- Email: [email protected]
Now or never: the case for measuring maternal mortality
VIEWPOINT
Viewpoint
Now or never: the case for measuring maternal mortality Wendy J Graham “The data we have are not the data we want. The data we want are not the data we need. The data we need are not available.” Finagel’s Laws
Today a woman’s risk of dying of pregnancy-related causes in the poorest countries is still estimated to be higher than it was more than a century ago in the richest nations. This disparity remains in spite of high levels of awareness among governments and international agencies that the vast majority of maternal deaths are avoidable. This disparity also remains in spite of the Safe Motherhood Initiative1 launched in 1987 and charged with the task of doing for mothers what the Child Survival Revolution2 has done for children. Of course, decrying a lack of progress is almost a universal principle in international health. But pregnancy is not a disease, and the reasons for poor progress are complex but not insurmountable. Maternal death in lessdeveloped countries has simply not been seen as a sufficient priority to commit the resources needed. This is demonstrated by the outcome of the recent G8 summit in Genoa, with maternal mortality failing to join HIV, tuberculosis, and malaria as a global priority. To be seen as a priority requires strong advocates being armed with strong data. The purpose of this paper is to show the pivotal role of evidence, both as part of the problem and the solution to poor progress. The application and the adverse consequences of Finagel’s Laws for maternal mortality will be described, and a case made for tackling now the evaluation challenges of safe motherhood.
The data we have The data we have for less-developed countries are inadequate with regard to the levels and trends in maternal mortality, and the effectiveness and costeffectiveness of intervention strategies. This is despite clear evidence of the vital contribution of information to the reduction of maternal mortality in the western world,3 and indeed in the very few transitional countries that seem to have achieved lower levels equitably within their populations, such as Sri Lanka, Thailand, and Malaysia. In all these settings, data on maternal deaths gathered through vital registration, health information systems, and specific routine enquiries (such as Confidential Enquiries into Maternal Deaths4) provided a stimulus for governments to act. These data also gave the essential encouragement to continue efforts and investment, particularly in the face of competing health Lancet 2002; 359: 701–04 Dugald Baird Centre for Research on Women’s Health, Department of Obstetrics and Gynaecology, Aberdeen Maternity Hospital, Cornhill Road, Aberdeen, Scotland AB25 2ZL, UK (Prof W J Graham DPhil (Oxon)) (e-mail: [email protected])
THE LANCET • Vol 359 • February 23, 2002 • www.thelancet.com
problems. The failure to take heed of this lesson—of underestimating the importance of being able to “tell the story”5— has a price that is now being paid in lessdeveloped countries. The lesson could have been learned at several points in the evolution of the Safe Motherhood Initiative and this measurement trap6 avoided. Instead there was ready acceptance of defeat in the task of tracking maternal mortality and a surprising reluctance to revisit the challenge. The Call to Action1 to reduce maternal deaths in the developing world was made in 1987, stimulated in part by a small number of studies gathering population-based data. These studies did not have the power to yield precise estimates of maternal mortality ratios, but they all suggested that levels were much higher than had been expected.7 The Call to Action set targets for reducing maternal mortality by half by the year 2000, ignoring the lack both of baseline estimates and of sources and methods for tracking change. One new approach to emerge in response to the Call to Action was the Sisterhood Method.8 This was devised to estimate the lifetime risk of maternal death, with the expectation that it would be replaced in due course by improved routine data sources and new methods. By the early-1990s, the view among many research groups was that measuring levels of maternal mortality was pretty much impossible and definitely not an efficient use of scarce resources.9,10 Process evaluation thus started to be promoted as the most pragmatic and appropriate way to show progress in safe motherhood. Maternal morbidity was proposed as a possible alternative outcome to mortality, but several research studies rapidly revealed the poor reliability of estimates based on women’s reports.11,12 The desire on the part of less-developed country governments, donor agencies, and international organisations for estimates of the level of maternal mortality did not, however, go away. A clear indication of this was the estimation exercise carried out by WHO and UNICEF to produce regional and country figures for the maternal mortality ratio for 1990.13 Much has been written on the reactions to these estimates and their powerful awareness-raising effect,5 but the accompanying controversy over the validity of the model used and the consequent questioning of the estimates was damaging. Many less-developed countries that had embarked on national safe motherhood activities were disillusioned by the much higher than expected modelled estimates. Donor agencies started to become sceptical about the prospects of ever being able to show benefit from their investments, at a time when both evidence-based decision making and a major competitor for resources—HIV/AIDS, were gaining ascendancy. 10 years on from the launch of the Safe Motherhood Initiative, a technical consultation was held in Colombo, Sri Lanka to review lessons learned and to plan for the future.14 This focus highlighted the continuing lack of reliable evidence that maternal mortality had been reduced by specific intervention strategies, such as
701
For personal use. Only reproduce with permission from The Lancet Publishing Group.
