Dying mothers: from the evidence to political will

Mothers die overwhelmingly because they are poor - but this gives an opportunity for targeted action

SUMMARY
The end of the first phase of the Immpact global research study on maternal mortality has leads to one main conclusion - that in any community, rich or poor, the poorest women suffer by far the worst maternal mortality. So to reach the Millennium Development Goals, the poor should be cared for first - and the message must be clearly communicated to policy-makers. Director of the Immpact study Wendy Graham explains her conclusions.

The number of mothers who die at or around childbirth is remarkably difficult to measure, but according to estimates made by WHO, the UN Population Fund (UNFPA) and UNICEF in the year 2000, the annual global figure was 529 000 lost lives. These deaths were almost equally divided between Africa (251 000) and Asia (253 000), with about 4% (22 000) occurring in Latin America and the Caribbean, and less than 1% (2 500) in the more developed regions of the world.

The global figure is estimated to be 400 mothers dying for each 100 000 live births - a figure called the 'maternal mortality ratio' (MMR). By region, the MMR was highest in Africa (830), followed by Asia (330), Oceania (240), Latin America and the Caribbean (190), and lowest in the developed countries (20).

Millennium Development Goal Five calls for the maternal mortality ratio to be reduced by three-quarters by 2015.

The "Immpact" research study on strategies to reduce maternal mortality in developing countries was launched on 1 June 2022 with initial development support from the Bill and Melinda Gates Foundation, the United Nations Population Fund (UNFPA) and WHO. Since then other donors entered the list, including the UK's Department for International Development (DFID) and the United States Agency for International Development (USAID).

Immpact began its first full four years of operation in February 2002. Results of that phase of the research are now in, and were reported at a dedicated Symposium in London in February 2007. Wendy Graham, the Director of the Immpact, speaks here to RealHealthNews about the results, and what she believes must happen next. In later pages we carry a story on maternal mortality in Uganda, and an interview with the Minister of Health for Sierra Leone, Abator Thomas, who attended the Immpact Symposium.

(May 07)

RHN: After all your work, what are the main conclusions from Immpact?

Wendy Graham: Since the Symposium in February, I’ve been trying to distil and distil. I think for a high-level decision-maker I’d say there were three main messages:

• The first conclusion is that the burden of maternal mortality is always much greater amongst the poorest women.
• The second is that because of where that burden lies, this gives countries an opportunity to accelerate progress to Millennium Development Goal Five [a 75% reduction in maternal mortality by 2015] by prioritizing quality skilled attendance at delivery for the poorest women.
• And the third message is that monitoring progress to Millennium Development Goal Five is possible, particularly using tools from Immpact.

RHN: Wasn’t the poverty correlation pretty predictable?

WG: Well it sounds like common sense; but my answer to that is first, why are we thinking that there will be something new, when this study affirms what we knew; and second, we’ve helped by quantifying that effect.

For example in Indonesia there is a six-fold difference between rich and poor in the uptake of skilled attendance at birth - and a four-fold difference between rich and poor in the risk of maternal mortality.

So now we can put numbers on it, and by doing that we can also show where you can start to have an effect. Unless you give the poorest access to skilled care at a price that they can afford, you can’t affect maternal mortality.

RHN: To what extent, would you say, can research on maternal mortality make a difference?

WG: I could throw that back to you – because the frontier is not lack of evidence, the frontier is communicating the evidence.

When we launched Immpact, it seemed at that time that the bottleneck was evidence on strategies. And we and others, like the Averting Maternal Death and Disability programme (AMDD) and Family Care International (FCI), have helped to fill that gap.

For strategies we could never have grade one, randomized control evidence, because there are too many technical challenges to doing those real-world evaluations. Nevertheless there is now a better understanding from us, and from others, of packages of care that can make a difference.

The issue now is the political will to act on that evidence. I think sometimes evidence is even used as a bit of a cop out. We don’t have evidence of the kind you can get for specific clinical interventions for children like vitamin A, but we all know that there is no magic bullet for maternal mortality.

So I think the goalposts have moved – there is nothing really new to say: it’s health system strengthening, it’s a multi-pronged approach, with effectively reaching the poor being the only way that you’ll have an effect on maternal mortality by 2015. The frontier now is the willingness to do that.

RHN: Is the immense gender inequality that exists in many countries going to be an obstacle to political commitment?

WG: It is in some ways, but in Africa for example there’s a growing number of very strong women activists; and I think there is a role for some of these civil society groups.

