Although a number of U.S. agencies and departments implement global health programs that might improve child survival and maternal health (CS/MH), this report focuses only on CS/MH programs conducted by the U.S. Agency for International Development (USAID) from FY2001 to FY2008. This report also discusses the interconnected nature of USAID's global health programs, such as how advancements made in addressing malaria might improve maternal and child survival. In the United Nations Children's Fund (UNICEF) report The State of the World ' s Children 2008: Child Survival , UNICEF Executive Director Ann Veneman celebrated the decline of total annual deaths among children under age five. In 2006, an estimated 9.7 million children in that age range died, representing a 60% drop in under-five mortality since 1960. Despite the decrease, Ms. Veneman asserted that a critical number of daily deaths among children under five remains high; some 26,000 die each day. Most studies that measure child mortality focus on deaths that occur before age five because 90% of childhood deaths occur during this time, while 37% occur during the neonatal period (the first 28 days), amounting to about 4 million annual newborn deaths. The majority of child deaths occur in developing countries, and almost half of them in Africa. On average, nearly 90% of all child deaths are caused by neonatal infections and five infectious diseases: acute respiratory infections (mostly pneumonia), diarrhea, malaria, measles and HIV/AIDS ( Table 1 ). According to UNICEF, undernutrition is the underlying cause of up to half of these deaths. Some health experts assert that maternal and child health are particularly important to monitor, because their mortality rates serve as a barometer for overall health conditions. Supporters of this idea often use the Millennium Development Goals (MDGs) listed in Table 2 to demonstrate the interconnected nature of health and development and to gauge improvements in child and maternal health ( Table 3 ). MDGs 4 and 5 call for a two-thirds reduction in child and maternal mortality. The ability to reach those goals, however, is affected by progress in other MDGs. For example, countries with significant undernourished populations (MDG 1) that lack sufficient access to clean water (MDG 7) tend to have higher maternal and child mortality rates (MDGs 4 and 5); undernourished women and children are also more likely to be impoverished (MDG 1) and are more susceptible to infectious diseases, such as HIV/AIDS, TB, and malaria (MDG 6). UNICEF found that 62 countries were making no progress towards the Millennium Development Goal on child survival; nearly 75% of these were in Africa. UNICEF asserts that child survival and maternal health are inextricably linked. More than 500,000 women die each year due to pregnancy-related causes, and an additional 15-20 million more suffer debilitating long-term effects, such as obstetric fistula (discussed below). The vast majority of women who die during or shortly after labor live in developing countries where maternal mortality rates are significantly higher than in industrialized nations ( Table 4 ). The United Nations Food and Agriculture Organization (FAO) maintains that almost all of these deaths could be prevented if women in developing countries had access to adequate diets, safe water and sanitation facilities, basic literacy, and health services during pregnancy and childbirth. UNICEF estimates that 20% of all maternal deaths are linked to undernutrition and that about 75% of maternal deaths are caused by obstetric complications including hemorrhage, sepsis, hypertensive disorders (mostly eclampsia), prolonged or obstructed labor, and unsafe abortions. Maternal mortality and morbidity rates are generally higher for mothers younger than 20 years who typically have more pregnancy and delivery complications, such as toxemia, anemia, premature delivery, prolonged labor, and cervical trauma, and are at higher risk of delivering low birth weight babies. Pregnancy-related complications are the leading cause of death among 15- to-19-year-olds around the world, and their babies have higher morbidity and mortality rates. The United Nations estimates that adolescents give birth to 15 million infants each year. Girls aged between 15 and 19 years are twice as likely to die from childbirth as women in their twenties, and those younger than 15 years are five times as likely to die. A survey conducted in Mali indicated that the maternal mortality rate for girls aged between 15 and 19 years was 178 per 100,000 live births and 32 per 100,000 for women aged between 20 and 34 years. Causes of maternal death vary significantly among regions. Data collected from 1990 through 2006 indicate that hemorrhage caused about 34% and 31% of maternal deaths in Africa and Asia, respectively. In industrialized nations and Latin America and the Caribbean, hemorrhage caused an estimated 13% and 21% of maternal deaths, respectively ( Table 5 ). The United Nations has found that regions with the lowest proportions of skilled health attendants at birth also have the highest maternal mortality rates. In sub-Saharan Africa, 43% of women gave birth with the