Operationalising an integrated mortality transition framework for programmatic priority setting across maternal and newborn health

Abstract

Data-driven decision making will be instrumental in reducing maternal mortality, newborn mortality, and stillbirth levels in the coming years as the Sustainable Development Goal targets draw near in 2030. Tailoring evidence to be context-specific is crucial to target relevant questions, priorities, and needs. In doing so, there remains value in grounding local data in the broader global health data landscape. Here, we introduce one resource - an interactive benchmarking tool- that presents local insights contextualized in a maturity model based on evidence from over 150 countries. This tool positions a country in one of five mortality phases, compares its performance across maternal/newborn health program areas to peers in its phase, and facilitates connections to lessons from high-performing Exemplar countries that have achieved success on relevant indicators. It offers an opportunity to set evidence-based priorities, helping to identify indicators and subnational regions that may be important to target moving forward to accelerate progress. In select countries, the benchmarking approach has been piloted to inform maternal and newborn health evaluations and planning processes. This approach is adaptable to local contexts and use-cases, while in parallel fostering a shared way of thinking around maternal and newborn health strategic planning. In a global health financing environment that is increasingly constrained, such a tool to support data-driven priority setting is a timely resource.

SUMMARY BOX.

• Data-driven decision making is crucial for accelerating progress towards Sustainable Development Goal targets, with an increasing focus on leveraging both global and local evidence.

• A previously published transition framework that incorporates maternal mortality, neonatal mortality and stillbirth rate has been operationalised to contextualise local evidence in a vast global health data landscape.

• A package of transition assessment and priority setting tools based on this framework has been created to empower stakeholders in priority setting discussions related to maternal and newborn health (MNH).

• These resources support country decision-makers in systematically identifying priorities while also facilitating connections to relevant interventions and lessons from peer contexts.

• While this approach is flexible and can be adapted across unique contexts, it is grounded in a common framework, fostering a shared way of thinking in the broader MNH community.

Introduction

When the Sustainable Development Goals (SDGs) were established in 2015, experts called for further progress on maternal and newborn health (MNH)—knowing that data-driven decision-making would be key for achieving these targets. In 2020, MNH measurement experts reconvened, this time emphasising that global efforts must be complemented by local, context-specific actions. This shift stemmed from a push to ensure that data-driven MNH decision-making was locally tailored, with in-country stakeholders empowered to take ownership over strategic planning that leveraged innovative approaches and promoted health equity.¹

While localised data for decision-making has the power to inform targeted planning, it should not be considered in a vacuum. Contextualising local data within a broader evidence landscape offers benefits as well. For instance, comparing progress to global trends or a peer country of interest may guide decisions about which aspects of MNH should be prioritised in a specific setting.

Cross-country evidence can shed light on typical trajectories of MNH-related indicators as countries reduce mortality. These may range from more distal factors like female education and fertility to more proximate indicators like antenatal care and institutional delivery rates. Critically, this evidence highlights that priorities and barriers predictably shift as countries progress from higher to lower mortality. Indicators related to emergency obstetric and newborn care—such as hospital delivery rate and caesarean section rate among the poor—are increasingly key considerations for countries looking to achieve universal coverage and the lowest levels of mortality.²

This piece describes how a previously published mortality transition framework² has been operationalised to support strategic MNH planning. It structures the vast global health data landscape, which in turn serves as the backdrop for discussions focused on local evidence, priorities and solutions. Together, a package of transition assessment and priority setting tools based on this framework reflects core principles previously described as key for reaching the SDGs—most notably that data-driven approaches should be innovative and relevant to local decision-makers.¹

Through a collaboration with both global and country-level implementing partners, this package of transition assessment and priority setting tools is beginning to inform MNH planning in several countries. Grounding this process in a common framework has the opportunity to foster a shared way of thinking across countries and partners in the global MNH community while still allowing for important tailoring across unique local contexts.

Context for the transition framework

A partnership between Exemplars in Global Health (EGH) and Countdown to 2030 for women’s, children’s and adolescents’ health has identified and conducted research in seven countries that experienced rapid declines in neonatal and maternal mortality. These countries, referred to as ‘Exemplars’, were selected because their progress in reducing neonatal mortality rate and maternal mortality ratio outpaced what would have been expected based on economic development alone. Learnings from these Exemplar countries were described within a previous supplement published in BMJ Global Health,³ complemented by publicly available in-depth country case studies (https://www.exemplars.health/topics/neonatal-and-maternal-mortality).

In evaluating factors that contributed to rapid progress in Exemplar countries, an updated mortality transition framework was created.² This framework is broader in scope than the well-known obstetric transition framework,⁴ as it considers maternal mortality, neonatal mortality and stillbirths cohesively. This approach is useful for categorising mortality levels—in recognition that contexts vary considerably across countries, with success factors varying substantially between higher- and lower-mortality settings.

