MDG 5: World Leaders - Are You Listening?
09/17/2010
Measuring progress on MDG5- do we have the right yardstick? Maternal health experts weigh in
As world leaders meet this week at the UN Summit to review progress toward the Millennium Development Goals (MDGs), it is essential that they ask themselves one question:
Are the present global benchmark indicators for maternal health enough? The answer is no.
Right now, the indicators we are using neither measure what we want to know or what we need to know. We need our measurements to tell us more about the actual care that women receive, that reduces risk to them and their newborns. But there are special challenges to measurement for maternal health. Ideally we would be tracking the number of maternal deaths but this requires functional vital registration systems or surveys with large sample sizes, often multiple sources of data and more detailed investigation of deaths to determine if they were pregnancy-related. Even with large samples, maternal mortality ratio estimates typically have wide variation.
To date, due to these difficulties, we have not relied primarily on the measurement of changes in maternal mortality ratios to assess the performance of programs aimed at saving women's lives.
Global benchmark indicators have a variety of important uses, in addition to monitoring progress on MDGS. Indicators of overall program performance can be used for accountability and advocacy, to help determine whether or not services are working well and when it is necessary to obtain a more detailed comprehensive picture to accurately direct efforts at improving program performance. Clearly, what we're really interested in at the end of the day is driving down the burden of maternal deaths. Since measuring the maternal mortality ratio presents challenges, we rely on other indicators for year-to-year monitoring of progress.
The two most widely used global benchmark indicators are the presence of a skilled birth attendant (SBA) at delivery and antenatal care (ANC) visits. Although they give us valuable information about certain aspects of service provision, they tell us only that a contact occurred but nothing about what happened during the contact with the patient that would actually reduce her risk of mortality or morbidity. Impact is achieved when these contacts are used to deliver high quality effective interventions, including managing obstetrical emergencies, which these two indicators alone do not address. That being the case, levels of use of skilled birth attendants or antenatal care correlate little at the national level with the maternal mortality ratio.
This is not to say that we should ignore use of SBA for deliveries and ANC visits. They are fundamentally important indicators of access and utilization of services and should be retained as benchmarks, provided that it is made very clear that they measure contact, not delivery of interventions that change outcomes - and not program performance. Use of such indicators alone as measures of program performance tends to incentivize the contact rather than content and quality. Relying exclusively on benchmark indicators that are not closely enough linked causally with the outcomes we are trying to influence can result in misdirected program efforts in maternal health, as it does in other technical areas.
Policy-makers need to select their strategies based on their unique country circumstances; strategies need to be developed which give the highest feasible coverage of interventions and services which can drive down mortality. Adding complementary indicators that capture important aspects of quality and content of case can be expected to direct program attention to content and quality of care
The intra-partum case-fatality rate could be considered as a benchmark indicator, reflecting not only how adequately needs are met for the newborn but also for the mother, as a proxy for timeliness, appropriateness and case. Use of oxytocin in the 3rd stage of labor may be another good indicator, directly reflecting provision of an intervention that reduces risk of death from bleeding.
One of the first steps that our world leaders may need to accept is that there isn't any one single indicator adequate for tracking overall maternal health program performance. Holding ourselves accountable as donors, policy makers and program managers using a larger set of content and quality indicators will better encourage a program focus that will yield improvements in population-level health outcomes and that will accommodate the variations in strategy that are needed in different settings. We need now to identify a suitable set of such indicators and the most appropriate means of measuring them. World leaders, are you listening?
Dr. Steve Hodgins is the global leadership team leader of USAID's Maternal and Child Health Integrated Program (MCHIP). Dr. Marge Koblinsky is the senior technical advisor at MCHIP. Dr. Koki Agarwal is the director of MCHIP.
I do agree with your comments that we need to add quality indicators to encourage a program.However in developing countries like Pakistan, with acute shortage of technical persons, monitoring these quality indicators is a big issue.Do you have any suggestions for monitoring them effectively.
— Shabana on 2010-09-22
Dear World leaders,
Please listen to our mothers in all parts of North India with over 40% home deliveries without any assistance and a maternal mortality rate of over 400 per 100,000 deliveries.
Vijaya srinivasan
— Dr.Vijaya Srinivasan on 2010-09-22
Nice article. You conclude by saying that new indicators should be explored for the actual measurement of maternal motrality but you don’t give any hint of such new indicators..it could have been better if you could have shared about the proposed new indicators…..
— sanjeev raj neupane on 2010-09-22
I think the MDG need to be review again because personally I think the goals are not met.
— Chi Roland Awah evina on 2010-09-22
World leaders, are you listening? Of course they listened, but they have higher priority target rather than maternal mortality. The programmatic language is not similar to world leader’s political language that usually dealing with personal reputation instead of people well-fare.
From my point of view, the current indicators are fine if not translated as numbers per se. WHO had published “Beyond the Numbers” since 2004 and Tracking MDG 2015 had entailed coverage, equity & equality, gender, policies, evidence-based health interventions & budget those might use to measure the efforts and accomplishment toward MDG 2015 targets, particularly number 4 & 5. Do not create new, just fill the gaps and do it now.
— george adriaansz on 2010-09-23
Cant think of luxury. People in remotest hills in Nepal suffer to death sans ORS. Their heads do not think & understand how health is wealth. It is nothing with their empty stomach. Other side of the reality, who goes to serve in difficult zones when he/she is medical/health professional with scope in urban centers.And, government is to rule, do politics in center if women die while delivering a baby and kids die of diarrhea epidemic. MDGs in such situations will show progress in papers not in citizenry level. Other versions will come, I am hopeful.
— rajendra adhikari on 2010-09-27
Thank you for the good comments. I agree that we need additional indicators. More so in poor resource settings like in my country Uganda where the challenge of the 3 delays is critical and hence poor maternal and newborn outcomes. We do have a disconnect between two critical behaviours ANC attendance and skilled delivery.Some mothers do come for ANC at the health facilities but prefer not to show up for skilled delivery. This requires a deeper understanding of the motivators for ANC attendance and de-motivators for skilled delivery by our health workers.
— Luwaga Liliane on 2010-10-02