Improving maternal and newborn health in Kyrgyzstan
Authors: Bernd Rechel, Saltanat Moldoisaeva
Journal: The Lancet Global Health (2020)

Maternal, newborn, and child health are key indicators of health system performance. They are also a major focus of national and international policies, including the Sustainable Development Goals. In The Lancet Global Health, Mahdis Kamali and colleagues1Kamali M Wright JE Akseer N et al.Trends and determinants of newborn mortality in Kyrgyzstan: a Countdown country case study.Lancet Glob Health. 2020; (published online Dec 10.)https://doi.org/10.1016/S2214-109X(20)30460-5Summary Full Text Full Text PDF PubMed Scopus (1) Google Scholar report the findings of a study on trends and determinants of newborn mortality in Kyrgyzstan. The study of newborn mortality in central Asia is an underexplored area for which survey data have to be weighed against data from vital registration systems. Kamali and colleagues used publicly available data repositories and the national birth registry of Kyrgyzstan to assess trends of reproductive, maternal, and newborn health and mortality between 1990 and 2018. The authors also did a review of national policies and programmes and a prospective Lives Saved Tool analysis, to identify interventions with the potential to avert the most maternal, neonatal, and child deaths. Their findings showed that, in the past two decades, Kyrgyzstan reduced newborn mortality rates by 46% and mortality rates of children younger than 5 years by 69%, whereas maternal mortality rates were reduced by 7% and stillbirth rates by 29%. With scale-up of a few essential neonatal and maternal interventions, 39% of neonatal deaths, 11% of stillbirths, and 19% of maternal deaths could be prevented by 2030. Although these findings reveal important progress in Kyrgyzstan, it is striking that a much larger decline in newborn mortality was achieved across the central Asian region (70% vs 46% in Kyrgyzstan). Additionally, maternal mortality in Kyrgyzstan declined by only 7% between 1990 and 2017 (from a rate of 82 to 76 deaths per 100 000 livebirths), compared with 54% in the central Asian region. This is perplexing, because Kyrgyzstan has undertaken several measures to promote mother and child health and has gained the reputation of being a pioneer of health reforms in the region. Some indication exists that the country's vital registration systems might be more complete than those in some other countries of the region,2Ibraimova A Akkazieva B Ibraimov A Manzhieva E Rechel B Kyrgyzstan: health system review.Health Syst Transit. 2011; 13 (xv–xx, 1–152.): xiiiPubMed Google Scholar but there are also wider challenges at play. Maternal and child health were strategic priorities already in the Soviet period and became so again after Kyrgyzstan gained its independence in 1991. In 2004, Kyrgyzstan introduced the international definition of livebirth and started setting up a facility-based register of newborn, child, and maternal mortality. In 2006, the Ministry of Health set up a National Mother and Child Health Unit and the Republican Centre for the Protection of Mother and Child Health. Since 2007, a national committee has done an annual review of all pregnancy-related and delivery-related deaths. Both the Manas Taalimi (2006–10) and the Den Sooluk health reform programme (2012–18) prioritised maternal and child health.1Kamali M Wright JE Akseer N et al.Trends and determinants of newborn mortality in Kyrgyzstan: a Countdown country case study.Lancet Glob Health. 2020; (published online Dec 10.)https://doi.org/10.1016/S2214-109X(20)30460-5Summary Full Text Full Text PDF PubMed Scopus (1) Google Scholar Yet, reform progress stalled in the past few years.3Ancker S Rechel B McKee M Spicer N Kyrgyzstan: still a regional ‘pioneer’ in HIV/AIDS or living on its reputation?.Central Asian Survey. 2013; 32: 66-84Crossref Scopus (5) Google Scholar Universal access to health services remains a challenge in view of high out-of-pocket payments, including informal payments. Private out-of-pocket payments accounted for 56% of current health expenditure in 2017.4WHOGlobal Health Expenditure database.https://apps.who.int/nha/database/ViewData/Indicators/enDate: 2020Date accessed: November 2, 2020Google Scholar The main drivers of out-of-pocket spending are medicines and medical products, which together accounted for more than 50% of household spending in 2000–14.5Akkazieva B Jakab M Temirov A Long-term trends in the financial burden of health care seeking in Kyrgyzstan, 2000–2014. WHO Regional Office for Europe, Barcelona2016Google Scholar While external donors remain important, the share of external aid as a percentage of current health expenditure declined from a high of 15·7% in 2004, to 5·6% in 2017.4WHOGlobal Health Expenditure database.https://apps.who.int/nha/database/ViewData/Indicators/enDate: 2020Date accessed: November 2, 2020Google Scholar A WHO assessment of sexual, reproductive, maternal, newborn, child, and adolescent health in the context of universal health coverage in Kyrgyzstan found a high proportion of out-of-pocket expenditure, high costs of drugs, and a high frequency of informal payments for