1000 Days: The beginning of a child’s right to health
Dan Irvine, Senior Director, Sustainable Health, World Vision International, discusses international policy and strategy for promoting the health and wellbeing of all the world’s young children.
I’ll take my cue from a singular line in the 1989 Convention on the Rights of the Child (CRC), Article 6.2: ‘State parties shall ensure to the maximum extent possible the survival and development of the child’. What a glorious day it was when this convention was ratified, marking essentially the transcendence of child well-being from something haphazardly hoped for, to an accountable right and responsibility. ‘Haphazard’, you ask? Well, consider that by the year 2000, over 40 percent of the world’s newborns still did not benefit from formal birth registration. Of course, the CRC speaks in far greater detail to the domains of child well-being: physical, mental, emotional, spiritual and moral, laying out an indelible blueprint for duty bearers and development agents worldwide. It is thus a pleasure to celebrate the 30th anniversary of the CRC this year.
It is roughly within this period of the last 30 years that the concept of 1000 days of child health and nutrition - pregnancy through the first two years - has flourished as a global accountability. For example, the World Health Organisation (WHO) launched its global polio eradication campaign in 1988. The Global Alliance for Vaccines and Immunisation was launched in 2000, and Scaling up Nutrition in 2009. In 2000 also, the Millennium Development Goals (MDG) were born, prioritizing reduction in under-five child mortality (by two thirds), maternal mortality (by three quarters), universal access to reproductive health and reversal in incidence of infectious diseases. Countdown 2015 was formed in 2003 to monitor health MDG progress at country level, capitalising on critical national data provided by the Demographic Health Surveys since 1984, and Multiple Indicator Cluster surveys since 1995. World Vision’s public health work was heavily influenced by the 2003 Lancet series on Child Survival, followed by their Neonatal Survival series in 2005. These are non-exhaustive highlights of an unprecedented global focus on maternal and child health that peaked in international health financing terms in 2013.
In 2019, a review of the ‘1000 day’ agenda has to start with an appreciation of the significant progress made. Maternal deaths decreased from 532,000 per year in 1990 (385/100,000 live births) to 303,000 in 2015 (216/100,000) Global infant mortality has declined from 8.8 million deaths in 1990 (65 per 1,000 live births) to 4.1 million in 2017 (29/1,000). For even greater perspective, consider that in 1950, global infant mortality exceeded 14 million per year. Essentially, we now know how to effectively prevent morbidity and mortality in mothers and newborns, and we have the tools with which to do it. To the extent that we can ensure full and consistent population coverage with these tools, with quality, we can win this fight.
Looking forward, we might say that we have an unfinished 1000 day agenda as per the MDG mortality construct, and a more recently expanded ‘thrive and transform’ agenda, well established in the 2016 Global Strategy for Women’s, Children’s and Adolescents’ Health. In developing contexts, we have seen significant reductions in under-five child mortality due to action on vaccine-preventable and infectious diseases, but slower progress in addressing neonatal causes of death, which now represent 45 percent of the total under-five mortality, and include pre-term birth complications, pneumonia, intrapartum complications and diarrhea. Following on from the Lancet Neonatal series, we now have the Essential Newborn Action Plan (2014) and the Family Planning 2020 movement (2012), each seeking to catalyze global action on these issues. One significant barrier to realization of these strategies remains low health worker density in many countries. The 2016 WHO ‘Global Strategy on Human Resources for Health: Workplan 2030’ suggests that an additional 40 million health and social care jobs, and 18 million health workers are required, in particular in low resource settings. Issues of equitable access to care, and quality of care, will only be successfully addressed when we care also for our health workforce, enabling them with regard to number, training, equipment, supervision and remuneration to perform optimally.
The 1000 day agenda has historically been largely concerned with nutrition which today, like the direct neonatal causes of mortality, has increased in proportionality as an indirect contributor to that mortality. In 2018, WHO submitted its biennial report on maternal, infant and young child nutrition to the World Health Assembly, and the news was not good: a modest global decline in stunting, increases in anemia in women of reproductive age, and obesity in children, little progress on exclusive breastfeeding, and virtually stagnant levels of wasting and low-birth weight. While it may be true that the current global hunger crisis exceeding 800 million people is largely driven by conflicts and natural disaster, we cannot pretend that this is the sole driver of global malnutrition affecting two billion people, and millions of women of reproductive age, pregnant women, newborns and infants in relatively stable contexts. I was recently evaluating a nutrition programme in a fragile but stable context with a moderate (seven percent) level of severe acute malnutrition (SAM) and was astonished to find that the country had no treatment policy to address it. As a result, the affected children are simply sent home. I was also astonished to read in the WHO report that only 10 percent of births occur in facilities designated as ‘baby friendly’. We know how to treat SAM, and there is an unequivocal rationale for certification in the Baby Friendly Hospital initiative. There seems to be a debilitating apathy in health systems towards developmental nutrition issues, almost as if it’s a ‘second rate’ problem. Globally, we have seen investment in direct nutrition intervention decrease over the last two years. As we approach the mid-point of the United Nations’ Decade of Action on Nutrition, we must advocate hard for a robust 2020 round of Nutrition for Growth commitments that will focus not only on financing, but also on improved policy and investment where we have strong evidence of returns.
