The Geography of Maternal and Newborn Health the State of the Art

• Review
• Open Access
• Published: 27 May 2015

The geography of maternal and newborn wellness: the country of the art

• Maria Guerra-Arias^two,
• James Campbell³,
• Andrew J. Tatem⁴,
• Allisyn C. Moran⁵,
• Fiifi Amoako Johnson^half-dozen,
• Helga Fogstad⁷,
• Karin Stenberg⁸,
• Sarah Neal⁶,
• Patricia Bailey^viii,
• Reid Porter⁹ &
• Zoe Matthews⁶

International Journal of Wellness Geographics book 14, Article number:19 (2015) Cite this article

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Abstract

As the borderline for the millennium development goals approaches, it has become clear that the goals linked to maternal and newborn wellness are the least probable to be achieved by 2015. It is therefore critical to ensure that all possible information, tools and methods are fully exploited to help address this gap. Among the methods that are under-used, mapping has ever represented a powerful mode to 'tell the story' of a wellness trouble in an hands understood way. In improver to this, the avant-garde belittling methods and models now existence embedded into Geographic Data Systems allow a more than in-depth assay of the causes behind adverse maternal and newborn health (MNH) outcomes. This paper examines the current land of the art in mapping the geography of MNH equally a starting indicate to unleashing the potential of these nether-used approaches. Using a rapid literature review and the clarification of the work currently in progress, this paper allows the identification of methods in use and describes a framework for methodological approaches to inform improved conclusion-making. The paper is aimed at health metrics and geography of wellness specialists, the MNH customs, equally well equally policy-makers in developing countries and international donor agencies.

Introduction

Maternal and newborn health (MNH) care refers to 'those activities whose primary purpose is to restore, improve and maintain the health of women and their newborn during pregnancy, childbirth and the 7-day postnatal period' ^{Footnote 1}[1]. Globe Health Organization (WHO) guidance on the activities that should be included in MNH intendance includes the essential packages of interventions that address pregnancy, childbirth, postpartum intendance to mothers and care to newborns [ii]. MNH outcomes are subject to wide geographic inequities, both at the regional, national and sub-national levels. The location of services is a fundamental determinant of women'south access to MNH care [iii–half-dozen], thus the application of geographic approaches and geographic information systems (GIS) to MNH is disquisitional to assess the situation and needs and guide policy decisions, leading to improved services and care and thus to improved MNH outcomes [7, 8].

The health and survival of women and their newborn babies has been a key priority in public health for decades, as highlighted by two of the eight 'Millennium Development Goals' (MDGs), from the Millennium Declaration endorsed past 189 fellow member states in the year 2000 [9]. Goal number five of these international priorities aims to cut maternal mortality by three-quarters from 1990 to 2015 and goal iv focuses on reducing newborn and kid mortality by two-thirds. However, every bit the borderline for these goals approaches, it has become clear that of the viii original goals (which as well target poverty, malnutrition, educational levels, ecology conditions and sanitation) goals 4 and five are the to the lowest degree probable to be achieved in the fourth dimension span set. Women all the same die in childbirth—289 000 per year in 2013 [10]—specially in low income countries and although kid mortality is dropping, neonatal deaths have not decreased at the aforementioned charge per unit, now representing 44 % of all deaths under 5 years [11].

In recognition of poor progress and a lack of information, the United nations Secretary-General commissioned a new Global Strategy for Women'due south and Children's Health in 2010 [12] to accelerate progress in reducing maternal and newborn mortality ahead of the rapidly approaching MDG deadline. Equally a result of this, a Committee on Data and Accountability for Women's and Children's Wellness was established [xiii] to systematically track progress every bit well as collect health system information that support the survival and wellbeing of pregnant women and their newborns. These data include indicators that mensurate the coverage of MNH services, including antenatal intendance and skilled birth attendance. ^{Footnote ii} Availability of these services is an important step to tackling the problem, but services as well need to be accessible to women, acceptable to them and their families and crucially, of a sufficient quality. Finally, women must exist able and enabled to make the decision to seek intendance, otherwise the availability, accessibility, acceptability and quality of services becomes irrelevant [xiv, xv].

