1. Millennium Development Goal 4: reducing perinatal and
neonatal mortality in low-resource settings
Abi C Smith MBChB,a
Wonderful Mutangiri MBChB,b
Robert Fox MD MRCOG,c,
* Joanna F Crofts MD MRCOG
d
a
Academic Clinical Fellow, Department of Women’s Health, Southmead Hospital, Bristol BS9 5NB, UK
b
Obstetric and Gynaecology Trainee, Mpilo Central Hospital, Bulawayo, Zimbabwe
c
Consultant Obstetrician and Gynaecologist, Musgrove Park Hospital, Taunton TA1 5DA, UK
d
NIHR Clinical Lecturer, School of Social and Community Medicine, University of Bristol, Southmead Hospital, Bristol BS10 5NB, UK
*Correspondence: Robert Fox. Email: indigofoxbat@hotmail.com
Accepted on 14 October 2013
Key content
Millennium Development Goal 4 (MDG4) set targets to reduce by
two-thirds the number of deaths of children aged 5 years by 2015
compared with 1990. In 2010, 7.7 million of these children died.
Progress is accelerating but many countries will not meet targets.
Stillbirths account for 2.65 million deaths but are not addressed in
international targets.
Possible solutions including ‘kangaroo mother care’, neonatal
resuscitation and breastfeeding are identified; a difference can be
made with basic training and resources.
Political leadership is required to make significant health gains.
The evidence for improving peri- and neonatal mortality exists.
The challenge is in the implementation.
Learning objectives
To understand MDG4 and the variation in pregnancy outcomes
for neonates globally.
To increase knowledge of simple interventions and key barriers to
improve peri- and neonatal mortality.
To help UK doctors understand the health background of
inward migrants.
Ethical issues
The increasing divide in health outcomes between rich and poor,
both within and between countries.
Gender inequalities may contribute to poor access to care.
Resource limitations are compounded by external factors such as
the ‘brain drain’ of health workers.
Keywords: Millennium Development Goals / neonatal death /
quality improvement / stillbirth
Please cite this paper as: Smith AC, Mutangiri W, Fox R, Crofts JF. Millennium Development Goal 4: reducing perinatal and neonatal mortality in low-resource
settings. The Obstetrician Gynaecologist 2014;16:1–5.
Introduction
The Millennium Declaration set out development aims
that the world would strive to meet by 2015.1
This
included a set of health-related aspirations, known as the
Millennium Development Goals (MDGs). They have focused
the global community’s attention and funding on specific
health-related issues.
MDG4 set out to reduce by two-thirds the death rate of
children aged 5 years (‘under-five mortality rate’—
U5MR), between 1990 and 2015. This article explores the
impact of MDG4 on perinatal and infant death in the
developing world. As this article is targeted towards those
providing maternity care, much of the discussion focuses
on neonatal death: babies who die within the first 28 days
of life. There has been least progress regarding this element
of the U5MR: the proportion of U5MR accounted for in
the neonatal period had risen from 37% in 1990 to 42%
in 2010.2
It is important to note that there is no mention of stillbirth
within the MDGs, and there remains no global target for its
reduction. Every year 2.65 million babies are stillborn, with
98% of all stillbirths occurring in low- and middle-income
countries. It is estimated that 45% of stillbirths occur during
the intrapartum period, a rate much higher than for countries
with advanced healthcare systems.3
A reduction in stillbirths
in low-resource settings is achievable, and many of the
interventions discussed in this article have the potential to
reduce the incidence of stillbirth, as well as of neonatal
mortality. Any progress towards collecting similar data for
stillbirth is hampered by debates around definition of
stillbirth, difficulties of registration of stillbirth, and the issues
of distinguishing between antepartum and intrapartum
deaths. These data challenges compound the lack of
political visibility.4
ª 2013 Royal College of Obstetricians and Gynaecologists 1
DOI: 10.1111/tog.12074
The Obstetrician Gynaecologist
http://onlinetog.org
2014;16:1–5
Review

2. Progress towards Millennium Development
Goal 4 (MDG4)
Between 1990 and 2010 the U5MR fell by just 35%,5
but this
rate of decline is accelerating. In 2010 approximately 7.7
million children died before their fifth birthday.6
Some
regions (such as North Africa) have been successful at
reaching their MDG4 targets, but the U5MR in Sub-Saharan
Africa and Oceania had only fallen by 30% by 2010.5
Almost all regions have seen slower declines in their
neonatal mortality rate than U5MR.5
Annually there are
approximately 2.1 million neonatal deaths.6
One million of
these deaths occur as a consequence of premature birth.2
Although there has been substantial progress towards
MDG4, with 31 countries on target to reach their goals, 23
countries in Sub-Saharan Africa are unlikely to achieve
MDG4 targets before 2040.7
Where countries have progressed
rapidly, the common theme is a governmental commitment
to make the required improvements.8
The model of
improvement of U5MR in Nepal clearly demonstrates this
point, but also provides a useful short case study for potential
cross-sector interventions to improve neonatal health.
