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U.S. GLOBAL HEALTH POLICY T H E U . S . GOVERNMENT’S EFFORTS TO ADDRESS G L OB A L MATERNAL, NEW BORN, AND CHILD HEALT H: T h e G l o b al Health Initiative and Beyond May 2010 U.S. GLOBAL HEALTH POLICY T H E U .S . GOVERNMENT’S EFFORTS TO ADDRESS G L O BA L MATERNAL, NEWBORN, AND CHILD HEALT H: T h e G lo bal Health Initiati ve and Beyond M ay 2 01 0 P re pare d by K e l li e M o ss , A ll is o n Valen tin e, an d Jen K at es, w it h as s i s tan ce f ro m Kim B o o rtz an d A da m Wexler Table of Contents Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Global Status of Efforts to Improve MNCH. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 The U.S. Government Response . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 Key Policy Issues & Questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 Appendix A. Glossary of Key Terms and Acronyms. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 Appendix B. Causes of Maternal, Newborn, and Child Mortality. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 Appendix C. Key Approaches & Interventions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Appendix D. Key U.S. and Global MNCH Efforts by Country. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 Appendix E: U.S. Funding for MNCH/Nutrition by Country & Region, FY 2008 & FY 2011. . . . . . . . . . . . 22 Figure Sources. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 Endnotes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 Overview This is an important moment to assess the U.S. government’s role in improving global maternal, newborn, and child health (MNCH). Along with growing international momentum on these issues, the Obama Administration’s newly launched Global Health Initiative (GHI) includes a strong focus on MNCH as part of a broader women- and girls-centered approach to global health and development. Each year, millions of women, children and newborns die from what are largely preventable or treatable causes, and there is growing concern that the world is not on track to reach the eight Millennium Development Goals (MDGs), particularly those for maternal health (MDG 5) and child health (MDG 4). Although global initiatives to address MNCH have been undertaken in the past, these efforts have only recently gained traction on the international agenda (see Figure 1).1,2 The U.S. government has been engaged in efforts to improve MNCH in developing countries for several decades and is one of the largest global donors to such programs; however, its attention to and funding for MNCH have also only recently begun to move more toward center stage.3,4,5 In launching the GHI in May 2009, the Administration set forth a women- and girls-centered approach, including MNCH, and set specific targets for MNCH to be achieved by 2014.6,7 This emphasis places an increased focus on the health of mothers; child health programs have received most funding and attention in global MNCH efforts historically. The GHI is intended to build on disease-specific initiatives to combat HIV, TB and malaria, while expanding MNCH and other global health efforts, which are slated to receive an increased share of funding over the course of the six-year Initiative. U.S. funding for MNCH has increased in recent years, particularly since the launch of the GHI; the FY 2011 budget request, if appropriated, would represent the steepest annual increase in MNCH funding in recent years and bring total funding for MNCH during the GHI’s first three years to almost $2 billion. Beyond the GHI, the Administration has also elevated women’s rights, including reproductive rights, within U.S. foreign policy and reiterated its commitment to achieving global targets in this area, including the MDGs and the 1994 Cairo International Conference on Population and Development (ICPD) objectives.8,9 Importantly, in addition to the Administration’s interest in augmenting MNCH, Congress has and continues to show a strong interest in this area. Figure 1: Key Global Milestones in MNCH+ t 1982 Child Survival Revolution Global campaign to address child health, initiated by UNICEF t 1987 Safe Motherhood Initiative International conference sponsored by WHO, UNFPA, and the World Bank marks launch of global campaign to reduce maternal mortality t 1988 Global Polio Eradication Initiative World Health Assembly launches global polio eradication effort, leading to immunization of millions of children and polio eradication in many countries t 1994 Cairo International Conference on Population & Development (ICPD) Defines reproductive health and sets