Accountability for maternal and newborn health: Why measuring and monitoring broader social, political, and health system determinants matters.

This article offers four key lessons learned from a set of seven studies undertaken as part of the collection entitled, "Improving Maternal Health Measurement to Support Efforts toward Ending Preventable Maternal Mortality". These papers were aimed at validating ten of the Ending Preventable Maternal Mortality initiative indicators that capture information on distal causes of maternal mortality. These ten indicators were selected through an inclusive consultative process, and the research designs adhere to global recommendations on conducting indicator validation studies. The findings of these papers are timely and relevant given growing recognition of the role of macro-level social, political, and economic factors in maternal and newborn survival. The four key lessons include: 1) Strengthen efforts to capture maternal and newborn health policies to enable global progress assessments while reducing multiple requests to countries for similar data; 2) Monitor indicator "bundles" to understand degree of policy implementation, inconsistencies between laws and practices, and responsiveness of policies to individual and community needs; 3) Promote regular monitoring of a holistic set of human resource metrics to understand how to effectively strengthen the maternal and newborn health workforce; and 4) Develop and disseminate clear guidance for countries on how to assess health system as well as broader social and political determinants of maternal and newborn health. These lessons are consistent with the Kirkland principles of focus, relevance, innovation, equity, global leadership, and country ownership. They stress the value of indicator sets to understand complex phenomenon related to maternal and newborn health, including small groupings of complementary indicators for measuring policy implementation and health workforce issues. They also stress the fundamental ethos that maternal and newborn health indicators should only be tracked if they can drive actions at global, regional, national, or sub-national levels that improve lives.

Maternal death surveillance and response system reports from 32 low-middle income countries, 2011-2020: What can we learn from the reports?

Maternal Death Surveillance and Response (MDSR) systems generate information that may aid efforts to end preventable maternal deaths. Many countries report MDSR data, but comparability over time and across settings has not been studied. We reviewed MDSR reports from low-and-middle income countries (LMICs) to examine core content and identify how surveillance data and data dissemination could be improved to guide recommendations and actions. We conducted deductive content analysis of 56 MDSR reports from 32 LMICs. A codebook was developed assessing how reports captured: 1) MDSR system implementation, 2) monitoring of maternal death notifications and reviews, and 3) response formulation and implementation. Reports published before 2014 focused on maternal death reviews only. In September 2013, the World Health Organization and partners published the global MDSR guidance, which advised that country reports should also include identification, notification and response activities. Of the 56 reports, 33 (59%) described their data as incomplete, meaning that not all maternal deaths were captured. While 45 (80%) reports presented the total number of maternal deaths that had been notified (officially reported), only 16 (29%) calculated notification rates. Deaths were reported at both community and facility levels in 31 (55%) reports, but 25 (45%) reported facility deaths only. The number of maternal deaths reviewed was reported in 33 (59%) reports, and 17 (30%) calculated review completion rates. While 48 (86%) reports provided recommendations for improving MDSR, evidence of actions based on prior recommendations was absent from 40 (71%) of subsequent reports. MDSR reports currently vary in content and in how response efforts are documented. Comprehensive reports could improve accountability and effectiveness of the system by providing feedback to MDSR stakeholders and information for action. A standard reporting template may improve the quality and comparability of MDSR data and their use for preventing future maternal deaths.

[Improving access to maternities: a key challenge in low-resource settings]. / Améliorer l'accès aux maternités : un enjeu clé lorsque les ressources manquent.

In low- and middle-income countries, pregnant women face considerable challenges in accessing emergency obstetric and neonatal care services. Several factors contribute to this, such as insufficient availability of services, their inadequate geographical distribution, and a lack of qualified staff and infrastructure. The United Nations Population Fund, in collaboration with the University of Geneva, has deployed an innovative approach in 14 countries to optimise service quality and geographical accessibility. This approach has formed the basis for a new global indicator contributing to the reduction of maternal mortality. Calculating this indicator requires various types of data, going beyond traditional indicators, but allowing for a more comprehensive consideration of the different facets of access to services.

Dans les pays à revenu faible ou intermédiaire, les femmes enceintes sont confrontées à des défis importants pour accéder aux services obstétricaux et néonatals d'urgence. Plusieurs facteurs y contribuent, tels qu'une disponibilité insuffisante des services, leur répartition géographique inadéquate et un manque de personnel qualifié ainsi que d'infrastructure. Le Fonds des Nations Unies pour la population, en collaboration avec l'Université de Genève, a déployé dans 14 pays une approche innovante optimisant la qualité des services et l'accessibilité géographique. Elle a été la base d'un nouvel indicateur global participant à la réduction de la mortalité maternelle. Le calcul de cet indicateur requiert des données allant au-delà des indicateurs classiques, permettant une meilleure considération des différentes facettes de l'accès aux services.

Present and Future Drinking Water Security and Its Impacts on Maternities: A Multi-Scale Assessment of Sudan.