assistance of a skilled birth attendant, 65% in south Asia, and 99% in industrialized nations. One in every 22 women in sub-Saharan Africa will likely die from pregnancy-related causes, as will one in every 59 Asian women. In industrialized nations, meanwhile, one in every 8,000 woman faces the probability of dying from pregnancy-related causes. UNICEF has found that health systems in many countries do not have the capacity to reduce mortality nationwide. Of the 68 priority countries that account for 97% of all maternal and child deaths, 54 (80%) have health workforce densities below the critical threshold (2.5 health workers per 1,000 people) for significantly improving their health conditions and reaching the health-related MDGs ( Table 6 ). South Africa and Swaziland are the only two sub-Saharan African countries among the 68 priority countries that have reached the minimum standard. Child and maternal survival rates are higher in areas with ample numbers of health workers to administer immunizations, easy access to clean water, controlled mosquito populations, and sufficient access to nutritious food. While the greatest shortage of health care workers in absolute terms is in southeast Asia (mostly in Bangladesh, India, and Indonesia), sub-Saharan Africa suffers from the greatest proportional shortage of health care workers in the world. WHO estimates that there are 57 countries with critical shortages of health care workers, of which 36 are in Africa and none in industrialized nations. Globally, WHO estimates that an additional 4.3 million health workers are needed, and that on average, countries across Africa would need to increase their number of health workers by about 140% in order to meet the minimum threshold of 2.5 health care professionals per 1,000 people. The U.S. Agency for International Development is the lead U.S. agency responsible for improving child survival around the world. According to USAID, research that it supported during the 1970s and 1980s has been used to develop interventions and technologies now used to save millions of children. Over the past 20 years, USAID has committed more than $6 billion in support of global child survival efforts. About half of those funds were committed from FY2001-FY2008, when Congress appropriated $3.4 billion to child survival and maternal health efforts. Recognizing that six health problems (acute respiratory infections, diarrhea, malaria, HIV/AIDS, measles, neonatal complications) cause about 90% of all child deaths in developing countries and that undernutrition contributes to half of these, USAID allocates a significant proportion of its child survival funds to addressing these health issues. This section summarizes information USAID has presented about its efforts to improve child and maternal health. The United Nations Food and Agriculture Organization (FAO) argues that the vast majority of the nearly 10 million children who die each year "would not die if their bodies and immune systems had not been weakened by hunger and malnutrition." Ten WHO-supported community-based studies conducted from 1991 through 2001 of children under age five found that children who are mildly underweight are about twice as likely to die of infectious diseases as children who are better nourished; for those who are moderately to severely underweight, the risk of death is five to eight times higher. The studies also indicated that 45% of children who died after contracting measles were malnourished, as were more than 60% of children who died after the onset of severe diarrhea. Good nutrition can improve child survival, health, and cognitive development, while undernutrition impairs the immune system. Children with impaired immune systems disproportionately suffer from common childhood illnesses such as diarrhea, pneumonia, and measles. Undernourished children have also been found to be more susceptible to other infectious diseases such as malaria and tuberculosis. This section discusses USAID's nutrition programs, which focus on micronutrient supplementation and fortification and infant and young child feeding (IYCF). "USAID-supported micronutrient programs add vital immune-building micronutrients including zinc, vitamin A, iron, and iodine to processed foods such as rice and sugar." USAID funds are also used to expand research on biofortified crops, which could improve the micronutrient content of basic foods, such as maize enhanced with vitamin A, iron, and zinc; beans enhanced with iron and zinc; and sweet potatoes enhanced with vitamin A. Micronutrient supplementation and other USAID nutrition programs are integrated with other interventions, including safe water, hygiene and sanitation. USAID estimates that more than "two-thirds of malnutrition-related infant and child deaths are associated with poor feeding practices during the first two years of life." According to USAID, "less than one third of infants in most countries are exclusively breastfed during the first six months of life." Early cessation of breastfeeding and introducing foods either too early or too late expose infants to disease. USAID contends that the foods that are introduced are often nutritionally inadequate and unsafe.