Every day, over 800 women die during pregnancy or childbirth due to preventable causes. Despite global advancements in health system capacity, medical technology, and gender equality, maternal mortality and morbidity remain high. Women and societies deserve better, and we as maternal health advocates must step up to verify that sufficient progress is being made.
SDG 3.1 calls for a reduction of global maternal mortality to fewer than 70 maternal deaths per 100,000 live births by 2030. The 2.9% average annual rate of reduction in the maternal mortality ratio (MMR) observed between 2015 and 2017 falls short of the 6.4% annual rate needed to be on track. Setting ambitious goals is laudable, but duty-bearers – states and other entities that have responsibilities to respect, protect and fulfill human rights – must be held accountable for making progress. Target-setting is a key first step to improving maternal and newborn health (MNH), as it draws attention to areas of greatest concern and inspires actors to strategize and fund interventions. The critical next step after identifying these targets, however, is active and consistent follow-through.
Some of the most powerful tools for driving accountability in MNH are measurement and monitoring. According to the World Health Organization (WHO), “Monitoring is essential for tracking progress on achieving health outcomes at global, national and sub-national levels and to ensure that investments made are leading to the anticipated improvements in health and well-being.” At the facility level, continuous assessment of care quality measures and health outcomes allows for areas of concern to be quickly noticed and addressed in a timely manner. On a national and global level, data gaps are a security risk. At its core, national security is about protecting the interests of individual citizens, and when vulnerable women, children, and adolescents are not counted it threatens the state’s ability to protect them. The right to be counted from birth to death is a fundamental right of citizenship.
Investment and accountability cannot be isolated from one another – they are cyclically and inextricably linked. Data from measurements illustrate the magnitude of an issue and flag its importance for potential investments, and accountability measures must follow investments to track whether resources were deployed wisely and effectively. In the face of finite resources, data can help establish urgency and drive both public support and political will.
Further, a lack of coordinated, systematic data collection leaves states in a messy situation – in a notable high-income country example, the U.S. could not report an official national maternal mortality statistic between 2007 and 2020 due to inconsistencies in the reporting of pregnancy status on death certificates. Vital statistics, such as births, maternal and neonatal deaths, stillbirths, and causes of death, serve as crucial indicators of a nation’s health. In fact, quality death registration is associated with better nationwide health outcomes, independent of wealth, health system access, and development status.
To clarify measures specifically useful and relevant to the Strategies for Ending Preventable Maternal Mortality and to ensure that such measures are robust, research-validated, and demand-driven, the Improving Maternal Health Measurement Project is working with country partners to strengthen indicator quality and fill measurement gaps. Indicators measuring issues such as national health information system capacity and fundamental rights-based determinants of maternal health and survival add specificity and context to MNH dialogues. Measures that enable countries to count all deaths and understand their causes are necessary to identify and avert preventable maternal deaths — not just in theory, but in practice.
Trustworthy, transparent data available in the public domain not only help governments demonstrate they are upholding their duties and fulfilling their promises but are an important tool for citizen monitoring and social accountability in its many forms. Independent bodies in place to monitor progress towards intergovernmental goals include the UN Secretary-General’s Independent Accountability Panel, which provides a transparent review of progress towards the Every Woman Every Child Global Strategy for Women’s, Children’s and Adolescents’ Health, and The Countdown Initiative, which began as Countdown to 2015 in response to slow progress towards the MDGs and has now taken the form of Countdown to 2030. Grassroots efforts can also be extremely effective accountability mechanisms, amplifying citizen voices and centering their needs. The What Women Want campaign is an excellent example, as it generates investment and accountability for “what women want for their health, as they define it,” by surveying women and girls across rural and urban settings worldwide about their priorities for maternal and reproductive health services.
Challenges with data collection and accountability have been exacerbated by the COVID-19 pandemic. Resources shifted away from MNH to address COVID-19 have led to lapses in routine preventive services such as prenatal/postnatal care and cancer screenings, and pregnant and postpartum people have been experiencing gross violations of autonomy and other basic rights. Moreover, overwhelmed health systems are struggling to collect and report complete and accurate data. It is imperative that we document changes in health system capacity and health behavior along with maternal and neonatal outcomes so we can quantify the consequences of this pandemic and provide evidence for potential future crises.
Women, children, and adolescents are put at risk when countries lack the capacity to gather and analyze health and population data. As each day passes, an unacceptable number of women needlessly die. In the best of times, we need good data through good indicators and good monitoring to hold systems accountable for quality MNH services. Systems in crisis need data even more urgently to understand and manage the challenges at hand. And with so many challenges facing global public health at the current moment, we must focus on strengthening national information system capacity and insist on accountability from duty-bearers worldwide.