VIEWPOINT
training of traditional birth attendants or use of antenatal at-risk scoring. The few instances in which investigators suggested an impact could be challenged on the basis of weak study design, such as inability to allow for confounders or inadequate samples sizes to show reductions in all-cause or cause-specific maternal mortality.15,16 The Colombo conference promoted skilled attendance at delivery and essential obstetric care as interventions of proven effectiveness, although there was no serious debate on the quality of the evidence. On World Health Day in 1998, the Call to Action was repeated. At the 5-year review of the Cairo Programme of Action the goal for maternal mortality reduction was rephrased as a 75% reduction between 1990 and 2015, and the proportion of deliveries with skilled attendants (health professionals) was proposed as a benchmark indicator to monitor progress.17 In this new century, estimates of the level of maternal mortality have just been published18 by WHO, UNICEF, and the United Nations Population Fund (UNFPA) based on a revised model developed to take account of the earlier criticisms. These latest figures are for the year 1995, but cannot be compared to those from 1990 because of the different model used. In 2002, the women who lose their lives as a result of pregnancy and childbirth in poor countries, essentially remain invisible to the governments and agencies that need to see.
The data we want and the data we need The prevailing view is that the data we want relate to the processes rather than the outcomes of care. This derives not only from accepting defeat in the measurement of accurate levels and trends in maternal mortality, but also from the presumption that “we know how to prevent women dying” and that if these processes are applied, maternal mortality can be inferred to have declined. From this it appears logical that resources should be devoted to measuring the provision, uptake, and quality of care. Considerable effort has thus been spent in recent years on developing process indicators and promoting their use.19 There is still fairly limited experience when interpreting most of these measures, although their apparent simplicity and usefulness for delivering and assessing the success of intervention strategies is starting to be questioned.20 But a more fundamental issue is whether we do indeed know what reduces maternal mortality at the population level. This is not the same as knowing how to prevent a particular woman from dying. At the clinical level there is a considerable amount of rigorous evidence,21 mostly from more-developed countries, regarding procedures to prevent severe morbidity, such as active management of the third stage of labour reducing the incidence of postpartum haemorrhage. This, together with experiential or common-sense reasoning from clinical practice, is the basis for suggesting that most maternal deaths are avoidable— that “we know what to do”. Knowing that a particular procedure or drug is efficacious in the controlled and artificial context of a randomised trial is not, of course, the same as knowing that it can be provided effectively and cost-effectively to reduce maternal mortality in a real world population with real resource constraints. Moreover, these interventions are not delivered singly but rather as packages of care or strategies. It is at this aggregate level—for strategies and whole populations— that governments and donors need to be persuaded of benefit. Monitoring process indicators remains crucial to implementing these strategies, but without any
702
rigorous demonstrations of the causal link between process and outcomes, inferences about maternal mortality are ungrounded. Reliable evidence is needed now on the effectiveness and cost-effectiveness of the various intervention strategies that are already being implemented in many countries and assumed to reduce the level of maternal mortality.
