Carla AbouZahr

There is currently an unprecedented expressed need and demand for estimates of maternal mortality in developing countries. This has been stimulated in part by the creation of a Millennium Development Goal that will be judged partly on the basis of reductions in maternal mortality by 2015.

Public health decision-making is critically dependent on the timely availability of sound data. The role of health information systems is to generate, analyse and disseminate such data. In practice, health information systems rarely function systematically. The products of historical, social and economic forces, they are complex, fragmented and unresponsive to needs. International donors in health are largely responsible for the problem, having prioritized urgent needs for data over longer-term country capacity-building. The result is painfully apparent in the inability of most countries to generate the data needed to monitor progress towards the Millennium Development Goals. Solutions to the problem must be comprehensive; money alone is likely to be insufficient unless accompanied by sustained support to country systems development coupled with greater donor accountability and allocation of responsibilities. The Health Metrics Network, a global collaboration in the making, is intended to help bring such solutions to the countries most in need.

The health of mothers has long been acknowledged to be a cornerstone of public health and attention to unacceptably high level of maternal mortality has been a feature of global health and development discussions since the 1980s. However, although a few countries have made remarkable progress in recent years, the reality has not generally followed the rhetoric. Health and development partners have failed to invest seriously in safe motherhood and examples of large-scale and sustained programmes are rare. Safe motherhood has tended to be seen as a subset of other programmes such as child survival or reproductive health and is often perceived to be too complex or costly for under-resourced and overstretched health care systems that have limited capacity. Despite this, a consensus has emerged about the interventions needed to reduce maternal mortality and there are good examples (historical and contemporary) of what can be achieved within a relatively short time period. The activities of both grassroots organizations and international health and development agencies have helped to build political will and momentum. Further progress in improving maternal health will require outspoken and determined champions from within the health system and the medical community, particularly the obstetricians and gynaecologists, and from among decision-makers and politicians. But in addition, substantial and long-term funding—by governments and by donor agencies—is an essential and still missing component.

Sound information is the prerequisite for health action: without data on the dimensions, impact and significance of a health problem it is neither possible to create an advocacy case nor to establish strong programmes for addressing it. The absence of good information on the extent of the burden of maternal ill-health resulted in its relative neglect by the international health community for many years. Maternal deaths are too often solitary and hidden events that go uncounted. The difficulty arises not because of lack of clarity regarding the definition of a maternal death, but because of the weakness of health information systems and consequent absence of the systematic identification and recording of maternal deaths. In recent years, innovative approaches to measuring maternal mortality have been developed, resulting in a stronger information base. WHO, UNICEF and UNFPA estimates for the year 2000 indicate that most of the total 529,000 maternal deaths globally occur in just 13 countries. By contrast, information on the global burden of non-fatal health outcomes associated with pregnancy and childbearing remains patchy and incomplete. Nonetheless, initial estimates based on systematic reviews of available information and confined to the five major direct pregnancy-related complications indicate a problem of considerable magnitude.

The use of the disability-adjusted life year (DALY) as the unit in which to calculate the burden of disease associated with reproductive ill-health has given rise to considerable debate. Criticisms include the failure to address the problem of missing and inadequate epidemiological data, inability to deal adequately with co-morbidities, and lack of transparency in the process of ascribing disability weights to sexual and reproductive health conditions. Many of these criticisms could be addressed within the current DALY framework and a number of suggestions to do so are made. These suggestions include: (1) developing an international research strategy to determine the incidence and prevalence of reproductive ill-health and diseases, including the risk of long-term complications; (2) undertaking a research strategy using case studies, population-based surveillance data and longitudinal studies to identify, evaluate and utilize more of the existing national data sources on sexual and reproductive health; (3) comprehensively mapping the natural history of sexual and reproductive health conditions--in males and in females--and their sequelae, whether physical or psychological; (4) developing valuation instruments that are adaptable for both chronic and acute health states, that reflect a range of severity for each health state and can be modified to reflect prognosis; (5) undertaking a full review of the DALY methodology to determine what changes may be made to reduce sources of methodological and gender bias. Despite the many criticisms of the DALY as a measurement unit, it represents a major conceptual advance since it permits the combination of life expectancy and levels of dysfunction into a single measure. Measuring reproductive ill-health by counting deaths alone is inadequate for a proper understanding of the dimensions of the problem because of the young age of many of the deaths associated with reproductive ill-health and the large component of years lived with disability from many of the associated conditions.