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. 2025 Jun 27;29(8):1047–1060. doi: 10.1007/s10995-025-04121-7

Global Maternal Child Health Initiatives and Programs 1974 to 2023

Debra Jackson 1,2,✉
PMCID: PMC12443888  PMID: 40579684

Abstract

Aim

This review paper aims to review Global MCH initiatives and note trends across the last five decades (1974–2023).

Methods

As an organizing framework, MCH initiatives and programs have been classified into five categories: Global Health Conferences, Declarations or Strategies; Global Health Surveys; Global MCH Programs; Global MCH related Data Initiatives or Working/Advisory Groups; and Global MCH Partnerships or Networks.

Results

Over 50 Global MCH initiatives and programs have been implemented during this period. The first International Conference on Primary Health Care and the Alma Ata Declaration in 1978 initiated a new era of global public health. International conferences building on Alma Ata with a focus on population health and MCH, along with global surveys to measure the health status of populations across countries and global working groups to analyze these data, emerged over the next decades. Global MCH partnerships also emerged for advocacy and coordination of an increasing number of efforts to improve maternal, newborn, child and adolescent health and well-being—towards achieving the Millennium (2000–2015) and Sustainable (2016–2030) Development Goals.

Conclusion

Four trends were noted across these five decades: (1) MCH Mortality decreased but unacceptable inequities persist with COVID-19, ongoing conflicts and climate change threatening these gains. (2) Implementation of primary health care (PHC) as envisioned by Alma Ata in 1974 continues to see a debate about selective versus comprehensive programs. (3) As mortality declined (Survive), the field expanded focus to child well-being (Thrive) and across preconception through adolescents (Transform). (4) Global MCH issues are relevant across high-income (HIC) and low-middle income (LMIC) settings to achieve health and well-being of all women and children everywhere.

Keywords: Global Maternal and Child Health (MCH); Maternal, Newborn, Child, Primary Health Care (PHC); Millennium Development Goals (MDG); Sustainable Development Goals (SDG)

Significance

“Historical research is of central relevance to an understanding of public health in the present. Current developments cannot be understood without a knowledge of the past.”

(https://www.lshtm.ac.uk/research/centres/centre-history-public-health/about)

This paper aims to review maternal and child health (MCH) initiatives and programs and note trends across the last five decades of Global MCH. During the last 50 years Maternal and Child mortality has decreased substantially. However, unacceptable inequities, both across and within both high-income and low- and middle-income countries remain. As mortality declined (Survive) the field has expanded its focus to morbidity and child development (Thrive) and across the MCH lifespan from preconception through adolescents (Transform). This expanded focus and on-going disparities suggest substantial unfinished agendas across global maternal and child health. Programs need to address primary health care and the social determinants of health if we are to see further improvements in the health of women and children.

Introduction

Until the latter half of the twentieth century maternal and child health (MCH) was seen primarily a U.S. domestic issue (Rosenfeld & Min, 2009). In the 1960-1970s global overseas development assistance shifted from building colonial infrastructure and post WWII rebuilding to addressing global poverty (Phillips, 2013; Rosenfeld & Min, 2009). From the 1960s, three trends emerged ushering a new era of global health and development: (1) higher-income countries developed bilateral aid agencies to address poverty and further their own country agendas (e.g., USAID 1960s and UK DFID in 1970s); (2) multi-lateral organizations began to address ‘basic needs’ (e.g. World Bank in 1968); and (3) followed by global philanthropies support (e.g. Ford and Rockefeller Foundations) in the 1970s (Phillips, 2013). In this context, health, including MCH, was seen as a key issue in global development and poverty alleviation. Initiatives in 1974, such as the first World Population Conference & World Population Plan of Action (WPPA) and the WHO initiation of the Expanded Programme of Immunization (Rosenfeld & Min, 2009), began the emergence of a focus on Global MCH. These were followed by the seminal first International Conference on Primary Health Care and the Alma Ata Declaration in 1978, which aimed to address health as a human right with a focus on public health and primary health care in contrast to medicalized biomedical health systems (Rifkin, 2018).

Since the 1978 International Conference on Primary Health Care and the Alma Ata Declaration, there have been many global initiatives and programs to address global maternal, newborn and child health. They have ranged from Global Networks, Alliances and Action Plans to interventions or disease specific programs promoted by multi-lateral organizations like the World Health Organization (WHO), United Nations Children’s Fund (UNICEF) and the United Nations Family Planning Association (UNFPA); have been developed to guide government national health plans. Over 50 such initiatives and programs have been implemented in the past 50 years.

This paper aims to (a) review these MCH initiatives and (b) note trends across the last 5 decades of Global MCH. The following trends were noted over the last 50 years, which will be highlighted throughout this review:

  1. MCH Mortality has decreased substantially, but unacceptable inequities both across and within countries remain; and recent threats like COVID-19, ongoing conflicts and climate change (the 3 C’s) threaten these gains.

  2. The implementation of primary health care (PHC) services continues to see a debate about selective versus comprehensive programs.

  3. As mortality declined (Survive), the field expanded to focus morbidity and child development (Thrive) and an expanded focus from under-5-year-olds to across the MCH lifespan from preconception through adolescents (Transform).

