- Email: [email protected]
About the PMM Network
International Journal of Gynecology & Obstetrics 59 Suppl. 2 Ž1997. S3]S6
About the PMM Network
1. Introduction The seeds of the Prevention of Maternal Mortality ŽPMM. Network were planted in 1985, when an article by Allan Rosenfield and Deborah Maine appeared in The Lancet. In this article Žwhich had as it’s subtitle: Where’s the ‘M’ in ‘MCH’?., the authors decried the neglect of maternal mortality by international health programs and called for action w1x. In 1987, the Carnegie Corporation of New York gave a generous grant to the Center for Population and Family Health at Columbia University’s School of Public Health. This supported Žamong other activities. the formation of a network of multidisciplinary research teams in Africa. The Network was comprised of 12 teams } seven in Nigeria, two in Ghana, two in Sierra Leone and a technical support team at Columbia University, with a regional office in Accra, Ghana. A great deal has been accomplished since the first PMM Network workshop in 1988. Each of the teams has conducted a needs assessment, using both quantitative and qualitative methods. Based on the results of their needs assessments, the teams designed projects to reduce maternal deaths in their study areas. They also collected various kinds of information Žincluding cost information. for monitoring and evaluating their activities. The Carnegie Corporation of New York has been the major and consistent funder of the Network. It gave each of the African teams two grants } a small grant for the needs assessment and project planning phase, and a larger grant for
the intervention phase. The technical support team at Columbia University has been funded mainly by Carnegie Corporation, with additional grants from the Pew Charitable Trusts, the John D. and Catherine T. MacArthur Foundation and the Andrew W. Mellon Foundation. Throughout, Columbia staff and consultants from the New York and Accra offices have made site visits Žusually tworyear per team. to work with the teams on research methods, program design and implementation, and monitoring and evaluation. In addition, there were 8 week-long workshops at which PMM teams came together to discuss their projects and progress, and to concentrate on various technical topics. The PMM teams presented their findings to an international audience of researchers, policymakers and government officials at the PMM Results Conference, which was held in Accra, in June 1996. A book of abstracts of the conference presentations was published in November 1996 w2x, and the full papers are in this volume. This publication is designed to make the main findings of the projects available to an even wider audience. It is hoped that the lessons learned by the teams of the PMM Network will be put to use by those working to reduce maternal deaths in Africa and in other parts of the world.
2. What makes the PMM Network special?
From the outset, the PMM Network has had a
0020-7292r97r$17.00 Q 1997 International Federation of Gynecology and Obstetrics PII S0020-7292Ž97. 00140-9
S4
About the PMM Network r International Journal of Gynecology & Obstetrics 59 Suppl. 2 (1997) S3]S6
number of objectives: v
v
v
v
to strengthen the capacity of African institutions to design, implement and evaluate health programs in a variety of settings; to foster a cadre of professionals experienced in the field of maternal mortality; to develop program and operations research models for use in maternal mortality projects; and to inform decisionmakers about the importance of maternal mortality and to share information on effective strategies to reduce it.
Each of these objectives is important, and some might have been pursued alone. One of the things that makes the PMM Network special is that these objectives have been pursued simultaneously. In addition, the work of the PMM teams has been based on a number of explicit and innovative models. 3. The conceptual model When the PMM Program began, few tools existed for structuring discussions about causation and prevention. All too often, diverse factors, such as ‘lack of medical supplies’ and ‘low status of women’ were considered simultaneously. While both of these factors contribute to maternal deaths, they do so in disparate ways. Furthermore, activities designed to change these factors have quite different implications for programs. In other fields, such as family planning and child survival, the development of conceptual frameworks helped to clarify possible causal pathways through which various interventions might work. Columbia staff developed such a framework for maternal mortality w3x, and it was used extensively by the Network w4x. 4. The strategic model The underpinning of the network is a strategic model of maternal mortality that was, in the beginning, controversial, but which is now gaining wide acceptance. The central fact, from which this model follows, is that most life-threatening
obstetric complications cannot be predicted or prevented, but they can be successfully treated w5x. Therefore, working to ensure prompt access to adequate medical care for obstetric complications is fundamental to the teams’ projects. 5. The program model The 3 Delays Model, developed by PMM, has been a useful tool for identifying the points at which delay in receiving emergency obstetric care ŽEmOC. can occur: Ž1. delay in deciding to seek EmOC; Ž2. delay in reaching an EmOC facility; and Ž3. delay in actually receiving care after arriving at the EmOC facility w6x. Using this model, the PMM teams designed and implemented activities to address delays at each level. The teams have found it critical to address the last delay first. Only after health facilities nearby are capable of treating complications does it make sense to address the community-level barriers to care, such as lack of information or mistrust of health services. The teams have also found that interventions to improve EmOC need not be costly. By using existing resources, developing creative solutions to local problems and paying attention to management issues, the teams have demonstrated ways of improving EmOC that can be widely replicated. 6. The evaluation model Maternal mortality has traditionally been measured using ‘impact’ indicators, such as maternal mortality rates and ratios. But the data needed to calculate these indicators are difficult to collect. Furthermore, in a relatively small project, the number of deaths would be too small to assess change. The PMM has developed a number of ‘process’ indicators to evaluate interventions aimed at reducing maternal mortality w7x. For example, if the number of women receiving treatment for serious obstetric complications increases, and the proportion of these women who die decreases, then it can be inferred that progress is being made in preventing maternal deaths. Using process indicators is not only feasible, it
