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THE LANCET: Conflict, political instability linked to higher rates of maternal and child mortality in Muslim-majority countries

29 January 2018 The Lancet

Countdown to 2030 report tracks progress towards Sustainable Development Goals (SDG) for women and child health.

Muslim-majority countries have higher maternal, stillbirth, newborn and child mortality rates compared to the global average and compared to non-Muslim-majority countries, highlighting the impact of conflict and political instability on health outcomes for women and children, according to new research published in The Lancet.

There is no indication that religion affects health outcomes, and the findings of the study point to issues such as conflict, migration, political instability and government effectiveness, as key drivers of differences in maternal and child mortality.

Evidence from around the world also shows that higher literacy and empowerment of women positively impact on maternal and child health. While several Muslim-majority countries have made progress on indicators of empowerment and access to sexual and reproductive healthcare, the authors say greater efforts are now needed.

Every year, worldwide, an estimated 303000 mothers and 5.9 million children younger than 5 years die from largely preventable causes. More than 95% of these deaths occur in 75 countries of the world (known as Countdown countries [1]), predominantly in south Asia, the Middle East and Africa.

“There are several success stories among many Muslim-majority countries, especially for reductions in child mortality in Niger, Maldives, Morocco, Azerbaijan, Senegal, Bangladesh, and Egypt. Our analysis highlights that governance and structural factors, such as conflict and political instability, rather than religion, are among the key drivers behind the higher rates of maternal and child mortality in Muslim-majority countries,” says lead author Professor Zulfiqar A Bhutta from the Centre for Global Child Health at The Hospital for Sick Children (Toronto, Canada) and the Aga Khan University (Karachi, Pakistan). [2]

“At its core, the fundamental principles of the Islamic faith include the promotion of social justice and individual flourishing through personal hygiene, nutrition, abstinence from harmful substance use, and the fostering of healthy environments,” adds Professor Bhutta. “It is in this context that our findings of significantly lower rates of coverage of some essential services such as sanitation and childhood immunizations in Muslim-majority countries are a call for action to address these forthwith.” [2]

“Poor governance, lack of accountable and democratic governments as well as insecurity, conflict and population displacement emerge as key determinants driving health disparities. Unequal societies are also fertile grounds for the growth of rebellion and militancy, especially in young people. Efforts to improve the health of almost two billion Muslims worldwide, and reduce health inequalities, will prove vital to achieving the Sustainable Development Goals, including peace building over the next 15 years,” adds Professor Bhutta. [2]

The authors of the study compared mortality rates in all Muslim-majority countries worldwide against global averages and against non-Muslim-majority countries between 1990 and 2015. They also analysed the factors driving differences in mortality for 26 Muslim-majority and 48 non-Muslim-majority Countdown countries.

Also published today in The Lancet, is the first comprehensive report of Countdown to 2030, tracking global progress toward SDG targets on universal coverage for reproductive, maternal, newborn, child, and adolescent health and nutrition [3].

Between 2010 and 2015, average rates of maternal (230 vs 220 deaths per 100,000 live births), neonatal (25 vs 21 deaths per 1000 live births), stillbirths (23 vs 20 stillborn per 1000 births), and child mortality (28 vs 26 deaths per 1000 live births) were higher for Muslim-majority countries, compared to the global average.

Similarly, among Countdown countries, between 2010 and 2015, rates of maternal (263 vs 233 deaths per 100,000 live births), neonatal (28 vs 21 deaths per 1000 live births), stillbirths (26 vs 18 stillborn per 1000 births), and child mortality (33 vs 26 deaths per 1000 live births) were higher for Muslim-majority compared to non-Muslim-majority countries, respectively.

Countdown Muslim-majority countries performed worse in five governance indicators including control of corruption, government effectiveness, political stability or absence of terrorism, regulatory quality and rule of law.

In total, the 26 Countdown Muslim-majority countries experienced approximately five times more battle-related deaths (148207 vs 35731 deaths), and three times more terrorist incidents, deaths and injuries than all 48 non-Muslim-majority countries. Currently, about 11.6 million civilians are internally displaced within Muslim-majority countries.