Thus far, the measurement of progress has focused on aggregate indicators at the land level, but increasingly there are concerns that even where progress has been made, it is discipline to broad inequalities [16]. Even in countries where national maternal and newborn mortality rates have declined, at that place may be subgroups where survival rates and access to services have not inverse or have worsened. Investigation of sub-national situations through a geographical analysis is now increasingly required.

This paper arises from a workshop held in March 2013 entitled 'Geography four MNH' ^{Footnote three}, to explore and describe the current "Country of the Art" of MNH mapping. The workshop, hosted by Instituto de Cooperación Social Integrare and the University of Southampton, enabled collaboration across enquiry and development agencies to identify existing published and grey literature, draw current work in this field and develop a framework to accelerate the utilise of this capacity in priority countries with loftier maternal and neonatal mortality, in order to meliorate MNH outcomes.

The urgency with which the MNH community must encompass the geographical interpretation of existing databases is particularly critical, both in advance of the endpoint for the MDGs and to inform the mail service-2015 evolution agenda for health and the new generation of goals and data requirements over the catamenia 2015–2035 [17]. Successful examples of the application of geographic approaches and use of geospatial information to better MNH services show the potential of these technologies when integrated inside national health strategies. Examples include the employ in People's republic of bangladesh of an interactive EmONC monitoring GIS organization that tracks quality and gaps in services [seven]; the apply of GIS to evaluate the impact of a community-based health initiative in rural Ghana [eight]; and the UK's teenage pregnancy reduction strategy, which used ward level data of conceptions in immature women under 18 years to help in targeting interventions where most needed [18].

Review

What has been done then far – a rapid review of previous studies

A rapid review was conducted of the published and gray literature on geographical approaches related to the health and survival of women and children. To identify key sources, an exercise was conducted with technical and academic experts, who were invited to contribute relevant studies to be reviewed. Subsequently, a "snowballing technique" was used to identify further valuable references from these initial sources and so on. The selection was based on a review of title, abstruse and central words related to geography and MNH, including: distance, emergency obstetric care, geographic information systems, health facilities, health services accessibility, maternal wellness, maternal wellness services, newborn, pregnancy, spatial assay, etc. The start date for inclusion was the year 2000. As well as the articles identified through the "snowballing technique", additional studies were identified independently by the authors and added to the review.

In total, 33 studies were identified with a focus on MNH. Studies that focus on item health issues announced to be less common than those that focus on overall affliction surveillance, access or risk analysis. A systematic review in 2011 constitute 621 articles relating to the use GIS in health, out of which 227 related to disease surveillance, 189 to risk analysis (usually linked to environmental health), 138 to wellness access and planning, 115 on community profiling and 17 on full general or methodological bug [19].

An extraction table was used to compile primal information from each of the 33 retrieved papers, namely: twelvemonth of publication, region and country of implementation, geographical scope, objectives and themes covered, major findings, geographical data layers included, other data collected and GIS approaches used. Tabular array one presents selected dimensions of the literature retrieved.

Table 1 Selected data from a rapid literature review on mapping for MNH

Total size table

This review shows a clear increase in the number of GIS for MNH publications since 2010. The studies cover most regions of the world. As expected, in view of its high maternal and baby mortality levels [10] Africa has received the greatest inquiry focus with 19 studies. Asia (including Due south, South-East and East asia) and Europe follow with five studies each.

The majority of the studies conduct their assay at the national or sub-national level. One of the studies [twenty] covers the broader geographical region of W Africa, but individual analyses are conducted at the level of each land in the region.

The most common study objective is to examine geographic admission to wellness services. ^{Footnote iv} A variety of different GIS techniques are used to map, excerpt or model MNH related indicators, from simple thematic mapping, spatial analysis (straight line distance, buffers) or spatial modelling involving travel fourth dimension toll surfaces, which take transport networks and other geographical features into account.

Work in progress

One of the primal purposes of convening parties actively mapping the geography of MNH was to identify the work in progress that may influence the 'land of the art'. Table 2 provides examples of on-going work, looking at the who?, what? and where? for each project (full descriptions available on request).