The data not available There are three main reasons why the data we need are not available: technical concerns, leadership, and resources. The technical obstacles are the ones most frequently cited. Indeed these are not trivial otherwise they would have been tackled sooner. These obstacles can be divided into those peculiar to measuring maternal mortality and those generic to assessing effectiveness and cost-effectiveness.22 Much has been written on the former,23,24 emphasising the weaknesses in routine information systems, the rarity of deaths and thus large sample size requirements, the problems of misclassification, and the under-reporting of deaths in early pregnancy and especially from complications of induced abortion. Overcoming these technical challenges requires strong leadership to advocate rigorous evaluation of health outcomes and, in turn, to lobby for appropriate resources. Within the partnership of international agencies spearheading the Safe Motherhood Initiative the emphasis given to advocacy has tended to take precedence over the quality of the evidence needed to make the case. Uncertainty about the respective roles and comparative advantages of the various groups has sometimes been the cause of disharmony, as for example with the 1990 maternal mortality estimates. In these circumstances, leadership regarding data needs has been difficult—a difficulty compounded by changes within the United Nations regarding information-gathering responsibilities. Meanwhile, technical capacity in lessdeveloped countries for maintaining routine information systems and for programme evaluation has declined, and in many settings sources such as vital registration and census enumeration are largely dysfunctional. Thus, champions of evaluation have been missing within countries and international partnerships, and this can be linked to the resources obstacle. The inadequate resources provided to safe motherhood5 are both a cause and an effect of inadequate data with which to prioritise, plan, implement, and sustain effective intervention strategies. The comparative lack, until recently, of large-scale programmes25 attempting to address maternal mortality means that there have been few opportunities to look for impact. Furthermore, there has been an understandable desire among international agencies and technical experts to focus the limited resources that have been made available on implementing actions rather than on measuring their consequences. In other words, the opportunity costs of impact evaluation have been regarded as too high. The direct costs of tracking trends in maternal mortality and attributing these to specific intervention strategies are indeed high, but the indirect costs of failing to do this are now proving even greater.
The adverse consequences Evidence-based decision making clearly requires quality evidence, without which there is a real risk that resources will be wasted and that this waste will go undetected. Recently, for example, training of traditional birth attendants has ceased to be regarded as
THE LANCET • Vol 359 • February 23, 2002 • www.thelancet.com
For personal use. Only reproduce with permission from The Lancet Publishing Group.
VIEWPOINT
a priority. This has happened after many years of funding, but without adequate evaluation that allowed for the presence or absence of a referral system to enable them to practise as they were trained. Skilled attendance at delivery, on the other hand, is now being promoted as a crucial intervention strategy, but again based on plausibility assessment rather than rigorous evaluations26 showing this to be effective and cost effective in specific settings or health systems. Clearly changing programmatic priorities requires a rationale that should include evidence of expected health gain and efficiency savings. Without sound evidence for decision making, safe motherhood programme activities, internationally and in-country, have lacked continuity and engendered uncertainty and disillusionment among governments and donors. Disillusionment, in turn, can lead to a weaker case being made for resources, and so the measurement trap is re-sprung: lack of data and low priority being self-reinforcing. Although it is hard to find reliable information on funding streams, it is estimated that maternal health services represent just 5–11% of total donor contributions to the health sector in less-developed countries, and 4–12% of domestic health expenditure.27 Insights on trends in this funding are even more limited. The World Bank28 provides a rare example of a systematic analysis of its funding for safe motherhood activities, and is now the largest source of external assistance in this area. However even among high maternal mortality countries, only seven of the 22 World Bank funded projects in the areas of family planning and maternal health focused specifically on essential obstetric care. In recent years, the Bill and Melinda Gates Foundation has made the single largest donation for maternal health25 (US$50m), whereas WHO’s entire Making Pregnancy Safer Initiative has considerably fewer funds than this at its disposal.5
(Initiative for Maternal Mortality Programme Assessment).31 With initial funds from the Bill and Melinda Gates Foundation, UNFPA, and WHO, the developmental phase has commenced for a major 7 year effort to develop realistic methods for tracking maternal mortality and severe morbidity, and to determine the most effective and cost-effective strategies for specific country settings. This not only requires methodological innovation, but also partnership innovation to ensure that the measurement scientists do indeed address the needs of practitioners, managers, and policy makers— now rather than never.
