REDUCING MATERNAL MORTALITY THEORIES, MODELS, AND PRACTICE

Ravi Pamnani MS&E 408

Pamnani MS&E408 Prof J Pietzsch 2/17 .

Current global health programs have not been able to meet international goals to reduce maternal mortality. there is no existing model which can help evaluators compare different programs prior to implementation. In this report. the maternal mortality ratio shows the greatest discrepancy between developed and developing countries. but some are useful. multifactorial etiology of maternal death and injury. 3/17 . Analytical models have been used to address the complex.” George E. Although past models can elucidate the inter-relationships between factors affecting maternal health. Box ABSTRACT Of all health indicators.Pamnani MS&E408 “All models are wrong. P. I propose a framework for a predictive model which can be used to quantitatively assess alternative maternal health strategies and therefore optimize programs prior to implementation.

NGOs.2 Nearly 99% of deaths occur in the developing world. In the areas where there is the largest concern—Sub-Saharan 4/17 .6 Therefore.4 However. The loss of the mother represents the loss of a productive member of society whose labor and activities are essential to families and communities.7 In 2000. the UN reaffirmed its international commitment by setting a key Millennium Development Goal to reduce maternal mortality from its 1990 level by three-quarters in the year 2015. policymakers need to prioritize public and private investment in maternal health as major part of an integrated development strategy. or disease from pregnancy. seriously impacting their future productivity. displaying the greatest discrepancy between developed and developing countries. maternal health has evolved into a development measure used by many international agencies.4 The maternal mortality ratio (MMR) is measured by the number of maternal deaths per 100. almost 10 million women each year suffer injury. In 1987. In South Asia. 2005.1 Maternal mortality and morbidity is a worldwide epidemic. and socially-minded for-profit enterprises have committed to tackling this growing issue. Because of the stark differences in MMR.000 deaths per day. launched the Safe Motherhood Initiative.4 Beyond fulfilling humanitarian objectives. and are less likely to obtain an education.300 in developed countries. one woman dies because of preventable complications during pregnancy and child birth— nearly 15. or about 530. are at a higher risk of malnourishment. Children without mothers die more frequently. the World Bank. in a partnership with the World Health Organization (WHO) and the United Nations Population Fund (UNFPA). it is estimated that one in 22 women will die of complications from pregnancy and childbirth. one in 200 will die. Additionally.or birth-related complications. Compare this with one in 7. studies show that the health of the mother considerably influences that of their children.Pamnani MS&E408 BACKGROUND Every minute. Many government programs.000 deaths per year. there are significant societal benefits for pursuing the improvement of maternal health in developing countries. Global Maternal Mortality Ratios – Deaths per 100.000 live births.000 live births in each country (Figure 1). 5. Figure 1.3 In subSaharan Africa. little progress has been made. infection. Additionally.

