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.
This blog was originally published in Global Health Council's Magazine blog