The principles agreed at Alma-Ata 30 years ago apply just as much now as they did then. "Health for all" by the year 2000 was not achieved, and the Millennium Development Goals (MDGs) for 2015 will not be met in most low-income countries without substantial acceleration of primary health care. Factors have included insufficient political prioritisation of health, structural adjustment policies, poor governance, population growth, inadequate health systems, and scarce research and assessment on primary health care. We propose the following priorities for revitalising primary health care. Health-service infrastructure, including human resources and essential drugs, needs strengthening, and user fees should be removed for primary health-care services to improve use. A continuum of care for maternal, newborn, and child health services, including family planning, is needed. Evidence-based, integrated packages of community and primary curative and preventive care should be adapted to country contexts, assessed, and scaled up. Community participation and community health workers linked to strengthened primary-care facilities and first-referral services are needed. Furthermore, intersectoral action linking health and development is necessary, including that for better water, sanitation, nutrition, food security, and HIV control. Chronic diseases, mental health, and child development should be addressed. Progress should be measured and accountability assured. We prioritise research questions and suggest actions and measures for stakeholders both locally and globally, which are required to revitalise primary health care.

21 years ago, Rosenfield and Maine 1 Rosenfield A Maine D Maternal mortality—a neglected tragedy. Where is the M in MCH?. Lancet. 1985; 2: 83-85 Abstract PubMed Scopus (326) Google Scholar , 2 Rosenfield A Maine D Freedman L Meeting MDG-5: an impossible dream?. Lancet. 2006; published online Sept 28. DOI:10.1016/S0140-6736(06) 69386-0 Google Scholar , 3 Starrs AM Safe motherhood: 20 years and counting. Lancet. 2006; published online Sept 28. DOI:10.1016/S0140-6736(06)69385-9 PubMed Google Scholar posed the question “where is the M in MCH?”, conceiving the safe motherhood movement. What has happened to maternal and child health (MCH) since? Mothers are the cornerstone of families; their health and wellbeing is fundamental to the health of newborn babies and children, topics which have already been the focus of series in The Lancet. 4 Black RE Morris SS Bryce J Where and why are 10 million children dying every year?. Lancet. 2003; 361: 2226-2234 Summary Full Text Full Text PDF PubMed Scopus (1752) Google Scholar , 5 Lawn JE Cousens S Zupan J 4 million neonatal deaths: when? Where? Why?. Lancet. 2005; 365: 891-900 Summary Full Text Full Text PDF PubMed Scopus (2562) Google Scholar The Lancet now focuses on maternal health, providing an opportunity to assess progress, to review epidemiology 6 Ronsmans C Graham WJ Maternal mortality: who, when, where and why. Lancet. 2006; published online Sept 28. DOI:10.1016/S0140-6736(06) 69380-X Google Scholar and evidence to guide priority setting, 7 Campbell O Graham WJ Strategies for reducing maternal mortality: getting on with what works. Lancet. 2006; published online Sept 28. DOI:10.1016/S0140-6736(06)69381-1 Google Scholar and to analyse programmatic 8 Koblinsky M Matthews Z Hussein J et al. Going to scale with professional skilled care. Lancet. 2006; published online Sept 28. DOI:10.1016/S0140-6736(06)69382-3 Google Scholar and financing options. 9 Borghi J Ensor T Somanathan A Lissner C Mills A Mobilising financial resources for maternal health. Lancet. 2006; published online Sept 28. DOI:10.1016/S0140-6736(06)69383-5 Google Scholar The ultimate goal is to accelerate efforts to save lives. 10 Lawn JE Cousens SN Darmstadt GL et al. 1 year after The Lancet Neonatal Survival Series-was the call for action heard?. Lancet. 2006; 367: 1541-1547 Summary Full Text Full Text PDF PubMed Scopus (82) Google Scholar

A woman's right to health includes her right to a healthy childbirth and newborn, and the baby possesses his or her own right to life as well. White overall child mortality has declined, 4 million newborns still die each year, primarily in the first days of life. Most could be prevented through existing, cost-effective interventions.Field trials and programs show that low-cost, home- or community-based neonatal care can quickly lead to dramatic decline in neonatal mortality. Newborn health should be integrated with maternal and child health-and these programs should be strengthened and expanded-in order to achieve both the child and maternal survival Millennium Development Goats. Policies and programs should include participatory household and community-based care, with links to the format health system.Despite recent attention to newborn health, much remains to be done to achieve sustained, high coverage of effective interventions, especially in poor communities where most newborns are born and die, mostly in the first week of life. (c) 2006 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.