  4. The distinction of high-income/high resource (HIC) versus low-middle income/low resource (LMIC) settings has blurred. There is now an expanded focus based on the Sustainable Development Goals (SDGs) to cover all countries and the promotion of multi-directional learning across countries, not just HIC to LMIC.

Maternal, Newborn and Child Mortality Trends in the Last 50 Years

Throughout history, infant (birth to 1 year of age) and child (under five years) mortality have been considered markers for a country’s health status and development; as reductions in these mortality rates often paralleled improvements in economic and social development. Therefore, MCH initiatives over the past 50 years have heavily focused on reducing MCH mortality rates.

Child, Infant and Neonatal Mortality

In the first World Fertility Survey implemented in 1974 and conducted in 40 countries, under-five mortality measured as per 1000 live births, ranged from 36.6 in Portugal to 262.4 in Senegal, while infant mortality ranged from 32.8 in Panama to 161.5 in Yemen. In addition, neonatal mortality (birth to 28 days of age) ranged from 13.9 in Malaysia to 79.9 in Pakistan (Chidambaram et al., 1985). The latest UN estimates for newborn, infant and child mortality were released in 2023. The global under-five mortality rate was 38 in 2021, which had declined by 59 per cent, from 93 deaths per 1000 live births in 1990 (Fig. 1). With a range of 1.7 in San Marino to 115.2 in Niger (UNICEF, 2023b). Similar reductions are seen for neonatal and infant mortality, also with the noted disparities in mortality rates across countries and regions (Fig. 1).

Fig. 1.

Fig. 1

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UN Inter-agency Group for Child Mortality Estimation (IGME) Newborn and Child Mortality 1990–2021 by SDG Region (UNICEF, 2023a, 2023b, 2023c)

Maternal Mortality

Maternal mortality received substantial attention starting the 1980s (Rosenfeld & Maine, 1985). The global MMR in 2020 was estimated at 223 maternal deaths per 100 000 live births down from 339 in 2000, representing a 34.3% reduction over the 20-year period. Again, wide disparities are seen across countries with 1223 in South Sudan to 1 in Belarus a thousand-fold difference (WHO, 2023).

Stillbirth

In addition to the 2.3 million newborn deaths annually, there are also approximately 1.9 million stillbirths (death of the fetus before birth beyond 28 weeks gestation) (UNICEF, 2023b, 2023c). These deaths in the last 20 years have received increased attention. Recent estimates suggest a global stillbirth rate of 13.9 stillbirths per 1000 total births, again with wide disparities across regions and countries (UNICEF, 2023c).

Timeline of Global MCH and Related Initiatives and Programs 1974–2023

Tables 1, 2, 3 provide a timeline of the evolution of initiatives and programs in the field of global maternal and child health (MCH) over the past 50 years (1970–1989; 1990–2009; 2010–2023). Inspired by the work of Moller et al. (2019), the author scanned initiatives and programs across these periods and developed the following investigator-derived categories for this review: (1) Global Health Conferences, Declarations or Plans relevant to MCH; (2) Global MCH related Surveys; (3) Global MCH Programs; (4) Global MCH related Data Initiatives or Working/Advisory Groups; or (5) Global MCH Partnerships or Networks. ‘Global’ initiatives included in this review are defined as having one or more stakeholders, e.g., multilaterals (WHO, UNICEF, UNFPA), academic institutions, non-governmental organizations and governments. The review does not include: (a) single entity initiatives, such as Saving Newborn Lives (SNL, Save the Children) or Averting Maternal Death and Disability (AMDD, Columbia University); or (b) guidelines and MCH programs not from or endorsed by a UN agency.

Table 1.

Global Maternal and Child Health Initiatives 1974–1989

1974–1989
Global Health Conferences, Declarations or Strategies Global Health Surveys Global MCH Programs Global MCH-related Data Initiatives or Working/Advisory Groups Global MCH Partnerships or Networks
World Population Conference & World Population Plan of Action (WPPA) (1974) 1st World Fertility Survey (WFS) (1974) WHO Expanded Programme of Immunization (1974)
International Conference on Primary Health Care & Alma Ata Declaration (1978) 1st Demographic & Health Survey (DHS) (1984) GOBI-FFF Initiative (1983)
International Conference on Population Mexico City (1984) Safe Motherhood Initiative (1987)
Safe Motherhood Conference (1987) Water, Sanitation & Hygiene (WASH) (1988)
UN Convention on the Rights of the Child (1989)
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Table 2.