Rising to the challenge
6
The challenge of measuring maternal mortality and attributing progress needs revisiting. We must stop saying this cannot be tackled and acknowledge the damage caused so far. We must recognise the risks of continuing to neglect the data needed by poor countries to inform their allocation of scarce resources, and find the funds, the tools, and the opportunities to meet these needs. We must build a sustainable evaluation capacity at the country level and a greater demand for reliable measurement of maternal mortality and severe morbidity. Now is the time to take up the challenge. Health sector reforms are being implemented in a number of less-developed countries. It has long been recognised that maternal health services are dependent on the functioning of the entire health system. Reform programmes thus have huge implications for maternal health.29,30 Data are needed to ensure that the most effective and cost-effective intervention strategies for safe motherhood are integrated into essential service packages, and also to track the impact of the reform process using realistic and affordable information systems. Similarly, opportunities must be seized now to foster links with other global initiatives, such as the Massive Effort Against the Diseases of Poverty, and to recognise the commonalities both in terms of the target populations and the requirements for data and rigorous evaluation. A window has recently been opened on the challenge through a research initiative called IMMPACT
THE LANCET • Vol 359 • February 23, 2002 • www.thelancet.com
Conflict of interest statement The author is the main investigator of IMMPACT.
Acknowledgments I thank my colleagues for commenting on an earlier version: Carla AbouZahr, Jacqueline Bell, Colin Bullough, John Cairns, Jeremy Grimshaw, Marion Hall, Julia Hussein, Sally Stearns, and Edwin van Teijlingen. The author is funded by the University of Aberdeen and holds research grants from: the Bill and Melinda Gates Foundation; DFID; the European Commission; the Scottish Executive; the United Nations Population Fund; and the WHO.
References 1 2
3
4
5
7
8 9
10
11
12
13
14
15
16
17
18
Mahler H. The Safe Motherhood Initiative: a call to action. Lancet 1987; 1: 668–70. Bennett FJ. Child survival. In: Wallace HM, Giri K, eds. Health Care of Women and Children in Developing Countries. California: Third Party Publishing Co, 1990: 364–81. de Brouwere V, Tonglet R, Van Lerberghe W. Strategies for reducing maternal mortality in developing countries: what can we learn from the history of the industrialised West? Trop Med Int Health 1998; 3: 771–82. Department of Health. Why Mothers Die. Report on the Confidential Enquiries into Maternal Deaths in the United Kingdom 1994–1996. London: HM Stationery Office, 1998. Abou Zahr C. Cautious champions: international agency efforts to get safe motherhood onto the agenda. Stud Health Services Organ Policy 2001; 17: 387–414. Graham WJ, Campbell OMR. The measurement trap. Soc Sci Med 1992; 35: 967–76. WHO. Prevention of Maternal Mortality: report of a WHO Inter-regional meeting. Geneva, Nov 11–15, 1985. Geneva: WHO, 1986 (WHO/FHE/86·1). Graham W, Brass W, Snow RW. Indirect estimation of maternal mortality: the sisterhood method. Stud Fam Plann 1989; 20: 125–35. Maine D. Safe Motherhood Programs: Options and Issues. Centre for Population and Family Health. New York: Columbia University, 1991. Walker GJA, McCaw-Binns A, Ashley DEC, et al. Identifying maternal deaths in developing countries; experiences from Jamaica. Int J Epidemiol 1990; 19: 599–605. Stewart K, Festin M. Validation study of women’s reporting and recall of major obstetric complications treated at the Philippine General Hospital. Int J Gynecol Obstetr 1995; 48: S53–66. Fortney JA, Smith JB. The Base of the Iceberg: prevalence and perceptions of maternal morbidity in four developing countries. North Carolina: Family Health International, 1996. Revised 1990 Estimates of Maternal Mortality. A New Approach by WHO and UNICEF. Geneva: WHO, 1996 (WHO/FRH/MSM/96·11). Starrs A. The Safe Motherhood Action Agenda: Priorities for the Next Decade. New York: Inter-Agency Group for Safe Motherhood and Family Care International, 1998. Ronsmans C, Vanneste AM, Chakraborty J, van Ginneken J. Decline in maternal mortality in Matlab, Bangladesh: a cautionary tale. Lancet 1997; 350: 1810–814. West KP, Katz J, Khatry SK, et al. Double-blind, cluster randomised trial of low supplementation of Vitamin A and betacarotene on mortality related to pregnancy in Nepal. BMJ 1999; 318: 570–75. United Nations. Key actions for the further implementation of the Programme of Action for the International Conference on Population and Development. New York: United Nations, 1999. Hill K, AbouZahr C, Wardlaw T. Estimates of maternal mortality for 1995. Bull World Health Organ 2001; 70: 182–93.
