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    • Despite the challenges since the Safe Motherhood

    2019-05-20

    Despite the challenges, since the Safe Motherhood Initiative was launched almost 30 years ago, international institutions such as the World Bank and WHO, and independent groups such as the Institute for Health Metrics and Evaluation, have developed, published, and continually refined estimates of maternal mortality. Indirect and sampled methods of estimation for MMR such as verbal autopsy studies, the sisterhood method, and the reproductive age mortality survey (RAMOS) as well as systematic analyses of vital registration data undertaken by the Global Burden of Disease study have all contributed to improvements in our understanding of maternal mortality. Maternal death reporting has evolved into an essential country-level indicator, providing critical evidence for policy formulation, priority setting, monitoring and evaluation, and accountability. Policymakers using POMR can draw on lessons from the MMR. First, POMR requires a clear and standard definition that is feasible to measure. In-hospital deaths are more feasible to count than the often-used definition of deaths within 30 days following a procedure, as post-discharge records may not be available. Yet POMR faces a unique definitional challenge: the types of procedures present in the denominator will vary with context, and thus for robust comparative analysis, a clear accounting of the types of procedures performed must be made. Second, reliable and accessible data sources must be identified and harnessed. Research has shown that low-cost, locally developed, facility-based databases in low-income and middle-income countries can provide accurate death statistics. The denominator of POMR is purely clinical (surgical procedure) rather than natural (pregnancy) and so facility-based records are sufficient for its calculation. For both POMR and MMR, institutional resistance to provide accurate but potentially self-damaging information may be a significant challenge; governments and regulatory bodies must be clear that they URB597 intend to use POMR to identify problems and allocate resources accordingly rather than for castigating the conscientious surgeons and institutions who care for the sickest patients with the highest POMR. It is important for all countries to have a common baseline for data: this is the POMR definition supported by the Commission and others. However, beyond the collection of this datum, the evidence does not yet exist on how countries can further evaluate trends in mortality and use this information to improve surgical safety. As with MMR, case studies may be used to illustrate successful approaches towards data collection and outcome improvement. Countries can propose feasible data collection systems to evaluate surgical deaths. The WHO and other UN organisations, academic institutions, and other technical partners can in turn provide guidelines and methodological support for governments wishing to engage in such analysis. In the early stages, aggregate POMR may be used to provide crude information on system performance in facilities where case mix information is not provided. Over time, a standardised approach to reporting and risk stratification can be adopted to allow for comparison of outcomes between countries and regions over time.
    As the Millennium Development Goals came to a close last year and we entered the new Sustainable Development Goals (SDGs) era, the global health community took stock of accomplishments over the past decades and continuing challenges for the future. Despite impressive reductions in maternal and under-5 mortality rates, neonatal mortality reduction continues to lag behind. Neonates account for an increasing share of child deaths, now reaching almost half (45%) of the burden of under-5 mortality. Most maternal and infant deaths occur in first 42 days after childbirth. Despite the critical importance of this period for both maternal and child survival, postnatal care consistently has among the lowest coverage of interventions on the continuum of maternal and child care, with a reported median for the Countdown countries at just 28%. To reduce mortality and improve health and survival rates of neonates, both access to and quality of services must be addressed.