Global Maternal and Child Health Initiatives 1990–2009

1990–2009
Global Health Conferences, Declarations or Strategies Global Health Surveys Global MCH Programs Global MCH-related Data Initiatives or Working/Advisory Groups Global MCH Partnerships or Networks
World Summit for Children & World Declaration on Survival, Protection and Development of Children (1990) Final Reproductive Health Survey (1992) Guidelines for monitoring the availability and use of obstetric services (EmOC) (1997) Child Health Epidemiology Reference Group CHERG (now Maternal Child Epidemiology Estimation Group (MCEEG) (2001) Emergency Nutrition Network (ENN) (1996)
International Conference on Population and Development (ICPD) & Program of Action (1994) 1st Multiple Indicator Survey (MICS) (1995) Integrated Management of Childhood Illness (IMCI) (1997) Countdown to 2015 (2003) Roll Back Malaria (RBM) Partnership to End Malaria (1998)
4th World Conference on Women (1995) Initiation of Emergency Obstetric Care (EmOC) Surveys (now EmONC) (1997) Integrated Management of Newborn and Child Illness (IMNCI) (1999) UN Interagency Group for Child Mortality Estimation (UN-IGME) (2004) The Vaccine Alliance (GAVI) (2000)
Millenium Summit & UN Millenium Declaration (2000) 1st Health Facility Assessment DHS Service Provision Assessment Survey (SPA) (1999) WHO Prevention of Mother to Child Transmission of HIV Program Guidelines (PMTCT) (2000) Newborn Indicators Technical Working Group (2008) UN Millenium Project & Millenium Campaign (2002)
World Health Assembly Resolution: Working towards universal coverage of Maternal and Child Health Interventions (2005) DHS, MICS & EmONC (Cont'd)

WHO/UNICEF Joint statement on Management Of Pneumonia

In Community Settings (2004)

 The Global Fund to Fight HIV, TB and Malaria (Global Fund) (2002)
Women Deliver 1st Global Conference (2007) SPA (Cont'd)—Also SARA (WHO) & SDI (WB) Community Integrated Management of Newborn and Child Illness (IMNCI)/Integrated Community Case Management (iCCM) (2006) Partnership for Maternal Newborn and Child Health (PMNCH) (2005)
International Health Partnership (IHP/IHP +) (2007)
Maternal Health Task Force (MHTF) (2008)
H4 (now H6) Partnership for women's, children's and adolescents' health (2008)
African Leaders Malaria Alliance (ALMA) (2009)
Global Action Plan for Pneumonia and Diarrhea (GAPPD) (2009)
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Table 3.

Global Maternal and Child Health Initiatives 2010–2023

2010–2023
Global Health Conferences, Declarations or Strategies Global Health Surveys Global MCH Programs Global MCH-related Data Initiatives or Working/Advisory Groups Global MCH Partnerships or Networks
Global Strategy for Women's & Children’s Health & Every Woman Every Child (2010) DHS, MICS & EmONC (Cont'd) Helping Babies Breathe (2012) UN Maternal Mortality Interagency Estimation Group (UN-MMIEG) (2010) Every Newborn Action Plan (ENAP) (2014)
World Health Assembly Resolution: Every Newborn Action Plan (2014) SPA, SARA & SDI (Cont’d) Essential Care for Every Newborn (ENC) (2015) Commission for Information and Accountability for Women's and Children's Health (CoIA) (2012) Ending Preventable Maternal Mortality (EPMM) (2015)
The 2030 Agenda for Sustainable Development & the Sustainable Development Goals (SDGs) (2015) Nurturing Care Framework (2018) Maternal Mortality Working Group (MMWG) (2012) The Global Financing Facility for Women, Children and Adolescents (GFF) (2015)
Global Strategy for Women's Children's and Adolescent's Health (GSWCAH) (2015) Child Health Redesign (2019) Every Newborn Metrics Group (2014) Health Data Collaborative (2016)
Global Maternal and Newborn Health Conference (2015) COVID-19 Global Pandemic Response (2020–2021) Mother and Newborn Information and Tracking Outcomes and Results (MoNITOR) Technical Working Group (2015) Quality of Care Network (2017)
Global Conference on Primary Health Care & Astana Declaration (2018) Primary Health Care Performance Initiative (PHCPI) (2015) Global Accelerated Action for the Health of Adolescents (AA-HA!) (2017)
Global Forum on Childhood Pneumonia (2020) Countdown to 2030 (2016) Child Health Task Force (CHTF) (2018)
Protect the Promise (GSWCAH) Report and Action Plan (2022) Indicator and Monitoring Framework for the GSWCAH (2016) Universal Health Care 2030 (2019)
1st WHO Health Pavilion at UN Climate Change Conference (COP27) (2022) Child Health Accountability and Tracking (CHAT) & Global Adolescent Measurement and Accountability (GAMA) Technical Advisory Groups (2018) Global Action Plan for Health and Wellbeing for All (SDG3 GAP) (2019)
International Maternal and Newborn Health Conference (IMNCH) (2023) UN-IGME Releases 1st Global Stillbirth Estimates (2020) Global Action Plan for Child Wasting (2020)
Zero Dose Children Immunization Initiative (2020)
AlignMNH (2020)
ENAP & EPMM Combine to Every Woman, Every Newborn, Everywhere (EWENE) (2023)
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1970s & 1980s: Alma Ata to Safe Motherhood

Primary Health Care (PHC), Alma Ata and emerging MCH

As noted in the introduction, an emerging focus on population/family planning and primary health care began in the 1970s. The period was headlined by the first International Conference on Primary Health Care and the Alma Ata Declaration on comprehensive primary health care and the slogan “Health for All by the Year 2000” in 1978 (Cueto, 2004). The first global programs focusing on children were initiated in 1974; i.e., the WHO Expanded Program of Immunization (EPI). Building on the Alma Ata Declaration and EPI, the 1980’s additionally increased global focus on PHC for specific populations, such as women and children, with a particular focus on survival (i.e., mortality reduction).