About the PMM Network r International Journal of Gynecology & Obstetrics 59 Suppl. 2 (1997) S3]S6
yields valuable information about the types of actions that are needed. The PMM teams are among the first in the field to use this approach, and their work will set new standards for research on safe motherhood. 7. The model for strengthening human resources The PMM Network is built upon the belief that, in international collaboration, different participants bring with them various assets. In the PMM Network, African team members bring indepth knowledge of the cultures and health systems of their countries, their experience in providing services and doing research in those contexts, and expertise in their own disciplines. The Columbia team brings knowledge of the literature, a global view of the field, and experience with the implementation and evaluation of programs in many contexts. Respectful collaboration among professionals with different areas of expertise and different experiences is a hallmark of the PMM Program. Other key characteristics of the Network } multidisciplinary teamwork, regional collaboration, and skills development } are discussed briefly below. 7.1. Multidisciplinary teamwork The core members of each West African team are: an obstetrician, a nurse-midwife, a social scientist and a community physician. The Columbia University team also comprises a mixture of clinical, social science and public health professionals. One of the benefits of this multidisciplinary collaboration is that clinicians gain greater understanding of epidemiological and social science methods and perspectives. Another benefit is the involvement of social scientists in evaluating services in health facilities. 7.2. Skills de¨elopment The technical assistance visits and the workshops have facilitated the development of a range of skills. These skills include qualitative and quantitative research methods and project design and management. Network members have also
S5
learned new techniques of monitoring and evaluation, particularly in the area of process indicators. Members of some teams have contributed their expertise in specific areas, such as costtracking and record-keeping, to the Network as a whole. 7.3. Regional collaboration Over the years, the PMM Network has held eight workshops to facilitate collaboration. Teams in the Network are conducting operations research projects with common goals under different conditions. The workshops have given Network members opportunities to compare notes and learn from one another. At the same time, they have helped encourage a sense of shared purpose that crosses national and professional boundaries. 8. What next? Columbia University’s role as technical coordinator has recently come to an end, but that does not mean the end of the PMM Network. Appropriately, the Network has become an entirely African institution. During the conference in Accra, Network members from the three African countries met and decided unanimously to continue to work together as a network of regional and national non-governmental organizations ŽNGOs., called the Regional Prevention of Maternal Mortality ŽRPMM. Program. The headquarters, in Accra, are headed by Angela Kamara Žwho was the Deputy Director of Columbia’s PMM program.. The PMM teams from each country are forming national and local NGOs. The objective of RPMM is to replicate the program models they have developed and tested, and to foster the development of additional teams and projects in other parts of Africa. Thus, although the structure of the PMM Network has changed, the substance ofthe Network will survive. The cohort of West African professionals that the Network has fostered form the basis of a new Network. They will bring their expertise to whatever challenges they undertake, and are sure to make contributions to the field of international health for decades to come.
About the PMM Network r International Journal of Gynecology & Obstetrics 59 Suppl. 2 (1997) S3]S6
S6
Table 1 The PMM Network teams
w2x
Ghana Accra Kumasi Nigeria Benin Calabar Enugu I LorinU
w3x
Lagos Sokoto Zaria
w4x
w5x
Sierra Leone Bo FreetownrMakeni
w6x
United States Columbia University
w7x
U
No longer active.
References w1 x
Rosenfield A, Maine D. Maternal mortality }
a neglected tragedy: Where is the M in MCH? Lancet 1985;2:83]85. The PMM Network. PMM Results Conference: Abstracts. New York: Center for Population and Family Health, Columbia University, November 1996. McCarthy J, Maine D. A framework for analyzing the determinants of maternal mortality. Stud Fam Plann 1992;23:23]33. The PMM Network. Barriers to treatment of obstetric emergencies in rural communities of West Africa. Stud Fam Plann 1992;23:279]291. Maine D. Safe Motherhood Programs: Options and Issues. New York: Center for Population and Family Health. Columbia University, 1991. Thaddeus S, Maine D. Too Far to Walk: Maternal Mortality in Context. New York: Center for Population and Family Health, Columbia University, 1990. Maine D, McCarthy J, Ward V. Guidelines for Monitoring Progress in the Reduction of Maternal Mortality. New York: UNICEF, October 1992.
