(February 2007) Every year an estimated half million women die in childbirth, mainly from hemorrhage, infection, and complications of abortion. These deaths tend to occur in developing countries plagued by weak health systems and substandard quality of care, among many other deficits. For years, safe motherhood experts have struggled to improve childbirth outcomes for mothers. But several key components were missing: solid methods to generate evidence, robust evaluations to strengthen the evidence-base, and better in-country capacity to use the methods and act upon evidence.

In the following interview with the Population Reference Bureau (PRB), Wendy Graham, principal investigator at Immpact and professor of obstetric epidemiology at the University of Aberdeen, describes innovative approaches Immpact, a global research initiative, is taking to improve maternal health and survival in developing countries. She highlights some of its early achievements in helping researchers design more cost-effective safe motherhood strategies.

PRB: What is the goal of the Immpact project?

WG: We’re trying to improve maternal health and survival in developing countries by providing rigorous evidence of the effects of safe motherhood strategies. To do this, Immpact offers new tools and methods for measuring maternal death and other safe motherhood indicators. The data collected can then be used to design and implement evidence-based safe motherhood strategies.

PRB: Where is Immpact working and what research questions Immpact is exploring in each country?

WG: Immpact has conducted more than four years of collaborative research in Ghana, Burkina Faso, and Indonesia. In each country, we evaluated different maternal health strategies to see what barriers prevent women from accessing skilled delivery care. How effective is Ghana’s delivery-fee-exemption policy and which households benefit most and how much? In Indonesia, what is the relationship between the number of midwives living in a village and the relative risk of maternal death? In Burkina Faso, which women were most likely to experience a life-threatening obstetric complication? These are just some of the policy-relevant questions we researched.

PRB: What makes Immpact different or particularly innovative? And how do these innovations advance the field?

WG: I have my own personal view of what the letters in Immpact symbolize. For me, the “I” is for innovation. The ethos of Immpact I was innovation: We had to develop new ways to design, implement, and synthesize this research initiative from Day 1 and this continues today as we apply novel analytical techniques to the wealth of data accumulated in the first four years. If you were to press me, I would mention three truly new developments: the tools to look at women’s physical, social, and mental health after pregnancy; the methods for measuring maternal mortality; and our early work using causal networks to map and predict relationships between the determinants of maternal outcomes and hence inform resource allocation.

I think the tools for capturing outcomes after pregnancy play a key advocacy role—revealing a burden which is still poorly appreciated and challenging assumptions about how we judge the “success” of interventions. Although our work on constructing a causal network for maternal mortality reduction has not generated a working model, the developmental work which was applied to secondary data from the Federation of International Gynecologists & Obstetricians Save the Mothers initiative, has demonstrated the potential of this innovation and encouraged us to look for ways to advance the field in our second phase. Innovation is indeed the “I” in Immpact.

PRB: What are the main findings from the research that you are particularly proud of and why?

WG: Another tough question if a short answer is desired! How can I point to a few nuggets in a gold mine that has not yet been fully excavated? One of the key findings which helps justify the investment in Immpact is evidence showing that poverty undermines the effectiveness of current skilled attendance strategies. Failure to tackle the inequities in access to skilled care is arguably the biggest obstacle that could prevent us from reaching MDG5’s target—a 75 percent reduction in maternal mortality by 2015.

These inequities exist at the level of individual women and their families, as well as between communities, districts, regions, and countries. This may seem like an obvious and hardly a new finding. What’s different is how consistent Immpact’s findings are regarding the influence of poverty on maternal health. The evidence was consistent in two main regards: (1) across very different country and programmatic scenarios (community-based midwifery care, free delivery services, or a comprehensive skilled care initiative); and (2) using a wide range of process and outcome indicators, including maternal mortality.

In terms of policy and program implications, Immpact’s evidence can be used to back pro-poor strategies, and to show that not only more resources are needed to save the lives of women and newborn babies, but also that these resources must be distributed in ways which do actually reach the poorest families and communities. Without such changes, the prospects are bleak not just for MDG5—but also MDG4, which aims to reduce child mortality.

PRB: From your perspective, since this year is the 20th anniversary of the Safe Motherhood Initiative, what is the importance of Immpact’s achievements in moving maternal health onto the global health agenda, for example at the next Group of Eight (G8) summit?

WG: I think of Immpact as part of a “family” of initiatives which keeps maternal health on the global health agenda. We are not alone. Like all families, this one has been divided at times, perhaps not surprisingly given what is at stake: the lives of women and their children. But the family will be united in this 20th year, and I hope Immpact can help here by providing hard evidence of program effects, thereby reducing this area of family disagreement.

Our key finding on poverty undermining skilled attendance strategies is highly relevant to the global agenda and certainly to the G8. For safe motherhood, a key issue will be packaging this message so it does not become conflated with poverty reduction per se. Communication is, in my view, the next frontier in safe motherhood, and I will speak to this issue at the Immpact symposium and in our Immpact publications.

To get back to your question, I think the importance of Immpact’s achievements related to the global agenda can be summarized in this way:

(1) Immpact showed that progress towards MDG5 can be measured in developing countries and it provided new and enhanced means to do this.

(2) It provided evidence that increasing coverage of skilled care at delivery is a necessary, but not sufficient condition for achieving MDG5. Inequities in access to care must also be reduced.

PRB: Looking forward, what are the next steps for Immpact?

WG: While we need to have a vision for our objectives through 2015 when MDG5 is to be judged, in the short-term, our main task is communicating findings from Immpact’s first phase to relevant stakeholder groups at national and international levels. Alongside this effort, new work will also be undertaken in two main areas.

The research arm of Immpact II will focus on providing global technical leadership in measurement to reduce maternal mortality. This stream of work is currently referred to as “MM+,” implying research not only on maternal mortality, but also other relevant mortality outcomes and related indicators.

The second main activity of Immpact II is referred to as “Ipact.” This resource will provide technical support for robust program evaluations and build such capacity in developing countries. It will always seek opportunities to collaborate with clients to integrate research into evaluations, be it developing and validating evaluation tools, or clarifying the interactions between “context” and “process.”

More will be said about Immpact II at the upcoming symposium (to be held on Feb. 21-23, 2007 at the Royal College of Obstetricians and Gynaecologists in Regents Park, London), and our website is being updated to reflect our new vision. So do watch that space (www.immpact-international.org). We certainly have much to do in the months ahead, and with other family members—much to do before the 30th year of Safe Motherhood.