Table ii Examples of work in progress on mapping for MNH

Full size table

The work in progress is consistent with the findings of the literature review, both in terms of countries studied and methods employed. Several partners are involved in these activities, creating some overlap in the countries beingness covered and calling for coordination.

These dissimilar projects span a wide range of methods: from the use of thematic maps to visualize indicators at different levels of disaggregation, to the use of circuitous spatial assay and modeling techniques in order to assess the accessibility of MNH services. In each case, the ability of GIS is used to represent, excerpt or produce new evidence of interest to the controlling procedure (encounter the next section for a description of the benefits of each method).

Of detail interest is that several of the multi-country initiatives (H4+, USAID and WHO) take independently adopted the Tanahashi framework of constructive coverage [fourteen] to guide their technical analyses. This framework considers the dimensions of availability, accessibility, acceptability and quality of services when measuring population and facilitates the identification of bottlenecks and solutions, as appropriate to the geography. This convergence between geography and therefore indirectly GIS and the Tanahashi framework is encouraging and provides telescopic for 'good exercise' to exist documented and disseminated. Some other encouraging finding is that professional person learning and capacity-building are incorporated within some of the activities with a longer elapsing, east.g. the multi-state work supported past WHO and Prove for Action (E4A). Noesis transfer on the methods, assay and policy implications will be critical to integrate the geography of MNH into national policy and planning cycles in the future.

The field of Minor Area Estimation (SAE) is besides emerging in the geographical analysis of MNH and allows the estimation of measures for very small geographies by linking the variable of interest with covariate or contextual information from census, administrative or geographic data systems information to derive model-based estimates for small areas. If information on the variable of interest are available simply for a express number of individuals in the small expanse, the covariate data is available for all individuals in the expanse and is causeless to explicate role of the between expanse variability [21, 22]. Two broad types of small-surface area models exist. Area-level models are used when the auxiliary data is available just at the surface area level [22] and nested error unit-level models are used the auxiliary data is available at the individual level and is related to the variables of involvement at the unit-level [23]. Such methods have been employed widely in high income countries and for economical variables such equally poverty indices [24, 25] – only less so for health variables [26, 27]. Amoako-Johnson et al. [26] apply SAE for skilled attendance and unmet demand for contraception and Ahmed et al. [28] have reviewed maternal mortality ratios in Bangladesh.

In demographic and health research, particularly in the interpretation of maternal and newborn healthcare indicators at that place are methodological as well as information challenges that limit the application of small expanse estimation techniques [29–32]. Despite these limitations, more than and more than low and middle income countries are using this blazon of analysis to reduce the extent of inequality in access to health care as, in these countries, local level statistics on healthcare provision and outcomes are rare if non not-existent for assist planning, monitoring and evaluation of programs.

Moving towards comprehensive GIS for MNH

The review of the literature and piece of work in progress presented here has identified three types of GIS methods, namely:

1. 1.

   Thematic mapping (creation of maps to convey information near a topic or theme);

2. 2.

   Spatial analyses (extraction or creation of new information from spatial data);

3. iii.

   Spatial modelling (spatial analysis that includes the use of a mathematical model to simulate natural or anthropogenic phenomena).

Each of these methods adds specific value to the policy discussion. Thematic maps are powerful instruments that allow visualizing sub national information from a geographic perspective. Spatial analysis techniques, including spatial modelling, are advanced methods that are used to provide a more than in-depth analysis and agreement of the health systems factors and behaviours backside MNH related wellness outcomes.

These methods are listed not only in order of increasing complexity simply likewise by their reliance on data in terms of volume, abyss (having all the information on the map), timeliness (chronologic consistency between the different sources of information) and accurateness (precise location of each geographic object), and the advanced level of GIS skills required to apply them.

The possibility for countries to benefit from any of these applications volition be influenced by the availability and quality of data and technical resources. Thus, an appropriate and fairly financed institutional framework is needed, to sustain and improve the availability and quality of the data and to further enhance the required technical skills and equipment. Table 3, while non exhaustive, provides an overview of the components that would support such an institutional framework to advance the application and implementation of GIS in MNH.