internationallyagreed upon goal to achieve universal access to reproductive health, including maternal health t 2000 UN Millennium Development Goals Summit Eight international development goals agreed to by all nations for 2015, including MDG 4 (reduce child mortality) & MDG 5 (improve maternal health). Universal access to reproductive health added to MDG 5 in 2007 t 2000 Global Alliance for Vaccines and Immunisation (GAVI) Global health partnership representing stakeholders in immunization from both private and public sectors, with particular focus on child health t 2005 Partnership on Maternal, Newborn, and Child Health Launched when the world’s three leading maternal, newborn and child health alliances joined forces, with WHO serving as Secretariat t June 2010 G-8 Summit Canada, the G-8 host, is expected to launch new maternal and child health initiative t September 2010 UN MDG Review Annual review of international progress toward reaching the MDGs by 2015; Joint Maternal and Child Health Action Plan expected Against this backdrop, there are several other ongoing or near-term international efforts likely to galvanize additional attention to MNCH. These include this year’s Group of Eight (G-8) Summit at which the Canadian host government is expected to launch a new maternal and child health donor initiative; the September gathering of all nations at the UN to review progress toward the MDGs, with the expectation that a new joint action plan for accelerating progress on maternal and child health will be released; and increasing global dialogue about whether or not a new multilateral financing vehicle for MNCH is needed. Given this context and the important role played by the U.S. in global health, this report provides an overview of U.S. global MNCH policy, programs, and funding, including the new emphasis placed on MNCH by the GHI. It also identifies some possible opportunities and issues on MNCH for the U.S. going forward. (For a more general discussion of key issues on the GHI, see the Kaiser Family Foundation, The U.S. Global Health Initiative: Key Issues, April 2010.) THE U.S. GOVERNMENT’S EFFORTS TO ADDRESS GLOBAL MATERNAL, NEWBORN, AND CHILD HEALTH 1 Global Status of Efforts to Improve MNCH Maternal health, as defined by the World Health Organization (WHO), refers to the health of women during pregnancy, childbirth, and in the postpartum period.10 Child health generally refers to the health of children from birth through adolescence, although the specific age range varies. Newborn health captures the health of babies from birth through the first 28 days of life. These are most often considered in concert since they are integrally related to one another. Maternal health has a large impact on whether a child survives and thrives. When a mother dies, her children are three to ten times as likely to die as well.2,11 Babies are most vulnerable to health threats during the first 28 days of life, and although in many developing countries children’s health remains precarious throughout childhood, the riskiest time is during the first five years of life. (See Appendix A for glossary of key terms and acronyms and Appendix B for the main causes of maternal, newborn, and child mortality.) Figure 2: Progress Toward MDGs 4 & 5+ MDG 4: Reduce Child Mortality Target: Reduce by two-thirds, between 1990 and 2015, the under-five mortality rate. MDG 5: Improve Maternal Health Target 1: Reduce by three quarters, between 1990 and 2015, the maternal mortality ratio. Target 2: Achieve, by 2015, universal access to reproductive health. The latest MDG global status report found that countries had made the least progress toward MDG 5, reducing maternal mortality; many were also making little or no progress toward MDG 4. Of the 68 priority countries for maternal, newborn and child health identified by the Countdown to 2015, 50 were evaluated as making either no or insufficient progress toward MDG 4 (reduce child mortality) and having high or very high maternal mortality ratios, the key indicator for MDG 5 (improve maternal health). Only 10 countries had shown good progress toward both MDGs (see Appendix D). In 2000, world leaders gathered at the United Nations (UN) and adopted the United Nations Millennium Declaration, committing nations to a set of time-bound, international development goals for 2015, designed to tackle some of the world’s most pressing challenges—extreme poverty, disease, inequality, hunger, and illiteracy—in the poorest countries.12 Among the eight MDGs adopted at the summit are two specific to maternal (MDG 5) and child (MDG 4) health, each of which has specific