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VIEWPOINT
19 UNICEF. Programming for Safe Motherhood. New York: UNICEF, 1999. 20 Goodburn EA, Hussein J, Lema V, Damisoni H, Graham W. Monitoring obstetric services: putting the UN guidelines into practice in Malawi. I: developing the system. Int J Gynecol Obstetr 2001; 74: 105–117. 21 The Cochrane Collaboration. Cochrane Pregnancy and Childbirth Group. http://www.liv.ac.uk/lstm/nwc-pc1.html, accessed May 21, 2001. 22 Graham W, Filippi V, Ronsmans C. Demonstrating programme impact using maternal mortality. Health Policy Plann 1996; 16–20. 23 AbouZahr C. Maternal mortality overview. In: Murray CJL, Lopez AD. Health Dimensions of Sex and Reproduction. Global Burden of Disease and Injury Series, Volume III. Geneva: WHO, 1998. 24 Berhane Y, Andersson T, Wall S, Byass P, Hogberg U. Aims, options and outcomes in measuring maternal mortality in developing countries. Acta Obstet Gynecol Scand 2000; 79: 968–972. 25 Maine D, Rosenfield A. Averting Maternal Death and Disability—
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26
27 28
29
30
31
The AMDD program: history, focus and structure. Int J Gynecol Obstetr 2001; 74: 99–103. Graham W, Bell J, Bullough C. Can skilled attendance at delivery reduce maternal mortality in developing countries? Stud Health Serv Organ Policy 2001; 17: 97–130. Borghi J. What is the cost of maternal health care and how can it be financed? Stud Health Serv Organ Policy 2001; 17: 247–96. World Bank. Lessons from 10 years of experience. Safe Motherhood and The World Bank. Washington DC: The World Bank, Human Development Network. 1999. McDonagh M, Goodburn E. Maternal health and health sector reform: opportunities and challenges. Stud Health Serv Organ Policy 2001; 17: 371–86. Goodburn E, Campbell O. Reducing maternal mortality in the developing world: sector-wide approaches may be the key. BMJ 2001; 322: 917–920. University of Aberdeen. IMMPACT Development Phase. http://www.abdn.ac.uk/dugaldbairdcentre/immpact, accessed May 24, 2001.
THE LANCET • Vol 359 • February 23, 2002 • www.thelancet.com
For personal use. Only reproduce with permission from The Lancet Publishing Group.
Viewpoint
Now or never: the case for measuring maternal mortality Wendy J Graham “The data we have are not the data we want. The data we want are not the data we need. The data we need are not available.” Finagel’s Laws
Today a woman’s risk of dying of pregnancy-related causes in the poorest countries is still estimated to be higher than it was more than a century ago in the richest nations. This disparity remains in spite of high levels of awareness among governments and international agencies that the vast majority of maternal deaths are avoidable. This disparity also remains in spite of the Safe Motherhood Initiative1 launched in 1987 and charged with the task of doing for mothers what the Child Survival Revolution2 has done for children. Of course, decrying a lack of progress is almost a universal principle in international health. But pregnancy is not a disease, and the reasons for poor progress are complex but not insurmountable. Maternal death in lessdeveloped countries has simply not been seen as a sufficient priority to commit the resources needed. This is demonstrated by the outcome of the recent G8 summit in Genoa, with maternal mortality failing to join HIV, tuberculosis, and malaria as a global priority. To be seen as a priority requires strong advocates being armed with strong data. The purpose of this paper is to show the pivotal role of evidence, both as part of the problem and the solution to poor progress. The application and the adverse consequences of Finagel’s Laws for maternal mortality will be described, and a case made for tackling now the evaluation challenges of safe motherhood.