Progress towards targets in Nepal
Between 2001 and 2006 the perinatal mortality rate in Nepal
decreased from 47 to 4 per 1000 live births. A sector-wide
approach was introduced in 1991, and was subsequently
developed into a ‘Safe Motherhood and Neonatal Health
long-term Plan for 2006–17’. Nepal’s strategy includes:
comprehensive antenatal care,
training for birth attendants,
increasing attended deliveries through the introduction of
Maternity Incentive Schemes (e.g. provision of money for
transport costs, payment for giving birth within a
healthcare facility) designed to encourage women to
deliver in a health institution,
postnatal care promoting breastfeeding and immunisation,
maternal and perinatal death review reports identifying
preventable factors.9
These measures have increased the attended delivery rate
in Nepal from 7% in 2001 to 31.6% in 2009, and increase the
institutional delivery rate from 9% in 2001 to 19% in 2009.
Interventions to improve perinatal and
neonatal death
The causes of perinatal and neonatal death are multi-factorial
and include social factors. The interventions required to
reduce mortality are, therefore, not all directly related to
healthcare. Improved nutrition, education, sanitation and
access to healthcare are all required8
alongside a political will
to implement multi-sector solutions. This discussion is
limited to interventions directly related to health care.
Key healthcare interventions that reduce intrapartum,
perinatal and neonatal mortality are detailed below. These
interventions perform best as part of a continuum of care in a
functioning, integrated healthcare system. However, some
could be implemented even in fragile states.10
Community mobilisation
Community mobilisation covers interventions ranging from
home visits to facilitation of local women’s groups to advocate
for the local health resources required. Community
mobilisation can strengthen facility-based interventions and
contribute to effective healthcare10
and has been shown to be
cost-effective.11
When at least one-third of pregnant women in
a community participated in such an intervention, neonatal
mortality decreased by up to 33%.11
Skilled attendance at birth
Skilled attendance at birth has the potential to improve
neonatal mortality, especially when coupled with good
referral systems.8,12
An attended, clean delivery with access
to antibiotics is important for the prevention of infection.
Currently 15% of newborn deaths are as a consequence
of infection.8
Neonatal resuscitation is lifesaving. Basic skills can enable
the 5–10% of babies who require assistance with breathing at
birth to survive. The equipment required is of low cost (bag
and mask), but training is crucial.4
All birth attendants
should be trained in neonatal resuscitation as it is not
possible to predict accurately which babies will need
intervention.4
Training is simple and feasible.10
A
meta-analysis of training for traditional birth attendants
demonstrated that neonatal training packages can reduce
perinatal and neonatal mortality with a relative risk reduction
in both the randomised and non-randomised trials of
24–30% and 21–39% respectively.12
Administration of corticosteroids in prematurity
Corticosteroids for promotion of lung maturation in
preterm births to reduce respiratory distress syndrome is
supported by high-quality evidence.13
This intervention is
low cost (for example, a corticosteroid course in India costs
just US$0.51), and could save 340 000 newborn lives
annually.8
If preterm labour is identified in a timely
fashion, the administration of corticosteroids is relatively
simple and moderately effective.
Kangaroo care of the newborn
Kangaroo mother care (KMC) for preterm babies (weighing
2000 g) comprises three components: (i) thermal care; (ii)
exclusive breastfeeding; and (iii) early recognition/response
to illness.14
In premature babies who are stable, KMC is more
2 ª 2013 Royal College of Obstetricians and Gynaecologists
Millennium Development Goal 4

3. effective than nursing in an incubator.8
A meta-analysis of
randomised controlled trials of KMC starting in the first
week of life demonstrated a reduction in mortality of 50%,
together with a reduction in serious morbidity of 60%.14
KMC is low cost and easy to implement.