Adequate access to drinking water for hydration and hygiene depends on many factors. We developed the Drinking Water Security Index (DWSI) to assess relative multifactorial drinking water security at different spatial and temporal scales. DWSI is a function of four key indicators of drinking water security: water quality, water accessibility, water continuity, and water availability. We built DWSI with a total of 10 variables and applied the new index in Sudan to assess historical and future drinking water security at state, local, and maternity levels. Analyses at the state level found that the Red Sea and River Nile states are most vulnerable, with the lowest DWSI for both historical and future periods. The 1 km2 pixel level analysis shows large differences in water security within the major states. Analyses at the maternity level showed that nearly 18.97 million people are affected by the 10% of maternities with the lowest DWSI, a number projected to increase by 60% by 2030. Current and future DWSI of maternities providing Emergency Obstetric and Newborn Care was assessed to identify those where urgent action is needed to ensure quality health care in water-secure conditions. This work provides useful information for stakeholders in the health and drinking water sectors in Sudan, to improve public health, reduce preventable mortality, and make the population more resilient to projected environmental changes.

Maternal death surveillance efforts: notification and review coverage rates in 30 low-income and middle-income countries, 2015-2019.

OBJECTIVE: Performance of maternal death surveillance and response (MDSR) relies on the system's ability to identify and notify all maternal deaths and its ability to review all maternal deaths by a committee. Unified definitions for indicators to assess these functions are lacking. We aim to estimate notification and review coverage rates in 30 countries between 2015 and 2019 using standardised definitions. DESIGN: Repeat cross-sectional surveys provided the numerators for the coverage indicators; United Nations (UN)-modelled expected country maternal deaths provided the denominators. SETTING: 30 low-income and middle-income countries responding to the Maternal Health Thematic Fund annual surveys conducted by the UN Population Fund between 2015 and 2019. OUTCOME MEASURES: Notification coverage rate ([Formula: see text]) was calculated as the proportion of expected maternal deaths that were notified at the national level annually; review coverage rate ([Formula: see text]) was calculated as the proportion of expected maternal deaths that were reviewed annually. RESULTS: The average annual [Formula: see text] for all countries increased from 17% in 2015 to 28% in 2019; the average annual [Formula: see text] increased from 8% to 13%. Between 2015 and 2019, 22 countries (73%) reported increases in the [Formula: see text]-with an average increase of 20 (SD 18) percentage points-and 24 countries (80%) reported increases in [Formula: see text] by 7 (SD 11) percentage points. Low values of [Formula: see text] contrasts with country-published review rates, ranging from 46% to 51%. CONCLUSION: MDSR systems that count and review all maternal deaths can deliver real-time information that could prompt immediate actions and may improve maternal health. Consistent and systematic documentation of MDSR efforts may improve national and global monitoring. Assessing the notification and review functions using coverage indicators is feasible, not affected by fluctuations in data completeness and reporting, and can objectively capture progress.

Travel scenario workshops for geographical accessibility modeling of health services: A transdisciplinary evaluation study.

Introduction: Limited geographical access to quality Emergency Obstetric and Newborn Care (EmONC) is a major driver of high maternal mortality. Geographic access to EmONC facilities is identified by the global community as a critical issue for reducing maternal mortality and is proposed as a global indicator by the Ending Preventable Maternal Mortality (EPMM) initiative. Geographic accessibility models can provide insight into the population that lacks adequate access and on the optimal distribution of facilities and resources. Travel scenarios (i.e., modes and speed of transport) used to compute geographical access to healthcare are a key input to these models and should approximate reality as much as possible. This study explores strategies to optimize and harmonize knowledge elicitation practices for developing travel scenarios. Methods: Knowledge elicitation practices for travel scenario workshops (TSW) were studied in 14 African and South-Asian countries where the United Nations Population Fund supported ministries of health and governments in strengthening networks of EmONC facilities. This was done through a mixed methods evaluation study following a transdisciplinary approach, applying the four phases of the Interactive Learning and Action methodology: exploration, in-depth, integration, and prioritization and action planning. Data was collected in November 2020-June 2021 and involved scoping activities, stakeholder identification, semi-structured interviews (N = 9), an evaluation survey (N = 31), and two co-creating focus group discussions (N = 8). Results: Estimating realistic travel speeds and limited time for the workshop were considered as the largest barriers. The identified opportunities were inclusively prioritized, whereby preparation; a favorable composition of attendees; validation practices; and evaluation were anticipated to be the most promising improvement strategies, explaining their central place on the co-developed initial standard operating procedure (SOP) for future TSWs. Mostly extensive preparation-both on the side of the organization and the attendees-was anticipated to address nearly all of the identified TSW challenges. Conclusion: This study showed that the different identified stakeholders had contradicting, complementing and overlapping ideas about strategies to optimize and harmonize TSWs. Yet, an initial SOP was inclusively developed, emphasizing practices for before, during and after each TSW. This SOP is not only relevant in the context of the UNFPA EmONC development approach, but also for monitoring the newly launched EPMM indicator and even in the broader field of geographic accessibility modeling.