and then propose a framework for the development of a predictive model to evaluate maternal health programs. a far cry from the UN goal of 75%. and human investment. resulting in a large number of preventable deaths. Within the postpartum period. To mitigate these risks. and the postpartum period.Pamnani MS&E408 Africa and South Asia—MMR has dropped by 2% and 20%. With the ability of modern medicine to delay death following significant complications. these pilot phases may be lengthy and too narrowly-focused. anemia. If one pilot phase is limited in its efficacy.9 Maternal deaths occur throughout pregnancy. An effective model can help steer public health programs toward effective. and more than 65% happen within the first week. the postpartum period is too often neglected by caregivers. labor. Causes are categorized as “direct” or “indirect. from any cause related to or aggravated by the pregnancy or its management but not from accidental or incidental causes.4 Without significant acceleration in public health investments or new policies in the developing How should policymakers decide on how to achieve maternal health improvements? The root causes of maternal morbidity and mortality are multifactorial and include many clinical and socioeconomic aspects. the top five of which are hemorrhage. respectively.10 Figure 2. I propose a framework for a predictive. Malaria. eclampsia. programs have run as small pilot phases to demonstrate cost-effectiveness.”8 The selection of “42 days” is historical. However. Programs that address these aspects have high opportunity costs that require significant financial.” Indirect causes of maternal death make up 20% of the worldwide total and are typically pre-existing or concurrent diseases that are not related to pregnancy.10 Many different types of complications can lead to maternal death (Figure 2). I will examine the existing analytical models for maternal mortality in the developing world. and unsafe abortion. Direct causes make up the remaining 80% of worldwide maternal deaths.a 5/17 . prior to implementation at larger-scale scales. site-specific interventions based on local epidemiological. HIV/AIDS. In this report. as opposed to a study on the timing of maternal deaths. decision-making model that has the potential to evaluate optimal interventions. irrespective of the duration and site of the pregnancy. OVERVIEW OF MATERNAL MORTALITY AND MORBIDITY Maternal death is defined by the WHO as a “death of a woman while pregnant or within 42 days of termination of pregnancy. obstructed labor. and geographical characteristics. Although most causes of postpartum death result from complications that resulted during childbirth. the latest WHO guidelines have also introduced the concept of late maternal death up to one year following pregnancy. program managers have little choice but to implement the mildly effective program or start over with a different approach. childbirth. and is theorized to originate with specific Western religious and cultural beliefs. 45% of maternal deaths occur within the first 24 hours. These conditions can either complicate the pregnancy or can worsen as a result of the pregnancy. time. and cardiovascular disease are common indirect causes of maternal death. Causes of maternal death10. The majority of maternal deaths (50-71%) occurs postpartum. infection. socioeconomic.

Pamnani MS&E408 a Total is more than 100% due to rounding For each maternal death. understand how different causes and effects are interconnected. at least 30 women suffer injuries or permanent disability due to childbirth. In one prospective observational study from Maharashtra.9 Maternal mortality and morbidity are the results of a complex array of factors. scientific methodology. either through the visualization of the connections. with 15. it must provide the users of the model some kind of insight into the system being analyzed. or attempts at suicide. malnutrition can be exacerbated by pregnancy. using sensitivity analysis. substance abuse.12 Preexisting psychiatric disorders surface as depression. a user can understand how modifying one area of the model will affect other areas. especially in conjunction with unwanted pregnancies. or through the development of analytic relationships between connections. For a model to be useful.10 Other indirect factors may contribute to longer-term morbidities. a model is most useful when it has predictive qualities.3 Although international organizations estimate 15% of pregnancies develop complications.11 High rates of mental illness in pregnant women of the developing world have also been reported. Furthermore. EXISTING ANALYTICAL MODELS The purpose of a maternal health model is to help researchers and policymakers approach the issue. For example. These predictive abilities are most powerful when the model can distinguish the relative impacts or weights of different factors. a quantitative model can predict how well the program must perform in order to achieve the desired effect on maternal mortality. many local studies suggest a higher rate of morbidity. namely. and design solutions to address the cause using a rigorous. Additionally. the incidence of maternal morbidity requiring medical care was estimated at 56. leading to a cascade of detrimental health effects. India. This will be illustrated in the PROPOSED MODEL section on page 10. 6/17 . as well. Any model which attempts to provide a complete understanding of the issue will inevitably be complex and multifactorial.2%. This is what distinguishes a qualitative model—one that demonstrates highlevel connections between factors—and a quantitative one—one that demonstrates the ability to weigh measures and predict outcomes.3% requiring emergency obstetric care.

