished During an emergency such as a food crisis, pregnant and
the situation in 2008 was that the hike in world prices affects lactating mothers, together with infants, are among those
not just a selected few products but nearly all major food and considered most at risk of undernutrition, owing to their
feed commodities. higher nutritional requirements. For example, pregnant
women require almost 285 additional calories per day, and
lactating women require an additional 500 calories per day.
Figure 1.8
Their micronutrient needs are also higher, and they require
Food prices have risen sharply across the board* adequate intake of iron, folate, vitamin A and iodine to
ensure the health of both mother and infant.
350
1998–2000 = 100
In the face of the food crisis, FAO has urged a rapid supply
Oils and fats response to restore a better balance between food supply
300
and demand, especially in the countries worst affected. In
Index of food commodity prices
addition, while food aid is being supplied to countries, poli-

250
cies must be applied to offset patterns of food distribution
Dairy between family members that may result in pregnant and
Cereals
lactating women consuming less than their minimum require-
200 ments. Where food aid is being provided to those most at risk
of shortages and undernutrition, additional food for pregnant
Sugar
women should be supplied, usually as a take-home ration,
150 either through the general ration distribution or through sup-
Meat
plementary feeding programmes. Pregnant and lactating
women may also require other complementary, nutrition-
100
J J A S O N D J F M A M J
related interventions, including food fortification, micronutri-
ent supplementation, additional safe drinking water, malaria
2007/2008
management during pregnancy, prophylaxis for management
* The food commodity price indices displayed above are the weighted averages of of internal parasites, and nutrition education counselling.
price indices from a basket of basic goods under each commodity group. The
weights are the average export trade shares for 1998–2000. For examples, the Oils
and Fats Price Index consists of the price indices of 11 different oils (including ani- Communication and advocacy campaigns concerning food aid
mal and fish oils) weighted with average export trade shares of each oil product for
1998–2000. For a fuller explanation of the composition of each food commodity should highlight the special nutritional needs of pregnant and
group index, see Source. lactating women and include messages to families and com-
Source: Food and Agriculture Organization of the United Nations, Food Price munities explaining why these women are being provided
Indices, <http://www.fao.org/worldfoodsituation/FoodPricesIndex/en>, accessed 1 extra food. The information should stress the importance of
August 2008.
exclusive breastfeeding for the first six months of a child’s life,
with complementary feeding for older infants. For HIV-positive
By June 2008, the Food and Agriculture Organization of the mothers, breastfeeding practices may differ, since the virus
United Nations (FAO) had identified 22 developing countries can be transmitted through breast milk, depending on the
as being particularly vulnerable to the food crisis. Its assess- availability and safety of replacement feeding.
ment was based on a combination of three risk factors:
Information and early warning continue to have a crucial role
• An underweight prevalence rate of 30 per cent or more in in ensuring that timely and appropriate action can be taken to
the population. avoid suffering. FAO’s Global Information and Early Warning
• A high degree of dependence on imports of food staples System is demonstrating its capacity to alert the world to
such as rice, wheat and maize. emerging food shortages. More needs to be done, however,
• A high degree of dependence on imported petroleum to create strong response mechanisms to food crises and to
products. develop national and international policies that prioritize and
safeguard food and nutrition security – and take into account
Comoros, Eritrea, Haiti, Liberia and Niger are among the the special nutritional needs of women and young children.
countries that demonstrate worrisome levels of all three of
these identified risk factors. It comes as little surprise that See References, page 107.
most of these nations are among the least developed and
lowest-income countries. Even within these countries,
Creating a supportive environment for

2 maternal and newborn health
© UNICEF /HQ05-2185/Giacomo Pirozzi

Improving maternal and newborn health requires delivering essential services at critical times and
in key locations where they can be readily accessed by women and children. Establishing and
consolidating these continua of care necessitate more than just enhanced primary-health-care
interventions; it also demands a supportive environment for mothers and children that safeguards
and promotes their rights. The second chapter of The State of the World’s Children 2009 explores the
fundamentals of the supportive environment and the ways in which it strengthens efforts to enhance
primary health care.
I
n October 2008, more than 500 mothers and children. Other core pri- practitioners that the interrelated
health leaders from 65 countries orities included disease control, access health needs of women, newborns
met in Almaty, Kazakhstan, at to family planning, safe water supplies and children require the type of
an international conference mark- and sanitation. Citizens were to be integrated solutions championed
ing the 30th anniversary of the Alma- encouraged to participate in their own in the Alma-Ata Declaration. This
Ata Declaration on primary health health care, particularly in the provi- recognition has resulted in renewed
care. The participants exchanged expe- sion of preventive care and adoption interest in and support for integrat-
riences from the past three decades of healthy behaviours and practices.1 ed frameworks of health-service
and renewed their commitment to the (See Panel on page 29) delivery. Regular refinement of
principles of primary health care as a such frameworks as the Integrated
way of strengthening health systems. Considerable progress has been Management of Childhood Illness,
The World Health Organization achieved across the developing world introduced by UNICEF and the
launched the World Health Report in the 30 years that have ensued, in World Health Organization in 1992,
2008, which also addressed the theme controlling several major diseases, and collaboration between national
of primary health care, on the eve of including polio and measles, and in and international partners over the
the conference. reducing child mortality – particularly past two decades have recently
in the post-neonatal period (between consolidated into a comprehensive
The Alma-Ata Declaration, which 29 days and five years of age). Yet paradigm that integrates the hitherto
emerged from a similar meeting given the widening inequities in health- often disparate programmes for
convened by UNICEF and WHO in care provision between and within maternal and child health: the
1978 in the same city, in effect charted countries across the developing world, continuum of care for mothers,
a new course for public health. It the Alma-Ata agenda of comprehen- newborns and children.
advocated that countries broaden the sive primary health care – which
remit of health care beyond medical emphasizes the importance of a sup- The continuum of care
interventions to address the social, portive environment and preventive
cultural and infrastructure constraints and curative interventions in determin- The continuum of care aims to inte-
on providing quality health services to ing health outcomes – is perhaps as grate maternal, newborn and child
all their citizens. A principal focus of pertinent today as it was in 1978. health care. Its central premise can be
the primary-health-care approach that summarized as follows: essential serv-
emerged from Alma-Ata is the same There is a growing recognition ices for mothers, newborns and chil-
as the subject of this report: care for among health policymakers and dren are most effective when they are
The interrelated health needs of women and newborns require integrated
primary-health-care solutions.
delivered in integrated packages at Figure 2.1

critical points in the life cycle of The continuum of care
mothers and children, in a dynamic Connecting care during the lifecycle (A) and at places of caregiving (B). Adapted from Partnership
health system that spans key loca- for Maternal, Newborn and Child Health, with permission.
tions, underpinned by an environment A cy Neonata
l pe
an
supportive of the rights of women egn rio
Pr d
and children.
In
fa
Birth
nc
28 days
y
The critical points for service delivery
are adolescence, pre-pregnancy, preg- Death
nancy, birth, post-partum, neonatal, Ageing 1 year
years
Pr
infancy and childhood.
e s
Adulthood Childhood
e
c
ctiv
ho ol y
du 20 years 5 years
The essential services for mothers, ro
ea
10 years
newborns and children include
p
rs
Re
basic health care, quality maternal, nc

e
ho
Sc
sce ol
newborn and child health care, ade- Adole age
quate nutrition and improved water Adolescence and Post-natal

Pregnancy Birth Maternal health
and sanitation facilities, and hygiene before pregnancy (mother)
Post-natal
practices. (newborn)
Infancy Childhood
The key delivery modes for services B

Appr
are household and community, out- op
Hospitals and health facilities
ria
reach and outpatient, and health
te
facilities.2
Outpatient and outreach services re
ferral an
The supportive environment requires

df
respect for the rights of women and Family and community care
o
llo
w-u
children; quality education; a decent
p
standard of living; protection from

abuse, exploitation, discrimination Source: Kevbes, Kate J., et. al., 'Continuum of Care for Maternal, Newborn and Child Health: From
slogan to service delivery', The Lancet, vol. 370, no. 9595, 13 October 2007, p.1360.
and violence; equal participation in
home, community, social and politi-
cal life; empowerment of women; the World’s Children 2008 and are • Health systems are most useful when
and greater involvement of men in summarized here. they integrate dynamically the differ-
maternal and child care. ent modes of care – facility-based,
• Actions to improve the health of outreach and outpatient services,
The continuum of care broadly women, newborns and children and community and family care.
reflects a set of strategic principles are most effective and sustainable
based on lessons learned from a cen- when they are integrated and • Strengthening health systems to
tury of evolving health-care systems delivered in convenient, cost- improve health outcomes for
and practices. These principles were effective packages to communities mothers and children requires
explored in depth in The State of and families. combining and integrating the
C R E AT I N G A S U P P O R T I V E E N V I R O N M E N T F O R M AT E R N A L A N D N E W B O R N H E A LT H 27
Much ill health among women during pregnancy
is preventable, detectable or treatable through
antenatal visits. A health worker prepares to
measure a pregnant woman’s blood pressure at
a clinic, Bangladesh.
the exploration of the continuum

of care for mothers and newborns
begins by examining the various
constituents of a supportive envi-
ronment for the rights of women
and girls.
strengths of vertical and horizontal much less effective, sustainable
approaches to health-service or even possible. Creating a supportive
delivery, rather than choosing environment for women
either approach in isolation. Consider, for example, the problem and children
of low birthweight, which is a back-
• A results-oriented approach to ground factor in 70 per cent of Improving maternal and newborn
health-systems development, cen- neonatal deaths. Most low birth- health is not simply a practical matter
tred on effective and evidence-based weight babies suffered intrauterine of making available better and more
interventions, is useful in setting growth restriction in the womb, usu- extensive maternity services. It also
agendas and policies and in moni- ally as a result of the poor nutritional involves addressing and reversing the
toring and evaluating progress. and health status of the mother neglect of women’s rights and the
before and during pregnancy. The structural discrimination and mal-
• Results are best achieved through majority of such cases occur in South treatment often suffered by girls
collaborative action between pro- Asia, the region with highest rates and women.
grammes, policies and partnerships of undernutrition among girls and
working towards improving mater- women, and the only one with clear Discrimination on the basis of gender
nal, newborn and child care.3 evidence of gender discrimination in – often passed on from generation to
nutrition among children under five generation by cultural tradition and
These precepts form the basis and in adolescence.4 economic, social and political norms –
of programmes, policies and part- has numerous pernicious effects. It
nerships seeking to establish and Reducing neonatal deaths necessi- can deny girls and women access to
extend continua of quality health tates not only the provision of ante- education, which research shows
care for mothers, newborns and natal care and the attendance of could lower their exposure to the
children. To be truly effective, skilled health personnel at delivery; risks of maternal and infant deaths.5
however, and to move closer to it also requires that girls and women It may prevent them from receiving,
meeting the Alma-Ata challenge receive adequate nutrition and or from seeking, adequate health care
of delivering primary health care health care from birth through and vital life skills to protect them
for all, essential services for childhood and into adolescence, against sexually transmitted infec-
mothers and children require a womanhood and their potential tions – including HIV – inadequate
supportive environment that safe- childbearing years. birth spacing, violence, abuse and
guards and promotes their rights. exploitation. It can constrain their
Without actions to address gender This is but one example – more are income-earning capacity when they
discrimination, inequities and given in the remainder of this chap- become women and can force them
abuses that are perpetuated ter – of how the survival and health into a life of servitude and sub-
against women and girls in particu- of newborns and children depend servience when they marry – often
lar, actions in support of enhanced critically on the fulfilment of when they are still children under
primary health care risk being women’s rights. For this reason, 18 years of age.
Promoting healthy behaviours for mothers, newborns and
children: The Facts for Life guide
Creating a supportive environment for maternal and newborn Clear, brief and practical key messages explained recom-
health requires altering behaviours that discriminate against mended actions and offered supplementary information.
women and girls and adopting healthy practices that safe-
guard them from disease and injury. Healthy practices, such One underlying principle of the guide is that communication
as exclusively breastfeeding an infant for the first six months involves more than simply providing information. It also
of its life or washing hands with soap, must be evidence- requires presenting the information in an interesting and
based and established by medical experts. accessible way and helping people understand its relevance.
The guide also discusses ways to take action and overcome
Describing these practices to parents and other caregivers in bottlenecks and barriers.
non-technical language is critical to empowering women and
girls and supporting maternal and newborn health. Twenty Facts for Life has been widely disseminated, with more than
years ago, eight UN agencies – UNICEF, WHO, UNFPA, 15 million copies in circulation in 215 languages by 2002.
the United Nations Educational, Scientific and Cultural A new edition of the guide is being prepared.
Organization, the United Nations
Development Programme, the Joint
United Nations Programme on HIV/AIDS,
the World Food Programme and the World
Bank – jointly published a guide to make
such life-saving knowledge available to
everyone. The guide, entitled Facts for
Life, was addressed to communicators –
health workers, the media, government
officials, non-governmental organizations,
teachers, religious leaders, employers,
trade unions, women’s groups, communi-
ty organizations and others. Its third edi-
tion, published in 2002, addressed a broad
range of topics:
• Timing of births
• Safe motherhood
• Child development and

early learning
• Breastfeeding
• Nutrition and growth
• Immunization
• Diarrhoea
• Coughs, colds and more

serious illnesses
• Hygiene
• Malaria
• HIV and AIDS
• Injury prevention
• Disasters and emergencies
Gender equality produces a double dividend, enhancing the lives
of both women and children.
In addition, the heavy workloads of life; and empowering them to claim Declaration of Human Rights, the
women – who in general work longer their rights and essential services for 1989 Convention on the Rights of the
hours than men – can deny them the themselves and their children. Greater Child and other human rights instru-
time for leisure and rest. involvement of men in maternal and ments.6 It is also pivotal to improving
newborn health care and in addressing maternal and neonatal health, reduc-
Creating a supportive environment for gender discrimination and inequalities ing the incidence of child marriage –
maternal and newborn health requires is also critical to establishing a sup- with its largely inevitable consequences
challenging the social, economic and portive environment. The remainder of of premature pregnancy and mother-
cultural barriers that perpetuate gender this chapter will briefly examine each hood, eliminating extreme poverty
inequality and discrimination. This of these challenges in turn. and hunger, and enhancing knowledge
will involve several key actions: edu- of health risks and life skills. Since dis-
cating girls and women, and reducing Quality education and a crimination against girls and women is
the poverty they experience; protecting decent standard of living known to begin early, promoting gen-
girls and women from abuse, exploita- der equality and respect for the rights
tion, discrimination and violence; fos- Securing a quality education of women and encouraging fathers to
tering their participation and their play active roles in child care, should
involvement in household decision- Education is a right for children and begin with early childhood education
making and economic and political adolescents under the 1948 Universal programmes.
Figure 2.2
Although improving, the educational status of young women is still low in several
developing regions
26 Female net secondary
West/Central Africa 66 school attendance
18 Female youth (15–24 years)
Eastern/Southern Africa 69 literacy rate
43
South Asia 74
52
63
N/A
CEE/CIS 76
99
44
World 85
22
43
24
0 20 40 60 80 100
percentage, 2000–2007
* Sub-Saharan Africa comprises the regions of Eastern/Southern Africa and West/Central Africa.
Sources: Female youth literacy rate—UNESCO Institute of Statistics. Female net secondary school attendance—Demographic and Health Surveys and Multiple Indicator Cluster
Surveys.
Primary health care: 30 years since Alma-Ata
The 1978 Declaration of Alma-Ata was groundbreaking The International Conference on Primary Health Care was itself
because it linked the rights-based approach to health to a a milestone. At the time, it was the largest conference ever
viable strategy for attaining it. The outcome document of the held devoted to a single topic in international health and devel-
International Conference on Primary Health Care, the declara- opment, with 134 countries and 67 non-governmental organi-
tion identified primary health care as the key to reducing zations in attendance. Yet there were obstacles to fulfilling its
health inequalities between and within countries and thereby promise. For one thing, the declaration was non-binding.
to achieving the ambitious but unrealized goal of “Health for Furthermore, conceptual disagreements over how to define
All” by 2000. Primary health care was defined by the docu- fundamental terms such as ‘universal access’, which persist
ment as “essential health care” services, based on scientifi- today, were present from the beginning. In the context of the
cally proven interventions. These services were to be univer- cold war, these terms revealed the sharp ideological differ-
sally accessible to individuals and families at a cost that com- ences between the capitalist and communist worlds, discord
munities and nations as a whole could afford. At a minimum, perhaps heightened by the fact that the Alma-Ata conference
primary health care comprised eight elements: health educa- took place in what was then the Union of Soviet Socialist
tion, adequate nutrition, maternal and child health care, basic Republics.
sanitation and safe water, control of major infectious dis-
eases through immunization, prevention and control of local- As the 1970s gave way to a new decade, a tumultuous
ly endemic diseases, treatment of common diseases and economic environment contributed to a diversion away from
injuries, and the provision of essential drugs. primary health care in favour of the more affordable model
of selective health care, which targeted specific diseases and
The declaration urged governments to formulate national poli- conditions. Nonetheless, despite the mixed success of pri-
cies to incorporate primary health care into their national health mary health care in the countries where it has been imple-
systems. It argued that attention be given to the importance mented, advances in improving public health illustrate the
of community-based care that reflects a country’s political community-based model’s flexibility and applicability.
and economic realities. This model would bring “health care
as close as possible to where people live and work” by Insufficient progress towards the Millennium Development
enabling them to seek treatment, as appropriate, from Goals, coupled with the threats posed to global health and
trained community health workers, nurses and doctors. It human security by climate change, pandemic influenza and
would also foster a spirit of self-reliance among individuals the global food crisis, have led to renewed interest in com-
within a community and encourage their participation in the prehensive primary health care. Yet the many challenges that
planning and execution of health-care programmes. Referral prevented Alma-Ata’s implementation have evolved and
systems would complete the spectrum of care by providing must be confronted to achieve its goals now. Drawing on the
more comprehensive services to those who needed them growing body of evidence about cost-effective initiatives that
most – the poorest and the most marginalized. integrate household and community care with outreach and
facility-based services – such as those for maternal and child
Alma-Ata grew out of the same movement for social justice health described in Chapter 3 – will enable governments,
that led to the 1974 Declaration on the Establishment of a international partners and civil society organizations to
New International Economic Order. Both stressed the interde- revitalize primary health care.
pendence of the global economy and encouraged transfers of
aid and knowledge to reverse the widening economic and See References, page 108.
technological divides between industrialized countries and
developing countries, whose growth had, in many cases,
been stymied by colonization. Examples of community-based
innovations in poorer countries after World War II also pro-
vided inspiration. Nigeria’s under-five clinics, China's bare-
foot doctors and the Cuban and Vietnamese health systems
demonstrated that advances in health could occur without
the infrastructure available in industrialized countries.
© UNICEF/HQ05-2374/Anita Khemka
Outreach health providers bring vital services to communities and households. A community health worker holds up an infant growth chart during
an education session for young mothers, India.
Securing quality education for girls to wait until they are out of their than that of an infant born to a
and young women is a key challenge teenage years – when pregnancy mother older than 19.11
of the Millennium Development risks are highest – before starting a
Goals, which aim to achieve univer- family, and are also likely to have • Even if the child survives, he or
sal primary education (MDG 2) and healthier babies.8 The benefits of she is more likely to suffer from
to eliminate gender disparity at all delaying pregnancy until after ado- low birthweight, undernutrition
levels of education by 2015 as part of lescence are high. Consider the fol- and late physical and cognitive
efforts to promote gender equality lowing facts: development.12
and empower women (MDG 3).
• Maternal deaths related to preg- The gains from education go
Although considerable progress has nancy and childbirth are an impor- beyond reducing the risk of maternal
been made in reaching gender parity tant cause of mortality for girls and newborn deaths and ill health.
in primary education – all regions are aged 15–19 worldwide, accounting Research shows that educated women
currently deemed to be on track to for 70,000 deaths each year.9 are more likely to delay marriage,
meet this target – there are sizeable ensure their children are immunized,
gaps in several countries and in West • The younger a girl is when she be better informed about nutrition
and Central Africa in particular. becomes pregnant, the greater the for themselves and their children, and
Furthermore, gaps have closed less health risks. Girls who give birth undertake improved birth spacing
rapidly in secondary education.7 before the age of 15 are five times practices. In turn, their children have
more likely to die in childbirth higher survival rates than those of
Research has long confirmed the than women in their twenties.10 uneducated women and tend to be
merits of education not only for better nourished.13
women and girls, but also for fami- • If a mother is under the age of 18,
lies and societies. Studies show that her infant’s risk of dying in its first Education is also essential to the
educated adolescents are more likely year of life is 60 per cent greater fulfilment of women’s rights. It
Creating a supportive environment for maternal and newborn health
requires challenging the social, cultural and economic barriers that
perpetuate gender inequity.
enhances women’s influence in Convention on the Rights of the young daughters and sons due to
household decision-making and Child, it is linked to other rights strong social pressures at the com-
opens up opportunities for women’s and is recognized in the Universal munity level. Worldwide, more than
economic and political participation. Declaration of Human Rights as 60 million women aged 20–24 were
the “right to free and full consent married before they reached the age
Protection from abuse, to marriage” (article 16). The of 18.14 In the developing world
exploitation, discrimination Convention on the Elimination of excluding China, the latest interna-
and violence All Forms of Discrimination against tional estimates indicate that 36
Women states that “the betrothal per cent of women aged 20–24 were
Preventing child marriage and the marriage of a child shall married or in union before the age
have no legal effect” and calls upon of 18. In some regions, the incidence
Child marriage is a violation of child states to set legal minimum ages for of child marriage is particularly
rights, compromising the develop- marriage and to make marriage reg- high, at 49 per cent in South Asia,
ment of girls and often resulting in istration compulsory (article 16). and 44 per cent in West and Central
premature pregnancy and social Despite international commitment to Africa, according to the latest
isolation. Although child marriage change, many societies and commu- estimates.15
is not directly addressed in the nities continue the marriage of their
In addition to an increased risk of
Figure 2.3 maternal death from pregnancy and
childbirth, adolescent wives are also
Gender parity in attendance has improved markedly,
susceptible to violence, abuse and
but there are still slightly more girls than boys out of exploitation. Child marriage also
primary school increases the risk that adolescent girls
Male
will drop out of school – with atten-
West/Central Africa 12 14
dant negative implications for mater-
Eastern/Southern Africa 10 10 Female
nal and newborn health and for
South Asia 16 19
income-earning capacity, described
Middle East/North Africa 3 4
previously. This, in turn, contributes
East Asia/Pacific 2 3 to the vicious cycle of gender discrimi-
Latin America/Caribbean 2 2 nation, with poorer families being
CEE/CIS 1 1 more willing to permit the premature
Industrialized countries 2 1 marriage of daughters out of econom-
World 48 53 ic necessity.16
Sub-Saharan Africa* 22 24
Developing countries 47 52
Given the health risks associated with
adolescent pregnancy and birth (see
Least developed countries 21 22
page 32), the greater likelihood of ado-
0 10 20 30 40 50 60 70 80 90 100 110
Absolute number of primary-school-age children
lescent pregnancy for girl wives, and
out of primary school (millions), 2006 the high incidence of this practice
across several developing regions, it is
evident that improving maternal health
Source: Estimates derived by the Statistical Information Section, United Nations Children’s Fund, requires ending child marriage. This
using attendance data from household surveys (Demographic and Health Surveys and Multiple
Indicator Cluster Surveys) and UNESCO Institute of Statistics. will require, among other actions,
stronger government legislation to set foster an open dialogue to address have undergone this practice. Though
and enforce the age of 18 as the mini- and challenge the economic pressures the practice has declined, its preva-
mum legal age of marriage, and to and societal traditions that perpetu- lence is still strong in several coun-
promote both birth and marriage ate child marriage. tries and communities.17
registration; the former is required
to establish the age of the child. Abandoning female genital In addition to being a rights violation,
mutilation/cutting
female genital mutilation and cutting
While child marriage is becoming less Female genital mutilation and cutting pose serious risks for childbirth,
common overall, the pace of change violates girls’ and women’s human heightening the possibility of such
is slow. Challenging prevailing atti- rights, denying them their physical complications as obstructed labour
tudes towards child marriage will also and mental integrity, their right to and post-partum haemorrhage in con-
require addressing gender inequality. freedom from violence and discrimi- texts outside the hospital setting.
Action by parties other than govern- nation and, in the most extreme
ments is crucial, including religious cases, their lives. A study by the World Health
and community leaders, as is the pro- Organization showed that not only
motion of education, particularly at Around 70 million girls and women does female genital mutilation/cutting
the secondary level. For their part, aged 15–49 in 27 countries of Africa (FGM/C) affect the reproductive
civil society and the media can help and the Middle East are estimated to health of women and cause severe
Figure 2.4
Child marriage is highly prevalent in South Asia and sub-Saharan Africa
South Asia 49
East Asia/Pacific* 19
Latin America/Caribbean N/A
CEE/CIS 11
Sub-Saharan Africa** 40
Developing countries* 36
0 10 20 30 40 50 60
Percentage of women aged 20–24 years who were married or in union before they were 18 years old, 1998–2007
* Excludes China. ** Sub-Saharan Africa comprises the regions of Eastern/Southern Africa and West/Central Africa.
Source: Demographic and Health Surveys, Multiple Indicator Cluster Surveys and other national surveys.
Addressing the health worker shortage: A critical action for
improving maternal and newborn health
One of the biggest challenges for maternal and neonatal Organisation for Economic Co-operation and Development
health is the shortage of skilled health personnel. A 2006 countries was equivalent to 23 per cent of the doctors still
World Health Organization survey reveals that while Africa domestically employed in those countries.
accounts for more than 24 per cent of the global disease bur-
den, it has only 3 per cent of the world’s health workers and Demographic trends within countries are also strong influ-
spends less than 1 per cent of total global resources dedicat- ences on the health worker shortage. Rapid urbanization in
ed to health, even after loans and grants from abroad are developing countries is exacerbating the shortage of health
taken into account. In contrast, the Americas region, which workers in rural areas, as trained professionals seek work
covers Latin America and the Caribbean along with North in more affluent urban conurbations. Health workers, who
America, has only 10 per cent of the global burden of disease usually qualify in urban settings, are often reluctant to base
but commands 37 per cent of the world’s health workers and themselves in a rural location on the grounds that it involves
spends more than 50 per cent of global resources allocated greater hardship, more basic living conditions and less
to health. access to urban amenities and entertainment. One survey in
South and South-east Asia found, for example, that rural
According to the World Health Organization, the world is postings were shunned because of lower income, low pres-
facing a shortage of 4.3 million health workers, with every tige and social isolation.
region except Europe showing a shortfall. More specifically,
there are not enough skilled health workers – doctors, nurses AIDS, too, is having a deleterious effect on health systems
or midwives – to attend all the world's births. A study by the in the countries where it has reached epidemic proportions.
Joint Learning Initiative found that countries needed an aver- Health workers in these countries face the same risks in their
age of 2.28 health-care professionals per 1,000 people to private lives as other people in high-prevalence countries,
achieve the minimum desired level of coverage for skilled but are also exposed to significant risks at work in circum-
attendance at delivery. Of the 57 countries that fall below this stances where protective equipment and practices are often
threshold, 36 are in sub-Saharan Africa. Although the coun- deficient. A 2004 study in South Africa indicated that younger
tries with the largest shortages of health workers in absolute health workers there had an HIV-prevalence rate of 20 per
terms are found in Asia – notably in Bangladesh, India and cent. Such workers deserve much greater protection and
Indonesia – the largest relative need is in sub-Saharan Africa. care, including better supplies of protective equipment, safe-
This region would need to increase its numbers of health ty schemes to prevent needle-stick injuries, prophylaxis in
workers by 140 per cent to reach the requisite density. An the event of possible exposure to the virus, and antiretroviral
earlier WHO estimate calculated that 334,000 skilled birth treatment if they become infected with HIV.
attendants would need to be trained worldwide in the
coming years to cover 73 per cent of births. Establishing continua of quality health care to reduce mater-
nal and neonatal mortality and morbidity will require strate-
Shortages of skilled health workers arise from many factors, gies to reduce the shortfalls in health-care personnel. While
including underinvestment in training and recruitment, weak part of this gap will be filled by the recruitment and training
incentives for health-care workers, low remuneration and of community health workers – whose resourcefulness has
high levels of stress. Heavy migration of skilled health work- been shown to have great potential to provide basic services
ers from developing countries to industrialized nations – – much more needs to be done to train and retain skilled
spurred by the burgeoning demand for health workers in health-care workers, particularly in sub-Saharan Africa and
industrialized countries with ageing populations – has also South Asia.
taken its toll. A survey of 10 African countries showed that
the number of locally trained doctors now working in eight See References, page 108.
pain, it can also result in prolonged leads to an extra one to two perinatal Abandoning female genital mutila-
bleeding, infection, a variety of deaths per 100 deliveries.18 tion and cutting is critical to ensur-
reproductive health problems including safe motherhood and reducing
ing infertility, and even death. It also The risks to both mothers and neonatal deaths. Successful initia-
affects newborns of women who babies increase according to the tives in Senegal and other countries
have been subjected to the practice. severity of the mutilation, but can where female genital mutilation and
The study provides clear evidence include shock, haemorrhaging, cutting is widespread are based on
that complications in deliveries are infection and ulceration of the the collective abandonment of this
significantly more likely among genital area – all of which increase practice through community
women with FGM/C. It also found the risks of maternal and neonatal empowerment, open dialogue
that FGM/C is harmful to babies and mortality and distress.19 and a collective consensus.20
© UNICEF/HQ06-2778/Bruno Brioni
Enhancing health facilities and strengthening referral systems are effective ways of improving maternal and newborn health. A mother watches
as her infant is weighed by a health care worker at a maternal and child health centre, Côte d'Ivoire.
Eliminating violence, abuse and

women and girls and increased risk • Violence before or during pregnan-
exploitation of women and girls
of maternal mortality and morbidity. cy can lead to multiple health risks
Violence is prevalent in all societies. for the mother and child, including
It undermines the physical health • A study of 400 villages in rural miscarriage, preterm labour and
and emotional and psychological India revealed that 16 per cent of fetal distress. It can also prevent
well-being of its victims. Gender all deaths among pregnant women them from seeking medical care. A
inequities within households, work- were due to partner violence.22 study from Nicaragua has shown
places and societies can foster a that around 16 per cent of low
permissive context for violence. • Sexual violence, especially rape, birthweight in infants was related
can result in involuntary pregnan- to physical abuse of a partner
The extent of violence against cies, particularly when used as a during pregnancy.25
women and girls and its impact on weapon of war in such conflicts as
them has long been acknowledged. those in Bosnia and Herzegovina • There are also reproductive impli-
Until relatively recently, however, its and in Rwanda, when women cations of violence against women,
measurement was largely restricted to were raped repeatedly until they including chronic pain, genital
specific studies. Large-scale studies conceived.23 bruising and scarring, and un-
by the World Health Organization healthy weight loss.26
and the recent United Nations studies • Data suggest that involuntary preg-
on violence against women and chil- nancies carry a greater risk than • The psychological consequences of
dren have revealed astounding levels those that are wanted and that violence against women can also be
of violence against women and chil- women with unwanted pregnancies devastating: depression, stress and
dren, but also sharp disparities in lev- are less likely to receive early ante- anxiety disorders, post-traumatic
els within countries and regions.21 natal care or give birth under med- stress and suicide.27
The health consequences of violence ical supervision. Such pregnancies
increase the risk of poor physical and may also carry a greater risk of • Violence against mothers can create
reproductive outcomes. Although unsafe abortion – a significant difficulties for the care and feeding
many of the studies are indicative cause of maternal death – depres- of newborns. In addition, increasing
rather than conclusive, they show a sion, suicide and adverse family evidence suggests that infants and
correlation between violence against reactions to the pregnancy.24 young children are also at risk from
Combating violence against women and children is critical to improving
maternal and newborn health.
violence, and that deaths from phys- regions reported that they were not newborn health. When women are
ical violence are underestimated.28 fully involved in household able to participate in key decisions,
decision-making.29 studies have shown that they are
Combating violence and abuse more likely to ensure that their chil-
against women and girls is a multi- Enabling women to participate more dren are well nourished and to seek
faceted process that will require equally in the critical and routine appropriate medical care for them-
strong action from governments, civil decision-making processes that affect selves and their children.30
societies, international partners and their lives, and those of their chil-
communities to confront and address dren, is pivotal to creating a support- Enhancing women’s ability to parti-
both the direct and underlying causes ive environment for maternal and cipate in household decisions is only
and consequences. Comprehensive
mechanisms, covering legislation Figure 2.5
and its enforcement, research, pro- Female genital mutilation/cutting, though in decline,
grammes and budgets, increasing is still prevalent in many developing countries
women’s voices in the debate and
sustaining attention on the issue, Somalia 98
will be imperative to reduce violence Egypt 96
from its current level. Guinea 96

Sierra Leone 94
Djibouti 93
Participation in family, Eritrea 89
community, economic, social Sudan 89

Mali 85
and political life Gambia 78
Ethiopia 74
Discrimination on the basis of gen- Burkina Faso 73
der can prevent women – the pri- Mauritania 72
45
mary caregivers for children in all Chad
Guinea-Bissau 45
societies – from fully participating
Côte d’Ivoire 36
in the critical decisions and actions Kenya 32
taken in households and communi- Senegal 28
ties that can affect maternal and Central African Republic 26

Yemen 23
child health. This issue was exam-
Nigeria 19
ined extensively in The State of the United Republic of Tanzania 15
World’s Children 2007: The double Benin 13
dividend of gender equality, which Togo 6

Ghana 4
showed that in a number of coun-
Niger 2
tries across sub-Saharan Africa, Cameroon 1
South Asia and the Middle East and Uganda 1
North Africa, more than one third Zambia 1
of women surveyed said that their 0 20 40 60 80 100

husbands alone made the decisions Percentage of girls and women aged 15–49 who have been mutilated/cut, 2002–2007*
regarding their health care. A con-
siderable percentage of women sur- * Data refer to the most recent year available during the period specified.
veyed in 30 countries across six Source: Demographic and Health Surveys, Multiple Indicator Cluster Surveys and other national surveys.
Towards greater equity in health for mothers and newborns
by Cesar G. Victora, Professor of Epidemiology, Universidade Federal de Pelotas, Brazil
The issue of equity in health outcomes, and in access to mothers from the richest income quintile in that region. The
essential primary-health-care services, is receiving greater other developing regions exhibit similar disparities; even in
attention in the field of maternal, newborn and child health. Europe and Central Asia – where most countries with survey
This focus is increasingly supported by emerging evidence information are former socialist republics – the proportion of
and research on the extent of disparities in health and other deliveries attended by skilled health personnel is significantly
development areas. Inequities are defined as systematic lower for the poorest women than for the most affluent.
differences between population groups that are unfair and
avoidable, and generally include disparities related to Other measures of disparity in health-care provision are also
socio-economic position, gender, ethnic group and place pronounced. Urban mothers and children in developing coun-
of residence, among other factors. tries tend to have greater access to health care and better
health status than their rural counterparts. Socio-economic
Having a skilled attendant at delivery – a key intervention for inequities are similarly marked within urban areas, where
improving maternal and neonatal health and survival – is health conditions among slum dwellers are particularly
among the most inequitably distributed health interventions. adverse. Within countries, state and provincial differentials in
Figure 2.6 shows the average share of births attended by maternal and child health are also often wide, as exemplified
skilled health personnel, based on results from recent nation- by the sharp variations in health indicators between Brazil’s
al surveys of low- and middle-income countries. There are more prosperous southern states and its more impoverished
marked inequalities between the regions of the world, with north-eastern regions.
Europe and Central Asia showing the highest coverage levels
for all income groups, and sub-Saharan Africa and South Asia Poor mothers and children are underserved along the whole
in particular trailing well behind. continuum of care. Data from several sub-Saharan African
countries were used to document the proportion of mothers
In addition to variations between regions, within each region and children who received a package of four essential inter-
there are important disparities by socio-economic position – as ventions: antenatal care, skilled attendance at delivery, post-
observed by comparing skilled attendance at delivery across natal care and childhood immunization. Coverage with all
income quintiles. Among the poorest 20 per cent of South four interventions was two to six times higher – depending
Asian mothers, fewer than 10 per cent of births are delivered on the country – among the richest groups than it was in the
by a skilled attendant, compared to 56 per cent of births for poorest groups. This inequitable pattern of health-care
Figure 2.6
Mothers who received skilled attendance at delivery, by wealth quintile and region
Delivery attended by a medically trained person (%), 1991–2004
100 Europe and Central Asia*
Latin America and Caribbean*

80
East Asia and Pacific*
60 Middle East and North Africa*
Sub–Saharan Africa*
40
South Asia*
20
0
Poorest 2nd 3rd 4th Richest
Wealth quintiles
* See References on page 108.
Source: Gwatkin, D. R., et al., Socio-economic differences in health, nutrition, and population within developing countries: An overview, Health,
Nutrition and Population, World Bank, Washington, D.C., September 2007, pp. 123–124.
provision both reflects and entrenches the social exclusion sector. Figure 2.7 shows how implementation of the Accelerated
faced by the poorest and the most marginalized groups and Child Survival and Development (ACSD) strategy has reduced
helps explain why maternal, neonatal and child mortality show inequities in access to antenatal care in Mali. Whereas both
such marked socio-economic variations. ACSD and control districts showed marked social disparities
before the programme was deployed in 2001, five years later
Health systems have an important role in overcoming these access to antenatal care was significantly more equitable in dis-
disparities. Examples from across the developing world show tricts with ACSD than in the control areas. The ACSD strategy
that much can be, and is being, done to address and reduce relied heavily on outreach initiatives aimed at improving access
disparities in access to essential services. for rural mothers living in remote areas. This finding, however,
was not replicated in other ACSD countries where outreach
• In the United Republic of Tanzania, prioritizing interventions activities were not strongly implemented.
to combat diseases that affect poor mothers and children,
and allocating district health budgets preferentially to these The reduction of inequalities in health is essential for the full
conditions, led to marked reductions in mortality. achievement of human rights. Gaps in health-care provision
contribute to the generation of these inequalities; consequently,
• In Peru, the poorest departments (provinces) in the country health systems also play a role in their elimination. This is par-
are earmarked as the first to receive new vaccines; only after ticularly true because the greatest gains in maternal, neonatal
high coverage levels are reached in these districts are vac- and child survival depend on effectively reaching the poorest
cines rolled out to the rest of the country. and the most marginalized, who suffer the greatest burden of
disease. There are many examples of successful initiatives that,
• In Bangladesh, the Integrated Management of Childhood when implemented with sufficient political support and ade-
Illness (IMCI) strategy was systematically deployed in the quate resources, have led to substantial reductions in health
poorest areas of the country; a similar strategy is employed inequities. The main challenge for countries and societies is to
by Brazil’s Family Health Programme. disseminate these success stories, adopt best practices, and
generate and sustain the political will to put equity at the top of
Because the poor are more likely to live in rural and remote the health agenda.
areas, use of appropriate channels for reaching them with
essential services should be a primary concern of the health See References, page 108.
Figure 2.7
Women in Mali receiving three or more antenatal care visits, before and after the
implementation of the Accelerated Child Survival and Development (ACSD) initiative
80
ACSD districts (2006,

Women receiving 3 or more antenatal visits (%)
70
post-implementation)
Control group
60 (2006)
ACSD (2001,
50 pre-implementation)
Control group
40 (2001)
30
20
10
0
Poorest 2nd 3rd 4th Richest
Wealth quintiles
Source: Johns Hopkins University 2008.
Figure 2.8 part of the solution. Evidence from
Many women in developing countries have no say in Demographic and Health Surveys
indicates that much of women’s
their own health-care needs
decision-making power is exerted
Mali 75
at the community level.31 When
women are empowered to participate
Burkina Faso 74
in their communities, they can chal-
Nigeria 73
lenge the attitudes and practices
Malawi 71
that entrench gender discrimination,
Benin 61 share work, pool resources and col-
Cameroon 58 lectively devise and sustain initiatives
Nepal 51 to improve maternal and newborn
Bangladesh 48 health. It is the acumen of women
Rwanda 48 acting collectively that is among the
Zambia 47 strongest reasons why most newborns
Kenya 43
and mothers survive pregnancy and
Egypt
childbirth.
41
United Rep.
of Tanzania 39
Increasing women’s participation in
Uganda 38
key decision-making processes in
Ghana 35
employment and political life is also
Morocco 33 critical to improving maternal and
Mozambique 32 newborn outcomes. Improving
Zimbabwe 32 economic status can be vital to
Haiti 21 enhancing women’s participation
Armenia 20 in decision-making, with attendant
Peru 16 implications for the health of their
Indonesia 13
children. When women have greater
Madagascar
influence in the management of
12
household decisions, they are more
Jordan 12
likely than men to ensure that chil-
Nicaragua 11
dren eat well and receive medical
Bolivia 10
care.32 Owning assets can also enhance
Turkmenistan 9 women’s influence in household
Eritrea 9 decision-making; a study in rural
Colombia 9 Bangladesh showed that women who
Philippines 5 have a greater share of assets than
0 10 20 30 40 50 60 70 80
their husbands before their own
wedding have a stronger influence
Percentage of women who say their husbands alone made the decisions regarding their health care, 2000–2004*
on household decision-making.33
* Data refer to the most recent year available during the period specified.
Source: UNICEF calculations based on data derived from Demographic and Health Surveys.
Despite some progress at increasing
their representation in national legisla-
Encouraging women to participate more fully in decision-making is
key to creating a supportive environment for mothers and newborns.
tures, women still accounted for less fits of women’s participation go well best possible care during pregnancy
than 19 per cent of parliamentarians beyond their impact on health out- and delivery and will safeguard the
worldwide as of May 2008.34 comes. They enable communities and health of their babies.
According to United Cities and Local societies to focus attention on the criti-
Governments, an organization that cal issues that affect two thirds of their Cooperation between women at
has been publishing data on women citizens – women and children – and a local level is often a vital encour-
in local decision-making since 2003, to arrive at decisions from a richer agement for women’s empowerment.
they are also underrepresented in base of influences and considerations. Informal women’s groups generally
municipal governments, accounting gather for a practical purpose, such
for just 9 per cent of mayors in 60 Empowering women and girls as organizing a vegetable garden
countries surveyed and 21 per cent to provide a source of income inde-
of local councillors in 67 countries There is a considerable body of pendent of their husbands – though
surveyed.35 Given their limited, and evidence testifying to the multiplier the sense of solidarity and the prob-
relatively recent, engagement in par- effects of investing in gender equal- lems shared in such groups can add
liamentary politics, the influence of ity and women’s empowerment. to the sense of empowerment and
women parliamentarians in determin- Targeted investments in the edu- to the demand for better maternal,
ing maternal and newborn health out- cation, reproductive health, and neonatal and child health services.
comes is still unclear. The evidence economic and political rights of
suggests, however, that women parlia- women can bring about progress Involving men and
mentarians are likely to strongly sup- in poverty reduction, sustainable adolescent boys in
port and promote measures to assist development and peace. maternal and newborn
women and children – prioritizing ini- health and care
tiatives to provide improved child The focus on wider economic
care and strengthen women’s rights.36 and social benefits in international Men are often conspicuously absent
reports is understandable – they from reports advocating gender
Women’s groups can also make a dif- are often making a case for invest- equality – except in so far as they
ference at the local level. In 2004, ment that competes with other represent the problem. They may
the advocacy by women’s rights development priorities for limited appear in the guise of abusers or
activists persuaded the Government funds. But it is easy to lose sight domestic tyrants, as wasters frittering
of Morocco to support a landmark of the benefits of women’s empower- away precious family income on
family law countering gender ment in and of itself. Women who inessentials or as irresponsible sexual
inequality and protecting children’s are empowered are more able to partners taking no responsibility for
rights. In the same year, women’s take control of their own lives, act contraception.
groups in Mozambique successfully as change agents in their communi-
campaigned to raise the legal age of ties and actively pursue the best In the field of maternal and newborn
marriage by two years to 16 with interests of their children and fami- health, men are generally missing
parental consent and to 18 without.37 lies. This may take the form of from the literature. The hundreds of
ensuring that income entering the millions of fathers and partners who
Empowering women to participate household is spent on the things are actively involved in seeking the
more fully in household decisions, the that matter most, such as nutritious best possible maternity care and who
economy and political life is key to food, education and health care. take full parental responsibility for
creating a supportive environment for It may also mean demanding the their children’s well-being could be
mothers and newborns. But the bene- services that will afford women the forgiven for feeling disregarded.
Focus On Adapting maternity services to the cultures of rural Peru
Peru, a lower-middle-income country where 73 per cent of the • Fostering family and community support to make maternity
population lives in urban areas, has made enormous progress and the mother’s condition a priority.
in reducing child deaths from 1 in every 6 children in 1970 to
1 in 50 by 2006. Between 1990 and 2007, the country’s under- • Increasing access to the lntegral Health Service, which
five mortality rate dropped by 74 per cent – the fastest rate of covers the cost of antenatal, intrapartum and post-partum
decline in the entire Latin American and Caribbean region for care for poor families.
that period. It has had less success, however, in the area of
maternal health. Its maternal mortality ratio, estimated at 240 • Adapting maternity services to eliminate barriers between
maternal deaths per 100,000 live births in 2005, is among the the staff at health facilities and mothers who have deeply
highest in the region. Moreover, Peruvian women face a life- rooted cultural traditions for childbirth.
time risk of maternal mortality estimated in 2005 at 1 in 140,
twice the regional average of 1 in 280. The maternal waiting houses, dubbed ‘Mamawasi’, are con-
structed to encourage women in rural areas to choose the
The country’s relative lack of progress in reducing maternal option of giving birth in health centres instead of at home.
deaths has resulted in its inclusion on the expanded list of Currently, there are almost 400 houses located on grounds
priority countries for the Countdown to 2015 initiative, whose belonging to health centres or hospitals; others are in rented
criteria have now been broadened to include maternal mor- buildings in the regions of Apurímac, Ayacucho and Cuzco.
tality thresholds in addition to those for child mortality set Pregnant women from near and distant communities can
out in 2005. According to the Ministry of Health, women in stay in the waiting rooms until they deliver. Women from
rural areas are twice as likely as those in urban areas to die remote villages may stay for weeks or months. The
from causes related to pregnancy. A skilled attendant was Mamawasi is designed to resemble a typical indigenous
present at just 20 per cent of deliveries in rural communities family home in a farming village. Expectant mothers are
in 2000, compared to 69 per cent in urban areas. allowed to bring family members with them to the houses,
which increases their confidence and comfort level in
Like other Latin American and Caribbean countries, Peru’s using the service.
challenge for improving maternal and newborn health – and
greatest potential for progress – is to address disparities Health centres have also changed their practices. For
due to ethnicity, geography and extreme poverty. This will instance, the vertical birth position is accommodated, a
require delivering quality services to women and infants in family member or traditional midwife is allowed to accompa-
or near their places of residence and providing integrated ny women during birth, and the centres are kept at a warmer
routine and emergency maternity and newborn care. temperature.
Part of the challenge is to adapt current health services, often This programme has transformed everyday health services
facility-based or outreach, to the customs of the communities by promoting cultural sensitivity in health care. Huancarani
currently underserved by the health system. For example, district, located in the Andean province of Paucartambo, in
following tradition and cultural practice, rural women may the Cuzco region, has been the most successful in imple-
prefer to give birth at home in an upright position, under the menting the new strategy. Overall, almost 3 out of every 4
guidance of traditional birth attendants, rather than in a health pregnant women now visit health-care centres in the regions
centre delivery room. Moreover, even if these mothers did served, especially for childbirth, whereas previously the ratio
decide to seek formal care, distance to a health facility, cost was 1 in 4. The programme has been integrated into district
of services, language barriers and other impediments might and provincial health policies and was adopted in 2004 by
deter them. the Ministry of Health as a national standard to be imple-
mented throughout the country. The Ministry of Health has
Ensuring that mothers have the option of delivering in their also created training modules to teach health personnel how
homes, with the assistance of skilled birth attendants and a to make services culturally appropriate.
strong referral system to emergency obstetric care, if it is
needed, may be an appropriate way to integrate formal See References, page 108.
health services with traditional practices. Towards this end,
the Ministry of Health, in conjunction with UNICEF Peru, has
developed a maternal health project that includes four key
strategies:
• Establishing maternal waiting houses to resolve the difficul-

ty posed by geographic distance from health services.
Focus On Southern Sudan: After the peace, a new battle
against maternal mortality
After 21 years of conflict, civil war between the north and ment and supplies, poor referral systems and inadequate
south of the Sudan came to an end in 2005. While the physical infrastructure and transportation also impede
fighting has mostly ceased, Southern Sudan is facing health-care delivery. Post-natal care services are virtually
another struggle – against maternal and neonatal mortali- non-existent, despite the fact that most of the maternal
ty. According to the 2006 Sudan Household Health and newborn deaths in Southern Sudan occur during the
Survey, the maternal mortality ratio for Western Equatoria, post-natal period.
a province in Southern Sudan, stood at 2,327 deaths per
100,000 live births, one of the highest in the world. The Against this background, the Government of Southern
2006 neonatal mortality rate was 51 deaths per 1,000 live Sudan and its partners are making efforts to strengthen
births, significantly above the Sudan’s national ratio of maternal health services. The Interim Health Policy for
41 per 1,000 live births. 2006–2011 outlines an integrated approach that recog-
nizes the need to improve health services while protecting
Overall health-care coverage, mostly managed through a women's rights. The Ministry of Health has committed to
small number of non-governmental organizations, is esti- establishing more primary, reproductive and maternal
mated at just 25 per cent. Even when health care is avail- health facilities, while supporting the use of mass media
able, maternal health services are limited and not often and counselling services to disseminate information on
used. Part of the reason may be a lack of education. The nutrition, harmful traditional practices and sexual health.
United Nations Population Fund (UNFPA) estimates that in To meet immediate health-care needs, community
2006 the literacy rate for Southern Sudanese women was midwives who hold basic qualifications are being ‘fast-
just 12 per cent, compared to 37 per cent for men; women tracked’, with support from UNFPA. In June 2006, the first
therefore have limited access to health information. fistula repair centre in Southern Sudan was established at
the Juba Teaching Hospital.
Another possible reason is that pregnant women must
travel long distances on foot to reach antenatal centres; To accelerate implementation of this strategy, the
consequently, attendance rates vary sharply depending on Government has already established a Reproductive
location, from 17.4 per cent in Unity State in 2006 to nearly Health Directorate and is recruiting state coordinators to
80 per cent in Western Equatoria. Fewer than 15 per cent facilitate, monitor and coordinate maternal and neonatal
of births in Southern Sudan are attended by skilled health health activities in each state. UNICEF is supporting the
personnel, and 80 per cent take place at home under the expansion of antenatal and emergency obstetric services
supervision of relatives, traditional birth attendants or vil- in several states and the dissemination of key health mes-
lage midwives (a female birth attendant who has typically sages over the radio and through community outreach.
received around nine months of training). Yet most of the
causes of maternal death – including prolonged obstructed There are challenges ahead. The return of refugees and
labour, haemorrhage, sepsis and eclampsia – could be the movements of many displaced populations, Southern
managed by better-trained attendants. Sudan’s high fertility rate (6.7) and increasing rates of HIV
infection among some populations necessitate a system-
The quality of available antenatal and delivery services is atic health programme. The struggle may be a long one,
low due to a lack of technically skilled service providers. but those committed to winning it are already at work.
In all 10 states of Southern Sudan, midwives, traditional
birth attendants and other maternal and neonatal care See References, page 108.
providers lack the necessary training required to perform
simple lifesaving or nursing procedures. Lack of equip-
The other side of the coin is that in Evidence has shown that men the sexes and encouraging a more
removing men from the picture, they are more likely to be engaged, equal division of childcare duties.
may somehow be let off the hook, participatory fathers when they In addition, workplaces need to
validated in their lack of responsibili- feel positive about themselves recognize the role played by both
ty for this most essential aspect of and their relationships, and parents in child rearing, so that
family life. when families and friends sup- men as well as women are encour-
port their involvement in their aged to reconcile their work and
The birth of a child, particularly children’s lives. A man who family responsibilities.
a first child, is often a landmark shares the responsibility for
moment in a man’s life. It can parenthood is also more likely Linking the supportive
crystallize his sense of himself as a to share the household decision- environment to the
caring, responsible human being on making with his female partner, continuum of care
whom other people depend. More thereby contributing to her own
generally, involving men in the care empowerment.38 Creating a supportive environment
of their pregnant partners and for maternal and neonatal health
newborn children can be a signifi- Programmes that encourage the will provide a strong foundation
cant opportunity to establish participation of both men and for upscaling essential interventions
a positive, supportive relation- women can help this process by within a dynamic continuum of care,
ship that will last a lifetime. increasing communication between which is the focus of Chapter 3.
3 The continuum of care across time

and location: Risks and opportunities
An effective continuum of care delivers essential services for mothers and children at critical points in
adolescence, pre-pregnancy, pregnancy, birth, post-natal and neonatal periods and at key locations of
the household and community, through outreach/outpatient interventions and in health facilities where
they can be readily accessed by women and children. Community partnerships in health are essential
components of a continuum of care. Perhaps most vital to reducing maternal and newborn mortality,
however, are quality antenatal care, skilled health personnel attending deliveries and post-natal care for
mothers and newborns. Ensuring that emergency obstetric and newborn care is available to address
birth complications could save many lives currently lost during childbirth and the early neonatal period.
The third chapter of The State of the World’s Children 2009 examines the key services underpinning the
continuum of care and how these interventions can be expanded and improved.
The continuum of care: Chapter 3 outlines the essential Subsequently, a new MDG frame-
Delivering services at services required to support a con- work was adopted and the revised
critical points tinuum of maternal and neonatal goals of January 2008 include a
At every stage of life, from childbirth care, including enhanced nutrition; reproductive health target (see Panel,
to old age, there are pressing health safe water, sanitation and hygiene page 20, for details of the new
demands. The services that aim to facilities and practices; disease target and indicators).
respond to the interrelated health prevention and treatment; quality
needs of mothers and newborns reproductive health services; The new target reflects, in part,
require high levels of continuity adequate antenatal care; skilled a growing consensus on the need
and integration – characteristics assistance at delivery; basic and to improve reproductive health.
that have not always been evident comprehensive emergency obstetric Another goal is to curb the growing
in national and international health and newborn care; post-natal incidence of reproductive tract and
policies, programmes and partner- care; neonatal care; and Integrated sexually transmitted infections,
ships seeking to improve maternal Management of Neonatal and including HIV. The World Health
and newborn health. Childhood Illness. Organization (WHO) has identified
unsafe sex as the second most
The continuum of care framework This chapter also briefly examines important risk factor for death and
aims to transcend the traditional the points of delivery for health serv- disability in the poorest countries
emphasis on single, disease-specific ices: at the household and communi- and the ninth most important in
interventions. It advocates a model ty level, outreach and outpatient developed countries.2 Almost half
of primary health care that embraces services, and facility-based care. of all new HIV infections occur in
every stage of maternal, newborn young people, particularly women,
and child health. The success of Quality reproductive health with around double the number of
services
this framework, however, depends women as men infected with HIV in
on delivering essential services and While targets for reproductive health sub-Saharan Africa.3
implementing improved practices were not initially included in the
at key points in the life cycle, link- Millennium Development Goals Building reproductive health capaci-
ing mothers, newborns and their (MDGs), at the World Summit in ty at the national level will necessi-
households and communities with September 2005 the decision was tate identifying problems, setting
quality basic health care and mater- taken to achieve universal access to priorities and formulating strategies
nity services.1 reproductive health by 2015. with the participation of all stake-
Adequate nutrition for women, including increased food intake and
micronutrient supplementation, is critical to the health and survival
of mothers and newborns.
holders. WHO has identified five 18.5 kg/m2) for pregnant women to strengthen the nutritional status of
key priorities for action on repro- increases the risk of both maternal pregnant women and mothers.
ductive health-care services. These and neonatal mortality; the same
include strengthening health systems applies if a mother is stunted. Low Folic acid supplementation to prevent
capacity; improving information body mass can restrict the growth neural tube defects has proved suc-
for setting priorities; mobilizing of the fetus, which is a risk factor cessful, and in general, antenatal
political will; creating supportive for neonatal conditions such as programmes should also offer other
legislative and regulatory frame- low birthweight.5 micronutrients, such as zinc. There are
works; and strengthening monitor- proven links between zinc deficiency
ing, evaluation and accountability.4 Programmes targeted towards improv- and stunting, diarrhoea and malaria.6
ing maternal health are increasingly
Enhancing nutrition for mothers focusing on enhancing the nutrition of Gaining the confidence of pregnant
and newborns
girls and women across the life cycle. women through such programmes
Adequate nutrition for adolescent Along with increased food intake, of micronutrient supplementation
girls and pregnant women is criti- folic acid and iron supplementation can be a useful way to encourage
cal for the health and survival are being encouraged during pre- their continued attendance for other
prospects of both mothers and pregnancy and pregnancy, and vitamin forms of professional antenatal
newborns. The undernutrition of A supplementation during the post- care. Increased use of clinics and
young mothers increases the health partum period. In addition, dietary hospitals will also help in collecting
risks for both them and their babies. diversification, the use of iodized salt data on the health of pregnant
A low body mass index (less than and deworming are key interventions women and mothers, which is
More skilled health work-

