EDITORIAL The World Health Report 2005: ‘‘Make every mother and child count’’ – including Africans Do not go gentle into that dark night Rage, rage, rage against the dying of the light. (Dylan Thomas) ULF HO ¨ GBERG Epidemiology and Public Health Sciences, Department of Epidemiology and Public Health, Umea ˚ University, Sweden Globally the chances of safely giving birth to a live baby and watching it grow up in good health are better than ever. The World Health Report 2005 [1] gives national examples from South-East Asia and Latin America of continuously halving maternal mortality rates in 4–9 years, achieved through community participation, skilled birth attendants, a shift to facility deliveries, and quality improvements. The gloomy part of the WHO report, however, is the description of the emerging global health divide, an increasing poor–rich divide, marginalization, and inequality. The global estimate of annual maternal deaths is as big as two decades ago. From the 1980s ‘Where is the M in the MCH’ [2], to the 1990s metaphor of a jumbo jet full of pregnant women crashing every six hours [3], to today’s ‘Every mother and child counts’ [1] the message is that we have the knowledge, we have the means, but the problem of maternal mortality persists or is getting worse. Global averages hide important regional averages. With 10 years left before the target date of 2015 there is little hope of achieving the Millennium Development Goals of reducing maternal mortality by three-quarters and child mortality by two-thirds. There is a slowdown of child mortality decline in 51 countries (48% world population). In 29 countries (8%) mortality rates are stagnating, and in 14 (4%) countries, situated overwhelmingly in the African Region, there is a reversal. These countries also report the highest neonatal and maternal mortality rates. Even though less than 50% of the world’s population register their deaths, demographic sur- veillance in areas beyond vital statistics has turned mortality rates into a societal thermometer. Who could foresee that changes in infant mortality in the short run would be the public health litmus paper of marginalized society? Years before the outbreak of the civil war in Somalia infant mortality increased as society collapsed [4]. Even maternal deaths, counted per 100,000, turn out to be sensitive to politics and macroeconomics. For a long time the repulsive example given was the dark age of Romania where restrictive abortion legislation was introduced in 1965, causing a doubling of the maternal mortality rate (MMR), which persisted until the fall of the Ceaus ¸escu regime. The WHO report now adds more examples: the temporary reversal of MMR in Mongolia during the social chaos, economic col- lapse, drop in investment, and meltdown of social service and healthcare; a doubling of MMR in Iraq during the 1990s sanctions; and an MMR increase in Tajikistan during the turmoil of the early 1990s, with a startling erosion of healthcare available for skilled birth attendance. Poverty, war, and civil unrest are the big enemies of health. Those countries, especially in the African region, with stagnation or reversal in mortality have a pattern of weak, low-density, and fragile health systems characterized by massive exclusion, widen- ing inequalities, and marginalization. The Unmet Obstetric Needs Network reveals that 25% of urban Correspondence: Ulf Ho ¨ gberg, Epidemiology and Public Health Sciences, Department of Epidemiology and Public Health, Umea ˚ University, SE-901 85 Umea ˚, Sweden. Tel: +46 (0)90 785 68 33. Fax: +46 (0)90 13 89 77. E-mail: Ulf.hogberg@obgyn.umu.se Scandinavian Journal of Public Health, 2005; 33: 409–411 ISSN 1403-4948 print/ISSN 1651-1905 online/05/060409-3 # 2005 Taylor & Francis DOI: 10.1080/14034940500217037