Mothers, newborns, and children are inseparably linked in life and in health care needs. In the past, maternal and child health policy and programmes tended to address the mother and child separately, resulting in gaps in care which especially affect newborn babies. How can these gaps be addressed, especially during birth and the first days of life, when most mothers and newborns die, and at home, where most newborn deaths in Africa occur?

The proportion of child deaths that occurs in the neonatal period (38% in 2000) is increasing, and the Millennium Development Goal for child survival cannot be met without substantial reductions in neonatal mortality. Every year an estimated 4 million babies die in the first 4 weeks of life (the neonatal period). A similar number are stillborn, and 0.5 million mothers die from pregnancy-related causes. Three-quarters of neonatal deaths happen in the first week-the highest risk of death is on the first day of life. Almost all (99%) neonatal deaths arise in low-income and middle-income countries, yet most epidemiological and other research focuses on the 1% of deaths in rich countries. The highest numbers of neonatal deaths are in south-central Asian countries and the highest rates are generally in sub-Saharan Africa. The countries in these regions (with some exceptions) have made little progress in reducing such deaths in the past 10-15 years. Globally, the main direct causes of neonatal death are estimated to be preterm birth (28%), severe infections (26%), and asphyxia (23%). Neonatal tetanus accounts for a smaller proportion of deaths (7%), but is easily preventable. Low birthweight is an important indirect cause of death. Maternal complications in labour carry a high risk of neonatal death, and poverty is strongly associated with an increased risk. Preventing deaths in newborn babies has not been a focus of child survival or safe motherhood programmes. While we neglect these challenges, 450 newborn children die every hour, mainly from preventable causes, which is unconscionable in the 21st century.

The global community recently declared a commitment to "create an environment—at the national and global levels alike—which is conducive to development and to the elimination of poverty". 1 United Nations General AssemblyUnited Nations Millennium Declaration: resolution adopted by the General Assembly 55/2. 8th Plenary Meeting, Sept 8, 2000. http://www.un.org/millennium/declaration/ares552e.htm Google Scholar This declaration led to an agreement on eight goals in key areas of global concern: the Millennium Development Goals. Central among those goals are two that aim to reduce maternal and child mortality, goals 4 and 5. Investment in maternal, newborn, and child health is not only a priority for saving lives, but is also critical to advancing other goals related to human welfare, equity, and poverty reduction. 2 Freedman L Wirth ME Waldman R Chowdhury M Rosenfield A Millennium Project Task Force 4: child health and maternal health interim report. Millennium Project, New York2004http://www.unmillenniumproject.org/html/tf4docs.shtm Google Scholar Newborn survival: putting children at the centrePublished online March 3, 2005. http://image.thelancet.com/extras/05cmt82web.pdf Full-Text PDF Epidemiological transition, medicalisation of childbirth, and neonatal mortality: three Brazilian birth-cohortsOver the past two decades, Brazil has seen improvements in women's nutritional status, education, smoking habits, and antenatal care. Neonatal mortality rates (deaths of liveborn infants up to 1 month of age), however, have changed little. In this issue of The Lancet, Fernando Barros and colleagues present fascinating data from three birth-cohorts which suggest that falling mortality in term infants (37 weeks' gestation or more) has been offset by a rise in preterm births and deaths, resulting in little change in neonatal mortality. Full-Text PDF Conceiving and dying in AfghanistanSince the first International Safe Motherhood Conference in 1987, there has been increased focus on maternal health and maternal mortality. The design and implementation of effective programmes for maternal health require data of adequate quality, despite the challenges of generating such data.1 Typical approaches have produced data of low quality and limited usefulness.2 Therefore, Linda Bartlett and colleagues' report in today's Lancet is of particular merit for its use of rigorous methodology. Full-Text PDF 4 million neonatal deaths: When? Where? Why?The proportion of child deaths that occurs in the neonatal period (38% in 2000) is increasing, and the Millennium Development Goal for child survival cannot be met without substantial reductions in neonatal mortality. Every year an estimated 4 million babies die in the first 4 weeks of life (the neonatal period). A similar number are stillborn, and 0·5 million mothers die from pregnancy-related causes. Three-quarters of neonatal deaths happen in the first week—the highest risk of death is on the first day of life. Full-Text PDF

Four million newborns die every year at home, often without skilled care at delivery or any other contact with the formal health system. Improved household practices and use of services, often in the community, should improve survival. We developed a conceptual framework for household and community newborn and maternal care that acknowledges the inseparability of the mother and neonate, yet stresses elements relating to the newborn, heretofore underemphasized in safe motherhood and child-survival programs. The framework identifies five paths that, if implemented well, would generally improve newborn outcomes: (1) use of routine maternal and newborn care and good-quality services; (2) response to maternal danger signs; (3) response to the nonbreathing newborn; (4) care for the low birth weight baby; and (5) response to newborn danger signs, particularly those of infection. This model, balancing preventive (19 routine behaviors) and curative care (14 special behaviors), is rooted in the community, bridges safe motherhood and child survival, and provides a framework for newborn health research, programmatic, and advocacy agendas for developing countries.

