Jennifer Bryce explains why measuring coverage of maternal, newborn, and child health interventions matters and what we can learn from the new PLOS Collection
Coverage matters, because we have interventions that can save the lives of mothers and children in poor countries, but only if they are available, affordable and used. My preoccupation with intervention coverage started in the early 2000s while working in the WHO department that developed the Integrated Management of Childhood Illness (IMCI) strategy. IMCI brings together numerous life-saving interventions for children, but when we looked at the numbers on how many of the children who needed those interventions were actually getting them, it was horrifying. We had affordable solutions, but they were not reaching enough children, especially in the places with the highest rates of child mortality.
To improve coverage, we need to measure it
Effective action requires sound evidence. If we want to reach the women and children who are not benefitting from health services, we must understand who these families are, and where they live, so that we can devise ways to connect them to the interventions they need. Since 2005, Countdown to 2015 has helped draw attention to gaps in maternal, newborn and child health (MNCH) coverage. Countdown publishes country-by-country profiles of intervention coverage for the countries with the highest rates of mortality, and publicizes the gaps to show what needs to happen — and where — to speed up progress toward the Millennium Development Goals for mothers and children in 2015 and beyond.
But measuring coverage is not easy
Countdown also drew new attention to how we were actually measuring coverage, and the indicators we were using. Almost all coverage data for MNCH interventions come from one of two global survey programs: the USAID-supported Demographic and Health Surveys (DHS), and the UNICEF-supported Multiple Indicator Cluster Surveys (MICS). Without these two crucial programs, most governments and their partners would have no data on coverage for their health intervention programs. But close scrutiny of these survey programs revealed aspects of coverage measurement through household surveys that could be improved.
We can do better
To address these measurement gaps, WHO and UNICEF brought together a group of scientists from around the world through the Child Health Epidemiology Reference Group (CHERG). CHERG’s mandate is to improve the evidence base across the entire MNCH continuum. The coverage group began by reviewing the state-of-the-art in coverage measurement for all proven interventions tracked by Countdown. We focused our efforts on the highest-impact interventions for which no other group was investigating coverage measurement.
Examples of the issues that need to be addressed are whether mothers can recall the interventions that they receive while giving birth, or that their sick child receive during an episode of pneumonia, malaria or diarrhea. Some of the indicators used at present to monitor coverage refer only to service contacts — such as antenatal care or the presence of a skilled health professional at birth — rather than the specific interventions that should be delivered during those contacts. Finding better ways to produce more accurate data on intervention coverage is an urgent priority.
The PLOS Collection
The Collection, which was spearheaded by CHERG, presents new assessments of coverage metrics and proposes new strategies for continuously improving our understanding of intervention coverage. The Collection relies on years of work by CHERG and addresses some of our most pressing measurement challenges, advancing the state-of-the-art in several areas:
Example 1: Treatment of Pneumonia - A long and difficult path to measure
Before a child is correctly treated for pneumonia, many steps have to be taken successfully, from recognizing symptoms to obtaining and administering the correct treatment. Each step is a measurement challenge, and combined they are a nightmare. Collection studies in Pakistan and Bangladesh assess whether mothers are able to report accurately on their child’s pneumonia treatment, and test strategies to improve the accuracy of their reports.
Example 2: Interventions around the Time of Birth - What can mothers report about their own care?
Many indicators track contacts between a woman and a health provider, such as antenatal or postnatal care visits or the presence of a skilled health provider when a child is born. But they do not reflect whether specific life-saving interventions are delivered during that contact. The Collection makes important strides in figuring out what women can recall about interventions received around the peripartum period and emergency Cesarean sections.
The learning agenda in coverage measurement
We are only beginning to understand the challenges of coverage measurement. But this work has already led to changes in the MICS and DHS survey programs, and will continue to do so. In addition, decision makers at all levels must gain a better understanding of coverage metrics, and what they mean. Only with better measurement, and better data that are an integral part of the decision making process, can we plan and implement strategies that will reach more women and children, and save their lives.
Jennifer Bryce coordinates CHERG work on Measuring Coverage of Maternal, Newborn, and Child Health, including the preparation of this Collection. She is a Senior Scientist at the Institute for International Programs in the John Hopkins Bloomberg School of Public Health, and she leads several major evaluations of child health and nutrition programs.
The Measuring Coverage of Maternal, Newborn, and Child Health Collection was produced with support from the Child Health Epidemiology Reference Group (CHERG). Financial support for CHERG is provided by The Bill & Melinda Gates Foundation through their grant to the US Fund for UNICEF.
Read the full collection: http://www.ploscollections.org/measuringcoverageinmnch