e.” i. Although McCarthy and Maine acknowledged that other authors have attempted to understand the complete process that results in maternal mortality and morbidity. must operate through 7/17 . The model is meant to show that any improvement in “Distant Determinants. McCarthy and Maine presented a qualitative framework to determine the relationship between factors contributing to maternal mortality (Figure 3). The model was developed in response to an increase in maternal health programs—addressing a wide range of issues from women’s status to emergency obstetric care—without explicit or systematic consideration of the mechanism in which these various factors impacted maternal mortality.. The McCarthy/Maine Model: A detailed framework for analyzing the determinants of maternal mortality and morbidity. socioeconomic and cultural factors.Pamnani MS&E408 Two analytical models for maternal health have been discussed in the literature: the McCarthy/Maine Model and the Three Delays Model.13 The McCarthy/Maine Model is purposefully broad in scope. The McCarthy/Maine Model In 1992. (including the Three Delays Model described in the next section). they felt none have been “comprehensive” or “fully-developed.” 13 Figure 3.

Therefore. the primary factor attributed to maternal deaths per the above assumptions is delay.14 Specifically. blood. 2. they emphasize the importance of the model to provide structure for researchers and program planners to discuss and consider various new intervention programs. The first phase of delay is in the individual’s or family’s decision to seek care.14 The strength of the model is its focus on the big picture. They also acknowledge that not all of the relationships are represented in this model—but instead. and the quality of care. etc. the likelihood of reaching the facility. only those most important to the discussion. McCarthy and Maine claim that all determinants of maternal mortality (and therefore. all efforts to reduce it) must operate through three intermediate factors: (1) the likelihood that a woman will become pregnant.10. the available transportation options. drugs. McCarthy and Maine argue that the consideration of interventions in the framework of their model compels the planner to specify the chain of events by which a program might reduce maternal mortality. Finally. the likelihood of receiving adequate and appropriate treatment. The third phase of delay is receiving adequate care at the facility. The model states that once an obstetric complication occurs.” there are no other relative measures in the McCarthy/Maine Model against which to compare programs. A break anywhere along the chain of these three phases can result in increased likelihood of maternal mortality and morbidity. The second phase of delay is identifying and reaching an adequate health care facility. if a woman is able to reach a facility. accessibility of facilities.16 Socioeconomic and cultural factors. Phase II. This first step is critical. These delays are separated into three distinct. the other phases of delay (identifying and reaching a facility.Pamnani MS&E408 the closer “Intermediate Factors. and the competency of the physicians) impact Phase III. allowing the planner to compare and contrast more distant factors from more intermediate ones. Besides the qualities of “distant” versus “intermediate. when comparing two different interventions. the quality of care (quality and availability of trained staff. 3. However. The Three Delays Model The Three Delays Model is based upon the following two assumptions: (1) about 80% of maternal deaths result from direct obstetric causes (Figure 2) and (2) the majority of deaths can be prevented with timely medical treatment. because unless the mother or family decides to seek care. Once a decision is made to seek care. policymakers can use this model to see how they are related and how they will reduce maternal mortality.15 The Three Delays Model employs a different view of maternal mortality by taking on the perspective of a woman who is experiencing an obstetric complication (Figure 4).13 McCarthy and Maine admit the model is simplistic in nature and that the components can be divided into many subcomponents. the accessibility of the facilities (the actual distance.16 The model also describes how the three phases are influenced by the following factors: socioeconomic and cultural factors. and the costs of transportation) impacts Phase II. which is the individual’s or family’s decision to seek care. (2) the likelihood that a pregnant woman will experience a serious complication of pregnancy or childbirth. Phase III. and (3) the likelihood of an adverse outcome for women with complications.” in order to impact maternal health outcomes. However. chronological phases: 1. Phase I. as well as perceived accessibility and perceived quality of care impact Phase I. the model does not quantitatively predict how two interventions might perform against each other. 8/17 . the availability of equipment. and receiving quality care once there) are irrelevant.