Hans Troedsson, Jose Martines, Jelka Zupan Research and implementation of programs to improve perinatal and neonatal health are carried out by a broad collaboration of clusters at the WHO. Most activities are centered in the Family and Community Health cluster, but research and development activities also occur in the Health Technology and Pharmaceuticals cluster, the Sustainable Development and Healthy Environments cluster (nutrition), and Communicable Diseases cluster. The Tobacco-Free Initiative, a cabinet project, also seeks to improve perinatal health by reducing smoking during pregnancy. Major strategies to develop and adapt evidence -based guidelines for detection and treatment of clinical conditions are done through Integrated Management of Pregnancy and Childbirth ( IMPAC) and Integrated Management of Childhood Illness ( IMCI). Research and development activities to improve facility -based care of pregnant women and their infants currently focus on field testing and validation of IMPAC guidelines; revision of IMCI young infant guidelines; managerial tools for strengthening access to and quality of the health care system; development of simpler, effective treatments of neonatal infections and follow-up of infants at risk. Community -based research and interventions seek to: improve home care and care seeking; provide linkages with the community and support for women with special needs; early initiation of exclusive breast feeding; prevention of MTCT of HIV through feeding; and maximize the benefits of IMCI feeding counseling. Specific research activities to improve infant feeding in settings of high prevalence of HIV infections include: assessing the influence of infant feeding patterns on MTCT, infant morbidity, and mortality; identifying feasible and practical ways of improving the quality and safety of replacement feeding; determining how best to ensure that the transition period between exclusive breast feeding and no breast feeding carries a minimum risk of HIV transmission, nutritional, and psychological risks for infant and mother; examining the role of mastitis in HIV transmission through breast milk and how to minimize such problems; and assessing the effects of infant feeding recommendations for HIVinfected mothers on general population behaviors related to breast feeding. One study on care seeking and adherence to treatment for neonatal illness has recently been completed in a periurban cohort in New Delhi, India. WHO researchers found that 60% of deaths occurred within 24 hours of recognition of illness, 40% of caregivers did not seek outside care, and 70% of care was sought from private providers. Half of those private providers had no formal medical education, and failed to refer 70% of the newborns that eventually died. Lastly, less than half of caregivers followed referral recommendations. Further work is currently in progress to understand the barriers to care seeking for young infants and develop interventions to improve it.

Mothers, newborns, and children are inseparably linked in life and in health care needs. In the past, maternal and child health policy and programmes tended to address the mother and child separately, resulting in gaps in care which especially affect newborn babies. How can these gaps be addressed, especially during birth and the first days of life, when most mothers and newborns die, and at home, where most newborn deaths in Africa occur? Policy and programme attention is shifting towards a maternal, newborn, and child health (MNCH) continuum of care. Instead of competing calls for mother or child, the focus is on universal coverage of effective interventions, integrating care throughout the lifecycle and building a comprehensive and responsive health system. The MNCH continuum of care can be achieved through a combination of well defined polices and strategies to improve home care practices and health care services throughout the lifecycle, building on existing programmes and packages. What is the current coverage of MNCH essential packages along the continuum of care, and how can these be strengthened to increase coverage, equity, and quality of care? Which interventions within the continuum of care would save newborn lives? Are there specific opportunities that could be seized?

Improving women's health requires a strong and sustained commitment by governments and other stakeholders, a favorable policy environment, and well-targeted resources. Long term improvements in education and employment opportunities for women will have a positive impact on the health of women and their families. In the short term, significant progress can be achieved by strengthening and expanding essential health services for women, improving policies, and promoting more positive attitudes and behavior towards women's health. In the design and implementation of programs, constraints to women's acess to care need to be taken into account. Outreach, mobile clinics and community-based services can be helpful. Women should be empowered to make more informed decisions and to act on them. Quality of care is a significant factor in women's decision to seek care. Effective client-provider interaction is increasingly recognized as a key factor for improving quality of services. In addition to strengthening services, through legislation, legal enforcement, and information, education, and communication, harmful practices such as gender discrimination, domestic violence, and female genital mutilation can be curbed. Close collaboration among government, non-governmental organizations, communities, and women's groups will make service more responsive to women and improve utilization and impact.