Advancing Maternal Health: Validating Indicators for Progress

Strengthening Maternal Health Measurements

In 2015, the World Health Organization (WHO) released the "Strategies toward Ending Preventable Maternal Mortality (EPMM)" report, outlining global targets and strategies for reducing maternal mortality. These targets and strategies identified in the report are grounded in research and a human rights approach to maternal health and aim to address the broad spectrum of key social, political, economic, and health system determinants of maternal health and survival.

The Sustainable Development Goals (SDGs) have a broad focus on the structural determinants of social, biomedical, and planetary wellbeing. Reflecting this broader perspective, research has shown that upstream determinants are critical to ending preventable maternal deaths. However, these upstream determinants are not as well represented in maternal health measurement efforts, which tend to focus on service delivery.

To achieve and track progress toward SDG 3.1, calls were made for strengthening maternal health measures and measurement approaches. Five guiding principles (focus, relevance, innovation, equity, and global leadership) were proposed to direct such efforts, and these were updated in 2020 to include country ownership as an over-arching sixth principle.

Validating EPMM Indicators: A Comprehensive Effort

To drive progress toward achieving the EPMM Strategies, a core set of maternal health indicators was developed. From 2016-2017, extensive consultation and research efforts were undertaken to systematically appraise existing measures and identify a menu of 25 indicators and 7 standard stratifiers tailored to the 11 Key Themes in the EPMM Strategies.

In 2019-2020, landmark analysis and a definitional framework for indicator validity in the specific context of maternal newborn health measurement were published. These papers underscore the need for rigorous research methods and testing efforts to ensure that indicators used in monitoring maternal health capture concepts or phenomena accurately.

With this goal, the Improving Maternal Health Measurement Capacity and Use (IMHM) Project, led by the Women & Health Initiative at the Harvard T.H. Chan School of Public Health, conducted research studies to validate ten EPMM indicators in India, Ghana, and Argentina.

Overview of Validation Studies

Access to Legal Abortion:

Discrepancies between data reported by global monitoring mechanisms and domestic policy reviews highlighted weaknesses in the indicator's validity, as well as inaccuracies in data reported to global mechanisms. The study also revealed context-specific barriers to legal abortion not captured by the indicator.

Free Maternal Health Services:

The study found that women were paying for services that should be free by law, indicating that the policy indicator did not accurately reflect Universal Health Coverage (UHC) across the three study settings.

Midwifery Practice:

Discrepancies were found between data reported in global monitoring frameworks and the national policy and regulatory frameworks in all three countries. Variation was also observed between midwives' authorization to perform emergency obstetric and newborn care functions and their self-reported skills and actual provision of services.

Midwifery Workforce:

The study found considerable variation in national midwifery scopes of practice and competencies compared to global reference standards. The results suggest that the density of midwives as an indicator of an adequate midwifery workforce may not be fully representative of the workforce's skills and competencies.

Emergency Obstetric and Neonatal Care (EmONC) Availability:

The study highlighted significant differences in the value of estimates of sufficient EmONC coverage derived from country data depending on the definition of the indicator and measurement approach used. The optimal definition and calculation of a core measure to capture this construct are subject to uncertainty.

Maternal Death Review Coverage:

Substantial underreporting of facility maternal deaths to the district level was revealed, reducing the value of the indicator. The study also uncovered incompleteness in death reviews recorded at facilities and reported to districts.

Demand Satisfied for Family Planning:

The study suggests that the percentage of women with 'demand satisfied' for family planning after incorporating person-centered constructs of demand, choice, and satisfaction is significantly lower than that obtained using the standard definition of this indicator. These results have implications for the delivery of contraceptive counseling and services.

SDG Indicator 5.6.2:

The study proposed a revised calculation for SDG indicator 5.6.2., related to access to sexual and reproductive health care, information, and education, and discussed the implications of systematic differences found.