The process and outcomes described above are a timely and important contribution to global maternal health monitoring. They address the lack of measures for the social, political, and economic determinants of maternal health and survival, complement other maternal health monitoring efforts at the policy, system, and facility level, and provide a framework to support countries as they endeavor to achieve the maternal health target set by the SDGs.
Maternal health and survival are situated within the broader context of a woman’s full life course, including but not limited to adolescence and sexual and reproductive health. This continuum cannot be addressed in isolation from the social and political dynamics and structural inequalities that influence the systems in which women not only live, but also seek and receive healthcare [23, 24]. The SDGs and the Global Strategy place emphasis on poverty reduction, gender equality, universal health coverage, and a human rights approach to health, exemplified by attention to the fundamental human rights principles of equity and non-discrimination, transparency, participation, and accountability. Nevertheless, several commentaries highlight the lack of sufficient global-level work on the development of measures for the more distal determinants of health as we enter the SDG period [25, 26]. Indeed, most global and national monitoring frameworks focus heavily on indicators that track health status and service coverage. For example, the WHO Global Reference List of 100 Core Health Indicators largely lacks indicators to track distal determinants of health outcomes beyond measures of health system status—such as enabling laws and policies, and social determinants like education, gender, and socio-economic barriers that impact on health status .
We acknowledge the critical importance of ongoing work to determine the best measures to drive facility, community, national, and regional progress. But it is clear that coverage and quality of essential clinical interventions at the bedside (e.g. immediate administration of uterotonics after birth), and the attendant improvement in health outcomes at the client level (e.g., effective prevention of postpartum hemorrhage), are highly dependent on upstream factors such as adequate health workforce (e.g. density of midwives), enabling policies (e.g. midwives are authorized to deliver basic emergency obstetrics and newborn care) and facility readiness (e.g. a reliable supply chain for essential commodities). These factors, in turn, are affected by structural social, political, and economic factors, such as the status of women in societies, measurement capacity and data quality for effective surveillance and response, and adequate allocation of resources to maternal health.
The burden on individual providers of collecting data has been well documented [28, 29], as has the lack of use of data collected at such great cost [30,31,32], which breaks the feedback mechanism whereby monitoring and review can result in improved provision of interventions. Global level indicators to address social determinants of health may seem distal, too, from the day to day process of managing clinical care. Because the indicators identified here were designed to tackle the social and distal determinants of care, and aim to address determinants of health that lie upstream from the most immediate factors which influence a woman’s health outcome, they may seem beyond the scope of influence of the individual provider even though typically, that provider lives and acts in the same environment and is affected by the same cultural norms. The results of tracking progress on social determinants may not appear, at first blush, as immediate as counting the number of women treated for PPH, but over time, increases in girls’ educational attainment may well prove greatly significant in ending preventable deaths [33, 34].
It is clear that global policies and strategies must be grounded in the realities and challenges of care in settings where women are dying. Real change, however, must be systemic and will only come when the concept that no woman should die in pregnancy or childbirth is engrained throughout every culture and society as a fundamental right and an indisputable truth. Therefore, the tripartite components of accountability adopted by the Independent Accountability Panel—monitor, review, and act—must be applied at every level from critical distal determinants of maternal health and survival to those at the bedside level in order to ensure high-quality, high-performing health systems that are able to ensure the highest attainable level of health for all.
Underscoring the need for more work in this area, in March 2017 WHO established a Global RMNCAH Policy Reference Group (PRG) charged with advising WHO on which policies to monitor under the umbrella of the Global Strategy. In this context, the work described above to identify relevant, useful, valid and feasible maternal health-specific indicators for less-developed global monitoring areas such as health financing, laws, and policies was especially timely and important.
There are a number of global efforts to improve maternal and newborn health monitoring at the policy, system, and facility levels and the process to develop the Phase II core indicators complemented these efforts well. At the policy and systems level, for example, representatives from the High-Level Working Group on Health and Human Rights, the Commission on Social Determinants of Health, the Global Financing Facility, the Countdown to 2030 Working Group on Drivers, and the WHO Health Policy Reference Group were all included in several rounds of the Phase II process, participating in webinars, surveys, and the expert meeting, consulting on relevant themes, and receiving information on the process’s outcomes through direct outreach. This helped to ensure that the Phase II process was well-coordinated with the aforementioned groups’ efforts to implement the Office of the High Commissioner of Human Rights (OHCHR)’s “Technical guidance on the application of a human rights-based approach to the implementation of policies and programmes to reduce preventable maternal mortality” . In addition, coordination with the WHO Quality of Care Network, Every Newborn Action Plan (ENAP), Improving Coverage Measurement, and the Countdown to 2030 ensured that the Phase II process also complemented efforts aimed at driving improvements at the facility level .
The outcomes of the Phase II process also complement a number of other maternal and newborn monitoring efforts, not least of which are the SDGs and Global Strategy. Upon completion, the set of EPMM Phase II indicators was delivered to the Mother Newborn Information for Tracking Outcomes and Results (MONITOR) expert review groupFootnote 3, which was recently formed by the WHO and tasked with advising the WHO on maternal and newborn health monitoring, mapping the full complement of available metrics for maternal newborn health monitoring, and providing technical guidance for the incorporation of those indicators into routine use at country level. The Phase II set of indicators has also been used in the development of the Countdown to 2030’s indicator lists. Future steps for the Phase II set include targeted testing and validation of the indicators developed during this process and support for their incorporation into global and national monitoring frameworks and data systems for routine use.
