wendy j graham: new approaches to maternal mortality in africa
DESCRIPTION
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 trapsTRANSCRIPT
M t lMaternal mortality:mortality:
evidence gaps & measurement
trapstraps
Professor Wendy J Graham
N h l li i Af iNew approaches to maternal mortality in AfricaUniversity of Cambridge: July 2‐3rd 2012
Millennium Development Goal 5a is off‐target* globally
450
350
400
e births X
250
300
100 00
0 liv
150
200
deaths per
50
100
Materna
l d
MM TargetX
0
1990 1995 2000 2005 2010 2015
* 75% reduction in the maternal mortality ratio between 1990 and 2015. Source: UN, May 2012
Can the maternal health knowledgecommunity do better in what we do
and the way we do it?and the way we do it?
Knowledge actorsKnowledge Community Knowledge actorsCommunity
Identify knowledge gaps
Gather &
Measurement traps*: concepts Gather &
synthesize new knowledge
Translate & communicate
concepts, definitions, indicators, knowledge
sources, tools
Knowledge actorsKnowledge actors
* Graham & Campbell, 1992
Provocation 1:Provocation 1:
How should we define & measure “success”?
Nigeria: maternal mortality trends 1985‐2011
1400
using UN & IHME* estimates
1000
1200 2015 target: MMR 275
600
800MMR
200
400R
2015 target: MMR 100
01985 1990 1995 2000 2005 2008 2010 2011
YearYear
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)IHME 2011 means estimates for year 2011 published by Lozano et al (2011)
* Institute of Health Metrics & Evaluation, University of Washington
i d i 20th 20 0Hindustan Times, August 20th 2010
100 %
Dipping‐in &‐out of the health system: Nigeria (2008)
8090100 %
506070
304050
01020
ANC 1 visit
natal Tetnu
s
s Injectio
ns
C 4/4+
visits
SAD
al deliveries
stnatal visit
Breast
feed
ing
DPT 1 do
se
Full Vaccine
ceptive use
Met need
Neo
n
2+ Te
tanu ANC
Institu
tiona Po
F
Contra
Poorest 2 3 4 RichestPoorest 2 3 4 Richest
Source: Immpact analysis of DHS data; Graham & Fitzmaurice, 2011 – most recent birth only
The age of accountabilityThe age of accountability
“ d ’ &“ In considering society’s expectations & our own goals {ask knowledge actors}, we believe that there
l d h fis a moral imperative to reconsider how scientific data are judged & used.”
Y t l PL S M d 2008 201Young et al. PLoS Med 2008; e201
“If bj i i l h f il“If our objective is to learn, then failure represents an immense opportunity, and if our
aim is to seize the greatest opportunities available to us, then we need to becomeavailable to us, then we need to become
connoisseurs of failure...
What is a great failure is a project in pursuit of a bl l I i l f ”noble goal... It is one we learn from.”
Gunderman, RD. (2010)
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
900ve
g
700
800
0,00
0 liv “Maternal mortality is a great blot
on public health administration.”
500
600
per 1
00th
s
Minister of Health, 1935
300
400
Dea
ths
birt
100
200
ater
nal
01850 1870 1890 1910 1930 1950 1970 1990 2010
Ma
Year
Do we ever learn?Do we ever learn?
“bli d ”Two current “blind spots”:
1. Skilled a endant at birth ≠ skilled care at birth
2. High coverage is necessary but not sufficient
Skilled Care at Birth: the complete “package”
CommunityEnabling environment e.g. supplies,
Skilled attendants
g g pp ,infrastructure, transport, etc
Skills to promote Skills to provide Referral
utilisation of delivery care and to conduct normal deliveries
pcomprehensive emergency
obstetric care
Skills to provide basic emergency obstetricemergency obstetric
care
Percentage of deliveries with skilled attendants* 2008attendants 2008
<25%25 49%25‐49%50‐74%75‐94%>95%>95%
No data
*Defined as health professionals (doctors, midwives, nurses). Data source: WHO (2008), WRA Birth Atlas 2010
“Higher coverage is critical butHigher 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 SummaryDecade Report. Executive SummaryCountdown to 2015. June 2010
Provocation 3:Provocation 3:
Are we responsive to changing needs d d d ?and demands?
A dynamic burden: medical causes of ymaternal deaths, Bangladesh 2010
Eclampsia20%
Obstructed Hemorrhage
31%Prolonged Labor7%Abortion
31%
Abortion1%
Other Direct5%5%Undetermined
1%
Indirect35%35%
Source: BMMS 2010 Summary report
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
Global Strategy for Women’s & Children’s Health ?Global Strategy for Women s & Children s Health ?
• Country‐led health plansy p
• Comprehensive package of essential interventions and servicesservices
• 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
“Maternal mortality is much moreMaternal mortality is much more than a medical issue”than a medical issue
Ban Ki‐moon
U it d N ti S t G lUnited Nations Secretary General
2009
Knowledge stakeholders are diverse
Media
Private sector
Research institutions
Think tanks
Funding bodies
Government bodies
Advocates, civil
institutions tanksbodies bodies
Advocates, civil society, NGOs, parliamentarians
Adapted from: Alliance for Health Policy and Systems Research. 2007.
“There is nothing {we} like so little as t b ll i f d it k d i ito be well informed; it makes decision‐
making so complex and difficult.”making so complex and difficult.
J M KeynesJ M Keynes (1883‐1946)
“Policy‐makers are from Mars.Researchers are from Venus.”*
*Adapted from John Gray, 2004
“The role of the scientist is to use research to ascertainThe 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.
Can the maternal health knowledgecommunity do better in what we do
and the way we do it?and the way we do it?