© UNICEF/DJBA00265/Giacomo Pirozzi
ers are needed to provide

vital services to women
at critical points during
pregnancy. A pregnant
woman lies on a table
as a nurse performs an
antenatal consultation
at the Engueila Health
Centre, Djibouti.
T H E C O N T I N U U M O F C A R E A C R O S S T I M E A N D L O C AT I O N : R I S K S A N D O P P O RT U N I T I E S 47
Reducing the incidence of infectious conditions and preventing
and treating HIV and malaria are vital to improving maternal and
newborn health.
particularly scarce in the least transmitted infections, and preventing the 17 countries with sufficient data,
developed regions and poorest and treating HIV and malaria, are HIV prevalence rates among pregnant
countries and communities. therefore critical to improving mater- women aged 15–24 have declined
nal and newborn health (see Panel on since 2000/2001.7 This positive devel-
Addressing infectious diseases, Eliminating maternal and neonatal opment is encouraging, but much
HIV and malaria
tetanus, page 49). more needs to be done to boost HIV
As Chapter 1 underscored, severe prevention activities and to address
infections are among the leading Preventing HIV infection in women the social, economic and political
direct causes of maternal and neo- of childbearing age and treating drivers of the AIDS epidemic.
natal deaths. They accounted for infected pregnant women with avail-
roughly 36 per cent of neonatal able drug combinations can greatly In line with the new MDG focus on
deaths in 2000, the latest year for reduce the transmission of the virus reproductive health, programmes
which firm estimates of cause of death to children. Raising levels of compre- aimed at improving maternal survival
are available. Reducing the incidence hensive knowledge of HIV among should include interventions to help
of infectious conditions such as sep- young women and men aged 15–24 is reduce the incidence of, and treat,
sis/pneumonia, tetanus and sexually vital to averting infection. In 14 of sexually transmitted infections.
Figure 3.1 The distribution of insecticide-

Protection against neonatal tetanus treated mosquito nets to pregnant
women in malaria-endemic areas
West/Central Africa 71 can reduce the incidence of malaria
infection, improving the health of
both the pregnant woman and her
South Asia 85
unborn child. Intermittent preven-
tive treatment of malaria during
Middle East/North Africa 77 pregnancy is being used to both
prevent and treat the disease. It
East Asia/Pacific N/A
consists of administering a single
Latin America/Caribbean 83 dose of a combined antimalarial
medicine at least twice during preg-
CEE/CIS N/A
nancy whether the pregnant woman
has the disease or not. Although
considered efficacious, coverage
World 81 of this treatment remains limited
in malaria-endemic areas.8
Expanding antenatal care

Much ill health among pregnant
women is preventable, detectable or
0 10 20 30 40 50 60 70 80 90 treatable through antenatal visits.
Percentage of pregnant women vaccinated against tetanus, 2007
Antenatal care provides an opportu-
* Sub-Saharan Africa comprises the regions of Eastern/Southern Africa and West/Central Africa. nity to reach pregnant women with
Source: UNICEF and the World Health Organization. multiple interventions that could be
Eliminating maternal and neonatal tetanus
Tetanus remains a significant cause of maternal and neonatal between 1999 and 2005. The results have been impressive at
deaths, taking the lives of more than 180,000 newborns and the country level:
between 15,000 and 30,000 mothers in 2002. The condition
develops when a bacterium, Clostridium tetani, infects a cut • In Nepal, before immunization started in the early 1980s,
or wound. Unclean delivery or abortion practices can result surveys showed high rates of neonatal tetanus among new-
in maternal tetanus, while neonatal tetanus is caused by the borns. After the introduction of immunization of adult
unhygienic care of the umbilical cord or umbilical stump in women and the implementation of the high-risk approach,
babies. In the absence of intensive hospital care, neonatal the rate had fallen by 2005 to less than 1 death from neona-
tetanus is nearly always fatal. As with other causes of mater- tal tetanus per 1,000 live births in every district.
nal and neonatal deaths, most of the fatalities from tetanus
take place in sub-Saharan Africa and Asia, especially in poor • A survey conducted in Egypt in 1986 indicated that
and marginalized communities where women have limited or for every 1,000 children born, 7 would die of neonatal
no access to quality health care and little knowledge of safe tetanus, with rates of 10 per 1,000 live births in rural areas.
delivery practices. Following implementation of the high-risk approach, by 2007,
the rate was brought down to less than 1 death per 1,000 live
Tetanus is readily preventable through the vaccination births in all districts.
of adult women and through hygienic delivery practices.
Increasing implementation of both measures, particularly • In the mid-1980s, Bangladesh had a high rate of neonatal
immunization of pregnant women, has significantly tetanus, which stood at 20–40 cases for every 1,000 live
reduced the number of cases and deaths from maternal births in some parts of the country. At that time, only 5 per
and neonatal tetanus since 1980, the earliest year for which cent of women of childbearing age were immunized with
comprehensive data are available. In 1988, tetanus was tetanus toxoid and only 5 per cent of pregnant women
responsible for causing around 800,000 neonatal deaths, were able to have a clean delivery. Adoption of the high-
and more than 90 countries reported one or more cases of risk approach helped Bangladesh reduce its mortality from
neonatal tetanus per 1,000 live births at the district level. neonatal tetanus to less than 1 death per 1,000 live births
By mid-2008, the number of countries reporting one or by 2008.
more cases of maternal and neonatal tetanus at the district
level had dropped to 46. Some places have used the high-risk approach to deliver
other interventions alongside tetanus toxoid vaccine, includ-
Immunization has been among the most significant countering measles vaccine (e.g., Kenya, Southern Sudan) and vita-
actions against maternal and neonatal tetanus. Tetanus tox- min A (e.g., Democratic Republic of the Congo). Others, such
oid has proved efficacious against the disease, with two as Ethiopia, Uganda and Zambia, have incorporated the
doses providing protective concentrations of antitoxins in the approach in mechanisms for delivering packages of essential
majority of cases, and almost 100 per cent immunity after the interventions. A key benefit of the high-risk approach is that,
third dose. The global rate of vaccination against neonatal in addition to reducing neonatal tetanus, it diminishes
tetanus for pregnant women has risen sharply since 1980, inequities in access to maternal and neonatal health care
when it stood at just 9 per cent, to 81 per cent in 2007. within countries and shows that it is possible to deliver
Nonetheless, this still leaves almost 1 in every 5 newborns health interventions to populations that have often been for-
without protection. In part, this is due to missed opportuni- gotten or omitted.
ties for vaccinating pregnant women who visit facilities to
receive antenatal services, to women arriving too late for See References, page 109.
immunization, or to the failure to provide post-partum immu-
nization to protect future pregnancies.
Those at risk of tetanus live in communities that have little

access to health and immunization services. To reach them,
an innovative solution – dubbed the ‘high-risk approach‘ –
was initiated. This approach aims to immunize all women of
childbearing age living in areas deemed to be high risk with
at least two doses of tetanus toxoid (TT) vaccine. The risk
factors for tetanus, which include unhygienic delivery prac-
tices and lack of immunization, are explained to the commu-
nities. Improvements in delivery practices are promoted, and
surveillance for neonatal tetanus is strengthened. Booster
shots are provided to women with no recorded history of
receiving tetanus toxoid vaccine when they were children.
The high-risk approach has been widely adopted, enabling 64

million women to receive at least two doses of tetanus toxoid
Antenatal care provides an opportunity to reach pregnant women
with multiple interventions, such as immunization, micronutrient
supplementation and improved hygiene practices.
vital to their well-being and that of ing measures to detect and treat In the developing world as a whole,
their babies. Nutritional supplements malaria and anaemia; tetanus three quarters of pregnant women
for protein, folic acid and iron pro- immunization; management of sexu- receive antenatal care from a skilled
vided by skilled health workers or ally transmitted infections and anti- health provider at least once, though
community health workers can have retroviral therapy for HIV-positive the household surveys that record
beneficial effects, reducing the likeli- pregnant women; and provision this data give no indication of the
hood of undernutrition and anaemia of vital information to pregnant quality of the care or the informa-
in the mother and low birthweight in women on risks in pregnancy and tion conveyed.
the newborn. delivery. Owing to data limitations,
and the fact that many countries are In three regions – Latin America and
The minimum number of antenatal delivering far below the UN inter- the Caribbean, Central and Eastern
care visits during pregnancy recom- agency minimum recommendation, Europe and the Commonwealth of
mended by UNICEF and WHO is most of the data relate to women Independent States, and East Asia and
four. These visits help provide key who have received at least one the Pacific – around 9 out of every
services to pregnant women, includ- antenatal visit.9 10 pregnant women receive antenatal
visits one or more times. These per-
Figure 3.2 centages are far lower in the Middle
Antiretroviral prophylaxis for HIV-positive mothers to East and North Africa, sub-Saharan
prevent mother-to-child transmission of HIV Africa (both 72 per cent) and South
Asia (68 per cent).
West/Central Africa
Even at the relatively low coverage
11
rates in these regions, however, ante-
natal care represents a significant
opportunity to reach a large propor-
tion of pregnant women with essen-
South Asia 13 tial interventions.10
Packaging essential interventions,

including those for which there is
already a strong interest — such as
Latin America/Caribbean 36 insecticide-treated mosquito nets —
has the potential to strengthen demand
CEE/CIS 71
for, and use of, antenatal services. It
may also encourage women to attend
clinics and outreach events for antena-
Low- and middle-income
33
countries tal care earlier in their pregnancies.
0 10 20 30 40 50 60 70 80 90
Ensuring skilled attendance
Estimated percentage of HIV-positive pregnant women who received antiretrovirals for prevention at delivery
of mother-to-child transmission of HIV, 2007
Childbirth can be a time of risk not

Source: UNICEF, UNAIDS and WHO, Towards Universal Access: Scaling up HIV services for women and children in
the health sector – Progress Report 2008, UNICEF, New York, 2008, p.43. only for the baby but also for the
In the least developed countries, 1 in 3 women do not receive any antenatal
care during pregnancy, and 3 in 5 women deliver their babies without the
assistance of a skilled health worker.
Figure 3.3
Antenatal care coverage
Antenatal visits from
West/Central Africa 71 skilled health personnel
44
during pregnancy:
40
At least four times
South Asia 68
34
At least once
N/A
66**
83
CEE/CIS 90
N/A
World 77
47
42
46**
32
0 10 20 30 40 50 60 70 80 90 100
Percentage of women aged 15–49 receiving antenatal care during pregnancy, 2000–2007
* Sub-Saharan Africa comprises the regions of Eastern/Southern Africa and West/Central Africa. ** Excludes China.
Source: Demographic and Health Surveys, Multiple Indicator Cluster Surveys and other national household surveys.
mother. Three quarters of all mater- complications, they should also rec- Saharan Africa. In the 2000–2007
nal deaths occur from complications ognize when serious complications period, skilled health workers attend-
either during delivery or in the imme- arise that require more specialized ed 61 per cent of the total number of
diate post-partum period. These com- emergency care. Even skilled health births in the developing world. The
plications include: haemorrhage (25 workers, however, require access to improvement has been particularly
per cent of maternal deaths); infections essential drugs, supplies and equip- striking in the Middle East and
(15 per cent); complications of abor- ment to provide adequate care – par- North Africa, which increased its
tion (13 per cent); eclampsia or related ticularly when complications such as coverage from 55 per cent in 1995
hypertensive disorders (12 per cent); haemorrhage, sepsis and obstructed to 81 per cent in 2000–2007. The
and obstructed labour (8 per cent).11 labour occur. They also require the two regions with the lowest levels
skills and judgement to recognize of skilled birth attendance – sub-
Reducing maternal deaths from birth serious complications and to manage Saharan Africa (45 per cent) and
complications is possible through an effective referral. South Asia (41 per cent) – are also
increasing the number of births the regions with the highest incidence
attended by a skilled health worker – There has been a marked increase of maternal mortality.12
a doctor, nurse or trained midwife. in the number of deliveries attended
Trained health personnel should not by skilled personnel across the devel- A quarter of the world’s unattended
only be able to assist with a normal oping world over the last decade, deliveries take place in India, which
delivery or a delivery with moderate with the notable exception of sub- is also one of the 10 countries that
With three quarters of all maternal deaths occuring during childbirth or
the immediate post-partum period, having skilled health personnel attend
deliveries is pivotal to reducing maternal mortality.
together account for two thirds of holds are around half as likely to management of the third stage of
births not attended by skilled health be attended by skilled health work- labour, which follows the completed
workers. India is currently seeking to ers as those from the richest house- delivery of the newborn child and
address the problem by encourging holds.14 (For a fuller discussion of lasts until the completed delivery of
facility-based care with financial disparities in access to maternity the placenta. Active management
incentives13 (see Panel on Integrating services, see Panel on page 38, involves administering a uterotonic
maternal and newborn health care in Towards greater equity in health to facilitate contractions for delivery
India, page 84). for mothers and newborns.) of the placenta and delayed clamp-
ing, cutting and traction of the
Worldwide, births in urban areas WHO has made several recommen- umbilical cord.
are twice as likely to be attended by dations for reducing post-partum
skilled health personnel as those in bleeding or haemorrhage, a leading WHO recommends active manage-
rural areas. In West and Central cause of maternal death. The most ment by skilled attendants for all
Africa, where the disparity is great- common causes of post-partum mothers but does not recommend the
est, they are two and a half times as bleeding are failure of the uterus to package for unskilled attendants. The
likely. Disparities along economic contract sufficiently, tears of the gen- agency has called for further research
lines are also notable; for the devel- ital tract and retention of the placen- on optimal times for cord clamping
oping world as a whole, deliveries tal tissue. The most widely accepted and what drugs, if any, non-skilled
of women from the poorest house- method of intervention is active attendants should administer.
Figure 3.4
Delivery care coverage
46 Institutional**
deliveries
40 Skilled attendant***
35 at birth
South Asia 41

81
87
86
Latin America/Caribbean
85
89
CEE/CIS 94
54
World 62
45
61

39
0 20 40 60 80 100
Percentage, 2000–2007
** Institutional deliveries refers to the proportion of women aged 15–49 years who gave birth in the two years preceding the survey and delivered in a health facility.
*** Skilled attendant at birth refers to the percentage of births attended by skilled health personnel (doctors, nurses and midwives).
Source: Demographic and Health Surveys, Multiple Indicator Cluster Surveys, World Health Organization and UNICEF.
Addressing disparities will be critical to improving maternal health.
Women from the poorest quintile of households are only half as likely to
be attended by skilled health workers as those from the richest households.
Hypertensive disorders: Common yet complex

Hypertensive disorders are the most common medical prob- both industrialized and developing countries, and follow-up
lems in pregnancy and account for a significant proportion – studies have produced strong evidence that magnesium
between 12 and 20 per cent – of maternal deaths worldwide. sulfate given to women in the pre-eclampsia stage can
They affect women in every region, causing nearly 10 per reduce their risk of progression to eclampsia. Subsequent
cent of maternal deaths in Africa and Asia, over 16 per cent in studies have strengthened the evidence base for this critical
industrialized countries, and more than one quarter in Latin and cost-effective intervention.
America and the Caribbean. Hypertension in pregnancy can
result in a range of conditions, from elevated blood pressure, Ideally, care should begin before conception, so that a repro-
the least severe, to cerebral haemorrhage, which is fatal. It ductive woman’s medical history can be tracked and her
can result in fetal death, preterm delivery and low birthweight options for managing chronic hypertension known.
in newborns. Hypertensive women also need information about their risks
in pregnancy and changes in their lifestyle that illness may
The causes of hypertension are still not fully understood, but require. Bed rest is a common recommendation for hyperten-
research suggests that obesity, high salt intake and genetic sive pregnant women. Regular examinations by skilled health
predisposition are factors. Some forms of hypertension in personnel are required to monitor the onset and development
pregnancy may arise from the biology of pregnancy itself. Pre- of pre-eclampsia and other hypertensive conditions.
eclampsia, which develops after the first 20 weeks of pregnan-
cy, is defined as pregnancy-induced hypertension accompa- Hypertension in pregnancy has long been understood as an
nied by excess protein in the urine, and brings the greatest obstetric condition, with interventions focusing mostly on
risk to maternal and fetal health, particularly when it accompa- outcomes for the pregnancy and less on long- and short-term
nies chronic hypertension. It is a leading cause of premature effects on the mother. New research has shown, however,
births. that hypertension in pregnancy can also affect the post-natal
health of a mother, increasing her risks of developing chronic
Several risk factors predispose mothers to these disorders, hypertension and cardiovascular disease. With high maternal
including first pregnancy, multiple pregnancy, history of mortality and morbidity resulting from these disorders, fur-
chronic hypertension, maternal age over 35, gestational dia- ther research is warranted. Treatment
betes, obesity and fetal malformation. One study showed or management of these conditions will have great signifi-
that intervals of 59 months or longer between pregnancies cance for the continuum of care model of maternal and new-
were also associated with higher rates of pre-eclampsia and born health care.
eclampsia. Researchers have also proposed that hormonal
imbalances, calcium deficiency and insulin resistance are See References, page 109.
possible causes.
Calcium supplementation has been shown to be an effec-

tive intervention in developing countries where pregnant
women may be calcium deficient, reducing the incidence of
pre-eclampsia by 48 per cent. If this intervention has a simi-
lar effect on maternal deaths from hypertensive disorders,
calcium supplementation could prevent some 21,500 mater-
nal deaths. The Magpie Trial, the largest trial for hyperten-
sive disorders of pregnancy, conducted in 1998–2002 in
Providing emergency obstetric and newborn care, and making post-natal
care available, are key challenges and opportunities for enhancing maternal
and newborn health.
Other risks from childbirth can also tions. The quality of care delivered rates of Caesarean section are around
be addressed with skilled care. The by the facility is critical: To provide 2 per cent.16
World Health Organization recom- adequate assistance it must have
mends that a woman with eclampsia adequate medicines, supplies, equip- Factors hindering the provision of
or pre-eclampsia be hospitalized in ment and personnel. In addition, it emergency obstetric care include dis-
the days leading up to delivery to should be able to perform potential- tance, direct user charges, transporta-
receive treatment with magnesium ly life-saving functions such as tion and accomodation costs, knowl-
sulphate. Most infections are treat- Caesarean sections, blood transfu- edge and cultural barriers, among oth-
able with antibiotics. Some infections, sions and newborn resuscitation. ers. Furthermore, the quality of care
such as tetanus, can easily be avoided offered may also prove a deterrent, as
through immunization programmes Data on emergency obstetric care in shown in a study in northern United
and sterile umbilical cord practices15 developing countries are often scarce. Republic of Tanzania, which indicated
(see Panel on page 49, Eliminating Studies have shown that around 15 that the poor quality of care in facili-
maternal and neonatal tetanus). per cent of live births are likely to ties was the main barrier to access.17
need emergency obstetric care, and
Providing emergency obstetric Caesarean sections may be required Making post-natal care available
and newborn care
in 5–15 per cent of births. It is evi- There is a clear need for far greater
Timely care in a medical facility is dent that there are many important emphasis on post-natal care – an
often necessary to save the life of a gaps in coverage, especially in rural intervention that has long been neg-
woman experiencing birth complica- areas of sub-Saharan Africa, where lected in many developing countries,
and one that represents a gap in the
Figure 3.5 continuum of care. An urgent need is
for care in the immediate post-partum
Emergency obstetric care: Rural Caesarean section
period, as evidence indicates that the
risks of maternal mortality and mor-
bidity are high in the 48 hours imme-
diately following birth. Post-natal
South Asia 5
care is often critical for newborns,
Middle East/North Africa 12 particularly immediately after birth.
East Asia/Pacific* 4 Around three quarters of neonatal
deaths take place in the first week,
with up to half of these occurring
CEE/CIS 6
within 24 hours of birth.
World 4 In many developing countries, moth-

Sub-Saharan Africa** 2 ers are likely to be discharged from a
Developing countries*
health facility within 24 hours of giv-
4
ing birth or may lack access to skilled
professional care. Evidence shows
0 2 4 6 8 10 12 14 that even once the high-risk period is
Percentage of live births in rural areas
delivered by Caesarean section, 2000–2006
over, the risks of maternal mortality
and morbidity continue for at least 42
Source: Demographic and Health Surveys, other national household surveys and UNICEF. days after birth, and can even extend
Establishing a continuum of quality maternal and neonatal health care
will require the recruitment and training of skilled health personnel
and community health workers. A nurse tends to a newborn baby at
a paediatric hospital, Democratic People’s Republic of Korea.
(See Panel on page 62, Kangaroo life events, the experience of mother-
mother care in Ghana). hood and infant temperament as crit-
ical factors in the onset of depression
Even mothers who benefit from during the post-natal year.
immediate post-partum care are often
neglected in the days and weeks that While it is estimated that around
follow. Their next contact with 10–15 per cent of women in industri-
health workers may be at the six- alized countries may experience
© UNICEF/HQ07-0367/Dan Thomas
week period, when the baby is due to depression during the weeks and
receive the first round of immuniza- months after delivery, information on
tions. Evidence shows that mothers this condition in the developing world
seek post-natal care less often than is scarce. Small-scale studies from
antenatal care or a supervised deliv- Pakistan and Viet Nam indicate that
ery, even if they are suffering from women who suffer from depression
post-partum bleeding or conditions tend to have underweight infants, and
to six months to a year. The main such as fistula and uterine prolapse.20 research from India suggests that chil-
causes of post-partum mortality are dren of depressed mothers may face a
severe bleeding, infections and hyper- Effective post-natal care requires care higher risk of stunting.21
tensive disorders. Treating these con- and attention during the immediate
ditions will require the skilled care post-partum period and also several Healthy practices for
newborn care
and attendance at birth outlined in follow-up visits. Enabling mothers to
earlier sections of this chapter.18 return to health facilities, or follow- Prevention of newborn deaths
ing up with outreach visits in the requires skilled care more than
Routine post-natal visits are necessary days and weeks following childbirth, technology, and demands flexible
in the high-risk post-partum period, can be challenging – there may be and responsive systems of interven-
when any complications need to be costs or difficulties in arranging tion. The state of the health system,
promptly detected and referred to transport and visitation, or cultural social context and local practices
more expert services if required. Even reasons that make a return to the matter just as much as epidemiolog-
in the absence of complications, these clinic or hospital unlikely. This is ical risks. Neonatal health can be
visits can provide essential informa- why outreach visits can have a vital improved, for example, by practices
tion and guidance on maternal and part in maintaining maternal and that do not have high costs attached,
newborn health – especially on the neonatal health, irrespective of such as clean delivery conditions
care and feeding of babies, the dan- where the birth took place. (See and the promotion of early and
ger signs of illness, referral processes Panel on page 57, The first 28 days exclusive breastfeeding, and by
and improved hygiene practices. of life, and Panel on pages 80–81, ensuring that the mother is healthy
Studies show that fewer neonatal Saving mothers and newborn lives – when she gives birth.
deaths occur when mother and baby the crucial first days after birth).
are visited within 48 hours of birth. Recent progress has been achieved
Mothers who are HIV-positive and Little is known about the effects and in providing simple, cost-effective
babies born prematurely need partic- extent of depression during pregnan- interventions that have a positive
ular attention.19 Low birthweight cy and the post-partum period in impact on neonatal health, including
infants require special attention, par- developing countries. Research has tetanus immunization, the use of
ticularly for temperature management. identified partner and social support, insecticide-treated nets to combat
Promoting healthy behaviours for mothers and newborns, particularly in
nutrition and hygiene, is vital to reducing health risks and morbidity.
© UNICEF/HQ05-1795/Giacomo Pirozzi
Skilled health personnel, with access to proper equipment and support, can provide critical life-saving interventions when emergencies
arise during labour and childbirth. A newborn is monitored by a medical worker in a children's hospital, Ukraine.
malaria and micronutrient supple- UNICEF and the World Health incentive for people to use them and
mentation. A study tracking cover- Organization, became known as the greater opportunity to extend and
age of interventions for maternal, Integrated Management of Childhood enhance coverage. The goal is to
newborn and child survival found Illness (IMCI), and it has met with develop a comprehensive primary-
greater improvement in the delivery increasingly positive results. More health-care system that provides
of these types of preventive interven- recently, this integrated model has women and children with essential
tion than of curative care. Progress been incorporated into the maternal, interventions and strengthens the
on actions focusing on behavioural newborn and child health continuum links between households and health
changes, such as breastfeeding, was of care. facilities that have so often been
mixed.22 missing in the past.
The continuum of care:
Since the early 1990s, the emphasis Household practices and
Linking lives to places behaviours
in coping with these manifold threats
to the lives of children has been on a It is now recognized that linking When children fall ill, the first point
broad, cross-cutting approach that interventions in packages can also of intervention inevitably lies in the
recognizes there is normally more increase their efficiency and cost- hands of their families, especially
than one contributory cause to any ail- effectiveness. In addition, when serv- their parents, close relatives and
ment. This approach, introduced by ices are integrated there is both more guardians. The initial diagnosis of
The first 28 days of life
by Zulfiqar A. Bhutta, Professor and Chairman, Department of Paediatrics & Child Health, Aga Khan University, Karachi, Pakistan
It is widely recognized that a large proportion of child deaths deliver an integrated package of preventive and curative
occur in the newborn period, the first 28 days of life. Of an newborn care in Sylhet, rural Bangladesh. While home-based
estimated 9.2 million deaths of children under five around care provision was important in these studies, it is possible
the world in 2007, around 40 per cent occurred in the new- that major benefits also accrued from improved family prac-
born period. In many developing countries, deaths of new- tices and newborn care. In a study in Makwanpur, in rural
borns account for over half of all deaths in infancy, with the Nepal, women’s support groups, assisted by trained facilita-
vast majority occurring in the first few days of life. The major tors, effected a significant reduction in neonatal mortality.
causes of such deaths are serious infections (36 per cent), Further studies have shown that a concerted strategy of
prematurity (27 per cent), birth asphyxia (23 per cent) and community-based education in newborn care can lead to
congenital malformations (7 per cent). These figures do not significant change in practices and reductions in neonatal
include an estimated 3 million stillbirths annually. Some mortality.
30–40 per cent of these stillbirths may be related to events
during labor and delivery, which in turn may result from All of these recent studies provide evidence that community-
intrauterine problems and asphyxiation. based education in improved maternal and newborn care
and home-based treatment for newborn infections can signif-
The relative lack of progress in reducing newborn deaths is icantly enhance newborn survival. To affect public-health
due to several factors. Most important is that, unlike health systems in the foreseeable future, these strategies need to be
in the post-natal period (29 days to 59 months), newborn replicated at scale using feasible motivation and training of
health is closely tied to maternal health. Improving it available health-care workers. Such an expansion has taken
requires interventions that address complex issues such place in rural Pakistan, where community-based Lady Health
as maternal empowerment, sociocultural taboos and health- Workers work with village health committees and women’s
system responsiveness. groups. A recent evaluation of the Pakistan initiative has
shown a significant reduction in perinatal and neonatal mor-
Specific factors leading to neonatal deaths include: tality and improved care-seeking for skilled maternal care.
• A lack of attention to maternal health, with limited access This emerging evidence provides support for strategies to
to skilled care providers. improve maternal and newborn health in the very communi-
ties and families with the highest burden of mortality and least
• The poor state of maternal health care, especially during
access to quality health care. The challenge is to integrate
home births, which are associated with at least half of all
effective strategies and interventions across the continuum of
newborn deaths.
maternal and newborn care in both community settings and
• Inadequate recognition of newborn illnesses and insuffi- health facilities. Recent estimates indicate that providing basic
cient care-seeking among families and communities. preventive and curative interventions for mothers and new-
• A limited repertoire of interventions for early neonatal borns in primary-health-care settings at pragmatic levels of
disorders such as birth asphyxia and problems due to coverage has the potential to reduce maternal and newborn
premature birth. deaths by 20–40 per cent.
• A lack of consensus on interventions and delivery strate-
gies to prevent and treat serious neonatal infections – While these measures show promise, particularly when sever-
other than neonatal tetanus – in community settings. al complementary interventions are packaged together and
delivered through a range of health-care providers, important
Recent years have brought significant improvement in our bottlenecks to improved service delivery remain in many
understanding of neonatal illnesses and mortality. Inequities developing countries, including poorly functioning health-
in distribution of maternal and newborn deaths indicate that system facilities and limited numbers of skilled health-care
most deaths occur in poor, rural populations and in often- providers. These bottlenecks can and must be addressed
ignored urban squatter settlements. Many countries also through strategies targeted to reach those families, communi-
recognize that reaching the Millennium Development Goal ties and districts most at risk of missing out on basic health
for reducing child mortality will not be possible without care and maternity services. Despite these difficulties, and the
improving care for mothers and newborns, focusing efforts still important gaps in our knowledge of how best to tackle
on reducing deaths during the first 28 days of life. difficult newborn problems such as birth asphyxia, the fragili-
ty of preterm infants and serious bacterial infections in com-
munity settings, one point is clear: We know enough about
The evidence supporting strategies and interventions that
what works to make a difference. The critical need is to imple-
use community partnerships has also improved. A number of
ment what we know and create the policy framework for
programmes, largely based in South Asia, have attempted to
appropriate maternal and newborn care where it matters:
reduce newborn morbidity and mortality in community set-
among the rural and urban poor.
tings using innovative approaches. In a landmark study
undertaken in rural Maharashtra, India, Dr. Abhay Bang and
his colleagues trained community health workers, working See References, page 109.
with traditional birth attendants, to recognize serious neona-
tal illnesses such as birth asphyxia or suspected bacterial
infections and treat them with home-based resuscitation or
oral and injectable antibiotics, respectively. The programme
showed a significant reduction in neonatal mortality through
these home-based newborn care strategies. More recently,
researchers from Johns Hopkins University have demonstrat-
ed the efficacy of using trained community health workers to
Community partnerships in health care can help expand coverage of essential services and improve practices in health and nutrition.
A community health volunteer who is also a trained birth assistant visits a pregnant woman in a village, Nepal.
any childhood illness is most often any problem that arises before, during identifying and coping with child-
made not by a doctor or nurse, but and after birth, but families inevitably hood or maternal illness. In addi-
by a mother, who assesses the symp- play a key role, especially in deciding tion, although in the developing
toms, decides on their severity and whether it is necessary to seek exter- world as a whole a small majority
either settles on a form of care and nal, and often expensive, medical (54 per cent) of births take place
treatment within the home or decides assistance. In addition, sociocultural in clinics or hospitals, in both sub-
that a trained health worker must be factors may mean that women need Saharan Africa and South Asia – the
consulted. Irrespective of whether a to receive the permission of their regions with the greatest burden of
health worker is sought, it also falls husbands or other family members to maternal and neonatal mortality –
to family members to nurse sick chil- seek care during pregnancy, childbirth more than 60 per cent of women
dren and to administer any necessary or the post-partum period. give birth at home.23 Even those
medicines or other remedies. women who give birth in a health
The competence of family members facility are often discharged from
A similar process often applies to to make judgements on medical hospitals within 24 hours of deliv-
women who are pregnant or have matters varies enormously, of ery, and the main burden of post-
recently given birth, although to a course, but no health system can partum and neonatal care and
lesser extent. The woman herself will afford to ignore the vital part played supervision falls on family members
have her own view of the severity of by families or household members in of the mother and newborn.
Community partnerships in health can promote early and exclusive
breastfeeding, which provides vital protection for newborns against
ill health and disease.
At a more basic level, nutrition and considerable potential to improve the Community partnerships in
hygiene practices in the household are health and well-being of families. primary health care
prime determinants of the health risks
faced by mothers and newborns. Simple messages regarding basic Communities have a vital role in
Inadequate maternal nutrition, unhy- hygienic practices in food prepara- health care and nutrition of mothers,
gienic practices at delivery, and in car- tion – such as keeping food in cov- newborns and children. The notion
ing for the umbilical stump or cord, ered containers to exclude insects of the community as a cornerstone of
inattention to basic hygiene practices and drying cloths used to clean dish- primary health care was asserted in
such as hand washing with soap or es or pans in the sun – can have the Alma-Ata Declaration of 1978,
ashes after using latrines and before beneficial results. Improving house- and it is clear that the goal of health
preparing and eating meals, and hold knowledge of elementary care for all cannot be achieved with-
indoor air pollution can accentuate health, nutrition and environmental out community participation, especial-
the spread of infections and diseases health interventions, along with ly in poorer and more remote areas. It
such as tetanus, diarrhoea and acute increased empowerment of women is beneficial that communities take an
respiratory infections. Raising aware- to make decisions about their own active part in improving health care,
ness of improved individual house- or their children’s health, could have hygiene practices, nutrition and water
hold practices and behaviours, such a strong positive impact on health and sanitation services. This is, how-
as exclusively breastfeeding newborns outcomes both for children and new ever, not merely a necessary tool in
and infants up to six months, has or expectant mothers. the absence of more expensive alterna-
Figure 3.6
Early and exclusive breastfeeding
South Asia 44
East Asia/Pacific* 43
Latin America/Caribbean N/A
CEE/CIS 20
World 38
Sub-Saharan Africa** 31
Developing countries* 38
0 10 20 30 40 50
Percentage of infants less than six months old that are exclusively breastfed, 2000–2007
Source: Demographic and Health Surveys, other national household surveys and UNICEF.
Focus On Midwifery in Afghanistan
Decades of conflict and instability have disrupted Although much remains to be done to improve maternal
Afghanistan’s basic health infrastructure. Women in and newborn health in Afghanistan, many successful
particular have suffered from a lack of access to health efforts to date have focused on expanding and strength-
services. As a consequence, maternal mortality among ening midwifery.
Afghan women is extremely high, standing at 1,800
deaths per 100,000 live births in 2005, according to the Afghanistan’s Government is collaborating with local
latest inter-agency estimates. and international partners, including UNICEF, to develop
a comprehensive approach that includes strengthening
Women in Afghanistan face a lifetime risk of death from and expanding midwifery education, creating policies to
causes related to pregnancy or childbirth of 1 in 8, the ensure the pivotal role of midwives in providing essential
second highest rate in the world. More women die in obstetric and newborn care, supporting the establishment
Afghanistan from these causes than from any other, with of a professional association for midwives, and develop-
haemorrhage and obstructed labour the most common. ing initiatives to increase access to skilled care during
The proportion of maternal deaths ranges from 16 per cent childbirth.
of all deaths of women of childbearing age in Kabul (the
largest urban center in Afghanistan) to 64 per cent in the The Community Midwifery Education (CME) programme,
Ragh district of Badakhshan. an 18-month, skills-based training programme that has
less stringent entry requirements than previous midwifery
The high rates of maternal death reflect several factors, programmes, is considered an appropriate approach to
including limited access to quality maternal health care, scaling up training and deployment of skilled birth atten-
particularly in rural parts of Afghanistan; a lack of knowl- dants. In 2008, there were 19 CME programmes, each
edge of maternal health and safe delivery; and the scarci- with 20–25 trainees. This represents a marked increase
ty of qualified female health providers, since there is a in training capacity over 2002, when there were only six
strong cultural preference for women to be cared for by nurse midwifery training programmes run by the Institute
other women. It is estimated that 9 out of 10 rural women of Health Science at regional centres, and one community
deliver their babies at home, without skilled birth atten- midwifery programme in Nangahar province. The number
dants or access to emergency obstetric care. Sociocultural of midwives available in the country has increased rapid-
factors that inhibit women’s mobility without the permis- ly, from 467 in 2002 to 2,167 in 2008.
sion or escort of male relatives can also limit their access
to essential services. Other factors contributing to mater- The CME encourages applications from women in dis-
nal mortality are the low social status of women and girls, tricts with shortages, with the understanding that they will
poverty, poor nutrition and lack of security. work in those districts once they are trained. This policy
has resulted in a sharp increase in facilities having skilled
Improving the survival rates of mothers in Afghanistan is female health personnel (doctors, nurses or midwives),
an issue of immense importance. Midwives can provide from 39 per cent in 2004 to 76 per cent in 2006. It is also
crucial care. The World Health Organization recommends having a tangible impact on maternal care; the number
one midwife or other skilled birth attendant for every 175 of deliveries attended by skilled workers has risen from
women during pregnancy, childbirth and the post-natal roughly 6 per cent in 2003 to 19.9 per cent in 2006. The
period. Using this estimate with the estimated number of success of the skills-based training approach has resulted
births, Afghanistan should have 4,546 midwives to cover in the existing midwifery programmes adopting the CME
90 per cent of pregnancies. The country actually had only curriculum and certification process.
467 trained midwives in 2002. Fewer than half of health
facilities had any female staff. In rural Nooristan, the ratio See References, page 109.
of male to female health personnel was as high as 43 to 1.
Outreach and outpatient services can act as a bridge between the
household and health facilities, providing reproductive, antenatal,
intrapartum and post-natal services.
© UNICEF Peru/2005
Addressing cultural, social and geographic barriers to health care helps increase access to health services in rural communities. A mother
and her newborn are attended by a health worker in a health centre, Peru.
tives but rather a desirable route for voluntary, while others involve pay- improve people’s access to services
empowerment and participation.24 ment of some sort. Some operate inde- and facilitate closer contact between
pendently of the national health-care health workers and individuals or
Community partnerships are especial- system, while others are fully integrat- households, but also encourage
ly valuable in improving maternal, ed within it. Programmes seeking to behavioural change and social mobi-
newborn and child health. There are use community partnerships as an lization. At their most challenged,
almost as many different kinds of approach have to be careful to adapt community partnerships are short-
community partnerships as there are to the particular local context. staffed, poorly coordinated, under-
communities. Some are small and funded and ill-supplied. Examples of
local, while others form part of a At their best, community partner- successful community partnerships in
national network. Some are entirely ships in health and nutrition not only health across the developing world
demonstrate that the balance sheet as better caring or hygiene practices. Nepal provides one such example.
a whole is positive.25 Exclusive breastfeeding, hand wash- Trained community health workers
ing with soap or ashes and the use of collaborate with skilled health per-
The role of community health insecticide-treated mosquito nets for sonnel to provide care to mothers,
workers in maternal and
malaria prevention are three of the newborns and children. A random-
newborn health
most common interventions advocat- ized study in rural Nepal shows that
Community partnerships in health ed by community health workers. In these partnerships have reduced
often involve training people as addition, many community partner- neonatal mortality by 30 per cent.
community health workers. These ships in health include workers who These findings are complemented by
workers undertake basic health care advise on prevention of mother- a study in rural India, which shows
and nutrition activities – whether to-child transmission of HIV and a 62 per cent reduction in neonatal
through home visits or at an estab- contribute to the management of mortality when community health
lished location. Community health childhood illnesses such as malaria, workers provided home-based care
workers also lead campaigns for pneumonia and neonatal sepsis. for the newborn, including resuscita-
Kangaroo mother care in Ghana

Kangaroo mother care for low-birthweight babies was participants to focus on one aspect of newborn care,
introduced in Colombia in 1979 by Drs. Hector Martinez and implement it well and in the process integrate it into the
Edgar Rey as a response to, inter alia, high infection and normal spectrum of newborn care practices.
mortality rates due to overcrowding in hospitals. It has
since been adopted across the developing world and has The implementation model identifies specific roles for
become an essential element in the continuum of neonatal districts and regions, depending on the way authority is
care across the world. devolved in a country. In Ghana, the region is the nodal
point for implementation, with districts being responsible
The four components of kangaroo mother care are all essen- for the actual implementation actions. Although half of all
tial for ensuring the best care options, especially for low births still occur at home, one of the cornerstones of the
birthweight babies. They include skin-to-skin positioning of KMC Ghana project is the establishment of centres of excel-
a baby on the mother’s chest; adequate nutrition through lence at regional hospitals and 24-hour, continuous kangaroo
breastfeeding; ambulatory care as a result of earlier mother care in each district hospital.
discharge from hospital; and support for the mother
and her family in caring for the baby. Implementation is overseen by a KMC Steering Committee
in each region, consisting of one member from each of the
The most important method of spreading kangaroo mother districts. These representatives, in turn, establish steering
care has been by means of training programmes. Often, committees at the district level. Although the focus is on
the training remains confined to hospital settings. A new introducing KMC in district hospitals, other health care
approach was adopted in Ghana under a kangaroo mother facilities and community organizations are also sought
care (KMC Ghana) project undertaken in four regions, with as partners.
the support of UNICEF and the South African Medical
Research Council’s Unit for Maternal and Infant Health Care While a comprehensive evaluation of the KMC Ghana
Strategies. Instead of merely providing training, a longitudi- programme has yet to take place, preliminary evidence
nal, ‘open door’ approach based on continuous support from suggests that it is effective in improving the survival of low
health-care facilities was adopted. birthweight babies and strengthening the bond between
mothers and newborns.
Under the programme, kangaroo mother care is singled out
for special attention for two to three years. This requires See References, page 109.
HIV/malaria co-infection in pregnancy
Co-infection with HIV and malaria presents specific com- meaning that HIV-positive women in their second, third and
plications for pregnant women and fetal development. fourth pregnancies have the same low immunity to malaria
HIV lessens pregnancy-specific malaria immunity normally as women in their first pregnancy. Pregnant women infected
acquired during the first and second pregnancies. Placental with HIV become twice as susceptible to clinical malaria,
malaria is associated with increased risk of maternal anaemia regardless of gravidity. In these women, malaria can restrict
and HIV infection, especially among younger women and fetal growth, cause preterm delivery and low birthweight in
those experiencing their first pregnancy. The role of co- newborns and reduce the transfer to children of maternal
infection in mother-to child transmission of HIV is unclear, immunities and cellular responses to infectious diseases
with some studies reporting an increase and others reporting such as streptococcus pneumonia, tetanus and measles.
no change. The potential risks of adverse drug interactions Recent evidence suggests that HIV-positive mothers with
have critical implications for effective management of malaria are more likely to have low-birthweight infants; in
co-infection, and call for increased research. turn, low-birthweight infants were shown to have signifi-
cantly higher risks of mother-to-child transmission of HIV
Although malaria affects Asia, Latin America and the compared with infants of normal birthweight.
Caribbean, and sub-Saharan Africa, the largest burden of
co-infection lies in Africa, the continent with the greatest The effects of malaria on HIV are less clear, though episodes
burden of malaria, and where more than three quarters of of acute malaria can increase viral load and hasten disease
all HIV-infected women live. Variations exist across the progression. Malaria infection during pregnancy may increase
African continent. Most affected by HIV/malaria co-infection the risk of mother-to-child transmission of HIV in utero and
are the Central African Republic, Malawi, Mozambique, during birth, and higher viral load can result in greater risk of
Zambia and Zimbabwe, where some 90 per cent of adults transmission during breastfeeding. Some research shows
are exposed to malaria and average adult HIV-prevalence that viral loads can return to pre-episode levels following
surpasses 10 per cent. In parts of southernmost Africa, malaria treatment, which suggests that management of
where the HIV epidemic is most severe, there is a lower malaria may be critical to slowing the spread of HIV and
incidence of malaria, although outbreaks do occur in its progression to AIDS.
particular areas, such as Kwazulu-Natal, South Africa.
One of the most pressing questions about co-infection
Data for other regions are not as clear, but the overlap of concerns drug therapies. The World Health Organization
infections may be present in the general populations of recommends that all pregnant women in areas of high HIV
Belize, El Salvador, Guatemala, Guyana and Honduras – and, prevalence (>10 per cent) receive at least three doses of
to a lesser extent, Brazil. Research indicates that certain pop- sulfadoxine-pyrimethamine as intermittent preventive treat-
ulations, such as migrant goldmine workers in Brazil and ment (IPT), even in asymptomatic cases, unless they are
Guyana, may have greater risk of co-infection. The HIV epi- receiving cotrimoxazole for the treatment of opportunistic
demic is generalized in Asian countries such as Myanmar infections of HIV.
and Thailand, but malaria transmission is unstable and het-
erogeneous across this region, as in Latin America and the Many African governments use artemisinin-based combina-
Caribbean. The most common species of malaria in each tion therapy for malaria case management in pregnancy;
region also differs – P. falciparum in Africa, P. vivax in Asia with research still limited, WHO continues to recommend
and Latin America and the Caribbean – and the effects of the this treatment be used for uncomplicated malaria in preg-
disease may vary by the degree of immunity a women has nancy during the first trimester, if it is the only effective
achieved by the time she becomes pregnant. Women in Asia treatment available. In cases of severe anaemia, treatment
are less exposed to intense malaria transmission and there- with either artemisinin-based therapy or quinine, should be
fore have less opportunity to develop acquired immunity. administered, although the former is preferred in the sec-
This is also true of areas of unstable malaria transmission in ond or third trimester. There is little published information
parts of southern Africa. Most studies of malaria in pregnan- on the risks of co-administration of antiretrovirals and anti-
cy are from Africa, and more are needed from other regions malarials, including artemisinin derivatives, but artemisinins
and non-falciparum species. have not yet been observed to have important toxicities
when co-administered with antiretrovirals or when given
Malaria sufferers with severe anaemia who require blood in early pregnancy.
transfusions, particularly children, also are at higher risk of
acquiring HIV. Every year, between 5,300 and 8,500 children See References, page 109.
in areas of endemic malaria in Africa become infected with
HIV from blood transfusions administered for severe malaria.
Regional differences notwithstanding, co-infection affects all

pregnant women in similar ways. HIV in pregnancy com-
bined with malaria increases the risk of severe anaemia and
reduces any acquired immunity that women living in areas of
stable malaria transmission may have developed – effectively
The challenges faced by adolescent girls in Liberia
by the Honourable Vabah Gayflor, Minister of Gender and Development, Liberia
Ensuring that adolescent girls have a supportive environment from causes related to pregnancy and childbirth than those
for their growth and development and are protected from of ages 20–24.
abuse, exploitation, violence and premature entry into adult
roles such as marriage and labour is particularly challenging – may be left with a delivery-related injury if she survives
in my country, Liberia. her pregnancy, such as fistula or uterine prolapse.
An adolescent girl living in Liberia: – faces a high lifetime risk of death from her first and subse-
quent pregnancies; the lifetime risk of maternal deaths
– has probably not been to primary school; the net primary stands at 1 in 12.
school enrolment for girls stands at only 39 per cent,
according to the latest national estimates. – may see her child die within the first year of life, with almost
1 in every 10 infants dying before their first birthday.
– is unlikely to go on to secondary school; just 14 per cent
of girls of secondary school age are enrolled in – will probably not have support from a partner, even if
secondary education. she is married.
– is at high risk of being illiterate, like 24 per cent of adoles- – has little or no recourse to protection from further abuse,
cent girls and young women aged 15–24 in the country. exploitation and disempowerment.
– has a high risk of suffering rape – the most frequently Creating a supportive environment for adolescent girls in
reported crime, with girls aged 10–14 the most frequent Liberia begins with protecting them from violence and abuse,
victims of rape. and ensuring that they obtain a quality education.
– probably has limited knowledge of HIV and AIDS; only 21 It will also necessitate ensuring that families do not allow
per cent of young women aged 15–24 have comprehensive their girls to marry before age 18 or allow them to be
knowledge of HIV and AIDS. engaged in exploitative labour.
– has a high probability of either being married or in union; It requires that knowledge of HIV and AIDS be promoted
40 per cent of women aged 20–24 in Liberia were married among young people, and that victims of sexual violence
before the age of 18. have recourse to justice.
– faces the strong likelihood of being pregnant; the adoles- It necessitates investment in reproductive, maternity and
cent birth rate for girls aged 15–19 stands at 221 per 1,000 – basic health care for millions of adolescent girls.
the second highest rate in the world.
Most of all, it demands that communities and society respect
– is unlikely to give birth in a hospital or health facility, as the rights of women and girls, and have the courage to
only 37 per cent of births take place in institutional settings. address customs and practices that harm and discriminate
against them.
– will possibly have to give birth without the assistance of a
skilled health worker, which only attend 51 per cent of births. Under the leadership of President Ellen Johnson-Sirleaf, the
Government of Liberia is striving to provide the protection
– runs a high risk of death from pregnancy and childbirth; adolescent girls need and to help them acquire the skills that
the maternal mortality rate stands at 1,200 per 100,000 will enable them to protect themselves. We welcome the sup-
live births. port of the international development community in assisting
us to act quickly and effectively.
– has an even higher risk of death from maternal causes if
under 15; girls aged 10–14 are five times more likely to die See References, page 109.
Facility-based care is essential for referrals and providing a range of
routine and emergency services for mothers and newborns.
tion for birth asphyxia and treatment sexual and reproductive health. For detect sexually transmitted infections
of sepsis with antibiotics.26 example, antenatal care can of and treat them promptly. Many out-
course be offered at clinics or hospi- patient or outreach services in repro-
Community partnerships in health tals, but it is entirely appropriate as ductive health currently offer only
care can help expand coverage of an outreach service. poor-quality interventions, however,
essential services and improved prac- which deter people from using them.30
tices in health and nutrition. Perhaps Antenatal outreach services should
even more importantly, such partner- screen for and treat disorders such Facility-based care
ships can also enable health systems as anaemia, hypertension, diabetes, Health facilities generally provide
to reach out to their communities, syphilis, tuberculosis and malaria, the broadest range of preventive and
however poor or marginalized they as well as check the baby’s position. curative treatments for maternal and
may be. They should also provide tetanus child health, and potentially the most
immunization, distribute insecticide- skilled pool of health-care workers.
Outreach and outpatient services treated mosquito nets and offer These facilities generally fall into two
Outreach and outpatient services, intermittent preventive treatment of main categories: clinics and hospitals.
such as antenatal care and immu- malaria in malaria-endemic areas, The facility closest to the community
nization, are delivered on a routine in addition to counselling on such is likely to be a clinic providing
basis through one of two modes: sta- matters as diet, hygiene, the danger immediate, generalized care, possibly
tionary clinics visited by pregnant signals in pregnancy and breastfeed- overseen by a nurse. Clinic staff can
women and their children, or mobile ing. It is also important, however, often cope with uncomplicated births
services whereby health workers not to overburden outpatient or and offer support and advice on the
undertake essential interventions to outreach services to the point at care of the newborn. They should
mothers and children in their com- which they become overstretched.28 also be able to deal with some of the
munities. In almost all cases, recipi- key complications – able, for exam-
ents are not assessed as clinical cases Outreach services can also be ple, to remove the placenta manually,
but receive a standardized service. adapted to provide post-natal care, or to offer resuscitation to a new-
Many of these interventions do not as mentioned earlier in this chapter. born. Given the potential risks asso-
need to be delivered by skilled med- Key services include recognizing and ciated with labour and childbirth,
ical staff to prove beneficial, but can checking for danger signs for moth- however, staff in clinics, as well as
be dispensed by semi-skilled health ers and newborns, guidance on those engaged in outreach attendance
workers and by community health feeding – particularly early and at birth, need the skilled knowledge
workers with some training. This, exclusive breastfeeding – and caring to recognize swiftly when a complica-
in turn, makes it easier and more for the newborn, referral for treat- tion in the delivery, or the degree of
cost-effective to increase coverage ment of mother or baby if appropri- sickness in the newborn, is beyond
of outreach-based services to large ate, and support and counselling on their competence and to refer it to a
sectors of the population.27 healthy practices.29 higher level.
Outreach and outpatient services Reproductive health is another area That next level is likely to be a
can act as a bridge between home appropriate to outreach and out- district hospital where doctors can
and community care and facility- patient services. Outreach services can offer medical diagnosis, treatment,
based care. They are vital mecha- raise awareness of options for repro- care, counselling and rehabilitation
nisms for delivering antenatal and ductive health services and practices, services. In some health systems
post-natal care, as well as promoting including birth spacing. They can also there may be a referral hospital
providing complex clinical care, Geographical distance is not the The continuum of care:
but in many communities across the only impediment to accessing Practical steps towards
developing world, the facility-based health-care facilities, however; there primary health care for
health needs of mothers and infants are cases where women living in the mothers and newborns
are met by clinics or the district vicinity of a health facility will only
hospital, if at all.31 visit for antenatal care but not the Health-care services function best
delivery itself. Cultural reservations when they link care in the home
Access to emergency obstetric care about a woman’s delivery being through the community to outreach
can pose a major challenge for preg- attended by strangers, and economic services and beyond to clinics and
nant women living in rural areas, costs of skilled attendance at deliv- hospitals. This is by no means a new
owing to the distance to be covered ery, are examples of deterrents that insight: The evidence and knowledge
to reach a suitable facility and the impede usage of health-care facili- have been available for decades.
lack of transport or adequate roads ties. Lack of health-care personnel Their application has the potential
by which it can be reached. Even if and inadequate medical equipment to reduce markedly the toll of pre-
transportation vehicles and infra- and drugs can also deter families ventable maternal and neonatal
structure are available, travel and from seeking an institutional deliv- deaths. The challenge now is to put
accommodation costs, together with ery. One particular challenge is to in place the levels of investment in
indirect costs such as the income lower the incidence of facility- health services that will guarantee
foregone by accompanying family acquired diseases – a serious risk a continuum of care. Chapter 4
members, may prove prohibitive. in sub-Saharan Africa – that can outlines a framework for devising
Families living in geographically iso- increase the risk of infection from strategies and apportioning
lated communities therefore face ele- blood transfusions and the reuse resources to deliver the improve-
vated risk of maternal and neonatal of needles.33 Despite these impediments in maternal and neonatal
mortality when birth complications ments, it is clear that upgrading health that the developing world
arise. A recent study of maternal maternity clinics, health centres and urgently requires.
deaths in Afghanistan, for example, hospitals to provide at least basic
showed that physical remoteness emergency obstetric care would be a
added to the epidemiological risks major step towards reducing mater-
that women faced.32 nal and neonatal mortality.
4 Strengthening health systems to

improve maternal and newborn health
Establishing effective continua of care will involve taking practical steps to strengthen health systems. The
key elements for health systems development – deepening the evidence base, expanding and enhancing
the health workforce, upgrading and broadening infrastructure and logistics, providing equitable financing
solutions and stimulating demand for care through social mobilization, ensuring the quality of care and
fostering political commitment and leadership through collaboration – are increasingly accepted by national
governments and local and international agencies. Chapter 4 of The State of the World’s Children 2009
examines each of the first six steps, illustrating their practical application through country examples. The
seventh step – political leadership and commitment – is addressed in the final chapter of the report.
M
eeting Millennium progress are being continually communications technology,
Development Goal enriched through data collection, facilities and management
5 will be challeng- research and analysis, monitoring capacity to ensure quality care
ing. As a whole, and evaluation, and collaborative and effective referral.
the world is far behind on improv- actions. Chapter 4 contributes to • Improving the quality of care
ing maternal health, with little these efforts by summarizing a across the health system.
progress achieved in sub-Saharan series of practical steps towards • Fostering political commitment
Africa in particular since 1990. strengthening health systems to and leadership through stronger
Even within those developing support the continuum of care collaboration between partners.
countries and regions that have outlined in Chapter 3. These
seen more progress, pockets of involve the following actions: This chapter examines the first six
poverty and marginalization con- of these steps, illustrating their prac-
tinue to exclude many from essen- • Enhancing data collection and tical application through country
tial maternity and basic health- analysis of trends, levels, risks, examples. The seventh step will be
care services. (See Chapter 1 for causes of and interventions for addressed in Chapter 5.
a full description of trends in maternal and newborn mortality
maternal mortality.) and morbidity. Step 1: Enhancing data
• Expanding the primary health-care collection and analysis
Faster progress and major workforce in developing countries Since no single indicator can
improvements in maternal and and enriching skills levels. adequately describe the varied
newborn survival and health are • Mobilizing societies to demand dimensions of either maternal or
possible through packaging and better maternal and newborn newborn health, a wide array of
scaling up proven, affordable health care and a supportive envi- indicators is useful to guide and
interventions, delivered through ronment for the rights of women monitor programmes. Vital infor-
a continuum of care and under- and children. mation for policies and pro-
pinned by a supportive environ- • Establishing practical, equitable grammes includes demographics,
ment for the rights of women and sustainable financing mecha- nutritional status, socioeconomic
and children. nisms for basic health care and status, health-care provision, care-
maternity services. seeking practices and the applica-
Policy recommendations on the • Investing in infrastructure, tion of improved health and
frameworks required to accelerate logistics, information and nutrition practices.
Good data on maternal and newborn health and survival
form the foundation for sound policies, effective programmes
and collaborative partnerships.
These measures strengthen under-

standing of the burden, trends, risks
and causes of maternal and newborn
mortality and morbidity. But much
more needs to be done. Gaps in
knowledge of many aspects of mater-
nal and newborn health – from the
estimation of mortality figures to
risks to pregnancy posed by HIV and
AIDS, to name but two elements –
remain significant. Health informa-
tion systems remain incomplete in
many developing countries, compli-
cating efforts to determine the status
of maternal and newborn health and
apply the most appropriate strategies
and interventions.1
Strengthening the knowledge base

that forms the foundation for poli-
cies, programmes and partnerships is
therefore an essential component for
developing health systems. Work has
begun on the process of enriching
data collection. The World Health
Organization has developed guide-
lines to assist governments and other
agencies in expanding data collection
and improving data quality on
maternal health. WHO recommends
that health information systems
should strive to capture data in
five key areas relevant to maternal
and child health:
• Maternal and newborn mortality

rates.
• Factors or determinants contribut-
ing to morbidity and mortality.
• Community perceptions of these
health problems and appropriate Providing essential care such as immunization and micronutrient supplementation to preg-
nant women protects them against disease and undernutrition. A health worker provides
actions, including types of services consultations that include weight and blood-pressure measurements, tetanus vaccination
and attitudes towards care seeking. and iron supplementation, Papua New Guinea.
S T R E N G T H E N I N G H E A LT H S Y S T E M S T O I M P R O V E M AT E R N A L A N D N E W B O R N H E A LT H 69
A wide array of methods is being employed to enhance data collection
on maternal and newborn survival, including censuses, household
surveys, and facility-based data gathering.
Figure 4.1
Emergency obstetric care: United Nations process indicators and recommended levels
UN process indicator Definition Recommended level
1. Amount of EmOC services Number of facilities that provide EmOC Minimum: 1 comprehensive EmOC facility and 4
available basic facilities for every 500,000 people
2. Geographical distribution of Facilities providing EmOC well-distributed Minimum: 100% of subnational areas have the
EmOC facilities at subnational level minimum acceptable numbers of basic and
comprehensive EmOC facilities
3. Proportion of all births in Proportion of all births in the population Minimum: 15%
EmOC facilities that take place in EmOC facilities
4. Met need for EmOC services Proportion of women with obstetric Minimum: 100% (estimated as 15% of expected
complications treated in EmOC facilities births)
5. Caesarean sections as a Caesarean deliveries as a proportion of Minimum: 5%

percentage of all births all births in the population Maximum: 15%
6. Case fatality rate Proportion of women with obstetric com- Maximum: 1%

plications admitted to a facility who die
Source: United Nations.
• Availability of and access to quali- the only household-level survey verbal-autopsy questionnaires – one
ty health-care services. large enough to allow for the meas- to ascertain deaths within the first
• Quality of care.2 urement of geographic and socio- four weeks of life, another for chil-
economic variations in maternal dren aged four weeks to 14 years,
A number of tools exist to facilitate mortality. A census may include fol- and a third for persons aged 15 and
the collection of this information, low-up questions aimed at assessing over – with the goal of helping stan-
including censuses, verbal autopsy, the timing of deaths of women of dardize measurement criteria and
death registration, surveys or studies, child-bearing age in each household methods. This level of scrutiny takes
data obtained from health facilities within the past 12 months. It into account the critical issue of
and health surveillance. Since each should be noted, however, that timing that has in the past not
method has strengths and weakness- some countries are not using their been adequately emphasized.3
es, more than one mechanism should censuses to collect this information,
be employed to assess maternal and missing out on an opportunity to Obtaining information on cause of
newborn health. collect valuable information on death can be challenging. According
maternal health. to the World Health Organization,
Censuses, questionnaires and only 31 of its 193 member states
household surveys
Verbal autopsy is another method of report high-quality cause-of-death
National censuses are a key source gathering information on mortality statistics. Several countries are now
of data and information on mater- and morbidity. The World Health using surveillance tools such as
nal health. Often they provide Organization has developed three Demographic Surveillance Systems in
Household surveys such as DHS and MICS are providing vital data
on a wide range of outcome and coverage indicators.
smaller geographic areas to ascertain topics. Since 1995, nearly 200 MICS misses’ – life-threatening complica-
cause of death. Methods used include have been conducted in 100 countries. tions that heightened the risk of
follow-up investigations of deaths mortality but which ultimately
using verbal autopsy to ask family Facility- and community-based did not result in death – that are
data collection
members, health-care providers and important for improving service
community members to explain Data derived from health facilities quality.5
circumstances of death. These systems across the wide range of public
are called sample vital registration and private health-care providers Governments, research institutions
with verbal autopsy systems. A no- are also useful in assessing the state and other agencies also conduct
blame policy, in which the respon- of maternal and newborn health. health surveillance, defined by the
dents are not held liable for answers The number of deaths in facilities Centers for Disease Control as ‘‘the
to survey questions, is pivotal to can be readily monitored and pro- ongoing, systematic collection, analy-
enlisting and retaining community vide opportunities to learn about sis, interpretation, and dissemination
support for these endeavours.4 improvements needed to avert of data regarding a health-related
further deaths, particularly those event that is for use in public health
A number of factors influence in institutional settings, in a process action to reduce morbidity and mor-
maternal and newborn health out- known as ‘maternal death review or tality and improve health.”6 This
comes, including biological factors audit’. This type of data can also method of data gathering can be
such as nutritional status; socioeco- provide insights into the ‘near- combined with others to assess the
nomic determinants such as income
and education; health-seeking Figure 4.2
behaviours and healthy practices;
barriers to accessing health services; Distribution of key data sources used to derive the 2005
and behavioural risk factors such maternal mortality estimates
as domestic violence and smoking. Total number of countries: 171
Household surveys and studies are
the primary methods used to assess Civil registration,
complete, good
the frequency of these types of No national data
attribution of cause
35%
determinants, which can then be of death
35%
analyzed to better understand the
population for which health pro-
grammes are intended. Civil registration,
complete,
Special studies
uncertain/poor
4%
Important periodic cross-sectional attribution of cause
Census of death
household surveys include the 3% 4%
Direct sisterhood
Demographic and Health Surveys Disease
estimates
surveillance/sample
(United States Agency for International registration 16%
Development), Multiple Indicator 1%
Reproductive age
Cluster Surveys (UNICEF) and Repro- mortality studies
ductive Health Surveys (Centers for 2%
Disease Control). These international

