The 2025 report of the Lancet Countdown to 2030 for women's, children's, and adolescents' health: tracking progress on health and nutrition

Abstract

In line with previous progress reports by Countdown to 2030 for Women's, Children's, and Adolescents' Health, this report analyses global and regional trends and inequalities in health determinants, survival, nutritional status, intervention coverage, and quality of care in reproductive, maternal, newborn, child and adolescent health (RMNCAH) and nutrition, as well as country health systems, policies, financing, and prioritisation. The focus is on low-income and middle-income countries (LMICs) where 99% of maternal deaths and 98% of child and adolescent deaths (individuals aged 0–19 years) occur, with special attention to sub-Saharan Africa and South Asia.
Recognising the urgency of reaching the Sustainable Development Goal (SDG) for health, SDG 3, and health-related targets by 2030, the report assesses whether the momentum needed to reach these goals has been sustained, accelerated, stagnated, or regressed in comparison with the Millennium Development Goal (MDG) period (2000–15). Although most health and health-related indicators continue to show progress, there has been a notable slowdown in the rate of improvement after 2015, falling well short of the pace needed to achieve the 2030 SDG targets. This deceleration in pace contrasts sharply with the aspired grand convergence in health, characterised by drastic reductions in mortality and RMNCAH inequalities, which was expected to occur during the SDG period based on the assumption that the spectacular progress achieved during the MDG period would continue unabated. Multiple threats, external and internal to the RMNCAH health community, must be addressed to safeguard the gains in RMNCAH and nutrition and to accelerate progress. Furthermore, a large gap between sub-Saharan Africa, especially West and Central Africa, and other parts of the world persists for many indicators, necessitating further prioritisation of this region.
Deteriorating context for women's, children's, and adolescent's health
The global health and development agenda, including RMNCAH and nutrition, is facing major obstacles. Economic trends are of great concern, including slowing economic growth, stagnating poverty reduction, and a major debt crisis. In 2021, 25 (58%) of 43 countries with data in sub-Saharan Africa spent more on public external debt servicing than health. Additionally, the pace of improvements in education and gender equity has slowed since 2015.
More countries are affected by armed conflicts and high numbers of battle-related deaths. In 2022, an estimated 327 million women and 507 million children lived near conflict zones, representing a 29% increase for women and a 24% increase for children since 2015. The number of women and children younger than 18 years uprooted by conflict increased from 46·3 million in 2015 to 80·7 million in 2023. Food insecurity has risen during the SDG period, fuelled by the COVID-19 pandemic, economic volatility, and armed conflict. Climate change, with its associated consequences of extreme weather events, infrastructure destruction, food insecurity, emerging diseases, and altered disease transmission patterns, poses a severe threat to women's, children's, and adolescents' health.
These crises and challenges are exacerbated by, and often contribute to, vast inequalities between and within countries. Women, children, and adolescents living in the least favourable social and economic environments, where multiple dimensions of inequality intersect, are the most vulnerable to the consequences of these challenges.
Progress in mortality and nutritional status but insufficient pace
The analyses of this report consider maternal mortality and deaths of individuals aged between 28 weeks of gestation and 20 years, recognising the importance of the first two decades of life. Although mortality for all age groups in this range generally continued to decline during the first half of the SDG period, the average annual rates of reduction in stillbirth, maternal, newborn, child, and adolescent mortality in low-income countries (LICs) and lower-middle-income countries during 2016–22 were generally in the range of 2% to 3%. This rate is much lower than the pace of decline during 2000–15 and far below the pace needed to achieve the SDGs. The SDG mortality targets are particularly remote for countries in sub-Saharan Africa. Exceptions are upper-middle-income countries, which have already achieved the SDG targets as a group, and the region of South Asia, where mortality continued to decline rapidly, particularly for under-5 mortality.
Mortality due to leading infectious causes of child deaths, such as acute respiratory disease and diarrhoea, continued to decline globally, except for malaria. Neonatal deaths, a subgroup of all deaths younger than 20 years, increased in all regions, as neonatal mortality rates declined slower than rates at older ages, with preterm birth as the leading cause of these neonatal deaths.
Undernutrition in children, adolescents, and women has declined during the SDG period in most regions and country income groups at a similar pace as during the MDG period in LICs and sub-Saharan Africa, and accelerated in pace in lower-middle-income countries and South Asia. Most countries, however, are not on pace to achieve the SDG targets and particularly slow progress on reducing low birthweight prevalence is striking. At the same time, obesity rates in older children and adolescents (ie, individuals aged 5–19 years) and women increased rapidly in all regions and country income groups, a concerning trend with potential long-term and costly health implications.
Improving coverage, reducing inequalities, and major quality of care gaps
Ensuring high coverage of essential interventions is crucial to achieve the SDGs. However, coverage for 20 indicators along the RMNCAH and nutrition continuum of care is uneven. For most indicators, coverage was higher in 2016–23 than during the MDG period (2000–15), but is still inadequate. Skilled birth attendance reached the highest coverage, with a median of 95·6% (IQR 76·5–99·5) for 113 LMICs.