Promotion of breastfeeding
Exclusive breastfeeding can prevent sepsis (gastrointestinal
diseases and respiratory infection) and offers the opportunity
to gain immunity and prevent hypoglycaemia.15
In most
regions, fewer than half of newborns are breastfed within
an hour of birth.8
Furthermore, exclusive breastfeed-
ing contributes to birth spacing through prolonged
lactational amenorrhea.16
Birth spacing
Birth spacing improves pregnancy outcomes. Preterm birth
and low birthweight are associated with either short
(18 months) or long (59 months) intervals between
pregnancies. Enabling women to optimally space their
children can reduce poor perinatal outcomes.17
Education
and access to family planning methods is crucial,8
and can
reduce up to 40% of unplanned pregnancies.
Immunisation programme
Immunisation is effective at reducing mortality. For example,
offering two doses of an antenatal tetanus vaccine costs
approximately US$0.40 and could prevent the death of
58 000 newborns annually.8
Postnatally childhood morbidity
and mortality has been reduced with the implementation of a
vaccine schedule including measles and haemophilius
influenza vaccination.15
Malaria reduction
Malaria is a risk factor for low birthweight and contributes to
approximately 100 000 deaths annually.18
There are
cost-effective proven interventions to prevent malarial
infection, which include intermittent preventive treatment
(IPT), antimalarial prophylaxis and insecticide-treated
bed-nets. These measures could reduce perinatal mortality
due to malaria by 27% in affected areas.18
Emergency obstetric care
Access to emergency obstetric care is necessary.10
Whereas
many interventions can be carried out in the community
there still needs to be a strong link to facility-based care.11
Caesarean section is indicated in 5–15% of births and could
go some way to preventing the 30% of intrapartum
stillbirths.4
Moreover, if a mother dies as a result of
childbirth, the risk of her children dying before they reach
the age of 5 years more than doubles.8,19
Improving
antenatal, intrapartum and postnatal care is vital for the
health of the mother, baby and wider family.
Continuum of care
The continuum of care is crucial; effective care for mothers
must have a pregnancy-course approach. Antenatal care must
run seamlessly into intrapartum and postnatal care. Postnatal
care should facilitate the integration of community and
outreach interventions with facility-based care where
necessary.20
It can enable promotion of healthy practices
such as breastfeeding, nutrition and immunisation while
facilitating the early identification of illnesses and access to
curative care.10,20
Barriers to the implementation of evidence
into practice
Much of the evidence on mortality reduction has now existed
for well over a decade but implementation is patchy; the
challenge remains how to implement evidence into practice
consistently. The overarching barrier to achieving MDG4 is
that of political will. If the government of a country does not
commit to improving perinatal and neonatal mortality, then
very few gains will be made. Some of the other main barriers
to success include paucity of health workers and training,
cultural issues, and inability to access services. These are
discussed below.
Lack of healthcare workers
Lack of healthcare workers to deliver services leads to
increased challenges.19
Skilled care at birth can decrease
intrapartum death and birth asphyxia, but worldwide there
remains a shortage of 5 million health workers with 350 000
more midwives required alone.8
A lack of update training of
existing health workers further compounds this problem; it is
estimated that 50% of health workers in low-resource settings
have not received enough training to be able to adequately
perform basic neonatal resuscitation.4
Various methods have
been considered to combat this problem. Many countries are
moving to develop a new cadre of health professionals with
shorter training who are now undertaking roles which were
previously only performed by qualified staff. There have been
successful examples of this in Mozambique and the
Democratic Republic of Congo.
Existing cultural practices
Existing cultural practices can contribute to poor neonatal
outcomes. For example, in rural India women give birth on
to a dirt floor and breastfeeding is discouraged for several
days. In Bangladesh and Ethiopia the mother and baby may
be isolated to fend off evil spirits.8,21
Other traditional
practices, such as not feeding the baby colostrum, are
prevalent.21
There may also be erroneous perceptions of
some interventions being inferior despite evidence to the
contrary; kangaroo care being viewed as a poor man’s
alternative to an incubator, or breastfeeding less good than
ª 2013 Royal College of Obstetricians and Gynaecologists 3
Smith et al.