One of the criticisms of the safe motherhood movement is that we talk to ourselves all the time, and we don’t talk to others enough about the issues. Women’s groups and civil society groups are a case in point – I think that in terms of making the case for women’s rights to life our issue has become rather medicalised. Other groups outside the health movement are much stronger.

So yes, there is a gender element, but I am more optimistic about that in Africa than I am in Asia, India and Bangladesh in particular. This is partly because there are many economically strong women in Africa – although there are pockets in for example Ethiopia and Sudan and Northern Nigeria that are not so strong. But in general in Africa women have access to the means of production.

RHN: Nevertheless if there is some stronger evidence that can be brought to a decision maker, it can make a difference, can’t it? For example Anne Phoya of the Ministry of Health in Malawi said at the Immpact Symposium that the importance of strong evidence is that “it helps you negotiate with the treasury”.

WG: Yes, and that’s where the translation of research to policy-making enters: the two need to come together smoothly rather than collide. Because ‘what works?’ is never going to have a simple answer, not the simple answer that a politician would want.

The closest I’ve got to that is ‘focus on the poor’. Then there’s the way to say that - I could say that they can’t reach the 2015 target without focusing on the poor; but that’s rather negative, and I think the best way is to say that they can accelerate progress that way.

But at the same time we have to be careful about not making it sound overly simple. Focussing on the poor is not straightforward.

RHN: Another thing that struck me forcibly at the Symposium was how many factors can be said to cause maternal mortality. There is a wide spread of different issues that you have to address, isn’t it?

WG: There is. And that has bedevilled the history of safe motherhood. Early in the history of the movement we were talking about training of traditional birth attendants, or antenatal care and screening for example – very specific things as if they might be the solution. Then in the early 1990s it got broadened to become part of reproductive health agenda; and then it got on board with health system strengthening, which of course is genuinely what needs to happen.

But the history of safe motherhood is that it has got broader and broader over time – and clearly with gender issues coming in, including the gender Millennium Development Goal [MDG 3, to promote gender equality and empower women], it’s become very very big.

Which it is; but from a messaging point of view people don’t want to hear ‘it requires strengthening of the whole health system’, or even ‘it needs poverty reduction’. And that’s the problem. So I think it’s an art, so the scientists who are generating the evidence can feel comfortable and not uneasy or untruthful.

Research also reveals uncertainty – but that’s also unpopular among decision-makers! So after the Symposium I was faced with two groups of people, one saying ‘I wish you hadn’t mentioned uncertainty’, and the other ‘I wish you’d said more about that’!

RHN: Disagreement among scientists is also a problem, isn’t it - and I understand that there has been a bit of a division in the maternal mortality community between those who believe that the solution is to provide quality care at a first referral health centre, and those who believe it’s best to provide it in the home…

WG: Yes - partly, what you are picking up there is a balance between what is right for the mother and what is right for the child. It’s very difficult, and in communicating on this you can sound as if you are not for child survival, whereas everyone working in maternal health is also very much wanting to see improved child survival, and vice versa; so it’s not as if we don’t have the same ultimate goals.

But if you are put on the spot, and you are asked simply how to prevent women dying, we know that home-based care simply can’t have that dramatic effect – because sooner or later you are going to need emergency obstetric care, a blood transfusion, or life-saving surgery.

That’s not to say that you can’t do some things at home; but if you are saying what is the route to avoiding mothers’ deaths, we don’t have the same sort of home-based care that might work for a child like oral rehydration salts (ORS) for diarrhoea.

RHN: I think it’s clear that maternal mortality is a wonderful test case of whether a country is genuinely committed to improving its health system, or at least a portion of that system, because so many health interventions for the poorest remain vertical, focused on very particular interventions, which they drive through; and they don’t link up with one another. Here, it seems to me, you have to link up a series of different ideas.

WG: Absolutely. Because even if there were a magic bullet, you’d need an implementation mechanism to deliver that. Take antiretrovirals for HIV/AIDS for example. I know South Africa quite well, and the thing that is creaking at the seams is the delivery mechanism - the health system.

Although some areas of disease and health give the impression that they can work without the health system, they meet it sooner or later. Unless you have a project that has so much money that it can create its own health workers and its own drug supply system and so on, sooner or later it has to fall back on the health system.

Some groups have addressed that problem of the health system more than others, and the maternal mortality group has just had to address it, because what you need to reduce maternal mortality is a functioning health system.

RHN: To what extent has Immpact been able to harden up the numbers on maternal mortality?

WG: I think we’ve made a significant contribution in measuring the variation within countries. In many countries, even quite small countries like Sri Lanka, national figures hide more than they reveal. And the challenge has always been to measure at a sub national level – though some countries don’t even have a national figure.

