Analytic Approaches to Reducing Maternal Mortality

The vast majority of maternal deaths occur in poor women who lack access to family planning, safe abortion and emergency obstetrical care. What are the fundamental drivers of effective and cost-effective strategies to reduce maternal mortality? Given that adequate facilities and skilled human resources will not be immediately available in all settings, how can we contextualize approaches to provide interim guidance to decision makers?  While no single empirical study can answer these questions, decision-analytic models can provide useful insights to inform policy and planning.

Maternal Mortality: Why Decision Analysis?

To reduce maternal mortality in resource-limited settings, identifying evidence-based strategies that consider the local context is imperative. Decision analytic methods are well suited for this task. Adopting a systematic approach to decision-making under uncertainty, the field encompasses quantitative methods that assist in identifying optimal solutions to complex problems with multiple alternatives, inevitable tradeoffs, and the potential for different perspectives. Inherent in a decision analytic approach is an explicit focus on identifying, measuring, and valuing the outcomes of decisions, as well as the uncertainty that exists at the time they are made. Read about our analysis in India.

Maternal Mortality in Afghanistan

Afghanistan has one of the highest rates of maternal mortality in the world. We assessed the health outcomes and cost-effectiveness of strategies to improve the safety of pregnancy and childbirth in Afghanistan. Using national and sub-national data, we adapted a validated model that simulates the natural history of pregnancy and pregnancy-related complications. We incorporated data on antenatal care, family planning, skilled birth attendance and information about access to transport, referral facilities and quality of care. We evaluated single interventions (e.g. family planning) and strategies that combined several interventions packaged as integrated services (transport, intrapartum care). Read the results of this study.

Maternal Mortality in Nigeria

We explored the benefits and cost-effectiveness of individual and integrated packages of interventions to prevent pregnancy-related deaths in Nigeria. We adapted a previously validated maternal mortality model to Nigeria, differentiating Southwest and Northeast zones using survey-based data. Early intensive efforts to improve family planning and control of fertility choices, accompanied by a stepwise effort to scale-up capacity for integrated maternal health services over several years, will save lives and provide equal or greater value than many public health interventions we consider cost-effective. Read more.

Looking Under the Hood: Our Maternal Mortality Simulation Model

Our initial prototype model, motivated by a policy fractured environment of analysts and advocates for family planning, safe abortion and intrapartum care, was developed to capture the interdependencies between these different dimensions of reproductive health, safe pregnancy and childbirth. Initially applied to Mexico, it simulates the natural history of pregnancy (e.g., miscarriage, abortion), related complications (e.g., heavy bleeding, obstructed labor, hypertensive disorders, infection, unsafe abortion), and availability of health services (e.g., prenatal care, intrapartum and postpartum care). Our later models, motivated be the need for contextualization of "evidence-based recommendations” to subnational realities, were improved to differentiate the location of childbirth (e.g., home, center, facility, etc.), reflect uncertainty about recognition of complications and willingness to pursue referral, specify the presence or absence of skilled birth attendant or other provider, and availability of transport, facilities, and quality of care. Using country-specific data, models were contextualized to India, Afghanistan and Nigeria, simulating the status quo. Following calibration and validation, we superimposed stepwise investments–individual, paired and packaged maternal health services, to compare different approaches for scaling up programs and policies.

In our first analysis to illustrate synergies between family planning, safe abortion, and intrapartum care, we leveraged state-level data over time to assess the impact of pro-poor maternal health efforts in Mexico.

In an analysis about family planning efforts in Afghanistan, we used the Maywand district in Kandahar province as a representative rural area to assess the impact on mortality of facilitated birth spacing and limiting.

To inform assumptions for model-based analyses of state-level maternal health programs, we conducted a rapid survey analysis of 121 facilities in Nigeria engaging 700 women seeking care at these facilities.