Global MCH Programs: Growth monitoring, Oral rehydration, Breastfeeding, and Immunization—Female education, Food supplementation, and Family planning (GOBI-FFF)

James Grant became the Director of UNICEF in 1980 and by 1983 UNICEF recommended four interventions to reduce child mortality: growth monitoring, oral rehydration, breastfeeding, and immunization (GOBI), which later included three additional recommendations related to women/female education, family spacing and food supplements (FFF) (Rehydrate Project, 2014). However, GOBI-FFF was viewed by some global health experts as a narrow vertical program which did not address the social determinants of health. This controversy pitted ‘comprehensive’ PHC as envisioned by Alma Ata versus ‘selective’ PHC as promoted by programs such as GOBI-FFF. Proponents noted it as complementary to Alma Ata, which they felt was too broad for practical implementation; while opponents noted it as not consistent with the original declaration, which focused beyond just health care to broader determinants of health (Cueto, 2004; Werner et al., 1997). To some extent this debate continues till today in the form of vertical versus integrated programming and Universal Health Care versus Primary Health Care (Sanders et al., 2019).

Global MCH Programs: Safe Motherhood

By 1987, the global MCH focus expanded to include maternal mortality reduction with the publication of “Maternal mortality–a neglected tragedy. Where is the M in MCH?” (Rosenfeld & Maine, 1985) and the Safe Motherhood Initiative (Mahler, 1987). It was felt that maternal mortality was being ignored and these initiatives advocated for research and programs to improve maternal health and services during childbirth.

1990s & 2000s: World Summit for Children, Expansion of Global Health Surveys and MCH Programs, and Initiation of The Millenium Development Goals

World Summit for Children

The World Summit for Children, held in 1990, was led by 71 heads of state and 88 other senior officials, mostly at the ministerial level. The World Summit adopted the “Declaration on the Survival, Protection and Development of Children and a Plan of Action for implementing the Declaration in the 1990s” (United Nations, 1990). This document built on the 1989 UN Convention on the Rights of the Child which states “Every child has rights without discrimination of any kind, irrespective of the child’s or his or her parent’s or legal guardian’s race, color, sex, language, religion, political or other opinion, national, ethnic or social origin, property, disability, birth or other status”. The Convention remains the most widely ratified human rights treaty in the world, with all countries, except the United States of America and Somalia, having ratified the convention (UNICEF, 1989).

Expansion of Global Health Surveys

Building on earlier surveys, such as the World Fertility Survey in 1974 (Chidambaram et al., 1985) and the Demographic Health Surveys in 1984 (Fisher & Way, 1988), there was expansion in the 1990’s of the development and initiation of several global surveys (e.g. Demographic and Health Surveys (DHS), Multiple Indicator Surveys (MICS)). Most of these continue to this day and have been critical for generating data to assess the status of health and well-being of populations, including women and children, and progress towards global targets for mortality reduction and health services coverage.

Global MCH Programs: EmOC & IMCI & iCCM

Building on earlier efforts to reduce child and maternal mortality, expansion to more comprehensive initiatives and programs emerged during the late 1990s. The Guidelines for monitoring the availability and use of emergency obstetric services (EmOC), developed in 1997, built on the Safe Motherhood initiative. The Integrated Management of Childhood Illness (IMCI) (WHO, 1997a, with newborns added in 1999) developed a more comprehensive, rather than single disease approach, to management of illness in children. While these programs promoted substantial improvements in health services and care of mothers and children, they still had a narrow focus on ‘care of the sick’ rather than on prevention and social determinants of health.

Recognizing that the health facility-based IMNCI programs had remaining access barriers for children who were unable to reach health facilities, the program was expanded to include a community-based component, integrated Community Case Management (iCCM) of childhood illness. iCCM trained and deployed community health care workers as first line providers of treatment (WHO & UNICEF, 2006). While this program moves services closer to children and recognizes broader health services as integral to program success, it still focuses on treatment, not necessarily prevention of childhood illness and broader social determinants of health.

Global MCH Programs: Prevention of Mother to Child Transmission of HIV (PMTCT)

The rise of the HIV/AIDS Pandemic spurred global efforts to fight the high mortality, including for mothers and children, from this disease in the 1990s and 2000s. Relevant to MCH was the development of the first Prevention of Mother to Child Transmission (PMTCT) trials in Thailand (1998) and Uganda (1999) which showed HIV transmission could be reduced from infected mothers to their babies with a single dose of the antiviral treatment Nevirapine in labor (Namara-Lugolobi et al., 2022). Based on these landmark studies, WHO released its first guidelines for PMTCT programs in low resource settings in 2000; and over the next 10 years, the science of PMTCT and development and implementation of PMTCT programs advanced rapidly (WHO, 2010). Now with combination therapies, HIV transmission from mother to child can be reduced to 1–2% and the last UNAIDS report noted that 2022 had the lowest number of new HIV infections due to vertical transmission since the 1980’s. However, there continue to be pockets of higher transmission in certain extremely disadvantaged populations, so attention to HIV is still a global priority (UNAIDS, 2023). Of note, despite the success of PMTCT programs, they generally again took a single disease approach rather than broader comprehensive PHC.

