Wendy J Graham (Professor of Obstetric Epidemiology at the School of Medicine and Dentistry, University of Aberdeen; Senior Research Advisor, Department for International Development): Maternal mortality: evidence gaps and measurement traps

1. Maternal
M t l
mortality:
evidence gaps &
measurement
traps
Professor Wendy J Graham
New approaches to maternal mortality in Africa
N h l li i Af i
University of Cambridge: July 2‐3rd 2012

2. Millennium Development Goal 5a is off‐target* globally
450
400 X
deaths per 100 000 live births
350
300
250
200
150
Maternal d
100 MM Target
X
50
0
1990 1995 2000 2005 2010 2015
* 75% reduction in the maternal mortality ratio between 1990 and 2015.
Source: UN, May 2012

3. Can the maternal health knowledge
community do better in what we do
and the way we do it?
and the way we do it?

4. Knowledge
Knowledge actors
Knowledge actors
Community
Identify knowledge gaps
Measurement
traps*:
concepts,
concepts Gather &
Gather &
Translate & definitions, synthesize new
communicate indicators, knowledge
knowledge
sources, tools
Knowledge actors Knowledge actors
* Graham & Campbell, 1992

5. Provocation 1:
Provocation 1:
How should we define & measure
“success”?

6. Nigeria: maternal mortality trends 1985‐2011
using UN & IHME* estimates
1400
1200 2015 target: MMR 275
1000
M 800
M
600
R
400
2015 target: MMR 100
200
0
1985 1990 1995 2000 2005 2008 2010 2011
Year
UN 2010 IHME 2010 IHME 2011 UN 2012
Notes: UN 2012means estimates for year 2010 published 2012
IHME 2008 means estimates for year 2008 published by Hogan et al (2010)
* Institute of Health Metrics &
IHME 2011 means estimates for year 2011 published by Lozano et al (2011) Evaluation, University of Washington

7. Hindustan Times, August 20th 20 0
i d i 20 2010

8. Dipping‐in &‐out of the health system: Nigeria (2008)
100 %
90
80
70
60
50
40
30
20
10
0
DPT 1 dose
Met need
C 4/4+ visits
SAD
Postnatal visit
Contraceptive use
feeding
Full Vaccine
ANC 1 visit
natal Tetnus
al deliveries
2+ Tetanus Injections
Breast
F
Institutiona
ANC
Neon
Poorest 2 3 4 Richest
Source: Immpact analysis of DHS data; Graham & Fitzmaurice, 2011
– most recent birth only

9. The age of accountability
The age of accountability
“ In considering society’s expectations & our own
“ d ’ &
goals {ask knowledge actors}, we believe that there
is a moral imperative to reconsider how scientific
l d h f
data are judged & used.”
Young et al. PLoS Med 2008; e201
Y t l PL S M d 2008 201

10. “If our objective is to learn, then failure
“If bj i i l h f il
represents an immense opportunity, and if our
aim is to seize the greatest opportunities
available to us, then we need to become
available to us, then we need to become
connoisseurs of failure...
What is a great failure is a project in pursuit of a
noble goal... It is one we learn from.”
bl l I i l f ”
Gunderman, RD. (2010)

11. Provocation 2:
Provocation 2:
Do we ever learn?

12. Copyright North of Scotland Health Service Archive
Copyright North of Scotland Health Service Archive

13. MATERNAL MORTALITY: United Kingdom
g
900
ve
0,000 liv
800 “Maternal mortality is a great blot
700 on public health administration.”
M atern al D eath s p er 100
600 Minister of Health, 1935
b irt s
500
th
400
300
200
100
a
0
1850 1870 1890 1910 1930 1950 1970 1990 2010
Year

14. Do we ever learn?
Do we ever learn?
Two current “blind spots”:
“bli d ”
1. Skilled a endant at birth ≠ skilled care at birth
2. High coverage is necessary but not sufficient

15. Skilled Care at Birth: the complete “package”
Community
Enabling environment e.g. supplies,
g g pp ,
infrastructure, transport, etc
Skilled attendants
Skills to promote Referral
Skills to provide
p
utilisation of delivery comprehensive
care and to conduct emergency
normal deliveries obstetric care
Skills to provide basic
emergency obstetric
emergency obstetric
care

16. Percentage of deliveries with skilled
attendants 2008
attendants* 2008
<25%
25‐49%
25 49%
50‐74%
75‐94%
>95%
No data
*Defined as health professionals (doctors, midwives,
nurses). Data source: WHO (2008), WRA Birth Atlas 2010

17. “Higher coverage is critical but
Higher coverage is critical but
saving lives also depends on the
g p
quality of care.”
Taking stock of maternal, newborn and child survival: 2000‐2010
Decade Report. Executive Summary
Decade Report Executive Summary
Countdown to 2015. June 2010

21. Provocation 3:
Provocation 3:
Are we responsive to changing needs
and demands?
dd d?

22. A dynamic burden: medical causes of
y
maternal deaths, Bangladesh 2010
Eclampsia
20%
Hemorrhage
31% Obstructed
Prolonged
Labor
7%
Abortion
1%
Other Direct
5%
Undetermined
1%
Indirect
35%
Source: BMMS 2010 Summary report

23. Collectively, NCDs are the
leading cause of death for
women worldwide. They
cause 65% of all female
deaths, amounting to 18
million deaths each year.
No longer diseases of the rich
and elderly, NCDs are a
significant cause of female
death during childbearing
years and for women with
young families in developing
countries

24. Global Strategy for Women s & Children s Health ?
Global Strategy for Women’s & Children’s Health ?
• Country‐led health plans
y p
• Comprehensive package of essential interventions and
services
• Integrated care
• Health systems strengthening
• Health workforce capability building
• Coordinated research and innovation
• Accountability at all levels
Accountability at all levels
http://www.who.int/pmnch/activities/jointactionplan/en/index.html

25. “Maternal mortality is much more
Maternal mortality is much more
than a medical issue
than a medical issue”
Ban Ki‐moon
United Nations Secretary General
U it d N ti S t G l
2009

26. Knowledge stakeholders are diverse
Private sector
Media
Funding Research Think Government
bodies institutions tanks bodies
Advocates, civil
Advocates, civil
society, NGOs,
parliamentarians
Adapted from: Alliance for Health Policy and Systems Research. 2007.

27. “There is nothing {we} like so little as
to be well informed; it makes decision‐
t b ll i f d it k d ii
making so complex and difficult.
making so complex and difficult.”
J M Keynes
J M Keynes
(1883‐1946)

28. “Policy‐makers
are from Mars.
Researchers are
from Venus.”*
*Adapted from John Gray, 2004

29. “The role of the scientist is to use research to ascertain
The role of the scientist is to use research to ascertain
the effectiveness of innovative policies and programs.
This is in contrast to {their} role as advisor in which the
scientist can indulge in over advocacy ...
scientist can indulge in over‐advocacy ”.
Donald T Campbell 1988 The experimenting society.

30. Can the maternal health knowledge
community do better in what we do
and the way we do it?
and the way we do it?