About the PMM Network
1. Introduction The seeds of the Prevention of Maternal Mortality ŽPMM. Network were planted in 1985, when an article by Allan Rosenfield and Deborah Maine appeared in The Lancet. In this article Žwhich had as it’s subtitle: Where’s the ‘M’ in ‘MCH’?., the authors decried the neglect of maternal mortality by international health programs and called for action w1x. In 1987, the Carnegie Corporation of New York gave a generous grant to the Center for Population and Family Health at Columbia University’s School of Public Health. This supported Žamong other activities. the formation of a network of multidisciplinary research teams in Africa. The Network was comprised of 12 teams } seven in Nigeria, two in Ghana, two in Sierra Leone and a technical support team at Columbia University, with a regional office in Accra, Ghana. A great deal has been accomplished since the first PMM Network workshop in 1988. Each of the teams has conducted a needs assessment, using both quantitative and qualitative methods. Based on the results of their needs assessments, the teams designed projects to reduce maternal deaths in their study areas. They also collected various kinds of information Žincluding cost information. for monitoring and evaluating their activities. The Carnegie Corporation of New York has been the major and consistent funder of the Network. It gave each of the African teams two grants } a small grant for the needs assessment and project planning phase, and a larger grant for
the intervention phase. The technical support team at Columbia University has been funded mainly by Carnegie Corporation, with additional grants from the Pew Charitable Trusts, the John D. and Catherine T. MacArthur Foundation and the Andrew W. Mellon Foundation. Throughout, Columbia staff and consultants from the New York and Accra offices have made site visits Žusually tworyear per team. to work with the teams on research methods, program design and implementation, and monitoring and evaluation. In addition, there were 8 week-long workshops at which PMM teams came together to discuss their projects and progress, and to concentrate on various technical topics. The PMM teams presented their findings to an international audience of researchers, policymakers and government officials at the PMM Results Conference, which was held in Accra, in June 1996. A book of abstracts of the conference presentations was published in November 1996 w2x, and the full papers are in this volume. This publication is designed to make the main findings of the projects available to an even wider audience. It is hoped that the lessons learned by the teams of the PMM Network will be put to use by those working to reduce maternal deaths in Africa and in other parts of the world.
2. What makes the PMM Network special?
From the outset, the PMM Network has had a
0020-7292r97r$17.00 Q 1997 International Federation of Gynecology and Obstetrics PII S0020-7292Ž97. 00140-9
S4
About the PMM Network r International Journal of Gynecology & Obstetrics 59 Suppl. 2 (1997) S3]S6
number of objectives: v
v
v
v
to strengthen the capacity of African institutions to design, implement and evaluate health programs in a variety of settings; to foster a cadre of professionals experienced in the field of maternal mortality; to develop program and operations research models for use in maternal mortality projects; and to inform decisionmakers about the importance of maternal mortality and to share information on effective strategies to reduce it.
Each of these objectives is important, and some might have been pursued alone. One of the things that makes the PMM Network special is that these objectives have been pursued simultaneously. In addition, the work of the PMM teams has been based on a number of explicit and innovative models. 3. The conceptual model When the PMM Program began, few tools existed for structuring discussions about causation and prevention. All too often, diverse factors, such as ‘lack of medical supplies’ and ‘low status of women’ were considered simultaneously. While both of these factors contribute to maternal deaths, they do so in disparate ways. Furthermore, activities designed to change these factors have quite different implications for programs. In other fields, such as family planning and child survival, the development of conceptual frameworks helped to clarify possible causal pathways through which various interventions might work. Columbia staff developed such a framework for maternal mortality w3x, and it was used extensively by the Network w4x. 4. The strategic model The underpinning of the network is a strategic model of maternal mortality that was, in the beginning, controversial, but which is now gaining wide acceptance. The central fact, from which this model follows, is that most life-threatening
obstetric complications cannot be predicted or prevented, but they can be successfully treated w5x. Therefore, working to ensure prompt access to adequate medical care for obstetric complications is fundamental to the teams’ projects. 5. The program model The 3 Delays Model, developed by PMM, has been a useful tool for identifying the points at which delay in receiving emergency obstetric care ŽEmOC. can occur: Ž1. delay in deciding to seek EmOC; Ž2. delay in reaching an EmOC facility; and Ž3. delay in actually receiving care after arriving at the EmOC facility w6x. Using this model, the PMM teams designed and implemented activities to address delays at each level. The teams have found it critical to address the last delay first. Only after health facilities nearby are capable of treating complications does it make sense to address the community-level barriers to care, such as lack of information or mistrust of health services. The teams have also found that interventions to improve EmOC need not be costly. By using existing resources, developing creative solutions to local problems and paying attention to management issues, the teams have demonstrated ways of improving EmOC that can be widely replicated. 6. The evaluation model Maternal mortality has traditionally been measured using ‘impact’ indicators, such as maternal mortality rates and ratios. But the data needed to calculate these indicators are difficult to collect. Furthermore, in a relatively small project, the number of deaths would be too small to assess change. The PMM has developed a number of ‘process’ indicators to evaluate interventions aimed at reducing maternal mortality w7x. For example, if the number of women receiving treatment for serious obstetric complications increases, and the proportion of these women who die decreases, then it can be inferred that progress is being made in preventing maternal deaths. Using process indicators is not only feasible, it