Source: World Health Organization, United Nations Children's Fund, United Nations Population
surveys provide comprehensive quan- Fund and the World Bank, Maternal Mortality in 2005: Estimates developed by WHO, UNICEF,
titative data on a wide range of health UNFPA and the World Bank, WHO, Geneva, 2007, p. 9.
Increasing the number of births attended by skilled health workers can reduce maternal deaths arising from complications during
childbirth. Two teachers demonstrate proper procedures for holding a baby after delivery during a training session for women at
a midwives training centre, Sudan.
health of a population over time and Averting Maternal Death and Beyond the Numbers, which describes
by geographical area. Disability Project.7 methods that can be used to relate the
story of a woman’s death as part of
Other aspects of maternal health care The Health Metrics Network, an efforts to reduce maternal mortality.
are also being measured, with strong international partnership dedicated These methods included community-
support from international agencies. to helping countries strengthen their based verbal autopsies, facility-based
Facility-based data are being collect- health management information sys- maternal death or near-miss reviews,
ed by UNICEF and its partners to tems, has developed a tool to assess clinical audits, and larger regional
provide indicators for emergency the completeness and quality of such or national confidential enquiries.8
obstetric care. Needs assessment for systems (see Panel on Enhancing In Mozambique, a review of maternal
emergency obstetric care has also health information systems: The deaths in health facilities has provided
been undertaken by UNICEF, the Health Metrics Network, page 104). valuable insights into the preventable
United Nations Population Fund The World Health Organization has factors behind these deaths and guided
and Columbia University in the led the development of a guide entitled policy and system responses.9
Using critical link methodology in health-care systems to prevent
maternal deaths
by Rosa Maria Nuñez-Urquiza, National Institute of Public Health, Mexico
Critical link methodology (CLM) examines each maternal One such example is provided by a CLM study of women
death as a sentinel event. It reviews all the health-care inter- with post-partum haemorrhage who died as they were trans-
actions between a woman and health personnel prior to her ferred from community hospitals to referral hospitals. The
death, providing a timeline of health-seeking actions and assessment identified the lack of stabilization of women prior
corresponding care provision across the health system. to transportation as a fatal omission. In the seven states
where the percentage of maternal deaths due to post-partum
CLM assesses health care through three dimensions: haemorrhage was above the national average, up to 60 per
cent of maternal deaths occurred while transporting patients
• clinical performance (delays, omissions and compliance to larger hospitals. When ambulances and trained personnel
with quality standards compared to established guidelines). were provided in one of those health districts, the maternal
mortality rate from post-partum haemorrhage fell by 30 per
• internal hospital organization. cent the following year.
• continuity of care between health-care facilities. CLM is helping to redesign the way facilities are networked
in each district health system. In addition, applying CLM
Through this process of review, CLM focuses on those crucial necessitates involving a broader group of stakeholders than
interventions that, if provided in an expeditious manner, can those traditionally engaged in safe motherhood committees,
avert future maternal deaths. It enables safe motherhood i.e., heads of clinical laboratories and blood banks, as well as
committees to shift their focus from a medical cause of death health district administrators.
to a managerial perspective of missed opportunities. This
change in perspective is highlighted through the following One outcome of CLM is that the reproductive health divisions
lines of enquiry: at both the Ministry of Health and the Instituto Mexicano de
Seguridad Social (IMSS, the Mexican social security system)
• During which interactions between the woman and the now report the Causes of maternal deaths not only as medical
health system could the condition leading to her death have causes, like “pre-eclampsia, sepsis, etc.,” but also by detected
been better addressed? failures in the process of care. For example, the report of
maternal mortality of a given district or state health system
• Based on this analysis, what specific steps must be done will now state, “15 per cent of maternal deaths due to lack of
differently in the future to prevent the deaths of women in IV solutions in health centres leading to failure to stabilize the
similar circumstances? women before transfer” or “10 per cent of maternal deaths
due to delays in bringing in the surgeon on call to district
• To sustain these specific changes, what processes in each hospitals during weekends.” Seeing beyond the medical
care unit require modification to ensure quality of care, and causes helps to diagnose health-system failures which, if
what factors of the health system should be redesigned to immediately addressed, will avert maternal deaths.
ensure the continuity of care during obstetric emergencies?
Furthermore, the comparison of near-miss cases (complica-
tions that lead to severe morbidity but which ultimately do
not prove fatal) with cases of maternal mortality highlights
the imperative of timely provision of care. This has resulted in
a new category of analysis: therapeutic time interval, which
calls for clinical research to establish the time interval during
which interventions are effective. The therapeutic time inter-
val helps demonstrate that even when appropriate treatment
is provided, it may fail to save women’s lives unless applied
in a timely manner.
From single-case red alerts to further research

Open and regular communication between CLM field supervi-
sors and federal authorities ensured that alerts detected by
individual case studies spurred further analysis of routine
data systems (hospital registries of 1,029,000 obstetric
patients yearly from 617 public hospitals) to explore the mag-
nitude and distribution of these gaps in maternal care across
the health system.
New technologies are also showing potential to assist in data collection
on maternal and newborn health.
Methods have also been devised to In one study conducted by the entry, often cited as a problem
assess the quality of care delivered by Initiative for Maternal Mortality in paper-based surveys. It also
health providers. Two such frame- Programmed Assessment trained and employed local school-
works include the Performance (IMMPACT) in eastern Burkina children with the requisite linguistic
Quality Improvement method devel- Faso, 127 interviewers using competence and familiarity with
oped by the United States Agency for personal digital assistants captured mobile phones.11
International Development, and the data from 86,376 households in just
client-oriented, provider-efficient over three months. Each unit cost It is apparent that there are numer-
services (COPE) method developed approximately US$ 350, amounting ous means of data collection that
by EngenderHealth.10 to US$ 60,000 for the equipment; can provide useful information
although no cost-effectiveness to guide programmes and policies.
In addition to new measurement analysis was completed, a paper Dissemination and analysis of
tools, new technologies are also being approach would have required over this data is essential, at local,
applied to assist in intelligence gath- 1 million printed pages, 100 global national and international levels,
ering. For example, surveys using positioning satellite receivers and to inform resources allocation
digital technologies show hope for 20 desktop computers and cost and policy responses, and achieve
improving data collection in the more. The PDA experiment had the the greatest impact in reducing
remotest areas. advantage of immediacy of data maternal deaths.
Figure 4.3
Skilled health workers are in short supply in Africa and South-East Asia in particular
WHO regions
Europe 78
32
The Americas 49
19
Nurses and
Western Pacific 20
14 Midwives
Eastern Mediterranean 15 physicians
10
South-East Asia 12
5
Africa 11
2
Country groups
by income level
Global 28
13
High income 87
28
Upper middle income 41
21
Lower middle income 17
13
Low income 11
5
0 10 20 30 40 50 60 70 80 90 100
Skilled health personnel (doctors, nurses or midwives, per 10,000 population), 2005
Source: World Health Organization, World Health Statistics 2008, WHO, Geneva, 2008, pp. 82–83.
New directions in maternal health
by Mario Merialdi, World Health Organization, and Jennifer Harris Requejo, Partnership for Maternal, Newborn and Child Health
Twenty-one years ago, the global health community came complications. Coverage indicators for proven interventions
together under the auspices of the Safe Motherhood Initiative and approaches linked to each of these three pillars – including
to focus on maternal mortality, whose upper and lower bounds antenatal care, availability of emergency obstetric care,
represent the starkest disparity in international public health. Caesarean section rates, contraceptive prevalence, skilled atten-
Yet by 1990, the baseline year for the Millennium Development dance at delivery, post-natal care and unmet need for family
Goals, more than half a million women, 99 per cent of them in planning – are now being tracked in the Countdown to 2015 ini-
developing countries, were still dying every year due to compli- tiative, by national governments, UN agencies, international
cations related to pregnancy and childbirth. Maternal mortality health partnerships and non-governmental organizations.
estimates for 2005 indicate that around 536,000 women continue
to die each year in pregnancy and childbirth, equivalent to Improvements in documenting the global distribution of
roughly one woman dying every minute from largely preventa- maternal mortality and morbidity, and identifying and tracking
ble causes. These deaths, which are heavily concentrated in the effective interventions, have been complemented by impor-
most disadvantaged population groups within low-resource tant research findings on ways of countering maternal health
countries, are reflective of a persistent, unjust, social inequality risks. Several interventions, shown to improve maternal sur-
that is long overdue for greater attention. These deaths are dis- vival in epidemiological studies and appropriate for universal
proportionately occurring in sub-Saharan Africa, which accounts application, are now ready for wide-scale implementation.
for half of annual maternal deaths, and South Asia (35 per cent), These include magnesium sulphate and calcium supplementa-
leaving the world a long way from its target of reducing the tion for the prevention of hypertensive disorders of pregnan-
maternal mortality ratio by three quarters between 1990 and cy, effective dissemination strategies for guidelines on the pre-
2015 (Millennium Development Goal 5, Target A). vention and treatment of post-partum haemorrhage, and the
recommended provision of at least four antenatal visits to
Despite the disappointing lack of progress in reducing pregnant women and one post-partum visit to new mothers.
maternal mortality since the launch of the Safe Motherhood Increasing awareness of the inextricable link between mater-
Initiative, important advances in maternal health have been nal and newborn health has also resulted in the introduction
achieved on several fronts. An unprecedented amount of of effective programmes for the prevention and treatment of
resources apportioned to health at the international level, malaria and HIV, through measures to expand provision of
combined with renewed political commitment to primary insecticide-treated mosquito nets and intermittent preventive
health care and with new complementary initiatives focusing treatment of malaria in pregnancy, interventions to prevent
specifically on maternal, newborn and child health, suggests mother-to-child transmission of HIV, preventive measures to
that momentum is building to address the historically neglect- avoid HIV infection – particularly among young people – and
ed issue of maternal mortality. Other developments in this antiretroviral treatment for HIV-positive women and children.
direction include the adoption of the continuum of care as a
core framework for public health programs; the establishment Key areas of promising research include activities focused on
of the Partnership for Maternal, Newborn and Child Health in developing strategies for ensuring the delivery of comprehen-
2005 to guide and promote the continuum; ratification of the sive packages of maternal and newborn health services along
Maputo Plan of Action to implement the continental frame- the continuum of care. An essential component of these
work for sexual and reproductive health and rights in Africa; strategies is the establishment of mechanisms for integrating
the addition of a new MDG 5 target (5.B) that seeks universal services traditionally delivered through vertical approaches –
access to reproductive health by 2015; and the inclusion of such as immunization and micronutrient supplementation –
maternal survival in the Countdown to 2015 assessments. with antenatal and post-natal care as part of health-system
These developments are testament to the revitalized focus strengthening. Recent years have also witnessed an encourag-
in the global health community on maternal and newborn ing trend towards the establishment of collaborative partner-
survival and well-being. ships between international organizations, governmental
agencies, research institutions, non-governmental organiza-
Improvements in procedures for estimating maternal mortality, tions and the private sector to promote multi-country research
new estimates of the incidence of abortion and increased projects on major complications in pregnancy and childbirth –
efforts to map the global burden of maternal ill-health are including preterm delivery, stillbirths, impaired fetal growth,
important epidemiological advancements that will enable better hypertensive disorders, post-partum haemorrhage and
decision-making by governments and their partners. The grow- obstructed labour and obstetric fistula.
ing recognition of the causal role of undernutrition in maternal
mortality has resulted in renewed interest in micronutrient sup- The growing political and financial support for programmatic
plementation during pregnancy and a stronger emphasis on the and research initiatives aimed at improving maternal and
need to address underlying and basic factors, such as poverty newborn health, and the shift from single issue, sectoral
and gender discrimination and disempowerment – including approaches to health care to collaborative forms of delivering
limited access to education for many girls and young women primary health care in a continuum of care, raises hopes and
and their high exposure to infections. A broad consensus has expectations that the long-awaited gains in maternal, newborn
also emerged about the core health-sector strategies required and child health that are so critical for the well-being and
to reduce maternal mortality. Comprehensive reproductive development of populations will become increasingly
health care is now considered to include family planning, skilled apparent in the near future.
care for all pregnant women during pregnancy and delivery, and
emergency care for all women and infants with life-threatening See References, page 111.
Strengthening the health system in the Lao People’s Democratic Republic
The Lao People’s Democratic Republic is a mountainous, The programme also prioritizes education for women in
largely rural, country in South-East Asia with an average gross improved nutrition practices, including breastfeeding and com-
national income per capita of less than US$ 600 in 2007. Nearly plementary foods, since studies have shown strong linkages
40 per cent of the population in this ethnically diverse nation – between inappropriate feeding practices and child undernutri-
which comprises nearly 50 different ethnic groups – lives below tion in the Lao People’s Democratic Republic. The dissemination
the poverty line. Although the country is on track to meet of other health information, including clinical care and immu-
Millennium Development Goal 4, having managed to reduce its nization, is also an important component of the programme.
under-five mortality rate by 57 per cent between 1990 and 2007,
significant health challenges remain for mothers and newborns. The Sayaboury programme has shown significant success,
at a highly affordable cost of around US$4 million over a
Chief among them are undernutrition, improving feeding and 12-year period, representing a per capita expenditure of just
hygiene practices, immunization, environmental health and US$ 1 per year. The district’s maternal mortality ratio fell
ensuring adequate skilled health personnel to deliver quality from 218 per 100,000 live births to 110 per 100,000 live births
health services. More than 1 in 7 newborns suffer from low between 1998 and 2003. The median age at which infants
birthweight, a condition that is often associated with poor received complementary foods increased from 2.8 months in
maternal nutrition. Exclusive breastfeeding, at 23 per cent 1999 to 3.7 months in 2001, while the rate of exclusive breast-
according to the latest estimates, is far below the regional aver- feeding for the first four months rose from 28 per cent in 1999
age of 43 per cent for East Asia and the Pacific. Only 60 per cent to 66.2 per cent in 2004. Vaccination coverage remained inade-
of the population have access to improved drinking-water sup- quate, however, with only 50 per cent of children under age
plies, and just 48 per cent have access to adequate sanitation one receiving three or more doses of diphtheria, pertussis and
facilities. Access to both of these critical services is far lower still tetanus vaccine – the benchmark indicator for routine immu-
in rural areas. In 2007, only 40 per cent of infants under age one nization coverage – in 2007.
were immunized against measles and just 47 per cent of preg-
nant women were immunized against neonatal tetanus. With Complementing efforts to improve maternal and newborn
maternal mortality standing at 660 deaths per 100,000 live births health, the Caring Dads communication campaign encourages
in 2005, the Lao People’s Democratic Republic has the highest fathers to support pregnant women and mothers in caring for
rate of maternal deaths in the region. The lifetime risk of mater- themselves and their babies. The Ministry of Health, in collab-
nal death stood at 1 in 33 in 2005. oration with UNICEF and the Lao Trade Union, has collaborat-
ed on comprehensive methods to advocate for greater
Notwithstanding these challenges, advances are steadily involvement by men in family care. These campaigns are
being made to expand health services to the country’s large aimed primarily at wage-earning fathers, who have been
rural population. One such programme involves Save the identified as the group most likely to engage in commercial
Children Australia, which has worked with the Provincial sex, the source of the growing HIV prevalence within the
Health Office and other partners in Sayaboury to expand and country. While the Lao People’s Democratic Republic has a
enhance primary-health-care infrastructure in four three-year lower adult HIV prevalence rate than some of its neighbour-
phases. Their goals are: ing countries, poverty and cross-border migration are con-
tributing to the spread of the virus. Posters and booklets on
• Phase I: Strengthen the provincial management team themes such as the Caring Dad in Pregnancy have been
responsible for training district teams and village health vol- reprinted because of unexpectedly high demand.
unteers and traditional birth attendants, develop fixed and
mobile maternal and child health clinics and provide essen- Such programmes aimed at community initiatives in health,
tial equipment. together with expanded immunization and supplementation
• Phase II: Integrate primary health care at all levels – campaigns supported by UNICEF in 2007 and health
provincial, district and village. infrastructure-building, are steadily beginning to help
• Phase III: Expand programmes into four remote districts. reduce the still high burden of maternal and newborn
• Phase IV: Strengthen the skills of health workers through deaths in the Lao People’s Democratic Republic.
adoption of the Integrated Management of Childhood
Illness framework. See References, page 111.
Addressing the health worker crises is critical to improving maternal
and newborn health. The greatest shortages are in Africa and Asia.
Averting maternal death helps safeguard the survival and health of newborns. A mother lies in bed with her newborn daughter in a
maternity ward after a successful delivery, Pakistan.
Step 2: Enhancing human workers is uneven, with greater con- fall below this threshold, 36 are in
resources, training and centration in developed countries com- sub-Saharan Africa. The greatest
supervision pared to developing countries, and in shortage of health workers in
urban areas relative to their rural absolute terms is in Asia, especially
Many developing countries are facing counterparts within countries. India, Indonesia and Bangladesh, but
an acute shortage of skilled health the largest relative need is in sub-
workers. Mass migration, AIDS and In 2006, research by the World Saharan Africa, where the number
armed conflict are among the key Health Organization recommended of health workers must increase by
factors debilitating national health that countries should have an average 140 per cent to reach the requisite
workforces, which in turn is constrain- of 2.28 health-care professionals per density.12 In the World Health Report
ing progress in reducing maternal and 1,000 population to achieve adequate 2005, the World Health Organization
newborn mortality and morbidity. coverage of skilled health personnel estimates that increasing coverage of
Furthermore, the distribution of health at delivery. Of the 57 countries that maternal health care for women by
57 countries – 36 in sub-Saharan Africa – have less than the WHO
minimum threshold of 2.28 health workers per 1,000 population that
would provide adequate skilled assistance at delivery.
2030 would require coverage levels ering maternal mortality rates. A described as ‘birth attendants’ have
to rise threefold, with 334,000 skilled skilled birth attendant is defined the skills required.
health attendants needed to reach 73 by the World Health Organization
per cent coverage of births world- as “an accredited health profession- Midwives or other mid-level
wide by 2015 – along with thousands al – such as a midwife, doctor or providers who have been trained for
more doctors, surgeons, anaesthetists, nurse – who has been educated or shorter periods and require lower
technicians and maternity units trained in management of uncompli- entry education qualifications should
within facilities.13 cated deliveries and post-natal care form one cadre within a spectrum of
and in the identification, manage- health workers who can undertake
No substitute exists for the presence ment and referral of complications different roles, distribute workloads,
of skilled health workers at delivery, in women and newborns.”14 Yet the and build a referral system for preg-
which has been a common factor skills of health workers who fall nant women and newborns. It is
across a set of countries with diverse into this category vary widely by also critical to ensure that trained
profiles that have succeeded in low- country, and not all health workers birth attendants are supported by an
Figure 4.4
Uptake of key maternal, newborn and child health policies
by the 68 Countdown to 2015 priority countries
International Code of 25
Marketing of Breast Milk 28
13
Substitutes 2
Yes
0
Maternity protection in 20 Partial
accordance with ILO* 48
Convention 183 N/A No
18 No data
Community management
of pneumonia with 11
31
antibiotics 8
New oral rehydration 34

salts formula and 17
zinc for management 10
of diarrhoea 7
IMCI** adapted to cover 39

3
newborns 0–1 week 21
of age 5
23
Specific notification of 14
maternal deaths 18
13
Midwives authorized to 27
administer a core set of 25
5
life-saving interventions 11
0 5 10 15 20 25 30 35 40 45 50
* ILO: International Labour Organization

** IMCI: Integrated Management of Childhood Illness
Source: Countdown to 2015, Tracking Progress in Maternal, Newborn and Child Survival: The 2008 report, UNICEF, New York, 2008, pp. 200–201.
Strengthening the health workforce
through recruitment, training and
retention of skilled health personnel
and community health workers is a
key challenge for countries across
the developing world. A doctor con-
ducts a midwifery training course at
a hospital, Afghanistan.
ating overdependence on an over-

worked, small staff.
Countries also face the challenge of

developing worker-retention strategies
environment that enables their skills munity health workers pay monthly that adequately remunerate health
to be used. This requires effective visits to ‘high risk’ households – workers and respond to their needs.
teams, supplies, supervision and defined as homes including children In Mali, for example, the Ministry of
referral systems. In Mozambique, under one, pregnant women and Health offers newly graduated doctors
for example, midwives and nurse women of childbearing age – and training, accommodation, equipment,
midwives have helped obstetricians assist babies with breathing difficul- and transportation in exchange for
provide cost-effective quality emer- ties.16 The distribution of responsi- service in rural areas.17 In Pakistan,
gency obstetric care functions in bilities can give pregnant women the Punjab Safe Motherhood Initiative
under-serviced areas.15 In Peru, com- and children more care while allevi- rotates postgraduate doctors from
Figure 4.5
Asia has among the lowest levels of government spending on health care as a share
of overall public expenditure
WHO regions
The Americas 18
16
2000
Europe 15
14 2005
Africa 9
8
Eastern Mediterranean 7
7
South-East Asia 5
4
Western Pacific 3
4
Country groups
by income level
Global 8
9
High income 18
16

9

2
Low income 5
4
0 2 4 6 8 10 12 14 16 18 20
General government spending on health care as share of total government expenditure, 2005
Saving mothers and newborn lives – the crucial first days after birth
by Joy Lawn, Senior Research and Policy Advisor, Saving Newborn Lives/Save the Children-US, South Africa
Investing in post-natal care can generate high • Who for? Integration of post-natal care for mothers and
returns in maternal and newborn survival newborns provides more effective and efficient care than
Across the human lifespan, an individual faces the greatest separate approaches to post-partum and newborn care.
risk of mortality during birth and the first 28 days of life – the • Where? Routine post-natal visits should be provided at
neonatal period. Each year, nearly 4 million newborns die home or close to home, both to promote healthy behav-
during this period – equivalent to around 10,000 per day. iours and to link with curative care – instead of just hoping
Three quarters of these deaths take place within one week of that the mother or baby will be brought to a health facility
birth, and 1–2 million die during the first day following birth. if problems arise.
Most of these deaths occur at home, are unrecorded, and • When? Early contact with mothers and babies is critical,
remain invisible to all but their families. Millions more suffer ideally within 24 or at most 48 hours of birth for the first
severe illness each year, and an unknown number are affect- visit – instead of the more common visit six weeks after
ed with lifelong disabilities. Moreover, the risks of maternal birth. The indicator measuring post-natal care published
mortality and morbidity also are highest at birth and in the by the Countdown to 2015 in its 2008 report focuses on
immediate post-natal period. care within two days of birth. Large-scale surveys are
changing to measure this indicator in more countries
For babies and mothers facing such complications as neona- and communities.
tal sepsis or post-partum haemorrhage, delay of even a few
hours before appropriate care is delivered can be fatal or Closing the gap between policy and action
result in long-term injuries or disability. Important new data Changing policies and indicators to reflect the importance of
from Bangladesh show that a home visit on the first or sec- post-natal care is necessary, but not sufficient, to save lives.
ond day after birth can reduce neonatal deaths by two thirds, Services must also be scaled up to ensure high coverage and
but later visits are less effective at reducing mortality. The quality care during this period. While the content of a post-natal
early post-natal period – the first seven days of life – is also care package is fairly clear, the most effective delivery mecha-
the critical period for initiating high impact life-saving behav- nism will vary, especially to provide services in remote rural
iours, including exclusive breastfeeding. Optimal breastfeed- areas and to reach newborns and mothers immediately after
ing does not start at the six-week visit for infant immuniza- birth. Figure 4.5 maps delivery options with conditions of access
tion – evidence shows that effective support and coun- to health facilities and human-resource availability in facilities
selling in the first days of a child’s life directly increase rates and at community level. Many of the tasks involved in post-
of exclusive breastfeeding. Other key behaviours during the natal care can be delegated to an extension worker who is ade-
neonatal period, such as hygienic cord care and keeping the quately supervised and effectively linked with the health system.
baby warm, can make the difference between life and death –
particularly for babies who are born prematurely. The post- Case management of neonatal infections is an
natal period is also a critical time for preventing mother-to- urgent priority
child transmission of HIV and for providing women with While early post-natal care visits for preventive care are
access to family planning options. immensely important, these are most effective at reducing
mortality rates when integrated with curative care. Almost
Coverage gap for early postnatal care one third of newborn deaths result from infections; in poor,
Providing effective care for mothers and newborns during high-mortality settings, this proportion is far higher. Many of
the early post-natal period has the potential to generate the these babies are born preterm.
greatest gains in survival and health of any period in the con-
tinuum of care. Despite this promise, however, the first days With an effective post-natal care package, infections in new-
following birth are the time when coverage of appropriate borns will be identified early. In most countries, however,
services and behaviours is currently lowest. Among the 68 newborn illness can only be treated through referral to a
priority countries identified by the Countdown to 2015 initia- health facility; even then, only a low percentage of those
tive, a median of just 21 per cent of women received post- referred will actually seek the care. One option is to have
natal care. first level, routine IMCI health-care workers begin antibiotic
treatment. In countries where community health workers
Changing paradigms in post-natal care already provide case management for pneumonia or malaria,
Growing recognition of the critical importance of providing case management of neonatal infections may also be consid-
care to mothers and newborns, and the substantial gaps in ered to bring care closer to home. Several Asian studies have
coverage that currently exist, along with evidence generated shown how such strategies can result in large reductions in
mostly from trials in South Asia, have prompted paradigm neonatal mortality, and community case management of
shifts. Three tenets have emerged: neonatal sepsis is now being scaled up in Nepal, linked to case
management of childhood pneumonia. Of the 68 Countdown pri- provision of life-saving interventions where the majority of
ority countries, 39 have changed policy to include case manage- newborn deaths occur and particularly where access to health
ment of neonatal sepsis within the Integrated Management of facilities is low. A network of studies is under way in eight
Childhood Illness framework. The key challenge now is to identi- African countries examining nationally adapted packages and
fy the appropriate providers of such care in each country. potentially scalable cadres of workers. Analysis of lives saved
and costs will help guide policies and programmes to improve
Closing the knowledge gap maternal and newborn care in the earliest days of life.
Almost all (98 per cent) of newborn deaths occur in low- and
middle-income countries. Yet most research and funding have See References, page 111.
focused on incremental advances in highly technical care for
the 2 per cent of newborn deaths occurring in high-income
countries. An increasing number of studies are providing new
guidance on the ‘how, who, when and where?’ questions for
Figure 4.6
Post-natal care strategies: Feasibility and implementation challenges
Possible strategies for Mother- Provider- Implementation challenges
post-natal care contact friendly friendly
1 Mother and baby go to * *** Requires mother to go to the facility within a very short time after
facility birth. More likely following a facility birth, but still challenging in
first days after birth.
2 Skilled provider visits *** * Conditional on sufficient human resources, which is challenging.
the home to provide Providing post-natal care may not be highest priority for skilled
post-natal care for health personnel in settings where their attendance at birth is
mother and baby still low. Many post-natal care tasks can be delegated to another
cadre. A skilled provider may be able to provide home visits
during the post-natal period if rural health facilities are quiet
during afternoons.
3 Community health worker *** * Requires sufficient numbers of community health workers with
visits home to see mother adequate training, supervision and incentives.
and baby
4 Combination: Facility birth ** ** Requires team approach between facility-based and community
and first post-natal care visit health workers, sufficient human resources, management and
in facility, then home visit supervision, effective referral systems and an efficient information
within two to three days, tracking system so that the progress of the mother and baby is
with subsequent post-natal easy to track.
care visits at a health facility
Note: * Low degree. ** Moderate degree. *** High degree
Source: Lawn Joy, and Kate Kerber, editors, Opportunities for Africa’s Newborns: Practical data, policy and programmatic support for newborn care
in Africa, Partnership for Maternal, Newborn and Child Health, Cape Town, 2006.
Initiatives to include community partnerships in supporting maternity
services are showing promise in several developing countries.
sub-district hospitals to the district hos- for quality health care at the level of women themselves may be blamed
pital in Sheikhupura, providing quality households and communities. Social for their own ill health and disease,
obstetric and emergency care 24 hours inclusion must be prioritized and indi- and the mortality and morbidity of
a day.18 Other non-financial incentive vidual families – particularly women – newborns. Where stillbirths and new-
schemes, such as short-term rotation and communities must be included born deaths are common, they may
of midwives, training opportunities and treated as partners in health-care not be seen as preventable. While
and psychosocial support groups, provision. Numerous cases show that communities cannot be forced to
have been used in southern and east- negative experiences from contacts accept alternative practices, they can
ern Africa, with varying degrees of with formal health-care facilities can become partners in the promotion of
success, but larger-scale implementa- dissuade families and even entire their own health and well-being and
tion and further research are required communities from seeking care. that of their mothers and children.
to fully evaluate their impact.19
One of the most important interven- Although health education is cen-
Step 3: Fostering social tions to improve maternal and tral to fostering healthy practices
mobilization neonatal health is the recognition and behaviours and appropriate
of preventable risks. Entrenched cul- knowledge for care seeking, part-
Supply-side measures cannot be suc- tural attitudes and beliefs often sur- nerships that involve key communi-
cessful without strengthening demand round pregnancy and childbirth, and ty stakeholders directly in health
Figure 4.7
Lower-income countries pay most of their private health-care spending out of pocket
WHO regions
South-East Asia 90
88
88
2000
Western Pacific 83
88
Europe 68 2005
69
Africa 48
52
The Americas 31
34
Country groups
by income level
51
Global 53
High Income 36
39

69

91
Low income 91
90
0 10 20 30 40 50 60 70 80 90 100
Out-of-pocket expenditure on health as a percentage of private expenditure on health, 2005
Mobilizing families, including men and other relatives, to recognize
and respond to health risks is essential to strengthen the supportive
environment for maternal and newborn health.
Burundi: Government commitment to maternal and child health care

Burundi is one of the world’s least developed countries. and UNICEF. Another important step was taken in 2007, when
Protracted civil war and halting political restructuring have Burundi was one of eight countries to join the International
stymied economic and social progress. Poverty rates are Health Partnership, a country-led and outcome-driven collab-
soaring, with nearly 88 per cent of Burundians living on just oration between governments, international organizations
US$ 2 a day. Undernutrition affects 66 per cent of the popula- and non-governmental organizations. A major objective of
tion, and more than half of children under age five suffer this partnership is to identify a set of key goals, which
from moderate or severe stunting. In 2005, women faced a include raising the number of institutional deliveries and
lifetime maternal death risk of 1 in 16. The adjusted maternal increasing services to prevent mother-to-child transmission
mortality ratio stood at 1,100 deaths per 100,000 live births in of HIV.
2005, and the neonatal mortality rate was 41 per 1,000 live
births in 2004. Burundi’s National Reproductive Health Policy now includes
newborn care as a critical strategy in reducing child mortality.
Burundi has learned through experience the importance of A central feature of this policy will include scaling up services
providing affordable, quality health care for the poor in gen- to prevent mother-to-child transmission of HIV. The median
eral, and for mothers and children in particular. In February HIV-infection prevalence rate for young pregnant women aged
2002, the Government implemented a cost-recovery pro- 15–24 in Bujumbura stood at 16 per cent in 2005. One area for
gramme that required patients to pay for medical consulta- future programming may be securing greater male support
tions, tests and drugs. The initiative aimed to generate for prevention of mother-to-child transmission strategies.
resources for a nascent health-care system and was imple-
mented in 12 of 17 rural provinces, covering 5 million of the The country has also embarked on providing badly needed
country’s 8.5 million inhabitants. The programme’s intro- basic health care that will positively affect women and chil-
duction increased the numbers of patients who were unable dren. Immunization programmes have provided tetanus tox-
to pay for the medical services they received in public hos- oid vaccine to nearly three quarters of women in high-risk
pitals, and many of them were subject to detention in the districts. Such efforts have galvanized stakeholders at the
facility. Women who had delivered by Caesarean section national and local levels. But sustained governmental prioriti-
comprised an estimated 35 per cent of indigent hospital zation of health care for the poor will be necessary for the
patients included in a 2006 Human Rights Watch report on continued support of international and grass-roots actors in
patient detentions; 10 per cent of the indigent patients in building Burundi’s health infrastructure.
the study were children. In addition to the burdensome
expenses, health-care services for women and children See References, page 112.
were often of poor quality.
The current Government, led by President Nkurunziza, has

begun to take steps towards tackling this health-care crisis. In
2005, when Burundi joined the International Monetary Fund-
World Bank ‘Heavily Indebted Poor Countries Initiative’ with
interim debt relief in 2005, the health budget was tripled. In
2006, the Government took the critical step of announcing
free health care for pregnant women and children. A new
policy, ‘Road Map for the Reduction of Neonatal and
Maternal Mortality’, was drawn up and launched in that same
year with the assistance of the United Nations Population
Fund, World Health Organization, World Food Programme
Financing quality health care is a global challenge. Almost one third
of the 68 priority Countdown to 2015 countries spend less than the
initiative’s minimum threshold of US$ 45 per person each year.
provision are also important. One may help address the belief of some disease prevention, care, nutrition,
such example is under way in indigenous women that their cultural and other health determinants.22
Burundi, where traditional birth practices, such as vertical positioning
attendants have been included in during delivery, were excluding them Just as male and female parents can
institutional deliveries as assistants from modern health services.21 be mobilized, so, too, can other
to formal health-care workers and family members. In many societies
new mothers, who share food and Engaging men and other family where extended kin live in close
members
other gifts rather than paying the proximity, in-laws and other older
attendants money.20 The goal of greater unity requires relatives have influence in health-
not just inclusion of more women care decision-making. In Mali, for
Health systems can also enlist com- but of men as well. Studies suggest example, the involvement of grand-
munities through inclusion rather that men perceive a myriad of compli- mothers in community education
than coercion. Policymakers in cations that result in maternal mortal- led to increased awareness of good
Ecuador took such an approach ity, yet they do not always recognize nutrition for mothers and babies
by legally integrating intercultural their own roles in preventing these and the detrimental effects of heavy
approaches in reproductive and deaths. More extensive research on work for mothers as well as greater
sexual health, with the aim of men’s roles in maternal and child sur- involvement by fathers in the care
encouraging greater participation vival and health is needed because of their partners and newborns.
of indigenous women in sustainable most currently available studies focus The programme also improved
health development. This strategy on economic provision and less on relations between women and their
Figure 4.8
Low-income countries have only 10 hospital beds per 10,000 people
WHO regions
Europe 63
The Americas 24
Western Pacific 33
South East Asia N/A
Africa 9
Country groups
by income level
Global 30
High income 59
Low income 10
0 10 20 30 40 50 60 70
Hospital beds per 10,000 population, 2005
Integrating maternal and newborn health care in India
India’s progress is critical to improving maternal and newborn Some states have also taken the initiative to inaugurate
health on a regional and global scale. According to the latest health partnerships with the private sector. In Gujarat state,
international estimates, India’s maternal mortality ratio stood one of India’s most developed provinces, the shortage of
at 450 per 100,000 live births in 2005, while the neonatal mor- skilled health-care providers has prompted the state govern-
tality rate was 39 per 1,000 live births in 2004. Both figures ment to join with private hospitals to provide free obstetric
represent reductions of rates in previous years. Yet even as its care for pregnant women living below the poverty line,
economy grows rapidly – with real gross domestic product especially those of scheduled castes and scheduled tribes.
expanding at an average annual rate in excess of 9 per cent in Chiranjeevi Yojana – meaning ‘a programme for long life’ –
2007–2008 – widening disparities are prevalent in health out- was launched in 2005 and operates through a memorandum
comes between income groups and between social and caste of understanding between the Government of Gujarat and pri-
groups. Growing inequities, combined with shortages in the vate obstetricians. For every delivery, the Government pays
provision of primary health care and the rising cost of care, Rs 1,795 (US$ 40), which also includes Rs 200 towards trans-
are complicating the country’s efforts to meet the health- portation costs for each patient and Rs 50 for the person
related Millennium Development Goals. accompanying the beneficiary, to compensate for the loss
of earnings.
With a total population of roughly 1.1 billion, broad environ-
mental and sociocultural diversity and an intricate political In 2006, a United Nations Population Fund study of
system comprising 28 states and 7 union territories, India’s Chiranjeevi Yojana reported that the programme had success-
efforts to manage its citizens’ health care have been largely fully raised the number of births delivered in health facilities,
decentralized. The Government of India has emphasized and that private practitioners were mostly enthusiastic about
expanding primary health care, which is, by constitution, their participation in the initiative. It also noted the reluctance
under the purview of the states. Beginning in 2000, it began a of patients to utilize facilities for births, and that their spouses
greater push to provide care to women and children in rural and in-laws had great influence on decision-making, which
areas and in poor-performing states such as Bihar, Orissa and limited their ability to actively seek healthcare. The study
Rajasthan. It has also encouraged private health care, which made several recommendations, including the establishment
few can yet afford, while spending on public health care has of an independent body to ensure quality
fallen to just 2 per cent of gross domestic product. control and equitable implementation.
To address the widening disparities, the Government of The Gujarat Government’s initiative is a departure from
India has issued a commitment to ‘inclusive growth’. One previous practice in that it took sole responsibility for the
such initiative is Janani Suraksha Yojana, a government- reimbursement of private health-care providers, rather than
sponsored project under the National Rural Health Mission relying on intermediary parties such as insurers. The state
that provides cash incentives for antenatal care during preg- government is working with professional agencies such as
nancy, assisted institutional delivery, and post-partum care associations of obstetricians and academic organizations to
by field-level workers. The benefits extend to all pregnant plan and implement the new arrangements.
women aged 19 and older living below the poverty line in
10 states, for up to two pregnancies. Women who are not Showing remarkable successes, the programme has been
enrolled in the programme but who experience complica- expanded from five to all 25 districts of Gujarat. Between
tions such as obstructed labour, eclampsia and sepsis are January 2006 and March 2008, 180 doctors were enlisted.
also eligible for benefits. The programme also includes a Nearly 100,000 deliveries were performed, with each doctor
mechanism for accrediting and compensating participating performing an average of 540. While a promising experience,
private practitioners. ongoing monitoring and evaluation are required to ensure
improvements are made and the desired impact is achieved.
According to one follow-up study undertaken in select dis-
tricts in Rajasthan in 2007–2008, Janani Suraksha Yojana has See References, page 112.
increased access to antenatal and post-natal care. The review
also revealed that 76 out of 200 participants in the study, or
nearly 40 per cent, were girls under 18, the legal age of
marriage in India. The programme is successfully expanding
access to care while allowing the Government to monitor
more closely the situation of girls and women.
© UNICEF/HQ08-0043/David Turnley
Strengthening and integrating maternal and neonatal care requires national and international commitment and global health partnerships
among agencies and institutions. A woman holds her toddler and a cup of complementary food, Sierra Leone.
mothers-in-law, reducing shame associated with poor health out- in equitable social and economic
and mistrust that had created comes, gaps in staffing, and weak development. Many governments,
distances between them.23 investment in health-care infra- even in low-resource areas, are
structure and logistics.25 Data exploring different strategies for
Step 4: Ensuring equitable and from the Pan-American Health helping families manage the costs of
sustainable financing Organization have shown that in routine and emergency obstetric and
2004, the average expenditure on newborn care. Various options are
Financing quality health care is a public health was just 2.6 per cent possible, including reducing or elimi-
global challenge for industrialized of gross domestic product for low- nating direct user charges; imple-
and developing countries alike. and middle-income countries as a menting social protection initiatives
Although there are no international- whole, in sharp contrast to the such as cash transfers and vouchers
ly agreed thresholds on minimum near 7 per cent of GDP spent by on either a conditional or uncondi-
per capita total spending, the high-income countries. South Asia tional basis; and introducing nation-
Countdown to 2015 initiative has had among the lowest rate of al or community health insurance
estimated that per capita spending spending, at just 1.1 per cent of or subsidizing private provision of
of less than US$45 is insufficient gross domestic product. While health care for poor households.27
to provide quality basic health care sub-Saharan Africa spends slightly
services. Among the 68 priority more of its GDP on health care Direct user charges
countries for maternal, newborn (2.4 per cent in 2004), only a few A key area of debate in health finan-
and child health identified by the countries in this region are meeting cing is direct user charges, which are
Countdown to 2015 initiative, the commitment made in the 2001 an important barrier to accessing
21 have spending of less than Abuja Declaration of apportioning health services, particularly for poor
US$45 per capita.24 15 per cent of their national budg- people. Removing user fees has the
ets to health care spending.26 potential to improve access to health
Public expenditure on health can services, especially for the poor.
be a key determinant of health sys- Countries and donors are increasing- Several countries across the develop-
tem capacity. Countries with low ly recognizing the pivotal importance ing world have already abolished, or
rates of spending per capita may be of maternal and newborn health care are in the process of eliminating,
Options for improving equity in maternal and newborn health care
include increasing health budgets, eliminating direct user charges,
implementing insurance initiatives and cash transfer programmes.
some or all direct charges – often It should be emphasized that user It should be noted that the context
with encouraging increases in access fees are not the only barrier that for user fee removal is critical, and
to health-care services. These coun- the poor face. Other cost barriers no blanket policy is likely to address
tries range from Burundi in Eastern include informal fees; the cost of the needs of each country. Careful
Africa (see Panel on page 83) and medicines, laboratory and radiology analysis of the country-specific situa-
Ghana in West Africa to selected tests not supplied in public health tion, the equity implications of alter-
districts of Nepal.28 facilities; travel, food and accom- native financing and delivery strate-
modation; and charges in private gies and the multiple financial and
No systematic evaluation of user fee health-care facilities. These costs non-financial barriers to access is
removal across developing countries generally make up a significant pro- required to support decisions on the
has taken place so far. Preliminary portion of the total costs that house- most appropriate course of action.
evidence suggests that in countries holds face and disproportionately
where user fee removal was not affect the poor.31 Insurance and transfers
supported by other policy measures, National health insurance schemes
such as increased national budgets In addition, a number of quality, such as Bolivia’s social insurance for
for health care or careful planning information and cultural barriers maternal and child health-care servi-
and deliberate implementation must also be overcome before the ces can increase access for the poor-
strategies, health system problems poor can access adequate health serv- est women to antenatal and delivery
tended to increase and performance ices. The evidence indicates that the care.33 Yet this form of financing is
weakened. In countries where fee poor are disproportionately affected hard to expand in countries with lim-
removal was carefully planned and by these non-cost barriers. ited formal sector employment, low
managed, however, there are signs of incomes, dispersed households and
increased utilization of services and Although user fees are only one of minimal infrastructure.
indications that the poor may have many barriers facing the poor, they
benefited most, although the inci- are among the most amenable areas Community health insurance schemes,
dence of catastrophic expenditures for policy action. As the recent expe- which operate more informally and
among the poor did not fall.29 rience from Uganda has shown, the on a smaller scale than social insur-
policy process of fee elimination can ance schemes, have increased institu-
The experiences of Uganda and have a catalytic effect in allowing tional-delivery rates by 45 per cent
South Africa suggest that for fee governments to confront other issues, in Rwanda and by 12 per cent in the
removal to be effective, it needs to such as drug supply and procurement, Gambia.34 A cost-sharing scheme in
be part of a broader package of budget allocation or financial man- an urban district of Burkina Faso
reforms that includes increasing agement, which pose further barriers increased the number of emergency
budgets to offset lost revenue, to progress.32 referrals from 84 to 683 in a year.35
maintain quality and respond to It may be difficult to expand such
increased demand. It also requires Clearly, removing user fees is not a schemes for wider coverage, however,
clear communication and wide simple exercise. Countries that seek and they require government or donor
stakeholder buy-in, careful monitor- to move in this direction require sup- support because they may not be self-
ing to ensure that official fees are port in planning and implementating financing and are dependent on effec-
not replaced by informal fees, and this policy change, and need to link tive community mobilization.
appropriate management of the the removal of direct user charges to
alternative financing mechanisms broader measures for strengthening Conditional cash transfers and
that are replacing user fees.30 health systems. voucher schemes are being piloted
Financing and development strategies should take account of the
national and local context, and also focus on indirect barriers to access,
such as transport costs and infrastructure.
to generate demand for specific serv- Attention to the emerging public- logistics, transportation and the
ices among the poor. Cash transfers private mix in health systems is referral process. Greater investment
have increased antenatal care during urgently required as inequitable in expanding health-care facilities is
the first trimester among poorer financing profiles and the unregulat- urgently needed, particularly in low-
women in Mexico by 8 per cent ed nature of the private sector can income countries. The latest WHO
and in Honduras by 15–20 per cent.36 affect government commitments to estimates indicate that there are just
India has provided financial incen- health care, public confidence and 10 hospital beds per 10,000 popula-
tives for deliveries in facilities for socio-economic disparities. Findings tion in low-income countries, com-
women from marginalized groups from studies of private services in pared with almost six times that
in priority districts. While these India, Indonesia and Mexico show number for higher-income countries.39
initiatives have increased access the challenges of assessing quality
to health-care services, effective of care across the public and private Where facilities exist, governments
improvements in maternal health sectors and the importance of taking and other supervising agencies must
outcomes may not be realized without into consideration the national ensure that they are properly func-
concomitant improvements in quality context before drawing definitive tioning and maintained. In Uganda,
of services. Continued monitoring conclusions about either sector.38 where declines in maternal mortality
and evaluation of these financing Governments face the challenge of have been registered, a review of
innovations are required to inform improving the regulation of private emergency obstetric care facilities
appropriate scale-up by policymakers. health-care providers, using interna- showed that in 54 districts out of 56
tional guidelines to develop national throughout the country, over 97
Private-sector providers policies that mandate minimum per cent of facilities expected to pro-
The private sector has become an standards for such services as ante- vide basic emergency services were
important health-care provider, par- natal care, case management of HIV not able to do so. Lack of running
ticularly in Asia, but the evidence and AIDS, maximum acceptable water, electricity, and functioning
base to measure its effectiveness is rates for Caesarean-section deliveries operating theatres were among the
still limited, with most evaluations and other critical issues in maternal key impediments to service delivery.40
measuring short-term changes in and newborn care. Further reviews are urgently required
provider behaviour, not health out- to ensure that existing facilities are
comes or other impacts on beneficiar- Step 5: Strengthening upgraded and new ones are estab-
ies. The private sector is heteroge- infrastructure, transportation, lished in a sustainable manner.
neous in nature and encompasses a logistics, supplies and the Funding for medical supplies, includ-
variety of providers, including tradi- referral process ing essential medicines, is a further
tional healers and birth attendants, priority. The UN inter-agency list of
church-based hospitals, spas and cor- Strengthening health systems to sup- essential medicines for reproductive
porate global entities that may oper- port maternal and newborn care health serves as a useful guide to the
ate without regulation and oversight. requires investing in sectors that sup- minimum number of effective, cost-
In many low-income countries, pri- port essential maternity and basic saving drugs that should be
vate providers work in environments health-care services. In addition to available.41
where formal regulatory controls, enhancing information systems, it is
whether in the form of professional also imperative to expand human Plans for health infrastructure
associations, legislative enforcement resources, foster social mobilization development should consider the
or government taxation, are weak.37 and establish equitable financing, best means of improving transporta-
and develop infrastructure, supplies, tion systems to aid women and
Enhancing the quality of care is required both to ensure safety and
well-being, and to encourage greater use of health-care services.
children in accessing routine and learning mechanism for referral in ized services. Such care should strive
facilities-based emergency care government services.43 to obtain the best possible medical
and, in some environments, to outcome; satisfy providers, patients,
enable mobile healthcare teams. To be more responsive and effective, and families; maintain sound mana-
Programmes in India (see Panel referral systems must at a minimum gerial and financial performance;
on page 84) and rural Nepal offer ensure: communication between and develop existing services in
examples of how incentives can be facilities to prepare for urgent cases, order to raise the standards of care
offered to finance transportation transportation and clinical stabiliza- provided to all women.44
for pregnant women.42 tion of patients, accompaniment
during referral, follow-up of each While existing health systems in
Improving transportation infrastruc- case and the ability to move care to industrialized and middle-income
ture will also assist in strengthening a patient if it is too risky to transport countries may need reform to
the referral process, which remains the patient. More broadly, referral provide more accessible and better
a neglected and under-researched systems must assess population needs maternity and neonatal services,
element of emergency maternal- and health system capabilities, encour- emerging health systems may build
newborn services and of health age active collaboration between quality of care mechanisms into
systems more broadly. Yet it is referral levels and across sectors, for- new programmes. In Côte d’Ivoire,
often a crucial element for the malize communication and transport for example, a national programme
survival of mothers and newborns. arrangements, develop protocols for was launched in 2000 to integrate
referrer and receiver, ensure account- prevention of mother-to-children
Reducing the time between referral ability for provider performance and transmission of HIV into existing
and getting women to facilities is supportive supervision, provide pro- maternal health services. A recent
often critical to their survival. In a tection against the financial costs, study has shown that the programme
study in rural west Maharashtra, and develop indicators to monitor has improved overall quality of
India, the distance to general health effectiveness. care in many areas, including
services was 3 km for women who administration of oxytocin in the
died from complications and 2.5 km third stage of labour and checking
for women who survived similar Step 6: Improving the quality the uterus post-partum.45 Such pro-
complications. But the distance to of care grammes offer staff new training
reach appropriate treatment for Definitions of quality maternity and opportunities and greater investment
birth complications was 63.5 km neonatal care have expanded from in their own responsibilities as well
for women who died and 39.3 km an exclusive focus on biomedical as critical opportunities to save lives.
for women who survived. A study outcomes to a more inclusive
in Karnataka, India, showed that approach that also takes into consid- Various organizations have under-
referrals of women for emergency eration patient rights and satisfac- scored the need for emergency
obstetric care reflected multiple, tion, standards, equity, and the obstetric care by engaging in quality
but haphazard and frequently futile, responsibilities and rights of health of care measures in such diverse
attempts to get effective care from a institutions and workers. Good qual- countries as Mali, Peru and Viet
range of poorly functioning govern- ity care provides a minimum level of Nam. Building on the foundation for
ment services and informal and pri- care to all pregnant and intrapartum emergency obstetric care, these meas-
vate providers. Although informal women and neonates, while having ures improved and simplified report-
networks connected private the capacity to attend to those ing and monitoring mechanisms,
providers, there was no feedback or requiring emergency or more special- developed protocols and standards in
Creating a supportive environment and strong political will are critical to
the success of health-system strengthening.
an inclusive and participatory man- tively bring about change, nor be also commitment, as stated in both
ner and fostered competency through held effectively accountable for lack this and last year’s report, to creating
skill-based training and continuous of change, if their working environ- a supportive environment for mater-
supportive supervision. Improved ments are not supported by health nal, newborn and child survival and
teamwork was facilitated through adminstrators and the elected lead- health that respects and advances the
better communication and referral ers that direct them. rights of women and children.
systems. Women’s concerns and
rights were addressed, partnerships Translating promise into purposeful
with communities were initiated and Developing health systems: The action will take more than strong
providers were empowered to employ case for collaborative action words or firm commitments. It will
problem-solving innovations.46 require nothing less than the concert-
The key elements for health systems ed action of national governments, the
For these measures to succeed, they development – strengthening the evi- international development community,
need senior managerial support and dence base, expanding and enhancing civil society organizations, the private
ownership. Evaluations of Health the health workforce, upgrading and sector, and households and communi-
Workers for Change found that broadening infrastructure and logis- ties themselves, to take responsibility
while changes were carried out at tics, providing equitable financing for improving the health of mothers
local levels, they were not necessari- solutions and stimulating demand for and newborns as a barometer of
ly supported by concomitant higher- quality care through social mobiliza- national and international respect for
level policy measures.47 Problems tion – are being increasingly accepted human rights and commitment to
that require higher levels of manage- by national governments and local human progress. Chapter 5 examines
rial accountability or policy change – and international agencies. some of the partnerships that are driv-
staff vacancies and transfers, finan- ing this process forward, and suggests
cial discretion for staff, reporting Furthermore, there is a growing con- how such collaborations may be
formats, availability of critical sensus on the merits of scaling up enhanced in the coming years.
inputs like blood – can limit the integrated packages of essential serv-
effect of local quality of care ices and leveraging community part-
processes on maternal health out- nerships in the provision of maternal
comes. Health workers cannot effec- and newborn care. Finally, there is
5 Working together for maternal

and newborn health
Improving maternal and newborn health will require collaboration, commitment and creativity. International
and national efforts are becoming increasingly cooperative in meeting the challenges of the Millennium
Development Goals and other internationally agreed objectives. It is time to apply the same determination,
evidence, innovation and resources that enabled swift and sustained gains to be made in many aspects of
child survival to maternal and newborn health. The final chapter of The State of the World’s Children 2009
examines the collaborative partnerships and programmes that are striving to create supportive environments,
establish continua of care and strengthen health systems to improve maternal and newborn health. It
explores ways of strengthening collaboration, enhancing aid effectiveness and applying resources and
commitment to achieve concrete results.
T
he halfway point for communities and socio-economic require country-specific actions
meeting the health-related groups that are falling behind in their where the mix of corrective action
Millennium Development efforts to meet the goals and merit depends on country profiles, policy
Goals has come and gone. stronger efforts in support of mater- choices, specific cost functions and
The report card on progress to date nal and newborn health. the creation of a supportive environ-
has been mixed. Much has been done ment for maternal and newborn
in recent years to accelerate advances The need for collaborative action is health based on respect for the rights
in maternal, newborn and child paramount. Meeting the challenge of of women and children.
health, coordinate actions and scale improving maternal and newborn
up essential interventions. Concrete health will require creative, consis- To this end, the final chapter of The
gains have been achieved, particular- tent and concerted efforts at the State of the World’s Children 2009
ly in reducing the number of deaths macro level to create supportive focuses on recent developments in
of children between 29 days and five environments for women and girls, global health partnerships, briefly
years of age (the post-neonatal peri- establish continua of care and exploring three key areas: collabora-
od) in many developing countries. strengthen health systems. tion; aid effectiveness; resources and
International assistance for maternal, commitment for results.
newborn and child health has risen, This report has reiterated a widely
encouraging higher aid inflows, known truth: There is nothing myste- Strengthening collaboration
strengthening partnerships and con- rious about maternal and neonatal Recent years have seen an expansion
solidating frameworks for action. mortality. The reasons women and of global health partnerships, spurred
babies die from causes related to in part by the emphasis on collabora-
The challenge is to build on these pregnancy and childbirth – and why tion embodied in MDG 8 – which
gains over the remaining years to millions of children die during the seeks to develop a global partnership
2015 and beyond. Particular attention first 28 days of life – are well under- for development – and the 2002
must be given to the needs of Africa stood. Addressing them requires Monterrey Consensus on Financing
and Asia, the two continents that good data and analysis, sound strate- for Development. These initiatives
have the greatest burden of maternal gies, adequate resources, political are having a crucial effect in several
and neonatal deaths. Within all devel- commitment and collaborative part- areas, particularly research, evalua-
oping regions, including those broad- nerships. As outlined in previous tion and prevention and treatment of
ly on track to meet all or some of the chapters, the weaknesses of health communicable diseases such as AIDS,
health MDGs, there are countries, systems in individual countries tuberculosis, measles and malaria.
One example relates to measles: In income countries received antiretro- recent years. This has led to the for-
2007, Africa was able to report a viral therapy to prevent transmission mation of several new collabora-
91 per cent drop in measles deaths of HIV to their children, up from tions that complement the work of
between 2000 and 2006. This 15 per cent in 2005. In addition, longstanding partnerships in efforts to
unprecedented success resulted from the number of children receiving accelerate progress towards MDG 5.
a concerted drive by national govern- antiretroviral therapy has almost
ments and international partners to tripled, from 75,000 in 2005 to The increase in global health partner-
boost measles immunization.1 200,000 in 2007.2 ships for maternal, newborn and
child health is not without challenges,
Prevention of malaria, too, is being These are but three of the examples however. Depending on the definition
addressed through distribution of how coordinated action between used, global health partnerships num-
of insecticide-treated mosquito national governments and interna- ber over 100, and developing coun-
nets, increasingly available free tional partners is delivering concrete tries have sometimes reported difficul-
through mass campaigns. The drive improvements in the lives of mothers, ties in interacting with the large num-
to combat HIV and AIDS, mean- newborns and children. ber of initiatives.3 Further, while there
while, is making progress on many is a consensus around the imperative
fronts. In 2007, 33 per cent of the Maternal and newborn health has of creating effective continua of care
estimated 1.5 million HIV-positive drawn specific attention from global for mothers, newborns and children,
pregnant women in low- and middle- health partnerships and initiatives in the challenge remains to complement
vertical flows of aid on disease-specif-
ic interventions with a strengthening
of integrated approaches, combined
with health-systems development.
Integrating the work of global

health partnerships in establish-
ing national continua of care is
a key challenge for the coming
years. Several bilateral donors
are already taking steps to
harmonize their collaboration
and improve the effectiveness
of their contributions through
partnerships. These include the