National optimisation of accessibility to emergency obstetrical and neonatal care in Togo: a geospatial analysis.

OBJECTIVES: Improving access to emergency obstetrical and neonatal care (EmONC) is a key strategy for reducing maternal and neonatal mortality. Access is shaped by several factors, including service availability and geographical accessibility. In 2013, the Ministry of Health (MoH) of Togo used service availability and other criteria to designate particular facilities as EmONC facilities, facilitating efficient allocation of limited resources. In 2018, the MoH further revised and rationalised this health facility network by applying an innovative methodology using health facility characteristics and geographical accessibility modelling to optimise timely access to EmONC services. This study compares the geographical accessibility of the network established in 2013 and the smaller network developed in 2018. DESIGN: We used data regarding travel modes and speeds, geographical barriers and topographical and urban constraints, to estimate travel times to the nearest EmONC facilities. We compared the EmONC network of 109 facilities established in 2013 with the one composed of 73 facilities established in 2018, using three travel scenarios (walking and motorised, motorcycle-taxi and walking-only). RESULTS: When walking and motorised travel is considered, the 2013 EmONC network covers 81% and 96.6% of the population at the 1-hour and 2-hour limit, respectively. These figures are slightly higher when motorcycle-taxis are considered (82.8% and 98%), and decreased to 34.7% and 52.3% for the walking-only scenario. The 2018 prioritised EmONC network covers 78.3% (1-hour) and 95.5% (2-hour) of the population for the walking and motorised scenario. CONCLUSIONS: By factoring in geographical accessibility modelling to our iterative EmONC prioritisation process, the MoH was able to decrease the designated number of EmONC facilities in Togo by about 30%, while still ensuring that a high proportion of the population has timely access to these services. However, the physical access to EmONC for women unable to afford motorised transport remains inequitable.

Categorising interventions to levels of inpatient care for small and sick newborns: Findings from a global survey.

BACKGROUND: In 2017, 2.5 million newborns died, mainly from prematurity, infections, and intrapartum events. Preventing these deaths requires health systems to provide routine and emergency care at birth, and quality inpatient care for small and sick newborns. Defined levels of emergency obstetric care (EmOC) and standardised measurement of "signal functions" has improved tracking of maternal care in low- and middle-income countries (LMICs). Levels of newborn care, particularly for small and sick newborns, and associated signal functions are still not consistently defined or tracked. METHODS: Between November 2016-November 2017, we conducted an online survey of professionals working in maternal and newborn health. We asked respondents to categorise 18 clinical care interventions that could act as potential signal functions for small and sick newborns to 3 levels of care they thought were appropriate for health systems in LMICs to provide: "routine care at birth", "special care" and "intensive care". We calculated the percentage of respondents that classified each intervention at each level of care and stratified responses to look at variation by respondent characteristics. RESULTS: Six interventions were classified to specific levels by more than 50% of respondents as "routine care at birth," three interventions as "special care" and one as "intensive care". Eight interventions were borderline between these care levels. Responses were more consistent for interventions with relevant WHO clinical care guidelines while more variation in respondents' classification was observed in complex interventions that lack standards or guidelines. Respondents with experience in lower-income settings were more likely to assign a higher level of care for more complex interventions. CONCLUSIONS: Results were consistent with known challenges of scaling up inpatient care in lower-income settings and underline the importance of comprehensive guidelines and standards for inpatient care. Further work is needed to develop a shortlist of newborn signal functions aligned with emergency obstetric care levels to track universal health coverage for mothers and their newborns.

Proposing standardised geographical indicators of physical access to emergency obstetric and newborn care in low-income and middle-income countries.

Emergency obstetric and newborn care (EmONC) can be life-saving in managing well-known complications during childbirth. However, suboptimal availability, accessibility, quality and utilisation of EmONC services hampered meeting Millennium Development Goal target 5A. Evaluation and modelling tools of health system performance and future potential can help countries to optimise their strategies towards reaching Sustainable Development Goal (SDG) 3: ensure healthy lives and promote well-being for all at all ages. The standard set of indicators for monitoring EmONC has been found useful for assessing quality and utilisation but does not account for travel time required to physically access health services. The increased use of geographical information systems, availability of free geographical modelling tools such as AccessMod and the quality of geographical data provide opportunities to complement the existing EmONC indicators by adding geographically explicit measurements. This paper proposes three additional EmONC indicators to the standard set for monitoring EmONC; two consider physical accessibility and a third addresses referral time from basic to comprehensive EmONC services. We provide examples to illustrate how the AccessMod tool can be used to measure these indicators, analyse service utilisation and propose options for the scaling-up of EmONC services. The additional indicators and analysis methods can supplement traditional EmONC assessments by informing approaches to improve timely access to achieve Universal Health Coverage and reach SDG 3.