Alyssa Sharkey Keeps a Finger on the Pulse of Health Equity Amid Historic Report

For the first time, the World Health Organization, UNICEF, and the United Nations Population Fund have produced a joint report analyzing global progress on maternal deaths, newborn deaths and stillbirths. Alyssa Sharkey, lecturer of public and international affairs, an affiliate in the Center for Health and Wellbeing, and an associate in the Office of Population Research, was the report’s lead writer. Here, she breaks down some of the findings in “Improving Maternal and Newborn Health and Survival and Reducing Stillbirth – Progress Report 2023.”

SPIA: This report is historic in that it is the first time that data about women and newborns before and after childbirth have been analyzed and presented jointly since global targets were developed with the Millennium Development Goals in 1990. As the lead writer, what were your big takeaways from the data?

AS: Overall, there has been good progress since global targets were initially created to reduce preventable maternal and child deaths. The biggest improvements by far have been in reducing deaths among children under 5 years of age, which dropped from over 12 million in 1990 down to around 5 million in 2021. This is because the main causes of death among the under-5 age group, such as pneumonia, diarrhea, and malaria, can all be treated by community health workers who have very little education or training. This has made it relatively easy for many countries to roll out programs to address these causes, even in very remote or disadvantaged settings.

In contrast, reductions in maternal and newborn mortality and stillbirths have been slower over time, and that’s because most of the main causes of death among pregnant women and babies pre- and post-birth can only be addressed with quality health care that’s delivered in facilities by trained doctors, midwives, and nurses. Our analysis concluded that there are still 4.5 million maternal deaths, stillbirths, and newborn deaths each year.

One big takeaway is that greater investment is needed in the programs and services that we already know can save women and babies. This includes training health workers to provide emergency obstetric care, care for sick newborns, and ensuring that facilities have the necessary infrastructure, functional equipment, and supplies to prevent and treat these problems.

We also see that inequities are driving high mortality rates. Without greater attention to the most disadvantaged populations and areas where mortality is almost always the highest, national and global targets won’t be reached. Even in the United States, we saw an increase in maternal deaths during the pandemic, with particularly high rates among Black women.

Finally, from the health system side, we are becoming more aware of the importance of engaging families and communities as key partners. These individuals help with planning and promoting accountability, and they also ensure that maternal and newborn health services are being implemented in a way that is acceptable to local families. Without this, people won’t show up, even if local health services exist.

SPIA: How has the COVID-19 pandemic interrupted progress toward the goals?

AS: Even before the pandemic, financing was insufficient to match political commitments to maternal and newborn health in many countries, but the COVID-19 pandemic has compounded so many problems. Almost half of the 106 countries we surveyed reported that their domestic financing challenges for health became even more dire with the onset of the pandemic. In addition, widespread service disruptions led to huge drops in the utilization of lifesaving interventions. The two regions with the largest numbers of maternal and newborn deaths — sub-Saharan Africa and Central and Southern Asia — have fallen way behind where we hoped they would be today. Similarly, fragile and conflict-affected countries, where maternal and newborn mortality rates are among the world’s highest, have been particularly affected and are having a much harder time recovering post-pandemic.

It’s worth noting that the lack of progress on stillbirths over time has been particularly disappointing. Most stillbirths are preventable, but only if countries provide interventions like antenatal care, fetal growth monitoring, delivery with a skilled birth attendant, and fetal heart monitoring during labor. Stillbirths are truly devastating for families, but so far, they have not received the necessary attention and investments at global, regional, or country levels.

SPIA: What is the path forward here in 2023 and beyond? How can these numbers grow positively and what do you anticipate are some continued hurdles that will need to be addressed?

AS: The truth is that we already know what is needed to prevent the vast majority of these deaths. The technologies and lifesaving interventions exist, but investments in the health workforce and the health system are critical to make these available to all women and babies, particularly those who are the most vulnerable. Pro-equity policies that can help with this include exempting maternal and newborn health services from user fees or creating insurance programs for pregnant women and newborns to ensure universal access. In fact, some countries have enacted these policies or other innovations and, as a result, they’re making great progress on all three of the global targets.

As far as hurdles go, one that will be important to overcome is the traditional siloed approach that we so often see in health programs. The needs of women and babies are so aligned in many ways, but surprisingly, policies and programs are not often designed to address both. This report is just a first step toward advocating for joint partnerships, policies, and programs that address common challenges and opportunities so that there can be greater gains for both women and newborns.

SPIA: Are there plans to revisit the data to see if things have changed?

AS: The plan is to keep monitoring progress every two years to see how things have changed and what big challenges remain both within and across countries and regions. Frequent monitoring and advocacy will be key to accelerating progress over the coming years.

SPIA: What about your other work in this arena? Can you tell us a little about that?

AS: A lot of the work I do — whether it’s for UNICEF, the World Health Organization, or within the courses I teach at Princeton — all highlight the importance of health equity. For example, I recently worked on a paper for UNICEF’s flagship State of the World’s Children 2023 report, summarizing key evidence on the impact of the COVID-19 pandemic and pandemic responses on health systems, particularly on routine immunization in the world’s most disadvantaged settings. I also created a website for UNICEF this past year that includes an online learning tool on gender-related barriers to immunization and an interactive tool for pro-equity strategies.

One recent activity I led, in collaboration with the Institute for Global Health Equity Research in Rwanda, and with the support of the Center for Health and Wellbeing, SPIA, and the Office of Population Research, was a conference on “Research and Policy to Support Health Equity in Africa.” This conference brought together researchers and policymakers from multiple African countries to discuss the importance of health equity, emerging challenges in light of the pandemic, inequities in research funding, collaborations, and processes, and innovations that are already happening within African settings to improve research equity as well as health policy and program equity. The conference ended with participants committing to various actions including joint publications as well as collaborating as a network. Quite a few of my undergraduate and graduate students were in attendance as well.