targets (see Figure 2). Numerous indicators are used to assess MNCH, including several used to measure progress toward MDGs 4 and 5: maternal mortality ratio, lifetime risk of maternal death, presence of a skilled birth attendant during delivery, neonatal mortality rate, underfive (or child) mortality rate, and the proportion of infants (less than one year old) immunized against measles (see Table 1). Maternal, newborn, infant, and child mortality are often viewed as barometers of overall socioeconomic well-being. For example, maternal mortality is seen as an important measure of whether a health system is well-functioning because of the many facets of the healthcare mechanism that must function smoothly to ensure a safe outcome.13,14,15,16 Table 1: Key Maternal, Newborn, and Child Health Indicators24 Maternal Mortality Ratio, 2005 Lifetime Risk of Maternal Death, 2005 Births with Skilled Birth Attendant, 2003–2008 Neonatal Mortality Rate, 2004 Infant Mortality Rate, 2008 Under-Five Mortality Rate, 2008 Infants Immunized against Measles, 2008 (deaths/ 100,000 live births) (1 in: ) (%) (deaths/ 1,000 live births) (deaths/ 1,000 live births) (deaths/ 1,000 live births) (%) World 400 92 64 28 45 65 83 Sub-Saharan Africa 900 22 46 40 86 144 72 Middle East and North Africa 210 140 76 25 33 43 86 South Asia 500 59 42 41 57 76 74 East Asia and Pacific 150 350 91 18 22 28 91 Latin America and Caribbean 130 280 91 13 19 23 93 CEE/CIS 46 1300 97 16 20 23 96 Industrialized countries 8 8000 – 3 5 6 93 450 76 63 31 49 72 81 UNICEF Region Developing countries 2 THE U.S. GOVERNMENT’S EFFORTS TO ADDRESS GLOBAL MATERNAL, NEWBORN, AND CHILD HEALTH Most maternal, newborn and child deaths occur in the developing world, with Sub-Saharan Africa being the hardest hit region, followed by South Asia. An estimated 82% of maternal, newborn, and child deaths take place in sub-Saharan Africa and South Asia, and within these regions, several countries have particularly high rates of maternal and child mortality (see Figure 3).17 One recent study concluded that in 2008 more than 50% of all maternal deaths occurred in six countries: Afghanistan, the Democratic Republic of the Congo, Ethiopia, India, Nigeria, and Pakistan.18 Similarly, almost half of underfive child deaths in 2008 occurred in five countries: China, the Democratic Republic of Congo, India, Nigeria, and Pakistan.19 In addition, a number of countries, especially in sub-Saharan Africa, have made little progress in reducing child mortality with some even seeing reversals in their progress.13 FIGURE 3: Top 10 Countries, Maternal Mortality Ratio and Under-Five Mortality Rate+ Under-Five Mortality Rate, 2008 (per 1,000 live births) Maternal Mortality Ratio, 2005 (per 100,000 live births) 2100 Sierra Leone Afghanistan 1800 Angola Niger 1800 Chad 1500 Chad 257 Afghanistan 220 209 200 Somalia Angola 1400 Congo, (Dem. Rep. of) Somalia 1400 Guinea-Bissau 195 Mali 194 Sierra Leone 194 Rwanda Liberia 1300 1200 Burundi 1100 Nigeria Malawi 1100 Central African Republic 199 186 173 Despite these impacts, WHO reports that declines in maternal mortality have occurred in some regions since the 1990s, including East Asia, South-East Asia, Latin America and the Caribbean, and North Africa. Among the shared attributes of these regions are increased use of contraception to delay and limit childbearing; better access to and use of high quality healthcare services; and broader social changes, such as increased education and enhanced status for women.20 Child mortality rates have also declined substantially in many regions over this same period, including East Asia and the Pacific, Central and Eastern Europe and the Commonwealth of Independent States (CEE/CIS), and Latin America and the Caribbean.13 Although many effective interventions and programs exist to help reduce maternal and child mortality (see Appendix C), the latest global progress report on MDGs 4 and 5 indicates that countries are not on track to meet the 2015 goals, with the least progress on MDG 5.12 Several barriers have stalled global progress. First, funding shortages have resulted in access and coverage limitations for needed services and programs, particularly for maternal health.21 According to the Partnership for Maternal, Newborn, and Child Health (PMNCH), based on estimates developed by the High Level Task Force on Innovative International Financing for Health Systems, an additional $30 billion in program costs is needed from 2009 through 2015 (i.e., above current global spending, additional annual costs growing from $2.5 billion in 2009 to $5.5 billion in 2015) to achieve global MNCH