By Andrea Blanchard (University of Manitoba) & Neha Singh (London School of Hygiene & Tropical Medicine)
Long and winding roads
How can we answer some of the most complex questions in public health? As researchers, we often don’t go far enough to locate our understandings of specific, short-term pathways within the longer, winding journey to health impact. Among the impacts that remain important in the global Sustainable Development Goals and related national targets are reducing mothers’ and newborns’ mortality rates. Yet many have shied away from attempting to uncover how these are achieved in real-world contexts. There are good reasons for this, such as short project timelines, limited coordination or data challenges. However, to truly track progress, pursue equity, and hold ourselves accountable, we need ways to dig into the broader journey to health improvements with the best frameworks, methods, and evidence.
Life-saving approaches to optimize maternal, late fetal and newborn health are closely intertwined. Equally, the pathways to reducing maternal and neonatal mortality are complex and context-dependent. Conceptual frameworks help researchers to make sense of what they are studying. Those seeking to uncover nuance and complexity try to avoid linear cause-effect relationships with our boxes and arrows, yet these often creep in or even get foisted on us. Still, it’s arguably worthwhile to develop frameworks to better integrate and clarify theories, concepts and evidence, malleable enough to be adapted in diverse settings, to capture the dynamic pathways towards health improvements.
Taking on the challenge
A multi-country study called “Exemplars in maternal and neonatal mortality reduction” was recently conducted in seven countries that experienced greater than expected reductions in maternal and neonatal mortality (interestingly, starting at different levels) relative to their socio-economic progress since 2000, namely Morocco, Senegal, Niger, Ethiopia, India, Nepal and Bangladesh. National academic and government leaders worked closely with global researchers at 12 organisations including the London School of Hygiene and Tropical Medicine, University of Manitoba, Johns Hopkins University, Federal University of Pelotas, and the Countdown to 2030 consortium.
To begin, we explored the array of existing concepts, theories and frameworks to guide how we could understand the impact of health and non-health factors on mortality by searching published literature and consulting global experts. We found that they either concentrated on “zoomed in”, selective interventions and service delivery, or on broader “zoomed out” approaches around health systems or contextual changes. Yet there was a lack of unified frameworks to helpfully guide the interdisciplinary, mixed-methods approach we wanted to take. Hence, we brought together concepts from prevailing frameworks and evidence together, and developed a holistic framework on the range of interrelated drivers that can lead to mortality reductions at multiple levels.
Our recent Health Policy and Planning article provides detail on the holistic framework’s development, components and application. Briefly on the components, to achieve the ultimate outcomes of maternal, late fetal and newborn survival, the most proximate drivers include coverage and equity of health interventions across the continuum of care. These link back to programs and service delivery levers like access, quality and integration at the intermediate level, which can in turn be achieved through intentional policies and health systems changes at the distal level. Finally, numerous dimensions of individual, household, community, national and transnational contexts can influence the intentional levers or the outcomes directly.
Building from the framework’s interdisciplinary approach, the teams used mixed-methods in each country study. While the specific methods varied, we started with describing changes in the past few decades both in the outcomes and hypothesized drivers across the framework, through quantitative trend analyses and qualitative desk reviews. Next, we sought to develop explanations by combining more complex quantitative methods to analyse the contribution of key drivers to changes in mortality, with key informant interviews and other qualitative data to expand our understandings on the processes through which changes in these drivers together led to impact.
Bumps along the way
Not surprisingly given our aspiration to uncover complexity and contextual nuance, we encountered challenges in applying the holistic MNH framework. There was not always consistent data over time, including for mortality (being a rare outcome), and for some health systems elements (e.g. MNH-specific financing or numbers and skills of health workers). Inconsistent recall around past events or undocumented changes, particularly around implementation processes, was also common. These issues made it more difficult to determine and compare the relative contribution and interaction of drivers in and between countries. Some drivers like fertility reduction operated at multiple levels, requiring careful interpretation. In efforts to overcome these, we pooled data sources, compared statistical approaches, synthesized existing research, iteratively built explanations, and drew on the complementary strengths of the diverse research teams. It would be valuable to keep improving data collection and analytical approaches, and continue adapting the framework, to fuel creative future research.
Looking back to look forward
Despite challenges, we hadn’t fully anticipated the value of consolidating what is known, carefully analysing time trends using all available data sources, and talking to people who were “in the room” or who used the health services. This study revealed that learning from past efforts in this way can actually develop rich insights to propel us forward. Not only will the specific results on how countries have improved maternal and neonatal mortality provide a platform for further learning within and between countries, but the research process also brought policy-makers, practitioners and researchers together to honour past successes and motivate continued action. Rather than resting satisfied, all expressed being keen to keep pursuing equitable improvements in MNH.
The phrase ‘positive public health’ has come to embody the collaborative research endeavour of this study, which provides a needed springboard for partners to continue working to close the know-do gap. It has taught us that we must not give up; business as usual is not enough. In fact, we are left encouraged to embrace rather than obscure complexity and contextual nuance. The added effort and investment will no doubt be worthwhile to more holistically uncover the pathways towards positive health impacts, to make the world safer and fairer for all mothers and newborns.