Sustaining Maternal and Child Health in the Sustainable Development Agenda
The health and well-being of women and children are not only fundamental human rights, but are crucial for economic development, peace and stability. Goals and targets established by the United Nations are important in shaping the national strategies of partner countries and serve to increase consistency across domestic policies and programmes. The United Nations announced the Agenda for Sustainable Development in late 2015, described as “a plan of action for people, planet and prosperity”.  The Sustainable Development Goals (SDGs) were established to build on the Millennium Development Goals (MDGs) and to complete what was not achieved by 2015.  Although significant achievements were made on many of the MDG targets worldwide, several targets were not met by most countries by 2015, and progress has been uneven across regions.  Two of the eight MDGs focused on maternal, neonatal and child health (MNCH), placing it at the heart of the Millennium Declaration’s blueprint for development. In contrast, there are 169 targets associated with 17 SDGs, one of which directly addresses health, aiming to “ensure healthy lives and promote well-being for all at all ages”.  Within this goal (SDG3), maternal health occupies one target (3.1) and neonatal and under-five mortality is addressed in target 3.2. 
In order to make MNCH a global action priority, the importance of maternal and child health must be emphasised, and goals and targets should be feasible and quantifiable.
The lower profile of MNCH in the SDGs could result in less attention from political powers, and potentially lower prioritisation in the wider context of other development issues. The central nature of child and maternal health in the Millennium Declaration reflected the global consensus at the time that the health of mothers and children were key indicators of a nation’s progress. Rather than a sector-specific concern, health was identified by the Millennium Declaration as essential for economic growth and development. The establishment of initiatives, including the Partnership for Maternal, Newborn, and Child Health (PMNCH), the Countdown to 2015 Initiative, and the UN Secretary-General’s Global Strategy for Women’s and Children’s Health, demonstrated the heightened global attention to maternal and child health. [3-5] Although many countries did not achieve MDGs 4 and 5, progress in maternal and child health accelerated during the last five years of the Millennium Declaration era . This suggests that further gains are possible if intensive efforts are sustained, keeping MNCH in a dominant role in the development agenda.
By contrast, maternal and child health does not occupy a central role in the SDGs, with only one health-focused goal incorporating both maternal and child health. Additionally, there is no reference to adolescent pregnancy in the SDGs. More than 15 million of the estimated 135 million live births worldwide are to girls aged between 15 and 19, who are at greater risk of complications. Pregnant adolescents are also more likely than adults to have unsafe abortions.  This is an area that must be emphasised in the SDGs indicators, as it is both important to MNCH, and reflective of the wider socioeconomic marginalisation of girls.
The SDGs are markedly broader than the MDGs, with a number of aspirational or diffuse targets. Two of the three specific maternal and child health targets within the MDGs were readily quantifiable, and eight of the nine indicators were measurable. Annual reporting of statistics kept maternal and child health at the forefront of the political agenda, and increased emphasis on high quality data supported accountability.  The lack of specific indicators at this point in time makes assessment of the SDGs difficult, particularly given the ambitious and vague nature of the goals. Once specific indicators have been set for each SDG target, the role of monitoring and reporting will become clearer. A robust data system to measure the coverage of evidence-based interventions for reducing maternal, newborn, and child mortality is needed to enhance services, improve health, and monitor achievement of long-term goals. One strategy for improving accountability and action surrounding the SDGs is refinement of the goals and targets. Norheim et al suggest adapting the health-related SDG to be quantitative.  They propose that SDG3 read: “to avoid, in each country, 40% of premature deaths (i.e., deaths under age 70 years that would be seen in the 2030 population at 2010 death rates) and improve health care at all ages”.  Reinforcing this are four global sub-targets for 2030, including “avoid two-thirds of child and maternal deaths”.  These targets provide quantifiable benchmarks against which progress could be measured across different geographical regions.
The SDGs have adopted a global picture for MNCH, with a shift from percentage-reduction targets in the MDGs to absolute thresholds. However, there are marked inequalities in health between high, low and middle-income countries, to which the SDGs draw greater focus. For example, the maternal mortality ratio in developing regions is 14 times higher than in developed regions.  In 2013, nearly 800 women died every day from maternal causes, 99% occurring in developing countries.  Achieving a maternal mortality ratio of 70 per 100,000 live births is achievable, if not already guaranteed, for most developed regions. However, this target is highly ambitious in other low-resource settings. The majority of maternal deaths are a result of preventable causes, for which necessary medical interventions exist and are widely accessible in developed countries.  Aiming for relative reductions in key outcomes is beneficial to partnerships between high and low-income countries, particularly where the main obstacles to achieving better health are national health systems and policies. If MNCH is not on the agenda for high income regions, it is likely that this will this result in worse outcomes for low- and middle-income countries with reduced MNCH programmes and technology flowing from high to low- and middle-income countries. In order to achieve equitable improvements in MNCH globally, all stakeholders need to be equally invested in achieving the outcomes. Equally, it is essential to tailor specific targets and interventions to regions that have made slower progress in MNCH, such as sub-Saharan Africa, in order for goals to be achievable and ensure additional resources are targeted to areas. [8,9]
In order to sustain the progress in MNCH seen during recent years, there must be continued focus and prioritisation of this area. Gaps and inequalities seen in provision of care and services during the Millennium Development era must be addressed by strengthening health systems and supporting evidence-based initiatives. The Agenda for Sustainable Development does not present child and maternal health as a priority. There is currently a lack of central targets and no concrete framework with which to measure progress in the area of child and maternal health. While the approach of the SDGs to consider health as an integrated part of social development may benefit some areas of health, it may overlook others. The lack of focus on MNCH in the SDGs could jeopardise the progress achieved in the Millennium Development area while also impacting upon further potential progress. In order to make substantial gains, it is essential to create a coherent vision for MNCH as a key component of development. This will require political leadership and community engagement and mobilisation for effective, evidence-based interventions. Consistent funding, effort and attention are necessary in order to sustain MNCH as a health priority in the global vision of development for 2030.
Dr Katharine Noonan, MBBS (Hons) is currently studying for her MSc in Global Health Science at Oxford University.
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