4. the more modern formula feeding.4
Furthermore, issues of
gender roles can lead to men hindering access to care,
resulting in critical delays in receiving treatment.8,19
Access to services
Access to services is central to improving perinatal health. In
addition to the gender disparity, financial, geographical and
poor quality services affect the ability of women to access
healthcare services. The most obvious financial barrier is the
requirement to pay user fees (direct payment made by the
patient’s family for the care required); however, the cost
implications of seeking care are much broader.19
These include
time off work and costs of transport and accommodation.19
All of these factors can make the out-of-pocket costs
catastrophic for families. Solutions are being sought,
including investigation of conditional cash transfers to
improve care-seeking,9
and the abolition of user fees.19
Geographical variations are numerous, with a rural/urban
divide in access to care, with health facilities being
concentrated in urban, easy-to-reach areas. This is
compounded by poor infrastructure making it difficult for
the rural population to reach the health facility.19
Quality of services
The quality of services patients receive at a healthcare facility
affects health-seeking behaviour. Fewer women access
poor-quality services.4
Multiple problems can be responsible
for lack of quality of care, including absenteeism of staff and
lack of good management, training and equipment.4,21
Addressing health inequities
The MDGs were designed to address inequalities between
countries. We are quickly approaching their end, but
Sub-Saharan Africa and South Asia still continue to bear the
majority of the burden of disease. Sub-Saharan Africa has just
11% of the world’s population, but accounts for nearly half of
all newborn and child deaths.10
Eighty per cent of the babies
who die in their first day of life, live and die in Sub-Saharan
Africa and South Asia,8
illustrating the inequalities that have
continued despite the MDGs. Each country’s target does not
demand equity of services within the country. This has often
led to improvement in outcomes for those parts of the
population that are easy to reach, and with no improvement or
even worsening outcomes in the harder-to-reach populations.8
There are many examples of health inequity. Babies born
to the poorest fifth of the population are 40% more likely to
die than those born to the richest fifth.8
Estimates from low-
and middle-income countries suggest a caesarean section rate
of approximately 12%; however, in 42 countries the
caesarean section rate is only 1% for the poorest fifth of
the population,4
and in Sub-Saharan Africa the coverage for
skilled birth attendance is five-times lower for the least poor
compared with most of the poor.10
Sophisticated solutions
are still required to ensure that the needs of the poorest, most
vulnerable members of society are not simply overlooked.
It is beyond the scope of this article to address many of the
important non-health sector interventions that could lead to
improved neonatal outcomes. Female education can lead to
later marriage and childbearing and it decreases chances of
dying in childbirth, in turn reducing child mortality.8,19
Poverty is associated with poor housing, undernutrition and
poor sanitation, which all impact on the ability of families to
make healthy choices.19
Addressing these issues concurrently
could result in significant health gains.
Conclusion
MDG4 has served to highlight the issue of child health
globally, and, despite a slow start, progress towards achieving
the goal has recently accelerated. Much evidence for effective,
affordable interventions that prevent neonatal and childhood
deaths already exists. The task now is to ensure that these are
implemented consistently and evenly, within and between
countries. It remains a role of individual countries to identify
and address local priorities, supported by the wider global
community. Looking beyond 2015, the development agenda
is unclear. However, the energy created through the MDGs
would be wasted if momentum for reducing neonatal deaths
were not maintained. Obstetricians have a vital role in
advocating for improvements in reproductive health—
improvements that can save the lives of mothers, their
babies and their children.
Acknowledgements
North Bristol NHS Trust and Mpilo Central Hospital are
Health Partners. The Health Partnership Scheme is funded by
the UK Department for International Development (DFID)
and managed by the Tropical Health Education
Trust (THET).
Disclosure of interests
Dr Joanna Crofts is a member of the PROMPT Maternity
Foundation, a Registered Charity that enables maternity units
to run their own multi-professional obstetric emergencies
training. AS, WM and RF have no interests to disclose.
References
1 United Nations. United Nations Millennium Declaration; 18 September
2000. p. 1–9.
2 Lawn JE, Gravett MG, Nunes TM, Rubens CE, Stanton C. GAPPS Review
Group. Global report on preterm birth and stillbirth (1 of 7): definitions,
description of the burden and opportunities to improve data. BMC
Pregnancy Childbirth 2010;10(Suppl 1):S1.