The Millenium Development Goals (MDGs)

The Millennium Development Goals, supported by the UN and UN Member States and initiated in 2000, set targets for eight goals to be reached by 2015; of these, six related to health and four related to women and children. These included: (i) gender and women’s empowerment, (ii) maternal mortality, (iii) child mortality and (iv) HIV/AIDS). This was the first time the UN had set global targets for countries to work towards; and this effort spurred a host of initiatives to measure progress towards these targets, such as the UN Interagency Mortality Estimation Group (UNICEF, 2023a) and Countdown to 2015 (WHO and UNICEF, 2010). The latter published country-level MCH data in an accessible short graphic format. While significant achievements were made globally towards these goals by 2015, improvements were uneven across regions and countries, with emerging threats, such as environmental degradation and ongoing conflicts, hampering progress (United Nations, 2015a, 2015b).

Emergence of Global Partnerships

In the previous decade, two single disease partnerships (i.e., Emergency Nutrition Network and Roll Back Malaria) emerged on the global stage in efforts to promote coordination and address fragmentation across global health and development agencies. Starting in 2000 and beyond, there was a proliferation of global partnerships to combat specific aspects of MCH. Some were vertical in focus, such as The Global Vaccine Alliance (GAVI) and The Global Fund to Fight HIV, TB and Malaria. Others focused global advocacy across the spectrum of maternal and child health, such as the Partnership for Maternal, Newborn and Child Health (PMNCH). The H4 (now H6) Partnership for women's, children's and adolescents' health (2008) aimed to coordinate UN agencies working on maternal, child and adolescent health. Many of these partnerships continue to this day. GAVI, Global Fund and the 2019 Global Financing Facility for Women, Children and Adolescents, known as Global Health Initiatives (GHIs) (WHO, 2009), are also major financing mechanisms for in-country MCH programs.

2010 to 2023: Global Strategy for Women’s, Children’s and Adolescent’s Health and The Sustainable Development Goals

The Global Strategy for Women’s, Children’s and Adolescent Health

As the Global Health community approached the 2015 MDG targets, the Secretary General Ban Ki-Moon in 2010 launched The UN Secretary General’s Global Strategy for Women’s and Children’s Health and ‘Every Women, Every Child’ (EWEC) to outline the global UN policy and focus on MCH (UN Secretary General, 2010). The strategy aimed to move beyond mortality to include reduced morbidity and improved well-being: “Survive, Thrive and Transform”. In 2015 the strategy was updated to focus on the Sustainable Development Goals (SDGs) and add adolescent health. (United Nations, 2015b).

Sustainable Development Goals (SDGs)

By the end of the MDG period (2000–2015), the UN released the Sustainable Development Goals (SDGs) which were developed through a wide consultation process across UN Member States. Whereas health, and in particular MCH, were a large focus in the MDGs; for the SDGs, health is only one of 17 goals (United Nations, 2015c). As part of the SDGs, 169 targets for countries to achieve by 2030 were set. Of the 13 targets for SDG3 (Health), two are directly related to MCH (maternal mortality and child mortality), while the remainder address other issues also relevant to MCH (e.g., HIV, TB, Malaria, Neglected Tropical Diseases, Sexual and Reproductive Health, health risks and prevention). Alignment of prior efforts such as the Global Strategy for Women’s, Children’s and Adolescent’s Health to support the Global Goals, and a proliferation of networks, partnerships, and global action plans aimed at assisting countries to reach these goals across all sectors (United Nations, 2015c).

At of the halfway mark towards the 2030 goals, “146 out of 200 countries have already met or are on track to meet the SDG target on under-5 mortality. Effective HIV treatment has cut global AIDS-related deaths by 52 per cent since 2010 and at least one neglected tropical disease has been eliminated in 47 countries. However, insufficient progress has been made in other areas, such as on reducing maternal mortality and expanding universal health coverage” (UNSTATS, 2023).

Further increases in systems to monitor these 17 goals emerged throughout this period. Multiple commissions and working groups were created, such as Commission for Information and Accountability for Women's and Children's Health (CoIA). Along with these emerging data collaborations, global technical advisory groups (TAGs) for improving MCH metrics and use of data for policy and programming in maternal newborn health (MoNITOR), child health (CHAT) and adolescent Health (GAMA) were created by the World Health Organization.

Global Conference on Primary Health Care and The Astana Declaration

To celebrate 40 years since Alma Ata and re-affirm the primary health care approach, the global health community recommitted to The Alma Ata Declaration and PHC 40 years after the original declaration in the form of the 2018 Global Conference on Primary Health Care and the Astana Declaration. The Astana Declaration also included a strong focus on universal health care (UHC) as a measure of PHC. UHC, which focuses more on health services and financing rather than broader well-being and social determinants of health and prevention, meant that the debate about comprehensive versus selective PHC continues (Sanders et al., 2019).