rather than the prevention of the obstetric complication itself. non-emergent factors such as reproductive behavior (e.Pamnani MS&E408 Figure 4. In this way. Although experts debate the relative importance of socioeconomic and purely medical interventions. For example. as it focuses on the interval between the onset of an obstetric complication and its outcome. a focused emphasis on the management and treatment of women with obstetric complications may lead to wider benefits for women across all socioeconomic levels. there is evidence that even among women who are well-nourished and well-educated. The Three Delays Model16 The Three Delays Model is narrower in scope than the McCarthy/Maine Model. there may be some reduction. then the presence of a new. even if an NGO builds a new hospital in a village district (addressing accessibility and quality of care). etc).g.g. allowing for a more comprehensive understanding of how different programs might impact overall maternal mortality.. decision analysis) may be able to incorporate quantitative elements into the model. the use of more sophisticated techniques (e.g. the Three Delays Model does not allow for quantitative comparisons between alternative interventions. It also does not include consideration of other. advanced hospital may not reduce maternal mortality as intended. women’s status) and health status (e.. However. as Phase II and Phase III delay may be mitigated by the presence of the new hospital (depending on the cost of treatment. a large percentage undergo serious complications during childbirth. alternative interventions can be interpreted through the lens of the pregnant woman herself. Additionally. condom use. nutrition). Like the McCarthy/Maine Model. One advantage of the Three Delays Model is the framing of the problem in terms of the decision and experiences of the pregnant woman facing a potential complication.. if there exists a major Phase I delay based on cultural stigmatization of hospitals.14 Therefore. because the Three Delays Model is built upon the initial decision to seek care. 9/17 .

and avoiding inconsistencies and errors. by incorporating existing data to project future outcomes.Pamnani MS&E408 WHY USE DECISION ANALYSIS? To develop a predictive model for maternal health. researchers have employed decision analysis techniques to explore a wide array of topics. Finally. the likelihood of reaching a medical facility influences the perceived accessibility of care. especially in problems where the patients are asymptomatic (e.18 For example. and therefore may not be cost-effective (depending on the cost of the test and the prevalence of the disease) or clinically-effective (depending on any potential complications from the diagnostic test itself). where accurate data collection is challenging. An elliptical node indicates an uncertainty or probability distribution..g. pertussis. I propose using decision analysis. In this section. The decision diagram consists of nodes arranged in a network connected by arrows. Using Bayesian probabilities. which is often the case in developing countries. The model must be able to answer questions such as: (1) What is the likelihood that a proposed program will achieve the community’s maternal health goals? (2) What is the minimum level of effectiveness that the program needs to reach to achieve these goals (for example. Decision analysis also provides for an explicit. The uncertainties in the diagram influence the decision to be made and other uncertainties.19 Researchers have also used decision analysis to study the effectiveness of immunization practices (e. which in this case. I will outline the underlying framework for the development of a broad. which in turn influences the decision of the mother/family to seek care. swine flu.17 In the developing world. customizable maternal health model.17 Decision analysis is particularly useful in modeling these scenarios because screening tests are rarely 100% sensitive or specific. For example. hypertension screening. hepatitis) for the same reasons. the factors influencing the decision. the techniques have been employed for disease screening. is the decision made by the mother/family to seek medical care. decision analysis can provide predictive insight into a problem. methodological approach. which maps the decision to be made. The rectangular node indicates a decision. The technique requires a meticulous. The decision analysis technique combines logic and probability to assess alternative strategies and make decisions based on the best evidence available. The 10/17 . thereby ensuring transparency.g. The foundation of the model is the decision diagram. cancer screening.17 Researchers have advocated the use of decision analysis in public health for at least 20 years. structuring complex alternatives in a rational way. if the proposed program is a better way to transport women to the hospital—what percentage of women need to participate to reduce the MMR to a certain target level)? (3) How does this compare to other potential programs? PROPOSED MODEL To begin developing a decision analysis-based model.21 An effective decision analysis-based model for maternal mortality would be able to help policymakers achieve their goals. Decision analysis allows for the incorporation of expertise and information from a variety of consultants without yielding the decision to any single person.. rubella. glaucoma screening. toxic substance exposure screening. decision analysis is capable of handling significant uncertainty. etc). as mentioned above. I have reconfigured the Three Delays Model as a decision diagram (Figure 5). reproducible process that allows other program evaluators to navigate the logic behind the decision. and the potential outcome. ranging from female sterilization in Bangladesh20 to reducing mother-to child transmission of HIV. I have selected the Three Delays Model as the starting point because it lends itself to a decision analysis interpretation due to the formulation of the maternal health problem as a decision by the mother/family.