Global Campaign for the Health
Millennium Development Goals,
led by the Government of Norway;
Providing for Health Initiative,
led by Germany and France;
Comprehensive reproductive health care; skilled care during pregnancy; delivery by a the Catalytic Initiative to Save
trained midwife, nurse or doctor; and emergency obstetric care for life-threatening a Million Lives, led by Canada;
complications should be available to expecting mothers and newborns. A doctor leads
a training session for nursing students as part of Woman’s Right to Life and Health
and GAVI’s Health Systems
Initiative, Pakistan. Strengthening Window.
W O R K I N G T O G E T H E R F O R M AT E R N A L A N D N E W B O R N H E A LT H 93
Focus On Working together for maternal and newborn health
by Sarah Brown, Patron of the White Ribbon Alliance for Safe Motherhood and wife of Gordon Brown,
Prime Minister of the Government of the United Kingdom.
Much of my work over the past few years has focused on precious resources and respond to genuine local need. We
preventive programmes to improve the health of infants born have seen the difference that effective health services can
prematurely or following difficult pregnancies. Increasingly, make. The evidence is clear.
by working together, the medical community in the developed
world is improving interventions to ensure that a newborn Japan reduced its maternal mortality rate by two thirds in
arriving in difficult circumstances receives the necessary care in the decade following 1945. It achieved this by introducing
the first crucial stages of life to survive and enjoy quality of life. community health workers that provided consistent health
care from pregnancy right through to when a child starts
However, the state of infant survival in the developing world school. Mothers were educated on their rights and the impor-
sits in stark contrast to the situation in industrialized countries tance of quality health care through a mother-and-child hand-
like the United Kingdom. As a representative of the internation- book of which the Japanese are rightly proud. Also important
al advisory board of the Royal College of Obstetricians and to this achievement was the vital injection of political will and
Gynaecologists, I have observed the training programmes that momentum that continue even today. International leadership
the RCOG conducts in numerous countries in Africa and Asia at is critical to focusing attention and channelling resources for
first hand. What this practical experience has brought home to maternal health.
me is the realization that you cannot start saving the most vul-
nerable infants and children without first ensuring the health Right now, as we count down to the MDG deadline in 2015, we
of their mothers. have worldwide momentum. Right now we can achieve world-
wide change. Never before has this issue had so much visibili-
The reason is simple: It is the mothers who do the work of rais- ty and support from so many different sources around the
ing their children, feeding them, getting them into school and world. At the G8 Summit in Japan this year, for the first time,
taking them for their vaccinations. By contrast, children who maternal health was on the agenda.
have lost their mothers are almost five times more likely to die
in infancy than those who still have their mothers, and mother- However, we must understand that governments cannot dramat-
less newborns are ten times more likely to die. ically reduce maternal mortality on their own. Non-governmental
organizations are increasingly making maternal health a priori-
The scale of this problem becomes evident when you look at ty and working together. They are joining grass-roots organiza-
annual numbers of maternal deaths, which are little changed in tions, such as the White Ribbon Alliance for Safe Motherhood,
almost 20 years. Across the world this year, more than half a whose members have been campaigning in more than 90
million mothers will lose their lives in pregnancy and child- countries for progress. An impressive start has been made
birth, and almost all of these deaths will occur in poorer by the world’s midwives, obstetricians and gynaecologists.
countries. In addition, for every mother who dies, 20 women Their professional organizations, led by the International
are left suffering from injuries and disabilities as a result of Federation of Gynaecology and Obstetrics and the Inter-
complications in childbirth. national Confederation of Midwives, are committed to
working together to help developing countries train health
It is vital that we – governments, non-governmental organiza- workers in antenatal care, delivery and infant care skills.
tions, faith-based organizations, private-sector companies and
committed individuals – all work together to ensure that in We can all play our part in reducing maternal mortality.
every country and community around the globe, women have Individuals can campaign for change, communities can
access to essential primary health care and skilled health raise awareness among their men and women, and non-
workers. This is what will save the lives of mothers – and so governmental organizations, private-sector organizations
bring better life chances to newborns and children otherwise and governments can work together to find practical solutions.
at grave risk.
Let each of us bring our skills to the table and work together to
If we get this right, we will save lives at every stage of the life raise the bar in maternal and child health around the world.
cycle. Millennium Development Goal 5, which seeks to improve
maternal health, lies at the heart of all of the MDGs. Access to We must work together to ensure that there is access to
skilled health workers supports the continuum of care women well-trained health workers in every country and community
and their children need. Mothers give birth safely when they that needs them, and that each government is ready to put
can access antenatal support and skilled care during childbirth them to work.
and the critical time afterwards. A well staffed, well stocked
health centre will also ensure that infants receive essential We owe it to the millions of mothers who have lost their
vaccinations and that the necessary medications are available lives unnecessarily over the last 20 years. We owe it to the
to keep them from dying from malaria or pneumonia. thousands of pregnant women around the world giving birth
every day in fear of their lives.
We must do more than focus on vertical solutions. All active
organizations working to eradicate poverty and disease and to We owe it to the next generation of children born in the poor-
improve health care and education must find the opportunity est countries of the world – children who need, and deserve,
to integrate delivery. We need to maximize the effectiveness of their mothers.
For their part, the work of the eight
major international health agencies –
the World Health Organization,
UNICEF, the World Bank, GAVI, the
United Nations Population Fund, the
Joint United Nations Programme on
HIV/AIDS (UNAIDS), the Global
Fund to Fight AIDS, Tuberculosis and
Malaria, and the Bill & Melinda Gates
Foundation – is being enriched by
increased dialogue through the infor-
mal Health-Eight (H8) group. The H8,
which held its inaugural session in July
2007, meets twice a year to examine
the challenges to expanding key health
© UNICEF/ALBA000331/Giacomo Pirozzi
interventions and accelerating progress
towards the health-related MDGs.4
The International Health Partnership

(IHP), launched in September 2007,
is a coordinating partnership that
brings together governments, donors
and international agencies to harmo- Strong public investment in the overall health system and unified national and international action
nize their efforts and support nation- and commitment will lead to improved maternal and neonatal survival and health. A nurse
attends a newborn at a UNICEF-supported health centre for mothers and children, Albania.
al health development plans. Country
and global compacts are the key
mechanisms by which the IHP aims Paris Declaration on Aid Effectiveness, the need to accelerate aid effectiveness
to support this process. In August a set of best practices for global health in three key areas: strengthening coun-
2008, Ethiopia became the first coun- partnerships has been generated with try ownership, building more effective
try in which the Government and a focus on harmonization of efforts, and inclusive partnerships, and focus-
partners have signed a country com- alignment of support with national ing on development results – and
pact with the IHP. Mozambique also strategies and systems, country owner- openly accounting for them.
endorsed a country compact in ship, mutual accountability and
September 2008, and other countries managing for results. The OECD Within the area of partnerships, the
in Africa and Asia are set to sign Development Assistance Committee Accra Agenda for Action recom-
agreements in the coming months.5 has also responded to the need for mended that partnerships adopt five
further practical guidance. In key tenets to improve aid effective-
Improving the effectiveness of September 2008, a third High Level ness. These include:
international aid Forum on Aid Effectiveness took place
in Accra, Ghana. The Accra Agenda • Reducing the cost fragmentation
Several high-level forums have set for Action, endorsed by the Forum’s of aid through enhancing the
out to tackle the problem of aid participants, deepened and strength- complementarity of donor efforts
effectiveness. Based on the 2005 ened the commitment. It underlined and promoting a better division
Key global health partnerships for maternal and newborn health
In recent years, global health partnerships have emerged • Women Deliver was launched in London in October 2007 to
to lend attention to, and raise resources for, maternal and mark the 20th anniversary of global efforts to reduce high
newborn health. Some of the key partnerships are rates of maternal and newborn death and disability in the
highlighted below. developing world – and to apply the knowledge gained
from two decades of study and experience. The initiative
• The Partnership for Maternal, Newborn and Child Health is aims to reframe maternal health as a basic human right and
a global health partnership launched in September 2005 an integral strategy for achieving just development, reduc-
that brings together maternal, newborn and child health ing poverty and ensuring environmental sustainability. The
organizations into an alliance of some 240 member groups. organizing partner is Family Care International.
The Partnership, hosted and administered from Geneva by
the World Health Organization, advocates for greater • Saving Newborn Lives is a Save the Children project to
investment and commitment to saving the lives of mothers improve newborn survival in high-mortality countries. Since
and children. In July 2008, it issued a Global Call asking G8 its launch in 2000, the initiative has reached more than 20
leaders to fund basic health services for women, newborns million mothers and babies with critical health services in
and children and urging organizations and individuals to 18 countries in Asia, Africa and Latin America.
sign on to its demands for political leadership and invest-
ment. • The White Ribbon Alliance for Safe Motherhood is an inter-
national coalition of individuals and organizations formed
• Deliver Now for Women + Children Campaign is a new to promote safe pregnancy and childbirth for all women.
advocacy drive to eliminate maternal and child deaths and Members of the Alliance take action in their own countries
improve the health of women and children around the to make this issue a priority for their governments and
world, co-ordinated by the Partnership for Maternal, other international organizations.
Newborn & Child Health. It is a response to concern that
the world is lagging far behind in reaching the Millennium • The Initiative for Maternal Mortality Programme
Development Goals (MDGs) for reducing maternal and Assessment (IMMPACT) is a global research initiative whose
child deaths. aim is to promote better health for mothers-to-be in devel-
oping countries. By carrying out studies of different strate-
• The Global Campaign for the Health Millennium gies, and judging their effectiveness and the value for
Development Goals was unveiled on 26 September 2007 money they represent, IMMPACT aims to improve measure-
by Norwegian Prime Minister Jens Stoltenberg at the ment and the supporting evidence that will help in the
Clinton Global Initiative in New York. The Global Campaign assessment of each strategy’s potential.
is supported by several governments, including the UK,
Norway, Canada, France and Germany, as well as a number • Countdown to 2015 was formed in 2005 by a group of
of prominent global health and advocacy organizations. scientists, policymakers, activists and institutions to
It attaches special importance to the health of women and track progress towards Millennium Development Goal 4.
children, “whose needs remain the most neglected.” The Coverage reports were made available at a conference for
Global Campaign brings together a number of related 60 priority countries for child survival initiatives. The second
initiatives including: conference, held in April 2008, expanded the mandate of
the Countdown to include maternal and neonatal survival,
• The International Health Partnership, launched in and the number of countries tracked in reports increased to
London by UK Prime Minister Gordon Brown in 68.
September 2007, aims to help build national health
systems in some of the poorest countries in the world. • Averting Maternal Death and Disability is a global pro-
gramme run by the Mailman School of Public Health,
• The Catalytic Initiative to Save a Million Lives, launched Columbia University, New York, that contributes to reducing
by Canadian Prime Minister Stephen Harper in maternal mortality and morbidity through research, advoca-
November 2007, aims to strengthen health systems by cy, policy analysis and programme support. In recent years,
training frontline health workers and delivering afford- the programme has operated in around 50 countries across
able healthcare services directly to local communities. the developing world.
• Innovative Results-Based Financing, launched by Norway See References, page 112.

and the World Bank in November 2007, seeks the most
cost-effective ways of obtaining better health outcomes.
• Providing for Health Initiative, launched by Germany and

France in 2008, aims to strengthen health systems by put-
ting appropriate social health protection mechanisms in
place with a view to achieving universal coverage.
Greater political and institutional commitment to maternal and newborn
health is being complemented by rising financial flows to these areas.
of labour between partners. city and situation analysis, foster- capacity-building and result-based
Discussions on improving the ing collaboration between donors financing; compacts for mutual
divisions of labour across coun- and national governments to for- accountability in several countries;
tries will begin in June 2009. mulate a set of practical objectives improvements in harmonization and
that can address the root causes of alignment of aid; adoption of core
• Increasing aid’s value for money by conflict and fragility, encouraging principles of global health partnerships
untying aid, promoting local and the participation of women, and for operations at the country level;
regional procurement, and respect- working on flexible, rapid and and the establishment of H8 and the
ing international agreements on long-term funding modalities. International Health Partnership to
corporate social responsibility. ensure that aid interventions become
These actions are particularly relevant more cohesive and comprehensive.6
• Working with all development actors for global health partnerships because
by recognizing the importance of the health sector has been chosen by Sustained engagement and refinement
South-South cooperation, encourag- donors and partner countries to moni- of the best-practice principles are
ing developing countries to utilize tor progress on implementing the Paris steadily consolidating a framework
their international cooperation pro- Declaration. Steps are already being for the actions of global health part-
grammes to assist other developing taken to strengthen and harmonize aid nerships and a set of indicators of
countries, and deepening triangular directed towards the health sector. progress and targets that can be
cooperation. Global funds and pro- Important advances include: a stronger measured nationally and monitored
grammes are urged to support coun- focus on harmonized approaches, internationally.
try ownership, align and harmonize
their assistance, ensure mutual Figure 5.1
accountability and continue their
focus on achieving results.
Key global health initiatives aimed at strengthening
health systems and scaling up essential interventions
• Deepening engagement with civil
society organizations through
inviting them to examine how they Strengthening Health Systems and
can apply the Paris Declaration Scaling Up for Better Health
principles to their own activities,
engage in a multi-stakeholder
process to promote their develop- Catalytic Innovative
International UN SG Results- Providing for
Initiative to
ment effectiveness, and provide a Health Save a
MDG Africa Based Health
Partnership Initiative Initiative
supportive environment that Million Lives Financing
enables them to optimize their

contributions to development.
GAVI Global Fund

• Adapting aid policies for countries Global Health Health
Health National
Deliver Now Harmonization
Workforce Metrics for Women for Health
in fragile situations through moni- Alliance Network
Systems Strategy
and Children in Africa
Strengthening Applications
toring implementation of the
Principles for Good International
Engagement in Fragile States and Source: International Health Partnership, <www.internationalhealthpartnership.net/ihp_plus_
Situations, conducting joint capa- about_initiatives.html>, accessed 1 September 2008.
Deepening global
political commitments
and resources for better
health outcomes
Measures to improve the quality of
aid are being complemented by grow-
© UNICEF/HQ07-0346/Christine Nesbitt
ing political commitment and higher

financial flows directed at maternal
and newborn health. Several years
ago, issues of maternal and child
health were rarely addressed by
world leaders. Today, maternal
and child health are on the agenda
Investing resources at both national and international levels to train and retain skilled staff is vital of world leaders and major confer-
to improving maternal and neonatal health. A measuring tape and a traditional fetal stethoscope lie
on an examining table in a maternity ward that offers antenatal and neonatal services, as well as ences, including the G8.
services to prevent mother-to-child transmission of the HIV virus, Nigeria.
At the 2008 G8 summit meeting,
the issue of maternal mortality was
Figure 5.2
discussed, and the Partnership for
Official development assistance for maternal and Maternal, Newborn and Child
neonatal health has risen rapidly since 2004 Health asked leaders to increase
spending on maternal and child
health care and family planning
4000
by US$10.2 billion per year.8
Total:
3,482
3500 2,309 In parallel with the 2008 G8
Total: Summit, a G8 Health Experts
2,935 Official development
3000
US$ (constant 2005), millions
2,035 assistance for maternal

Group was established. The group
and neonatal health set out principles for action, pledg-
2500 ing to take comprehensive action
Total:
Total:
2,119
2,057 to address the health-related
1,415
2000 1,509
Official development
Millennium Development Goals,
assistance for child health and underlining the importance of
1500 both disease-specific initiatives and
health-systems strengthening. It also
1,173
1000 emphasized the need for a longer-
901
term perspective that extends
704
500 548 beyond the 2015 MDG deadline,
and the imperative of mobilizing a
0
wide range of stakeholders.
2003 2004 2005 2006
Source: Greco, Giulia, et al., 'Countdown to 2015: Assessment of donor assistance to maternal,
Action was pledged in five key
newborn, and child health between 2003 and 2006', The Lancet, vol. 371, 12 April 2008, p. 1269. areas: health systems strengthening;
Focus On Partnering for mothers and newborns in the
Central African Republic
The Central African Republic is among the world’s lowest and post-natal practices prevail and access to maternal
income countries, with a gross national income per capita tetanus toxoid immunization during pregnancy is poor.
of US$360 in 2007. Located in the heart of the African
continent, the country has endured a decade of conflict. Despite the challenges posed by ongoing insecurity, interna-
The worst-affected regions are located in the northeast and tional agencies are collaborating with the Government to
northwest, where rebel groups and government forces fre- tackle maternal and neonatal tetanus as part of a wider effort
quently clash. This ongoing violence has resulted in mass in support of maternal, newborn and child health. In January
displacement and disruption of public infrastructure such as 2008, the Ministry of Health, together with the World Health
health care services, especially in the northern region. Organization, the United Nations Population Fund and
UNICEF, launched the Mother and Child Survival Campaign.
Maternal and neonatal survival and health remain at risk from The first phase of the campaign prioritized immunization,
poverty and conflict. The lifetime risk of maternal death is 1 in resulting in the vaccination of 700,000 women of reproductive
25, and UN inter-agency estimates put the country’s maternal age against tetanus. A second round of immunization was
mortality ratio at 980 maternal deaths per 100,000 live births in held in March, and the campaign is set to reach 1.5 million
2005. The neonatal mortality rate was 52 per 1,000 live births in women and children across the country. The tetanus immu-
2004, above the West and Central Africa average of 44 per 1,000 nization campaign represents an important initial step in the
– which itself was the highest regional aggregate for this indica- drive to reduce maternal and neonatal deaths.
tor in the developing world. Only 53 per cent of women in the
country are attended by a skilled health worker at delivery. The Central African Republic and its partners face the
challenge of consolidating these gains and strengthening
Maternal and infant health is undermined by poor control the health system to deliver maternity services and basic
of communicable diseases, insecurity and the lack of com- health-care interventions that can help improve maternal
prehensive maternal health programmes. Among other and newborn health. Enhancing security will also be
infectious diseases, tetanus is an important cause of pivotal to widening access to women and children.
neonatal death. Cases are prevalent in poor, remote and
disenfranchised communities where unhygienic obstetric See References, pages 112.
maternal, newborn and child health; least US$60 billion for combating trained health personnel, more reliable
infectious diseases – including AIDS, major infectious diseases and commodity supply systems, improved
tuberculosis, malaria, polio and neg- strengthening health systems.9 labs and diagnostics and more home
lected tropical diseases; promotion and community based services, even as
of a cross-sectoral approach – Disease-specific funds, such as they focus on fighting specific diseases.
including the empowerment of the Global Fund to Fight AIDS,
women, reduction of gender Tuberculosis and Malaria, the GAVI The World Health Organization,
inequalities and violence against vaccine initiative and the US govern- UNICEF, the United Nations
women, and health; and resources. ment’s AIDS and malaria programmes Population Fund and the World
Developing countries were encour- provide opportunities to leverage sig- Bank have reinvigorated their com-
aged to allocate more of their own nificant resources for maternal and mitment to improve maternal and
resources to health care, and the G8 newborn health, through stronger newborn health (see Panel on page
reiterated its commitment to work- health systems and service provision. 102), and major global health part-
ing towards the goal of providing at These funds contribute to better nerships and programmes are mobi-
lizing sizeable resources to support
specific programmes and integrated
approaches to health-service delivery.
The increased political will and com-
mitment evident in low-income,
middle-income and donor countries
to accelerate progress on maternal
and child health is significantly
enhancing collaboration and cooper- Both community workers and trained medical staff have vital roles in ensuring the continuum
of care that runs from the home and the community right through to the clinic and the hospi-
ation and creating a global compact.
tal. A community health volunteer gives a pregnant woman vitamin A, iron and folic acid sup-
plements, during a home visit, Nepal.
Financial flows for maternal,
newborn and child health
official development assistance to and newborn health increased by 66
Greater political and institutional maternal, newborn and child health per cent. Disbursements for maternal,
commitment to maternal newborn rose by 64 per cent between 2003 and newborn and child health from GAVI
and child health is reflected in sharply 2006. Specifically, funds apportioned and the Global Fund to Fight AIDS,
rising aid flows to these areas. The to child health rose by 63 per cent, Tuberculosis and Malaria rose by
latest estimates indicate that global while those assigned to maternal 200 per cent over the same period.
Figure 5.3
Nutrition, PMTCT and child health have seen substantial rises in financing
Total ODA to maternal, newborn and Total ODA to maternal, newborn and
child-specific health projects, 2003: 1,193 million child-specific health projects, 2006: 1,680 million
IMCI, 16
PMTCT, 32 million (2%)
million (1%) Non-specified MNCH,
PMTCT, 49 million (4%) IMCI, 7 million
4 million (<1%) Child health, 128 million, (8%) (<1%)
Child health, 41 million (3%)
Nutrition,
113 million
(10%)
Nutrition,
223 million Non-specified MNCH,
(13%) 467 million (28%)
Maternal health/ Immunization, Maternal health/

safe motherhood, 552 million (47%) safe motherhood,
417 million (35%) 346 million (21%)
Immunization,
477 million (28%)
All figures in
US$ (constant 2005)
Source: : Greco, Giulia, et al., 'Countdown to 2015: Assessment of IMCI: Integrated Management of Childhood Illness
donor assistance to maternal, newborn, and child health between MNCH: maternal newborn and child health
2003 and 2006', The Lancet, vol. 371, 12 April 2008, p. 1269. PMTCT: prevention of mother-to-child transmission of HIV
The opportunity to save the lives of thousands of women and millions of
children lies within reach.
There remains ample scope to further and newborn health stood at US$704 With the bulk of financing still
increase resources directed to maternal million, the 2006 figure translates into going to support projects, funding
and newborn health. Recent analysis just US$12 per live birth. of health system development –
of official development assistance such as training, staffing, manage-
(ODA) flow to these areas indicates Research also shows that some coun- ment and logistics, urgently
that aid to maternal, newborn and tries experience sharp fluctuations in required to accelerate progress
child health-related activities account- aid inflows to maternal, newborn and on maternal and newborn health –
ed for just 3 per cent of gross ODA child health between years, complicat- remains limited in relative terms.10
disbursements. Moreover, the funds ing efforts for effective planning for Enhancing the predictability and
apportioned to maternal and neonatal strategic priorities in developing sustainability of aid flows will be
health activities are lagging behind countries – particularly those where critical to ensuring that the progress
those devoted to child health. Figures aid dependency is greatest. And achieved in maternal, newborn and
for 2006 indicate that global ODA to despite recent enhancements in the child health is both maintained and
maternal and neonatal health reached frameworks for aid effectiveness and deepened. Reduction of the transac-
US$1.2 billion, roughly half the sum moves towards sector and budget tion costs for national governments
apportioned to child health. While support, the bulk of financing for in their relations with global health
this represents a sharp increase since maternal, newborn and child health is partnerships and programmes must
2003, when global ODA for maternal apportioned through project funding. also be tackled, with implications
Figure 5.4
Financing for maternal, newborn and child health from global health initiatives has
increased sharply in recent years
Total ODA for maternal, newborn and child health, 2003: Total ODA for maternal, newborn and child health, 2006:
US$2,119 million US$3,482 million
Global:
172 million
(8%)
Global:
505 million
(15%)
Bilateral:
1,880 million
Multilateral: (54%)
651 million Multilateral:
Bilateral: (31%) 1,096 million
1,296 million (31%)
(61%)
All figures in
US$ (constant 2005)
Source: Greco, Giulia, et al., 'Countdown to 2015: Assessment of donor assistance to maternal, newborn, and child health between 2003 and 2006',
The Lancet, vol. 371, 12 April 2008, p. 1269.
UN agencies strengthen their collaboration in support of maternal
and newborn health
At the High Level Event on the Millennium Development Goals Core agency functions and responsibilities in the
held in September 2008 at the UN General Assembly, the continuum of maternal and newborn care
four major health agencies – the World Health Organization, In an earlier document on joint country support for accelerat-
UNICEF, United Nations Population Fund and the World Bank – ed implementation of maternal and newborn continuum of
made a joint declaration of their intent to intensify and harmo- care published in July 2008, the four agencies also pledged
nize their efforts towards Millennium Development Goal 5, the to work with governments to strengthen the continuum of
goal that has made the least progress. The main objective of maternal and newborn care. Based on their comparative
this renewed commitment to collaborative action is to coordi- advantages and expertise, the core functions to be
nate efforts at the country level and jointly raise the required undertaken by each agency were also specified:
resources.
World Health Organization: policy, normative, research,
The four agencies pledged to strengthen support to countries monitoring & evaluation.
with the highest levels of maternal mortality – especially the
25 countries with the most elevated maternal mortality ratios United Nations Population Fund: reproductive health com-
or numbers of maternal deaths. Based on their comparative modity security, support to implementation, human resources
advantage, core specialties and experience, and collective for sexual and reproductive health including maternal and
strengths, the agencies plan to jointly contribute to capacity newborn health, and technical assistance on building monitor-
building, health systems development and costing and financing and evaluation capacity.
ing of maternal, newborn and child health plans.
UNICEF: financing, support to implementation, logistics &
Strengthening national capacity supplies, and monitoring & evaluation.
The agencies will work with governments and civil society to
enhance national capacity in the following ways: World Bank: health financing, inclusion of maternal,
newborn and child health in national development frameworks,
• Conduct needs assessment and ensure that health plans are strategic planning, investment in inputs for health systems,
MDG-driven and performance-based; including fiduciary systems and governance, and taking
successful programs to scale.
• Cost national plans and rapidly mobilize required resources;
In addition, focal agencies, or shared focal agencies, were
• Scale up quality health services to ensure universal access identified for each component of the maternal and newborn
to reproductive health, especially for family planning, continuum of care to ensure optimal support, accountability
skilled attendance at delivery and emergency obstetric and enhanced coordination. The identification of agency
and newborn care, ensuring linkages with HIV prevention responsibilities, outlined in Figure 5.5, does not preclude the
and treatment; involvement of other agencies in each area, but rather implies
that the focal agency or agencies will coordinate the UN
• Address the urgent need for skilled health workers, particu- response to support the national health plan in that area.
larly midwives; Furthermore, the work of each agency will continue to be
guiding by the prevailing situation in each country, the exist-
• Address financial barriers to access, especially for the poorest; ing strengths and experience of each agency within the
country, and other contextual factors such as sector-wide
• Tackle the root causes of maternal mortality and morbidity, approaches (SWAps) and other national health plans or
including gender inequality, girls’ low access to education – compacts. In each case, the government will continue to
particularly at the secondary level, child marriage and lead and coordinate the process.
adolescent pregnancy;
• Strengthen monitoring and evaluation systems.
Figure 5.5
Focal and partner agencies for each component of the continuum of maternal
and newborn care and related functions
Area Focal agencies Partners
Continuum of maternal and newborn care
Family planning UNFPA, WHO UNICEF, World Bank
Antenatal care UNICEF, WHO UNFPA, World Bank
Skilled attendance at birth WHO, UNFPA UNICEF, World Bank

Basic emergency obstetric and
UNFPA, UNICEF WHO, World Bank
newborn care
Comprehensive emergency obstetric and
WHO, UNFPA UNICEF, World Bank
newborn care (C EmONC)
Post-partum care WHO, UNFPA UNICEF, World Bank

Newborn care WHO, UNICEF UNFPA, World Bank
UNICEF, WHO, WB (for maternal
Maternal and neonatal nutrition UNFPA
nutrition)
Additional areas of maternal and newborn health work
Girls’ education UNICEF UNFPA, World Bank
Gender/culture/male involvement UNFPA, UNICEF WHO, World Bank
Gender-based violence UNFPA, UNICEF WHO
Adolescent sexual reproductive

UNFPA, UNICEF, WHO World Bank
health – young people
Communication for development UNFPA, UNICEF WHO, World Bank
Obstetric fistula UNFPA WHO

Prevention of unsafe abortion/post abor-
WHO UNFPA
tion care
Female genital mutilation UNFPA, UNICEF, WHO World Bank
Maternal and newborn health in humani-
UNFPA, UNICEF, WHO World Bank
tarian situations
Sexually transmitted infections WHO UNFPA, UNICEF
HIV/AIDS and integration with family
As per UNAIDS Technical Support Division of Labor
planning
Pre-and-in-service training of human
WHO, UNFPA UNICEF, World Bank
resources for MNH
Regulations/legislation for human
WHO UNFPA, UNICEF, World Bank
resources for health
Essential drug list WHO UNFPA, UNICEF
Road maps’ development and

WHO, UNFPA, WB UNICEF
implementation
Source: WHO-UNFPA-UNICEF-World Bank Joint Country Support for Accelerated Implementation of Maternal and Newborn Continuum of Care,
22 July 2008.
for further streamlining and har- provides hope for greater gains in the new paradigm to illuminate the best
monization of aid and technical years to 2015 and beyond. way forward. The knowledge that can
assistance. save millions of newborn and mater-
Delivering for mothers and nal lives is available; data and analy-
Attention must also be paid to the newborns sis are improving rapidly; the frame-
need for sustainable, predictable, work for action is set; the challenge
flexible resources to support the In examining the global situation of the Millennium Development
long-term recurrent costs of health of mothers and newborns, and the Goals is clear.
provision, such as salaries, and for diverse and sometimes complex tasks
governments to create fiscal space for improving their survival and The opportunity to save the lives of
for health in their budgets. Further, health, it is possible to lose sight of thousands of women and millions
other sectors that have a direct the human side of the equation: the of children lies within reach. Efforts
impact on access to maternal and millions of women who face labour now must focus on ensuring that the
newborn health care – such as trans- and delivery with trepidation, given human and financial resources, the
portation – must also be given due the fact that this or subsequent preg- political will, and the commitment
consideration in initiatives to devel- nancies may result in their death or and collaboration increasingly evi-
op sustainable health systems. lifelong disfigurement, and that dent nationally and internationally
without adequate primary care, their all remain dedicated to the task of
These challenges are not insurmount- newborn is also very likely to face improving the health and survival
able. But they will require commit- death or illness. of mothers and newborns.
ment on behalf of all key partners
to work together to meet obligations Looking at the situation of mothers
to mothers, newborns and children. since 1990 puts the toll of death into
A focus on evidence and results sharp focus. Assuming that roughly
must drive efforts. The Millennium 500,000 women have died each year
Development Goals provide a firm since the beginning of that period,
reference point for action in the com- around 10 million women in all have
ing years. Achieving the goals will died from causes related to pregnan-
require building firm links between cy and childbirth. The latest available
all contributing partners – national estimates for newborn deaths place
governments, donors, global health them at nearly 4 million a year. The
partnerships and programmes, tragedy is that most of these lives
international agencies, civil society could have been saved with cost-
organizations, the private sector, and effective, proven interventions.
communities and families themselves.
The marked progress already achieved This situation must not be allowed
in recent years in strengthening to continue. There is no need to wait
collaboration and focusing on results for a scientific breakthrough or a
Enhancing health information systems:
The Health Metrics Network
Sound information is essential to public health decisions. partnership intends to set as the universal paradigm for data
It informs policy, programmes, budgets and evaluation and collection, reporting and usage by 2011. At the core of the
forms the basis of accountability for governments’ commitments framework is the HMN tool, a standardized questionnaire with
to their citizens. In many developing countries, however, which country stakeholders assess the current status of the
underinvestment in health information systems has left gaps health information against specific criteria. The tool provides
in data collection, dissemination and analysis. With health a gauge of baseline status, critical gaps in health information
challenges on the rise, and the deadline for the health-related results, processes, context and resources, and an assessment
Millennium Development Goals drawing ever closer, fulfilling of performance and achievements. Countries receiving techni-
the demand for sound information is imperative. cal and financial assistance from the partnership are required
to undergo an assessment using the HMN tool.
The Health Metrics Network (HMN) is an international part-
nership between developing countries, international agen- The purpose of the HMN Framework is twofold: to target
cies, foundations, global health partnerships and technical investment on the standardization of health information, and
experts that aims to strengthen health information systems. to enhance access and, by extension, usage of better health
Such systems incorporate all the multiple subsystems and information at the national and international levels. Rather
data sources that, taken together, contribute to generating than seeking to replace existing guidelines on health systems
health information: vital registration, censuses and surveys, information, the HMN framework seeks to build on appropri-
disease surveillance and response, service statistics and ate standards and promote best practices. The process is
health management information, financial data and resource envisaged as a dynamic one, which will evolve through the
tracking. In line with current trends in health-system develop- incorporation of better evidence and wider experience.
ment, HMN seeks to broaden the base of health information
and statistical systems beyond specific diseases and to foster In addition to developing the dynamic framework, the HMN
leadership in the production and use of health information at has two related objectives: to deepen health information
the national level. These objectives require enhanced coordi- systems through providing technical and catalytic financial
nation and cooperation between countries and international support to implement the HMN Framework; and to broaden
partners, and a harmonized plan to develop health informa- access, dissemination and usage of health information by
tion systems. A further aim of HMN is to focus donor partici- stakeholders at all levels. The partnership is based on a single
pation on a unified, country-owned plan to develop health and sound premise: It is not because countries are poor that
information systems, thereby reducing duplication, fragmen- they cannot afford good health information; it is because they
tation and overlap. are poor that they cannot afford to be without it.
Central to the harmonized plan is the development of the See References, page 112.
Framework and Standards for Country Health Information
Systems – known as the HMN Framework – which the
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STATISTICAL TABLES
Economic and social statistics on the countries and territories of the world, with
particular reference to children’s well-being.
General note on the data ....................................................................................page 114

Explanation of symbols ......................................................................................page 116
Under-five mortality rankings..............................................................................page 117
Summary indicators..............................................................................................page 152
Measuring human development:
An introduction to Table 10 ..............................................................................page 153
TABLES 1 Basic indicators............................................................................page 118

2 Nutrition ......................................................................................page 122
3 Health ..........................................................................................page 126
4 HIV/AIDS ......................................................................................page 130
5 Education ....................................................................................page 134
6 Demographic indicators ............................................................page 138
7 Economic indicators ..................................................................page 142
8 Women ........................................................................................page 146
9 Child protection ..........................................................................page 150
10 The rate of progress ..................................................................page 154
T H E S TAT E O F T H E W O R L D ’ S C H I L D R E N 2 0 0 9 113
Economic and social statistics on the countries and territories of the world,
STATISTICAL TABLES with particular reference to children’s well-being.
General note on the data

The data presented in the following statistical tables are mortality trends over time. It is important to note that com-
derived from the UNICEF Global Databases, which include parable under-five mortality estimates for the periods 1970,
only internationally comparable and statistically sound 1990 and the latest year are available in Table 10. In addi-
data; these data are accompanied by definitions, sources tion, the full time series for all countries is published at
and explanations of symbols. Data from the responsible <www.childinfo.org> and <www.childmortality.org>, the
United Nations organization have been used wherever website of the Inter-agency Group for Child Mortality
possible. In the absence of such internationally standard- Estimation. This time series is based on the most recent
ized estimates, the tables draw on other sources, particu- estimates produced by the Inter-agency Group for Child
larly data drawn from nationally representative household Mortality Estimation.
surveys. Data presented in this year’s report reflect infor-
mation available as of 1 July 2008. More detailed informa-
tion on methodology and the data sources is available at Multiple Indicator Cluster Surveys (MICS)
<www.childinfo.org>. For more than a decade, UNICEF has supported countries
in collecting statistically sound and internationally compa-
Several of the indicators, such as the data for life ex- rable data through the Multiple Indicator Cluster Surveys
pectancy, total fertility rates and crude birth and death (MICS). Since 1995, nearly 200 surveys have been con-
rates, are part of the regular work on estimates and projec- ducted in approximately 100 countries, and the latest
tions undertaken by the United Nations Population round of MICS surveys was conducted in more than 50
Division. These and other internationally produced esti- countries during 2005–2006, allowing for a new and more
mates are revised periodically, which explains why some comprehensive assessment of the situation of children
data will differ from earlier UNICEF publications. This and women globally. The next round of MICS surveys is
report includes the latest estimates and projections planned for 2009–2010.
from the World Population Prospects 2006.
The UNICEF-supported MICS, along with the Demographic
Data quality is likely to be adversely affected for countries and Health Surveys, are among the largest sources of
that have recently suffered human-caused or natural disas- data for monitoring progress towards the Millennium
ters. This is particularly true where basic country infra- Development Goals and may be used for reporting on 21
structure has been fragmented or major population of the 53 MDG indicators. These data are also used for
movements have occurred. monitoring other internationally agreed commitments,
such as the ‘World Fit for Children Plan of Action’ and
the global goals on AIDS and malaria. They have been
Mortality estimates incorporated into the statistical tables appearing in this
Each year, UNICEF includes in The State of the World’s report and have also been used to inform the report’s
Children mortality estimates, such as the infant mortality analyses. More information on these data is available at
rate, under-five mortality rate and under-five deaths, for at <www.childinfo.org>.
least two reference years, if possible. These figures repre-
sent the best estimates available at the time the report is
produced and are based on the work of the Inter-agency Revisions
Group for Child Mortality Estimation, which includes The following revisions have been made to indicators in-
UNICEF, the World Health Organization (WHO), the World cluded in this year’s statistical tables.
Bank and the United Nations Population Division. This
group updates these estimates every year, undertaking a Table 1. Basic Indicators: Table 1 presents estimates of child
detailed review of all newly available data points. At times, mortality as developed by the Inter-agency Group for Child
this review will result in adjustments to previously re- Mortality Estimation. Note that the neonatal mortality rates
ported estimates. Therefore, estimates published in con- for the year 2004, as presented in this table, are produced
secutive editions of The State of the World’s Children may by WHO and have not been formally assessed by the
not be comparable and should not be used for analysing Inter-agency Group for Child Mortality Estimation. These
estimates, therefore, may not necessarily be consistent with based surveys and expanded national sentinel surveillance
the age structure of child mortality implicit in the infant systems in a number of countries.
and under-five mortality estimates for 2007. In addition,
child mortality estimates for 12 countries in Eastern and Differences between the new UNAIDS and WHO estimates
Southern Africa (Botswana, Lesotho, Malawi, Mozambique, for adult HIV prevalence, adults and children living with HIV
Namibia, Rwanda, South Africa, Swaziland, Uganda, the and children orphaned by AIDS for 2007 are, for the most
United Republic of Tanzania, Zambia and Zimbabwe) part, less marked than estimates published in previous re-
were revised to reflect UNAIDS estimates of child deaths ports. Figures published in this report are not comparable
due to AIDS. These UNAIDS estimates are produced based to previous estimates and therefore do not reflect trends
on information related not only to the prevalence of HIV but over time. UNAIDS has published comparable estimates
also to recent efforts in HIV and AIDS prevention and treat- by applying the new methods to earlier HIV and AIDS esti-
ment. A more detailed explanation of these estimation mates, which can be accessed at <www.unaids.org>.
methods is available at <www.childmortality.org>.
Table 5. Education: The survival rate to grade 5 (percent-
Table 2. Nutrition: Prevalence of underweight, stunting age of primary school entrants reaching grade 5) was re-
and wasting among children under five years of age is placed by the survival rate to the last grade of primary
estimated by comparing actual measurements to an school (percentage of children entering the first grade of
international standard reference population. In April 2006, primary school who are expected to reach the last grade).
the World Health Organization released the ‘WHO Child The survival rate to the last grade replaced the survival
Growth Standards’ to replace the widely used National rate to grade 5 and became an official indicator for
Center for Health Statistics/WHO reference population, Millennium Development Goal 2 (universal primary
which was based on a limited sample of children from the education) in January 2008.
United States. The new standards are the result of an in-
tensive study project involving more than 8,000 children Table 7. Economics: The World Bank recently announced a
from Brazil, Ghana, India, Norway, Oman and the United new poverty line that is based on revised estimates of pur-
States. Overcoming the technical and biological drawbacks chasing power parity (PPP) price levels around the world.
of the old reference, the new standards confirm that chil- Table 7 reflects this updated poverty line, and thus reports
dren born anywhere in the world and given the optimum on the proportion of the population living below US$1.25
start in life have the potential to develop to within the per day at 2005 prices, adjusted for purchasing power
same range of height and weight, i.e., differences in parity. The new poverty threshold reflects revisions to
children’s growth to age five are more influenced by purchasing power parity exchange rates based on the
nutrition, feeding practices, environment and health results of the 2005 International Comparison Program.
care than genetics or ethnicity. The revisions reveal that the cost of living is higher across
the developing world than previously estimated. As a
This is the first year that Table 2 includes underweight esti- result of these revisions, poverty rates for individual coun-
mates according to the new ‘WHO Child Growth Standards’. tries cannot be compared with poverty rates reported in
It should be noted that due to the differences between the previous editions. More detailed information on the defini-
old reference population and the new standards, prevalence tion, methodology and sources of the data presented is
estimates of child anthropometry indicators based on these available at <www.worldbank.org>.
two references are not readily comparable.
Table 8. Women: In addition to presenting the proportion
Table 4. HIV and AIDS: In August 2008, the Joint United of women who were attended at least once during
Nations Programme on HIV/AIDS (UNAIDS) and WHO re- pregnancy by skilled health personnel, this year’s table
leased new global HIV and AIDS estimates for 2007 that presents the proportion attended at least four times by
were derived from a more refined methodology and reflect any provider. The two antenatal care indicators are part of
the availability of more reliable data from population- a revised monitoring framework for MDG 5 that went into
S TAT I S T I C A L TA B L E S 115
Economic and social statistics on the countries and territories of the world,
STATISTICAL TABLES with particular reference to children’s well-being.
General note on the data (continued)
effect in January 2008 under a new target: achieving disability are addressed to the parent or caretaker of the
universal access to reproductive health. child, who is asked to provide a personal assessment
of the child’s physical and mental development and
Table 9. Child Protection: Data on child disability are de- functioning. As of June 2008, the methodology used to
rived from household surveys, and the indicator is defined calculate these estimates from MICS surveys changed.
as the proportion of children aged 2–9 years who screened Previously, the estimates were calculated based on 9 of the
positive for at least one type of disability (e.g., cognitive, 10 MICS questions on disability. In this year’s report and
motor, seizure, vision or hearing). Questions on child going forward, the data will be based on all 10 questions.
Explanation of symbols
Because the aim of these statistical tables is to provide a broad picture of the situation of children and women worldwide,
detailed data qualifications and footnotes are seen as more appropriate for inclusion elsewhere. Sources and years for
specific data points included in the statistical tables are available at <www.childinfo.org>.
Symbols specific to a particular table are included in the table footnotes. The following symbols are common across all tables:
– Data are not available.