care to be important barriers to achieving universal health coverage. Almost a quarter of the population is not covered by the mandatory health insurance benefits package. This includes adolescents, who are no longer considered children but are not yet employed and do not contribute to mandatory health insurance. Inadequate health insurance funds further contributes to a financing gap, leading to insufficient funding of the state-guaranteed benefit package.6WHOAssessment of sexual, reproductive, maternal, newborn, child and adolescent health in the context of universal health coverage in Kyrgyzstan. WHO Regional Office for Europe, Copenhagen2019Google Scholar Access to contraceptives has declined rather than increased in the past few decades. According to the 2018 Multiple Indicator Cluster survey, as shown in the Article,1Kamali M Wright JE Akseer N et al.Trends and determinants of newborn mortality in Kyrgyzstan: a Countdown country case study.Lancet Glob Health. 2020; (published online Dec 10.)https://doi.org/10.1016/S2214-109X(20)30460-5Summary Full Text Full Text PDF PubMed Scopus (1) Google Scholar contraceptive use prevalence was 39% in 2018, down from 59% in 1997. This trend suggests that government attempts to improve access to contraceptives as part of the package of preferential drug provision under the State Benefits Programme have not been successful. In 2018, a 5-year programme was developed to gradually increase government funding to meet the contraceptive needs of 50% of women at high medical and social risk of maternal mortality, with improvements expected to be seen by 2023. Demographic trends make these challenges more acute. The total fertility rate has increased from 2·4 births per woman in 2000–02, to 3·3 in 2018.7World BankWorld development indicators.https://databank.worldbank.org/reports.aspx?source=World-Development-IndicatorsDate: 2020Date accessed: November 2, 2020Google Scholar There is also a high share of adolescent pregnancies, with an adolescent fertility rate (births per 1000 women aged 15–19 years) of 32·4 in 2018.7World BankWorld development indicators.https://databank.worldbank.org/reports.aspx?source=World-Development-IndicatorsDate: 2020Date accessed: November 2, 2020Google Scholar This rate is 2 times higher in rural than in urban areas.8National Statistical Committee of the Kyrgyz RepublicUNICEFKyrgyzstan Multiple Indicator Cluster Survey 2018, Survey Findings Report.https://mics-surveys-prod.s3.amazonaws.com/MICS6/Europe%20and%20Central%20Asia/Kyrgyzstan/2018/Survey%20findings/Kyrgyzstan%20MICS%202018_English.pdfDate: 2019Date accessed: September 18, 2020Google Scholar Overcoming these challenges has become much harder because of the COVID-19 pandemic. Estimates indicate that the impact of the pandemic on mother and child health in low-income and middle-income countries will be devastating9Roberton T Carter ED Chou VB et al.Early estimates of the indirect effects of the COVID-19 pandemic on maternal and child mortality in low-income and middle-income countries: a modelling study.Lancet Glob Health. 2020; 8: e901-e908Summary Full Text Full Text PDF PubMed Scopus (368) Google Scholar as a result of disruptions to routine health care and access to food. In Kyrgyzstan, the Ministry of Health has set up a coordinating committee on maternal and child health in the context of COVID-19 and endorsed a new protocol for home visits by primary care workers to healthy young children during the COVID-19 epidemic. The ministry also aimed to support the use of telemedicine for antenatal and postnatal care, supported by international development partners.10Artykova N Atatrah T Tilenbaeva N et al.Kyrgyzstan: COVID-19 health system response monitor.https://www.covid19healthsystem.org/countries/kyrgyzstan/countrypage.aspxDate: 2020Date accessed: November 2, 2020Google Scholar Despite these efforts, routine immunisations have been disrupted10Artykova N Atatrah T Tilenbaeva N et al.Kyrgyzstan: COVID-19 health system response monitor.https://www.covid19healthsystem.org/countries/kyrgyzstan/countrypage.aspxDate: 2020Date accessed: November 2, 2020Google Scholar and the mid-term to long-term consequences of the pandemic are, so far, difficult to predict. To not let improvements in maternal and newborn health slip, it will be imperative to maintain and improve access to essential health services. This can only be achieved through increased government funding, including for contraceptives, and by also covering the people outside the mandatory health insurance system. We declare no completing interests. Trends and determinants of newborn mortality in Kyrgyzstan: a Countdown country case studyKyrgyzstan has reduced newborn mortality rates considerably, with the potential for further reduction. To achieve and exceed the Sustainable Development Goal 3 targets for newborn survival and reducing stillbirths, Kyrgyzstan needs to scale up packages of interventions for the care of small and sick babies, assure quality of care in all health-care facilities with regionalised perinatal care, and create a linked national registry for mothers and neonates with rapid feedback and accountability. Full-Text PDF Open Access