goals.17,22 Second, a number of other broader development challenges—such as access to education, economic status, and availability of clean water and sanitation—have been shown to be closely linked to MNCH. Experts generally agree that MNCH programs should be complemented by such efforts if maternal and child mortality rates are to be sustainably reduced. Third, other complex factors affect the health of mothers and children. For example, MNCH is integrally related to and affected by the status of women and children, particularly girls, in a society. Finally, while strengthening health systems and increasing access to services, including through community-based clinics, are critical to improving the health of mothers, newborns, and children, many of the countries with high burdens of maternal and child mortality face critical shortages of health care workers, which may complicate efforts to implement or expand health services. Sub-Saharan Africa, for example, has 3% of the world’s health care workers but accounts for 50% of the world’s maternal and child deaths.23 THE U.S. GOVERNMENT’S EFFORTS TO ADDRESS GLOBAL MATERNAL, NEWBORN, AND CHILD HEALTH 3 Figure 4: Key Dates in the U.S. Global MNCH Response+ t 1961 U.S. begins child survival research t 1965 USAID begins international population and family planning activities t 1986 USAID develops first Child Survival Strategy t 1989 U.S. Child Survival Strategy expanded to include Maternal Health; Maternal and Newborn Health program launched t 2001 USAID develops first Newborn Strategy t The U.S. Government Response Over the past five decades, U.S. activities have played an important role in international efforts to improve maternal, newborn, and child health with the scope of U.S. efforts expanding over time (see Figure 4). Initial programs and interventions were focused on the health of children, beginning in the 1960s with child survival research, including pioneering research on oral rehydration therapy (ORT) that was conducted by the U.S. military, USAID, and the National Institutes of Health (NIH). Early U.S. child survival programs included efforts to control malaria and to fortify U.S. international food aid with Vitamin A. In 1985, the U.S. augmented its child survival activities by doubling its investment in these efforts and partnering with UNICEF for a “child survival revolution.” The following year, the first U.S. child survival strategy was developed by USAID.3,4,5,25 While the health of mothers and newborns was addressed within USAID’s child health programs, it was not until 1989 that USAID’s strategy was formally expanded to include maternal health and the first t 2009 President Obama announces Global Health U.S. international maternal and newborn health project was launched. In Initiative (GHI), a $63 billion, six-year comprehensive 2001, the agency developed a newborn survival strategy in response to global health effort with strong emphasis on MNCH growing concerns that the increased child survival efforts of the previous t two decades had largely overlooked newborns’ particular health risks 2010 GHI Implementation Plan and MNCH Targets and, therefore, failed to reduce newborn mortality.3,4,5 In 2008, largely in released response to congressional interest and direction, USAID developed an integrated five-year strategy to address MNCH, specifying goals and targets for FY 2008–FY 2013.3,26,27,28 More recently, with the launch of the Obama Administration’s Global Health Initiative, these targets have been updated and extended through FY 2014.7 In addition, the GHI includes an even broader emphasis on the health of women and girls. 2008 USAID develops an integrated, five-year MNCH strategy Structure, Programs, and Approach USAID serves as the lead government agency on MNCH efforts, and most funding and programs for MNCH are located at USAID. In addition to USAID, several other U.S. agencies also carry out activities or provide services that address MNCH including the Centers for Disease Control and Prevention (CDC), NIH, and the Peace Corps.29 Several key U.S. cross-cutting initiatives also play an important role in addressing conditions that affect the health of many women and children, including the President’s Emergency Plan for AIDS Relief (PEPFAR), the President’s Malaria Initiative (PMI), the U.S. Neglected Tropical Diseases (NTD) Initiative, and the Global Hunger and Food Security Initiative (GHFSI), now called “Feed the Future.”30 In addition to these bilateral efforts, the U.S. also participates in several international organizations that address MNCH. These major efforts are described below. USAID