Mortality levels in this framework² are divided into five phases, with phase 1 representing the highest levels of mortality and phase 5 representing the lowest levels of mortality. Assessing what phase a country is in helps to identify which factors might be most pivotal in driving future mortality reductions and also allows for the country’s performance on MNH indicators to be benchmarked relative to its peers.

As a part of this analysis,² several MNH indicators were quantitatively assessed leveraging data from 151 countries to characterise ranges of values typical by phase. This effort leveraged over 300 DHS/MICS surveys for several MNH indicators, WHO databases on health workforces and health financing, as well as estimates from other sources such as the United Nations (UN) and World Bank.

Applying the benchmarking approach

Over the last several months, EGH has sought to operationalise this transition framework, creating an easy-to-use interactive tool that can support strategic priority setting.

The EGH Interactive Benchmarking Tool (https://www.exemplars.health/tools/interactivetool) represents a key resource developed in service of this goal. This tool leverages phase-specific characterisations across a range of indicators relevant to MNH, helping to visualise priority indicators and subnational regions that emerge from the analysis. It allows countries to position themselves in a phase of a transition framework, compare their performance across key indicators to what is typical for that phase and identify potential strategies to address these barriers.

As one example, if a user selects a country in phase 3, the tool will compare that country’s performance across MNH indicators to ranges typical for phase 3—as shown in figure 1. The red, yellow and green colours used in this visualisation reflect whether that country is ‘off-track’, ‘on-track’ or ‘ahead-of-track’ compared with the values typical for phase 3.

Figure 1. From the Exemplars in Global Health Interactive Benchmarking Tool—assessing progress across maternal and newborn health-related indicators.

Users can then conduct a deeper dive into any indicator of interest. In this example, a deeper dive focused on institutional delivery is shown in figure 2, highlighting a country that progressed from late phase 2 to mid-phase 3.

Figure 2. From the Exemplars in Global Health Interactive Benchmarking Tool—evaluating progress over time contextualized in the transition framework.

In this figure, the blue boxes in the background represent typical ranges of institutional delivery rate by phase, which steadily increase from phase 1 on the left to phase 5 on the right. The solid points indicate that the country’s national-level institutional delivery rate increased slightly as the country progressed from phase 2 to phase 3—but also highlight that coverage lags behind what is typical for phase 3. The hollow points reflect subnational regions within the country, demonstrating that certain regions are particularly ‘off-track’ for institutional delivery rate, while others are ‘on-track’ and one is ‘ahead-of-track’.

For relevant indicators, a country’s progress is also compared with that of select Exemplar countries. The interactive benchmarking tool subsequently provides descriptions of policies, programmes and factors that Exemplars research identified as key drivers of in-country progress.

In the case of this example, the tool describes initiatives that contributed to rapid progress in improving institutional delivery in India and Senegal. This includes information about India’s Janani Suraksha Yojana cash incentive scheme⁵ and its network of accredited social health activists which helped generate demand for services,⁶ as well as learnings from Senegal that primarily feature the country’s National Free Delivery and Cesarean Policy which removed user fees for all institutional deliveries.⁷

Implications for using the transition framework

These insights can be powerful for identifying priorities as countries look towards the SDG targets in 2030. This approach also emphasises that there is no one-size-fits-all solution to driving progress across countries. Tailored, country-specific evidence that accounts for a particular context is therefore crucial for informed decision-making. At the same time, rooting these country-specific insights in a common approach helps to promote a shared method of structured problem solving.

In preliminary engagements with in-country stakeholders, this tool has helped to anchor MNH priority-setting discussions in the context of a broader evidence base. The ability to visualise priorities—especially at the subnational level—has brought nuance to priority-setting discussions. Our team has seen outputs from the benchmarking approach inform recommendations in strategic evaluations and planning processes (eg, mid- and end-line policy reviews, prospective strategic plans, investment cases) through prioritisation of specific indicators and regions that emerge through the analysis. In certain cases, this approach has fostered the consideration of broader factors related to maternal and newborn health, including more distal drivers like female education and adolescent fertility rates.

Conclusion

In operationalising the integrated mortality transition framework, we have created a priority setting tool that allows for self-assessment that facilitates connections to proven strategies. This approach empowers decision-makers with information and tools that are targeted enough to be powerful for one audience, but flexible enough to be useful for many. This approach, therefore, can help to bring a degree of consistency to priority-setting mechanisms across contexts.

Initial use of the benchmarking approach has been tested during a series of country engagements with stakeholders involved in strategic MNH planning. As partners at all levels navigate a shifting global health financing landscape, data-driven priority-setting tools such as this are a critical resource to maintain progress in improving maternal and newborn health. We look forward to continued uptake as countries set their sights on better mortality outcomes in service of the global goal to ensure a healthy life for every woman, every newborn, everywhere.

The author is a staff member of the World Health Organization. The author alone is responsible for the views expressed in this publication and they do not necessarily represent the views, decisions or policies of the World Health Organization.

Data availability statement

Data are available in a public, open access repository.