x Data refer to years or periods other than those specified in the column heading, differ from the standard definition or
refer to only part of a country. Such data are not included in the calculation of regional and global averages.
y Data refer to years or periods other than those specified in the column heading, differ from the standard definition or
refer to only part of a country. Such data are included in the calculation of regional and global averages.
* Data refer to the most recent year available during the period specified in the column heading.
§ Includes territories as well as countries within each category or regional group. Countries and territories in each country
category or regional group are listed on page 152.
Under-five mortality rankings
The following list ranks countries and territories in descending order of their estimated 2007 under-five mortality
rate (U5MR), a critical indicator of the well-being of children. Countries and territories are listed alphabetically in
the tables on the following pages.
Under-5 Under-5 Under-5
mortality mortality mortality
rate (2007) rate (2007) rate (2007)
Value Rank Value Rank Value Rank
Sierra Leone 262 1 Mongolia 43 67 Uruguay 14 132
Afghanistan 257 2 Uzbekistan 41 68 Bahamas 13 134
Chad 209 3 Botswana 40 69 Belarus 13 134
Equatorial Guinea 206 4 Micronesia (Federated States of) 40 69 Seychelles 13 134
Guinea-Bissau 198 5 Azerbaijan 39 71 Barbados 12 137
Mali 196 6 Guatemala 39 71 Bulgaria 12 137
Burkina Faso 191 7 Dominican Republic 38 73 Oman 12 137
Nigeria 189 8 Kyrgyzstan 38 73 Antigua and Barbuda 11 140
Rwanda 181 9 Algeria 37 75 Costa Rica 11 140
Burundi 180 10 Tuvalu 37 75 Dominica 11 140
Niger 176 11 Egypt 36 77 Kuwait 11 140
Central African Republic 172 12 Mexico 35 78 Malaysia 11 140
Zambia 170 13 Nicaragua 35 78 Bahrain 10 145
Mozambique 168 14 Trinidad and Tobago 35 78 Montenegro 10 145
Democratic Republic of the Congo 161 15 Morocco 34 81 Palau 10 145
Angola 158 16 Vanuatu 34 81 Brunei Darussalam 9 148
Guinea 150 17 Iran (Islamic Republic of) 33 83 Chile 9 148
Cameroon 148 18 Cape Verde 32 84 Latvia 9 148
Somalia 142 19 Kazakhstan 32 84 Lithuania 8 151
Liberia 133 20 Indonesia 31 86 Serbia 8 151
Uganda 130 21 Jamaica 31 86 Slovakia 8 151
Côte d’Ivoire 127 22 Georgia 30 88 United Arab Emirates 8 151
Djibouti 127 22 Maldives 30 88 United States 8 151
Congo 125 24 Nauru 30 88 Cuba 7 156
Benin 123 25 Lebanon 29 91 Hungary 7 156
Kenya 121 26 Paraguay 29 91 Poland 7 156
Ethiopia 119 27 Suriname 29 91 Thailand 7 156
Mauritania 119 27 Philippines 28 94 Australia 6 160
United Republic of Tanzania 116 29 Occupied Palestinian Territory 27 95 Canada 6 160
Ghana 115 30 Samoa 27 95 Croatia 6 160
Senegal 114 31 Belize 25 97 Estonia 6 160
Madagascar 112 32 Saudi Arabia 25 97 New Zealand 6 160
Malawi 111 33 Armenia 24 99 United Kingdom 6 160
Gambia 109 34 El Salvador 24 99 Belgium 5 166
Sudan 109 34 Honduras 24 99 Cyprus 5 166
Myanmar 103 36 Jordan 24 99 Israel 5 166
Togo 100 37 Ukraine 24 99 Republic of Korea 5 166
Sao Tome and Principe 99 38 Panama 23 104 Malta 5 166
Timor-Leste 97 39 Tonga 23 104 Netherlands 5 166
Cambodia 91 40 Turkey 23 104 Switzerland 5 166
Gabon 91 40 Brazil 22 107 Austria 4 173
Swaziland 91 40 China 22 107 Czech Republic 4 173
Pakistan 90 43 Ecuador 22 107 Denmark 4 173
Zimbabwe 90 43 Sri Lanka 21 110 Finland 4 173
Bhutan 84 45 Tunisia 21 110 France 4 173
Lesotho 84 45 Colombia 20 112 Germany 4 173
Haiti 76 47 Peru 20 112 Greece 4 173
Yemen 73 48 Grenada 19 114 Ireland 4 173
India 72 49 Saint Vincent and the Grenadines 19 114 Italy 4 173
Eritrea 70 50 Venezuela (Bolivarian Republic of) 19 114 Japan 4 173
Lao People’s Democratic Republic 70 50 Cook Islands 18 117 Monaco 4 173
Solomon Islands 70 50 Fiji 18 117 Norway 4 173
Namibia 68 53 Libyan Arab Jamahiriya 18 117 Portugal 4 173
Tajikistan 67 54 Moldova 18 117 San Marino 4 173
Comoros 66 55 Saint Kitts and Nevis 18 117 Slovenia 4 173
Papua New Guinea 65 56 Saint Lucia 18 117 Spain 4 173
Kiribati 63 57 Syrian Arab Republic 17 123 Andorra 3 189
Bangladesh 61 58 The former Yugoslav Republic of Macedonia 17 123 Iceland 3 189
Guyana 60 59 Argentina 16 125 Liechtenstein 3 189
South Africa 59 60 Albania 15 126 Luxembourg 3 189
Bolivia 57 61 Mauritius 15 126 Singapore 3 189
Democratic People’s Republic of Korea 55 62 Qatar 15 126 Sweden 3 189
Nepal 55 62 Romania 15 126 Holy See –
Marshall Islands 54 64 Russian Federation 15 126 Niue –
Turkmenistan 50 65 Viet Nam 15 126
Iraq 44 66 Bosnia and Herzegovina 14 132
TABLE 1. BASIC INDICATORS
% share
Infant Annual Total Primary of household
Under-5 mortality Annual no. of Life adult school net income
mortality rate Neonatal Total no. of under-5 GNI expectancy literacy enrolment/ 1995–2005*
Under-5 rate (under 1) mortality population births deaths per capita at birth rate attendance
Countries and mortality rate (thousands) (thousands) (thousands) (US$) (years) (%) (%) lowest highest
territories rank 1990 2007 1990 2007 2004 2007 2007 2007 2007 2007 2000–2007* 2000–2007* 40% 20%
Afghanistan 2 260 257 168 165 60 27145 1314 338 250x 44 28 61 – –
Albania 126 46 15 37 13 9 3190 52 1 3290 76 99 94 21 40
Algeria 75 69 37 54 33 22 33858 704 26 3620 72 75 95 19 43
Andorra 189 6 3 5 3 2 75 0 0 d – – 83 – –
Angola 16 258 158 150 116 54 17024 810 128 2560 42 67 58s – –
Antigua and Barbuda 140 – 11 – 10 8 85 0 0 11520 – – – – –
Argentina 125 29 16 25 15 10 39531 693 11 6050 75 98 99 11 55
Armenia 99 56 24 48 22 18 3002 37 1 2640 72 100 99s 21 43
Australia 160 9 6 8 5 3 20743 256 2 35960 81 – 96 18x 41x
Austria 173 9 4 8 4 3 8361 77 0 42700 80 – 97 22 38
Azerbaijan 71 98 39 78 34 35 8467 134 5 2550 67 99 73s 19 45
Bahamas 134 29 13 22 12 5 331 6 0 15730x 73 – 88 – –
Bahrain 145 19 10 15 9 4 753 13 0 19350 76 89 98 – –
Bangladesh 58 151 61 105 47 36 158665 3998 244 470 64 54 81s 21 43
Barbados 137 17 12 15 11 8 294 3 0 d 77 – 96 – –
Belarus 134 24 13 20 12 3 9689 91 1 4220 69 100 89 23 37
Belgium 166 10 5 9 4 2 10457 109 1 40710 79 – 97 22 41
Belize 97 43 25 35 22 17 288 7 0 3800 76 – 97 – –
Benin 25 184 123 111 78 36 9033 365 45 570 56 41 67s 19 45
Bhutan 45 148 84 91 56 30 658 12 1 1770 66 56 70s – –
Bolivia 61 125 57 89 48 24 9525 263 15 1260 65 90 78s 7 63
Bosnia and Herzegovina 132 22 14 18 13 10 3935 34 0 3580 75 97 91s 19 43
Botswana 69 57 40 45 33 46 1882 47 2 5840 50 83 84 9x 65x
Brazil 107 58 22 49 20 13 191791 3706 82 5910 72 91 94 9 61
Brunei Darussalam 148 11 9 10 8 4 390 8 0 26930x 77 95 94 – –
Bulgaria 137 18 12 15 10 7 7639 68 1 4590 73 98 92 22 38
Burkina Faso 7 206 191 112 104 32 14784 654 125 430 52 29 47 18 47
Burundi 10 189 180 113 108 41 8508 399 72 110 49 59 75 15 48
Cambodia 40 119 91 87 70 48 14444 382 35 540 59 76 90 17 50
Cameroon 18 139 148 85 87 30 18549 649 96 1050 50 68 84s 15 51
Canada 160 8 6 7 5 3 32876 340 2 39420 81 – 100 20 40
Cape Verde 84 60 32 45 24 9 530 15 0 2430 72 84 88 – –
Central African Republic 12 171 172 113 113 52 4343 158 27 380 44 49 59s 7x 65x
Chad 3 201 209 120 124 42 10781 492 103 540 51 26 36s – –
Chile 148 21 9 18 8 5 16635 250 2 8350 79 97 – 11 60
China 107 45 22 36 19 18 1328630 17374 382 2360 73 93 99 13 52
Colombia 112 35 20 28 17 13 46156 876 18 3250 73 94 89 10 61
Comoros 55 120 66 88 49 25 839 28 2 680 65 75 73 – –
Congo 24 104 125 67 79 30 3768 133 17 1540 55 87 86s – –
Cook Islands 117 32 18 26 16 10 13 0 0 – – – 74 – –
Costa Rica 140 18 11 16 10 8 4468 80 1 5560 79 96 92 13 53
Côte d’Ivoire 22 151 127 104 89 64 19262 687 87 910 48 49 62s 14 51
Croatia 160 13 6 11 5 5 4555 41 0 10460 76 99 90 22 38
Cuba 156 13 7 11 5 4 11268 118 1 c 78 100 97 – –
Cyprus 166 11 5 9 3 2 855 10 0 24940 79 98 99 – –
Czech Republic 173 12 4 10 3 2 10186 93 0 14450 76 – 93 25 36
Democratic People’s
Republic of Korea 62 55 55 42 42 22 23790 317 17 a 67 – – – –
Democratic Republic
of the Congo 15 200 161 127 108 47 62636 3118 502 140 46 67 52s – –
Denmark 173 9 4 7 4 3 5442 62 0 54910 78 – 96 23 36
Djibouti 22 175 127 116 84 45 833 24 3 1090 55 – 79s – –
Dominica 140 18 11 14 9 10 67 0 0 4250 – – 77 – –
Dominican Republic 73 66 38 53 31 18 9760 231 9 3550 72 89 78 12 55
Ecuador 107 57 22 43 20 13 13341 283 6 3080 75 93 97 11 58
Egypt 77 93 36 68 30 17 75498 1840 66 1580 71 72 96 22 42
El Salvador 99 60 24 47 21 12 6857 158 4 2850 72 86 94 10 56
Equatorial Guinea 4 170 206 103 124 47 507 20 4 12860 51 87 61s – –
Eritrea 50 147 70 88 46 21 4851 191 13 230 58 – 47 – –
Estonia 160 18 6 14 4 4 1335 14 0 13200 71 100 94 19 43
Ethiopia 27 204 119 122 75 41 83099 3201 381 220 53 36 45s 22 39
Fiji 117 22 18 19 16 10 839 18 0 3800 69 – 91 – –
Finland 173 7 4 6 3 2 5277 58 0 44400 79 – 97 24 37
…TABLE 1
% share
mortality rate (thousands) (thousands) (thousands) (US$) (years) (%) (%) lowest highest
rank 1990 2007 1990 2007 2004 2007 2007 2007 2007 2007 2000–2007* 2000–2007* 40% 20%
France 173 9 4 7 4 2 61647 758 3 38500 81 – 99 20 40
Gabon 40 92 91 60 60 31 1331 34 3 6670 57 86 94s – –
Gambia 34 153 109 104 82 44 1709 60 7 320 59 – 62 14 53
Georgia 88 47 30 41 27 25 4395 48 1 2120 71 – 95s 16 47
Germany 173 9 4 7 4 3 82599 678 3 38860 79 – 98 22 37
Ghana 30 120 115 76 73 43 23478 703 81 590 60 65 72 16 47
Greece 173 11 4 9 4 3 11147 103 0 29630 79 97 100 19 42
Grenada 114 37 19 30 15 11 106 2 0 4670 69 – 84 – –
Guatemala 71 82 39 60 29 19 13354 449 18 2440 70 73 94 12 54
Guinea 17 231 150 137 93 39 9370 377 57 400 56 30 51s 18 46
Guinea-Bissau 5 240 198 142 118 47 1695 84 17 200 46 65 54s 14x 53x
Guyana 59 88 60 64 45 22 738 13 1 1300 66 – 96s – –
Haiti 47 152 76 105 57 32 9598 270 21 560 61 62 50s 9 63
Holy See – – – – – – 1 – – – – – – – –
Honduras 99 58 24 45 20 17 7106 200 5 1600 70 83 79s 11 58
Hungary 156 17 7 15 6 5 10030 93 1 11570 73 99 88 22 39
Iceland 189 7 3 5 2 1 301 4 0 54100 82 – 98 – –
India 49 117 72 83 54 39 1169016 27119 1953 950 64 66 83s 19 45
Indonesia 86 91 31 60 25 17 231627 4386 136 1650 70 91 96 18 47
Iran (Islamic Republic of) 83 72 33 54 29 19 71208 1441 48 3470 71 85 94 17 45
Iraq 66 53 44 42 36 63 28993 935 41 2170x 59 74 89 – –
Ireland 173 9 4 8 4 4 4301 67 0 48140 79 – 95 20 42
Israel 166 12 5 10 4 3 6928 137 1 21900 81 – 97 16 45
Italy 173 10 4 8 3 3 58877 539 2 33540 81 99 99 19 42
Jamaica 86 33 31 28 26 10 2714 55 2 3710 72 86 97s 15 52
Japan 173 6 4 5 3 1 127967 1070 4 37670 83 – 100 25x 36x
Jordan 99 40 24 33 21 16 5924 154 4 2850 72 93 90 18 46
Kazakhstan 84 60 32 51 28 32 15422 297 10 5060 67 100 98s 19 42
Kenya 26 97 121 64 80 34 37538 1479 179 680 53 74 76 16 49
Kiribati 57 88 63 65 46 25 95 0 0 1170 – – 97 – –
Kuwait 140 15 11 13 9 7 2851 51 1 31640 78 94 84 – –
Kyrgyzstan 73 74 38 62 34 30 5317 115 4 590 66 99 92s 22 39
Lao People’s Democratic
Republic 50 163 70 120 56 30 5859 157 11 580 64 73 84 20 43
Latvia 148 17 9 13 7 6 2277 21 0 9930 73 100 90 19 43
Lebanon 91 37 29 32 26 19 4099 74 2 5770 72 – 82 – –
Lesotho 45 102 84 81 68 52 2008 59 5 1000 42 82 85s 6 67
Liberia 20 205 133 138 93 66 3750 189 25 150 45 56 40 – –
Libyan Arab Jamahiriya 117 41 18 35 17 11 6160 145 3 9010 74 87 – – –
Liechtenstein 189 10 3 9 2 – 35 0 0 d – – 88 – –
Lithuania 151 16 8 12 7 5 3390 30 0 9920 73 100 89 19 43
Luxembourg 189 9 3 8 2 3 467 5 0 75880 79 – 97 – –
Madagascar 32 168 112 103 70 41 19683 722 81 320 59 71 76s 13 54
Malawi 33 209 111 124 71 26 13925 573 64 250 48 72 91 18 47
Malaysia 140 22 11 16 10 5 26572 555 6 6540 74 92 100 13 54
Maldives 88 111 30 79 26 24 306 7 0 3200 68 97 97 – –
Mali 6 250 196 148 117 54 12337 595 117 500 54 23 61 16 47
Malta 166 11 5 10 4 3 407 4 0 15310 79 92 91 – –
Marshall Islands 64 92 54 63 49 24 59 0 0 3070 – – 66 – –
Mauritania 27 130 119 81 75 40 3124 102 12 840 64 56 57s 17 46
Mauritius 126 24 15 21 13 9 1262 19 0 5450 73 87 95 – –
Mexico 78 52 35 42 29 11 106535 2088 73 8340 76 92 98 13 55
Micronesia
(Federated States of) 69 58 40 45 33 11 111 3 0 2470 68 – 92 – –
Moldova 117 37 18 30 16 12 3794 43 1 1260 69 99 88 20 41
Monaco 173 9 4 7 3 2 33 0 0 d – – – – –
Mongolia 67 98 43 71 35 18 2629 49 2 1290 67 97 97s 20 41
Montenegro 145 16 10 14 9 9 598 8 0 5180 74 – 97s – –
Morocco 81 89 34 69 32 24 31224 641 22 2250 71 56 88 17 47
Mozambique 14 201 168 135 115 35 21397 855 144 320 42 44 60s 15 54
Myanmar 36 130 103 91 74 49 48798 891 92 220x 62 90 84s – –
Namibia 53 87 68 57 47 20 2074 53 4 3360 52 88 91s 4x 79x
Nauru 88 – 30 – 25 14 10 0 0 – – – 60 – –
TABLE 1. BASIC INDICATORS
% share
rank 1990 2007 1990 2007 2004 2007 2007 2007 2007 2007 2000–2007* 2000–2007* 40% 20%
Nepal 62 142 55 99 43 32 28196 796 44 340 64 57 84s 15 55
Netherlands 166 8 5 7 4 3 16419 184 1 45820 80 – 98 21 39
New Zealand 160 11 6 9 5 3 4179 57 0 28780 80 – 99 18 44
Nicaragua 78 68 35 52 28 16 5603 140 5 980 73 81 90 15 49
Niger 11 304 176 143 83 41 14226 701 123 280 57 30 38s 10 53
Nigeria 8 230 189 120 97 47 148093 5959 1126 930 47 72 63 15 49
Niue – – – – – 16 2 0 – – – – 90 – –
Norway 173 9 4 7 3 2 4698 56 0 76450 80 – 98 24 37
Occupied Palestinian Territory 95 38 27 33 24 – 4017 145 4 1230 73 93 76 – –
Oman 137 32 12 25 11 5 2595 58 1 11120 76 84 74 – –
Pakistan 43 132 90 102 73 53 163902 4446 400 870 65 55 56s 22 41
Palau 145 21 10 18 9 13 20 0 0 8210 – – 96 – –
Panama 104 34 23 27 18 11 3343 70 2 5510 75 93 99 9 60
Papua New Guinea 56 94 65 69 50 32 6331 190 12 850 57 58 – 12 57
Paraguay 91 41 29 34 24 12 6127 153 4 1670 72 94 94 9 62
Peru 112 78 20 58 17 11 27903 584 12 3450 71 91 96 11 57
Philippines 94 62 28 43 23 15 87960 2295 64 1620 72 93 91 15 51
Poland 156 17 7 15 6 5 38082 360 3 9840 76 99 96 19 43
Portugal 173 15 4 11 3 3 10623 112 0 18950 78 95 98 17 46
Qatar 126 26 15 20 12 4 841 14 0 12000x 76 90 94 – –
Republic of Korea 166 9 5 8 4 4 48224 448 2 19690 79 – 98 22 38
Romania 126 32 15 25 13 10 21438 211 3 6150 72 98 93 21 40
Russian Federation 126 27 15 23 13 7 142499 1515 23 7560 65 100 91 17 47
Rwanda 9 195 181 117 109 48 9725 435 79 320 46 65 86s 14 53
Saint Kitts and Nevis 117 36 18 30 16 11 50 1 0 9630 – – 71 – –
Saint Lucia 117 21 18 16 14 11 165 3 0 5530 74 – 98 – –
Saint Vincent
and the Grenadines 114 22 19 18 17 13 120 2 0 4210 71 – 90 – –
Samoa 95 50 27 40 22 14 187 5 0 2430 71 99 90 – –
San Marino 173 13 4 12 4 2 31 0 0 45130 – – – – –
Sao Tome and Principe 38 101 99 65 64 38 158 5 0 870 65 88 98 – –
Saudi Arabia 97 44 25 35 20 11 24735 618 15 15440 73 85 – – –
Senegal 31 149 114 72 59 35 12379 439 50 820 63 43 58s 17 48
Serbia 151 – 8 – 7 9 9858 127 1 4730 74 – 95 21 38
Seychelles 134 19 13 17 12 7 87 3 0 8960 – 92 99 – –
Sierra Leone 1 290 262 169 155 56 5866 268 70 260 42 38 69s 17 47
Singapore 189 8 3 6 2 1 4436 37 0 32470 80 94 – 14 49
Slovakia 151 15 8 13 7 4 5390 53 0 11730 75 – 92 24 35
Slovenia 173 11 4 9 3 2 2002 18 0 20960 78 100 95 21 40
Solomon Islands 50 121 70 86 53 23 496 15 1 730 63 – 62 – –
Somalia 19 203 142 121 88 49 8699 377 54 140x 48 – 22s – –
South Africa 60 64 59 49 46 17 48577 1092 64 5760 50 88 88 10 62
Spain 173 9 4 7 4 2 44279 476 2 29450 81 97 100 19 42
Sri Lanka 110 32 21 26 17 8 19299 292 6 1540 72 92 98 18 48
Sudan 34 125 109 79 69 27 38560 1230 134 960 58 61 54s – –
Suriname 91 51 29 41 27 17 458 9 0 4730 70 90 96 – –
Swaziland 40 96 91 70 66 40 1141 33 3 2580 40 80 84s 13 56
Sweden 189 7 3 6 3 2 9119 102 0 46060 81 – 95 23 37
Switzerland 166 8 5 7 4 3 7484 69 0 59880 82 – 89 20 41
Syrian Arab Republic 123 37 17 30 15 7 19929 535 9 1760 74 83 95 – –
Tajikistan 54 117 67 91 57 38 6736 186 12 460 67 100 89s 20 42
Thailand 156 31 7 26 6 9 63884 932 7 3400 70 94 94 16 49
The former Yugoslav
Republic of Macedonia 123 38 17 33 15 9 2038 22 0 3460 74 97 92 17 46
Timor-Leste 39 184 97 138 77 29 1155 48 5 1510 61 – 75s – –
Togo 37 150 100 89 65 39 6585 245 25 360 58 53 80 – –
Tonga 104 32 23 26 19 12 100 3 0 2320 73 99 96 – –
Trinidad and Tobago 78 34 35 30 31 10 1333 20 1 14100 70 99 98s 17x 45x
Tunisia 110 52 21 41 18 13 10327 173 4 3200 74 78 96 16 47
Turkey 104 82 23 67 21 16 74877 1381 32 8020 72 89 91 15 50
Turkmenistan 65 99 50 81 45 37 4965 109 5 b 63 100 99s 16 48
Tuvalu 75 53 37 42 30 21 11 0 0 – – – 100 – –
Uganda 21 175 130 106 82 30 30884 1445 188 340 51 74 82s 15 53
Ukraine 99 25 24 22 20 7 46205 419 10 2550 68 100 97s 23 37
United Arab Emirates 151 15 8 13 7 4 4380 71 1 26210x 79 90 88 – –
…TABLE 1
% share
rank 1990 2007 1990 2007 2004 2007 2007 2007 2007 2007 2000–2007* 2000–2007* 40% 20%
United Kingdom 160 9 6 8 5 3 60769 722 4 42740 79 – 98 18 44
United Republic of Tanzania 29 157 116 96 73 35 40454 1600 186 400 52 72 73s 19 42
United States 151 11 8 9 7 4 305826 4281 34 46040 78 – 92 16 46
Uruguay 132 25 14 21 12 7 3340 51 1 6380 76 98 100 14 51
Uzbekistan 68 74 41 61 36 26 27372 623 26 730 67 97 100s 19 45
Vanuatu 81 62 34 48 28 18 226 7 0 1840 70 78 87 – –
Venezuela
(Bolivarian Republic of) 114 32 19 27 17 11 27657 597 11 7320 74 93 91 12 52
Viet Nam 126 56 15 40 13 12 87375 1653 25 790 74 90x 95 18 45
Yemen 48 127 73 90 55 41 22389 860 63 870 62 59 75 19 45
Zambia 13 163 170 99 103 40 11922 473 80 800 42 68x 57s 12 55
Zimbabwe 43 95 90 62 59 36 13349 373 34 340 43 91 88 13 56
SUMMARY INDICATORS
Sub-Saharan Africa 186 148 109 89 41 767218 30323 4480 965 50 62 64 13 54
Eastern and Southern Africa 165 123 101 80 36 378926 14268 1761 1245 50 65 68 12 58
West and Central Africa 206 169 116 97 45 388292 16056 2719 698 50 60 60 16 48
Middle East and North Africa 79 46 58 36 25 389176 9726 445 3666 69 75 86 18 45
South Asia 125 78 89 59 41 1567187 37986 2985 889 64 63 80 19 46
East Asia and Pacific 56 27 42 22 18 1984273 29773 799 2742 72 93 97 16 46
Latin America and Caribbean 55 26 44 22 13 566646 11381 302 5628 73 91 93 11 56
CEE/CIS 53 25 44 22 16 405992 5560 138 5686 68 97 93 20 42
Industrialized countries§ 10 6 8 5 3 974913 11021 66 38579 79 – 96 20 40
Developing countries§ 103 74 71 51 31 5432837 122266 9109 2405 67 79 83 15 50
Least developed countries§ 179 130 112 84 40 804450 29076 3775 491 55 57 65 15 50
World 93 68 64 47 28 6655406 135770 9216 7952 68 81 85 19 42
§ Also includes territories within each country category or regional group. Countries and territories in each country category or regional group are listed on page 152.
DEFINITIONS OF THE INDICATORS MAIN DATA SOURCES
Under-five mortality rate – Probability of dying between birth and exactly five years of age, Under-five and infant mortality rates – UNICEF, World Health Organization, United Nations
expressed per 1,000 live births. Population Division and United Nations Statistics Division.
Infant mortality rate – Probability of dying between birth and exactly one year of age, expressed Neonatal mortality rate – World Health Organization using vital registration systems and
per 1,000 live births. household surveys.
Neonatal mortality rate – Probability of dying during the first 28 completed days of life, expressed
per 1,000 live births. Total population – United Nations Population Division.
GNI per capita – Gross national income (GNI) is the sum of value added by all resident producers, Births – United Nations Population Division.
plus any product taxes (less subsidies) not included in the valuation of output, plus net receipts of Under-five deaths – UNICEF.
primary income (compensation of employees and property income) from abroad. GNI per capita is
gross national income divided by midyear population. GNI per capita in US dollars is converted GNI per capita – World Bank.
using the World Bank Atlas method. Life expectancy – United Nations Population Division.
Life expectancy at birth – Number of years newborn children would live if subject to the mortality
risks prevailing for the cross section of population at the time of their birth. Adult literacy – UNESCO Institute for Statistics (UIS), including the Education for All 2000
Assessment.
Adult literacy rate – Number of literate persons aged 15 and above, expressed as a percentage of
the total population in that age group. School enrolment/attendance – UIS, Multiple Indicator Cluster Surveys (MICS) and Demographic
Primary school net enrolment/attendance ratios – Number of children enrolled in or attending and Health Surveys (DHS).
primary school, expressed as a percentage of the total number of children of primary school age. Household income – World Bank.
The indicator is either the primary school net enrolment ratio or the primary school net attendance
ratio. In general, if both indicators are available, the primary school net enrolment ratio is
preferred unless the data for primary school attendance is considered to be of superior quality.
Definitions for both the primary school net enrolment ratio and the primary school net attendance
ratio are given in Table 5, p. 134.
Income share – Percentage of income received by the 20 per cent of households with the highest
income and by the 40 per cent of households with the lowest income.
NOTES a: low income ($935 or less). – Data not available.

b: lower-middle income ($936 to $3,705). x Data refer to years or periods other than those specified in the column heading, differ from the standard definition
c: upper-middle income ($3,706 to $11,455). or refer to only part of a country. Such data are not included in the calculation of regional and global averages.
d: high income ($11,456 or more). s National household survey data.
TABLE 2. NUTRITION
% of under-fives (2000–2007*) suffering from: Vitamin A
supplementation
% of children (2000–2007*) who are: underweight† wasting stunting coverage rate
(WHO (NCHS/ (NCHS/ % of
underweight† (6–59 months)
% of infants breastfed with ref. pop.) WHO) WHO) households
(NCHS/WHO) 2007
with low exclusively complementary still consuming
birthweight breastfed food breastfeeding moderate moderate moderate moderate at least one full iodized salt
Countries and territories 2000–2007* (< 6 months) (6–9 months) (20–23 months) & severe & severe severe & severe & severe dose‡ (%) coverageΔ (%) 2000–2007*
Afghanistan – – 29 54 33y 39y 12y 7y 54y 94 92 28
Albania 7 40 69 22 6 8 1 7 22 – – 60
Algeria 6 7 39 22 3 4 1 3 11 – – 61
Andorra – – – – – – – – – – – –
Angola 12 11 77 37 26 31 8 6 45 36 36 35
Antigua and Barbuda 5 – – – – – – – – – – –
Argentina 7 – – 28 2y 4y – 1y 4y – – 90x
Armenia 8 33 57 15 4 4 0 5 13 – – 97
Australia 7 – – – – – – – – – – –
Austria 7 – – – – – – – – – – –
Azerbaijan 12 12 44 16 8 10 2 5 21 95 95w 54
Bahamas 7x – – – – – – – – – – –
Bahrain 8x 34x 65x 41x – 9x 2x 5x 10x – – –
Bangladesh 22 37 52 89 41 46 – 16 36 95 94 84
Barbados 14 – – – – – – – – – – –
Belarus 4 9 38 4 1 1 0 1 3 – – 55
Belgium 8x – – – – – – – – – – –
Belize 8 10 – 27 – 6 1 1 18 – – 90x
Benin 15 43 72 57 18 23 5 7 38 73 73 55
Bhutan 15x – – – 14x 19x 3x 3x 40x 48 48 96
Bolivia 7 54 74 46 5 8 1 1 27 – – 90
Bosnia and Herzegovina 5 18 29 10 1 2 0 3 7 – – 62
Botswana 10 34 57 11 11 13 2 5 23 – – 66
Brazil 8 – 30x 17x 4 5 – – – – – 88
Brunei Darussalam 10x – – – – – – – – – – –
Bulgaria 10 – – – – – – – – – – 100
Burkina Faso 16 7 50 85 32 37 14 23 35 95 73 34
Burundi 11 45 88 – 35 39 14 7 53 83 83 98
Cambodia 14 60 82 54 28 36 7 7 37 76 76 73
Cameroon 11 21 64 21 16 19 5 6 30 – – 49
Canada 6 – – – – – – – – – – –
Cape Verde 13x 57x 64x 13x – – – – – – – 0x
Central African Republic 13 23 55 47 24 29 8 10 38 78 78 62
Chad 22 2 77 65 – 37 14 14 41 54 54 56
Chile 6 85k – – – 1y – 0y 1y – – 100x
China 2 51 32 15 6 7 – – 11 – – 94
Colombia 9 47 65 32 5y 7y 1y 1y 12y – – 92x
Comoros 25 21 34 45 – 25 – 8 44 93 0 82
Congo 13 19 78 21 11 14 3 7 26 95 79 82
Cook Islands 3 19x – – – 10x – – – – – –
Costa Rica 7 35x 47x 12x – 5x 0x 2x 6x – – 92x
Côte d’Ivoire 17 4 54 37 16 20 4 7 34 63 4 84
Croatia 5 23x – – – 1x – 1x 1x – – 90x
Cuba 5 26 47 16 – 4 0 2 5 – – 88
Cyprus – – – – – – – – – – – –
Czech Republic 7 – – – – – – – – – – –
Republic of Korea 7 65 31 37 18y 23y 8y 7y 37y 95 95 40
Democratic Republic of the Congo 12 36 82 64 28 31 9 13 38 79 79 72
Denmark 5 – – – – – – – – – – –
Djibouti 10 1 23 18 24 29 10 21 33 95 94 0
Dominica 9 – – – – – – – – – – –
Dominican Republic 11 4 36 15 – 5 1 1 7 – – 19
Ecuador 16x 40 77 23 6 9 1 2 23 – – 99x
Egypt 14 38 67 37 5 6 1 4 18 87 87w 78
El Salvador 7 24 76 43 6y 10y 1y 1y 19y 20 13 62
Equatorial Guinea 13 24 – – – 19 4 7 39 – – 33
Eritrea 14 52 43 62 35 40 12 13 38 51 50 68
Estonia 4 – – – – – – – – – – –
Ethiopia 20 49 54 – 33 38 11 11 47 88 86 20
…TABLE 2
supplementation
(NCHS/WHO) 2007
2000–2007* (< 6 months) (6–9 months) (20–23 months) & severe & severe severe & severe & severe dose‡ (%) coverageΔ (%) 2000–2007*
Fiji 10x 47x – – – – – – – – – 31x
Finland 4 – – – – – – – – – – –
France 7x – – – – – – – – – – –
Gabon 14 6 62 9 8 12 2 3 21 90 0 36
Gambia 20 41 44 53 16 20 4 6 22 93 82 7
Georgia 5 11 35 20 2 2 0 2 10 – – 87
Germany 7x – – – – – – – – – – –
Ghana 9 54 58 56 13 18 3 5 22 95 77 32
Greece 8x – – – – – – – – – – –
Grenada 9 39x – – – – – – – – – –
Guatemala 12 51 67 47 18y 23y 4y 2y 49y 33 29 40
Guinea 12 27 41 71 22 26 7 9 35 95 94 51
Guinea-Bissau 24 16 35 61 15 19 4 7 41 66 64 1
Guyana 13 11 42 31 10 12 2 8 14 – – –
Haiti 25 41 87 35 18 22 6 9 24 – – 3
Holy See – – – – – – – – – – – –
Honduras 10 30 69 48 8 11 1 1 25 – – 80x
Hungary 9 – – – – – – – – – – –
Iceland 4 – – – – – – – – – – –
India 28 46 57 77 43 46 – 19 38 53 33 51
Indonesia 9 40 75 59 23 28 9 – – 87 87 73
Iran (Islamic Republic of) 7x 23 68 58 – 11x 2x 5x 15x – – 99
Iraq 15 25 51 36 6 8 1 5 21 – – 28
Ireland 6x – – – – – – – – – – –
Israel 8 – – – – – – – – – – –
Italy 6x – – – – – – – – – – –
Jamaica 12 15 36 24 3 4 – 4 3 – – 100x
Japan 8 – – – – – – – – – – –
Jordan 12 22 66 11 – 4 1 2 9 – – 88
Kazakhstan 6 17 39 16 4 4 1 4 13 – – 92
Kenya 10 13 84 57 16 20 4 6 30 22 15 91
Kiribati 5x 80x – – – 13x – – – – – –
Kuwait 7x 12x 26x 9x – 10x 3x 11x 24x – – –
Kyrgyzstan 5 32 49 26 2 3 0 4 14 95 95 76
Lao People’s Democratic Republic 14 23 10 47 31 37 9 7 40 83 69 75
Latvia 5 – – – – – – – – – – –
Lebanon 6 27 35 11 – 4 – 5 11 – – 92
Lesotho 13 36 79 60 – 20 4 4 38 85 38 91
Liberia – 35 70 45 23 26 8 6 39 85 85 –
Libyan Arab Jamahiriya 7x – – 23x 4x 5x 1x 3x 15x – – 90x
Liechtenstein – – – – – – – – – – – –
Lithuania 4 – – – – – – – – – – –
Luxembourg 8 – – – – – – – – – – –
Madagascar 17 67 78 64 36 42 11 13 48 95 95 75
Malawi 14 57 89 72 15 21 4 4 46 90 90 50
Malaysia 9 29x – 12x – 8 1 – – – – –
Maldives 22 10 85 – – 30 7 13 25 62 62 44
Mali 19 38 30 56 27 32 10 13 34 95 89 79
Malta 6 – – – – – – – – – – –
Marshall Islands 12x 63x – – – – – – – 39 39 –
Mauritania – 20 78 57 – 32 10 13 35 95 89 2
Mauritius 14 21 – – – 15x 2x 14x 10x – – 0x
Mexico 8 38x 36x 21x 3 5 – 2 13 – – 91
Micronesia (Federated States of) 18 60x – – – 15x – – – – – –
Moldova 6 46 18 2 – 4 1 4 8 – – 60
Monaco – – – – – – – – – – – –
Mongolia 6 57 57 65 5 6 1 2 21 95 94 83
Montenegro 4 19 35 13 2 3 1 3 5 – – 71
Morocco 15 31 66 15 9 10 2 9 18 – – 21
Mozambique 15 30 80 65 20 24 6 4 41 48 42 54
Myanmar 15 15 66 67 – 32 7 9 32 94 93 60
Namibia 14 24 72 28 – 24 5 9 24 – – 63
Nauru – – – – – – – – – – – –
TABLE 2. NUTRITION
supplementation
(NCHS/WHO) 2007
Countries and territories 2000–2007* (< 6 months) (6–9 months) (20–23 months) & severe & severe severe & severe & severe dose‡ (%) coverageΔ (%) 2000–2007*
Nepal 21 53 75 95 39 45 10 12 43 95 95 63
Netherlands – – – – – – – – – – – –
New Zealand 6 – – – – – – – – – – 83x
Nicaragua 12 31 83 43 – 7 1 1 17 95 – 97
Niger 27 9 73 – 39 44 15 10 50 95 95 46
Nigeria 14 17 64 34 24 29 9 9 38 77 55 97
Niue 0 – – – – – – – – – – –
Norway 5 – – – – – – – – – – –
Occupied Palestinian Territory 7 27 – – – 3 0 1 10 – – 86
Oman 9 – 91 73 13x 18x 1x 7x 10x – – 61x
Pakistan 19x 37 36 55 31 38 13 13 37 95 95 17
Palau 9x 59x – – – – – – – – – –
Panama 10 25x 38x 21x 6x 8x 1x 1x 18x – – 95x
Papua New Guinea 11x 59x 74x 66x – – – – – 7 7 –
Paraguay 9 22 60 – 3 4 – 1 14 – – 94
Peru 10 63 82 47 6 5 1 1 30 – – 91
Philippines 20 34 58 32 21 28 – 6 30 83 83 45
Poland 6 – – – – – – – – – – –
Portugal 8 – – – – – – – – – – –
Qatar 10x 12x 48x 21x – 6x – 2x 8x – – –
Republic of Korea 4 – – – – – – – – – – –
Romania 8 16 41 – 4 3 0 2 10 – – 74
Russian Federation 6 – – – – 3x 1x 4x 13x – – 35
Rwanda 6 88 69 77 18 23 4 4 45 89 76 88
Saint Kitts and Nevis 9 56x – – – – – – – – – 100
Saint Lucia 11 – – – – – – – – – – –
Saint Vincent and the Grenadines 8 – – – – – – – – – – –
Samoa 4x – – – – – – – – – – –
San Marino – – – – – – – – – – – –
Sao Tome and Principe 8 60 60 18 7 9 1 8 23 55 48 37
Saudi Arabia 11x 31x 60x 30x – 14x 3x 11x 20x – – –
Senegal 19 34 61 42 14 17 3 8 16 94 94 41
Serbia 5 15 39 8 1 2 0 3 6 – – 73
Seychelles – – – – – – – – – – – –
Sierra Leone 24 8 52 57 25 30 8 9 40 95 86 45
Singapore 8 – – – 3 3 0 2 2 – – –
Slovakia 7 – – – – – – – – – – –
Slovenia 6 – – – – – – – – – – –
Solomon Islands 13x 65 – – 16x 21x – – – – – –
Somalia – 9 15 35 32 36 12 11 38 89 4 1
South Africa 15x 7 46 – 10x 12x 2x 3x 25x – – 62x
Spain 6x – – – – – – – – – – –
Sri Lanka 22 53 – 73 23y 29y – 14y 14y – – 94
Sudan 31x 16 47 40 – 41 15 16 43 90 90 1
Suriname 13 9 25 11 7 10 1 5 8 – – –
Swaziland 9 32 77 31 5 7 – 2 24 – – 80
Sweden 4x – – – – – – – – – – –
Switzerland 6x – – – – – – – – – – –
Syrian Arab Republic 9 29 37 16 9 10 2 9 22 – – 79
Tajikistan 10 25 15 34 14 17 4 7 27 92 92 46
Thailand 9 5 43 19 7 9 0 4 12 – – 47
The former Yugoslav
Republic of Macedonia 6 37x 8x 10x 2 2 0 2 9 – – 94
Timor-Leste 12 31 82 35 – 49 15 25 54 57 50 60
Togo 12 28 35 44 22 26 7 14 24 95 64 25
Tonga 3 62x – – – – – – – – – –
Trinidad and Tobago 19 13 43 22 – 6 1 4 4 – – 28
Tunisia 7 47 – 22 – 4 1 2 12 – – 97
Turkey 16x 21 38 24 – 4 1 1 12 – – 64
Turkmenistan 4 11 54 37 8 11 2 6 15 – – 87
Tuvalu 5 – – – – – – – – – – –
Uganda 14 60 80 54 16 20 5 5 32 64 – 96
…TABLE 2
supplementation
(NCHS/WHO) 2007
2000–2007* (< 6 months) (6–9 months) (20–23 months) & severe & severe severe & severe & severe dose‡ (%) coverageΔ (%) 2000–2007*
Ukraine 4 6 49 11 – 1y 0y 0y 3y – – 18
United Arab Emirates 15x 34x 52x 29x – 14x 3x 15x 17x – – –
United Kingdom 8 – – – – – – – – – – –
United Republic of Tanzania 10 41 91 55 17 22 4 3 38 93 93 43
United States 8 – – – 1y 2y 0y 0y 1y – – –
Uruguay 8 54 32 31 – 5 1 2 11 – – –
Uzbekistan 5 26 45 38 4 5 1 3 15 84 84 53
Vanuatu 6 50x – – – – – – – – – –
Venezuela (Bolivarian Republic of) 9 7x 50x 31x – 5 – 4 12 – – 90x
Viet Nam 7 17 70 23 – 20 5 8 36 95 95w 93
Yemen 32x – – – 42 46 15 12 53 47 47w 30
Zambia 12 61 93 42 15 19 3 5 39 95 95 77
Zimbabwe 11 22 79 – 12 17 3 6 29 83 83 91
SUMMARY INDICATORS
Sub-Saharan Africa 15 31 68 51 24 28 8 9 38 77 67 64
Eastern and Southern Africa 14 40 71 56 23 28 7 7 40 73 68 56
West and Central Africa 15 23 65 47 24 28 9 10 36 81 67 72
Middle East and North Africa 12 26 57 36 11 17 5 8 26 – – 60
South Asia 27 44 53 75 41 45 – 18 38 64 50 51
East Asia and Pacific 6 43 45 27 11 14 – – 16 86 86** 86
Latin America and Caribbean 9 – – – 5 6 – 2 16 – – 83
CEE/CIS 6 20 41 23 – 5 1 2 12 – – 50
Industrialized countries§ 7 – – – – – – – – – – –
Developing countries§ 15 39 55 51 24 26 – 11 30 72 62** 70
Least developed countries§ 17 37 64 64 30 34 9 11 40 84 82 55
World 14 38 55 50 23 25 – 11 28 72 62** 68
Low birthweight – Percentage of infants weighing less than 2,500 grams at birth. Low birthweight – Demographic and Health Surveys (DHS), Multiple Indicator Cluster Surveys
Underweight (WHO ref. pop.) – Moderate and severe: Percentage of children aged 0–59 months (MICS), other national household surveys, data from routine reporting systems, UNICEF and WHO.
who are below minus two standard deviations from median weight for age of the WHO Child
Growth Standards published in 2006. Breastfeeding – DHS, MICS, other national household surveys and UNICEF.
Underweight (NCHS/WHO) – Moderate and severe: Percentage of children aged 0–59 months
who are below minus two standard deviations from median weight for age of the National Center Underweight, wasting and stunting – DHS, MICS, other national household surveys, WHO and
for Health Statistics (NCHS)/WHO reference population; Severe: Percentage of children aged UNICEF.
0–59 months who are below minus three standard deviations from median weight for age of the
NCHS/WHO reference population. Vitamin A – UNICEF.
Wasting (NCHS/WHO) – Moderate and severe: Percentage of children aged 0–59 months who are Salt iodization – DHS, MICS, other national household surveys and UNICEF.
below minus two standard deviations from median weight for height of the NCHS/WHO reference
population.
Stunting (NCHS/WHO) – Moderate and severe: Percentage of children aged 0–59 months who are
below minus two standard deviations from median height for age of the NCHS/WHO reference
population.
Vitamin A – Percentage of children aged 6–59 months who received vitamin A supplements in 2007.
Iodized salt consumption – Percentage of households consuming adequately iodized salt (15 parts
per million or more).
NOTES – Data not available.

x Data refer to years or periods other than those specified in the column heading, differ from the standard definition or refer to only part of a country. Such data are not included in the calcula-
tion of regional and global averages.
y Data refer to years or periods other than those specified in the column heading, differ from the standard definition or refer to only part of a country. Such data are included in the calculation of
regional and global averages.
k Refers to exclusive breastfeeding for less than four months.
w Identifies countries with national vitamin A supplementation programmes targeted towards a reduced age range. Coverage figure is reported as targeted.
† In this year’s report, the ‘underweight’ statistics apply the same indicators to two different reference populations. Due to this difference, the data presented here are not strictly comparable
with each other or with previous editions of this report. The WHO Child Growth Standards are gradually replacing the widely used NCHS/WHO reference population. For a more detailed de-
scription of this transition, please see the General note on the data on page 114.
The data for ‘wasting’ and ‘stunting’ refer to the same reference populations and are therefore comparable with each other and with data published in previous editions of this report.
‡ Refers to the percentage of children who received at least one dose in 2007 (the most recent coverage point at the time of reporting).
Δ
The percentage of children reached with two doses in 2007 is reported as the lower percentage of two coverage points. ‘0’ (zero) indicates that only one dose was delivered in 2007.
** Excludes China.
TABLE 3. HEALTH
% under- % under-
fives with fives with Malaria 2003–2007*
% of routine Immunization 2007 suspected % under- diarrhoea
% of population EPI pneumonia fives with receiving % % under- % under-
using improved % of population vaccines 1-year-old children immunized against: % taken to an suspected oral rehy- under- fives fives with
drinking-water using improved financed by new- appropriate pneumonia dration and fives sleeping fever
sources sanitation facilities government TB DPT Polio Measles HepB Hib borns health-care receiving continued sleeping under a receiving
2006 2006 2007 protected provider antibiotics feeding under a treated anti-
corresponding vaccines: against mosquito mosquito malarial
Countries and territories total urban rural total urban rural total BCG DPT1β DPT3β polio3 measles HepB3 Hib3 tetanusλ 2000–2007* 2000–2007* net net drugs
Afghanistan 22 37 17 30 45 25 0 77 93 83 83 70 83 – 73 28 – 48 – – –
Albania 97 97 97 97 98 97 100 98 98 98 99 97 98 – 87 45 38 50 – – –
Algeria 85 87 81 94 98 87 100 99 98 95 95 92 90 – 70 53 59 24 – – –
Andorra 100 100 100 100 100 100 – – 98 96 96 94 91 95 – – – – – – –
Angola 51 62 39 50 79 16 18 88 99 83 83 88 83 83 81 58 – 32 21 18 29
Antigua and Barbuda – 95 – – 98 – – – 99 99 98 99 97 99 – – – – – – –
Argentina 96 98 80 91 92 83 – 99 94 96 94 99 92 96 – – – – – – –
Armenia 98 99 96 91 96 81 33 94 96 88 90 92 85 – – 36 11 59 – – –
Australia 100 100 100 100 100 100 88 – 97 92 92 94 94 94 – – – – – – –
Austria 100 100 100 100 100 100 – – 95 85 85 79 85 85 – – – – – – –
Azerbaijan 78 95 59 80 90 70 72 98 97 95 97 97 97 – – 36 – 45 12x 1x 1x
Bahamas – 98 – 100 100 100 100 – 99 95 95 96 93 95 93 – – – – – –
Bahrain – 100 – – 100 – 100 – 97 97 97 99 97 97 66 – – – – – –
Bangladesh 80 85 78 36 48 32 60 97 97 90 96 88 90 – 91 30 22 49 – – –
Barbados 100 100 100 99 99 100 – – 93 93 93 75 93 93 – – – – – – –
Belarus 100 100 99 93 91 97 100 98 99 95 90 99 91 – – 90 67 54 – – –
Belgium – 100 – – – – – – 99 99 99 92 94 98 – – – – – – –
Belize – 100 – – – – 100 99 98 96 97 96 96 96 85 71 44 – – – –
Benin 65 78 57 30 59 11 11 88 84 67 64 61 67 67 93 36 – 42 47 20 54
Bhutan 81 98 79 52 71 50 0 94 92 95 93 95 95 – 86 – – – – – –
Bolivia 86 96 69 43 54 22 100 93 94 81 79 81 81 81 71 52 – 54 – – –
Bosnia and Herzegovina 99 100 98 95 99 92 95 98 96 95 95 96 94 95 – 91 73 53 – – –
Botswana 96 100 90 47 60 30 100 99 98 97 97 90 85 – 78 14 – 7 – – –
Brazil 91 97 58 77 84 37 – 99 98 98 99 99 95 98 93 46x 15x 28x – – –
Brunei Darussalam – – – – – – – 96 99 99 99 97 99 99 65 – – – – – –
Bulgaria 99 100 97 99 100 96 100 98 96 95 95 96 95 – – – – – – – –
Burkina Faso 72 97 66 13 41 6 23 99 99 99 99 94 99 99 80 39 15 42 18 10 48
Burundi 71 84 70 41 44 41 – 84 86 74 64 75 74 74 78 38 26 23 13 8 30
Cambodia 65 80 61 28 62 19 17 90 87 82 82 79 82 – 87 48 – 50 88 4 0
Cameroon 70 88 47 51 58 42 40 81 90 82 81 74 82 – 81 35 38 22 27 13 58
Canada 100 100 99 100 100 99 – – 97 94 90 94 14 94 – – – – – – –
Cape Verde – – – – – – 90 86 83 81 81 74 79 – 77 51 – – – – –
Central African Republic 66 90 51 31 40 25 1 74 65 54 47 62 – – 54 32 39 47 33 15 57
Chad 48 71 40 9 23 4 80 40 45 20 36 23 – – 60 12 – 27 27x 1x 53x
Chile 95 98 72 94 97 74 – 98 95 94 94 91 94 94 – – – – – – –
China 88 98 81 65 74 59 – 94 94 93 94 94 92 – – – – – – – –
Colombia 93 99 77 78 85 58 100 93 97 93 93 95 93 93 78 62 – 39 24x – –
Comoros 85 91 81 35 49 26 0 77 79 75 75 65 75 – 89 49 – 31 36x 9x 63x
Congo 71 95 35 20 19 21 100 86 80 80 80 67 80 – 90 48 – 39 68 6 48
Cook Islands 95 98 88 100 100 100 100 99 99 99 99 98 99 – – – – – – – –
Costa Rica 98 99 96 96 96 95 – 91 90 89 89 90 89 88 – – – – – – –
Côte d’Ivoire 81 98 66 24 38 12 31 94 93 76 75 67 76 – 76 35 19 45 17 3 36
Croatia 99 100 98 99 99 98 100 99 98 96 96 96 95 96 – – – – – – –
Cuba 91 95 78 98 99 95 99 99 97 93 99 99 93 97 – – – – – – –
Cyprus 100 100 100 100 100 100 36 – 99 97 97 87 93 90 – – – – – – –
Czech Republic 100 100 100 99 100 98 100 99 98 99 99 97 99 99 – – – – – – –
Republic of Korea 100 100 100 – – – – 96 93 92 99 99 92 – 91 93 – – – – –
Democratic Republic of the Congo 46 82 29 31 42 25 0 94 95 87 87 79 87 – 81 42 – 17 19 6 30
Denmark 100 100 100 100 100 100 100 – 97 75 75 89 – 75 – – – – – – –
Djibouti 92 98 54 67 76 11 0 90 92 88 88 74 25 25 77 62 43 33 9 1 10
Dominica – 100 – – – – 100 90 93 96 93 96 93 93 – – – – – – –
Dominican Republic 95 97 91 79 81 74 – 92 87 79 83 96 70 59 85 64 – 42 – – –
Ecuador 95 98 91 84 91 72 – 99 99 99 99 99 99 99 67 – – – – – –
Egypt 98 99 98 66 85 52 100 98 98 98 98 97 98 – 85 63 – 27 – – –
El Salvador 84 94 68 86 90 80 100 93 98 96 96 98 96 96 87 62 – – – – –
Equatorial Guinea 43 45 42 51 60 46 100 73 65 33 39 51 – – 62 – – 36 15x 1x 49x
Eritrea 60 74 57 5 14 3 – 99 99 97 96 95 97 – 80 44 – 54 12x 4x 4x
Estonia 100 100 99 95 96 94 100 98 98 95 95 96 95 95 – – – – – – –
Ethiopia 42 96 31 11 27 8 0 72 81 73 71 65 73 73 85 19 5 15 35 33 10
Fiji 47 43 51 71 87 55 100 90 82 83 84 81 84 83 94 – – – – – –
Finland 100 100 100 100 100 100 100 97 99 99 97 98 – 97 – – – – – – –
…TABLE 3
% under- % under-
total urban rural total urban rural total BCG DPT1β DPT3β polio3 measles HepB3 Hib3 tetanusλ 2000–2007* 2000–2007* net net drugs
France 100 100 100 – – – 10 84 98 98 98 87 29 87 – – – – – – –

Gabon 87 95 47 36 37 30 100 89 69 38 31 55 38 – 67 48 – 44 – – –
Gambia 86 91 81 52 50 55 8 95 90 90 85 85 90 90 90 69 61 38 63 49 63
Georgia 99 100 97 93 94 92 43 96 99 98 88 97 94 – – 74 56 37 – – –
Germany 100 100 100 100 100 100 – – 98 97 97 94 87 94 – – – – – – –
Ghana 80 90 71 10 15 6 54 99 96 94 94 95 94 94 88 34 33 29 33 22 61
Greece 100 100 99 98 99 97 – 88 96 88 87 88 88 88 – – – – – – –
Grenada – 97 – 97 96 97 100 – 91 99 99 98 99 99 – – – – – – –
Guatemala 96 99 94 84 90 79 – 97 94 82 82 93 82 82 80 64 – 22x 6x 1x –
Guinea 70 91 59 19 33 12 70 91 96 75 62 71 83 – 95 42 – 38 12 1 44
Guinea-Bissau 57 82 47 33 48 26 0 89 83 63 64 76 – – 92 57 42 25 73 39 46
Guyana 93 98 91 81 85 80 100 97 96 94 94 96 94 94 91 64 20 40 – – –
Haiti 58 70 51 19 29 12 0 75 83 53 52 58 – – 43 31 3 43 – – 5
Holy See – – – – – – – – – – – – – – – 56 54 49 – – –
Honduras 84 95 74 66 78 55 100 91 95 86 86 89 86 86 94 – – – – – 1
Hungary 100 100 100 100 100 100 100 99 99 99 99 99 – 99 – – – – – – –
Iceland 100 100 100 100 100 100 – – 97 97 97 95 – 97 – – – – – – –
India 89 96 86 28 52 18 100 85 81 62 62 67 6 – 86 69 13 33 – – 8
Indonesia 80 89 71 52 67 37 92 91 91 75 83 80 74 – 83 61 – 56 32x 0x 1x
Iran (Islamic Republic of) – 99 – – – – 100 99 99 99 98 97 97 – 83 93 – – – – –
Iraq 77 88 56 76 80 69 100 92 84 62 66 69 58 – 69 82 82 64 7x 0x 1x
Ireland – 100 – – – – – 93 97 92 92 87 – 92 – – – – – – –
Israel 100 100 100 – 100 – – – 98 96 95 97 99 95 – – – – – – –
Italy – 100 – – – – – – 98 96 96 87 96 95 – – – – – – –
Jamaica 93 97 88 83 82 84 100 87 85 85 85 76 85 85 54 75 52 39 – – –
Japan 100 100 100 100 100 100 – – 99 98 95 98 – – – – – – – – –
Jordan 98 99 91 85 88 71 100 90 99 98 98 95 98 98 87 75 87 44 – – –
Kazakhstan 96 99 91 97 97 98 – 99 97 93 94 99 94 – – 71 32 48 – – –
Kenya 57 85 49 42 19 48 – 92 89 81 76 80 81 81 74 49 – 33 15 6 27
Kiribati 65 77 53 33 46 20 100 90 99 94 93 93 96 – – – – – – – –
Kuwait – – – – – – – – 99 99 99 99 99 99 83 – – – – – –
Kyrgyzstan 89 99 83 93 94 93 50 98 98 94 94 99 94 – – 62 45 22 – – –
Lao People’s Democratic Republic 60 86 53 48 87 38 13 56 59 50 46 40 50 – 47 36 – 37 82x 18x 9x
Latvia 99 100 96 78 82 71 100 99 98 98 98 97 97 97 – – – – – – –
Lebanon 100 100 100 – 100 – 100 – 90 74 74 53 74 74 – 74 – – – – –
Lesotho 78 93 74 36 43 34 1 96 95 83 80 85 85 – 76 59 – 53 – – –
Liberia 64 72 52 32 49 7 1 86 99 88 84 95 – – 89 70 – – – – 59
Libyan Arab Jamahiriya – – – 97 97 96 100 99 98 98 98 98 98 56 – – – – – – –
Liechtenstein – – – – – – – – – – – – – – – – – – – – –
Lithuania – – – – – – 100 99 99 95 95 97 96 95 – – – – – – –
Luxembourg 100 100 100 100 100 100 100 – 99 99 99 96 87 99 – – – – – – –
Madagascar 47 76 36 12 18 10 26 94 92 82 81 81 82 – 72 48 – 47 30x 0x 34x
Malawi 76 96 72 60 51 62 33 95 96 87 88 83 87 87 86 52 30 27 31 25 25
Malaysia 99 100 96 94 95 93 – 99 88 96 96 90 87 89 89 – – – – – –
Maldives 83 98 76 59 100 42 100 99 99 98 98 97 98 – 94 22 – – – – –
Mali 60 86 48 45 59 39 100 77 83 68 62 68 68 44 89 38 – 38 41 27 32
Malta 100 100 100 – 100 – 80 – 84 74 76 79 82 72 – – – – – – –
Marshall Islands – – – – – – 3 92 99 93 91 94 93 83 – – – – – – –
Mauritania 60 70 54 24 44 10 100 92 92 75 75 67 74 – 60 45 24 9 43 – 21
Mauritius 100 100 100 94 95 94 100 98 97 97 96 98 97 96 86 – – – – – –
Mexico 95 98 85 81 91 48 – 99 99 98 98 96 98 98 87 – – – – – –
Micronesia (Federated States of) 94 95 94 25 61 14 5 82 92 79 79 92 90 79 – – – – – – –
Moldova 90 96 85 79 85 73 – 98 95 92 94 96 95 – – 60 – 48 – – –
Monaco – 100 – – 100 – – 90 99 99 99 99 99 99 – – – – – – –
Mongolia 72 90 48 50 64 31 19 99 95 95 99 98 98 78 – 63 71 47 – – –
Montenegro 98 100 96 91 96 86 100 98 98 92 92 90 90 89 – 89 57 64 – – –
Morocco 83 100 58 72 85 54 100 96 98 95 95 95 95 90 85 38 – 46 – – –
Mozambique 42 71 26 31 53 19 – 87 88 72 70 77 72 – 82 55 – 47 10 – 15
Myanmar 80 80 80 82 85 81 – 89 89 86 84 81 85 – 91 66 – 65 – – –
Namibia 93 99 90 35 66 18 100 95 88 86 81 69 – – 82 72 14 39 12 11 10
Nauru – – – – – – 100 99 99 99 99 99 99 – – – – – – – –
TABLE 3. HEALTH
% under- % under-
Nepal 89 94 88 27 45 24 29 89 85 82 82 81 82 – 83 43 25 37 – – 0
Netherlands 100 100 100 100 100 100 – – 98 96 96 96 – 96 – – – – – – –
New Zealand – 100 – – – – 100 – 91 88 88 79 88 78 – – – – – – –
Nicaragua 79 90 63 48 57 34 49 99 94 87 88 99 87 87 94 57 – 49 – – 2x
Niger 42 91 32 7 27 3 0 64 58 39 55 47 – – 72 47 – 34 15 7 33
Nigeria 47 65 30 30 35 25 – 69 72 54 61 62 41 – 53 33 – 28 6 1 34
Niue 100 100 100 100 100 100 – 99 99 99 99 99 99 99 – – – – – – –
Norway 100 100 100 – – – 60 – 97 93 93 92 – 95 – – – – – – –
Occupied Palestinian Territory 89 90 88 80 84 69 – 99 99 99 99 99 99 99 – 65 – – – – –
Oman – – – – 97 – – 99 99 99 97 97 99 99 95 – – – – – –
Pakistan 90 95 87 58 90 40 31 89 90 83 83 80 83 – 81 69 50 37 2 – 3
Palau 89 79 94 67 96 52 0 – 99 94 94 91 91 95 – – – – – – –
Panama 92 96 81 74 78 63 – 99 99 88 88 89 88 88 – – – – – – –
Papua New Guinea 40 88 32 45 67 41 100 67 76 60 61 58 59 – 60 75x – – – – –
Paraguay 77 94 52 70 89 42 – 68 86 66 65 80 66 66 81 51x 29x – – – –
Peru 84 92 63 72 85 36 – 97 95 80 95 99 80 80 82 67 – 57 – – –
Philippines 93 96 88 78 81 72 100 90 90 87 87 92 88 – 65 55 – 76 – – 0
Poland – 100 – – – – – 93 99 99 99 98 98 88 – – – – – – –
Portugal 99 99 100 99 99 98 – 98 94 97 96 95 97 97 – – – – – – –
Qatar 100 100 100 100 100 100 8 96 96 94 97 92 94 94 – – – – – – –
Republic of Korea – 97 – – – – – 96 95 91 91 92 91 – – – – – – – –
Romania 88 99 76 72 88 54 – 99 98 97 96 97 99 – – – – – – – –
Russian Federation 97 100 88 87 93 70 – 96 98 98 99 99 98 – – – – – – – –
Rwanda 65 82 61 23 34 20 24 89 96 97 98 99 97 96 82 28 – 24 16 13 12
Saint Kitts and Nevis 99 99 99 96 96 96 – 97 99 99 99 99 99 99 – – – – – – –
Saint Lucia 98 98 98 – – – 100 99 99 99 99 94 99 99 – – – – – – –
Saint Vincent and the Grenadines – – – – – 96 100 99 99 99 99 99 99 99 – – – – – – –
Samoa 88 90 87 100 100 100 – 91 85 71 71 63 69 – 5 – – – – – –
San Marino – – – – – – – – 92 92 92 92 92 92 – – – – – – –
Sao Tome and Principe 86 88 83 24 29 18 50 98 99 97 98 86 99 – – 47 – 63 53 42 25
Saudi Arabia – 97 – – 100 – 100 96 97 96 96 96 96 96 – – – – – – –
Senegal 77 93 65 28 54 9 31 99 99 94 93 84 94 94 86 47 – 43 28 16 22
Serbia 99 99 98 92 96 88 100 98 97 94 93 95 99 89 – 93 57 71 – – –
Seychelles – 100 – – – 100 100 99 99 99 99 99 99 – – – – – – – –
Sierra Leone 53 83 32 11 20 5 0 82 77 64 64 67 64 64 94 48 21 31 20 5 52
Singapore – 100 – – 100 – – 98 97 96 96 95 95 – – – – – – – –
Slovakia 100 100 100 100 100 99 100 98 99 99 99 99 99 99 – – – – – – –
Slovenia – – – – – – 60 – 98 97 98 96 – 98 – – – – – – –
Solomon Islands 70 94 65 32 98 18 0 84 84 79 77 78 79 – 84 – – – – – –
Somalia 29 63 10 23 51 7 – 52 58 39 39 34 – – 68 13 32 7 18 11 8
South Africa 93 100 82 59 66 49 100 99 99 97 97 83 97 97 72 75x – 37x – – –
Spain 100 100 100 100 100 100 100 – 98 96 96 97 96 96 – – – – – – –
Sri Lanka 82 98 79 86 89 86 31 99 99 98 98 98 98 – 91 58 – – 62 3 0
Sudan 70 78 64 35 50 24 0 83 95 84 84 79 78 – 72 57 – 38 23x 0x 50x
Suriname 92 97 79 82 89 60 100 – 96 84 84 85 84 84 93 74 37 28 – – –
Swaziland 60 87 51 50 64 46 100 99 97 95 95 91 95 – 86 73 24 22 1 1 1
Sweden 100 100 100 100 100 100 – 18 99 99 99 96 4 99 – – – – – – –
Switzerland 100 100 100 100 100 100 5 – 97 93 94 86 – 92 – – – – – – –
Syrian Arab Republic 89 95 83 92 96 88 100 99 99 99 99 98 98 99 92 77 71 34 – – –
Tajikistan 67 93 58 92 95 91 10 83 88 86 85 85 84 – – 64 41 22 2 1 2
Thailand 98 99 97 96 95 96 – 99 99 98 98 96 96 – 89 84 65 46 – – –
The former Yugoslav
Republic of Macedonia 100 100 99 89 92 81 100 95 98 95 96 96 96 – – 93 74 45 – – –
Timor-Leste 62 77 56 41 64 32 – 74 76 70 70 63 – – 59 24 – – 48x 8x 47x
Togo 59 86 40 12 24 3 97 91 94 88 78 80 – – 82 23 26 22 41 38 48
Tonga 100 100 100 96 98 96 56 99 99 99 99 99 99 99 – – – – – – –
Trinidad and Tobago 94 97 93 92 92 92 – – 90 88 90 91 89 88 – 74 34 32 – – –
Tunisia 94 99 84 85 96 64 100 99 99 98 98 98 98 – 96 43 – – – – –
Turkey 97 98 95 88 96 72 100 94 98 96 96 96 96 76 69 41 – 19x – – –
Turkmenistan – – – – – – 77 99 99 98 98 99 98 – – 83 50 25 – – –
Tuvalu 93 94 92 89 93 84 10 99 99 97 97 95 97 – – – – – – – –
Uganda 64 90 60 33 29 34 15 90 90 64 59 68 68 68 85 73 47 39 22 10 61
…TABLE 3
% under- % under-
Ukraine 97 97 97 93 97 83 – 97 98 98 99 98 96 11 – – – – – – –
United Arab Emirates 100 100 100 97 98 95 – 98 97 92 94 92 92 92 – – – – – – –
United Kingdom 100 100 100 – – – 100 – 97 92 92 86 – 92 – – – – – – –
United Republic of Tanzania 55 81 46 33 31 34 75 89 89 83 88 90 83 – 88 59 – 53 31 16 58
United States 99 100 94 100 100 99 – – 99 96 92 93 92 94 – – – – – – –
Uruguay 100 100 100 100 100 99 100 99 98 94 94 96 94 94 – – – – – – –
Uzbekistan 88 98 82 96 97 95 64 99 94 96 98 99 98 – – 68 56 28 – – –
Vanuatu – – – – – – 100 82 79 76 76 65 76 – 88 – – – – – –
Venezuela (Bolivarian Republic of) – – – – – – – 83 78 71 73 55 71 71 51 72 – 51 – – –
Viet Nam 92 98 90 65 88 56 87 94 92 92 92 83 67 – 86 83 55 65 95 5 3
Yemen 66 68 65 46 88 30 31 64 94 87 87 74 87 87 52 – 38 48 – – –
Zambia 58 90 41 52 55 51 24 92 92 80 77 85 80 80 89 68 – 48 34 29 38
Zimbabwe 81 98 72 46 63 37 0 76 77 62 66 66 62 – 78 25 8 47 7 3 5
SUMMARY INDICATORS
Sub-Saharan Africa 58 81 45 30 42 24 31 83 85 73 74 73 67 34 76 40 – 31 21 12 34
Eastern and Southern Africa 59 88 48 34 48 28 32 86 88 78 77 77 77 55 81 45 – 33 24 19 29
West and Central Africa 56 77 41 27 37 20 30 80 82 69 71 69 58 16 71 37 – 29 18 8 38
Middle East and North Africa 87 94 78 73 87 53 81 92 96 91 92 89 89 32 77 68 – 39 – – –
South Asia 87 94 84 33 57 23 83 87 84 69 69 71 29 – 85 63 18 35 – – –
East Asia and Pacific 88 96 81 66 75 59 – 93 93 89 91 90 87 2 – 65** – 61** – – –
Latin America and Caribbean 92 97 73 79 86 52 – 96 95 92 93 93 89 90 83 – – – – – –
CEE/CIS 94 99 86 89 94 81 81 96 97 96 97 97 96 23 – 57 – – – – –
Industrialized countries§ 100 100 98 100 100 99 – – 98 96 94 93 65 84 – – – – – – –
Developing countries§ 84 94 76 53 71 39 70 89 89 80 81 81 65 21 81 57** – 38** – – –
Least developed countries§ 62 81 55 33 49 27 28 85 89 79 79 76 75 28 81 42 – 37 – – –
World 87 96 78 62 79 45 71 89 90 81 82 82 65 26 81 57** – 38** – – –
Government funding of vaccines – Percentage of vaccines that are routinely administered in a country to protect children and are financed by the national government (including loans). Use of improved drinking-water sources
EPI – Expanded programme on immunization: The immunizations in this programme include those against tuberculosis (TB); diphtheria, pertussis (whooping cough) and tetanus (DPT); polio; and improved sanitation facilities –
and measles, as well as vaccination of pregnant women to protect babies against neonatal tetanus. Other vaccines, e.g., against hepatitis B (HepB), Haemophilus influenzae type b (Hib) or UNICEF and World Health Organization
yellow fever, may be included in the programme in some countries. (WHO), Joint Monitoring Programme.
BCG – Percentage of infants who received bacille Calmette-Guérin (vaccine against tuberculosis). Government funding of vaccines – UNICEF
and WHO.
DPT1 – Percentage of infants who received their first dose of diphtheria, pertussis and tetanus vaccine.
Immunization – UNICEF and WHO.
DPT3 – Percentage of infants who received three doses of diphtheria, pertussis and tetanus vaccine.
Suspected pneumonia – Demographic and
HepB3 – Percentage of infants who received three doses of hepatitis B vaccine. Health Surveys (DHS), Multiple Indicator
Hib3 – Percentage of infants who received three doses of Haemophilus influenzae type b vaccine. Cluster Surveys (MICS) and other national
% under-fives with suspected pneumonia taken to an appropriate health-care provider – Percentage of children (aged 0–4) with suspected pneumonia in the two weeks preceding household surveys.
the survey who were taken to an appropriate health-care provider. Oral rehydration – DHS and MICS.
% under-fives with suspected pneumonia receiving antibiotics – Percentage of children (aged 0–4) with suspected pneumonia in the two weeks preceding the survey who are Malaria – DHS and MICS.
receiving antibiotics.
% under-fives with diarrhoea receiving oral rehydration and continued feeding – Percentage of children (aged 0–4) with diarrhoea in the two weeks preceding the survey who
received either oral rehydration therapy (oral rehydration solutions or recommended home-made fluids) or increased fluids and continued feeding.
Malaria:
% under-fives sleeping under a mosquito net – Percentage of children (aged 0–4) who slept under a mosquito net.
% under-fives sleeping under a treated mosquito net – Percentage of children (aged 0–4) who slept under an insecticide-treated mosquito net.
% under-fives with fever receiving antimalarial drugs – Percentage of children (aged 0–4) who were ill with fever in the two weeks preceding the survey and received any appropriate
(locally defined) antimalarial drugs.