USAID operates the bulk of the government’s MNCH programs, which are broad in both scope and geographic reach. Its program activities are organized around the following components: maternal health and survival, child health and survival, maternal and child health research, vaccine introduction and new technologies, and polio.31 Although family planning and reproductive health (FP/RH) is part of the broader USAID MNCH strategy, Congress directs funding to and USAID operates these programs separately.32 USAID programs with MNCH components are currently operated in 62 countries.33,34 Of these, 30 are designated as MNCH “priority countries,” which are primarily in Africa and receive the majority of funding (see Figure 5).3 Priority countries are chosen based on several criteria: need (as reflected by countries’ maternal and child mortality rates); the presence of USAID Missions; and the capacity of those Missions and recipient countries to implement MNCH activities. Over time, an increasing share of USAID’s funding for MNCH has been concentrated within a smaller number of countries, primarily in Africa. For example, in FY 2008, 24% of MNCH funding was directed to countries in Africa. In the FY 2011 budget request, 37% would go to countries in this region (see Appendix E).35 4 THE U.S. GOVERNMENT’S EFFORTS TO ADDRESS GLOBAL MATERNAL, NEWBORN, AND CHILD HEALTH FIGURE 5: USAID MNCH Priority and Other Country Programs+ Priority Country Other Country USAID’s MNCH country programs are often located in countries where other U.S. global health programs operate. For example, most, but not all, countries with USAID MNCH programs also have USAID FP/RH programs; in addition, most have been designated as GHI countries (see Appendix D). USAID countries can also be compared to internationally designated priority countries for MNCH. For example, USAID supports MNCH programs in many of the 68 priority countries designated by the Countdown to 2015, a group of international experts who are monitoring progress toward MDGs 4 and 5, as having the greatest burden of maternal and child mortality.81 Of the 68 priority countries, a subset of 25 have been further targeted by the “Health 4” (H4)—UNICEF, UNFPA, WHO, and the World Bank—to receive increased resources to address their high rates of maternal mortality; USAID MNCH programs are present in all 25 of these. USAID’s MNCH strategy focuses on developing, introducing, and bringing to scale “high impact interventions” and health systems strengthening (e.g., healthcare workforce, pharmaceutical management, etc.). Programs and interventions are supported through direct and indirect mechanisms, including: USAID field staff working with governments and other on-theground partners; financial and technical support provided to countries, facilities, implementing partners, and others who in turn provide direct services and programs; training efforts (e.g., of community health workers, birth attendants); procurement of medications and other supplies; and operational research (see Table 2). Programs are also aimed at preventing malnutrition among mothers, infants, and children. USAID reports that, in 2008, more than 20 million children benefited from USAID infant and young child nutrition programs.36 Key efforts in this area include the following: • Exclusive breastfeeding for children under six months and continued breastfeeding through 24 months; • Improved feeding practices with an emphasis on diet quality and quantity for young children by promoting consumption of diverse, locally available foods; and • Introduction of innovative products like home-based or commercially prepared complementary foods, including micronutrient powders and lipid-based nutrient supplements.37 USAID also carries out health-related research activities, including playing a key role in vaccine development research and other global health-related research.38,39,40 Approximately 6–7% of its overall health-related budget supports research and development, including on issues of relevance to MNCH such as HIV/AIDS, FP/RH, infectious diseases, and MNCH, including polio and micronutrients.40 For MNCH research specifically, USAID obligated approximately $11 million in FY 2006, $9.7 million in FY 2007, $10.3 million in FY 2008, and $13.3 million in FY 2009.38,41 THE U.S. GOVERNMENT’S EFFORTS TO ADDRESS GLOBAL MATERNAL, NEWBORN, AND CHILD HEALTH 5 Table 2: U.S.