Why we need to streamline a multi-pronged response to child and maternal health initiatives

November 22, 2013

Why we need to streamline a multi-pronged response to child and maternal health initiatives

According to the WHO, in 2012, there were 6.6 million under-five child deaths, 44% of which occurred in their first 28 days of life. In 2010, 280 000 women died due to pregnancy or childbirth-related complications. The overwhelming number of preventable child and maternal deaths has urged a widespread response to the global crisis to help reduce deaths and mitigate negative consequences on those who are disproportionately affected in the developing world.

I recently had the privilege of attending a seminar on child and maternal health led by a leading Johns Hopkins professor in the field, Dr. Robert Black, hosted by Concern at the Concern Worldwide Office in Dublin. The purpose of the seminar was to discuss the tool as well as other important dimensions of child and maternal health that ought to be encompassed when designing interventions, and was attended by NGO representatives, academics and students.

Dr. Black and colleagues developed LiST, an incredibly powerful computer-based tool that estimates intervention impact. The intention is for policy makers, health personnel and the like to use the tool alongside planning national and district-level interventions.

What struck me about the seminar were three things:
1) how technical the field of child and maternal health (among other topics in global health) can get,
2) how much you might think you know about the field, but actually aren’t even scratching the surface, and
3) amongst other topics that lend themselves to the research world, how we aim to answer questions that are easily “researchable” and can be reliably evaluated after implementation. Of course this makes sense, but I found myself asking, are we systematically excluding important realms of this field because of how abstract they might be to measure?

What I learned in a nutshell: there are many proxy measures that gauge the health of mothers and children in a population because “child and maternal mortality” is a very vague concept to grasp.

Simple enough.

Proxies for child malnutrition and stunting include things like weight/height over time and weight/height for age. The program works alongside the Canadian International Development Agency (CIDA) to ascertain changes in maternal mortality through various outcomes (barring emergency obstetric care because the tool could not possibly reach everything).

In addition to maternal mortality, the LiST tool also looks at the effects of interventions to examine whether morbidity, wasting, and stunting outcomes change. What emerged from the tool was “Spectrum”, a robust model that allows measures to be inputted and calculated. What’s more, Spectrum can be used to even predict change.

The danger of the tool however, can be that in looking at “pockets” of population data one can misdirect the conclusions, but there is in fact great importance to understanding these pockets. We all broadly know that inequities are at the heart of the issue, but few of us have heard of the idea of ‘unequal’ inequity. Dr. Black explained the concept of dividing population data into quintiles. While four categories of people may be worse off, only one may be favourable – fittingly referred to as “bottom inequity”. If the opposite holds true, then the solution naturally is to focus on bringing the bottom quintile up to ensure that the worst of the worst off are getting care.

Some time was spent debating the merits of various proxies for nutrition: is it dietary quality, caloric intake, or micronutrients that matter most? More importantly, what can we do to ensure health workers are obtaining key data about the child so that they can visibly identify stunting during a clinical encounter? (Read: Is this child 8 years old or 12 years old? As a clinician, how can I flag severe acute malnutrition if I don’t know?). Further, adolescent health remains to be a large gap in the evidence, as growth spurt issues are largely ignored and can be easily supported through nutrition.

Dr. Black informed us on many next steps the field should to take, including but not limited to integrating social support for breastfeeding women rather than simply imploring women to breastfeed the way existing campaigns have largely poured their efforts into.

Perhaps the most contentious part of the discussion occurred when long-time Environmental Consultant Niall Roche expressed incredulity at the fact that basic water sanitation, hand hygiene and environmental conditions were placed low on the priority list of LiST efforts. While these targets are less amenable to be measured compared to counting the number children vaccinated against a disease, aren’t they just as important to child and maternal health? Woefully, if research has taught us one thing, it’s that it’s nearly impossible to measure whether someone is washing their hands 6 times a day and if sanitary conditions are actually present.

And thus it follows…. research chases outcomes and outcomes follow research; for better or for worse, the grey areas often get cast aside. “Of course it’s important”, says Dr. Black, “…it’s just that vaccines are inherently different from hand washing”.

With Dr. Black stating the UN has irresponsibly declared that the MDG for water sanitation has been met, and we’re still un-doing years of faulty programming from the billions spent on PEPFAR (Bush’s HIV initiative), I think maybe it’s time we ought to harness interconnectedness and drive research incentives that consider all of the above.

All in all it was a fascinating day. Hats off to Dr. Robert Black for his incredible work and engaging talk. I certainly hope that this tool reaches the millions of people who can benefit from it and continues to raise as many important issues as it addresses.

Manisha Sachdeva
[email protected]


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