ABSTRACT & COMMENTARY
Global Health: Infections Still Matter
Infectious diseases responsible for nearly half of child and maternal mortality
By Philip R. Fischer, MD, DTM&H
Professor of Pediatrics, Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, MN.
Dr. Fischer reports no financial relationships in this field of study.
SOURCE: Bhutta ZA, et al. Global maternal, newborn, and child health so near and yet so far. New Engl J Med 2013;369(23):2226-2235.
At the dawn of this century, world leaders signed a Millennium Declaration with the target of reaching eight specific health-related goals by 2015. There have been great gains toward meeting these goals, but rates of child and maternal mortality (the subjects of the 4th and 5th goals) remain unacceptably high. Significant opportunity for improvement still remains, especially in sub-Saharan Africa (for maternal and child mortality) and in the Indian sub-continent (for neonatal mortality).
What still accounts for the 274,000 annual maternal deaths? Table 1 summarizes reported causes of maternal mortality and shows that infections account for 40% of maternal deaths. Since many of these data come from verbal autopsies and imprecise measures, the details of these diagnostic categories are not always well-defined.
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Table 1. Causes of Maternal Death
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Cause
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Percent of
Maternal Deaths
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Sepsis
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9
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Hepatitis
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13
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Syphilis
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6
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"Other Infections"
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12
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Hemorrhage
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23
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Hypertension
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19
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Obstructed Labor
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4
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Other
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14
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Why are 6,600,000 pre-school-aged children still dying each year? Table 2 shows causes of deaths during the first 28 days (neonatal) and the rest of the first five years.
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Table 2. Causes of Childhood Death
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Age Group
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Cause
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% of Deaths
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Neonatal
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Sepsis/Meningitis
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5
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Pneumonia
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4
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Diarrhea
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1
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Tetanus
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1
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Prematurity
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14
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Intra-Partum Event
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9
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Congenital Anomaly
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4
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"Other"
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2
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1-60 months
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Pneumonia
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14
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Diarrhea
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10
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Malaria
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7
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Measles
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2
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Meningitis
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2
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HIV/AIDS
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2
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Injury
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5
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"Other"
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18
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Bhutta el al make the excellent point that we should not merely consider the causes of death but also the "causes of the causes" — the underlying social determinants that still allow women and children to die of these more direct causes. Poverty, undernutrition, poor sanitation, and inadequate medical services underlie the tangible infectious and non-infectious causes of death. In fact, undernutrition contributes to 45% of the childhood deaths. Sadly, more than a third of maternal and childhood deaths occur in countries where there is active armed conflict.
Application of existing evidence-based interventions could markedly reduce the current rates of maternal and child mortality. Only about half of women in the "Countdown Countries" (the 75 countries that account for 95% of maternal and child deaths) receive desired family planning, at least four antenatal visits, the presence of a skilled attendant at birth, and postnatal care. In these countries, only 40% of babies benefit from exclusive breastfeeding in the initial months of life; 80% get basic vaccines; less than 40% get antibiotics when they have pneumonia. Clearly, health care system changes will be needed to improve the world's currently unacceptable child and maternal mortality rates.
COMMENTARY
As the world's population has grown from 4.5 billion in 1990 to 7 billion now, annual deaths of pre-school aged children have dropped from 12.6 to 6.6 million. Several countries are on target to meet the Millennium Development Goals for child and maternal mortality, but there is still significant potential for ongoing progress — particularly in the half of countries that account for 95% of the deaths.
As death rates have dropped around the world, efforts have shifted from simple survival to improved health. Injuries and non-communicable diseases are appropriately receiving more attention. Nonetheless, as capably reviewed by Bhutta et al, infectious diseases are still responsible for nearly half of child and maternal mortality. Improvements in health care systems will be needed to decrease the risk of infectious disease deaths in women and children.
