CROSS-COUNTRY SYNTHESIS: NEONATAL AND MATERNAL MORTALITY

Overview

This cross-country synthesis describes high-level insights from our research in seven countries identified as Exemplars in neonatal and maternal mortality reduction. Additional information about each Exemplar country’s progress is available on their respective narrative pages, including those for Bangladesh, Ethiopia, India, Morocco, Nepal, Niger, and Senegal. This synthesis focuses on key drivers, insights, and lessons that emerged across Exemplar countries that could be relevant for other countries looking to learn from their successes.

In particular, this synthesis emphasizes the importance of context-specific recommendations that consider a country’s current performance across maternal and newborn health-related indicators – as success factors vary across higher- and lower-mortality settings. An Interactive Benchmarking Tool was developed to help target lessons from Exemplar countries to peer settings where they are most likely to be relevant.

Exemplar countries for neonatal and maternal mortality reduction are defined as those that have achieved more rapid declines in mortality at paces beyond what would be expected based on economic development alone. Seven countries were identified through this process—with their neonatal mortality rate (NMR) and maternal mortality ratio (MMR) trends shown in Figure 1.

Figure 1: NMR and MMR trends in Exemplar countries

UN MMEIG, UN IGME

All Exemplar countries have achieved substantial reductions in NMR and MMR since 2000. While continued progress is needed, several are on track to meet, or have already met, the Sustainable Development Goal targets for these indicators by 2030, generally outpacing other countries in their respective regions. Research in these countries aimed to identify and understand the drivers of progress—beyond economic growth—that contributed to these improvements.

In assessing drivers of maternal and neonatal mortality reduction, we leveraged a conceptual framework that categorizes factors as distal, intermediate, or proximal (Figure 2). This approach ensured that research in Exemplar countries considered both upstream as well as more immediate factors that directly influenced maternal and newborn mortality at the point of care.

NMR/MMR Conceptual Framework of Factors Contributing to Neonatal and Maternal Mortality Decline

As part of this research, certain factors were found to be stronger drivers for countries with higher mortality levels, while other factors were more strongly associated with progress in countries with lower mortality levels. To describe this trend, an integrated mortality transition framework¹—adapted from the well-known obstetric transition framework²—was developed.

In this integrated mortality transition framework, mortality levels are categorized into five phases, with phase 1 indicating higher mortality levels and phase 5 indicating lower mortality levels. The transition framework provides a foundation that can be used to benchmark country progress and chart a path to progress, with distinct drivers mapped to successive steps.

Through our multicountry analysis, we identified key factors associated with advances along the maternal and neonatal mortality transition. Advancements beyond phase 1 were often linked to increased contraceptive use and declining fertility rates. Further progress through phases 2 and 3 often corresponded with expanded coverage of antenatal care, facility-based deliveries, skilled birth attendance, and postnatal care, in part due to investments in physical infrastructure and the health workforce. These changes often led to a shift in causes of death in phase 3, with preventable deaths, particularly from infectious diseases, declining and indirect causes contributing to a growing share of deaths. Finally, transitions to phases 4 and 5 frequently reflect a growing prioritization of health equity, as vulnerable communities gain access to interventions that were previously limited to wealthier, urban, or more educated communities.¹

These trends were observed in the Exemplar countries, which are shown in the integrated mortality transition framework in Figure 3.

Figure 3: Positioning NMR/MMR Exemplar countries in the Integrated Mortality Transition Framework

Boerma, Ties, et al. 2023

Exemplar countries implemented programs and policies that often accelerated the trends described earlier. While context-specific implementation strategies varied from one Exemplar country to another, common strategies can be grouped into the following categories:

Removing user fees for key maternal and newborn health services
Incentivizing uptake of maternal and newborn health services
Mitigating physical and logistical barriers to care
Strengthening linkages between communities and the health system
Upskilling human resources for health and task shifting

Throughout this synthesis, specific countries are highlighted for each category, with links to other examples where relevant.

We also developed an Interactive Benchmarking Tool—described later in this synthesis—to help connect these research findings to peer contexts in a targeted manner. The tool assesses country performance across a range of maternal and newborn health-related indicators, supports evidence-based priority-setting, and facilitates relevant linkages to Exemplar settings that have performed particularly well on a given indicator. This approach is already being used in peer settings, where stakeholders are applying it to retrospective evaluations and prospective planning to inform future maternal and newborn health strategies.

1
Boerma T, Campbell OMR, Amouzou A, et al. Maternal mortality, stillbirths, and neonatal mortality: a transition model based on analyses of 149 countries. Lancet Glob Health. 2023;11(7):e1024-e1030. https://doi.org/10.1016/S2214-109X(23)00195-X
2
Souza JP, Tunçalp Ö, Vogel JP, et al. Obstetric transition: the pathway towards ending preventable maternal deaths. BJOG. 2014;121(suppl 1):1-4. https://doi.org/10.1111/1471-0528.12735