Patterns in coverage of maternal, newborn, and child health interventions: projections of neonatal and under-5 mortality to 2035.
BACKGROUND
Urgent calls have been made for improved understanding of changes in coverage of maternal, newborn, and child health interventions, and their country-level determinants. We examined historical trends in coverage of interventions with proven effectiveness, and used them to project rates of child and neonatal mortality in 2035 in 74 Countdown to 2015 priority countries.


METHODS
We investigated coverage of all interventions for which evidence was available to suggest effective reductions in maternal and child mortality, for which indicators have been defined, and data have been obtained through household surveys. We reanalysed coverage data from 312 nationally-representative household surveys done between 1990 and 2011 in 69 countries, including 58 Countdown countries. We developed logistic Loess regression models for patterns of coverage change for each intervention, and used k-means cluster analysis to divide interventions into three groups with different historical patterns of coverage change. Within each intervention group, we examined performance of each country in achieving coverage gains. We constructed models that included baseline coverage, region, gross domestic product, conflict, and governance to examine country-specific annual percentage coverage change for each group of indicators. We used the Lives Saved Tool (LiST) to predict mortality rates of children younger than 5 years (henceforth, under 5) and in the neonatal period in 2035 for Countdown countries if trends in coverage continue unchanged (historical trends scenario) and if each country accelerates intervention coverage to the highest level achieved by a Countdown country with similar baseline coverage level (best performer scenario).


RESULTS
Odds of coverage of three interventions (antimalarial treatment, skilled attendant at birth, and use of improved sanitation facilities) have decreased since 1990, with a mean annual decrease of 5·5% (SD 2·7%). Odds of coverage of four interventions--all related to the prevention of malaria--have increased rapidly, with a mean annual increase of 27·9% (7·3%). Odds of coverage of other interventions have slowly increased, with a mean annual increase of 5·3% (3·5%). Rates of coverage change varied widely across countries; we could not explain the differences by measures of gross domestic product, conflict, or governance. On the basis of LiST projections, we predicted that the number of Countdown countries with an under-5 mortality rate of fewer than 20 deaths per 1000 livebirths per year would increase from four (5%) of the 74 in 2010, to nine (12%) by 2035 under the historical trends scenario, and to 15 (20%) under the best performer scenario. The number of countries with neonatal mortality rates of fewer than 11 per 1000 livebirths per year would increase from three (4%) in 2010, to ten (14%) by 2035 under the historical trends scenario, and 67 (91%) under the best performer scenario. The number of under-5 deaths per year would decrease from an estimated 7·6 million in 2010, to 5·4 million (28% decrease) if historical trends continue, and to 2·3 million (71% decrease) under the best performer scenario.


CONCLUSIONS
Substantial reductions in child deaths are possible, but only if intensified efforts to achieve intervention coverage are implemented successfully within each of the Countdown countries.


BACKGROUND
The Bill & Melinda Gates Foundation.
Institute for International Programs, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205, USA. pneffwalker@yahoo.com
Neff
N
Walker
Gayane
G
Yenokyan
Ingrid K
IK
Friberg
Jennifer
J
Bryce
D000962:Antimalarials / Q000600:supply & distribution / Q000627:therapeutic use; D002648:Child; D002669:Child Welfare / Q000639:trends*; D003695:Delivery of Health Care / Q000706:statistics & numerical data / Q000639:trends*; D003906:Developing Countries / Q000706:statistics & numerical data*; D005260:Female; D005544:Forecasting; D006801:Humans; D007226:Infant Mortality / Q000639:trends*; D007231:Infant, Newborn; D008288:Malaria / Q000401:mortality / Q000517:prevention & control; D008428:Maternal Mortality / Q000639:trends*; D008880:Midwifery / Q000639:trends; D018743:Perinatal Care / Q000639:trends*; D012499:Sanitation / Q000592:standards / Q000639:trends
D000962:Antimalarials