It has been over 30 years since the international community launched the “Safe Motherhood” (SM) strategy to reduce maternal mortality (MMR). The strategy, which advocates increased access to family planning, quality antenatal care, skilled supervised births, access to essential obstetric care, and post-natal care has never really been rigorously evaluated. Part of the problem is that in general the programs tend to get adopted as a whole at the national level, there are many components to the SM approach, and implementation challenges in most settings have always hampered efforts to evaluate impact. So for the most part, we don’t know if the strategy really works, and if it does, which components are most important.
A new study, published this month in Health Economics, attempts to shed some light on this question by evaluating the impact the rollout of a SM program in China during the early 2000s. The program was targeted to some of the counties with the highest levels of MMR as well as those with the greatest capacity to implement the program. Unlike other attempts to reduce MMR through the SM approach, the Chinese program appears to have really focused on getting women into hospitals to give birth. I don’t know much about the Chinese context, but my guess is that access to family planning was already very high – given what I know about Chinese fertility rates. This is a much more aggressive strategy than has been adopted in most developing countries, where the focus has been on “supervised deliveries” whether institutional or not. Therefore, we may not be able to generalize these results too broadly and we may wish to question the belief that ensuring that a birth is supervised is enough.
Admittedly, I am not entirely convinced by the methods used in the paper to address the selection problems among the counties. The authors use a propensity score matching approach but given that one of the selection criteria was ability to implement the program, and the overlap between the treated and controls was less than optimal, this may not fully address the selection problem – but I am still encouraged by this effort to actually evaluate the program.
The authors find that in fact the program was able to increase the proportion of births that took place in hospitals and reduce MMR by about 10%, specifically deaths due to hemorrhaging, which would be consistent with getting more women into hospitals – believed to be very important in reducing such deaths. Whatever effect they found, however, took at least 4 years to become visible, which might suggest that it took a while for the program to affect the behavior of women, or perhaps some other alternative explanation.
So if we believe these findings, what it suggests is that getting women into hospitals is effective at reducing maternal mortality – by a lot. The Chinese program, however, is quite different from the approaches that have been used elsewhere – the focus on institutional delivery and a demand side subsidy which was not well explained – but it does give hope that some of the elements of the SM strategy might be effective if well designed and well implemented. This news comes at a crucial time where once again policy makers are debate what should and should not be included in programs to reduce maternal mortality – let’s just hope it is also taken as rationale for more, and more rigorous evaluation of such efforts.Share on Facebook