There are numerous risks to progress for maternal health in the current geopolitical context. The global framework put forward in the SDGs is much broader than that of the MDGs, with many more goals and targets; there is a risk that the unfinished maternal health agenda could fall through the cracks in the face of many more competing priorities. Furthermore, there is also a risk of sliding backwards on women’s sexual and reproductive health and rights, which would have significant repercussions for maternal health and survival . Now more than ever, attention is needed to ensure that maternal health and survival remain high on the global development agenda and tools and resources are readily available to ensure effective, strategic action to achieve the goal of ending preventable maternal deaths within a generation.
Fortunately, though collecting the indicator data may be challenging, the EPMM Phase II indicators have multiple implications for practical application. It is hoped that they will be useful for national planning, reporting, and monitoring, as well as cross-ministerial work, “health in all” policies, and other best practices regarding strategic planning and decision-making. They can provide a concrete monitoring framework for priority recommendations aimed at achieving strengthened health systems. These indicators acknowledge that health service quality is shaped at all levels of the health system. Especially for formidable and complex goals such as ensuring universal health coverage of comprehensive sexual, reproductive, maternal and newborn care, it is hoped that the indicators we propose can provide a means of implementation for achieving and tracking progress toward their progressive realization.
To further foster action at all levels of the health system, the indicators may also be applied in the context of social accountability and advocacy, an approach supported by the recommendations of the International Initiative on Maternal Mortality and Human Rights, which calls for a rights-based approach to maternal mortality reduction [37, 38]. Finally, they are intended to be useful for global monitoring and reporting and thus to support achievement of the SDGs and accountability for the full realization of all three pillars of the Global Strategy in the specific context of maternal health and survival.
Keeping in mind that ending preventable maternal mortality is a country-driven endeavor, stakeholder recommendations on the uses and target audiences for the final set of EPMM Phase II indicators were compiled. Participants in the expert meeting in particular proposed several suggestions to improve the presentation and user-friendliness of Phase II core indicator list. Suggestions included:
A comprehensive list of EPMM indicators that includes the indicators from both Phases I and II;
Lists that display the indicators by harmonization with other monitoring frameworks, key theme, and maternal health topic area; and
Operational guidance to facilitate the prioritization, selection, and use of EPMM indicators at the country level based on context-specific needs
The first two suggestions have been addressed. The comprehensive list of Phase I and II indicators can be found in Table 6. Lists displaying the Phase II indicators by key theme, harmonization with other monitoring frameworks, and maternal health topic area can be found in Additional file 1, Table 5, and Additional file 4, respectively. Mechanisms to address country requests for operational guidance to facilitate context-specific use of the indicators are under development by the EPMM Working Group.
This process included both strengths and limitations. One strength of this project was the use of a rigorous, systematic, and iterative process based on sound methodology. Another strength was the broad participation from maternal health stakeholders worldwide, which was achieved via active outreach to numerous constituencies and experts in sexual, reproductive maternal and newborn health, human rights, health policy, workforce planning, measure development, clinical quality improvement, health economics and financing, epidemiology, demography and health statistics and other relevant domains. Participants were from government agencies and non-governmental organizations, national Ministries of Health, bilateral and donor organizations, academic and research institutions, policy think tanks, clinical care facilities and program administration, among others.
There were also some limitations to this process. First, the number of participants at each stage was limited despite concerted efforts to be inclusive and representative. Second, many indicators recommended for inclusion in the final set have not yet been validated and tested at the national level. As noted above, however, work is currently being planned to test and validate these indicators. Finally, many indicators considered by the experts involved in this process were deemed important, relevant, and useful for tracking progress in key thematic areas but still in need further development before being recommended for monitoring at global and national levels. Those indicators could not be included in the core set of indicators. Nevertheless, this set of additional indicators for further development represents an important agenda for future research in the area of measure development for maternal newborn health monitoring, and provides a strong basis and rationale for the need for further work in this area.
Finally, a point of frequent discussion among participants in this process was that the mere presence of a policy does not indicate its effective implementation or impact. The policy indicators recommended here provide a point of entry for monitoring in these areas. Monitoring the presence of policies that aim to improve maternal health and survival establishes a basis for advocacy and holds policy makers to account for the effective implementation of said policies, as well as, when necessary, effective redress in the event of non-compliance. Consistent with the human rights concept of progressive realization, therefore, we recognize that indicators that capture the existence of policies addressing the social determinants of maternal health and survival, while necessary, may not be sufficient and look forward to further progress toward ensuring measures of effective implementation, and eventually, measures that track the impact of such policies . We look forward to the work of the recently established WHO Policy Reference Group in this area. At the same time, we hope that providing even an imperfect entry point for monitoring critical distal determinants of maternal health and survival will represent a useful contribution toward creating the enabling environment for functional health systems that are able to deliver high-quality care to all women and end preventable maternal deaths. Greater attention is being given to the roles that poorly functioning health systems and unaddressed upstream factors play in creating barriers to the provision of critical lifesaving interventions by frontline workers . The role of the health system has also been described and specifically called out in the process of refining the definition of skilled attendance at birth . The resulting moral distress and burnout they face [40, 41] thus highlights yet another way in which these distal determinants significantly influence provision and experiences of care at the facility level where maternal and perinatal deaths and disabilities occur and the rights of women are violated.