Dr. Lucy Chappell, Collection Editor of Measuring Coverage of Maternal, Newborn, and Child Health, explains what researchers of MNCH in High Income Country settings can learn from the Collection.
In the middle of 2012, I took on the task of Collection Editor for the PLOS Collection Measuring Coverage of Maternal, Newborn, and Child Health. But what did coverage measurement mean and why should it matter? These last nine months have opened my eyes to the importance of the topic and the challenges that are faced. They have made me realise how much more those who work in high-income countries can learn from those who work in other settings around the globe.
As an academic obstetrician, I am sadly used to presenting shocking statistics on maternal deaths, over 99% of which happen in low- and middle-income countries; as a researcher into complications of pregnancy in a high-income country, we must constantly question how our work will make a difference where it matters most.
Our triennial confidential enquiry process has examined every death in England related to pregnancy in the last 50 years, assessed standards of care, and produced lessons to be learned. When the reports repeatedly showed deaths from pulmonary oedema in women with pre-eclampsia, we became much more restrictive with fluid management in such cases, and deaths fell. We can generate hospital-level statistics on the proportion of women who have a caesarean section, and have great debates on what the ‘right’ proportion should be. If we introduce a new intervention, such as anti-retroviral drugs for prevention of mother to child HIV transmission, I am confident that delivery of the programme will be high, estimates of the impact reasonably accurate, and sustainability good. For some years, perinatal acquisition of HIV has been less than 1% in our hospital – a figure of which to be proud. We don’t really have to stop and think about whether we can access those data. They may not always be perfect, but we have plenty to work with. So how do we translate those numbers to make a difference in a global setting?
First, we need to be able to measure what is happening. The statistics with which I am familiar are incredibly hard to generate accurately when the healthcare systems lack the infrastructure that I take for granted. There are few local, regional or national databases in low- and middle-income countries that can tell us which women are receiving appropriate antenatal care, what the quality of that care is, and whether it translates into improved outcomes for mother and baby. So the population-level surveys that are used in low- and middle-income countries (such as DHS and MICS) are vital for providing this type of information. This collection provides a guide that should be readable for the uninitiated and thought-provoking for those more familiar, on use of these surveys, highlights important issues relating to survey error , discusses how to consider health inequalities and gives an overview of how the indicators were chosen.
And are the metrics valid? Original research papers present work on validation of some of those indicators, and demonstrate that we should be more cautious in assuming that the indicator measures what we think it does. For example, using hospital-based data as their reference standard, a study concluded that labelling a caesarean section as being an emergency could not be recommended for use in surveys as it could not be validated. Progress is being made on providing anti-retroviral drugs to pregnant women with HIV, but another paper reports that using data from a health facility may over-estimate the true proportion of infants exposed to HIV that received such drugs during pregnancy and breast-feeding. Other research papers in the collection tackle topics relating to maternal, newborn and child health in Mozambique, China, Zambia, and Pakistan and Bangladesh.
The collection will no doubt be useful to those who work in this area, but I would encourage others who are less familiar with the field to dip into it too. During my time handling the papers I learned plenty that is useful to me as an academic in the UK, but more importantly gained a timely reminder to keep my horizons wide when considering where our research could and should have an impact.
Dr. Lucy Chappell is Clinical Senior Lecturer in Maternal & Fetal Medicine and Honorary Consultant in Obstetrics at King’s College London. She is a Freelance Associate Editor at PLOS Medicine.
The Measuring Coverage of Maternal, Newborn, and Child Health Collection was produced with support from the Child Health Epidemiology Reference Group (CHERG). Financial support for CHERG is provided by The Bill & Melinda Gates Foundation through their grant to the US Fund for UNICEF.
Read the collection: http://www.ploscollections.org/measuringcoverageinmnch