Protocol Published by EN-BIRTH Study to Assess Validity of Newborn and Maternal Coverage Measurement in Bangladesh, Nepal, and Tanzania

In the SDG era, significant attention in the maternal and newborn health sphere has turned to measurement to track progress towards the global and national targets for reducing maternal and newborn deaths. As the scoping review published by the MoNITOR group in 2018 emphasizes, a critical step towards ending preventable deaths of mothers and newborns is conducting research to validate indicators (Moller et al, 2018). A number of initiatives that arose from the Every Newborn Action Plan (ENAP), Ending Preventable Maternal Mortality (EPMM), and Countdown to 2015 have taken distinct approaches to validation, and one such example is the Every Newborn-Birth Indicators Research Tracking in Hospitals (EN-BIRTH) study. This past June, the EN-BIRTH team based at the London School of Hygiene and Tropical Medicine published the protocol for their observational study to assess validity of measurement for selected high impact intervention indicators.

Like the Improving Maternal Health Measurement Capacity and Use (IMHM) project, the EN-BIRTH team is partnering with researchers at institutions in three low and middle-income countries: Bangladesh, Nepal, and Tanzania. The EN-BIRTH validation research is on the coverage and quality indicators selected by the ENAP measurement improvement roadmap and EPMM monitoring framework core indicators for: 1) uterotonic to prevent postpartum hemorrhage, 2) immediate newborn care, 3) newborn resuscitation, 4) kangaroo mother care, 5) treatment of neonatal infection, and 6) antenatal corticosteroid use.

While the EN-BIRTH validation research focuses on proximal, service-related interventions for newborn and maternal health, IMHM indicators by contrast are distal determinants of maternal health.

EN-BIRTH methodology uses direct observation of clinical practice as the “gold standard” to validate coverage of interventions as recorded in the hospital register and reported by women for  1)-4) above and verification from patient records for 5) and 6), when direct observation was not feasible. The results of survey of women’s report and routine register data extraction will be compared to the observation or verification to assess the accuracy  of the numerators of these coverage indicators.

In addition, choices of denominators will be considered to determine which best captures the corresponding constructs. The measurement of content and quality of care will be determined by detailed analysis of this dataset compared to the timing and content recommendations in WHO guidelines. To address the final objective on identifying barriers and enablers to routine measurement, the EN-BIRTH team will conduct interviews with health workers and study data collectors. The results of the EN-BIRTH study will strengthen measurement by informing recommendations on the relative strengths of the alternate data sources available to track coverage of selected indicators: registers for HMIS data, and household surveys that depend on maternal report.

Similarly, the research methods developed to validate the 10 policy and health system indicators of the IMHM project will study the validity of indicator numerators, denominators, and data sources.  However, the approach to validation will involve verification of policy through legal record review, through primary data collection via surveys with healthcare providers, facility staff, women at facilities and in the community, and geographic information system analysis. A study protocol for publication enumerating the methods for validation of indicators through the IMHM project is under development. Although the data collection methods for the IMHM project are distinct due to the nature of the indicators measuring upstream determinants of maternal health, the validation exercise will aim to answer similar questions about the accuracy of different numerators and denominators and the validity of the indicators intend to capture the underlying constructs that they seek to measure.

Ultimately, both IMHM and EN-BIRTH seek to inform a robust set of available measures to track progress toward the SDGs and the specific newborn and maternal health targets. Focusing on indicators for maternal and newborn health at different points in  the continuum of care, these efforts to improve data for action will be complementary within a comprehensive monitoring framework that addresses the broad range of factors influencing the ability of women and children to survive and thrive.