Comparing the MDG and SDG periods, there was a general slowdown in the increase of the RMNCAH composite coverage index (CCI), with progress reducing from 1·2 percentage points per year to 0·6 percentage points per year, based on 70 countries with sufficient survey data before and since 2016. The slowdown was most pronounced in Eastern and Southern Africa. West and Central Africa, the region with the lowest coverage in 2000–15, was the only region with an acceleration, from an annual increase of 0·6 percentage points per year during the MDG period to 1·6 percentage points per year from 2016.
Coverage inequalities between the poorest and richest households narrowed during the SDG period, with a CCI reduction of 2·0 percentage points per year, almost two-times faster than during the MDG period. However, subnational inequalities remained large in many countries, implying that many countries can make substantial progress by increasing focus on the regions that are lagging behind.
Monitoring progress in quality of care is challenging, given data limitations. Progress has been made in the content and timeliness of antenatal care in many countries and in the continuity of maternal and newborn care. Only small increases were observed in caesarean section prevalence in the poorest women: survey data showed that the median prevalence in 19 LICs increased from 1·4% in 2010 to 2·1% in 2019, indicative of a large unmet need for emergency care. This slow progress is occurring at the same time as escalating caesarean section rates in the wealthiest women in many countries.
Slow health systems progress
Country policy frameworks reflect prioritisation of RMNCAH and nutrition as well as commitment to protect the human right to health. Adoption of human-rights-based policies is far from universal across LMICs. Many countries are also falling behind in implementing broader protective legislation with major implications for RMNCAH and nutrition, such as child marriage laws, protection of sexual and reproductive health and rights, and commercial regulations, particularly around breastmilk substitutes and unhealthy foods.
Indicators of health financing, workforce, and information systems indicate slow progress in health system strengthening. Current health expenditure per capita has increased overall since 2015, but at a slow pace, and no increase was observed in LICs. Health workforce densities per 10 000 population increased slightly, but were still low; LICs and lower-middle-income countries have a seventh and a third, respectively, of the density of core health professionals (ie, doctors, nurses, and midwives) of upper-middle-income countries. Major obstacles to improving health workforce statistics include high rates of emigration to high-income countries, attrition of health workers to other sectors, and fiscal constraints to support training, remuneration, and career progression.
There have been improvements in the use of routine health facility data and data generated through rapid health facility assessments. However, donor-funded household surveys remained the mainstay for key RMNCAH and nutrition statistics, providing high-quality information about population health, whereas civil registration and vital statistics systems remained inadequate in most countries.
LMICs are undergoing demographic and epidemiological transitions at varying paces, with implications for their health systems. For example, as child mortality becomes predominated by small and sick newborn mortality, countries need to invest in neonatal intensive care units while maintaining strong primary health-care facilities that provide essential packages of services to all women, children, and adolescents. Countries in sub-Saharan Africa, where fertility remains high and more than half of the population is younger than 20 years, have the added pressure of needing to shore up their health systems to meet increasing demands. Further improvements in survival and health will require further system strengthening, especially access to secondary levels of care, which is challenging in the context of macroeconomic developments affecting country health budgets, but could benefit from innovations in the provision of services.
Decrease in global prioritisation and financing of RMNCAH and nutrition
Aid for RMNCAH increased slowly after 2015 but decreased in 2020–21, most likely because of a shift in funding towards pandemic response. Over the MDG and SDG periods, traditional large donors remained mostly stable until 2021. The targeting of aid to countries with greater health needs remained at a similar level to that of 2015. Donor aid flow should be considered against crippling debt servicing liabilities that many countries are facing, severely affecting their ability to adequately finance health services for RMNCAH and nutrition.
A range of factors, both external and internal to the RMNCAH health community, have reduced global prioritisation of RMNCAH in the SDG era. Although most analyses suggest that COVID-19 crowded out funding for RMNCAH, evidence and perceptions on the effects of advocacy and funding for universal health coverage on RMNCAH and nutrition are mixed. The broader landscape of fiscal constraints, climate change, the wars in Ukraine and Gaza, and waning commitment to multilateralism has also dampened RMNCAH visibility. Underfunded coordination platforms combined with the absence of a compelling unified framing has contributed to fragmentation of the RMNCAH community and, consequently, less collaboration on supporting the full continuum of care.
Conclusions and future directions
To address slowdown in RMNCAH and nutrition progress in the first half of the SDG era, as well as variations in progress across regions and country-income groups, we hope that this report's analyses will fuel dialogue and action needed to ensure acceleration of progress in women's, children's, and adolescents' health. Our recommendations fall into five themes (panel).

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Identifiers

ORCID for Winfred Dotse-Gborgbortsi: orcid.org/0000-0001-7627-1809

ORCID for Nyovani Madise: orcid.org/0000-0002-2813-5295

ORCID for Kristine Nilsen: orcid.org/0000-0003-2009-4019

ORCID for Andrew J Tatem: orcid.org/0000-0002-7270-941X

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