Increasing Focus and Integration of Maternal and Newborn Health Programs

As global child mortality rates declined, the proportion of child mortality occurring in the neonatal period (0–28 days) increased to approximately 47% of all child deaths (UNICEF, 2023a, 2023b, 2023c). To further reduce under-5 mortality, the global community recognized the need to address neonatal mortality and more recently stillbirths. Therefore, a rise in initiatives to advocate for increased attention and funding for improving perinatal services and data on rates and causes of neonatal mortality emerged, such as the Every Newborn Action Plan (ENAP) (WHO, 2018), followed by the Ending Preventable Maternal Mortality (EPMM) initiative (WHO, 2024). As the health and care of the mother during birth was critical for reducing newborn deaths and stillbirths, multiple global initiatives for maternal and newborn care emerged during this period as compared to previous decades. In 2024, ENAP and EPMM joined to become Every Woman Every Newborn Everywhere (EWENE), using a phrase first coined in a Lancet Commission Maternal Health Series (2016) and in a UN Commission report (2018) to provide a single combined approach to improving maternal and newborn health and survival and reducing stillbirths. These initiatives aim to improve coverage, quality, and equity of maternal and newborn health care. A joint report, with revised targets and priority actions for maternal and perinatal health, was issued in 2023 (WHO, UNICEF, UNFPA, 2023).

Thrive Agenda: Expanding Focus Beyond Mortality: Early Child Development & Adolescents

In addition to neonatal health, there was also an expanded focus on the ‘Thrive’ agenda in the form of the Nurturing Care Framework (WHO, UNICEF, World Bank Group, 2018) and Global Accelerated Action for the Health of Adolescents (AA-HA!) (WHO, 2023). The Nurturing Care Framework notes that every child needs an environment that “promotes health, nutrition, security, safety, responsive caregiving and opportunities for early learning” (WHO, UNICEF, World Bank Group, 2018, p. 2) and provides a roadmap for action. Consistent with the expanded 2015 Global Strategy, which added the health and well-being of adolescents, the 2017 AA-HA framework (updated in 2023) provides guidance on planning and implementing adolescent health and well-being programs. AA-HA, in addition to the “Thrive” agenda, also begins to address “Transform”, which works to promote an environment that transforms the adolescent in their transition towards being a healthy and productive adult.

Global MCH Programs: Child Health Redesign

Building on the concepts of Survive, Thrive and Transform, initiatives like Child Health Redesign (WHO, 2019, 2023) and the WHO/UNICEF/Lancet Commission on “The Future of the World’s Children” (Clark, 2020) have outlined priorities for the Global MCH community, governments and communities to promote and protect the health of women and children. The aim is for “An optimally healthy (physically, mentally, socially) appropriately educated young adult at 19 years of age, living in a safe and supportive environment, prepared to contribute socially and economically to her/his society” (WHO, 2023). The Child Health Redesign (WHO, 2023) outlines guiding principles for future MCH programs:

  • Adopt a life course approach as an organizing principle for the delivery of age appropriate and context- and condition-specific interventions and actions, focusing on first two decades while considering the impact of preconception, pregnancy and maternal health.

  • Adopt a rights-based and equitable approach by ensuring that essential interventions and services are equitably accessible and provided with quality to ALL EVERYWHERE to protect, promote health and prevent risk factors, disease and health complications.

  • Deliver seamless comprehensive integrated family-child and adolescent centered care (protection, prevention, promotion, treatment, rehabilitation) across all levels in an expanded supportive and enabling environment.

  • Empower individuals, families and communities in the generation of health and wellbeing and in addressing the social, cultural, political and economic determinants that underpin health and wellbeing of the population.

  • Promote strong multisectoral collaboration in programming with children and adolescents at the center of all policies and actions recognizing that health is most often determined by factors beyond the purview of the health sector.

Protect The Promise: EWEC Progress Report

The 2022 Progress Report on EWEC Global Strategy by WHO and UNICEF (WHO/UNICEF, 2022) identified three critical issues facing global MCH programs and threatening the health of women and children: COVID-19, Conflict and Climate Change, calling them the “3 C’s”.

COVID-19 Pandemic and MCH

The global COVID-19 pandemic emerged in 2020, and it highlighted the impact and threat of infectious disease outbreaks and pandemics on MCH. While the highest mortality risk was in the elderly and those with chronic diseases, the resulting lockdowns and burden on health services and health facilities were of great concern to the global MCH community as it compromised access to prevention and treatment services for pregnant women and sick children. Reduced service coverage of key MCH interventions was estimated to potentially increase child mortality by 10–45% (Roberton, 2020). Early reports from the field reinforced this concern for increased mortality in the face of reduced MCH services (Ashish, 2020). COVID-19 potentially threatened to erase the past 50 years of progress in reducing maternal, neonatal and child mortality and stillbirths.

The impact of infectious disease epidemics and pandemics on MCH is not limited to COVID-19. A systematic review by Palo et al. (2022) examined MCH services and trends across COVID-19, Zika and Ebola outbreaks; they concluded that: (a) “all study settings had positive trends in MCH indicators before pandemics despite several unmet goals”; (b) that “these improvements were halted and even reversed during the pandemics”; and that (c) “that the utilization of MCH services was hampered due to various attributes in the event of pandemics” (Palo et al., 2022, pg. 14). They go on to recommend that evidence-based MCH programs need to be continued during pandemics to protect women’s and children’s health. The global health community needs to prioritize preparedness and resilient health systems and MCH programs to protect women, children and communities from the ongoing risks of emerging infectious diseases.