So we’ve had to develop monitoring methods and evaluation instruments that can pick up whether there has been an increase in skilled attendance and so on locally.

RHN: So what’s the story in Sri Lanka?

WG: We didn’t study Sri Lanka directly. But we know that although the national level of skilled attendance is very high, in some parts of the country it falls below 50%. So using our evidence on the correlation between skilled attendance and mortality, one can predict about a two-fold higher mortality in those areas. I don’t want to diminish the work of Sri Lanka – it is a success story – but all over the world there are disadvantaged groups that don’t benefit in the same way.

RHN: Tell me about the Immpact ‘tool kit’, which was presented at the Symposium. Because it seems to me that one of the most important conclusions, or products, of Immpact, has been a way to measure this kind of variability within countries. Have you got something here that is practical for a small team to work with?

WG: Well they vary in terms of practicality. In our toolkit, on our CD package, we purposely selected tools that we thought others outside of research could use.

But we also have developed some intensive research tools – so we have a mixture. Some can be picked up and used by a district outside a research context, and others that because of their resource requirements in both funds and skills, will always remain research tools.

RHN: Can you draw that distinction for me a bit more sharply? What’s the difference between relevant data collection within the health system, and research – how do you distinguish the two things? What’s the research going to be doing that the data collection is not doing?

WG: It’s in terms of the volume of information, and contexts. For these evaluations we were carrying out, we were working outside of a trial design, looking at existing strategies. So we had to look very carefully at contextual factors, to see if there was something else that was changing that could easily explain the improvements we saw – these would be confounding factors.

When you come in as an external evaluator that’s right, and you must measure everything that moves – because you don’t know for example whether roads are suddenly going to be finished and change referral mechanisms much more than safe motherhood has ever done! So it becomes a ‘measurement fest’ – which is excusable and defensible for a very specific question.

But routinely, you would not need to gather that volume of information. On the other hand, it would depend on what decisions you wanted to make – is it an early warning system to know whether a particular hospital is failing to deliver, or more complex?

In tools, the bottom line is almost the other way around: you choose the tool depending on the decision you are trying to make. Because with some types of information, for advocacy for example, you don’t want ropey data - but it’s not the same as asking whether to commit a major resource to a new drug, for example.

RHN: You used the phrase ‘the bottom line’. Won’t the bottom line to the Minister be how many lives can I save at what cost – and cynically, how many do I save in my political domain?

WG: Absolutely, and we have instruments now that can either measure it directly or can estimate.

RHN: Regarding the political credibility of evidence, Sam Adjei of Ghana Health services made some interesting points at the Symposium. He said the institution creating the evidence has to be credible, and politically neutral. Well that’s generally true of an academic body. But then he stressed that there needs to be ‘ownership’ – which often means there has to be a local research group involved, with good connections with the Ministry so the Ministry itself knows about and wants the research from the beginning…

WG: I think we’ve learned quite a lot of lessons on that!

RHN: Well do tell us something about that.

WG: When I look at the timeline and where we are, I think some of our early processes were very slow. But then when I look back I realise that we were creating this ‘pull’ for the evidence, and that’s not something you can achieve overnight. It means working through and with, as you said, credible local institutions that have the ear of the users of the information, while keeping a degree of impartiality - so that you can tell both good news and bad news with impunity.

Interestingly that was very straightforward in Burkina Faso, but it was much harder to achieve in Indonesia, for a variety of reasons. So I think ‘neutrality’ never really exists in some situations, because the research institutions are so much a part of the government that they can never be neutral. So we have to acknowledge that as well.

It can be quite hard for a research institution to say in those situations that there has been no obvious progress. You can say this in a variety of positive ways, but it can become quite hard – and we can underestimate the difficulty that puts research institutions in.

RHN: What do you think actually could be achieved by applying your recommendations?

WG: Well I think that by 2015, by effectively focussing on the poorest with quality skilled attendance at delivery, countries will make detectable improvement towards Millennium Development Goal Five.

But it must not be poor care for the poor – that’s the risk. By talking about targeting and skilled attendance specifically for the poor my worry would be that this is seen as a second-class service, and it shouldn’t be. There should be skilled attendance, and it should be specifically given first to the poor.

Some countries have had 20-50% declines in mortality over times equal to the period we have left [to 2015], but it’s a lot of effort, and there will be questions of sustainability.

A 75% reduction in mortality, the MDG itself, is however a monumental goal.

here are two schools of thought there – one that it was never really meant to be taken that only 75% really mattered, that it was a lever to help stimulate countries; and the other, in the MDG community, that there is going to be huge disappointment if we don’t reach the goal.

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