Table 3 Required information, data quality issues and required GIS skills, by GIS arroyo to mapping for MNH

Total size tabular array

Additional considerations from the authors' feel to complement this table include:

1. 1)

   The lowest bachelor level of disaggregation should be used to avoid masking potential pockets of heterogeneity in aggregate information;

2. 2)

   Finding accurate GIS data is often a challenge as indicators might have been nerveless according to dissimilar types of divisions (administrative, statistical or even health) and/or at different periods in time;

3. 3)

   A item challenge resides in the use of MNH indicators that would be bachelor at the health facility level (presence of EmONC signal functions, for instance). A master list containing all national health facilities (rather than a sample) also as their geographic location (latitude/longitude) is an absolute necessity. Ensuring the use of such registry as well as the integration of geography in whatever health facility based survey would also contribute to facilitating the use of GIS as well every bit the comparison between maternal/neonatal health services provision and outcomes [33];

4. 4)

   At all levels it is important that the GIS technician works as part of a team of experts to produce timely, reliable and relevant results for controlling.

Table iii emphasises the importance of having a stiff wellness information arrangement in place just as well for this system to integrate and contextualise both geography and time finer and accurately. The former requires complete and up-to-appointment registries, to be established and maintained for each of the geographic objects to which MNH related statistics tin can be fastened (administrative, statistical, wellness divisions, health facilities). In add-on, advanced techniques such as spatial assay or spatial modelling crave the use of GIS data under the mandate of institutions outside of the health sector (for example, National Statistical Office, National Mapping Agency and/or National Road Potency). All these institutions therefore need to use compatible data based on common standards.

The use of GIS also requires that the health sector has the necessary capacity (human resource, software and hardware) in identify. While this capacity is increasing, thank you partly to the availability of open up source software, in a large number of Ministries of Wellness it remains at a basic level and limits analysis to thematic mapping. Sustained implementation and continued expertise in countries are needed. Good news on this comes from non-health sectors such as agronomics – where GIS expertise is beingness utilized more and more frequently and from Wellness Direction Information Systems evolution – where growing Information technology teams are increasingly embedding GIS within the standard monitoring tools. The need to support and harness GIS systems and expertise is also explicit in post −2015 plans for statistical development in countries – for example in the forthcoming 'road map for health measurement' to be discussed at a summit in Washington June 2015 [34], and among the new leaders of the Inter Agency Group for the SDGs [35], which is existence led past national statistical agencies and whose needs for capacity evolution are increasingly being heard.

Despite these challenges the emphasis on reducing maternal and newborn bloodshed is an opportunity for new synergies. The health sector can apply MNH as the driver to ameliorate GIS capacity, thus benefiting all health initiatives. This win-win situation would exist possible through an institutional framework in which:

1. 1)

   The health sector is actively involved in discussions aimed at standardising their own geospatial information. The forum for this is generally referred to as the National Spatial Data Infrastructure (NSDI);

2. two)

   International health partners supporting MNH program activities strengthen the existing GIS capacity through a coordinated approach; independently from specific health programme back up;

3. three)

   Institutions involved in the strengthening of health information systems include the integration of geographic and time dimensions in their arroyo;

4. 4)

   MNH oriented programs systematically consider geographic analysis and GIS as a tool to ameliorate the implementation and monitoring of MNH programs.

The institutional framework would ideally be developed and taken forward as an integral component of the Un Secretary-General's Every Woman, Every Child initiative, with linkages to the Commission on Information and Accountability for Women's and Children's Health (CoIA) and the independent Skilful Review Grouping (iERG).

Conclusions

Despite an encouraging trend of increased interest in applying GIS applied science for improving MNH outcomes in contempo years, much remains to be washed to develop national chapters in low- and middle-income settings, to perform geographical assay.

This state of the art serves as a baseline to raise awareness of the potential that GIS methods have to offer to MNH and provides the components of an institutional framework that nosotros recommend be included in the further piece of work of the CoIA and the iERG. Information technology calls for ameliorate communication and coordination amidst institutions working at improving the GIS capacity of the wellness sector, as well every bit between the health sector and other sectors. Improvements should ideally be independent of particular wellness priorities, as geography has a shared value to all efforts targeting improved health and population outcomes.

