|18. Cautious Champions: International Agency Efforts to Get Safe Motherhood onto the Agenda|
If a rights-based approach is to be useful for getting safe motherhood on to the agenda, clear and unambiguous indicators are needed against which to assess where countries stand and judge progress (Yamin & Maine 1999). This need for measurable process indicators was absorbed early on by UNICEF in drawing attention to the rights of the child. UNICEFs regular analysis of country progress towards the goals and the World Summit for Children is founded on a systematic review and analysis of key monitoring indicators3. UNICEF has not only worked on the conceptual development of such indicators, but has also invested considerable funding into generating the data, through, for example, its Multi-Indicator Cluster Surveys (MICS).
Unfortunately, we have not reached an equivalent stage in safe motherhood. Although some process indicators have been identified and are currently being promoted for monitoring progress (see for example, UNICEF/WHO/UNFPA 1997), more experience is needed with generating them in diverse country settings and with using them over sustained periods of time. Moreover, whereas there is a clear and unambiguous link between vaccination against measles, for example, and the decline in measles-related mortality, no such link has been scientifically demonstrated between maternal mortality and the most commonly advocated process indicators such as skilled attendant at delivery or access to emergency obstetric care.
The challenge is well illustrated by the example of the skilled attendant at delivery indicator. The indicator is intuitively easy to understand and readily available for many countries. The source of the information is generally the Demographic and Health Surveys, which have the advantage of providing a standardised methodology and sampling framework along with strict criteria regarding the maintenance of data quality. Although efforts are made to standardise definitions of skilled birth attendant, there remain doubts about the comparability of some of the results across countries and within countries at different time periods. One source of potential confusion is the differing interpretations as to who is a skilled attendant, particularly in settings where traditional birth attendants have been trained and where many of them work within a health setting. But more critically, while there is ecological evidence in support of a link between skilled attendant at delivery and reduced maternal mortality, and sound clinical reasons for assuming that the link is real, unequivocal evidence is lacking (AbouZahr & Wardlaw 2000).
This problem is not simply of academic interest. It means that it is hard to make a convincing advocacy case for maternal health and for investment in the needed interventions. Decision-makers, whether among governments or donor agencies, want to be able to demonstrate to a sceptical public that their investments are bearing fruit. The need to be able to tell the story has been underestimated by many working in the area of safe motherhood and it is a failure that has cost the issue dear in terms of keeping it at the forefront of the health and development agenda.