The data we have The data we have for less-developed countries are inadequate with regard to the levels and trends in maternal mortality, and the effectiveness and costeffectiveness of intervention strategies. This is despite clear evidence of the vital contribution of information to the reduction of maternal mortality in the western world,3 and indeed in the very few transitional countries that seem to have achieved lower levels equitably within their populations, such as Sri Lanka, Thailand, and Malaysia. In all these settings, data on maternal deaths gathered through vital registration, health information systems, and specific routine enquiries (such as Confidential Enquiries into Maternal Deaths4) provided a stimulus for governments to act. These data also gave the essential encouragement to continue efforts and investment, particularly in the face of competing health Lancet 2002; 359: 701–04 Dugald Baird Centre for Research on Women’s Health, Department of Obstetrics and Gynaecology, Aberdeen Maternity Hospital, Cornhill Road, Aberdeen, Scotland AB25 2ZL, UK (Prof W J Graham DPhil (Oxon)) (e-mail: [email protected])
THE LANCET • Vol 359 • February 23, 2002 • www.thelancet.com
problems. The failure to take heed of this lesson—of underestimating the importance of being able to “tell the story”5— has a price that is now being paid in lessdeveloped countries. The lesson could have been learned at several points in the evolution of the Safe Motherhood Initiative and this measurement trap6 avoided. Instead there was ready acceptance of defeat in the task of tracking maternal mortality and a surprising reluctance to revisit the challenge. The Call to Action1 to reduce maternal deaths in the developing world was made in 1987, stimulated in part by a small number of studies gathering population-based data. These studies did not have the power to yield precise estimates of maternal mortality ratios, but they all suggested that levels were much higher than had been expected.7 The Call to Action set targets for reducing maternal mortality by half by the year 2000, ignoring the lack both of baseline estimates and of sources and methods for tracking change. One new approach to emerge in response to the Call to Action was the Sisterhood Method.8 This was devised to estimate the lifetime risk of maternal death, with the expectation that it would be replaced in due course by improved routine data sources and new methods. By the early-1990s, the view among many research groups was that measuring levels of maternal mortality was pretty much impossible and definitely not an efficient use of scarce resources.9,10 Process evaluation thus started to be promoted as the most pragmatic and appropriate way to show progress in safe motherhood. Maternal morbidity was proposed as a possible alternative outcome to mortality, but several research studies rapidly revealed the poor reliability of estimates based on women’s reports.11,12 The desire on the part of less-developed country governments, donor agencies, and international organisations for estimates of the level of maternal mortality did not, however, go away. A clear indication of this was the estimation exercise carried out by WHO and UNICEF to produce regional and country figures for the maternal mortality ratio for 1990.13 Much has been written on the reactions to these estimates and their powerful awareness-raising effect,5 but the accompanying controversy over the validity of the model used and the consequent questioning of the estimates was damaging. Many less-developed countries that had embarked on national safe motherhood activities were disillusioned by the much higher than expected modelled estimates. Donor agencies started to become sceptical about the prospects of ever being able to show benefit from their investments, at a time when both evidence-based decision making and a major competitor for resources—HIV/AIDS, were gaining ascendancy. 10 years on from the launch of the Safe Motherhood Initiative, a technical consultation was held in Colombo, Sri Lanka to review lessons learned and to plan for the future.14 This focus highlighted the continuing lack of reliable evidence that maternal mortality had been reduced by specific intervention strategies, such as
701
For personal use. Only reproduce with permission from The Lancet Publishing Group.
VIEWPOINT
training of traditional birth attendants or use of antenatal at-risk scoring. The few instances in which investigators suggested an impact could be challenged on the basis of weak study design, such as inability to allow for confounders or inadequate samples sizes to show reductions in all-cause or cause-specific maternal mortality.15,16 The Colombo conference promoted skilled attendance at delivery and essential obstetric care as interventions of proven effectiveness, although there was no serious debate on the quality of the evidence. On World Health Day in 1998, the Call to Action was repeated. At the 5-year review of the Cairo Programme of Action the goal for maternal mortality reduction was rephrased as a 75% reduction between 1990 and 2015, and the proportion of deliveries with skilled attendants (health professionals) was proposed as a benchmark indicator to monitor progress.17 In this new century, estimates of the level of maternal mortality have just been published18 by WHO, UNICEF, and the United Nations Population Fund (UNFPA) based on a revised model developed to take account of the earlier criticisms. These latest figures are for the year 1995, but cannot be compared to those from 1990 because of the different model used. In 2002, the women who lose their lives as a result of pregnancy and childbirth in poor countries, essentially remain invisible to the governments and agencies that need to see.