-Funded Maternal, Newborn, and Child Health Interventions and Activities3,4 Women Newborns Children Antenatal care, including aseptic techniques to prevent sepsis Essential newborn care Skilled care at birth, including skilled birth attendants and active management of the third stage of labor Postnatal visits Emergency obstetric care, including postpartum hemorrhage treatment Treatment of severe newborn infection Prevention, care and treatment of severe childhood diseases, including antibiotics to treat respiratory infections/pneumonia, oral rehydration therapy (ORT) with zinc supplementation for diarrhea, antimalarials for malaria, and promotion of good hygiene behavior Improved access to reproductive health services and family planning, including contraceptives Immunizations, including polio eradication and measles control efforts Preventing malaria with insecticide-treated bed nets (ITNs) and intermittent preventive treatment during pregnancy (IPTp) HIV prevention/control, including prevention of mother-to-child transmission (PMTCT) of HIV Improved nutrition/supplementation, including Vitamin A fortification Clean water/sanitation efforts Health systems strengthening (health workforce, information systems, pharmaceutical management, infrastructure development) Research and development, including basic science research and implementation science CDC Along with those of USAID, CDC’s immunization efforts—against polio, measles, and other diseases—have saved the lives of millions of children over the years and prevented lifelong illness that often comes with childhood diseases.42 CDC has played an important role in confronting challenges to the eradication of polio as a leading partner in the Global Polio Eradication Initiative. CDC also provides significant scientific and technical assistance, working to build capacity in a broad array of MNCH and reproductive health areas, including developing surveillance systems, and conducting worldwide activities that improve the health of women, children, and families.43,44,45 CDC, in collaboration with Emory University, serves as a WHO Collaborating Center on reproductive, maternal, perinatal, and child health.46 The Center aims to build reproductive health capacity and provide technical assistance in ways that ultimately improve reproductive outcomes for mothers and infants around the world. It is also working with the Pan American Health Organization to improve monitoring and surveillance of maternal and neonatal health throughout Latin America. For FY 2011, the Administration has requested $2 million to begin a new initiative in global integrated MNCH at CDC. Among other things, CDC would use this funding, if appropriated by Congress, to establish an evidence base for integrating U.S. government MNCH programs. According to CDC, it will support country-specific activities, particularly the following: • Integrating and expanding service delivery programs targeted toward MNCH populations in one country with high burdens of maternal, neonatal, and infant mortality; • Implementing integrated service delivery programs and building capacity in laboratory, surveillance, and monitoring and evaluation activities, in order to provide a comprehensive package of interventions targeting the pregnancy, delivery, newborn and infancy periods in addition to strengthening the overall health system; •  roviding technical assistance to the Ministry of Health on laboratory diagnostics, surveillance, logistics, and P monitoring and evaluation to ensure that these interventions are fully integrated into MNCH programs; and •  valuating the impact of an integrated approach to MNCH health services delivery—using a standard package of E services—on maternal, infant and early childhood outcomes.42 In addition to the funding provided directly to CDC by Congress, a share of CDC’s MNCH funding is provided through interagency transfers such as for PMTCT activities through PEPFAR and malaria programs through the PMI.47 6 THE U.S. GOVERNMENT’S EFFORTS TO ADDRESS GLOBAL MATERNAL, NEWBORN, AND CHILD HEALTH NIH NIH leads U.S. global health basic science research and, through implementation science, contributes to advances in field programs by translating recent research into tools appropriate for developing country settings.48 In addition to offering grant support to leading scientists, NIH also invests in training scientists, including those from developing countries. NIH also engages with other countries through bilateral health agreements, which sometimes include a focus on maternal and child health research.49 Among its contributions to the field of MNCH is research demonstrating that an inexpensive drug not typically used in developed countries could be appropriately used in resource poor settings to prevent postpartum hemorrhage, since it did not require cold storage and