About the PMM Network r International Journal of Gynecology & Obstetrics 59 Suppl. 2 (1997) S3]S6
yields valuable information about the types of actions that are needed. The PMM teams are among the first in the field to use this approach, and their work will set new standards for research on safe motherhood. 7. The model for strengthening human resources The PMM Network is built upon the belief that, in international collaboration, different participants bring with them various assets. In the PMM Network, African team members bring indepth knowledge of the cultures and health systems of their countries, their experience in providing services and doing research in those contexts, and expertise in their own disciplines. The Columbia team brings knowledge of the literature, a global view of the field, and experience with the implementation and evaluation of programs in many contexts. Respectful collaboration among professionals with different areas of expertise and different experiences is a hallmark of the PMM Program. Other key characteristics of the Network } multidisciplinary teamwork, regional collaboration, and skills development } are discussed briefly below. 7.1. Multidisciplinary teamwork The core members of each West African team are: an obstetrician, a nurse-midwife, a social scientist and a community physician. The Columbia University team also comprises a mixture of clinical, social science and public health professionals. One of the benefits of this multidisciplinary collaboration is that clinicians gain greater understanding of epidemiological and social science methods and perspectives. Another benefit is the involvement of social scientists in evaluating services in health facilities. 7.2. Skills de¨elopment The technical assistance visits and the workshops have facilitated the development of a range of skills. These skills include qualitative and quantitative research methods and project design and management. Network members have also
S5
learned new techniques of monitoring and evaluation, particularly in the area of process indicators. Members of some teams have contributed their expertise in specific areas, such as costtracking and record-keeping, to the Network as a whole. 7.3. Regional collaboration Over the years, the PMM Network has held eight workshops to facilitate collaboration. Teams in the Network are conducting operations research projects with common goals under different conditions. The workshops have given Network members opportunities to compare notes and learn from one another. At the same time, they have helped encourage a sense of shared purpose that crosses national and professional boundaries. 8. What next? Columbia University’s role as technical coordinator has recently come to an end, but that does not mean the end of the PMM Network. Appropriately, the Network has become an entirely African institution. During the conference in Accra, Network members from the three African countries met and decided unanimously to continue to work together as a network of regional and national non-governmental organizations ŽNGOs., called the Regional Prevention of Maternal Mortality ŽRPMM. Program. The headquarters, in Accra, are headed by Angela Kamara Žwho was the Deputy Director of Columbia’s PMM program.. The PMM teams from each country are forming national and local NGOs. The objective of RPMM is to replicate the program models they have developed and tested, and to foster the development of additional teams and projects in other parts of Africa. Thus, although the structure of the PMM Network has changed, the substance ofthe Network will survive. The cohort of West African professionals that the Network has fostered form the basis of a new Network. They will bring their expertise to whatever challenges they undertake, and are sure to make contributions to the field of international health for decades to come.
About the PMM Network r International Journal of Gynecology & Obstetrics 59 Suppl. 2 (1997) S3]S6
S6
Table 1 The PMM Network teams
w2x
Ghana Accra Kumasi Nigeria Benin Calabar Enugu I LorinU
w3x
Lagos Sokoto Zaria
w4x
w5x
Sierra Leone Bo FreetownrMakeni
w6x
United States Columbia University
w7x
U
No longer active.
References w1 x
Rosenfield A, Maine D. Maternal mortality }
a neglected tragedy: Where is the M in MCH? Lancet 1985;2:83]85. The PMM Network. PMM Results Conference: Abstracts. New York: Center for Population and Family Health, Columbia University, November 1996. McCarthy J, Maine D. A framework for analyzing the determinants of maternal mortality. Stud Fam Plann 1992;23:23]33. The PMM Network. Barriers to treatment of obstetric emergencies in rural communities of West Africa. Stud Fam Plann 1992;23:279]291. Maine D. Safe Motherhood Programs: Options and Issues. New York: Center for Population and Family Health. Columbia University, 1991. Thaddeus S, Maine D. Too Far to Walk: Maternal Mortality in Context. New York: Center for Population and Family Health, Columbia University, 1990. Maine D, McCarthy J, Ward V. Guidelines for Monitoring Progress in the Reduction of Maternal Mortality. New York: UNICEF, October 1992.