x Data refer to years or periods other than those specified in the column heading, differ from the standard definition or refer to only part of a country. Such data are not included in the calculation of regional and global averages.
β Coverage for DPT1 should be at least as high as DPT3. Discrepancies where DPT1 coverage is less than DPT3 reflect deficiencies in the data collection and reporting process. UNICEF and WHO are working with national and
territorial systems to eliminate these discrepancies.
λ WHO and UNICEF have employed a model to calculate the percentage of births that can be considered as protected against tetanus because pregnant women were given two doses or more of tetanus toxoid (TT) vaccine.
The model aims to improve the accuracy of this indicator by capturing or including other potential scenarios where women might be protected (e.g., women who receive doses of TT in supplemental immunization activities).
A fuller explanation of the methodology can be found in the General note on the data, page 114.
** Excludes China.
TABLE 4. HIV/AIDS
Prevention among young people
Paediatric Orphans
infections % who % who
have used Children (aged 0–17)
Mother-to-child Estimated HIV prevalence compre- condom
Estimated Estimated number of people transmission number of among young hensive at last orphaned Orphan
adult HIV (all ages) living with HIV, children people knowledge higher-risk orphaned due to all school
prevalence 2007 (thousands) Estimated number of (aged 0–14) (aged 15–24), of HIV, sex, by AIDS, causes, attendance
rate women (aged 15+) living with 2007 2002–2007* 2002–2007* 2007 2007 ratio
(aged 15–49), low high living with HIV, 2007 HIV, 2007 estimate estimate
Countries and territories 2007 estimate estimate– estimate (thousands) (thousands) male female male female male female (thousands) (thousands) 2002–2007*
Afghanistan – – – – – – – – – – – – 2100 –
Albania – – <1.0 – – – – – 6 – – – – –
Algeria 0.1 21 11–43 6.0 – 0.1 0.1 – 13 – – – 570 –
Andorra – – – – – – – – – – – – – –
Angola 2.1 190 150–240 110 17 0.2 0.3 – – – – 50 1200 90x
Antigua and Barbuda – – – – – – – – – – – – – –
Argentina 0.5 120 90–150 32 – 0.6 0.3 – – – – – 610 –
Armenia 0.1 2.4 1.8–3.5 <1.0 – 0.2 0.1 15 23 86 – – 50 –
Australia 0.2 18 11–36 1.2 – 0.2 <0.1 – – – – – 140 –
Austria 0.2 9.8 7.6–13 2.9 – 0.2 0.1 – – – – – 52 –
Azerbaijan 0.2 7.8 4.7–16 1.3 – 0.3 0.1 5 5 31 – – 190 –
Bahamas 3.0 6.2 4.0–8.7 1.6 <0.2 3.2 1.5 – – – – – 7 –
Bahrain – – – – – – – – – – – – – –
Bangladesh – 12 7.7–19 2.0 – – – – 16 – – – 5000 84
Barbados 1.2 2.2 1.5–3.2 <1.0 – 1.3 0.6 – – – – – 3 –
Belarus 0.2 13 10–19 3.9 – 0.3 0.1 – 34 – – – 190 –
Belgium 0.2 15 8.9–29 4.1 – 0.2 0.1 – – – – – 78 –
Belize 2.1 3.6 2.2–5.3 2.0 <0.2 0.5 1.5 – 40 – – – 6 –
Benin 1.2 64 58–73 37 5.4 0.3 0.9 35 16 45 28 29 340 90
Bhutan 0.1 <0.5 <1.0 <0.1 – 0.1 <0.1 – – – – – 22 –
Bolivia 0.2 8.1 6.5–11 2.2 – 0.2 0.1 18 15 37 20 – 300 74p
Bosnia and Herzegovina <0.1 <0.5 <1.0 – – – – – 48 – 71 – – –
Botswana 23.9 300 280–310 170 15 5.1 15.3 33x 40x 88x 75x 95 130 99x
Brazil 0.6 730 600–890 240 – 1.0 0.6 – – 71 58 – 3200 –
Brunei Darussalam – – – – – – – – – – – – – –
Bulgaria – – – – – – – 15 17 70 57 – 95 –
Burkina Faso 1.6 130 110–160 61 10 0.5 0.9 – 19 – 64 100 690 61p
Burundi 2.0 110 78–130 53 15 0.4 1.3 – 30 – 25 120 600 85
Cambodia 0.8 75 67–84 20 4.4 0.8 0.3 45 50 84 – – 600 83
Cameroon 5.1 540 430–640 300 45 1.2 4.3 – 32 – 62 300 1100 91
Canada 0.4 73 43–110 20 – 0.4 0.2 – – – – – 180 –
Cape Verde – – – – – – – 36 36 79 56 – – –
Central African Republic 6.3 160 150–170 91 14 1.1 5.5 27 17 – 41 72 280 96
Chad 3.5 200 130–240 110 19 2.0 2.8 20 8 25 17 85 540 105
Chile 0.3 31 23–39 8.7 – 0.3 0.2 – – – – – 160 –
China 0.1 700 450–1000 200 – 0.1 0.1 – – – – – 17000 –
Colombia 0.6 170 110–230 47 – 0.7 0.3 – – – 36 – 790 85
Comoros <0.1 <0.2 <1.0 <0.1 – 0.1 <0.1 – 10x – – <0.1 27 –
Congo 3.5 79 65–94 43 6.6 0.8 2.3 35 26 36 16 69 210 88
Cook Islands – – – – – – – – – – – – – –
Costa Rica 0.4 9.7 6.1–15 2.7 – 0.4 0.2 – – – – – 36 –
Côte d’Ivoire 3.9 480 400–550 250 52 0.8 2.4 28 18 53 39 420 1200 83
Croatia <0.1 <0.5 <1.0 – – – – – – – – – – –
Cuba 0.1 6.2 3.6–12 1.8 – 0.1 0.1 – 52 – – – 99 –
Cyprus – – – – – – – – – – – – – –
Czech Republic – 1.5 <1.0–2.8 <0.5 – <0.1 – – – – – – 94 –
Republic of Korea – – <0.1 – – – – – – – – – 530 –
Democratic Republic
of the Congo – – 400–500 – – – – 21 15 26 17 – 4500 77
Denmark 0.2 4.8 3.7–6.9 1.1 – 0.2 0.1 – – – – – 53 –
Djibouti 3.1 16 12–19 8.7 1.1 0.7 2.1 – 18 51 26 5 42 –
Dominica – – – – – – – – – – – – – –
Dominican Republic 1.1 62 52–71 30 2.7 0.3 0.6 34 41 70 44 – 170 96
Ecuador 0.3 26 15–40 7.1 – 0.4 0.2 – – – – – 200 –
Egypt – 9.2 7.2–13 2.6 – – – – 4y – – – 1400 –
El Salvador 0.8 35 24–72 9.7 – 0.9 0.5 – – – – – 130 –
Equatorial Guinea 3.4 11 8.2–14 5.9 <1.0 0.8 2.5 – 4x – – 5 32 95x
Eritrea 1.3 38 25–58 21 3.1 0.3 0.9 – 37 – – 18 280 83
Estonia 1.3 9.9 5.4–19 2.4 – 1.6 0.7 – – – – – 20 –
Ethiopia 2.1 980 880–1100 530 92 0.5 1.5 33 20 50 28 650 5000 90
Fiji 0.1 – <0.5 – – 0.1 – – – – – – 22 –
Finland 0.1 2.4 1.4–4.4 <1.0 – 0.1 <0.1 – – – – – 48 –
…TABLE 4
Paediatric Orphans
2007 estimate estimate– estimate (thousands) (thousands) male female male female male female (thousands) (thousands) 2002–2007*
France 0.4 140 78–240 38 – 0.4 0.2 – – – – – 420 –

Gabon 5.9 49 37–68 27 2.3 1.3 3.9 22x 24x 48x 33x 18 67 98x
Gambia 0.9 8.2 3.7–13 4.5 <1.0 0.2 0.6 – 39 – 54 3 48 87
Georgia 0.1 2.7 1.5–6.1 <1.0 – 0.1 0.1 – 15 – – – 72 –
Germany 0.1 53 31–97 15 – 0.1 0.1 – – – – – 540 –
Ghana 1.9 260 230–290 150 17 0.4 1.3 33 25 56 42 160 1100 104p
Greece 0.2 11 6.1–19 3.0 – 0.2 0.1 – – – – – 73 –
Grenada – – – – – – – – – – – – – –
Guatemala 0.8 59 41–84 52 – – 1.5 – – – – – 360 –
Guinea 1.6 87 73–110 48 6.3 0.4 1.2 23 17 37 26 25 380 73
Guinea-Bissau 1.8 16 11–23 8.7 1.5 0.4 1.2 – 18 – 39 6 110 97
Guyana 2.5 13 7.6–18 7.1 <1.0 0.5 1.7 – 50 68 62 – 23 –
Haiti 2.2 120 100–140 58 6.8 0.6 1.4 40 34 43 29 – 380 86
Holy See – – – – – – – – – – – – – –
Honduras 0.7 28 18–44 7.4 1.6 0.7 0.4 – 30 – 24 – 170 108
Hungary 0.1 3.3 2.0–5.9 <1.0 – 0.1 <0.1 – – – – – 130 –
Iceland 0.2 <0.5 <1.0 <0.2 – 0.2 0.1 – – – – – 2 –
India 0.3 2400 1800–3200 880 – 0.3 0.3 36 20 37 22 – 25000 72
Indonesia 0.2 270 190–400 54 – 0.3 0.1 0y 1 – – – 4400 82y
Iran (Islamic Republic of) 0.2 86 68–110 24 – 0.2 0.1 – – – – – 1300 –
Iraq – – – – – – – – 3 – – – – 84
Ireland 0.2 5.5 4.1–7.7 1.5 – 0.2 0.1 – – – – – 38 –
Israel 0.1 5.1 2.5–12 2.9 – <0.1 0.1 – – – – – 44 –
Italy 0.4 150 110–210 41 – 0.4 0.2 – – – – – 320 –
Jamaica 1.6 27 19–36 7.6 – 1.7 0.9 – 60 – – – 53 –
Japan – 9.6 7.9–10 2.3 – – – – – – – – 520 –
Jordan – <1.0 <2.0 – – – – – 3y – – – – –
Kazakhstan 0.1 12 7.0–29 3.3 – 0.2 0.1 – 22 65x 32x – 470 –
Kenya – – 1500–2000 – – – – 47 34 47 25 – 2500 95
Kiribati – – – – – – – – – – – – – –
Kuwait – <1.0 <2.0 – – – – – – – – – – –
Kyrgyzstan 0.1 4.2 2.3–7.7 1.1 – 0.2 0.1 – 20 – 56 – 140 –
Lao People’s
Democratic Republic 0.2 5.5 3.3–13 1.3 – 0.2 0.1 – – – – – 210 –
Latvia 0.8 10 7.4–15 2.7 – 0.9 0.5 – – – – – 33 –
Lebanon 0.1 3.0 1.7–7.2 <1.0 – 0.1 0.1 – – – – – 71 –
Lesotho 23.2 270 260–290 150 12 5.9 14.9 18 26 53 53 110 160 95
Liberia 1.7 35 29–41 19 3.1 0.4 1.3 27 21 22 14 15 270 –
Libyan Arab Jamahiriya – – – – – – – – – – – – – –
Liechtenstein – – – – – – – – – – – – – –
Lithuania 0.1 2.2 1.2–4.6 <1.0 – 0.1 0.1 – – – – – 51 –
Luxembourg 0.2 – <1.0 <0.2 – 0.2 0.1 – – – – – 4 –
Madagascar 0.1 14 9.1–23 3.4 <0.5 0.2 0.1 16 19 12 5 3 840 75
Malawi 11.9 930 860–1000 490 91 2.4 8.4 42 42 58 40 550 1100 97
Malaysia 0.5 80 52–120 21 – 0.6 0.3 – – – – – 410 –
Maldives – – <0.1 – – – – – – – – – 9 –
Mali 1.5 100 88–120 56 9.4 0.4 1.1 22 18 36 17 44 550 87
Malta 0.1 <0.5 <1.0 – – 0.1 0.1 – – – – – 3 –
Marshall Islands – – – – – – – 39 27 – – – – –
Mauritania 0.8 14 8.3–26 3.9 <0.5 0.9 0.5 – – – – 3 83 –
Mauritius 1.7 13 7.5–28 3.8 <0.1 1.8 1.0 – – – – <0.5 21 –
Mexico 0.3 200 150–310 57 – 0.3 0.2 – – – – – 1400 –
Micronesia
(Federated States of) – – – – – – – – – – – – – –
Moldova 0.4 8.9 6.0–15 2.6 – 0.4 0.2 54y 42y 63 44 – 74 –
Monaco – – – – – – – – – – – – – –
Mongolia 0.1 <1.0 1.5 <0.2 – 0.1 – – 35 – – – 64 96p
Montenegro – – – – – – – – 30 – 66 – – –
Morocco 0.1 21 15–31 5.9 – 0.1 0.1 – 12 – – – 630 –
Mozambique 12.5 1500 1300–1700 810 100 2.9 8.5 33 20 33 29 400 1400 80
Myanmar 0.7 240 160–370 100 – 0.7 0.6 – – – – – 1600 –
Namibia 15.3 200 160–230 110 14 3.4 10.3 62 65 81 64 66 110 100
Nauru – – – – – – – – – – – – – –
Nepal 0.5 70 50–99 17 – 0.5 0.3 44 28 78 – – 990 –
Netherlands 0.2 18 10–32 4.9 – 0.2 0.1 – – – – – 110 –
TABLE 4. HIV/AIDS
Paediatric Orphans
New Zealand 0.1 1.4 <1.0–2.6 <0.5 – 0.1 – – – – – – 34 –

Nicaragua 0.2 7.7 5.3–15 2.1 – 0.3 0.1 – 22x – 17x – 110 106x
Niger 0.8 60 44–85 17 3.2 0.9 0.5 16 13 37y 18y 25 570 67
Nigeria 3.1 2600 2000–3200 1400 220 0.8 2.3 21 18 46 24 1200 9700 64p
Niue – – – – – – – – – – – – – –
Norway 0.1 3.0 1.7–5.0 <1.0 – 0.1 0.1 – – – – – 37 –
Occupied Palestinian Territory – – – – – – – – – – – – – –
Oman – – – – – – – – – – – – – –
Pakistan 0.1 96 69–150 27 – 0.1 0.1 – 3 – – – 3900 –
Palau – – – – – – – – – – – – – –
Panama 1.0 20 16–26 5.5 – 1.1 0.6 – – – – – 48 –
Papua New Guinea 1.5 54 53–55 21 1.1 0.6 0.7 – – – – – 330 –
Paraguay 0.6 21 12–38 5.8 – 0.7 0.3 – – – – – 130 –
Peru 0.5 76 57–97 21 – 0.5 0.3 – 19 – 32 – 570 85x
Philippines – 8.3 6.0–11 2.2 – – – 18 12 25 11 – 1800 –
Poland 0.1 20 11–34 5.5 – 0.1 0.1 – – – – – 440 –
Portugal 0.5 34 20–63 9.4 – 0.5 0.3 – – – – – 82 –
Qatar – – – – – – – – – – – – – –
Republic of Korea <0.1 13 7.5–42 3.6 – <0.1 <0.1 – – – – – 360 –
Romania 0.1 15 12–16 7.0 – 0.2 0.2 1y 3y – – – 300 –
Russian Federation 1.1 940 630–1300 240 5.2 1.3 0.6 – – – – – 4000 –
Rwanda 2.8 150 130–170 78 19 0.5 1.4 54 51 40 26 220 860 82
Saint Kitts and Nevis – – – – – – – – – – – – – –
Saint Lucia – – – – – – – – – – – – – –
Saint Vincent and
the Grenadines – – – – – – – – – – – – – –
Samoa – – – – – – – – – – – – – –
San Marino – – – – – – – – – – – – – –
Sao Tome and Principe – – – – – – – – 44 – 56 – – –
Saudi Arabia – – – – – – – – – – – – – –
Senegal 1.0 67 47–96 38 3.1 0.3 0.8 24 19 52 36 8 350 83
Serbia 0.1 6.4 3.9–12 1.8 – 0.1 0.1 – 42 – 74 – 130 –
Seychelles – – – – – – – – – – – – – –
Sierra Leone 1.7 55 42–76 30 4.0 0.4 1.3 – 17 – 20 16 350 83
Singapore 0.2 4.2 2.6–7.3 1.2 – 0.2 0.1 – – – – – 24 –
Slovakia <0.1 <0.5 <1.0 – – – – – – – – – – –
Slovenia <0.1 <0.5 <1.0 – – – – – – – – – – –
Solomon Islands – – – – – – – – – – – – – –
Somalia 0.5 24 13–45 6.7 <1.0 0.6 0.3 – 4 – – 9 590 78
South Africa 18.1 5700 4900–6600 3200 280 4.0 12.7 – – – – 1400 2500 –
Spain 0.5 140 80–230 28 – 0.6 0.2 – – – – – 210 –
Sri Lanka – 3.8 2.8–5.1 1.4 – <0.1 – – – – – – 330 –
Sudan 1.4 320 220–440 170 25 0.3 1.0 – – – – – 1800 96x
Suriname 2.4 6.8 4.2–12 1.9 <0.2 2.7 1.4 – 41 – 49 – 9 –
Swaziland 26.1 190 180–200 100 15 5.8 22.6 52 52 70 54 56 96 97
Sweden 0.1 6.2 3.5–11 2.9 – 0.1 0.1 – – – – – 66 –
Switzerland 0.6 25 14–43 9.2 – 0.4 0.5 – – – – – 39 –
Syrian Arab Republic – – – – – – – – 7 – – – – –
Tajikistan 0.3 10 5.0–23 2.1 <0.1 0.4 0.1 – 2 – – – 210 –
Thailand 1.4 610 410–880 250 14 1.2 1.2 – 46 – – – 1300 93
The former Yugoslav
Republic of Macedonia <0.1 <0.5 <1.0 – – – – – 27 – 70 – – –
Timor-Leste – – – – – – – – – – – – 48 –
Togo 3.3 130 110–150 69 10 0.8 2.4 – 28 – 50 68 260 94
Tonga – – – – – – – – – – – – – –
Trinidad and Tobago 1.5 14 9.5–19 7.7 – 0.3 1.0 – 54 – 51 – 20 –
Tunisia 0.1 3.7 2.7–5.4 1.0 – 0.1 <0.1 – – – – – 130 –
Turkey – <2.0 <5.0 – – – – – – – – – – –
Turkmenistan <0.1 <0.5 <1.0 – – – – – 5 – – – – –
Tuvalu – – – – – – – – – – – – – –
Uganda 5.4 940 870–1000 480 130 1.3 3.9 38 32 55 38 1200 2500 96
Ukraine 1.6 440 340–540 190 5.1 1.5 1.5 43 42 – – – 1000 98
United Arab Emirates – – – – – – – – – – – – – –
…TABLE 4
Paediatric Orphans
United Kingdom 0.2 77 37–160 22 – 0.3 0.1 – – – – – 520 –

United Republic of Tanzania 6.2 1400 1300–1500 760 140 0.5 0.9 40 45 46 34 970 2600 102
United States 0.6 1200 690–1900 230 – 0.7 0.3 – – – – – 2800 –
Uruguay 0.6 10 5.9–19 2.8 – 0.6 0.3 – – – – – 46 –
Uzbekistan 0.1 16 8.1–45 4.6 <0.2 0.1 0.1 – 31 – 61 – 690 –
Vanuatu – – – – – – – – – – – – – –
Venezuela
(Bolivarian Republic of) – – – – – – – – – – – – 430 –
Viet Nam 0.5 290 180–470 76 – 0.6 0.3 – 44 68 – – 1500 –
Yemen – – – – – – – – – – – – – –
Zambia 15.2 1100 1000–1200 560 95 3.6 11.3 37 34 48 38 600 1100 103y
Zimbabwe 15.3 1300 1200–1400 680 120 2.9 7.7 46 44 68 42 1000 1300 95
SUMMARY INDICATORS
Sub-Saharan Africa 5.0 22000 20500–23600 12000 1800 1.1 3.2 30 24 44 29 11600 47500 83
Eastern and Southern Africa 7.8 16400 15300–17600 8970 1300 1.5 4.5 38 31 47 30 8700 24900 92
West and Central Africa 2.6 5600 4800–6300 3000 480 0.7 1.9 23 19 42 29 3000 22700 76
Middle East and North Africa 0.3 480 370–620 220 28 0.1 0.2 – – – – – 5900 –
South Asia 0.3 2600 2000–3400 930 110 0.3 0.2 36 18 38 22 – 37400 73
East Asia and Pacific 0.2 2400 1900–3000 750 41 0.2 0.1 7** 18** – – – 30100 –
Latin America and Caribbean 0.6 1900 1700–2400 660 55 0.5 0.4 – – – – – 9400 –
CEE/CIS 0.8 1500 1100–1900 460 11 0.8 0.5 – – – – – 7600 –
Industrialized countries§ 0.3 2000 1400–2900 460 5.8 0.4 0.2 – – – – – 7200 –
Developing countries§ 0.9 29500 27300–32100 14600 2000 0.4 0.7 30** 19** – – – 130000 77
Least developed countries§ 2.2 10000 9500–11000 5300 900 0.6 1.4 32 23 45 29 – 40400 86
World 0.8 33000 30000–36000 15500 2000 0.4 0.6 – – – – 15000 145000 –
Estimated adult HIV prevalence rate – Percentage of adults (aged 15–49) living with HIV as of 2007. Estimated adult HIV prevalence rate – Joint United Nations Programme on HIV/AIDS
Estimated number of people (all ages) living with HIV – Estimated number of people (all ages) living with (UNAIDS), Report on the Global AIDS Epidemic, 2008.
HIV as of 2007. Estimated number of people (all ages) living with HIV – UNAIDS, Report on the
Estimated number of women (aged 15+) living with HIV – Estimated number of women (aged 15+) living Global AIDS Epidemic, 2008.
with HIV as of 2007. Estimated number of women (aged 15+) living with HIV – UNAIDS, Report on the
Estimated number of children (aged 0–14) living with HIV – Estimated number of children (aged 0–14) Global AIDS Epidemic, 2008.
living with HIV as of 2007. Estimated number of children (aged 0–14) living with HIV – UNAIDS, Report on
HIV prevalence among young people – Percentage of young men and women (aged 15–24) living with HIV the Global AIDS Epidemic, 2008.
as of 2007. HIV prevalence among young people – UNAIDS, Report on the Global AIDS
Comprehensive knowledge of HIV – Percentage of young men and women (aged 15–24) who correctly Epidemic, 2008.
identify the two major ways of preventing the sexual transmission of HIV (using condoms and limiting sex to Comprehensive knowledge of HIV – AIDS Indicator Surveys (AIS), Behavioural
one faithful, uninfected partner), who reject the two most common local misconceptions about HIV Surveillance Surveys (BSS), Demographic and Health Surveys (DHS), Multiple Indicator
transmission and who know that a healthy-looking person can be HIV-infected. Cluster Surveys (MICS), Reproductive Health Surveys (RHS) and other national
Condom use at last higher-risk sex – Percentage of young men and women (aged 15–24) who say they used household surveys, 2002–2007; ‘HIV/AIDS Survey Indicators Database’,
a condom the last time they had sex with a non-marital, non-cohabiting partner, of those who have had sex <www.measuredhs.com/hivdata>.
with such a partner during the past 12 months. Condom use at last higher-risk sex – AIS, BSS, DHS, RHS and other national
Children orphaned by AIDS – Estimated number of children (aged 0–17) who have lost one or both parents to household surveys, 2002–2007; ‘HIV/AIDS Survey Indicators Database’,
AIDS as of 2007. <www.measuredhs.com/hivdata>.
Children orphaned due to all causes – Estimated number of children (aged 0–17) who have lost one or both Children orphaned by AIDS – UNAIDS, Report on the Global AIDS Epidemic, 2008.
parents due to any cause as of 2007. Children orphaned due to all causes – UNAIDS unpublished estimates.
Orphan school attendance ratio – Percentage of children (aged 10–14) who have lost both biological parents Orphan school attendance ratio – AIS, DHS, MICS and other national household
and who are currently attending school as a percentage of non-orphaned children of the same age who live surveys, 2002–2007; ‘HIV/AIDS Survey Indicators Database’,
with at least one parent and who are attending school. <www.measuredhs.com/hivdata>.

y Data refer to years or periods other than those specified in the column heading, differ from the standard definition or refer to only part of a country. Such data are included in the calculation of
regional and global averages.
p Proportion of orphans (aged 10–14) attending school is based on small denominators (typically 25–49 unweighted cases).
** Excludes China.
TABLE 5. EDUCATION
Primary school Secondary school
Number per 100 Primary school enrolment ratio attendance Secondary school enrolment ratio attendance
population 2000–2007* ratio Survival rate to 2000–2007* ratio
Youth (15–24 years) 2000–2007* 2000–2007*
2006 last primary grade (%)
literacy rate gross net net gross net net
2000–2007* 2000–2007*
Internet
Countries and territories male female phones users male female male female male female admin. data survey data male female male female male female
Afghanistan 49 18 8 2 126 75 74 46 66 40 – 90 28 9 – – 18 6
Albania 99 100 60 15 106 105 94 93 92 92 90 100 78 75 74 72 79 77
Algeria 94 91 63 7 114 106 96 94 97 96 91 – 80 86 65 68 57 65
Andorra – – 97 56 90 90 83 83 – – – – 83 87 73 75 – –
Angola 84 63 14 1 69x 59x – – 58 59 – 83 19 16 – – 22 20
Antigua and Barbuda – – 134 64 – – – – – – – – – – – – – –
Argentina 99 99 81 21 113 112 99 98 – – 87 – 80 89 75 82 – –
Armenia 100 100 – 6 96 100 80 84 99 98 99 100 88 91 84 88 93 95
Australia – – 97 52 105 105 96 97 – – – – 154 146 87 88 – –
Austria – – 113 51 102 101 97 98 – – 99 – 104 100 – – – –
Azerbaijan 100 100 39 10 98 95 86 83 74 72 97 99 85 81 79 76 82 80
Bahamas – – 77 34 98 98 87 89 – – 81 – 91 91 83 85 – –
Bahrain 100 100 123 28 120 119 98 98 86 87 99 99 100 104 91 96 77 85
Bangladesh 71 73 13 0 101 105 87 91 79 84 65 94 43 45 40 42 36 41
Barbados – – 88 93 104 102 97 96 – – 97 – 100 104 88 89 – –
Belarus 100 100 61 56 97 95 90 89 93 94 99 100 95 97 87 89 95 97
Belgium – – 93 47 102 102 97 98 – – 94 – 112 108 89 85 – –
Belize – 89 44 11 125 121 97 97 95 95 92 – 77 81 64 70 58 60
Benin 63 41 12 1 105 87 87 73 72 62 65 89 41 23 23 11 40 27
Bhutan 83 73 10 4 103 101 79 79 74 67 84 – 51 46 38 39 – –
Bolivia 99 98 31 6 109 109 95 95 78 77 82 41 84 81 72 70 57 56
Bosnia and Herzegovina 100 100 48 24 – – – – 92 89 – 100 – – – – 89 89
Botswana 93 95 47 5 108 106 83 85 83 86 75 – 75 78 52 60 36 44
Brazil 97 99 53 23 141 133 94 95 95x 95x 81 88 101 111 75 83 42x 50x
Brunei Darussalam 100 100 79 42 107 106 94 94 – – 98 – 96 100 88 92 – –
Bulgaria 98 97 108 47 101 100 93 92 – – 95 – 108 104 90 88 – –
Burkina Faso 47 33 7 1 66 54 52 42 49 44 64 90 17 12 14 10 17 15
Burundi 77 70 3 1 108 98 76 73 72 70 78 74 16 12 – – 8 6
Cambodia 90 83 12 0 127 118 91 89 84 86 49 92 43 34 33 28 29 26
Cameroon 72 59 19 2 117 98 – – 86 81 59 95 27 21 – – 45 42
Canada – – 58 77 100 99 99 100 – – – – 119 116 – – – –
Cape Verde 97 98 21 6 108 103 88 87 97x 96x 89 – 75 86 56 63 – –
Central African Republic 70 47 3 0 72 49 53 38 64 54 39 65 – – 13 9 16 10
Chad 56 23 5 1 90 61 71 50 41 31 26 94 23 8 16 5 13 7
Chile 99 99 76 25 107 102 – – – – 98 – 90 92 – – – –
China 99 99 35 10 112 111 99 99 – – – – 75 76 – – – –
Colombia 98 98 64 14 117 115 89 88 90 92 82 89 78 87 62 69 64 72
Comoros 92 87 5 3 91 80 75 71 31 31 72 19 40 30 15 15 10 11
Congo 99 98 19 2 113 102 58 52 86 87 55 93 47 39 – – 39 40
Cook Islands – – – 27 79 80 73 75 – – – – 71 74 62 68 – –
Costa Rica 98 99 33 28 112 111 91 93 87 89 91 – 83 89 58 64 59 65
Côte d’Ivoire – 40 22 2 79 62 61 49 66 57 86 90 32 18 25 14 32 22
Croatia 100 100 96 37 99 99 91 90 – – 100 – 90 93 86 88 – –
Cuba 100 100 1 2 102 100 96 97 – – 97 – 93 94 86 88 – –
Cyprus 100 100 103 42 103 102 99 99 – – 99 – 96 97 93 95 – –
Czech Republic – – 122 35 100 100 91 94 – – 100 – 96 97 – – – –
Republic of Korea – – – – – – – – – – – – – – – – – –
Democratic Republic of
the Congo 78 63 7 0 68 54 – – 55 49 – 49 28 16 – – 18 15
Denmark – – 107 58 99 99 95 96 – – 92 – 118 121 88 90 – –
Djibouti – 48 5 1 49 40 42 34 80 78 – – 27 18 26 17 50 42
Dominica – – – 37 85 87 75 80 – – 88 – 107 105 77 85 – –
Dominican Republic 95 97 51 16 101 96 77 79 84 88 61 81 63 75 47 57 27 39
Ecuador 96 97 63 12 117 117 96 97 – – 76 – 67 68 57 58 – –
Egypt 90 82 24 8 108 102 98 94 96 94 97 98 91 85 82 78 72 67
El Salvador 95 96 55 10 116 112 94 94 – – 67 – 63 66 53 56 – –
Equatorial Guinea 95 95 27 2 125 119 91 83 61 60 33 – 41 23 – – 23 22
Eritrea 85 70 1 2 69 56 50 43 69 64 74 – 39 23 30 20 23 21
Estonia 100 100 125 55 100 98 95 94 – – 96 – 99 101 90 92 – –
Ethiopia 62 39 1 0 97 85 74 69 45 45 58 84 37 24 29 19 30 23
Fiji – – – 9 101 99 91 91 – – 81 – 80 88 76 83 – –
Finland – – 108 56 98 98 97 97 – – 99 – 109 114 96 96 – –
…TABLE 5
Youth (15–24 years) 2000–2007* 2000–2007*
2000–2007* 2000–2007*
Internet
male female phones users male female male female male female admin. data survey data male female male female male female
France – – 85 50 110 109 98 99 – – 98x – 114 114 98 100 – –
Gabon 98 96 64 6 153 152 88 88 94 94 56 – 53 46 – – 34 36
Gambia 63 41 26 5 71 77 59 64 60 62 – 95 47 43 40 37 39 34
Georgia – 99 38 7 94 97 88 91 94 95 100 – 83 86 77 81 89 88
Germany – – 104 47 103 103 98 98 – – 99 – 102 100 – – – –
Ghana 80 76 23 3 98 97 73 71 75 75 60 98 52 46 47 43 45 45
Greece 99 99 99 18 102 102 100 99 – – 98 – 104 102 92 93 – –
Grenada – – 45 21 94 91 84 83 – – 83 – 99 102 78 80 – –
Guatemala 88 83 56 10 118 109 96 92 80x 76x 63 – 56 51 40 37 23x 24x
Guinea 59 34 – 1 96 81 77 66 55 48 76 96 45 24 35 20 27 17
Guinea-Bissau 94 87 10 2 84 56 53 37 54 53 – 81 23 13 11 6 8 7
Guyana – – – 23 125 124 – – 96 96 59 96 106 104 – – 66 73
Haiti 76 87 14 8 – – – – 48 52 – 85 – – – – 18 21
Holy See – – 0 0 – – – – – – – – – – – – – –
Honduras 88 93 30 5 119 118 96 97 77 80 81 – 66 86 – – 29 36
Hungary 98 99 99 35 98 96 89 88 – – 98 – 96 95 90 90 – –
Iceland – – 109 65 98 97 98 97 – – 99 – 108 111 89 91 – –
India 87 77 15 11 114 109 90 87 85 81 73 95 59 49 – – 59 49
Indonesia 99 99 28 5 116 112 97 94 94 95 80 – 64 64 59 59 54 56
Iran (Islamic Republic of) 98 97 24 26 104 132 91 100 94 91 88 – 83 78 79 75 – –
Iraq 89 81 32 0 109 90 95 82 91 80 70 83 54 36 45 32 46 34
Ireland – – 113 34 104 103 95 95 – – – – 108 116 85 90 – –
Israel – – 123 28 109 111 96 98 – – 100 – 93 92 88 89 – –
Italy 100 100 135 53 104 103 99 98 – – 100 – 101 100 93 94 – –
Jamaica 91 98 94 49 95 95 90 90 97 98 87 – 86 89 77 80 88 92
Japan – – 79 68 100 100 100 100 – – – – 101 102 99 99 – –
Jordan 99 99 74 14 96 98 89 91 99 99 96 – 88 90 81 83 85 89
Kazakhstan 100 100 53 9 105 106 90 90 99 98 100 100 93 92 86 86 97 97
Kenya 80 81 21 8 107 104 75 76 79 79 84 90 52 49 43 42 12 13
Kiribati – – – 2 112 114 96 98 – – 81 – 82 94 65 72 – –
Kuwait 100 100 91 29 97 96 84 83 – – 96 – 87 91 75 79 – –
Kyrgyzstan 100 100 24 12 97 96 86 85 91 93 99 99 86 87 80 81 90 92
Lao People’s Democratic
Republic 85 80 17 1 123 109 86 81 81 77 62 93 49 38 38 32 40 33
Latvia 100 100 95 47 96 93 89 92 – – 98 – 98 99 – – – –
Lebanon – – 31 26 96 93 82 82 97 97 87 93 78 85 70 77 61 68
Lesotho 75 91 20 3 115 114 71 74 82 88 62 84 33 42 19 29 16 27
Liberia 68 76 8 0 96 87 40 39 – – – – 37 27 22 13 – –
Libyan Arab Jamahiriya 100 98 66 4 113 108 – – – – – – 86 101 – – – –
Liechtenstein – – 82 64 106 107 87 89 – – – – 120 104 62 69 – –
Lithuania 100 100 138 32 95 94 90 89 – – 97 – 99 99 92 93 – –
Luxembourg – – 117 72 102 103 96 98 – – 88 – 94 98 82 86 – –
Madagascar 73 68 5 1 142 137 96 96 74 77 36 93 24 23 17 18 17 21
Malawi 84 82 5 0 117 121 88 94 86 88 36 71 32 27 25 23 27 26
Malaysia 98 98 75 54 101 100 100 100 – – 99 – 66 72 66 72 – –
Maldives 98 98 88 9 118 114 97 97 – – – – 80 86 65 70 – –
Mali 36 23 11 1 90 71 68 54 45 33 73 90 35 21 – – 15 11
Malta 96 99 86 34 101 99 92 91 – – 99 – 99 100 84 90 – –
Marshall Islands – – – – 94 92 67 66 – – – – 66 67 43 47 – –
Mauritania 70 63 34 1 99 104 78 82 56 59 45 – 27 23 16 15 21 17
Mauritius 95 97 62 25 102 102 94 96 – – 99 – 89 88 81 82 – –
Mexico 98 98 53 19 114 111 98 97 97 97 92 – 86 88 71 70 – –
Micronesia
(Federated States of) – – 19 14 109 111 – – – – – – 80 86 – – – –
Moldova 100 100 32 17 97 96 88 88 84 85 97 100 87 91 80 83 82 85
Monaco – – 52 56 – – – – – – – – – – – – – –
Mongolia 94 97 29 12 99 102 90 93 96 98 91 97 84 95 77 87 85 91
Montenegro – 93 107 44 – – – – 98 97 – 97 – – – – 90 92
Morocco 84 67 52 20 112 100 91 85 91 87 74 – 53 45 37 32 39 36
Mozambique 58 48 12 1 113 97 79 73 63 57 40 68 18 13 4 4 8 7
Myanmar 97 96 0 0 114 115 99 100 83 84 72 100 49 49 46 46 51 48
Namibia 91 94 30 4 107 107 74 79 91 91 77 90 53 61 30 40 40 53
Nauru – – – – 78 80 – – – – 25 – 42 50 – – – –
TABLE 5. EDUCATION
Youth (15–24 years) 2000–2007* 2000–2007*
2000–2007* 2000–2007*
Internet
Nepal 85 73 4 1 129 123 91 87 86 82 81 95 46 41 – – 46 38
Netherlands – – 106 86 108 105 99 97 – – 98 – 119 117 88 89 – –
New Zealand – – 94 79 102 102 99 99 – – – – 117 123 91 93 – –
Nicaragua 85 92 33 3 117 115 90 90 77 84 50 56 62 70 40 47 35 47
Niger 53 26 3 0 58 43 56 40 44 31 53 88 14 9 12 7 13 9
Nigeria 89 85 24 6 105 87 68 59 66 58 63 96 36 29 28 23 38 33
Niue – – – – 107 102 – – – – – – 96 102 91x 96x – –
Norway – – 108 82 98 98 98 98 – – 100 – 113 113 96 97 – –
Occupied Palestinian Territory 99 99 22 7 82 83 76 76 91 92 98 – 91 97 87 92 – –
Oman 99 98 70 11 82 83 73 75 – – 99 – 90 87 78 77 – –
Pakistan 80 60 22 8 94 74 74 57 60 51 70 – 34 26 33 26 23 18
Palau – – 0 0 108 101 98 95 – – – – 96 105 – – – –
Panama 97 96 66 15 113 110 99 98 – – 85 – 67 73 61 68 – –
Papua New Guinea 63 65 – 2 60 50 – – – – – – – – – – – –
Paraguay 96 97 51 4 113 110 94 95 95 96 84 – 66 67 56 59 81 80
Peru 99 97 31 23 116 117 96 97 94 94 85 94 93 96 72 72 70 70
Philippines 94 95 51 6 110 109 91 93 88 89 70 90 79 88 55 66 55 70
Poland 100 99 95 37 98 97 96 96 – – 98 – 100 99 93 94 – –
Portugal 100 100 116 30 118 112 98 98 – – – – 94 102 78 86 – –
Qatar 97 98 110 35 105 104 93 94 – – 89 – 103 100 91 90 – –
Republic of Korea – – 84 71 107 103 100 93 – – 99 – 100 95 99 93 – –
Romania 97 98 80 52 105 104 93 93 – – 94 – 86 86 74 73 – –
Russian Federation 100 100 106 18 96 96 91 91 – – 99 – 85 83 – – – –
Rwanda 79 77 3 1 138 142 76 81 84 87 31 76 14 13 – – 5 5
Saint Kitts and Nevis – – – 32 86 103 64 78 – – 78 – 110 100 70 61 – –
Saint Lucia – – – 62 122 114 99 97 – – 96 – 80 95 65 80 – –
Saint Vincent and the
Grenadines – – 74 29 94 100 93 88 – – 64 – 67 83 57 71 – –
Samoa 99 100 25 4 100 100 90 91 – – 96x – 76 86 62 71 – –
San Marino – – 64 57 – – – – – – – – – – – – – –
Sao Tome and Principe 95 96 12 14 128 127 97 98 94 95 61 83 44 47 31 34 39 41
Saudi Arabia 98 96 78 19 – – – – – – – – – – – – – –
Senegal 59 44 25 5 81 79 71 70 58 59 54 93 27 21 23 18 20 16
Serbia – 96 63 13 97 97 95 95 98 98 – 100 87 89 – – 90 93
Seychelles 99 99 87 36 126 125 99 100 – – 99 – 105 119 94 100 – –
Sierra Leone 64 44 – 0 155 139 – – 69 69 – 91 38 26 27 19 21 17
Singapore 100 100 109 59 – – – – – – – – – – – – – –
Slovakia – – 91 42 101 99 92 92 – – 97 – 94 95 – – – –
Slovenia 100 100 93 64 101 100 96 95 – – 99 – 96 95 90 91 – –
Solomon Islands – – – 2 102 98 62 62 – – – – 33 27 29 25 – –
Somalia – 24 6 1 – – – – 24 20 – 85 – – – – 8 4
South Africa 95 96 83 8 108 103 88 88 80x 83x 77 – 92 98 59 66 41x 48x
Spain 100 100 106 43 106 104 100 99 – – 100 – 115 122 92 96 – –
Sri Lanka 97 98 26 2 108 108 98 97 – – 100 – 86 88 – – – –
Sudan 85 71 12 9 71 61 45 37 56 52 74 56 35 33 – – 17 22
Suriname 96 95 71 8 121 121 95 98 94 93 – 80 66 90 57 79 55 66
Swaziland 87 90 24 4 110 102 78 79 83 86 71 80 47 47 29 35 31 41
Sweden – – 106 77 96 95 95 95 – – – – 104 103 99 99 – –
Switzerland – – 99 58 98 97 89 89 – – – – 95 90 84 80 – –
Syrian Arab Republic 95 92 24 8 129 123 97 92 97 96 92 – 72 68 64 61 64 65
Tajikistan 100 100 – – 103 98 99 95 89 88 99 100 90 75 87 74 89 74
Thailand 98 98 63 13 108 108 95 94 98 98 – – 75 82 68 75 77 84
The former Yugoslav
Republic of Macedonia 99 99 70 13 98 98 92 92 97 93 98 – 85 83 82 80 79 78
Timor-Leste – – 5 0 103 95 70 67 76 74 – – 53 54 – – – –
Togo 84 64 11 5 110 95 86 75 82 76 68 84 54 27 30 14 45 32
Tonga 100 100 29 3 116 110 98 94 – – 91 – 92 96 54 68 – –
Trinidad and Tobago 100 100 69 22 96 94 85 85 98 98 84 97 75 78 64 67 84 90
Tunisia 97 94 72 13 110 107 96 97 95 93 94 – 81 89 61 68 – –
Turkey 98 94 71 18 96 92 93 89 91 87 94 95 86 71 74 64 52 43
Turkmenistan 100 100 4 1 – – – – 99 99 – 100 – – – – 84 84
…TABLE 5
Youth (15–24 years) 2000–2007* 2000–2007*
2000–2007* 2000–2007*
Internet
Tuvalu – – 15 19 106 105 – – – – 63 – 87 81 – – – –
Uganda 88 84 7 5 116 117 – – 83 82 25 72 20 16 16 14 16 15
Ukraine 100 100 107 20 102 102 90 90 96 98 98 100 94 93 83 84 90 93
United Arab Emirates 99 97 119 37 104 103 88 88 – – 99 – 89 91 78 80 – –
United Kingdom – – 117 63 105 106 98 99 – – – – 97 99 91 94 – –
United Republic of Tanzania 79 76 15 1 113 111 98 97 71 75 83 91 7x 6x 22 20 8 8
United States – – 80 70 98 99 91 93 – – 96 – 94 94 88 88 – –
Uruguay 98 99 67 24 117 113 100 100 – – 92 – 94 109 – – – –
Uzbekistan 99 99 9 4 97 94 – – 100 100 99 100 103 102 – – 91 90
Vanuatu 92 92 – – 110 106 88 86 – – 69x – 43 37 41 35 – –
Venezuela
(Bolivarian Republic of) 96 98 69 15 106 103 91 91 91 93 90 82 73 82 62 71 30 43
Viet Nam 95 94 18 17 109 103 – – 94 94 92 98 68 62 – – 77 78
Yemen 93 67 14 1 100 74 85 65 68x 41x 60 – 61 30 49 26 35x 13x
Zambia 73x 66x 14 4 118 116 90 94 55 58 76 80 33 27 31 25 17 19
Zimbabwe 98 99 6 9 102 101 87 88 91 93 62 79 42 39 38 36 46 43
SUMMARY INDICATORS
Sub-Saharan Africa 77 68 18 3 101 90 75 70 64 61 61 84 36 29 28 24 26 22
Eastern and Southern Africa 78 69 19 3 110 104 83 81 66 66 60 82 39 34 30 27 20 18
West and Central Africa 77 66 18 3 93 77 67 58 63 56 62 86 33 24 26 20 31 26
Middle East and North Africa 93 85 37 13 102 97 86 81 88 85 83 – 73 67 67 62 54 52
South Asia 84 74 15 9 111 104 88 83 81 77 72 94 54 45 – – 51 43
East Asia and Pacific 98 98 36 12 111 110 98 97 92** 92** 80** – 73 73 60** 62** 60** 63**
Latin America and Caribbean 97 97 54 19 120 116 94 95 90 91 84 – 87 94 69 74 – –
CEE/CIS 99 99 81 20 98 96 92 90 93 91 96 97 89 85 79 75 79 76
Industrialized countries§ – – 93 59 101 101 95 96 – – 97 – 102 101 91 92 – –
Developing countries§ 90 84 30 11 109 103 89 86 80** 77** 74** 90 62 58 51** 49** 48** 43**
Least developed countries§ 75 65 9 1 101 91 79 74 65 63 60 82 35 29 30 26 26 24
World 90 85 42 18 108 103 90 87 80** 77** 76** 90 67 63 58** 57** 48** 44**
Youth literacy rate – Number of literate persons aged 15–24, expressed as a percentage of the total population in Youth literacy – UNESCO Institute for Statistics (UIS).
that age group. Phone and Internet use – International Telecommunications Union, Geneva.
Primary school gross enrolment ratio – Number of children enrolled in primary school, regardless of age, Primary and secondary school enrolment – UIS.
expressed as a percentage of the total number of children of official primary school age.
Primary and secondary school attendance – Demographic and Health Surveys
Secondary school gross enrolment ratio – Number of children enrolled in secondary school, regardless of age, (DHS) and Multiple Indicator Cluster Surveys (MICS).
expressed as a percentage of the total number of children of official secondary school age.
Survival rate to the last grade of primary school – Administrative data: UIS,
Primary school net enrolment ratio – Number of children enrolled in primary school who are of official primary survey data: DHS and MICS.
school age, expressed as a percentage of the total number of children of official primary school age.
Secondary school net enrolment ratio – Number of children enrolled in secondary school who are of official
secondary school age, expressed as a percentage of the total number of children of official secondary school age.
Primary school net attendance ratio – Number of children attending primary or secondary school who are of
official primary school age, expressed as a percentage of the total number of children of official primary school age.
Secondary school net attendance ratio – Number of children attending secondary or tertiary school who are of
official secondary school age, expressed as a percentage of the total number of children of official secondary
school age.
Survival rate to the last grade of primary school – Percentage of children entering the first grade of primary
school who eventually reach the last grade of primary school.