Conflict and MCH

The highest rates of maternal, newborn and child mortality in the world exist in conflict affected states with rates three times higher than other LMIC. Women and children living in these states are increasingly forced to become migrants to flee conflicts such as those in Afghanistan, Ukraine, Gaza, Somalia. While the impact of conflicts on MCH is not new, these conflicts have constrained recovery after the end of the global COVID-19 pandemic (WHO/UNICEF, 2022) and the number of people living in conflict impacted regions is rising. It is estimated that from 2008/9 to 2018/19 that both the number of refugees (external migration) and internally displaced person due to conflict has doubled, and that the majority these are women and children (WHO/UNICEF, 2022). Addressing the sources and consequences of conflict on MCH must be a priority in the current and coming decades.

Climate Change and MCH

The third “C” is Climate Change. Clark et al. (2020) noted that “climate disruption is creating extreme risks from rising sea levels, extreme weather events, water and food insecurity, heat stress, emerging infectious diseases, and large-scale population migration.” Women and children are particularly vulnerable to climate change, e.g., extreme heat increases preterm birth and pre-eclampsia, air pollution increases respiratory diseases, and rising flood waters increase risks of diarrheal disease and vector-borne diseases such as malaria. These represent a threat to maternal, newborn and child mortality as recognized in the 2023 WHO/UNICEF/UNFPA/HRP report Protecting maternal, newborn and child health from the impacts of Climate Change: A Call for Action

It is important to note that like COVID-19, Climate Change are not an issue restricted to LMIC. A 2023 report from the US Environmental Protection Agency (EPA, 2023) outlines the substantial impact of climate change induced threats from extreme heat, air quality, pollen, flooding and vector-borne diseases on the health of children in the US. Addressing climate change to reduce carbon emissions is critical, a global multi-sectoral priority.

Discussion

Global Health Conferences, Declarations or Strategies

The period reviewed in this paper is to some extent bookended by Alma Alta in 1978 and Astana 2018 global conference on Primary Health Care (PHC). Throughout the last 40–50 years primary health care and health for all have been the underlying philosophy for global health, including MCH. However, approaches to achieving PHC have been debated throughout this period. Including the debate around selective versus comprehensive primary health care approaches (Sanders et al., 2019), as well as models of financing for global health and MCH programs, e.g., Universal Health Care and financing partnerships such as GAVI, Global Fund and GFF (further discussed below).

Also starting in the 1970s, global declarations and strategies, supported by UN Agencies, UN Member States and global partners, such as the Alma Ata Declaration, evolved as mechanisms to guide global MCH policy and programs. The most significant of these global declarations and strategies have been the Millenium Development Goals (2000–2015) and the Sustainable Development Goals (2015–2030). The UN Secretary General’s Every Woman Every Child Initiative further focused policy and programs specifically for women, children and adolescents within these broader goals. The MDGs and SDGs have been both lauded and criticized in the global health arena. The MDGs which focused primarily of poverty alleviation were seen as providing a simple and clear focus for motivation towards those goals (Kerry, 2015) but were also criticized as focusing “on (economic) poverty reduction without a clear focus on other development dimensions such as human rights, empowerment and equality” (de Jong & Vijge, 2021, pg.3). While the SDGs which followed were more comprehensive and attempted to address this latter criticism, they in turn have been criticized as too broad and encompassing, losing the original purpose of the MDGs as a tool to focus aid flows, and are almost impossible to implement (Kerry, 2015). Global Health is complex, needing to align both global goals with country priorities and also financing and economic development which is much broader than health alone (and beyond the scope of this review). So, while the MDGs and SDGs have been somewhat helpful to focus global, country and donor efforts, they are limited in that they represent governance which “relies on goals that are not legally binding, leave much national leeway, and do not come with strong institutional arrangements” (de Jong & Vijge, 2021).

Global Health Surveys and Global MCH Related Data Initiatives or Working/Advisory Groups

The first World Fertility Survey (1974) and the first Demographic & Health Surveys (1984) were followed in the 1990s by the Multiple Indicator Cluster Surveys (1995), Emergency Obstetric Care Surveys (1997) and the first Health Facility Surveys (1999), all demonstrated an increasing recognition of the need for data to track progress towards improving global health and MCH. All but the World Facility Surveys continue to this day and have provided a basis for monitoring progress and targets at both country and global levels. These surveys and global mortality estimates derived from them have documented the reduction of MCH mortality over the decades, while they also continued to demonstrate the ongoing inequities of mortality and morbidity both within and across countries.

While the global health surveys already existed prior to the MDGs and SDGs, the emergence of these global targets spurred the proliferation of newer data initiatives and working/advisory groups to make better use of the data for global and country monitoring (Moller, 2019).

