Maternal                                 M t      l                                mortality:                             ...
Millennium Development Goal 5a is off‐target*  globally                                           450                     ...
Can the maternal health knowledgecommunity do better in what we do       and the way we do it?      and the way we do it?
Knowledge                             Knowledge actors                            Knowledge actorsCommunity               ...
Provocation 1:        Provocation 1:How should we define & measure           “success”?
Nigeria: maternal mortality trends 1985‐2011                     using UN & IHME* estimates             1400             1...
Hindustan Times, August 20th 20 0 i d       i            20 2010
Dipping‐in &‐out of the health system: Nigeria (2008)   100 %    90    80    70    60    50    40    30    20    10     0 ...
The age of accountability         The age of accountability “ In considering society’s expectations & our own  “         d...
“If our objective is to learn, then failure      “If      bj i i         l       h f il represents an immense opportunity,...
Provocation 2: Provocation 2:Do we ever learn?
Copyright North of Scotland Health Service ArchiveCopyright North of Scotland Health Service Archive
MATERNAL MORTALITY: United Kingdom                              g                                         900             ...
Do we ever learn?           Do we ever learn?           Two current “blind spots”:                        “bli d      ”1. ...
Skilled Care at Birth: the complete “package” Community                     Enabling environment e.g. supplies,           ...
Percentage of deliveries with skilled attendants 2008attendants* 2008        <25%      25‐49%      25 49%      50‐74%     ...
“Higher coverage is critical but  Higher coverage is critical but saving lives also depends on the      g               p ...
Provocation 3:          Provocation 3:Are we responsive to changing needs            and demands?             dd       d?
A dynamic burden: medical causes of            y         maternal deaths, Bangladesh 2010                                 ...
Collectively, NCDs are the leading cause of death for women worldwide. They cause 65% of all female deaths, amounting to 1...
Global Strategy for Women s & Children s Health ?             Global Strategy for Women’s & Children’s Health ?    • Count...
“Maternal mortality is much more Maternal mortality is much more       than a medical issue      than a medical issue”    ...
Knowledge  stakeholders are diverse                                                     Private sector                    ...
“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...
“Policy‐makers                                 are from Mars.                                Researchers are              ...
“The role of the scientist is to use research to ascertain  The role of the scientist is to use research to ascertain  the...
Can the maternal health knowledgecommunity do better in what we do       and the way we do it?      and the way we do it?
Wendy J Graham: New Approaches to Maternal Mortality In Africa
Wendy J Graham: New Approaches to Maternal Mortality In Africa
Wendy J Graham: New Approaches to Maternal Mortality In Africa
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Wendy J Graham: New Approaches to Maternal Mortality In Africa

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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

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Wendy J Graham: New Approaches to Maternal Mortality In Africa

  1. 1. Maternal  M t l mortality: evidence gaps &  measurement  traps Professor Wendy J GrahamNew approaches to maternal mortality in AfricaN h l li i Af i University of Cambridge: July 2‐3rd 2012
  2. 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. 3. Can the maternal health knowledgecommunity do better in what we do  and the way we do it? and the way we do it?
  4. 4. Knowledge  Knowledge actors Knowledge actorsCommunity Identify knowledge gaps Measurement  traps*:  concepts,  concepts Gather &  Gather & Translate &  definitions,  synthesize new communicate indicators, knowledge  knowledge sources, toolsKnowledge actors Knowledge actors* Graham & Campbell, 1992
  5. 5. Provocation 1: Provocation 1:How should we define & measure  “success”?
  6. 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 2012Notes: 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. 7. Hindustan Times, August 20th 20 0 i d i 20 2010
  8. 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 RichestSource: Immpact analysis of DHS data; Graham & Fitzmaurice, 2011 – most recent birth only
  9. 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. 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. 11. Provocation 2: Provocation 2:Do we ever learn?
  12. 12. Copyright North of Scotland Health Service ArchiveCopyright North of Scotland Health Service Archive
  13. 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. 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. 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. 16. Percentage of deliveries with skilled attendants 2008attendants* 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. 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
  18. 18. Provocation 3: Provocation 3:Are we responsive to changing needs  and demands? dd d?
  19. 19. 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
  20. 20. 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
  21. 21. 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 levelshttp://www.who.int/pmnch/activities/jointactionplan/en/index.html
  22. 22. “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
  23. 23. Knowledge  stakeholders are diverse Private sector Media Funding  Research  Think  Government  bodies institutions tanks bodies Advocates, civil  Advocates, civil society, NGOs,  parliamentariansAdapted from: Alliance for Health Policy and Systems Research. 2007.
  24. 24. “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)
  25. 25. “Policy‐makers  are from Mars. Researchers are  from Venus.”**Adapted from John Gray, 2004
  26. 26. “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.
  27. 27. Can the maternal health knowledgecommunity do better in what we do  and the way we do it? and the way we do it?

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