** Excludes China.
TABLE 6. DEMOGRAPHIC INDICATORS
Average
Population Population annual
(thousands) annual growth rate
2007 growth rate Crude Crude Life Total % of of urban
(%) death rate birth rate expectancy fertility population population (%)
under under rate urbanized
Countries and territories 18 5 1970–1990 1990–2007 1970 1990 2007 1970 1990 2007 1970 1990 2007 2007 2007 1970–1990 1990–2007
Afghanistan 14526 5002 0.3 4.5 29 23 20 52 52 48 35 41 44 7.1 24 2.9 6.4
Albania 986 250 2.2 -0.2 8 6 6 33 24 16 67 72 76 2.1 47 2.9 1.4
Algeria 11780 3271 3.0 1.7 16 7 5 49 32 21 53 67 72 2.4 65 4.4 3.2
Andorra 14 4 3.9 2.0 – – – – – – – – – – 91 3.8 2.0
Angola 9022 3162 2.7 2.8 27 24 21 52 53 48 37 40 42 6.5 55 7.3 5.4
Antigua and Barbuda 28 8 -0.6 1.9 – – – – – – – – – – 38 -0.3 2.5
Argentina 12279 3364 1.5 1.1 9 8 8 23 22 18 66 71 75 2.3 90 2.0 1.5
Armenia 760 167 1.7 -1.0 5 8 10 23 21 12 70 68 72 1.4 64 2.3 -1.4
Australia 4802 1272 1.4 1.2 9 7 7 20 15 12 71 77 81 1.8 89 1.4 1.5
Austria 1573 393 0.2 0.5 13 11 9 15 12 9 70 76 80 1.4 66 0.2 0.5
Azerbaijan 2536 564 1.7 0.9 7 7 7 29 27 16 65 66 67 1.8 52 2.0 0.7
Bahamas 106 28 2.0 1.5 7 6 6 31 24 17 66 70 73 2.0 91 3.1 2.2
Bahrain 227 65 4.0 2.5 9 4 3 40 29 17 62 72 76 2.3 97 4.3 3.2
Bangladesh 64486 18900 2.4 2.0 20 12 8 45 35 25 44 54 64 2.9 26 7.2 3.8
Barbados 66 17 0.6 0.5 9 8 7 22 16 11 69 75 77 1.5 54 1.0 1.7
Belarus 1870 454 0.6 -0.3 7 11 15 16 14 9 71 71 69 1.2 73 2.7 0.2
Belgium 2128 558 0.2 0.3 12 11 10 14 12 10 71 76 79 1.6 97 0.3 0.4
Belize 124 36 2.1 2.6 8 5 4 40 35 25 66 72 76 3.0 49 1.7 2.9
Benin 4553 1525 3.0 3.3 22 15 11 47 47 40 46 53 56 5.5 41 6.7 4.5
Bhutan 248 60 3.0 1.1 23 14 7 47 38 19 41 52 66 2.2 12 6.1 4.2
Bolivia 4167 1245 2.3 2.1 20 11 8 46 36 28 46 59 65 3.5 65 4.0 3.2
Bosnia and Herzegovina 825 189 0.9 -0.5 7 7 9 23 15 9 66 72 75 1.2 47 2.8 0.5
Botswana 783 218 3.3 1.9 13 7 15 45 35 25 55 64 50 2.9 59 11.8 4.1
Brazil 62565 18110 2.2 1.5 10 7 6 35 24 19 59 66 72 2.3 85 3.7 2.4
Brunei Darussalam 132 41 3.4 2.5 7 3 3 36 28 22 67 74 77 2.3 74 3.7 3.4
Bulgaria 1298 341 0.2 -0.8 9 12 15 16 12 9 71 71 73 1.3 71 1.4 -0.5
Burkina Faso 7778 2670 2.4 3.0 24 17 15 51 49 44 42 50 52 6.0 19 6.8 5.2
Burundi 4383 1541 2.4 2.4 20 19 16 44 48 47 44 46 49 6.8 11 7.3 5.8
Cambodia 6247 1708 1.7 2.3 20 12 9 42 44 26 44 55 59 3.2 21 2.0 5.7
Cameroon 8908 2866 2.9 2.4 19 13 15 45 42 35 46 55 50 4.4 56 6.4 4.6
Canada 6909 1720 1.2 1.0 7 7 7 17 14 10 73 77 81 1.5 80 1.3 1.4
Cape Verde 242 74 1.4 2.4 12 8 5 40 39 29 56 65 72 3.4 59 5.5 4.3
Central African Republic 2137 674 2.4 2.2 22 16 18 42 42 36 42 50 44 4.6 38 3.9 2.5
Chad 5690 1989 2.5 3.3 21 16 15 46 48 46 45 52 51 6.2 26 5.5 5.0
Chile 4848 1234 1.6 1.4 10 6 5 29 23 15 62 73 79 1.9 88 2.1 1.8
China 341820 84062 1.6 0.9 8 7 7 33 21 13 62 68 73 1.7 42 3.9 3.6
Colombia 16196 4388 2.2 1.6 9 6 6 38 27 19 61 68 73 2.2 73 3.2 2.2
Comoros 403 130 3.3 2.7 18 11 7 50 41 34 48 56 65 4.4 38 5.1 4.8
Congo 1825 595 3.0 2.6 14 11 12 44 39 35 54 57 55 4.5 61 4.7 3.5
Cook Islands 5 1 -0.9 -1.7 – – – – – – – – – – 73 -0.5 -0.3
Costa Rica 1482 394 2.6 2.2 7 4 4 33 27 18 67 75 79 2.1 63 4.0 3.7
Côte d’Ivoire 9271 2872 4.4 2.4 18 13 16 51 45 36 49 54 48 4.5 46 6.1 3.5
Croatia 846 204 0.4 0.0 10 11 12 15 12 9 69 72 76 1.3 57 1.9 0.4
Cuba 2571 632 1.0 0.4 7 7 8 29 17 11 70 74 78 1.5 75 2.0 0.5
Cyprus 200 50 0.5 1.3 10 8 7 19 19 12 71 76 79 1.6 70 3.0 1.7
Czech Republic 1822 469 0.2 -0.1 12 12 11 16 12 9 70 72 76 1.2 73 2.1 -0.2
Democratic People’s Republic of Korea 6656 1562 1.7 1.0 7 6 10 35 21 13 62 71 67 1.9 62 2.1 1.4
Democratic Republic of the Congo 33784 12268 3.1 2.9 20 18 18 48 49 50 45 47 46 6.7 33 2.6 4.3
Denmark 1210 318 0.2 0.3 10 12 10 16 12 11 73 75 78 1.8 86 0.5 0.4
Djibouti 369 107 6.2 2.3 21 14 11 49 42 29 43 51 55 4.0 87 7.3 3.3
Dominica 22 6 0.3 -0.1 – – – – – – – – – – 73 2.1 0.3
Dominican Republic 3788 1113 2.3 1.7 11 6 6 42 29 24 58 67 72 2.8 68 3.9 3.1
Ecuador 5060 1403 2.7 1.5 12 6 5 42 29 21 58 68 75 2.6 64 4.4 2.5
Egypt 29422 8719 2.2 1.8 17 9 6 41 32 24 50 62 71 2.9 43 2.4 1.9
El Salvador 2696 772 1.8 1.7 12 7 6 44 30 23 57 65 72 2.7 60 2.9 3.1
Equatorial Guinea 247 82 0.8 2.4 25 19 15 41 42 39 40 47 51 5.4 39 2.0 3.3
Eritrea 2402 837 2.7 2.5 21 16 9 47 41 40 43 48 58 5.1 20 3.8 4.2
Estonia 254 68 0.7 -0.9 11 13 14 15 14 11 71 69 71 1.5 69 1.1 -1.2
Ethiopia 42124 13651 2.7 2.9 21 18 13 49 47 38 43 47 53 5.3 16 4.6 4.7
…TABLE 6
Average
18 5 1970–1990 1990–2007 1970 1990 2007 1970 1990 2007 1970 1990 2007 2007 2007 1970–1990 1990–2007
Fiji 320 88 1.6 0.9 8 6 7 34 29 21 60 67 69 2.8 52 2.5 2.3
Finland 1093 287 0.4 0.3 10 10 10 14 13 11 70 75 79 1.8 61 1.4 0.3
France 13573 3828 0.6 0.5 11 9 9 17 13 12 72 77 81 1.9 77 0.8 0.8
Gabon 555 159 2.8 2.2 20 11 12 34 36 26 47 61 57 3.1 85 6.6 3.6
Gambia 803 264 3.5 3.4 28 15 10 50 43 35 37 51 59 4.8 56 6.8 5.9
Georgia 1006 233 0.7 -1.3 9 9 12 19 16 11 67 71 71 1.4 52 1.5 -1.7
Germany 14286 3499 0.1 0.2 12 11 11 14 11 8 71 75 79 1.4 75 0.1 0.4
Ghana 10553 3216 2.7 2.4 16 11 9 45 40 30 49 57 60 3.9 49 3.9 4.5
Greece 1906 514 0.7 0.5 8 9 10 17 10 9 72 77 79 1.3 59 1.3 0.6
Grenada 42 10 0.1 0.6 9 10 8 28 28 18 64 66 69 2.3 31 0.1 0.3
Guatemala 6588 2093 2.5 2.4 15 9 6 44 39 34 52 62 70 4.2 48 3.2 3.5
Guinea 4656 1566 2.3 2.6 27 19 12 50 47 40 38 47 56 5.5 34 5.1 3.9
Guinea-Bissau 918 333 2.8 3.0 29 23 19 49 50 50 36 42 46 7.1 30 5.9 3.5
Guyana 267 70 0.1 0.1 11 9 8 38 25 17 60 62 66 2.3 28 0.2 -0.2
Haiti 4211 1250 2.1 1.8 18 13 9 39 37 28 47 54 61 3.6 40 4.1 3.8
Holy See – – – – – – – – – – – – – – – – –
Honduras 3257 948 3.0 2.2 15 7 6 47 38 28 52 66 70 3.3 47 4.6 3.4
Hungary 1903 471 0.0 -0.2 11 14 13 15 12 9 69 69 73 1.3 67 0.5 -0.1
Iceland 78 21 1.1 1.0 7 7 6 21 17 14 74 78 82 2.0 93 1.4 1.2
India 446646 126808 2.2 1.8 16 10 8 38 32 23 49 59 64 2.8 29 3.5 2.8
Indonesia 76805 21630 2.1 1.4 17 9 6 41 26 19 48 61 70 2.2 50 5.0 4.6
Iran (Islamic Republic of) 24229 6472 3.4 1.3 14 7 5 43 35 20 54 64 71 2.0 68 4.9 2.6
Iraq 13847 4217 3.0 2.6 12 8 9 46 39 32 56 63 59 4.3 67 4.1 2.5
Ireland 1063 323 0.9 1.2 11 9 7 22 15 16 71 75 79 2.0 61 1.3 1.7
Israel 2262 683 2.2 2.5 7 6 5 27 22 20 71 76 81 2.8 92 2.6 2.8
Italy 9882 2734 0.3 0.2 10 10 10 17 10 9 72 77 81 1.4 68 0.4 0.3
Jamaica 1007 273 1.2 0.8 8 7 7 35 25 20 68 72 72 2.5 54 2.1 1.4
Japan 21206 5549 0.8 0.2 7 7 9 19 10 8 72 79 83 1.3 66 1.7 0.5
Jordan 2500 731 3.5 3.5 16 6 4 52 36 26 54 67 72 3.1 83 4.8 4.6
Kazakhstan 4558 1316 1.2 -0.4 9 9 10 26 23 19 62 67 67 2.3 58 1.7 -0.3
Kenya 18593 6359 3.7 2.8 15 10 12 51 42 39 52 60 53 5.0 21 6.5 3.9
Kiribati 35 10 2.5 1.6 – – – – – – – – – – 50 4.0 4.1
Kuwait 785 242 5.3 1.7 6 2 2 48 24 18 66 75 78 2.2 98 6.0 1.8
Kyrgyzstan 1945 514 2.0 1.1 11 8 8 31 31 22 60 66 66 2.5 36 2.0 0.9
Lao People’s Democratic Republic 2681 720 2.3 2.1 19 13 7 44 43 27 46 54 64 3.2 21 4.7 4.3
Latvia 411 103 0.6 -0.9 11 13 14 14 14 9 70 69 73 1.3 68 1.3 -1.1
Lebanon 1365 362 1.0 1.9 9 7 7 33 26 18 65 69 72 2.2 87 2.7 2.3
Lesotho 953 271 2.2 1.3 17 11 19 43 36 29 49 59 42 3.4 19 5.7 2.1
Liberia 2017 725 2.2 3.3 22 21 18 49 50 50 42 43 45 6.8 60 4.9 5.2
Libyan Arab Jamahiriya 2183 688 3.9 2.0 16 5 4 49 26 24 51 68 74 2.8 85 6.7 2.7
Liechtenstein 7 2 1.5 1.1 – – – – – – – – – – 22 1.6 1.6
Lithuania 688 150 0.8 -0.5 9 11 12 17 15 9 71 71 73 1.3 66 2.4 -0.7
Luxembourg 102 27 0.6 1.2 12 11 9 13 13 11 70 75 79 1.7 83 1.0 1.4
Madagascar 9829 3190 2.8 2.9 21 15 10 47 44 37 44 51 59 4.8 27 5.3 4.0
Malawi 7479 2461 3.7 2.3 24 18 15 56 50 41 41 49 48 5.6 18 7.0 5.2
Malaysia 9663 2756 2.6 2.3 9 5 4 37 30 21 61 70 74 2.6 69 4.5 4.5
Maldives 121 31 2.9 2.0 17 9 6 40 40 23 50 60 68 2.6 31 6.8 3.2
Mali 6721 2321 2.3 2.8 26 20 15 52 52 48 39 47 54 6.5 32 4.7 4.9
Malta 84 20 0.9 0.7 9 8 8 17 15 10 70 76 79 1.4 96 0.9 1.1
Marshall Islands 22 6 4.2 1.3 – – – – – – – – – – 67 4.3 1.6
Mauritania 1443 462 2.6 2.8 18 11 8 45 40 33 47 57 64 4.4 41 7.6 3.1
Mauritius 358 94 1.2 1.0 7 6 7 28 20 15 62 69 73 1.9 42 1.4 0.9
Mexico 37772 10342 2.4 1.4 10 5 5 44 28 20 61 70 76 2.2 77 3.4 1.8
Micronesia (Federated States of) 50 14 2.2 0.8 9 7 6 41 34 26 62 66 68 3.8 22 2.4 0.0
Moldova 932 211 1.0 -0.9 10 10 12 18 19 11 65 68 69 1.4 47 2.9 -0.9
Monaco 6 2 1.2 0.5 – – – – – – – – – – 100 1.2 0.5
Mongolia 898 232 2.8 1.0 14 9 7 42 33 19 53 61 67 1.9 57 4.0 1.1
Montenegro 142 38 0.6 0.1 3 5 10 10 11 14 69 75 74 1.8 – – –
Morocco 11075 3005 2.4 1.4 17 8 6 47 30 20 52 64 71 2.4 60 4.1 2.8
TABLE 6. DEMOGRAPHIC INDICATORS
Average
18 5 1970–1990 1990–2007 1970 1990 2007 1970 1990 2007 1970 1990 2007 2007 2007 1970–1990 1990–2007
Mozambique 10909 3700 1.8 2.7 25 20 20 48 43 40 39 43 42 5.2 36 8.3 6.2
Myanmar 15617 4132 2.1 1.1 15 11 10 40 27 18 51 59 62 2.1 32 2.5 2.8
Namibia 939 248 3.0 2.2 15 9 13 43 42 26 53 62 52 3.2 36 4.1 4.1
Nauru 4 1 1.7 0.6 – – – – – – – – – – 100 1.7 0.6
Nepal 12606 3651 2.3 2.3 21 13 8 42 39 28 43 54 64 3.3 17 6.3 6.4
Netherlands 3576 969 0.7 0.6 8 9 9 17 13 11 74 77 80 1.7 81 1.2 1.6
New Zealand 1064 285 1.0 1.2 9 8 7 22 17 14 71 75 80 2.0 86 1.2 1.4
Nicaragua 2441 673 2.7 1.8 13 7 5 47 37 25 54 64 73 2.8 60 3.3 2.6
Niger 7724 2797 3.1 3.5 26 22 14 58 56 49 40 46 57 7.2 17 5.9 4.4
Nigeria 75065 24823 2.8 2.6 22 18 17 47 47 40 42 47 47 5.4 50 5.3 5.0
Niue 1 0 – – – – – – – – – – – – 37 – –
Norway 1092 284 0.4 0.6 10 11 9 17 14 12 74 77 80 1.8 78 0.9 1.1
Occupied Palestinian Territory 2095 685 3.4 3.7 19 7 4 49 46 36 54 68 73 5.2 72 4.5 4.2
Oman 1013 271 4.5 2.0 17 4 3 50 38 22 49 70 76 3.0 72 9.3 2.7
Pakistan 70609 19333 3.2 2.2 16 11 7 43 42 27 51 60 65 3.5 36 4.2 3.3
Palau 8 2 1.4 1.8 – – – – – – – – – – 68 2.2 1.8
Panama 1181 344 2.4 1.9 8 5 5 38 26 21 65 72 75 2.6 73 3.0 3.9
Papua New Guinea 2941 894 2.4 2.5 19 11 10 42 37 30 43 54 57 3.8 14 3.9 2.9
Paraguay 2537 734 2.7 2.2 7 6 6 37 33 25 65 68 72 3.1 60 4.0 3.6
Peru 10273 2817 2.5 1.5 14 7 6 42 30 21 53 65 71 2.5 73 3.4 1.9
Philippines 36804 11095 2.6 2.1 11 7 5 40 33 26 57 65 72 3.3 64 4.5 4.0
Poland 7471 1767 0.8 0.0 8 10 10 17 15 9 70 71 76 1.2 62 1.6 0.1
Portugal 1996 558 0.7 0.4 11 10 11 21 12 11 67 74 78 1.5 59 1.8 1.7
Qatar 208 65 7.2 3.5 13 3 2 34 23 16 60 69 76 2.7 96 7.4 3.9
Republic of Korea 10418 2319 1.5 0.7 9 6 6 31 16 9 60 71 79 1.2 81 4.5 1.3
Romania 4154 1051 0.7 -0.5 9 11 12 21 14 10 68 69 72 1.3 54 2.2 -0.5
Russian Federation 27044 7302 0.7 -0.2 9 12 16 14 14 11 69 68 65 1.3 73 1.5 -0.3
Rwanda 4921 1685 3.3 1.7 20 33 17 53 49 44 44 33 46 5.9 21 5.9 10.3
Saint Kitts and Nevis 17 5 -0.5 1.3 – – – – – – – – – – 32 -0.4 0.8
Saint Lucia 54 15 1.4 1.1 8 7 7 41 25 19 64 71 74 2.2 28 2.4 0.8
Saint Vincent and the Grenadines 42 12 0.9 0.6 11 7 7 40 25 20 61 69 71 2.2 47 3.0 1.5
Samoa 88 24 0.6 0.9 10 7 5 39 34 25 55 65 71 4.0 23 0.8 1.4
San Marino 6 2 1.2 1.5 – – – – – – – – – – 89 3.1 1.4
Sao Tome and Principe 76 23 2.3 1.8 13 10 8 47 38 33 55 62 65 3.9 60 4.2 3.9
Saudi Arabia 9781 2921 5.2 2.5 18 5 4 48 36 25 52 68 73 3.4 81 7.5 3.0
Senegal 5998 1942 2.9 2.6 21 12 9 48 43 35 45 57 63 4.7 42 4.2 3.3
Serbia 2204 610 0.8 0.2 9 10 12 18 15 13 68 71 74 1.8 – – –
Seychelles 44 15 1.6 1.1 – – – – – – – – – – 50 4.8 1.2
Sierra Leone 2889 1019 2.1 2.1 29 26 22 47 48 46 35 39 42 6.5 42 4.8 4.4
Singapore 994 200 1.9 2.3 5 5 5 23 18 8 69 75 80 1.3 100 1.9 2.4
Slovakia 1087 260 0.7 0.1 10 10 10 19 15 10 70 72 75 1.2 56 2.3 0.1
Slovenia 343 89 0.7 0.2 10 10 10 17 11 9 69 73 78 1.3 51 2.3 0.4
Solomon Islands 229 71 3.3 2.7 10 12 7 46 40 31 54 57 63 3.9 18 5.5 4.4
Somalia 4389 1539 3.1 1.5 24 22 17 51 46 43 40 42 48 6.1 36 4.5 2.8
South Africa 18385 5235 2.4 1.7 14 8 17 38 29 23 53 62 50 2.7 60 2.9 2.7
Spain 7742 2321 0.7 0.8 9 8 9 20 10 11 72 77 81 1.4 77 1.4 0.9
Sri Lanka 5504 1464 1.6 0.7 8 7 7 31 21 15 65 70 72 1.9 15 1.0 -0.1
Sudan 17961 5528 2.9 2.3 20 14 10 47 41 32 44 53 58 4.3 43 5.3 5.4
Suriname 158 44 0.4 0.8 8 6 7 37 24 20 63 68 70 2.4 75 2.4 1.4
Swaziland 534 147 3.2 1.6 18 10 21 50 41 29 48 59 40 3.5 25 7.5 2.2
Sweden 1912 505 0.3 0.4 10 11 10 14 14 11 74 78 81 1.8 84 0.4 0.5
Switzerland 1488 358 0.5 0.5 9 9 8 16 12 9 73 78 82 1.4 76 1.6 1.2
Syrian Arab Republic 8424 2544 3.5 2.6 13 5 3 47 37 27 55 68 74 3.1 51 4.1 3.1
Tajikistan 3081 857 2.9 1.4 10 8 6 40 39 27 60 63 67 3.4 24 2.2 -0.1
Thailand 16430 4518 1.9 1.0 10 7 9 37 19 15 59 67 70 1.8 33 3.6 1.7
The former Yugoslav
Republic of Macedonia 476 115 1.0 0.4 8 8 9 24 17 11 66 71 74 1.4 70 2.0 1.6
Timor-Leste 590 199 1.0 2.6 22 18 9 46 43 42 40 46 61 6.6 27 3.4 4.5
Togo 3260 1061 3.1 3.0 18 12 10 48 44 37 48 58 58 4.9 42 4.9 5.2
Tonga 44 12 -0.2 0.3 6 6 6 37 30 25 65 70 73 3.8 24 0.4 0.8
…TABLE 6
Average
18 5 1970–1990 1990–2007 1970 1990 2007 1970 1990 2007 1970 1990 2007 2007 2007 1970–1990 1990–2007
Trinidad and Tobago 357 94 1.2 0.5 7 7 8 27 21 15 66 70 70 1.6 13 -0.5 3.1
Tunisia 3178 830 2.4 1.3 14 6 6 39 27 17 54 69 74 1.9 66 3.8 2.1
Turkey 24623 6646 2.3 1.6 12 8 6 39 26 18 56 65 72 2.1 68 4.5 2.6
Turkmenistan 1845 494 2.6 1.8 11 8 8 37 35 22 58 63 63 2.5 47 2.3 2.1
Tuvalu 4 1 1.3 0.7 – – – – – – – – – – 57 4.6 2.8
Uganda 17349 6028 3.2 3.2 16 15 14 49 50 47 50 51 51 6.5 13 5.7 4.4
Ukraine 8389 2025 0.4 -0.6 9 13 16 15 13 9 71 70 68 1.2 68 1.4 -0.5
United Arab Emirates 1006 327 10.6 5.0 11 3 1 36 27 16 61 73 79 2.3 77 10.5 5.1
United Kingdom 13100 3503 0.1 0.4 12 11 10 16 14 12 72 76 79 1.8 90 0.8 0.5
United Republic of Tanzania 20630 7050 3.1 2.7 18 15 13 48 44 40 47 51 52 5.2 25 7.5 4.6
United States 75992 20957 1.0 1.0 9 9 8 16 16 14 71 75 78 2.1 81 1.1 1.6
Uruguay 938 252 0.5 0.4 10 10 9 21 18 15 69 72 76 2.1 92 0.9 0.7
Uzbekistan 10593 2879 2.7 1.7 10 7 7 36 35 23 63 67 67 2.5 37 3.1 1.2
Vanuatu 103 31 2.8 2.4 14 7 5 43 37 29 53 64 70 3.8 24 4.9 4.2
Venezuela (Bolivarian Republic of) 10089 2896 3.0 2.0 7 5 5 37 29 22 65 71 74 2.6 94 3.8 2.8
Viet Nam 30263 8109 2.2 1.6 18 8 5 41 31 19 49 65 74 2.2 27 2.7 3.6
Yemen 11729 3740 3.3 3.5 27 13 8 56 51 38 38 54 62 5.5 28 5.5 5.6
Zambia 6270 2030 3.2 2.3 17 16 19 49 44 40 49 49 42 5.2 35 4.5 1.7
Zimbabwe 6175 1706 3.5 1.4 13 8 19 48 37 28 55 63 43 3.2 37 6.1 3.0
SUMMARY INDICATORS
Sub-Saharan Africa 383988 127624 2.9 2.6 20 16 15 48 45 39 45 50 50 5.2 36 4.7 4.3
Eastern and Southern Africa 186875 61296 2.9 2.5 19 15 15 47 43 38 46 51 50 4.9 29 4.7 3.9
West and Central Africa 197113 66328 2.9 2.7 22 17 16 48 47 41 43 49 50 5.5 43 4.8 4.6
Middle East and North Africa 153178 44789 3.0 2.0 16 8 6 45 35 25 51 63 69 3.0 58 4.4 2.9
South Asia 614747 175250 2.3 1.9 17 11 8 39 33 24 49 59 64 3.0 29 3.8 3.0
East Asia and Pacific 559872 144441 1.8 1.0 10 7 7 35 22 15 59 67 72 1.9 44 3.9 3.5
Latin America and Caribbean 197226 55622 2.2 1.5 10 7 6 37 27 20 60 68 73 2.4 78 3.3 2.2
CEE/CIS 100110 26458 1.0 0.2 9 11 12 20 18 14 67 68 68 1.7 62 2.0 0.3
Industrialized countries§ 204334 54922 0.7 0.6 10 9 9 17 13 11 71 76 79 1.7 76 1.0 0.9
Developing countries§ 1962419 562128 2.2 1.6 13 9 8 38 29 22 55 63 67 2.8 44 3.8 3.1
Least developed countries§ 383853 124237 2.5 2.5 21 16 12 47 42 36 44 51 55 4.7 28 4.9 4.4
World 2213456 629106 1.8 1.4 12 9 9 32 26 20 59 65 68 2.6 49 2.7 2.3
Life expectancy at birth – Number of years newborn children would live if subject to the mortality Child population – United Nations Population Division.
risks prevailing for the cross section of population at the time of their birth.
Crude death and birth rates – United Nations Population Division.
Crude death rate – Annual number of deaths per 1,000 population.
Life expectancy – United Nations Population Division.
Crude birth rate – Annual number of births per 1,000 population.
Fertility – United Nations Population Division.
Total fertility rate – Number of children who would be born per woman if she lived to the end of
her childbearing years and bore children at each age in accordance with prevailing age-specific Urban population – United Nations Population Division.
fertility rates.
Urban population – Percentage of population living in urban areas as defined according to the
national definition used in the most recent population census.
TABLE 7. ECONOMIC INDICATORS
%
of population
Average below Debt service
GDP per capita annual international % of central government ODA inflow as a % of
GNI per average annual rate of poverty line expenditure (1997–2006*) ODA inflow as a % of exports of
capita growth rate (%) inflation of US$1.25 allocated to: in millions recipient goods and services
(US$) (%) per day US$ GNI
Countries and territories 2007 1970–1990 1990–2007 1990–2007 2005 health education defence 2006 2006 1990 2006
Afghanistan 250x – – – – – – – 3000 37 – –
Albania 3290 -0.7x 5.2 18 1 4 4 2 321 3 4x 3
Algeria 3620 1.6 1.4 13 7 17 4 24 209 0 62 –
Andorra d – – – – – – – – – – –
Angola 2560 0.4x 2.9 319 54 34x 6x 15x 171 1 7 13
Antigua and Barbuda 11520 8.3x 1.7 2 – – – – 3 0 – –
Argentina 6050 -0.7 1.5 6 5 3 5 5 114 0 30 13
Armenia 2640 – 5.8 69 11 – – – 213 4 – 6
Australia 35960 1.5 2.4 2 – 6 15 10 – – – –
Austria 42700 2.4 1.8 2 – 2 14 10 – – – –
Azerbaijan 2550 – 2.8 71 0 12 1 4 206 1 – 1
Bahamas 15730x 1.8 0.4x 3x – 3 16 20 – – – –
Bahrain 19350 -1.3x 2.4x 2x – 14 8 15 57x 1x – –
Bangladesh 470 0.6 3.1 4 50y 10 7 17 1223 2 17 3
Barbados d 1.5 1.3x 3x – – – – -1 0 – –
Belarus 4220 – 3.4 162 0 4 3 4 73 0 – 2
Belgium 40710 2.2 1.8 2 – 3 16 3 – – – –
Belize 3800 2.9 2.4 1 – 5x 8x 20x 8 1 5 16
Benin 570 0 1.3 6 47 17x 6x 31x 375 8 7 6x
Bhutan 1770 6.8x 5.2 7 26 – 9 13 94 10 – –
Bolivia 1260 -1.1 1.3 7 20 5 10 22 581 6 31 8
Bosnia and Herzegovina 3580 – 10.8x 5x 0 – – – 494 4 – 7
Botswana 5840 8.2 4.2 8 31 8x 5x 26x 65 1 4 1
Brazil 5910 2.3 1.2 72 8y 3 6 6 82 0 19 36
Brunei Darussalam 26930x -2.2x -0.3x 4x – – – – – – – –
Bulgaria 4590 3.4x 2.3 51 0 6 11 5 – – 19 10
Burkina Faso 430 1.3 2.5 3 57 14x 7x 17x 871 14 6 –
Burundi 110 1.1 -2.7 12 81 23 2 15 415 52 41 40
Cambodia 540 – 6.2x 3x 40 – – – 529 8 0x 1
Cameroon 1050 3.3 0.6 4 33 10 3 12 1684 9 18 15x
Canada 39420 2 2.2 2 – 6 9 3 – – – –
Cape Verde 2430 – 3.3 4 21 – – – 138 13 5 4
Central African Republic 380 -1.3 -0.8 3 62 – – – 134 9 8 –
Chad 540 -1 2.4 7 62 – 8x 8x 284 6 2 –
Chile 8350 1.5 3.7 6 1 7 15 17 83 0 20 19
China 2360 6.6 8.9 5 16y 12 0 2 1245 0 10 2
Colombia 3250 2 1 14 15 13 9 20 988 1 39 31
Comoros 680 0.1x -0.4 4 46 – – – 30 7 2 –
Congo 1540 3.2 -0.2 8 54 10 4 4 254 7 32 2x
Cook Islands – – – – – – – – 32 0 – –
Costa Rica 5560 0.7 2.5 13 2 0 21 22 24 0 21 4
Côte d’Ivoire 910 -1.9 -0.7 6 23 4x 4x 21x 251 2 26 0
Croatia 10460 – 3 33 0 4 13 8 200 0 – 33
Cuba c – 3.6x 4x – – 23x 10x 78 0 – –
Cyprus 24940 5.9x 2.2 4 – 4 6 12 – – – –
Czech Republic 14450 – 2.4 7 0 4 16 10 – – – –
Democratic People’s Republic of Korea a – – – – – – – 55 0 – –
Democratic Republic of the Congo 140 -2.4 -4.3 335 59 18 0 0 2056 27 – –
Denmark 54910 2 1.9 2 – 5 1 12 – – – –
Djibouti 1090 – -2.1 3 19 – – – 117 14 4x 6
Dominica 4250 4.7x 2.4 1 – – – – 19 7 4 13x
Dominican Republic 3550 2.1 3.8 11 5 4 10 13 53 0 7 8
Ecuador 3080 1.3 1.2 5 10 13x 11x 18x 189 0 27 23
Egypt 1580 4.3 2.5 7 2 9 3 15 873 1 18 5
El Salvador 2850 -1.8 1.8 4 14 3 14 14 157 1 14 12
Equatorial Guinea 12860 – 21.1 13 – – – – 27 1 2 –
Eritrea 230 – -0.3x 12x – – – – 129 15 – –
Estonia 13200 1.5x 5.2 24 0 5 16 7 – – – –
Ethiopia 220 – 2.2 5 39 17 1 5 1947 15 33 7
Fiji 3800 0.6x 1.5x 4x – 6x 9x 18x 56 2 12 1
Finland 44400 2.8 2.8 2 – 4 3 10 – – – –
…TABLE 7
%
of population
2007 1970–1990 1990–2007 1990–2007 2005 health education defence 2006 2006 1990 2006
France 38500 2.2 1.6 1 – 6x 16x 7x – – – –
Gabon 6670 0.3 -0.7 6 5 – – – 31 0 4 5x
Gambia 320 0.9 0.2 8 34 4x 7x 12x 74 15 18 11
Georgia 2120 3.2 1.8 102 13 23 7 11 361 5 – 7
Germany 38860 2.3x 1.4 1 – 4 19 1 – – – –
Ghana 590 -2.1 2.1 24 30 5x 7x 22x 1176 10 21 4
Greece 29630 1.3 2.7 6 – 8 7 11 – – – –
Grenada 4670 4.9 2.5 2 – – 10x 17x 27 6 2 5x
Guatemala 2440 0.2 1.4 7 12 11x 11x 17x 487 1 11 4
Guinea 400 0.3x 1.3 8 70 29x 3x 11x 164 4 18 17x
Guinea-Bissau 200 -0.2 -2.6 16 49 4x 1x 3x 82 27 21 35x
Guyana 1300 -1.5 3.1 8 8 – – – 173 20 20x 3
Haiti 560 -0.3 -2.1 18 55 – – – 581 14 4 3
Holy See – – – – – – – – – – – –
Honduras 1600 0.8 1.5 15 22 7x 10x 19x 587 7 30 5
Hungary 11570 3 3.3 13 0 3 6 5 – – 30 32
Iceland 54100 3.2 2.4 4 – 0 27 11 – – – –
India 950 2.1 4.5 6 42y 14 2 4 1379 0 25 7
Indonesia 1650 4.7 2.3 15 21y 7 1 4 1405 0 31 9
Iran (Islamic Republic of) 3470 -2.3 2.5 23 1 14 6 7 121 0 1 –
Iraq 2170x – – – – – – – 8661 0 – –
Ireland 48140 2.8 5.8 4 – 3 16 14 – – – –
Israel 21900 1.9 1.7 6 – 19 12 15 – – – –
Italy 33540 2.8 1.2 3 – 3 3 10 – – – –
Jamaica 3710 -1.3 0.8 15 0 2 7 15 37 0 20 11
Japan 37670 3 0.9 -1 – 4x 2x 6x – – – –
Jordan 2850 2.5x 2 2 0 19 10 16 580 4 18 5
Kazakhstan 5060 – 3.2 75 3 6 5 6 172 0 – 33
Kenya 680 1.2 0 11 20 6 7 26 943 5 26 6
Kiribati 1170 -5.3 1.8 2 – – – – -45 -36 – –
Kuwait 31640 -6.8x 1.1x 4x – 14 6 12 – – – –
Kyrgyzstan 590 – -0.5 46 22 7 12 11 311 12 – 4
Lao People’s Democratic Republic 580 – 4.2 25 44 – – – 364 13 8 –
Latvia 9930 3.4 4.7 21 0 5 12 6 – – 0x 29
Lebanon 5770 – 2.5 8 – 11 2 7 707 3 – 19
Lesotho 1000 3.1 1.8 8 43 5 6 25 72 4 4 4
Liberia 150 -4.2 1.9 42 84 9x 5x 11x 269 57 – 0
Libyan Arab Jamahiriya 9010 -4.9x – – – – – – 37 0 – –
Liechtenstein d – – – – – – – – – – –
Lithuania 9920 – 3 29 0 5 12 7 – – – 21
Luxembourg 75880 2.7 3.2 2 – 1 13 10 – – – –
Madagascar 320 -2.4 -0.4 14 68 5 8 13 754 14 32 5x
Malawi 250 -0.1 0.3 30 74 5x 7x 12x 669 30 23 –
Malaysia 6540 4 3.2 4 1 11 6 23 240 0 12 4
Maldives 3200 – 5.5x 1x – 5 8 14 39 4 4 5
Mali 500 -0.3 2.2 5 51 8x 2x 9x 825 13 8 4
Malta 15310 6.5 2.7x 3 – 2 14 13 11x 0x – –
Marshall Islands 3070 – -2 5 – – – – 55 28 – –
Mauritania 840 -0.9 0.6 8 21 – 4x 23x 188 8 24 –
Mauritius 5450 5.1x 3.7 6 – 1 9 15 19 0 6 6
Mexico 8340 1.6 1.6 14 1 3 5 25 247 0 16 19
Micronesia (Federated States of) 2470 – -0.2 2 – – – – 109 41 – –
Moldova 1260 1.8x -1.3 52 8 1 13 9 228 6 – 10
Monaco d – – – – – – – – – – –
Mongolia 1290 – 2.2 30 22 9 6 9 203 9 17x 2
Montenegro 5180 – 3.4x – – – – – 1586 68 – –
Morocco 2250 2 2 3 3 13 3 18 1046 2 18 12
Mozambique 320 -1x 4.1 20 75 35x 5x 10x 1611 23 21 2
Myanmar 220x 1.5 6.8x 24x – 23 3 13 147 0 17 1
Namibia 3360 -2.3x 1.8 9 49 7x 10x 22x 145 2 – –
Nauru – – – – – – – – 17 0 – –
TABLE 7. ECONOMIC INDICATORS
%
of population
Nepal 340 1.2 1.9 7 55 11 5 18 514 6 12 5
Netherlands 45820 1.5 2.1 2 – 4 10 11 – – – –
New Zealand 28780 0.8 2 2 – 3 16 19 – – – –
Nicaragua 980 -3.7 1.9 21 16 6x 13x 15x 733 14 2 4
Niger 280 -2.2 -0.6 4 66 – – – 401 11 12 5x
Nigeria 930 -1.4 1.2 23 64 3x 1x 3x 11434 12 22 16x
Niue – – – – – – – – 9 0 – –
Norway 76450 3.2 2.6 4 – 5 16 6 – – – –
Occupied Palestinian Territory 1230 – -2.9x 4x – – – – 1449 33 – –
Oman 11120 3.3 2.2x 2x – 33 7 15 35 0 12 1
Pakistan 870 3 1.6 10 23 18 1 2 2147 2 16 8
Palau 8210 – – 3x – – – – 37 23 – –
Panama 5510 0.3 2.6 2 9 – 18 16 30 0 3 25
Papua New Guinea 850 -0.7 -0.6 8 36 4 7 22 279 6 37 9x
Paraguay 1670 2.8 -0.3 11 9 11x 7x 22x 56 1 12 6
Peru 3450 -0.6 2.7 13 8 – 13 7 468 1 6 12
Philippines 1620 0.8 1.7 7 23 5 2 19 562 0 23 18
Poland 9840 – 4.4 13 0 4 11 12 – – 4 24
Portugal 18950 2.6 1.9 4 – 3 16 16 – – – –
Qatar 12000x – – – – – – – – – – –
Republic of Korea 19690 6.2 4.4 4 – 10 0 14 – – – –
Romania 6150 0.9x 2.3 57 1 5 14 5 – – 0 16
Russian Federation 7560 – 1.2 71 0 12 8 4 – – – 13
Rwanda 320 1.1 1.1 9 77 – 5x 26x 585 25 9 9
Saint Kitts and Nevis 9630 6.3x 2.8 3 – – – – 5 1 3 22x
Saint Lucia 5530 5.3x 1.3 2 21 – – – 18 2 2 6x
Saint Vincent and the Grenadines 4210 3.3 3 2 – – 12 16 5 1 3 11x
Samoa 2430 – 2.6 6 – – – – 47 11 5 6
San Marino 45130 – – – – – 18 9 – – – –
Sao Tome and Principe 870 – – – – – – – 22 17 28 37
Saudi Arabia 15440 -1.5 0.3 4 – 36x 6x 14x 25 0 – –
Senegal 820 -0.7 1.1 4 34 7 3 14 825 9 14 10x
Serbia 4730 – 2.6x – – – – – 96 0 – –
Seychelles 8960 2.9 1.4 3 – 3 9 8 14 2 7 18
Sierra Leone 260 -0.4 -0.4 19 53 10x 10x 13x 364 27 8 8
Singapore 32470 5.6 3.8 1 – 31 6 22 – – – –
Slovakia 11730 – 3.3 8 0 5 19 4 – – – –
Slovenia 20960 – 3.5 15 0 3 15 13 53x 0x – –
Solomon Islands 730 3.4 -1.6 7 – – – – 205 62 10 2
Somalia 140x -0.9 – – – 38x 1x 2x 392 0 25x –
South Africa 5760 0.1 1 8 26 – – – 718 0 – 6
Spain 29450 1.9 2.4 4 – 4 15 2 – – – –
Sri Lanka 1540 3 3.9 9 14 18 6 10 796 3 10 7
Sudan 960 0.1 3.6 38 – 28 1 8 2058 7 4 4
Suriname 4730 -2.4x 1.8 54 16 – – – 64 4 – –
Swaziland 2580 3.1 -0.3 12 63 8 8 20 35 1 6 2
Sweden 46060 1.8 2.2 2 – 5 3 6 – – – –
Switzerland 59880 1.2 0.7 1 – 5 0 5 – – – –
Syrian Arab Republic 1760 2 1.5 7 – 24 2 9 27 0 20 1
Tajikistan 460 – -2.2 99 21 9 2 4 240 9 – 5
Thailand 3400 5 2.9 3 0 6 9 20 -216 0 14 9
The former Yugoslav Republic of Macedonia 3460 – 0.5 30 0 – – – 200 3 – 15
Timor-Leste 1510 – – – 53 – – – 210 24 – –
Togo 360 -0.6 -0.2 4 39 11x 5x 20x 79 4 8 0x
Tonga 2320 – 2 4 – – 7x 13x 21 10 2 3
Trinidad and Tobago 14100 0.5 5.1 5 4 2 9 17 13 0 – –
Tunisia 3200 2.5 3.4 4 3 5 5 20 432 1 22 13
Turkey 8020 1.9 2.2 52 3 8 3 10 570 0 27 25
Turkmenistan b – -6.8x 408x 25 – – – 26 0 – –
Tuvalu – – – – – – – – 15 0 – –
Uganda 340 – 3.1 8 52 26x 2x 15x 1551 17 47 5
…TABLE 7
%
of population
Ukraine 2550 – -0.7 93 0 3 3 6 484 1 – 16
United Arab Emirates 26210x -4.8x -0.3x 3x – 30 7 17 – – – –
United Kingdom 42740 2 2.4 3 – 7 15 4 – – – –
United Republic of Tanzania 400 – 1.8 15 88 16x 6x 8x 1825 14 25 3
United States 46040 2.2 2 2 – 20 25 3 – – – –
Uruguay 6380 0.9 1.5 18 0 4 7 8 21 0 31 43
Uzbekistan 730 – 1.2 106 46 – – – 149 1 – –
Vanuatu 1840 1.1x -0.4 3 – – – – 49 13 2 1
Venezuela (Bolivarian Republic of) 7320 -1.6 -0.2 35 18 5 8 21 58 0 22 13
Viet Nam 790 – 6 10 21 – 4 14 1846 3 – 2
Yemen 870 – 1.6 17 18 19 4 22 284 2 4 2
Zambia 800 -2.3 0.1 34 64 4 13 14 1425 19 13 3
Zimbabwe 340 -0.4 -2.1x 62x – 7 8 24 280 6 19 –
SUMMARY INDICATORS
Sub-Saharan Africa 965 -0.1 1.3 35 51 – – – 35799 6 17 7
Eastern and Southern Africa 1245 – 1.4 40 49 – – – 13793 3 14 7
West and Central Africa 698 -0.6 1.3 26 53 – – – 22006 11 19 –
Middle East and North Africa 3666 -0.1 1.6 11 4 15 5 14 16660 1 21 8
South Asia 889 2.1 4.1 6 40 14 2 5 9191 1 21 7
East Asia and Pacific 2742 5.7 6.8 5 17 11 1 7 7477 0 16 4
Latin America and Caribbean 5628 1.4 1.5 35 8 4 7 14 5989 0 20 21
CEE/CIS 5686 – 1.6 67 4 9 7 6 5928 0 – 17
Industrialized countries§ 38579 2.3 1.9 2 – 12 18 4 – – – –
Developing countries§ 2405 2.4 4 18 25 10 3 9 77364 1 19 10
Least developed countries§ 491 -0.2 2.5 60 54 14 5 14 28181 9 12 6
World 7952 2.3 2.4 8 – 11 14 6 81045 0 18 11
GNI per capita – Gross national income (GNI) is the sum of value added by all resident producers GNI per capita – World Bank.
plus any product taxes (less subsidies) not included in the valuation of output plus net receipts of
primary income (compensation of employees and property income) from abroad. GNI per capita is GDP per capita – World Bank.
gross national income divided by midyear population. GNI per capita in US dollars is converted
Rate of inflation – World Bank.
using the World Bank Atlas method.
% of population below international poverty line of US$1.25 per day – World Bank.
GDP per capita – Gross domestic product (GDP) is the sum of value added by all resident producers
plus any product taxes (less subsidies) not included in the valuation of output. GDP per capita is Expenditure on health, education and defence – International Monetary Fund (IMF).
gross domestic product divided by midyear population. Growth is calculated from constant price
GDP data in local currency. ODA – Organisation for Economic Co-operation and Development (OECD).
% of population below international poverty line of US$1.25 per day – Percentage of Debt service – World Bank.
population living on less than US$1.25 per day at 2005 prices, adjusted for purchasing power
parity. The new poverty threshold reflects revisions to purchasing power parity exchange rates
based on the results of the 2005 International Comparison Program. The revisions reveal that the
cost of living is higher across the developing world than previously estimated. As a result of these
revisions, poverty rates for individual countries cannot be compared with poverty rates reported in
previous editions. More detailed information on the definition, methodology and sources of the
data presented is available at <www.worldbank.org>.
ODA – Net official development assistance.
Debt service – Sum of interest payments and repayments of principal on external public and
publicly guaranteed long-term debts.
NOTES a: low income ($935 or less). – Data not available.

b: lower-middle income ($936 to $3,705). x Data refer to years or periods other than those specified in the column heading, differ from the standard definition
c: upper-middle income ($3,706 to $11,455). or refer to only part of a country. Such data are not included in the calculation of regional and global averages.
d: high income ($11,456 or more). y Data refer to years or periods other than those specified in the column heading, differ from the standard definition or
refer to only part of a country. Such data are included in the calculation of regional and global averages.
TABLE 8. WOMEN
Maternal mortality ratio†
Enrolment and attendance ratios: Delivery care
Antenatal care coverage (%) 2005
Life Adult females as a % of males coverage (%)
expectancy: literacy rate: Net Net Contraceptive 2000–2007* Lifetime
2000–2007*
females as a females as a primary school secondary school prevalence Skilled risk of
Countries and % of males % of males 2000–2007* 2000–2007* (%) At least At least attendant Institutional 2000–2007* maternal
territories 2007 2000–2007* enrolled attending enrolled attending 2000–2007* once four times at birth delivery reported Adjusted death. 1 in:
Afghanistan 100 29 63 60 – 33 10 16 – 14 13 1600 1800 8
Albania 109 99 99 100 98 97 60 97 – 100 98 20 92 490
Algeria 104 79 98 99 106 112 61 89 – 95 95 120x 180 220
Andorra – – 101 – 103 – – – – – – – – –
Angola 108 65 – 102 – 90 6 80 – 47 46 – 1400 12
Antigua and Barbuda – – – – – – 53 100 – 100 – 0 – –
Argentina 111 100 99 – 110 – – 99 89y 99 99 48 77 530
Armenia 110 100 105 99 104 102 53 93 71 98 97 27 76 980
Australia 106 – 101 – 102 – – 100x – 100x – – 4 13300
Austria 107 – 101 – – – 51x 100x – 100x – – 4 21500
Azerbaijan 112 99 97 98 96 98 51 77 45 88 78 29 82 670
Bahamas 108 – 103 – 102 – – 98 – 99 – – 16 2700
Bahrain 104 96 100 100 105 111 62x 97x – 98x 98x 46x 32 1300
Bangladesh 103 82 104 106 104 114 56 51 21 18 15 320 570 51
Barbados 107 – 99 – 101 – 55x 100 – 100 – 0x 16 4400
Belarus 119 100 98 101 102 102 73 99 – 100 100 12 18 4800
Belgium 108 – 100 – 96 – 78x – – – – – 8 7800
Belize 108 – 101 100 108 103 34 94 76x 96 88 42 52 560
Benin 104 53 84 87 50 66 17 84 61 74 78 400 840 20
Bhutan 105 63 100 91 101 – 35y 88 – 56 55 260 440 55
Bolivia 107 90 101 99 98 98 58 79 58 67 57 230 290 89
Bosnia and Herzegovina 107 95 – 97 – 100 36 99 – 100 100 9 3 29000
Botswana 100 100 103 103 114 122 48 97 – 94 80x 330x 380 130
Brazil 111 101 102 100x 111 119x 77x 97 87 88x 97 53 110 370
Brunei Darussalam 106 96 100 – 105 – – 100x – 99x – 0x 13 2900
Bulgaria 110 99 99 – 98 – 86x – – 99 – 7 11 7400
Burkina Faso 106 59 82 90 72 91 17 85 18 54 51 480x 700 22
Burundi 106 78 97 97 – 79 9 92 – 34 29 620 1100 16
Cambodia 109 79 98 102 85 90 40 69 27 44 22 470 540 48
Cameroon 102 78 – 94 – 93 29 82 60 63 61 670 1000 24
Canada 106 – 100 – – – 75x – – 98 – – 7 11000
Cape Verde 109 88 99 100x 113 – 61 98 64x 78 78 15 210 120
Central African Republic 106 52 72 84 71 64 19 69 40x 53 51 540 980 25
Chad 105 31 70 76 33 51 3 39 18 14 13 1100 1500 11
Chile 108 100 – – – – 58y 95x – 100 100 20 16 3200
China 105 93 100 – – – 85 90 – 98 88 41 45 1300
Colombia 111 100 100 102 111 111 78 94 83 96 92 73 130 290
Comoros 107 87 95 100 101 103 26 75 52x 62 43x 380 400 52
Congo 105 89 90 101 – 104 21 86 75 83 82 780 740 22
Cook Islands – – 103 – 110 – 44 – – 98 – 6x – –
Costa Rica 106 101 102 102 110 110 96 92 – 99 94 36 30 1400
Côte d’Ivoire 104 63 80 87 57 69 13 85 45 57 54 540 810 27
Croatia 110 98 99 – 102 – – – – 100 – 10 7 10500
Cuba 105 100 101 – 103 – 77 100 – 100 – 21 45 1400
Cyprus 107 98 100 – 102 – – – – – – 0x 10 6400
Czech Republic 108 – 103 – – – 69x 99x 97x 100 – 8 4 18100
Republic of Korea 106 – – – – – 62x – – 97 – 110x 370 140
Democratic Republic
of the Congo 106 67 – 89 – 81 31 85 – 74 70 1300 1100 13
Denmark 106 – 101 – 103 – – – – – – 10x 3 17800
Djibouti 105 – 82 97 66 84 18 92 7 61 74 74x 650 35
Dominica – – 106 – 110 – 50x 100 – 99 – 0 – –
Dominican Republic 109 101 103 104 122 145 73 99 95 98 98 160 150 230
Ecuador 108 98 101 – 102 – 73 84 58 99x 74 110 210 170
Egypt 107 73 96 97 94 93 59 70 59 74 65 84 130 230
El Salvador 109 94 100 – 105 – 67 86 71 92 69 71 170 190
Equatorial Guinea 105 86 90 98 – 95 – 86 – 65 – – 680 28
Eritrea 109 – 87 93 67 92 8 70 41 28 26 1000x 450 44
Estonia 117 100 99 – 102 – 70 – – 100 – 7 25 2900
Ethiopia 105 46 92 101 65 77 15 28 12 6 5 670 720 27
Fiji 107 – 100 – 110 – 44 – – 99 – 34 210 160
Finland 108 – 100 – 100 – – 100x – 100x 100 6x 7 8500
France 109 – 100 – 102 – 75x 99x – 99x – 10x 8 6900
Gabon 101 91 99 100 – 106 33 94 63 86 85 520 520 53
…TABLE 8
2000–2007*
Gambia 103 – 109 103 94 87 18 98 – 57 55 730 690 32
Georgia 112 – 103 101 105 98 47 94 75 98 96 23 66 1100
Germany 107 – 100 – – – 75x – – – – 8x 4 19200
Ghana 101 81 97 100 91 99 17 92 69 50 49 210x 560 45
Greece 106 98 100 – 101 – – – – – – 1x 3 25900
Grenada 105 – 99 – 102 – 54y 100 – 100 – 0 – –
Guatemala 111 86 96 94x 92 103x 43 84 – 41 42 130 290 71
Guinea 106 42 86 87 57 66 9 82 49 38 31 980 910 19
Guinea-Bissau 107 72 71 97 55 88 10 78 – 39 36 410 1100 13
Guyana 109 – – 100 – 110 34 81 – 83 83 120 470 90
Haiti 106 106 – 107 – 117 32 85 54 26 25 630 670 44
Holy See – – – – – – – – – – – – – –
Honduras 110 102 102 104 – 123 65 92 81 67 67 110x 280 93
Hungary 112 100 99 – 100 – 77x – – 100 – 8 6 13300
Iceland 104 – 99 – 102 – – – – – – – 4 12700
India 105 71 96 96 – 83 56 74 37 47 39 300 450 70
Indonesia 106 93 97 101 100 104 61 93 81 72 40 310 420 97
Iran (Islamic Republic of) 105 88 110 97 94 – 79 77x 94y 97 96 25 140 300
Iraq 107 76 86 88 70 75 50 84 – 89 63 84 300 72
Ireland 106 – 101 – 106 – – – – 100 100 6x 1 47600
Israel 105 – 101 – 100 – – – – – – 5x 4 7800
Italy 108 99 99 – 101 – 60x – – – – 7x 3 26600
Jamaica 108 113 100 100 105 105 69 91 87x 97 94 95 170 240
Japan 109 – 100 – 100 – 56 – – 100x – 8x 6 11600
Jordan 105 93 102 100 103 104 57 99 94 99 99 41x 62 450
Kazakhstan 118 100 100 99 100 100 51 100 70x 100 100 70 140 360
Kenya 104 90 102 100 97 114 39 88 52 42 40 410 560 39
Kiribati – – 101 – 111 – 21x 88x – 85x – 56 – –
Kuwait 105 97 99 – 105 – 50x 95x – 98x 98x 5x 4 9600
Kyrgyzstan 113 100 99 103 102 103 48 97 81x 98 97 100 150 240
Lao People’s
Democratic Republic 104 83 94 95 86 84 38 27 – 19 – 410 660 33
Latvia 116 100 103 – – – 48x – – 100 – 9 10 8500
Lebanon 106 – 99 99 110 113 58 96 – 98x – 100x 150 290
Lesotho 99 123 104 108 154 171 37 90 70 55 52 760x 960 45
Liberia 104 85 97 – 58 – 11 85 – 51 37 580x 1200 12
Libyan Arab Jamahiriya 107 83 – – – – 45x 81x – 94x – 77x 97 350
Liechtenstein – – 103 – 111 – – – – – – – – –
Lithuania 116 100 99 – 101 – 47x – – 100 – 13 11 7800
Luxembourg 108 – 101 – 105 – – – – 100 – 0x 12 5000
Madagascar 106 85 100 104 104 125 27 80 40 51 32 470 510 38
Malawi 101 82 106 102 93 96 42 92 57 54 54 810 1100 18
Malaysia 107 95 100 – 110 – 55x 79 – 98 98 28 62 560
Maldives 102 100 100 – 109 – 39 81 – 84 – 140 120 200
Mali 109 51 79 74 – 68 8 70 35 45 45 460 970 15
Malta 105 104 99 – 107 – – – – 98x – – 8 8300
Marshall Islands – – 99 – 108 – 34 – – 95x – 74 – –
Mauritania 106 76 105 105 90 82 8 64 16 57 49 750 820 22
Mauritius 110 94 102 – 102 – 76 – – 98 98 22 15 3300
Mexico 107 96 99 100 99 – 71 86x – 93 86 62 60 670
Micronesia
(Federated States of) 102 – – – – – 45x – – 88 – 270x – –
Moldova 111 99 100 102 104 103 68 98 89 100 99 16 22 3700
Monaco – – – – – – – – – – – – – –
Mongolia 110 101 102 102 113 106 66 99 – 99 99 90 46 840
Montenegro 106 – – 99 – 101 39 97 – 99 100 23 – –
Morocco 106 63 94 95 84 93 63 68 31 63 61 230 240 150
Mozambique 102 58 93 90 91 80 17 85 53 48 48 410 520 45
Myanmar 111 92 101 102 100 94 34 76 – 57 16 320 380 110
Namibia 101 99 106 101 132 132 55 95 70 81 81 270 210 170
Nauru – – – – – – – – – – – – – –
TABLE 8. WOMEN
2000–2007*
Nepal 102 62 96 95 – 83 48 44 29 19 18 280 830 31
Netherlands 106 – 99 – 101 – 79x – – 100x – – 6 10200
New Zealand 105 – 100 – 103 – 75x 95x – 100x – 15x 9 5900
Nicaragua 109 102 100 108 116 132 72 90 78 74 66 87 170 150
Niger 97 37 71 70 63 65 11 46 15 33 17 650 1800 7
Nigeria 102 80 86 88 84 87 13 58 47 35 33 – 1100 18
Niue – – – – 105x – – – – 100 – – – –
Norway 106 – 101 – 101 – – – – – – 6x 7 7700
Occupied Palestinian
Territory 104 92 100 101 106 – 50 99 – 99 97 – – –
Oman 104 87 102 – 99 – 32 100 83y 98 98 13 64 420
Pakistan 101 59 78 85 77 78 30 61 28 39 34 530x 320 74
Palau – – 96 – – – 17 – – 100 – 0x – –
Panama 107 99 99 – 111 – – 72x – 91 92 66 130 270
Papua New Guinea 111 86 – – – – 26x 78x – 41 – 370x 470 55
Paraguay 106 99 101 100 106 99 73 94 79 77 74 120 150 170
Peru 107 90 102 101 100 100 71 91 87 71 72 190 240 140
Philippines 106 101 102 102 121 127 51 88 70 60 38 160 230 140
Poland 112 99 101 – 102 – 49x – – 100 – 3 8 10600
Portugal 108 97 99 – 110 – – – – 100 – 8x 11 6400
Qatar 102 100 101 – 98 – 43x – – 99x 98x 10x 12 2700
Republic of Korea 110 – 93 – 94 – 81x – – 100x – 20x 14 6100
Romania 110 99 100 – 98 – 70 94 76 98 98 15 24 3200
Russian Federation 123 100 100 – – – – – – 100 – 24 28 2700
Rwanda 107 84 107 103 – 88 17 94 13 39 28 750 1300 16
Saint Kitts and Nevis – – 122 – 87 – 54y 100 – 100 – 0 – –
Saint Lucia 105 – 98 – 124 – 47x 99 – 100 – 0 – –
Saint Vincent and
the Grenadines 106 – 96 – 124 – 48y 95 – 100 – 0 – –
Samoa 109 99 100 – 114 – 43x – – 100x – 29 – –
San Marino – – – – – – – – – – – – – –
Sao Tome and Principe 106 89 101 101 111 105 30 97 – 81 78 150 – –
Saudi Arabia 106 89 – – – – 32x 90x – 91x 91x – 18 1400
Senegal 107 61 98 102 76 78 12 87 40 52 62 400 980 21
Serbia 106 – 100 100 – 103 41 98 – 99 99 13 – –
Seychelles – 101 101 – 106 – – – – – – 57 – –
Sierra Leone 108 54 – 101 71 79 5 81 – 43 19 1800 2100 8
Singapore 105 94 – – – – 62x – – 100x – 6x 14 6200
Slovakia 111 – 101 – – – 74x – – 100 – 4 6 13800
Slovenia 110 100 100 – 101 – 74x 98x – 100 – 17 6 14200
Solomon Islands 103 – 99 – 87 – 7 – – 85x – 140x 220 100
Somalia 105 – – 82 – 51 15 26 6 33 9 1000 1400 12
South Africa 103 98 100 104x 112 117x 60 92 73x 92 – 170 400 110
Spain 108 98 99 – 103 – 81x – – – – 6x 4 16400
Sri Lanka 111 96 100 – – – 68 99 – 99 98 43 58 850
Sudan 105 73 83 93 – 133 7 60 – 87 – 550x 450 53
Suriname 110 95 103 99 138 121 46 90 – 90 88 150 72 530
Swaziland 100 97 101 103 121 132 51 85 79 69 74 590 390 120
Sweden 106 – 100 – 100 – – – – – – 5x 3 17400
Switzerland 107 – 99 – 95 – 82x – – – – 5x 5 13800
Syrian Arab Republic 105 85 95 100 95 101 58 84 – 93 70 65 130 210
Tajikistan 108 100 96 99 84 83 38 77 – 83 62 97 170 160
Thailand 113 97 99 100 111 109 77 98 – 97 97 12 110 500
The former Yugoslav
Republic of Macedonia 107 97 100 96 98 99 – 94 – 99 99 4 10 6500
Timor-Leste 103 – 96 98 – – 20 61 30 18 10 – 380 35
Togo 106 56 87 93 48 70 17 84 46x 62 63 480x 510 38
Tonga 103 100 97 – 125 – 33 – – 95 – 78 – –
Trinidad and Tobago 106 99 100 100 104 107 43 96 – 98 97 45x 45 1400
Tunisia 106 80 101 98 110 – 66 92 – 90 89 69x 100 500
Turkey 107 84 96 96 86 83 71 81 54 83 78 29 44 880
Turkmenistan 114 100 – 100 – 100 48 99 83 100 98 14 130 290
…TABLE 8
2000–2007*
Tuvalu – – – – – – 32 – – 100 – – – –
Uganda 103 80 – 99 90 94 24 94 47 42 41 440 550 25
Ukraine 119 100 100 102 101 102 67 99 – 99 99 17 18 5200
United Arab Emirates 106 98 100 – 102 – 28x 97x – 99x 99x 3x 37 1000
United Kingdom 106 – 101 – 104 – 84 – – 99x – 7x 8 8200
United Republic of
Tanzania 104 83 99 106 90 108 26 78 62 43 47 580 950 24
United States 107 – 102 – 100 – 76x – – 99x – 8x 11 4800
Uruguay 110 101 100 – – – 84 94x 97 100x – 35 20 2100
Uzbekistan 110 98 – 100 – 98 65 99 79x 100 97 28 24 1400
Vanuatu 106 95 99 – 87 – 28 – – 88x – 68x – –
Venezuela (Bolivarian
Republic of) 108 99 100 102 114 147 77x 94 – 95 95 61 57 610
Viet Nam 105 93x – 100 – 102 76 91 29 88 64 160 150 280
Yemen 105 53 76 60x 53 37x 28 41 11x 36 24 370 430 39
Zambia 101 78x 104 105 80 112 34 93 72 43 44 730 830 27
Zimbabwe 97 94 101 102 96 93 60 94 71 69 68 560 880 43
SUMMARY INDICATORS
Sub-Saharan Africa 104 75 93 95 84 87 23 72 42 45 40 – 920 22
Eastern and
Southern Africa 104 79 98 101 90 92 30 72 40 40 33 – 760 29
West and Central Africa 103 72 86 89 77 84 17 71 44 49 46 – 1100 17
Middle East and
North Africa 105 78 94 96 92 97 56 72 – 81 71 – 210 140
South Asia 104 71 94 95 – 85 53 68 34 41 35 – 500 59
East Asia and Pacific 106 93 99 101** 103** 105** 78 89 66** 87 73 – 150 350
Latin America
and Caribbean 109 99 100 101 107 – 69 94 83 85 86 – 130 280
CEE/CIS 115 97 98 98 95 96 64 90 – 94 89 – 46 1300
Industrialized countries§ 108 – 101 – 101 – 72 – – – – – 8 8000
Developing countries§ 105 86 96 96** 97** 91** 60 77 46** 61 54 – 450 76
Least developed countries§ 104 72 94 97 86 94 29 64 32 39 32 – 870 24
World 106 88 97 96** 98** 91** 62 77 47** 62 54 – 400 92

