A recent report by the NGO Save the Children paints a mixed picture of global efforts to protect the lives of mothers and children under five. And, while some African countries have made impressive gains in recent years, others ranked near the bottom of the 140-country survey. From Washington, VOA reporter William Eagle has the story.

At the bottom of the index are nine sub-Saharan countries that lead the world in mother and child mortality rates -- Ethiopia, Eritrea, Angola, Guinea Bissau, Chad, Sierra Leone, Yemen and Djibouti. Niger is last.

For some countries, like Nigeria, Angola and the Democratic Republic of Congo, the high numbers also reflected their large populations. They joined 10 other big countries, including China and India, which together had more than half of all maternal and child deaths.

Conflict accounts for high rates in other countries, including Sierra Leone, Ivory Coast and Liberia.

Eighty percent of all deaths of children under five in Africa are caused by malaria, diarrhea, pneumonia and newborn disorders.  But in a handful of African countries, including Botswana, Zimbabwe and Swaziland, AIDS has also become a major killer of children under five and is a major reason why these countries have not been able to lower child mortality rates.

Among those found to have worse mother and child health than they did 15 years ago are Botswana, Zimbabwe, and Swaziland.

For these countries, disease was a significant factor in their poor ratings.

Mike Kiernan, the communications director for Save the Children in Washington, spoke about Zimbabwe.

"The mortality rate has increased since 1990 by 65 percent,," he said,"due largely to HIV / AIDS. You have one in eight children dying before they reach their fifth birthday in Zimbabwe, more than 40 percent of those deaths are attributable to AIDS. Zimbabwe, South Africa, Botswana and Swaziland are countries where we see HIV / AIDS overwhelming the infrastructure to support children under five. That is not commonplace throughout Africa."

Economic performance does not always determine the effectiveness of a country?s health care services.

For example, South Africa and Botswana are relatively wealthy but their health care systems are affected by the AIDS pandemic sweeping much of southern Africa. Likewise, maternal and child mortality rates remain high in countries with oil money, including Nigeria, Angola, and Equatorial Guinea.

However, Kiernan said that political will has a large impact even among the poorest countries, including Malawi.

He said, "Malawi is a marvelous success story of a country with limited resources that has really focused on doing its part. The gross national product in Malawi is about 650 dollars per person, yet they have seen a 43 percent decline in the under five (years of age) mortality rates over the last 15 years."

"Malawi has taken a number of steps," he continued,"to make the health of mothers and children a top priority from the president on down. They are doing basic things that many countries could copy?."

Among those basic steps are distributing bed nets to prevent mother and child infection from malaria, providing mothers with health care before birth and ensuring that birth attendants are present during delivery. After birth, countries can ensure that all communities have access to nutritional supplements like Vitamin A to help guard against malnutrition and zinc and rehydration salts to stop diarrhea. They can also ensure that children are vaccinated against measles and other childhood diseases.

Kiernan says Tanzania is another example of a poor country that has made great progress through political will:

"Tanzania is one of the world?s poorest countries, with an income of $730 per person, per year, and yet they?ve been able to reduce child mortality (of those under five years of age) by 25 percent and of newborn mortality by 20 percent in the last five years," he said.  "Much of that progress has been made as a result of increased government spending on maternal and child health care."

Other countries have also cut child mortality since 1990.

Madagascar ?s commitment to improved health services and immunization rates helped reduce deaths by 29 percent and malnutrition from 42 to 35 percent.

Ethiopia, which still has a high number of deaths among mothers and children, has nonetheless managed to cut the rate by an impressive 20 percent in the past 15 years.

Save the Children found Egypt had a 63 percent decline in child deaths, thanks in part to a commitment to build access roads to rural areas, support immunization strategies, and ensure that midwives or skilled workers attend to births.

But Kiernan says no matter how far countries like Egypt have come, there?s always more to do.