is the MMR. as well. one study links socioeconomic status to average number of doctor visits: the higher the socioeconomic status. In the Three Delays Model. based on the Three Delays Model Accessibility of facilities Perceived accessibility of care Reaching a medical facility Cultural & Socioecono mic Factors Seek medical care? Clinical outcome MMR Perceived quality of Care Quality of care Receiving quality care For the purposes of the model. a program aimed at improving public transportation to the health facility does not necessarily impact cultural or socioeconomic factors). Economic status correlates to utilization of health services. In order to model these factors as uncertainties. 3. The way individuals in the target locality perceive the severity and etiology of the illness significantly influences health-seeking behavior. This is also related to educational status. Constraints on women’s independence and preferential treatment to males limit women’s access to health services. For example. these factors are broken down into the following four sub-factors16: 1. the more likely an individual is to visit the doctor. either from the target locality or a similar region. then those parts of the model can be ignored. Educational status.Pamnani MS&E408 octagonal node represents a value. or similar locality. Decision diagram for maternal mortality programs. Higher illness prevalence was found in rural areas and in the low socioeconomic areas of cities. If relevant data is not available. Women’s status. 2. Illness factors.22 Therefore. Cultural and socioeconomic factors Cultural and socioeconomic factors influence the decision to seek medical care. real-world data from the literature can be used to support probability assignment (e. as the model is developed. an individual/family in X socioeconomic category is X likely to seek health care). it is preferable to leverage existing research. Figure 5. but in the case of this public health decision diagram. Economic status. This is sub-factor is tied heavily to women’s status. expert opinions can be substituted instead. 4. Individuals must also be able to recognize their illness. as some women may believe that important signs of complications are part of a normal pregnancy. 11/17 . This is discussed further in the Customizing and implementing the model section on page 14. the nodes identified as “uncertainties” can be modeled as probability distributions as related to the “target locality” (the locality of interest to the program evaluator). Note that if the programs under evaluation do not impact one or more of the uncertainties (for example.. Higher educational status generally correlates to increased health-seeking behavior. which in many decision analysis scenarios is a monetary value.g. if data for the target locality are not available.

in turn. and (2) the actual delay in reaching a facility and receiving adequate care. etc). 12/17 . and availability of transport—impact a woman’s ability to physically reach a medical facility. the best way to model these factors may be through a probability distribution across the population. influence access to facilities (Figure 6). As with the accessibility of facilities. These factors can be further broken down.g.16 and therefore provide substantial data for modeling purposes. depending on the level of detail of the programs to be evaluated and the availability of the probability distributions for the relevant information. Multiple factors. Factors influencing accessibility of facilities Cost of travel Distance Availability of transport Reaching a medical facility Influences “Receiving Perceived accessibility of care Influences “Seek Quality of care After deciding to seek care and reaching a medical facility. once the decision to seek health care has been made. the accessibility of the facilities affects the model in two ways: (1) influencing the decision to seek care. Figure 6. expanding the bus route. The relative impacts of these factors are well-documented in the literature. one rural study in Kenya indicated that only 36% of women who intended to deliver in a hospital actually did. For example. Alternatively. expert opinion or other types of models—such as locationallocation models24—may substitute for data..Pamnani MS&E408 Accessibility of facilities As described in the Three Delays Model and mapped in the proposed decision diagram (Figure 5) . and is necessary when data is difficult to obtain or unreliable.23 Therefore. lowering the costs of buses. Three sub-factors—cost of travel. improving roads. Though this example is over-simplified. There are a wide variety of contributing factors that affect the quality of care (Figure 7). there are two dimensions to the quality of care per the Three Delays Model: (1) the perceived quality of care. which influences the decision to seek care. similar to the probability distributions mentioned in the previous section. In the case of perceived quality of care and its contributing factors (satisfaction with service and previous experience/reputation). Determining or estimating the proportion of expecting mothers who actually reach a facility can yield a simplified probability distribution. a simplified model may conjecture that there is a 36% chance of reaching the hospital for the target locality. and (2) the actual quality of care—labeled as receiving quality care—which influences the clinical outcome. the final delay is in receiving quality care itself. distance to the facility. it applies even in cases where more specific attributes are under evaluation (e. providing specialized transportation.