With this proliferation of data initiatives also came a lack of coordination among them. Many countries still do not have timely, reliable and actionable health data for use by policy makers to make informed decisions. The WHO through efforts like the Health Data Collaborative (and related MCH specific groups like MoNITOR, CHAT and GAMA) has “attempted to address these challenges by convening global health partners to align their technical, financial and political resources around a common agenda for measurement and accountability in health” (WHO, HDC). While these groups are global, they do actively work to engage countries to lead local data initiatives and monitoring.

Global MCH Programs

The initiatives included primarily in this review have focused on reducing maternal, newborn and child mortality and stillbirths in low-and-middle income countries. However, global MCH health conceptual and practice transitions discussed throughout this paper have followed similar temporal transition patterns found in US MCH history—albeit at a bit later in time than seen in the US and other high-income countries (Bazzano, 2024; Payton, 2022).

Also, many of the global health initiatives are relevant for high-income countries, like the USA, such as the 1989 Convention on the Rights of the Child and the 2015 Sustainable Development Goals (SDGs), which are meant for all countries across the economic spectrum. In addition, recent global MCH programs initiatives have expanded to a life cycle approach, which addresses a broader range of health and well-being in the context of sustainable global development, which would be applicable for the USA and other high-income countries.

Global MCH Partnerships or Networks

During the COVID-19 pandemic, protecting and adapting services to maintain coverage and protect mothers and children became a clear concern A number of new partnerships developed to achieve the SDGs (Graham, 2020; WHO/UNICEF, 2022), including initiatives such as the Women, Children and Youth Working Group of the World Federation of Public Health Associations and the Global MCH Network of the American Public Health Association. These initiatives aim to increase multi-directional learning across high-, middle- and low-income countries. This approach is consistent with the SDGs, which focus on all countries, unlike the MDGs, which primarily focused on LMICs.

Many global MCH partnerships, such as GAVI and The Global Fund, were created to increase coordination both globally and within countries (Spasenoska, et al., 2024). While these initiatives were generally intended to address fragmentation across development agencies and partners in response to country complaints. However, except for PMNCH, which is a broad advocacy group, there is concern that these programs continue to promote verticalization and selective PHC approaches (Spasenoska, et al., 2024). While these partnerships have clearly improved collaboration in some areas (immunization, HIV/AIDS), the continued proliferation of partnerships issuing guidance and competing for funds and policy and program attention is potentially problematic for overall coordination of efforts to improve the health of mothers and children.

Future MCH Global Practice and Policy Directions

Looking to the future—what are the priorities for global MCH policy and practice. The 2022 WHO/UNICEF document “Protect the Promise” takes a comprehensive look at future priorities for MCH. It outlines several priorities to address the unfinished agendas for women, children and adolescent health which have been highlighted in this review:

  1. Strengthen primary health care systems to deliver essential interventions;

  2. Improve multisectoral collaborations so that services are better integrated;

  3. Improve women’s empowerment and bolster women’s and adolescent girls’ leadership opportunities;

  4. Advance and leverage private–public partnerships to improve funding and services;

  5. Secure increased financial investments by governments and their partners in women’s, children’s and adolescents’ health; and.

  6. Secure the food supply and prioritize humanitarian food assistance while also building more resilient food systems.

These recommendations take a comprehensive approach addressing all age groups across the lifespan, all countries and regions, and broader health determinants, which are critical for improving women’s, children’s and adolescents’ health.

Conclusion

While Clark et al., (2020) note that “Over the past 50 years we have seen dramatic improvements in survival, education, and nutrition for children worldwide”, there remain a number of unfinished agendas in Global MCH. Even prior to COVID-19, reductions in MCH mortality were beginning to stall (WHO, UNICEF, 2022); with inequities in health and well-being across countries, regions and vulnerable populations continuing to impact overall trends. These trends threaten continuing reductions in mortality and morbidity, across not only the under-5-year-olds, but across the preconception to adolescents lifespan focus of current MCH programming.

In addition, global health is still very far from the original Alma Ata vision of “Health for All” through comprehensive primary health care, almost a quarter of a century past the original target of 2000. This is as true in low-and-middle income countries as in high-income countries like the USA.

The initiatives, commitments and priorities in this review generally take a rights-based approach, consistent with the Convention on the Rights of the Child and have expanded in type and scope in the last 50 years. To achieve improved global maternal, newborn, child and adolescent health, there is much to learn from each other across both low-and-middle income and high-income countries. There is also a critical need to increase emphasis on social determinants of health, multi-sectoral approaches, integration, and a vision more consistent with comprehensive PHC for all women and children everywhere to promote health and well-being and build healthy communities.

Acknowledgements

I would like to acknowledge colleagues of the APHA MCH Section History Committee for their support. The authors’, own career has spanned this half centennial, and she would like to also acknowledge all the global health colleagues who over the last 50 years have worked tirelessly on behalf of all women and children everywhere!!

Author Contributions

DJ conceptualized the paper with the support of the APHA MCH Section History Committee, as part of a paper series on the last 50 years of MCH. DJ wrote and approved the final manuscript.

Funding

This work was funded by the Takeda Chair in Global Child Health at London School of Hygiene and Tropical Medicine.

Declarations

Conflicts of interest

None to Declare.

Footnotes

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

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