The average density of health workers including physicians, nurses, and midwives was lower in Countdown Muslim-majority countries (20 vs 31 per 10,000 people) and was below the WHO recommended threshold of 23 workers per 10,000. Total health expenditure (4.2% vs 5.4% of GDP), and coverage of some essential services was also lower for Muslim-majority countries compared to non-Muslim majority countries in Countdown. For example, contraceptive use (60% vs 79%), skilled birth attendance (59% vs 96%), measles vaccination (76% vs 98%), DTP3 vaccination (78% vs 98%), and access to sanitation facilities (61% vs 76%) was lower in Muslim majority countries. Exclusive breastfeeding was higher in Muslim-majority countries (39% vs 27%).

The authors find that legislation and policies specifically protecting women were often insufficient or poorly implemented in Muslim-majority compared to non-Muslim-majority countries, including fewer countries with specific policies on domestic violence (21% vs 49%).

Analysing how these contextual factors affect mortality rates within Muslim-majority countries, the researchers found that under-5 mortality increased with higher numbers of refugees, and decreased with better political stability or absence of terrorism, greater political rights or government effectiveness, improvements in national income per capita, higher total adult literacy, higher female adult literacy and greater female to male enrolment in secondary school.

The authors note that Islam, like many religions, is often invoked by fundamentalists as a justification for violating women’s rights. But, while some Islamic countries have shown to be more repressive of women’s rights, several countries have exercised reproductive rights with relatively liberal abortion and family planning laws, namely in Egypt and Tunisia. Similarly, many Muslim countries, such as Bangladesh, have made significant progress on the empowerment of young women, increasing literacy, and the prevention of child marriage.

Among the Countdown countries, the best performing Muslim-majority countries were Azerbaijan, Bangladesh, Egypt, Indonesia, Kyrgyzstan, Morocco, Niger and Senegal, which had higher coverage of family planning interventions and newborn or child vaccinations, and generally performed better on many of the contextual determinants when compared to other Muslim-majority countries.

“Evidence from around the world shows us that insufficient empowerment and lack of social support for women limits their accessibility to basic healthcare, including family planning, and adversely impacts health, nutrition and well-being of the entire family. Used as facets of female empowerment, the low levels of female literacy, high fertility rates, and early marriage of young girls seen in many Muslim-majority countries need urgent remediation,” states Nadia Akseer, first author of the report from the SickKids Centre for Global Child Health (Toronto, Canada).

The authors also note that the Islamic faith calls on all Muslims with financial capacity to allocate 2.5% or more of their net assets to those in need, and say that the Organisation for Islamic Cooperation should help facilitate resource sharing from wealthier Islamic countries to poorer and more fragile states, to encourage equity across the Islamic world.

The authors note that while the study compared Muslim-majority and non-Muslim majority countries, it did not explore Muslim versus non-Muslim subpopulations within Islamic countries, countries such as India, China, and Nigeria, which have substantial Muslim populations (but less than 50%), or how the individual practices of Islam are implemented within countries. Further research will be needed to examine these questions.

Writing in a linked Comment, Amina Mohammed, Deputy Secretary-General, United Nations, says: “Greater investments in reproductive, maternal, newborn, child, and adolescent health are (also) some of our greatest tools in the face of rising levels of conflict and humanitarian crisis, which disproportionately affect Muslim-majority countries. We must prioritise the potential of women and adolescents as agents of peace through greater investments across health, education, and economic sectors."

NOTES TO EDITORS
The study was funded by the US Fund for UNICEF under the Countdown to 2015 for Maternal, Newborn, and Child Survival, the Centre for Global Child Health, Hospital for Sick Children, and the Aga Khan University.
[1] Countries were classified as a Muslim-majority country if over 50% of the population self-identified as Muslim, or if the country was part of the Organisation for Islamic Cooperation (OIC). In 2000, the Millennium Declaration set a target for improving health and reducing mortality of children by two thirds (MDG 4) and mothers by three-quarters (MDG 5) from 1990 base figures. Globally, the maternal mortality ratio dropped by about 44% from 1990 to 2015, and the under-5 mortality rate declined by 53%. Still, an estimated 303000 mothers and 5.9 million children younger than 5 years die every year from largely preventable causes. More than 95% of these deaths occur in 75 countries of the world so-called Countdown countries. Of the 75 Countdown countries, 74 were included in the analysis. Nigeria has a roughly 50-50 split of Muslims and Christians so was not included in the analysis to avoid misclassification.
[2] Quote direct from author and cannot be found in the text of the Article
[3] www.countdown2030.org

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