” which is used because it is the public health metric of interest when comparing alternative maternal health strategies. which can be represented in the model as either available (1) or not available (0). the adequacy of management is dependent on the training of the clinical staff.” contributing factors like the availability of staffing and availability of equipment are not true uncertainties. 13/17 . These characteristics can best be modeled in a binary fashion (1 or 0—is it available or not). However. Therefore. if one physician is available for every fifty nurses). obtaining care at X quality. Even with perfect accessibility and perfect quality of care. The literature may suggest that even the most well-trained team may perform diagnostic mistakes or management mistakes. as the presence of staffing or equipment in a given facility is determinable. based on these two distinctions. Figure 7.” which can be split up into an infinite array of categories. which is captured in the next phase. Factors influencing the quality of care Availability of staffing Availability of equipment Adequacy of managemen t Satisfaction with service Receiving quality care Influences “Clinical Previous experience/ reputation Perceived quality of care Influences “Seek Clinical outcome The clinical outcome will result in at least three possibilities: (1) death (maternal mortality). A probability distribution may be useful. The literature or expert opinion can provide supporting data for these portions of the model (Clinical outcome section). even if the contributing factors are broken down further. or (3) “disability. For example. The clinical outcome measure is the maternal mortality rate. For example. this uncertainty node captures the probability of the potential outcomes. The uncertainty is captured later on in the model. equipment can be broken down into: availability of gauze or availability of drugs. or (2) survival. the evaluator can map the likelihood of clinical outcomes for each of these alternatives. The clinical outcome node represents the uncertainty inherent in any medical treatment. when estimations on how the availability of staff or equipment impacts the outcome. and may still be subject to uncertainty. if the quality of the team is variable (for example. Then. there may still be some uncertainty in the outcome. and a 95% chance of being treated by a non-physician. given the prior information (reaching a facility within X time interval. This method is applicable. the distinctions for the “Adequacy of management” node may state that there is a 5% chance of being treated by a physician.Pamnani MS&E408 For “Receiving quality care. simply based on the variations in illness and recovery. etc). depending on the morbidities of interest to the evaluator. captured in a value node “MMR.