The authors of this paper encourage institutions and individuals working or interested in this surface area, to make themselves known to the Geography of MNH platform in lodge to strengthen coordination mechanisms and disseminate global public appurtenances.

Notes

1. The neonatal period for the newborn baby is commonly divers as the beginning 28 days of life, and the postpartum health of a woman is similarly considered for a month after the birth. All the same – most of the agin outcomes related to the nascence occur during the first vii days.

2. The 'Countdown to 2015' initiative collects these service information – and Countdown is the official bureau for tracking indicators for the Commission on Information and Accountability. Skilled birth omnipresence – a fundamental MDG indicator– is a crucial human resource indicator [three, 36].

4. The purpose of this newspaper is not to compare methods that investigate geographical access to services. Please refer to Higgs [37] or Guagliardo [38] for a comparison and description of several of these methods.

Abbreviations

CoIA:

Commission on Information and Accountability for Women's and Children's Health

GIS:

Geographic information systems

iERG:

Independent Proficient Review Group

MDG:

Millennium evolution goals

MNH:

Maternal and newborn health

NSDI:

National spatial data infrastructure

SAE:

Small surface area estimation

WHO:

World Health Organization

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Acknowledgements

This newspaper is an output of the 'Mapping for MNH' enquiry project co-managed by ICS Integrare (Spain/Uk) and the University of Southampton (UK) and WorldPop project (world wide web.worldpop.org), with funding from the Norwegian Agency for Development (Norad). Our appreciation is extended to Norad for their fiscal support.

Individuals participating in the Platform activities acknowledge support from the Science and Technology Advisers, Department of Homeland Security; the Fogarty International Center, National Institutes of Health; NIH/NIAID; the Bill and Melinda Gates Foundation; the UK Department for International Evolution on the programme 'Show for Action'; the Economic & Social Enquiry Quango (ESRC) (Res-167-25-0343); and the Un Population Fund.

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Affiliations

1. Gaia GeoSystems, Muscat, Oman

   Steeve Ebener

2. ICS Integrare, Barcelona, Spain

   Maria Guerra-Arias

3. WHO, Geneva, Switzerland

   James Campbell

4. WorldPop, Academy of Southampton, Southampton, Uk

   Andrew J. Tatem

5. USAID, Washington, DC, United states of america

   Allisyn C. Moran

6. Academy of Southampton, Southampton, UK

   Fiifi Amoako Johnson, Sarah Neal & Zoe Matthews

7. NORAD, Oslo, Norway

   Helga Fogstad

8. AMDD and FHI 360, Durham, USA

   Karin Stenberg & Patricia Bailey

9. The University of Texas at Austin, Austin, USA

   Reid Porter

Corresponding writer

Correspondence to Steeve Ebener.

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Competing interests

The authors declare that they accept no competing interests.

Authors' contributions

SE conceptualized the paper, designed the structure of the paper and was the lead for enquiry and writing of all sections. MGA conducted the literature review and was involved in researching and writing the paper. JC conceptualized the paper and conducted enquiry and writing of all sections. AT was involved in conceptualizing the paper, providing research inputs regarding GIS methodology and commenting on revisions. AM as well collaborated in the conceptualization of the paper, collaborated in writing the "work in progress" section and commented on revisions. FAJ provided research and writing inputs for the "piece of work in progress" section. HF and RP participated in designing the concept for the paper and commented on revisions. KS reviewed the drafts of the paper and provided inputs and revisions on the "work in progress" department and tables. SN was involved in revising the manuscript. Atomic number 82 provided research, writing inputs and revisions of the manuscript. ZM was an architect of the main concepts in the newspaper and was involved with the literature review and writing all sections of the paper. All authors read and approved the concluding manuscript.

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Ebener, South., Guerra-Arias, M., Campbell, J. et al. The geography of maternal and newborn health: the land of the art. Int J Wellness Geogr fourteen, xix (2015). https://doi.org/ten.1186/s12942-015-0012-ten

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• Received: 17 March 2015

• Accepted: xiii May 2015

• Published: 27 May 2015

• DOI : https://doi.org/10.1186/s12942-015-0012-x

Keywords

• Maternal health
• Newborn wellness
• Geography
• GIS
• Inequalities
• Millennium development goals

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