We understand health and nutrition in the 1000 day period to be a foundational longitudinal prerequisite for a healthy and successful life. This is the basis for the expanding early childhood development agenda, which continues to emphasize 1000 day health and nutrition objectives while calling for a more holistic approach to babies, toddlers and young children. This is best articulated in the Nurturing Care Framework for Early Child Development (NCF) launched in 2018. Building on the evidence of health and nutrition impact on early brain development, we are now broadening our appreciation of the developmental importance of safe, clean and stimulating environments for these children. The nurturing care approach is wonderful in its emphasis on compassionate care-giving by care givers at the household level, as well as its call for positive policy structures, enabling environments, and competent health workers, who are deemed to be the professional frontline in this interaction. World Vision published research in 2019 demonstrating that integrating a set of ‘early child development’ behavioral interventions into a ‘maternal and child health’ package led to an 83 percent increase in cognitive, language and motor skills amongst children 0 – 23 months, as well as better child care, nutrition practice and early learning support. This more holistic approach to 1000 day child development has the opportunity to both strengthen core health and nutrition interventions and exponentially increase child well-being impact through addressing a more comprehensive set of determinants. Advocating for NCF adoption is one the best current opportunities to positively influence these outcomes as it implies cross-sectoral leverage and improved national policy frameworks.
Moving forward, one additional opportunity for the 1000 day agenda is the relatively new global prioritization of adolescent health and nutrition. ‘Adolescents’ are now consistently appended to ‘Maternal, Newborn and Child’ health strategies and in 2017, the Every Woman Every Child Independent Accountability Panel published a very good adolescent accountability framework. These strategies call for comprehensive sexuality education and enhanced sexual and reproductive health services and rights, addressing sexual violence including early marriage, prevention of sexually transmitted diseases including HIV, improved nutrition, and life-skills. The potential impact on the health of young mothers and newborns is tremendous. This is an agenda that can help us improve family planning, address maternal anemia and low-birthweight, and prevent mother to child transmission of HIV. Adolescents have every right to health and are a critical link in a 1000 day-focused lifecycle approach.
As the CRC was being written in 1989, I was finishing my undergraduate work in psychology. One of my muses in those days was the clinical psychologist, George Kelly, an early pioneer of cognitive clinical psychology. Dr. Kelly developed personal construct psychology, essentially proposing that cognition is the outcome of the sum of personal experience. We now know that the longitudinal impact of that experience is heavily weighted to the 1000 day period, commences no later than the second trimester of pregnancy, and that not only physical but sensory and emotional experiences are influential. We know that nurturing needs to commence pre-conception, as an enabling environment is required from conception. And we know that if this environment is not optimal, lifelong opportunities begin to vanish irrevocably. It is clear that in our age of aspiration for universal health coverage, we must look beyond health service delivery to healthy families and healthy communities. Children’s health is everyone’s responsibility.
Documents informing this editorial:
Accountability for the Health and Human Rights of Women, Children and Adolescents in the 2030 Agenda. WHO, 2017
Birth Registration: Right from the Start. UNICEF, 2002
Global Health Observatory (GHO) data: Infant mortality. WHO, 2017
Global Strategy on Human Resources for Health: Workforce 2030. WHO, 2016
Maternal, Infant and Young Child Nutrition Comprehensive Implementation Plan on Maternal, Infant and Young Child Nutrition: Biennial Report. WHO, 2018
Millennium Development Goals (MDG) monitoring. UNICEF, 2011
Nurturing Care for Early Childhood Development: A Framework for Helping Children Survive and Thrive to Transform Health and Human Potential. WHO, 2018
Rosales, A. et al. (2019) Behavior change communication model enhancing parental practices for improved early childhood growth and development outcomes in rural Armenia – A quasi-experimental study. Preventive Medicine Reports, 14:100820
The Global Strategy for Women’s, Children’s and Adolescents’ Health (2016-2030), Survive, Thrive, Transform, 2018
The Two Best Ways to Reduce Infant Mortality. World Economic Forum, 2018
Tracking Progress Towards Universal Coverage for Women’s, Children’s and Adolescents’ Health. UNICEF & WHO, 2017
Trends in Maternal Mortality: 1990 to 2015 Estimates by WHO, UNICEF, UNFPA, World Bank Group and the United Nations Population Division. WHO, 2015
United Nations Convention on the Rights of the Child, 1989