3 Lawn JE, Blencowe H, Pattinson R, Cousens S, Kumar R, Ibiebele I, et al.
Stillbirths: Where? When? Why? How to make the data count? Lancet
2011;377:1448–63.
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5. 4 Victora CG, Rubens CE. Global report on preterm birth and stillbirth
(4 of 7): delivery of interventions. BMC Pregn Childbirth 2010;
10(Suppl 1):S4.
5 United Nations. The Millennium Development Goals Report; June 2012. p.
1–72.
6 Rajaratnam JK, Marcus JR, Flaxman AD, Wang H, Levin-Rector A, Dwyer L,
et al. Neonatal, postneonatal, childhood, and under-5 mortality for 187
countries, 1970–2010: a systematic analysis of progress towards
Millennium Development Goal 4. Lancet 2010;375:1988–2008.
7 Lozano R, Wang H, Foreman KJ, Rajaratnam JK, Naghavi M, Marcus JR, et
al. Progress towards Millennium Development Goals 4 and 5 on maternal
and child mortality: an updated systematic analysis. Lancet
2011;378:1139–65.
8 Save the Children. Surviving the First Day. London: Save The Children; 2013.
p. 1–88.
9 Malla DS, Giri K, Karki C, Chaudhary P. Achieving Millennium Development
Goals 4 and 5 in Nepal. BJOG 2011;
118:60–8.
10 Friberg IK, Kinney MV, Lawn JE, Kerber KJ, Odubanjo MO, Bergh A-M, et al.
Sub-Saharan Africa’s mothers, newborns, and children: how many lives
could be saved with targeted health interventions? PLoS Med 2010;7:
e1000295.
11 Prost A, Colbourn T, Seward N, Azad K, Coomarasamy A, Copas A, et al.
Women’s groups practising participatory learning and action to improve
maternal and newborn health in low-resource settings: a systematic review
and meta-analysis. Lancet 2013;381:1736–46.
12 Wilson A, Gallos ID, Plana N, Lissauer D, Khan KS, Zamora J, et al.
Effectiveness of strategies incorporating training and support of traditional
birth attendants on perinatal and maternal mortality: meta-analysis. BMJ
2011;343:d7102–2.
13 Roberts D, Dalziel SR. Antenatal corticosteroids for accelerating fetal lung
maturation for women at risk of preterm birth. Cochrane Database Syst Rev
2006;(3):CD004454.
14 Lawn JE, Mwansa-Kambafwile J, Horta BL, Barros FC, Cousens S. “Kangaroo
mother care” to prevent neonatal deaths due to preterm birth
complications. Int J Epidemiol 2010;39(Suppl 1):i144–54.
15 Jones G, Steketee RW, Black RE, Bhutta ZA, Morris SS. Bellagio Child Survival
Study Group. How many child deaths can we prevent this year? Lancet
2003;362:65–71.
16 Kramer MS, Kakuma R. Optimal duration of exclusive breastfeeding.
Cochrane Database Syst Rev 2012;(8):CD003517.
17 Conde-Agudelo A, Rosas-Bermudez A, Kafury-Goeta AC. Birth spacing and
risk of adverse perinatal outcomes. JAMA 2006;295:1809–23.
18 Desai M, ter Kuile FO, Nosten F, McGready R, Asamoa K, Brabin B, et al.
Epidemiology and burden of malaria in pregnancy. Lancet Infect Dis
2007;7:93–104.
19 Kinney MV, Kerber KJ, Black RE, Cohen B, Nkrumah F, Coovadia H, et al.
Sub-Saharan Africa’s mothers, newborns, and children: where and why do
they die? PLoS Med 2010;7:e1000294.
20 Kerber KJ, de Graft-Johnson JE, Bhutta ZA, Okong P, Starrs A, Lawn JE.
Continuum of care for maternal, newborn, and child health: from slogan to
service delivery. Lancet 2007;370:1358–69.
21 Sayem AM, Nury ATMS, Hossain MD. Achieving the millennium
development goal for under-five mortality in Bangladesh: current status and
lessons for issues and challenges for further improvements. J Health Popul
Nutr 2011;29:92–102.
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Smith et al.