The data we want and the data we need The prevailing view is that the data we want relate to the processes rather than the outcomes of care. This derives not only from accepting defeat in the measurement of accurate levels and trends in maternal mortality, but also from the presumption that “we know how to prevent women dying” and that if these processes are applied, maternal mortality can be inferred to have declined. From this it appears logical that resources should be devoted to measuring the provision, uptake, and quality of care. Considerable effort has thus been spent in recent years on developing process indicators and promoting their use.19 There is still fairly limited experience when interpreting most of these measures, although their apparent simplicity and usefulness for delivering and assessing the success of intervention strategies is starting to be questioned.20 But a more fundamental issue is whether we do indeed know what reduces maternal mortality at the population level. This is not the same as knowing how to prevent a particular woman from dying. At the clinical level there is a considerable amount of rigorous evidence,21 mostly from more-developed countries, regarding procedures to prevent severe morbidity, such as active management of the third stage of labour reducing the incidence of postpartum haemorrhage. This, together with experiential or common-sense reasoning from clinical practice, is the basis for suggesting that most maternal deaths are avoidable— that “we know what to do”. Knowing that a particular procedure or drug is efficacious in the controlled and artificial context of a randomised trial is not, of course, the same as knowing that it can be provided effectively and cost-effectively to reduce maternal mortality in a real world population with real resource constraints. Moreover, these interventions are not delivered singly but rather as packages of care or strategies. It is at this aggregate level—for strategies and whole populations— that governments and donors need to be persuaded of benefit. Monitoring process indicators remains crucial to implementing these strategies, but without any
702
rigorous demonstrations of the causal link between process and outcomes, inferences about maternal mortality are ungrounded. Reliable evidence is needed now on the effectiveness and cost-effectiveness of the various intervention strategies that are already being implemented in many countries and assumed to reduce the level of maternal mortality.
The data not available There are three main reasons why the data we need are not available: technical concerns, leadership, and resources. The technical obstacles are the ones most frequently cited. Indeed these are not trivial otherwise they would have been tackled sooner. These obstacles can be divided into those peculiar to measuring maternal mortality and those generic to assessing effectiveness and cost-effectiveness.22 Much has been written on the former,23,24 emphasising the weaknesses in routine information systems, the rarity of deaths and thus large sample size requirements, the problems of misclassification, and the under-reporting of deaths in early pregnancy and especially from complications of induced abortion. Overcoming these technical challenges requires strong leadership to advocate rigorous evaluation of health outcomes and, in turn, to lobby for appropriate resources. Within the partnership of international agencies spearheading the Safe Motherhood Initiative the emphasis given to advocacy has tended to take precedence over the quality of the evidence needed to make the case. Uncertainty about the respective roles and comparative advantages of the various groups has sometimes been the cause of disharmony, as for example with the 1990 maternal mortality estimates. In these circumstances, leadership regarding data needs has been difficult—a difficulty compounded by changes within the United Nations regarding information-gathering responsibilities. Meanwhile, technical capacity in lessdeveloped countries for maintaining routine information systems and for programme evaluation has declined, and in many settings sources such as vital registration and census enumeration are largely dysfunctional. Thus, champions of evaluation have been missing within countries and international partnerships, and this can be linked to the resources obstacle. The inadequate resources provided to safe motherhood5 are both a cause and an effect of inadequate data with which to prioritise, plan, implement, and sustain effective intervention strategies. The comparative lack, until recently, of large-scale programmes25 attempting to address maternal mortality means that there have been few opportunities to look for impact. Furthermore, there has been an understandable desire among international agencies and technical experts to focus the limited resources that have been made available on implementing actions rather than on measuring their consequences. In other words, the opportunity costs of impact evaluation have been regarded as too high. The direct costs of tracking trends in maternal mortality and attributing these to specific intervention strategies are indeed high, but the indirect costs of failing to do this are now proving even greater.