using existing data from their locality. For example.. the evaluator should consider certain cultural. They walk through the model three times—first. The model can then be used in the following two ways: 1. Registration systems in developing countries are often absent or inadequate. through a sensitivity analysis). One program is to obtain a five year supply of much-needed drugs. Additionally. while a second program is to develop a long-term educational program on maternal health danger signs during pregnancy and delivery. developing countries. The unreliability of the data in these cases may be mitigated through extrapolation based on prior knowledge. using program alternative #1. As before. Comparing two. but this reduces the confidence in the model. Using sensitivity analysis. Validation studies have shown disagreement between women’s self-reports of obstetric complications and medical data.Pamnani MS&E408 Customizing and implementing the model The basic framework for the model is outlined in Figure 5. socioeconomic. the evaluator can elaborate on certain sections. particularly in low-income. particularly with morbidity information. By using a comprehensive and customizable model. Existing data may only exist on different localities. data from ten or fifteen years ago may be extrapolated and projected to have a relatively accurate estimation of the target locality’s current maternal health status. the evaluator can then perform sensitivity analyses to validate the robustness of the model. By comparing the estimated MMR outcomes and costs. Using standard decision analysis techniques. the data may be ten or fifteen years old.26 Sampling hospital deliveries introduces significant selection bias. or geographical differences that are known between the target locality and the origin of the source data set. there are significant limitations to such an approach. the influence diagrams and uncertainties can be modeled into decision trees (or their mathematical equivalents). the evaluator can see how the MMR will be affected by modifying the inputs to the model. or different continents altogether. its usefulness. The relevance of a given data set in this case is questionable. Reliance upon existing data Using existing data provides the most real-world evidence to support the model. and to establish his or her confidence in the choice. using program alternative #2. This may be particularly useful if the target MMR is outside of the estimated MMR achieved in the first-pass of the model. completely different programs. if certain trends in the population are well-understood.25 Data regarding maternal mortality and morbidity are mostly collected from hospital deliveries or women’s self-reports through questionnaires. the evaluator will arrive at an estimated MMR result.g. As particular areas become relevant to a program evaluator. and as a result. reliable epidemiological information is scarce. At the same time. and third. with source data from the literature or expert opinions. there are a couple of important shortcomings which need to be addressed. Additionally. 14/17 . Assessing how much change a program must achieve to achieve an MMR goal. those elements can be fleshed out with additional uncertainties and influence diagrams.27 Questionnaires may also be unreliable. second. SHORTCOMINGS If the model is developed further. In the first round of setting up the model for a specific analysis. 2. using a base case. the evaluator can see if there is a clearly superior choice. as an estimated 63% of deliveries globally occur at home. Because maternal mortality and morbidity are difficult to measure.28 The unreliability of the information may be mitigated by considering a range of values (e.

The model must be scalable. village-scale studies on the effectiveness of a variety of interventions. The maternal mortality ratio is a powerful development metric to assess the overall status of a region’s health care system since prevention and treatment of obstetric complications is dependent on so many aspects of society. predictive model is refined with further research and field validation. combines the existing understanding of maternal health determinants with data weighing the degree to which these determinants interact. it may not be universal. exist as a software tool with a simple user interface. or validate any assumptions. successful reduction of maternal mortality is achievable. A new framework. Once this quantitative. which would provide the most useful feedback in later iterations. and therefore may be impractical from a program evaluator’s point of view. so that adept users can experiment and make modifications in the field. If the model is too detailed. 4. The model must maintain complete transparency. 2. Use aggregate data from the literature to build specific quantitative impacts of each uncertainty node. a single. Establish the model as an open source. Validate the model by comparing the model’s predicted results to actual results of an intervention (an intervention not used in building the model itself). FUTURE STEPS The next steps to continue developing this model to be a useful. and in its ideal form.Pamnani MS&E408 Practicality The model may be attempting to take on too much at once. predictive tool for program planners are: 1. it can help to optimize maternal health programs prior to implementation. 3. Obtain expert opinion and conduct surveys to fill in any gaps. using decision analysis. This will yield the highest potential for adoption. As increasing evidence becomes available from small. CONCLUSION The significance of maternal health cannot be exaggerated and is especially important in the developing world. If the model is too broad and general. it may require too much specialized knowledge for the program evaluator to implement in his or her local setting. integrated approach to compare program alternatives in areas where maternal mortality still remains a significant issue. software tool and disseminate widely. WORKS CITED 15/17 . Existing analytical models to assess maternal health are descriptive. Set up a forum to obtain feedback for continuous improvement of the model. but cannot predict the efficacy of potential programs to succeed in a given region. as well as compare alternative programs when resources are scarce. Current programs to reduce the MMR to the UN Millennium Development Goal levels have failed. With implementation of a predictive model based on the proposed framework. could provide an effective public health policy tool for program planners.

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