Life expectancy at birth – Number of years newborn children would live if subject to the mortality risks prevailing for the Life expectancy – United Nations Population Division.
cross section of population at the time of their birth. Adult literacy – UNESCO Institute for Statistics (UIS).
Adult literacy rate – Number of literate persons aged 15 and above, expressed as a percentage of the total population in
that age group. Primary and secondary school enrolment – UIS.
Enrolment and attendance ratios: females as a % of males – Girls’ net enrolment and attendance ratios divided by Primary and secondary school attendance – Demographic and Health Surveys (DHS)
those of boys, as a percentage. and Multiple Indicator Cluster Surveys (MICS).
Primary or secondary school net enrolment ratio – Number of children enrolled in primary or secondary school who Contraceptive prevalence – DHS, MICS, United Nations Population Division and UNICEF.
are of official primary or secondary school age, expressed as a percentage of the total number of children of official
primary or secondary school age. Antenatal care coverage – DHS, MICS and other national household surveys.
Primary school net attendance ratio – Number of children attending primary or secondary school who are of official Skilled attendant at birth – DHS, MICS, WHO and UNICEF.
primary school age, expressed as a percentage of the total number of children of official primary school age.
Secondary school net attendance ratio – Number of children attending secondary or tertiary school who are of official Institutional delivery – DHS, MICS, WHO and UNICEF.
secondary school age, expressed as a percentage of the total number of children of official secondary school age. Maternal mortality – WHO and UNICEF.
Contraceptive prevalence – Percentage of women in union aged 15–49 currently using contraception.
Lifetime risk – WHO and UNICEF.
Antenatal care coverage – Percentage of women 15–49 years old attended at least once during pregnancy by skilled
health personnel (doctors, nurses or midwives) and the percentage attended by any provider at least four times.
† The maternal mortality data in the column headed ‘reported’ are those reported
Skilled attendant at birth – Percentage of births attended by skilled health personnel (doctors, nurses or midwives).
by national authorities. Periodically, UNICEF, WHO, UNFPA and the World Bank
Institutional delivery – Proportion of women 15–49 years old who gave birth during the two years preceding the survey
and delivered in a health facility. evaluate these data and make adjustments to account for the well-documented
Maternal mortality ratio – Annual number of deaths of women from pregnancy-related causes per 100,000 live births. problems of under-reporting and misclassification of maternal deaths and to
The ‘reported’ column shows country-reported figures that are not adjusted for under-reporting and misclassification. develop estimates for countries with no data. The column with ‘adjusted’
Lifetime risk of maternal death – Lifetime risk of maternal death takes into account both the probability of becoming estimates for the year 2005 reflects the most recent of these reviews.
pregnant and the probability of dying as a result of that pregnancy accumulated across a woman’s reproductive years.
x Data refer to years or periods other than those specified in the column heading, differ from the standard definition or refer to only part of a country.
Such data are not included in the calculation of regional and global averages.
y Data refer to years or periods other than those specified in the column heading, differ from the standard definition or refer to only part of a country.
Such data are included in the calculation of regional and global averages.
** Excludes China.
TABLE 9. CHILD PROTECTION
Attitude
towards
Female genital mutilation/cutting 2002–2007* domestic Child Child
Child labour Child marriage Birth registration violence disability◊ discipline
1998–2007* a b
(5–14 years) 1999–2007* 2000–2007* women (15–49 years) daughters 2001–2007* 1999–2007* 2005–2007*
Countries and territories total male female total urban rural total urban rural total urban rural total total total total
Afghanistan 30 28 33 43 – – 6 12 4 – – – – – – –
Albania 12 14 9 8 7 8 98 97 98 – – – – 30 16 49
Algeria 5 6 4 2 2 2 99 99 99 – – – – 68 1y 86
Angola 24 22 25 – – – 29 34 19 – – – – – – –
Argentina 7y 8y 5y – – – 91y – – – – – – – – –
Armenia 4y – – 10 7 16 96 97 95 – – – – 22 12y –
Azerbaijan 7y 8y 5y 12 – – 94 96 92 – – – – 49 – 75
Bahrain 5 6 3 – – – – – – – – – – – – –
Bangladesh 13 18 8 64 58 69 10 13 9 – – – – – 21 –
Belarus 5 6 4 7 6 10 – – – – – – – – – 83
Belize 40 39 42 – – – 94 92 97 – – – – 12 44 68
Benin 46 47 45 34 19 47 60 68 56 13 9 15 2 47 – –
Bhutan 19y 16y 22y – – – – – – – – – – – – –
Bolivia 22 22 22 26 22 37 74 76 72 – – – – – – –
Bosnia and Herzegovina 5 7 4 6 2 7 100 99 100 – – – – 5 10 36
Botswana – – – 10x 13x 9x 58 66 52 – – – – – – –
Brazil 6y 7y 4y 24x 22x 30x 89y – – – – – – – – –
Burkina Faso 47y 46y 48y 48 29 61 64 86 58 73 76 71 25 71 – 83
Burundi 19 19 19 18 14 18 60 62 60 – – – – – – –
Cambodia 45y 45y 45y 23 18 25 66 71 66 – – – – 55 – –
Cameroon 31 31 30 36 23 57 70 86 58 1 1 2 1 56 33 92
Cape Verde 3y 4y 3y – – – – – – – – – – – 1y –
Central African Republic 47 44 49 61 57 64 49 72 36 26 21 29 7 – 48 88
Chad 53 54 51 72 65 73 9 36 3 45 47 44 21 – 3y –
Chile 3 3 2 – – – 95y – – – – – – – – –
China – – – – – – – – – – – – – – 2y –
Colombia 5 6 4 23 19 38 90 97 77 – – – – – 3y –
Comoros 27 26 28 30x 23x 33x 83 87 83 – – – – – – –
Congo 25 24 25 31 24 40 81y 88y 75y – – – – 76 – –
Costa Rica 5 6 3 – – – – – – – – – – – – –
Côte d’Ivoire 35 36 34 35 27 43 55 79 41 36 34 39 9 65 – 90
Cuba – – – – – – 100y 100y 100y – – – – – – –
Democratic People’s Republic of Korea – – – – – – 99 99 99 – – – – – – –
Democratic Republic of the Congo 32 29 34 – – – 34 30 36 – – – – – – –
Djibouti 8 8 8 5 5 13 89 90 82 93 93 96 49 – – 70
Dominican Republic 10 12 7 40 38 47 78 82 70 – – – – 9 5y 83
Ecuador 12 12 13 22 – – 85 85 85 – – – – – – –
Egypt 7 8 5 17 9 22 99 99 99 96 92 98 28y 50 8y 92
El Salvador 6y 9y 4y 27 – – – – – – – – – – – –
Equatorial Guinea 28 28 28 – – – 32 43 24 – – – – – – –
Eritrea – – – 47 31 60 – – – 89 86 91 63 – – –
Ethiopia 53 59 46 49 27 55 7 29 5 74 69 76 38 81 – –
Gabon – – – 34 30 49 89 90 87 – – – – – – –
Gambia 25 20 29 36 24 45 55 57 54 78 72 83 64 74 – 84
Georgia 18 20 17 17 12 23 92 97 87 – – – – 7 30 66
Ghana 34 34 34 22 15 28 51 69 42 4 2 6 1 47 21 89
Guatemala 29 25 32 34 25 44 – – – – – – – – 2y –
Guinea 25 26 24 63 45 75 43 78 33 96 94 96 57 86 – –
Guinea-Bissau 39 41 37 24 14 32 39 53 33 45 39 48 35 52 – 80
Guyana 19 21 17 20 15 22 93 96 92 – – – – 18 – 74
Haiti 21 22 19 30 27 33 81 87 78 – – – – 29 – –
Honduras 16 16 15 39 33 46 94 95 93 – – – – 16 – –
India 12 12 12 47 29 56 41 59 35 – – – – 54 – –
Indonesia 4y 5y 4y 24 15 33 55 69 43 – – – – 25 – –
Iraq 11 12 9 17 16 19 95 95 96 – – – – 59 21 84
Jamaica 6 7 5 9 7 11 89 88 89 – – – – 6 24 87
Jordan – – – 10 – – – – – – – – – 90 – –
Kazakhstan 2 2 2 7 6 9 99 99 99 – – – – 10 – 52
Kenya 26 27 25 25 19 27 48y 64y 44y 32 21 36 21 68 – –
Kyrgyzstan 4 4 3 10 7 14 94 96 93 – – – – 38 – 51
Lao People’s Democratic Republic 25 24 26 – – – 59 71 56 – – – – – – –
Lebanon 7 8 6 11 – – – – – – – – – – – –
Lesotho 23 25 21 23 13 26 26 39 24 – – – – – – –
Liberia – – – 40 – – – – – – – – – – – –
Madagascar 32 36 28 39 29 42 75 87 72 – – – – 28 – –
Malawi 29 28 29 50 38 53 – – – – – – – 28 – –
Maldives – – – – – – 73 – – – – – – 70 – –
Mali 34 35 33 71 60 77 53 75 45 85 81 87 69 75 – –
Mauritania 4y 5y 3y 35 27 44 56 75 42 72 60 84 66 – 30 –
Mexico 16y 15y 16y 28x 31x 21x – – – – – – – – – –
Moldova 32 32 33 19 16 22 98 98 98 – – – – 21 – –
Mongolia 18 19 17 9 7 12 98 98 99 – – – – 20 26 79
Montenegro 10 12 8 5 5 5 98 98 99 – – – – 11 14 61
Morocco 11y 13y 9y 16 12 21 85 92 80 – – – – – – –
Mozambique – – – 56 41 66 – – – – – – – – – –
Myanmar – – – – – – 65y 88y 59y – – – – – – –
Namibia 13y 15y 12y 9 – – 67 83 59 – – – – 35 – –
Nepal 31y 30y 33y 51 41 54 35 42 34 – – – – 23 – –
Nicaragua 15 18 11 43 36 55 81 90 73 – – – – 17 – –
Niger 43 43 43 75 42 84 32 71 25 2 2 2 1 70 – –
Nigeria 13y – – 43 27 52 33y 52y 25y 19 28 14 10 65 – –
Occupied Palestinian Territory – – – 19 – – 96y 97y 96y – – – – – – 95
Pakistan – – – 32x 21x 37x – – – – – – – – – –
Panama 3 5 2 – – – – – – – – – – – – –
Paraguay 15 17 12 24x 18x 32x – – – – – – – – – –
…TABLE 9
Attitude
towards
Female genital mutilation/cutting 2002–2007* domestic Child Child
Child labour Child marriage Birth registration violence disability◊ discipline
1998–2007* a b
(5–14 years) 1999–2007* 2000–2007* women (15–49 years) daughters 2001–2007* 1999–2007* 2005–2007*
Countries and territories total male female total urban rural total urban rural total urban rural total total total total
Peru 19 20 19 18 13 31 93 95 90 – – – – – – –
Philippines 12 13 11 14 10 22 83 87 78 – – – – 24 – –
Portugal 3y 4y 3y – – – – – – – – – – – – –
Romania 1 1 1 – – – – – – – – – – – – –
Rwanda 35 36 35 13 9 14 82 79 83 – – – – 48 2y –
Sao Tome and Principe 8 8 7 33 31 37 69 70 67 – – – – 32 29 –
Senegal 22 24 21 39 23 55 55 75 44 28 22 34 20 65 – –
Serbia 4 5 4 6 4 8 99 99 99 – – – – 6 14 73
Sierra Leone 48 49 48 56 34 66 48 62 44 94 86 97 35 85 34 92
Somalia 49 45 54 45 35 52 3 6 2 98 97 98 46 76y – –
South Africa – – – 8 5 12 78y – – – – – – – – –
Sri Lanka 8 9 7 12y – – – – – – – – – – – –
Sudan 13 14 12 34 24 40 33 53 22 89 88 90 43y – – –
Suriname – – – 19 14 33 97 98 95 – – – – 13 39 84
Swaziland 9 9 9 5 1 6 30 38 28 – – – – 38 – –
Syrian Arab Republic 4 5 3 13 15 12 95 96 95 – – – – – – 87
Tajikistan 10 9 11 13 13 13 88 85 90 – – – – 74y – 74
Thailand 8 8 8 20 12 23 99 100 99 – – – – – 15 –
The former Yugoslav Republic of Macedonia 6 7 5 4 3 4 94 95 93 – – – – 21 21 69
Timor-Leste 4 4 4 – – – 53y – – – – – – – – –
Togo 29 29 30 24 15 36 78 93 69 6 4 7 1 53 – 90
Trinidad and Tobago 1 1 1 8 – – 96 – – – – – – 8 – 75
Tunisia – – – 10x 7x 14x – – – – – – – – – –
Turkey 5 4 6 18 17 22 84 87 79 – – – – 39 – –
Turkmenistan – – – 7 9 6 96 96 95 – – – – 38y – –
Uganda 36 37 36 46 27 52 21 24 21 1 0 1 – 70 11y –
Ukraine 7 8 7 6 6 10 100 100 100 – – – – 5 – 70
United Republic of Tanzania 36 37 34 41 23 49 8 22 4 15 7 18 4 60 – –
Uruguay 8y 8y 8y – – – – – – – – – – – – –
Uzbekistan 2 2 2 7 9 7 100 100 100 – – – – 70 3 –
Venezuela (Bolivarian Republic of) 8 9 6 – – – 92 – – – – – – – – –
Viet Nam 16 15 16 10 3 13 88 94 86 – – – – 64 4y 93
Yemen 11y 11y 12y 32 28 35 22 38 16 23x 26x 22x 20x – 29 94
Zambia 12y 11y 12y 42 32 49 10 16 6 1 1 1 – 85 – –
Zimbabwe 13y 12y 14y 34 20 44 74 83 71 – – – – 48 – –
SUMMARY INDICATORS
Sub-Saharan Africa 35n 36n 34n 40 25 48 37 52 30 34 30 37 19 65 – –
Eastern and Southern Africa 36 38 33 36 20 43 32 41 24 43 36 46 28 65 – –
West and Central Africa 35n 34n 35n 44 28 55 41 57 35 28 28 29 14 64 – –
Middle East and North Africa 9 10 8 18 12 23 75 86 67 – – – – – – 89
South Asia 13 13 12 49 32 58 36 52 30 – – – – 53 – –
East Asia and Pacific 10** 11** 10** 19** 12** 25** 72** 81** 67** – – – – 34** 3 –
Latin America and Caribbean 11 11 10 – – – 89 92 82 – – – – – – –
CEE/CIS 5 5 5 11 11 13 92 93 92 – – – – 32 – –
Industrialized countries§ – – – – – – – – – – – – – – – –
Developing countries§ 16*** 17*** 15*** 36** 22** 46** 50** 65** 39** – – – – 51** – –
Least developed countries§ 30 31 28 49 37 55 29 42 25 – – – – – – –
World – – – – – – – – – – – – – – – –
Child labour – Percentage of children 5–14 years old involved in child labour at the moment of the survey. A child is considered to be involved in child labour under the Child labour – Multiple Indicator Cluster
following conditions: (a) children 5–11 years old who, during the week preceding the survey, did at least one hour of economic activity or at least 28 hours of domestic Surveys (MICS) and Demographic and
work, or (b) children 12–14 years old who, during the week preceding the survey, did at least 14 hours of economic activity or at least 28 hours of domestic work. Health Surveys (DHS).
Child labour background variables – Sex of the child; urban or rural place of residence; poorest 20 per cent or richest 20 per cent of the population
constructed from household assets (a more detailed description of the household wealth estimation procedure can be found at <www.childinfo.org>); mother’s Child marriage – MICS, DHS and other
education, reflecting mothers with and without some level of education. national surveys.
Child marriage – Percentage of women 20–24 years old who were married or in union before they were 18 years old. Birth registration – MICS, DHS, other national
Birth registration – Percentage of children less than five years old who were registered at the moment of the survey. The numerator of this indicator includes surveys and vital registration systems.
children whose birth certificate was seen by the interviewer or whose mother or caretaker says the birth has been registered. MICS data refer to children alive
at the time of the survey. Female genital mutilation/cutting –
Female genital mutilation/cutting – (a) Women – the percentage of women 15–49 years old who have been mutilated/cut. (b) Daughters – the percentage of MICS, DHS and other national surveys.
women 15–49 years old with at least one mutilated/cut daughter. Female genital mutilation/cutting is the cutting or alteration of the female genitalia for Attitudes towards domestic violence –
social reasons.
MICS, DHS and other national surveys.
Attitudes towards domestic violence – Percentage of women 15–49 years old who consider a husband to be justified in hitting or beating his wife for at
least one of the specified reasons. Women were asked whether a husband is justified in hitting or beating his wife under a series of circumstances, i.e., if his Child disability – MICS, DHS and other
wife burns the food, argues with him, goes out without telling him, neglects the children or refuses sexual relations. national surveys.
Child disability – Percentage of children 2–9 years old with at least one reported disability (i.e., cognitive, motor, seizure, vision, hearing or speech).
Child discipline – MICS, DHS and other
Child discipline – Percentage of children 2–14 years old who experience any psychological or physical punishment. national surveys.
y Data refer to years or periods other than those specified in the column heading, differ from the standard definition or refer to only part of a country.
Such data are included in the calculation of regional and global averages.
n Excludes Nigeria.
◊ A fuller explanation of the methodology and the recent changes in calculating these estimates can be found in the General note on the data, page 114.
** Excludes China.
*** Excludes China and Nigeria.
Summary indicators
Averages given at the end of each table are Colombia; Costa Rica; Cuba; Dominica; Republic of); Iraq; Israel; Jamaica; Jordan;
calculated using data from the countries and Dominican Republic; Ecuador; El Salvador; Kazakhstan; Kenya; Kiribati; Kuwait;
territories as grouped below. Grenada; Guatemala; Guyana; Haiti; Honduras; Kyrgyzstan; Lao People’s Democratic
Jamaica; Mexico; Nicaragua; Panama; Republic; Lebanon; Lesotho; Liberia; Libyan
Sub-Saharan Africa Paraguay; Peru; Saint Kitts and Nevis; Saint Arab Jamahiriya; Madagascar; Malawi;
Angola; Benin; Botswana; Burkina Faso; Lucia; Saint Vincent and the Grenadines; Malaysia; Maldives; Mali; Marshall Islands;
Burundi; Cameroon; Cape Verde; Central Suriname; Trinidad and Tobago; Uruguay; Mauritania; Mauritius; Mexico; Micronesia
African Republic; Chad; Comoros; Congo; Venezuela (Bolivarian Republic of) (Federated States of); Mongolia; Morocco;
Côte d’Ivoire; Democratic Republic of the Mozambique; Myanmar; Namibia; Nauru;
CEE/CIS Nepal; Nicaragua; Niger; Nigeria; Niue;
Congo; Equatorial Guinea; Eritrea; Ethiopia;
Gabon; Gambia; Ghana; Guinea; Guinea- Albania; Armenia; Azerbaijan; Belarus; Occupied Palestinian Territory; Oman;
Bissau; Kenya; Lesotho; Liberia; Madagascar; Bosnia and Herzegovina; Bulgaria; Croatia; Pakistan; Palau; Panama; Papua New
Malawi; Mali; Mauritania; Mauritius; Georgia; Kazakhstan; Kyrgyzstan; Moldova, Guinea; Paraguay; Peru; Philippines; Qatar;
Republic of; Montenegro; Romania; Russian Republic of Korea; Rwanda; Saint Kitts and
Mozambique; Namibia; Niger; Nigeria;
Federation; Serbia; Tajikistan; The former Nevis; Saint Lucia; Saint Vincent and the
Rwanda; Sao Tome and Principe; Senegal;
Yugoslav Republic of Macedonia; Turkey; Grenadines; Samoa; Sao Tome and Principe;
Seychelles; Sierra Leone; Somalia; South
Turkmenistan; Ukraine; Uzbekistan Saudi Arabia; Senegal; Seychelles; Sierra
Africa; Swaziland; Togo; Uganda; United
Leone; Singapore; Solomon Islands; Somalia;
Republic of Tanzania; Zambia; Zimbabwe
Industrialized countries/territories South Africa; Sri Lanka; Sudan; Suriname;
Andorra; Australia; Austria; Belgium; Swaziland; Syrian Arab Republic; Tajikistan;
Middle East and North Africa
Canada; Cyprus; Czech Republic; Denmark; Thailand; Timor-Leste; Togo; Tonga; Trinidad
Algeria; Bahrain; Djibouti; Egypt; Iran and Tobago; Tunisia; Turkey; Turkmenistan;
(Islamic Republic of); Iraq; Jordan; Kuwait; Estonia; Finland; France; Germany; Greece;
Holy See; Hungary; Iceland; Ireland; Israel; Tuvalu; Uganda; United Arab Emirates;
Lebanon; Libyan Arab Jamahiriya; Morocco; United Republic of Tanzania; Uruguay;
Occupied Palestinian Territory; Oman; Qatar; Italy; Japan; Latvia; Liechtenstein; Lithuania;
Luxembourg; Malta; Monaco; Netherlands; Uzbekistan; Vanuatu; Venezuela (Bolivarian
Saudi Arabia; Sudan; Syrian Arab Republic; Republic of); Viet Nam; Yemen; Zambia;
New Zealand; Norway; Poland; Portugal; San
Tunisia; United Arab Emirates; Yemen Zimbabwe
Marino; Slovakia; Slovenia; Spain; Sweden;
South Asia Switzerland; United Kingdom; United States
Least developed countries/territories
Afghanistan; Bangladesh; Bhutan; India; Developing countries/territories Afghanistan; Angola; Bangladesh; Benin;
Maldives; Nepal; Pakistan; Sri Lanka Bhutan; Burkina Faso; Burundi; Cambodia;
Afghanistan; Algeria; Angola; Antigua and
Cape Verde; Central African Republic; Chad;
East Asia and Pacific Barbuda; Argentina; Armenia; Azerbaijan;
Comoros; Democratic Republic of the Congo;
Bahamas; Bahrain; Bangladesh; Barbados;
Brunei Darussalam; Cambodia; China; Cook Djibouti; Equatorial Guinea; Eritrea; Ethiopia;
Belize; Benin; Bhutan; Bolivia; Botswana;
Islands; Democratic People’s Republic of Gambia; Guinea; Guinea-Bissau; Haiti;
Brazil; Brunei Darussalam; Burkina Faso;
Korea; Fiji; Indonesia; Kiribati; Lao People’s Kiribati; Lao People’s Democratic Republic;
Burundi; Cambodia; Cameroon; Cape Verde;
Democratic Republic; Malaysia; Marshall Lesotho; Liberia; Madagascar; Malawi;
Central African Republic; Chad; Chile; China;
Islands; Micronesia (Federated States of); Maldives; Mali; Mauritania; Mozambique;
Colombia; Comoros; Congo; Cook Islands;
Mongolia; Myanmar; Nauru; Niue; Palau; Myanmar; Nepal; Niger; Rwanda; Samoa;
Costa Rica; Côte d’Ivoire; Cuba; Cyprus;
Papua New Guinea; Philippines; Republic of Sao Tome and Principe; Senegal; Sierra
Democratic Republic of the Congo;
Korea; Samoa; Singapore; Solomon Islands; Leone; Solomon Islands; Somalia; Sudan;
Democratic People’s Republic of Korea;
Thailand; Timor-Leste; Tonga; Tuvalu; Timor-Leste; Togo; Tuvalu; Uganda; United
Djibouti; Dominica; Dominican Republic;
Vanuatu; Viet Nam Republic of Tanzania; Vanuatu; Yemen;
Ecuador; Egypt; El Salvador; Equatorial
Zambia
Guinea; Eritrea; Ethiopia; Fiji; Gabon; Gambia;
Latin America and Caribbean Georgia; Ghana; Grenada; Guatemala;
Antigua and Barbuda; Argentina; Bahamas; Guinea; Guinea-Bissau; Guyana; Haiti;
Barbados; Belize; Bolivia; Brazil; Chile; Honduras; India; Indonesia; Iran (Islamic
Measuring human development
An introduction to Table 10
If development is to be measured by a com- presents a more accurate, if far from perfect,

prehensive and inclusive assessment, then picture of the health status of the majority of
the need arises for a method of measuring children and of society as a whole.
human as well as economic progress. From
UNICEF’s point of view, there is a need for an The speed of progress in reducing the U5MR
agreed method of measuring the level of can be measured by calculating its average
child well-being and its rate of change. annual rate of reduction (AARR). Unlike the
comparison of absolute changes, the AARR
The under-five mortality rate (U5MR) is used reflects the fact that the lower limits to
in Table 10 (pages 150–153 ) as the principal U5MR are approached only with increasing
indicator of such progress. In 2007, the num- difficulty. As lower levels of under-five mor-
ber of children dying before their fifth birth- tality are reached, for example, the same
day fell to 9.2 million. In comparison, in 1960, absolute reduction obviously represents a
approximately 20 million children were dying greater percentage reduction. The AARR
every year – highlighting an important long- therefore shows a higher rate of progress for
term decline in the global number of under- a 10-point reduction, for example, if that
five deaths. reduction happens at a lower level of under-
five mortality. A fall in the U5MR of 10 points
The U5MR has several advantages. First, it from 100 to 90 represents a reduction of
measures an end result of the development 10 per cent, whereas the same 10-point fall
process rather than an ‘input’, such as school from 20 to 10 represents a reduction of 50
enrolment level, per capita calorie availability per cent. (A negative value for the percent-
or the number of doctors per thousand popu- age reduction indicates an increase in the
lation – all of which are means to an end. U5MR over the period specified.)
Second, the U5MR is known to be the result When used in conjunction with gross do-
of a wide variety of inputs: antibiotics to treat mestic product (GDP) growth rates, the
pneumonia; insecticide-treated mosquito nets U5MR and its rate of reduction can therefore
to prevent malaria; the nutritional health and give a picture of the progress being made by
the health knowledge of mothers; the level of any country, territory or region, and over any
immunization and oral rehydration therapy use; period of time, towards the satisfaction of
the availability of maternal and child health some of the most essential of human needs.
services, including prenatal care; income and
food availability in the family; the availability of As Table 10 shows, there is no fixed relation-
safe drinking water and basic sanitation; and ship between the annual reduction rate of
the overall safety of the child’s environment. the U5MR and the annual rate of growth in
per capita GDP. Such comparisons help to
Third, the U5MR is less susceptible to the shed light on the relationship between eco-
fallacy of the average than, for example, per nomic advances and human development.
capita gross national income (GNI). This is
because the natural scale does not allow the Finally, the table gives the total fertility rate
children of the rich to be one thousand times for each country and territory and the corre-
as likely to survive, even if the human-made sponding average annual rate of reduction.
scale does permit them to have one thou- It is clear that many of the nations that have
sand times as much income. In other words, achieved significant reductions in their
it is much more difficult for a wealthy minor- U5MR have also achieved significant
ity to affect a nation’s U5MR, and it therefore reductions in fertility.
TABLE 10. THE RATE OF PROGRESS
Under-5 GDP per capita

mortality Average annual average annual Total Average annual
Under-5 rate rate of reduction (%)Θ Reduction growth rate (%) fertility rate rate of reduction (%)
mortality since 1990
Countries and territories rank 1970 1990 2007 1970–1990 1990–2007 (%)Θ 1970–1990 1990–2007 1970 1990 2007 1970–1990 1990–2007
Afghanistan 2 320 260 257 1.0 0.1 1 – – 7.7 8.0 7.1 -0.2 0.7
Albania 126 107 46 15 4.2 6.6 67 -0.7x 5.2 4.9 2.9 2.1 2.6 2.0
Algeria 75 220 69 37 5.8 3.7 46 1.6 1.4 7.4 4.7 2.4 2.3 4.0
Andorra 189 – 6 3 – 4.1 50 – – – – – – –
Angola 16 – 258 158 – 2.9 39 0.4x 2.9 7.3 7.2 6.5 0.1 0.6
Antigua and Barbuda 140 – – 11 – – – 8.3x 1.7 – – – – –
Argentina 125 68 29 16 4.3 3.5 45 -0.7 1.5 3.1 3.0 2.3 0.1 1.7
Armenia 99 – 56 24 – 5.0 57 – 5.8 3.2 2.5 1.4 1.2 3.7
Australia 160 21 9 6 4.2 2.4 33 1.5 2.4 2.7 1.9 1.8 1.9 0.3
Austria 173 29 9 4 5.9 4.8 56 2.4 1.8 2.3 1.5 1.4 2.3 0.2
Azerbaijan 71 – 98 39 – 5.4 60 – 2.8 4.6 3.0 1.8 2.2 3.1
Bahamas 134 49 29 13 2.6 4.7 55 1.8 0.4x 3.6 2.6 2.0 1.6 1.5
Bahrain 145 82 19 10 7.3 3.8 47 -1.3x 2.4x 6.5 3.7 2.3 2.8 2.8
Bangladesh 58 238 151 61 2.3 5.3 60 0.6 3.1 6.4 4.4 2.9 1.9 2.5
Barbados 137 54 17 12 5.8 2.0 29 1.5 1.3x 3.1 1.7 1.5 3.1 0.6
Belarus 134 – 24 13 – 3.6 46 – 3.4 2.3 1.9 1.2 1.0 2.6
Belgium 166 24 10 5 4.4 4.1 50 2.2 1.8 2.2 1.6 1.6 1.7 -0.2
Belize 97 – 43 25 – 3.2 42 2.9 2.4 6.3 4.5 3.0 1.7 2.5
Benin 25 256 184 123 1.7 2.4 33 0 1.3 7.0 6.8 5.5 0.2 1.3
Bhutan 45 288 148 84 3.3 3.3 43 6.8x 5.2 6.7 5.9 2.2 0.6 5.7
Bolivia 61 243 125 57 3.3 4.6 54 -1.1 1.3 6.6 4.9 3.5 1.5 1.9
Bosnia and Herzegovina 132 82 22 14 6.6 2.7 36 – 10.8x 2.9 1.7 1.2 2.6 2.0
Botswana 69 144 57 40 4.6 2.1 30 8.2 4.2 6.6 4.7 2.9 1.7 2.8
Brazil 107 134 58 22 4.2 5.7 62 2.3 1.2 5.0 2.8 2.3 2.9 1.3
Brunei Darussalam 148 78 11 9 9.8 1.2 18 -2.2x -0.3x 5.7 3.2 2.3 2.8 2.0
Bulgaria 137 33 18 12 3.0 2.4 33 3.4x 2.3 2.2 1.7 1.3 1.2 1.6
Burkina Faso 7 281 206 191 1.6 0.4 7 1.3 2.5 7.6 7.3 6.0 0.2 1.1
Burundi 10 219 189 180 0.7 0.3 5 1.1 -2.7 6.8 6.8 6.8 0.0 0.0
Cambodia 40 – 119 91 – 1.6 24 – 6.2x 5.9 5.8 3.2 0.1 3.5
Cameroon 18 215 139 148 2.2 -0.4 -6 3.3 0.6 6.2 5.9 4.4 0.2 1.8
Canada 160 22 8 6 5.1 1.7 25 2 2.2 2.2 1.7 1.5 1.5 0.5
Cape Verde 84 – 60 32 – 3.7 47 – 3.3 7.0 5.5 3.4 1.2 2.8
Central African Republic 12 232 171 172 1.5 0.0 -1 -1.3 -0.8 5.7 5.7 4.6 0.0 1.2
Chad 3 – 201 209 – -0.2 -4 -1 2.4 6.5 6.7 6.2 -0.1 0.4
Chile 148 98 21 9 7.7 5.0 57 1.5 3.7 4.0 2.6 1.9 2.1 1.8
China 107 118 45 22 4.8 4.2 51 6.6 8.9 5.6 2.2 1.7 4.7 1.4
Colombia 112 105 35 20 5.5 3.3 43 2 1 5.6 3.0 2.2 3.1 1.8
Comoros 55 215 120 66 2.9 3.5 45 0.1x -0.4 7.1 6.1 4.4 0.7 2.0
Congo 24 142 104 125 1.6 -1.1 -20 3.2 -0.2 6.3 5.4 4.5 0.8 1.0
Cook Islands 117 – 32 18 – 3.4 44 – – – – – – –
Costa Rica 140 83 18 11 7.6 2.9 39 0.7 2.5 5.0 3.2 2.1 2.3 2.4
Côte d’Ivoire 22 236 151 127 2.2 1.0 16 -1.9 -0.7 7.4 6.6 4.5 0.5 2.2
Croatia 160 42 13 6 5.9 4.5 54 – 3 2.0 1.7 1.3 0.9 1.3
Cuba 156 39 13 7 5.5 3.6 46 – 3.6x 4.0 1.8 1.5 4.2 0.9
Cyprus 166 31 11 5 5.2 4.6 55 5.9x 2.2 2.6 2.4 1.6 0.4 2.5
Czech Republic 173 24 12 4 3.5 6.5 67 – 2.4 2.0 1.8 1.2 0.5 2.3
Republic of Korea 62 70 55 55 1.2 0.0 0 – – 4.0 2.4 1.9 2.6 1.5
Democratic Republic
of the Congo 15 235 200 161 0.8 1.3 20 -2.4 -4.3 6.4 6.7 6.7 -0.3 0.0
Denmark 173 16 9 4 2.9 4.8 56 2 1.9 2.1 1.7 1.8 1.2 -0.5
Djibouti 22 – 175 127 – 1.9 27 – -2.1 7.4 6.2 4.0 0.9 2.5
Dominica 140 60 18 11 6.0 2.9 39 4.7x 2.4 – – – – –
Dominican Republic 73 131 66 38 3.4 3.2 42 2.1 3.8 6.2 3.3 2.8 3.1 0.9
Ecuador 107 140 57 22 4.5 5.6 61 1.3 1.2 6.3 3.7 2.6 2.7 2.0
Egypt 77 236 93 36 4.7 5.6 61 4.3 2.5 6.2 4.4 2.9 1.7 2.4
El Salvador 99 162 60 24 5.0 5.4 60 -1.8 1.8 6.4 3.7 2.7 2.7 1.8
Equatorial Guinea 4 – 170 206 – -1.1 -21 – 21.1 5.7 5.9 5.4 -0.2 0.5
Eritrea 50 237 147 70 2.4 4.4 52 – -0.3x 6.6 6.2 5.1 0.3 1.2
Estonia 160 20 18 6 0.5 6.5 67 1.5x 5.2 2.1 1.9 1.5 0.4 1.6
Ethiopia 27 241 204 119 0.8 3.2 42 – 2.2 6.8 6.8 5.3 0.0 1.4
Fiji 117 – 22 18 – 1.2 18 0.6x 1.5x 4.5 3.4 2.8 1.5 1.2
Finland 173 16 7 4 4.1 3.3 43 2.8 2.8 1.9 1.7 1.8 0.3 -0.2
…TABLE 10

rank 1970 1990 2007 1970–1990 1990–2007 (%)Θ 1970–1990 1990–2007 1970 1990 2007 1970–1990 1990–2007
France 173 18 9 4 3.5 4.8 56 2.2 1.6 2.5 1.8 1.9 1.7 -0.5
Gabon 40 – 92 91 – 0.1 1 0.3 -0.7 4.8 4.8 3.1 0.0 2.6
Gambia 34 311 153 109 3.5 2.0 29 0.9 0.2 6.7 6.0 4.8 0.5 1.4
Georgia 88 – 47 30 – 2.6 36 3.2 1.8 2.6 2.1 1.4 1.0 2.4
Germany 173 26 9 4 5.3 4.8 56 2.3x 1.4 2.0 1.4 1.4 1.9 0.0
Ghana 30 183 120 115 2.1 0.3 4 -2.1 2.1 6.7 5.8 3.9 0.7 2.3
Greece 173 32 11 4 5.3 6.0 64 1.3 2.7 2.4 1.4 1.3 2.5 0.5
Grenada 114 – 37 19 – 3.9 49 4.9 2.5 4.6 3.7 2.3 1.1 2.8
Guatemala 71 168 82 39 3.6 4.4 52 0.2 1.4 6.2 5.6 4.2 0.6 1.7
Guinea 17 326 231 150 1.7 2.5 35 0.3x 1.3 7.0 6.7 5.5 0.2 1.2
Guinea-Bissau 5 – 240 198 – 1.1 18 -0.2 -2.6 6.8 7.1 7.1 -0.2 0.0
Guyana 59 – 88 60 – 2.3 32 -1.5 3.1 5.6 2.6 2.3 3.8 0.6
Haiti 47 222 152 76 1.9 4.1 50 -0.3 -2.1 5.8 5.4 3.6 0.3 2.5
Holy See – – – – – – – – – – – – – –
Honduras 99 169 58 24 5.3 5.2 59 0.8 1.5 7.3 5.1 3.3 1.7 2.5
Hungary 156 40 17 7 4.3 5.2 59 3 3.3 2.0 1.8 1.3 0.6 2.0
Iceland 189 16 7 3 4.1 5.0 57 3.2 2.4 3.0 2.2 2.0 1.6 0.3
India 49 190 117 72 2.4 2.9 38 2.1 4.5 5.4 4.0 2.8 1.5 2.0
Indonesia 86 172 91 31 3.2 6.3 66 4.7 2.3 5.5 3.1 2.2 2.8 2.1
Iran (Islamic Republic of) 83 191 72 33 4.9 4.6 54 -2.3 2.5 6.6 5.0 2.0 1.3 5.3
Iraq 66 125 53 44 4.3 1.1 17 – – 7.2 5.9 4.3 1.0 1.9
Ireland 173 23 9 4 4.7 4.8 56 2.8 5.8 3.9 2.1 2.0 3.1 0.4
Israel 166 29 12 5 4.4 5.1 58 1.9 1.7 3.8 3.0 2.8 1.2 0.4
Italy 173 33 10 4 6.0 5.4 60 2.8 1.2 2.4 1.3 1.4 3.1 -0.3
Jamaica 86 62 33 31 3.2 0.4 6 -1.3 0.8 5.5 2.9 2.5 3.1 1.1
Japan 173 17 6 4 5.2 2.4 33 3 0.9 2.1 1.6 1.3 1.3 1.3
Jordan 99 107 40 24 4.9 3.0 40 2.5x 2 7.9 5.5 3.1 1.8 3.3
Kazakhstan 84 88 60 32 1.9 3.7 47 – 3.2 3.5 2.8 2.3 1.1 1.3
Kenya 26 156 97 121 2.4 -1.3 -25 1.2 0 8.1 5.9 5.0 1.6 1.0
Kiribati 57 – 88 63 – 2.0 28 -5.3 1.8 – – – – –
Kuwait 140 59 15 11 6.8 1.8 27 -6.8x 1.1x 7.2 3.5 2.2 3.6 2.8
Kyrgyzstan 73 – 74 38 – 3.9 49 – -0.5 4.9 3.9 2.5 1.2 2.7
Lao People’s
Democratic Republic 50 218 163 70 1.5 5.0 57 – 4.2 6.4 6.2 3.2 0.2 3.9
Latvia 148 20 17 9 0.8 3.7 47 3.4 4.7 1.9 1.9 1.3 0.0 2.3
Lebanon 91 54 37 29 1.9 1.4 22 – 2.5 5.1 3.1 2.2 2.4 2.1
Lesotho 45 171 102 84 2.6 1.1 18 3.1 1.8 5.8 4.9 3.4 0.8 2.2
Liberia 20 284 205 133 1.6 2.5 35 -4.2 1.9 6.9 6.9 6.8 0.0 0.1
Libyan Arab Jamahiriya 117 160 41 18 6.8 4.8 56 -4.9x – 7.6 4.8 2.8 2.3 3.3
Liechtenstein 189 – 10 3 – 7.1 70 – – – – – – –
Lithuania 151 22 16 8 1.6 4.1 50 – 3 2.3 2.0 1.3 0.7 2.7
Luxembourg 189 23 9 3 4.7 6.5 67 2.7 3.2 2.0 1.6 1.7 1.1 -0.3
Madagascar 32 180 168 112 0.3 2.4 33 -2.4 -0.4 6.8 6.2 4.8 0.4 1.5
Malawi 33 334 209 111 2.3 3.7 47 -0.1 0.3 7.3 7.0 5.6 0.2 1.2
Malaysia 140 70 22 11 5.8 4.1 50 4 3.2 5.6 3.7 2.6 2.0 2.1
Maldives 88 – 111 30 – 7.7 73 – 5.5x 7.0 6.2 2.6 0.6 5.1
Mali 6 372 250 196 2.0 1.4 22 -0.3 2.2 7.5 7.4 6.5 0.0 0.8
Malta 166 28 11 5 4.7 4.6 55 6.5 2.7x 2.1 2.0 1.4 0.0 2.4
Marshall Islands 64 – 92 54 – 3.1 41 – -2 – – – – –
Mauritania 27 233 130 119 2.9 0.5 8 -0.9 0.6 6.6 5.8 4.4 0.6 1.6
Mauritius 126 86 24 15 6.4 2.8 38 5.1x 3.7 3.7 2.2 1.9 2.5 1.1
Mexico 78 111 52 35 3.8 2.3 33 1.6 1.6 6.7 3.4 2.2 3.4 2.5
Micronesia
(Federated States of) 69 – 58 40 – 2.2 31 – -0.2 6.9 5.0 3.8 1.7 1.6
Moldova 117 65 37 18 2.8 4.2 51 1.8x -1.3 2.6 2.4 1.4 0.3 3.2
Monaco 173 – 9 4 – 4.8 56 – – – – – – –
Mongolia 67 – 98 43 – 4.8 56 – 2.2 7.5 4.1 1.9 3.0 4.6
Montenegro 145 – 16 10 – 2.8 38 – 3.4x 2.4 2.0 1.8 0.9 0.6
Morocco 81 184 89 34 3.6 5.7 62 2 2 7.1 4.0 2.4 2.8 3.1
Mozambique 14 277 201 168 1.6 1.1 16 -1x 4.1 6.6 6.2 5.2 0.3 1.1
Myanmar 36 179 130 103 1.6 1.4 21 1.5 6.8x 6.1 3.4 2.1 2.8 3.0
Namibia 53 126 87 68 1.9 1.4 22 -2.3x 1.8 6.5 5.8 3.2 0.5 3.5
Nauru 88 – – 30 – – – – – – – – – –
TABLE 10. THE RATE OF PROGRESS

rank 1970 1990 2007 1970–1990 1990–2007 (%)Θ 1970–1990 1990–2007 1970 1990 2007 1970–1990 1990–2007
Nepal 62 237 142 55 2.6 5.6 61 1.2 1.9 5.9 5.2 3.3 0.6 2.6
Netherlands 166 16 8 5 3.5 2.8 38 1.5 2.1 2.4 1.6 1.7 2.2 -0.6
New Zealand 160 21 11 6 3.2 3.6 45 0.8 2 3.1 2.1 2.0 2.0 0.2
Nicaragua 78 165 68 35 4.4 3.9 49 -3.7 1.9 6.9 4.8 2.8 1.9 3.2
Niger 11 318 304 176 0.2 3.2 42 -2.2 -0.6 8.1 7.9 7.2 0.1 0.5
Nigeria 8 265 230 189 0.7 1.2 18 -1.4 1.2 6.9 6.8 5.4 0.1 1.3
Niue – – – – – – – – – – – – – –
Norway 173 16 9 4 2.9 4.8 56 3.2 2.6 2.5 1.9 1.8 1.5 0.1
Occupied Palestinian Territory 95 – 38 27 – 2.0 29 – -2.9x 7.9 6.4 5.2 1.0 1.3
Oman 137 200 32 12 9.2 5.8 63 3.3 2.2x 7.2 6.6 3.0 0.4 4.6
Pakistan 43 184 132 90 1.7 2.3 32 3 1.6 6.6 6.3 3.5 0.2 3.4
Palau 145 – 21 10 – 4.4 52 – – – – – – –
Panama 104 68 34 23 3.5 2.3 32 0.3 2.6 5.3 3.0 2.6 2.8 0.9
Papua New Guinea 56 156 94 65 2.5 2.2 31 -0.7 -0.6 6.2 4.8 3.8 1.2 1.3
Paraguay 91 75 41 29 3.0 2.0 29 2.8 -0.3 5.7 4.5 3.1 1.2 2.2
Peru 112 170 78 20 3.9 8.0 74 -0.6 2.7 6.3 3.9 2.5 2.4 2.6
Philippines 94 89 62 28 1.8 4.7 55 0.8 1.7 6.3 4.3 3.3 1.8 1.7
Poland 156 35 17 7 3.6 5.2 59 – 4.4 2.2 2.0 1.2 0.4 3.0
Portugal 173 66 15 4 7.4 7.8 73 2.6 1.9 2.8 1.5 1.5 3.0 0.3
Qatar 126 51 26 15 3.4 3.2 42 – – 6.9 4.4 2.7 2.3 2.9
Republic of Korea 166 54 9 5 9.0 3.5 44 6.2 4.4 4.5 1.6 1.2 5.2 1.7
Romania 126 52 32 15 2.4 4.5 53 0.9x 2.3 2.9 1.9 1.3 2.0 2.3
Russian Federation 126 40 27 15 2.0 3.5 44 – 1.2 2.0 1.9 1.3 0.3 2.0
Rwanda 9 223 195 181 0.7 0.4 7 1.1 1.1 8.2 7.6 5.9 0.4 1.5
Saint Kitts and Nevis 117 – 36 18 – 4.1 50 6.3x 2.8 – – – – –
Saint Lucia 117 66 21 18 5.7 0.9 14 5.3x 1.3 6.1 3.3 2.2 3.0 2.5
Saint Vincent
and the Grenadines 114 72 22 19 5.9 0.9 14 3.3 3 6.0 3.0 2.2 3.5 1.8
Samoa 95 101 50 27 3.5 3.6 46 – 2.6 6.1 4.8 4.0 1.2 1.0
San Marino 173 – 13 4 – 6.9 69 – – – – – – –
Sao Tome and Principe 38 104 101 99 0.1 0.1 2 – – 6.5 5.4 3.9 0.9 1.9
Saudi Arabia 97 185 44 25 7.2 3.3 43 -1.5 0.3 7.3 5.8 3.4 1.1 3.2
Senegal 31 276 149 114 3.1 1.6 23 -0.7 1.1 7.0 6.6 4.7 0.3 1.9
Serbia 151 – – 8 – – – – 2.6x 2.4 2.1 1.8 0.6 1.0
Seychelles 134 59 19 13 5.7 2.2 32 2.9 1.4 – – – – –
Sierra Leone 1 371 290 262 1.2 0.6 10 -0.4 -0.4 6.5 6.5 6.5 0.0 0.0
Singapore 189 27 8 3 6.1 5.8 63 5.6 3.8 3.0 1.8 1.3 2.7 1.9
Slovakia 151 31 15 8 3.6 3.7 47 – 3.3 2.5 2.0 1.2 1.0 2.9
Slovenia 173 29 11 4 4.8 6.0 64 – 3.5 2.3 1.5 1.3 2.0 1.0
Solomon Islands 50 – 121 70 – 3.2 42 3.4 -1.6 6.9 5.9 3.9 0.8 2.4
Somalia 19 – 203 142 – 2.1 30 -0.9 – 7.3 6.8 6.1 0.3 0.6
South Africa 60 113 64 59 2.8 0.5 8 0.1 1 5.6 3.6 2.7 2.2 1.7
Spain 173 25 9 4 5.1 4.8 56 1.9 2.4 2.9 1.3 1.4 3.9 -0.2
Sri Lanka 110 100 32 21 5.7 2.5 34 3 3.9 4.4 2.5 1.9 2.7 1.7
Sudan 34 168 125 109 1.5 0.8 13 0.1 3.6 6.6 6.0 4.3 0.5 1.9
Suriname 91 – 51 29 – 3.3 43 -2.4x 1.8 5.7 2.7 2.4 3.6 0.7
Swaziland 40 199 96 91 3.6 0.3 5 3.1 -0.3 6.9 5.7 3.5 0.9 2.9
Sweden 189 13 7 3 3.1 5.0 57 1.8 2.2 2.0 2.0 1.8 0.1 0.7
Switzerland 166 18 8 5 4.1 2.8 38 1.2 0.7 2.0 1.5 1.4 1.4 0.5
Syrian Arab Republic 123 128 37 17 6.2 4.6 54 2 1.5 7.6 5.5 3.1 1.6 3.4
Tajikistan 54 138 117 67 0.8 3.3 43 – -2.2 6.9 5.2 3.4 1.4 2.5
Thailand 156 103 31 7 6.0 8.8 77 5 2.9 5.5 2.1 1.8 4.8 0.8
The former Yugoslav
Republic of Macedonia 123 119 38 17 5.7 4.7 55 – 0.5 3.2 1.9 1.4 2.4 1.8
Timor-Leste 39 – 184 97 – 3.8 47 – – 6.3 5.3 6.6 0.8 -1.2
Togo 37 219 150 100 1.9 2.4 33 -0.6 -0.2 7.0 6.4 4.9 0.5 1.6
Tonga 104 50 32 23 2.2 1.9 28 – 2 5.9 4.6 3.8 1.3 1.2
Trinidad and Tobago 78 54 34 35 2.3 -0.2 -3 0.5 5.1 3.5 2.4 1.6 1.8 2.4
Tunisia 110 201 52 21 6.8 5.3 60 2.5 3.4 6.6 3.6 1.9 3.0 3.7
Turkey 104 201 82 23 4.5 7.5 72 1.9 2.2 5.5 3.0 2.1 3.0 2.1
Turkmenistan 65 – 99 50 – 4.0 49 – -6.8x 6.3 4.3 2.5 1.9 3.2
…TABLE 10

rank 1970 1990 2007 1970–1990 1990–2007 (%)Θ 1970–1990 1990–2007 1970 1990 2007 1970–1990 1990–2007
Tuvalu 75 – 53 37 – 2.1 30 – – – – – – –
Uganda 21 195 175 130 0.5 1.7 26 – 3.1 7.1 7.1 6.5 0.0 0.5
Ukraine 99 36 25 24 1.8 0.2 4 – -0.7 2.1 1.9 1.2 0.6 2.6
United Arab Emirates 151 84 15 8 8.6 3.7 47 -4.8x -0.3x 6.6 4.4 2.3 2.1 3.8
United Kingdom 160 21 9 6 4.2 2.4 33 2 2.4 2.3 1.8 1.8 1.2 0.0
United Republic of Tanzania 29 217 157 116 1.6 1.8 26 – 1.8 6.8 6.1 5.2 0.5 0.9
United States 151 23 11 8 3.7 1.9 27 2.2 2 2.2 2.0 2.1 0.6 -0.2
Uruguay 132 60 25 14 4.4 3.4 44 0.9 1.5 2.9 2.5 2.1 0.7 1.0
Uzbekistan 68 – 74 41 – 3.5 45 – 1.2 6.5 4.2 2.5 2.2 3.0
Vanuatu 81 155 62 34 4.6 3.5 45 1.1x -0.4 6.3 4.9 3.8 1.2 1.6
Venezuela
(Bolivarian Republic of) 114 62 32 19 3.3 3.1 41 -1.6 -0.2 5.4 3.4 2.6 2.2 1.7
Viet Nam 126 85 56 15 2.1 7.7 73 – 6 7.0 3.7 2.2 3.2 3.2
Yemen 48 309 127 73 4.4 3.3 43 – 1.6 8.6 8.1 5.5 0.3 2.2
Zambia 13 179 163 170 0.5 -0.2 -4 -2.3 0.1 7.4 6.5 5.2 0.7 1.2
Zimbabwe 43 131 95 90 1.6 0.3 5 -0.4 -2.1x 7.4 5.2 3.2 1.8 2.8
SUMMARY INDICATORS
Sub-Saharan Africa 232 186 148 1.1 1.3 20 -0.1 1.3 6.8 6.3 5.2 0.4 1.1
Eastern and Southern Africa 202 165 123 1.0 1.7 25 – 1.4 6.8 6.0 4.9 0.6 1.2
West and Central Africa 260 206 169 1.2 1.2 18 -0.6 1.3 6.8 6.6 5.5 0.1 1.1
Middle East and North Africa 195 79 46 4.5 3.2 42 -0.1 1.6 6.8 5.0 3.0 1.5 3.0
South Asia 197 125 78 2.3 2.8 38 2.1 4.1 5.7 4.3 3.0 1.4 2.2
East Asia and Pacific 121 56 27 3.9 4.3 52 5.7 6.8 5.6 2.5 1.9 4.1 1.6
Latin America and Caribbean 122 55 26 4.0 4.4 53 1.4 1.5 5.3 3.2 2.4 2.5 1.8
CEE/CIS 91 53 25 2.7 4.4 53 – 1.6 2.8 2.3 1.7 0.9 1.9
Industrialized countries§ 24 10 6 4.4 3.0 40 2.3 1.9 2.3 1.7 1.7 1.3 0.2
Developing countries§ 162 103 74 2.3 1.9 28 2.4 4 5.8 3.6 2.8 2.3 1.6
Least developed countries§ 241 179 130 1.5 1.9 27 -0.2 2.5 6.7 5.8 4.7 0.7 1.3
World 143 93 68 2.2 1.8 27 2.3 2.4 4.7 3.2 2.6 1.9 1.3
Under-five mortality rate – Probability of dying between birth and exactly five years of age, Under-five mortality rate – UNICEF, United Nations Population Division and United Nations
expressed per 1,000 live births. Statistics Division.
Reduction since 1990 (%) – Percentage reduction in the under-five mortality rate (U5MR) from GDP per capita – World Bank.
1990 to 2007. The United Nations Millennium Declaration in 2000 established a goal of a two-
thirds (67 per cent) reduction in U5MR from 1990 to 2015. This indicator provides a current Fertility – United Nations Population Division.
assessment of progress towards this goal.
GDP per capita – Gross domestic product (GDP) is the sum of value added by all resident producers
plus any product taxes (less subsidies) not included in the valuation of output. GDP per capita is
gross domestic product divided by midyear population. Growth is calculated from constant price
GDP data in local currency.
Total fertility rate – Number of children who would be born per woman if she lived to the end of
her childbearing years and bore children at each age in accordance with prevailing age-specific
fertility rates.

Θ
A negative value indicates an increase in the under-five mortality rate since 1990.
Acronyms
ACSD Accelerated Child Survival and MICS Multiple Indicator Cluster Surveys
Development
OECD Organisation of Economic Co-operation
AIDS acquired immune deficiency syndrome and Development
EmOC emergency obstetric care PMTCT prevention of mother-to-child transmission

(of HIV)
FGM/C female genital mutilation/cutting
UN SG United Nations Secretary-General
GDP gross domestic product
UNAIDS Joint United Nations Programme
HIV human immunodeficiency virus on HIV/AIDS
HMN Health Metrics Network UNESCO United Nations Educational, Scientific and
Cultural Organization
IMCI Integrated Management of
Childhood Illness UNFPA United Nations Population Fund
IMNCH Integrated Management of UNICEF United Nations Children’s Fund

Newborn and Child Health
WHO World Health Organization
MDG Millennium Development Goal
UNICEF Offices UNICEF The Americas and Caribbean
Regional Office
UNICEF Headquarters Avenida Morse
UNICEF House Ciudad del Saber Clayton
3 United Nations Plaza Edificio #102
New York, NY 10017, USA Apartado 0843-03045
UNICEF Regional Office for Europe Panama City, Panama
Palais des Nations UNICEF East Asia and the Pacific
CH-1211 Geneva 10, Switzerland Regional Office
UNICEF Central and Eastern Europe/ P.O. Box 2-154
Commonwealth of Independent 19 Phra Atit Road
States Regional Office Bangkok 10200, Thailand
Palais des Nations
UNICEF Middle East and North Africa
CH-1211 Geneva 10, Switzerland
Regional Office
UNICEF Eastern and Southern Africa P.O. Box 1551
Regional Office Amman 11821, Jordan
United Nations Complex Gigiri
UNICEF South Asia Regional Office
P.O. Box 44145-00100
P.O. Box 5815
Nairobi, Kenya
Lekhnath Marg
UNICEF West and Central Africa Kathmandu, Nepal
Regional Office
Further information is available at
P.O. Box 29720 Yoff our website <www.unicef.org>.
Dakar, Senegal
United Nations Children’s Fund
3 United Nations Plaza
New York, NY 10017, USA
Email: [email protected]
Website: www.unicef.org
US $25.00 UK £12.10 €16.80

ISBN: 978-92-806-4318-3
Sales no.: E.09.XX.1
© United Nations Children’s Fund (UNICEF)

December 2008

The State of The Worlds Children 2009

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THE STATE OF THE WORLD’S CHILDREN 2009

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EDITORIAL AND RESEARCH PROGRAMME AND POLICY GUIDANCE

Two thirds of all maternal deaths occur in just 10

Acknowledgements ......................................................................ii Adapting maternity services to the cultures of rural Peru........42

1 Maternal and newborn health:

The global food crisis and its potential impact on maternal

2 Creating a supportive environment

Maternal and Newborn Health

5 Working together for maternal and

1 Maternal and newborn health:

required data are not routinely

relation to that pregnancy must be

The trend estimates available for mater- Figure 1.2

Global trends can obscure the wide West/Central Africa

Working together to improve estimations See References, page 107.

Figure 1.3 years and bore children at each age in

Eastern/Southern Africa 790 woman gives birth.

Middle East/North Africa 270

Latin America/Caribbean 180 and maternity services, can have life-

CEE/CIS 63 long implications for women’s sur-

Eastern/Southern Africa 3.4 Neonatal mortality

Latin America/Caribbean 0.4

Middle East/North Africa 34

Least developed countries 41

Neonatal deaths (0–28 days) per 1,000 live births, 2004

Other forms of maternal morbidity

globally are the direct result of three

Africa Asia Latin America/Caribbean

Tetanus (7%) Congenital (7%)

* Percentages may not total 100% because of rounding.

Maternal and neonatal Outcomes

Lack of education, Insufficient Inadequate Insufficient access Poor water/

Quantity and quality of actual

Potential resources: environment, technology, people

Expanding Millennium Development Goal 5: Universal access to

Deaths of children under five, 2007 Maternal deaths, 2005

Source: UNICEF global databases. Source: UNICEF global databases.

Deaths among children Maternal deaths

• Half of the world’s under-five deaths occurred in Africa,

Source: UNICEF global databases. Source: UNICEF global databases.

Nutritional status of young children Primary education

addition, while food aid is being supplied to countries, poli-

Creating a supportive environment for

© UNICEF /HQ05-2185/Giacomo Pirozzi

delivered in integrated packages at Figure 2.1

basic health care, quality maternal, nc

quate nutrition and improved water Adolescence and Post-natal

The key delivery modes for services B

The supportive environment requires

standard of living; protection from

the exploration of the continuum

• Child development and

• Nutrition and growth

• Coughs, colds and more

• HIV and AIDS

Note: * Low degree. Moderate degree. * High degree