The adverse consequences Evidence-based decision making clearly requires quality evidence, without which there is a real risk that resources will be wasted and that this waste will go undetected. Recently, for example, training of traditional birth attendants has ceased to be regarded as
THE LANCET • Vol 359 • February 23, 2002 • www.thelancet.com
For personal use. Only reproduce with permission from The Lancet Publishing Group.
VIEWPOINT
a priority. This has happened after many years of funding, but without adequate evaluation that allowed for the presence or absence of a referral system to enable them to practise as they were trained. Skilled attendance at delivery, on the other hand, is now being promoted as a crucial intervention strategy, but again based on plausibility assessment rather than rigorous evaluations26 showing this to be effective and cost effective in specific settings or health systems. Clearly changing programmatic priorities requires a rationale that should include evidence of expected health gain and efficiency savings. Without sound evidence for decision making, safe motherhood programme activities, internationally and in-country, have lacked continuity and engendered uncertainty and disillusionment among governments and donors. Disillusionment, in turn, can lead to a weaker case being made for resources, and so the measurement trap is re-sprung: lack of data and low priority being self-reinforcing. Although it is hard to find reliable information on funding streams, it is estimated that maternal health services represent just 5–11% of total donor contributions to the health sector in less-developed countries, and 4–12% of domestic health expenditure.27 Insights on trends in this funding are even more limited. The World Bank28 provides a rare example of a systematic analysis of its funding for safe motherhood activities, and is now the largest source of external assistance in this area. However even among high maternal mortality countries, only seven of the 22 World Bank funded projects in the areas of family planning and maternal health focused specifically on essential obstetric care. In recent years, the Bill and Melinda Gates Foundation has made the single largest donation for maternal health25 (US$50m), whereas WHO’s entire Making Pregnancy Safer Initiative has considerably fewer funds than this at its disposal.5
(Initiative for Maternal Mortality Programme Assessment).31 With initial funds from the Bill and Melinda Gates Foundation, UNFPA, and WHO, the developmental phase has commenced for a major 7 year effort to develop realistic methods for tracking maternal mortality and severe morbidity, and to determine the most effective and cost-effective strategies for specific country settings. This not only requires methodological innovation, but also partnership innovation to ensure that the measurement scientists do indeed address the needs of practitioners, managers, and policy makers— now rather than never.
Rising to the challenge
6
The challenge of measuring maternal mortality and attributing progress needs revisiting. We must stop saying this cannot be tackled and acknowledge the damage caused so far. We must recognise the risks of continuing to neglect the data needed by poor countries to inform their allocation of scarce resources, and find the funds, the tools, and the opportunities to meet these needs. We must build a sustainable evaluation capacity at the country level and a greater demand for reliable measurement of maternal mortality and severe morbidity. Now is the time to take up the challenge. Health sector reforms are being implemented in a number of less-developed countries. It has long been recognised that maternal health services are dependent on the functioning of the entire health system. Reform programmes thus have huge implications for maternal health.29,30 Data are needed to ensure that the most effective and cost-effective intervention strategies for safe motherhood are integrated into essential service packages, and also to track the impact of the reform process using realistic and affordable information systems. Similarly, opportunities must be seized now to foster links with other global initiatives, such as the Massive Effort Against the Diseases of Poverty, and to recognise the commonalities both in terms of the target populations and the requirements for data and rigorous evaluation. A window has recently been opened on the challenge through a research initiative called IMMPACT
THE LANCET • Vol 359 • February 23, 2002 • www.thelancet.com
Conflict of interest statement The author is the main investigator of IMMPACT.
Acknowledgments I thank my colleagues for commenting on an earlier version: Carla AbouZahr, Jacqueline Bell, Colin Bullough, John Cairns, Jeremy Grimshaw, Marion Hall, Julia Hussein, Sally Stearns, and Edwin van Teijlingen. The author is funded by the University of Aberdeen and holds research grants from: the Bill and Melinda Gates Foundation; DFID; the European Commission; the Scottish Executive; the United Nations Population Fund; and the WHO.
References 1 2
3
4
5
7
8 9
10
11
12
13
14
15
16
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