could be administered by trained nurse-midwives rather than specialized medical personnel.49 Most of NIH’s Institutes and Offices are engaged in MNCH efforts. The National Institute for Childhood Development (NICHD) carries out much of the global research related to MNCH, including sponsoring research on development, before and after birth; maternal, child, and family health; reproductive biology and population issues; and medical rehabilitation.50 NICHD’s Center for Research for Mothers and Children also hosts the Global Network for Women’s and Children’s Health Research which includes the National Center for Complementary and Alternative Medicine, the National Institute of Dental and Craniofacial Research, the National Cancer Institute, and the Fogarty International Center.51,52 Major U.S. Disease-Specific and Nutrition Initiatives That Address MNCH Infectious diseases, such as HIV/AIDS, malaria, NTDs, and tuberculosis (TB), and undernutrition cause or contribute to many maternal, newborn, and child deaths each year. As targeted efforts to reduce the impact of these health threats, U.S. global health initiatives such as PEPFAR, PMI, the U.S. NTD Initiative, and Feed the Future each contribute to U.S. efforts to reduce the global burden of maternal, newborn, and child deaths. These initiatives are largely focused on sub-Saharan Africa, where the greatest burdens of these diseases as well as maternal and child mortality exist, but—in the case of PEPFAR and the NTD Initiative—also reach other parts of the world, such as Asia and Latin America and the Caribbean. Although estimates for how much these programs invest in interventions that improve MNCH are not readily available (and such disaggregation is difficult), the activities of these programs often target mothers, newborns, and children and improve their health. • P  EPFAR, originally launched in 2003, is the largest effort by any nation focused on a single disease. Its programs aim to address the particular needs of mothers and children in HIV prevention, treatment, and care. PEPFAR’s impact on maternal and newborn health has been substantial. For example, PEPFAR reports that during its first six years, it prevented HIV infection in 340,000 babies through its support for a drug that prevents mother-to-child transmission of HIV (PMTCT) during pregnancy and childbirth.53 PEPFAR’s second phase, as specified in PEPFAR’s five-year strategy and the GHI, aims to provide increased services to mothers and children and to increase links between PEPFAR programs and MNCH efforts.54 For example, PEPFAR aims to double the number of at-risk babies born HIV-free and significantly scale up coverage of HIV testing for pregnant women. • P  MI programs focus on preventing and treating malaria infections through the use of several tools: insecticide-treated nets (ITNs) for mosquitoes to be used while sleeping, intermittent preventive treatment during pregnancy (IPTp) with a drug that prevents the mother from passing malaria to her child, and indoor residual spraying (IRS) with insecticides. Stressing free provision of ITNs for pregnant women and young children as well as expanded coverage of IPTp, PMI’s contributions to MNCH are in the initial stages of being evaluated. However, early data suggests that in 6 of the 15 PMI countries, child mortality dropped by 19-36% between 2003 and 2008, which is attributed at least in part to U.S. malaria support through the PMI and prior U.S. efforts.55 The U.S. government’s recently released six-year global malaria strategy specifies that, as part of the GHI, U.S. global malaria efforts, including PMI activities, will work to ensure that women remain at the center of USG-supported malaria prevention and treatment activities, and will target pregnant women and children under five, the two groups most vulnerable to the effects of malaria.56 PMI’s malaria prevention and control activities are implemented as part of integrated MNCH services. • T  he U.S. NTD Initiative is designed to address seven tropical diseases that are most commonly associated with poverty, poor sanitation, lack of access to clean water, and substandard housing. Pregnant women and children are more vulnerable to these diseases, which can cause serious health problems among these groups including anemia, malnutrition, impaired growth and development, severe disfigurement, and adverse pregnancy outcomes.57,58 With an emphasis on mass drug administration to address these diseases, the NTD Initiative reports that 50% of the recipients were women.36 THE U.S. GOVERNMENT’S EFFORTS TO ADDRESS GLOBAL MATERNAL, NEWBORN, AND CHILD HEALTH 7