Abstract
Research is needed to understand why some countries succeed in greater improvements in maternal, late foetal and newborn health (MNH) and reducing mortality than others. Pathways towards these health outcomes operate at many levels, making it difficult to understand which factors contribute most to these health improvements. Conceptual frameworks provide a cognitive means of rendering order to these factors and how they interrelate to positively influence MNH. We developed a conceptual framework by integrating theories and frameworks from different disciplines to encapsulate the range of factors that explain reductions in maternal, late foetal and neonatal mortality and improvements in health. We developed our framework iteratively, combining our interdisciplinary research team’s knowledge, experience and review of the literature. We present a framework that includes health policy and system levers (or intentional actions that policy-makers can implement) to improve MNH; service delivery and coverage of interventions across the continuum of care; and epidemiological and behavioural risk factors. The framework also considers the role of context in influencing for whom and where health and non-health efforts have the most impact, to recognize ‘the causes of the causes’ at play at the individual/household, community, national and transnational levels. Our framework holistically reflects the range of interrelated factors influencing improved MNH and survival. The framework lends itself to studying how different factors work together to influence these outcomes using an array of methods. Such research should inform future efforts to improve MNH and survival in different contexts. By re-orienting research in this way, we hope to equip policy-makers and practitioners alike with the insight necessary to make the world a safer and fairer place for mothers and their babies.
Highlights
Over the past few decades, many countries have achieved notable declines in maternal and neonatal mortality (Collaboration, 2018)
Conceptual frameworks are central to this process of discovery because they provide a cognitive means of rendering order to the world around us
Researchers integrate theories and evidence into conceptual frameworks to display the relationships among a range of constructs or variables, often in relation to health outcomes (Miles and Huberman, 1994), They are less propositional than theoretical frameworks, and allow researchers to integrate theories or concepts in new ways and apply them to guide research
Summary
Over the past few decades, many countries have achieved notable declines in maternal and neonatal mortality (Collaboration, 2018). Late fetal mortality (stillbirth) rates are not an explicit SDG target (Qureshi et al, 2015) and are still widely neglected, yet they share many of the same biomedical and social causes as maternal and neonatal mortality Preventing all these deaths, and improving health, are amenable to multiple preventive and curative interventions as well as a range of programmatic approaches to ensure these interventions are adopted (Bhutta et al, 2008). This framework was developed in the context of the Exemplars in MNH study to orient seven mixed-methods case studies in low- and middle-income countries (LMIC) – Bangladesh, Ethiopia, India, Morocco, Nepal, Niger, and Senegal – with better than expected progress in reducing maternal and neonatal mortality since 2000, where we aim to learn lessons that can further advance efforts and inform strategies in other settings (Exemplars). Rather than seeing each component of the framework separately as “determining” the outcomes, the framework helps to remind us to consider how various factors worked together over time, in a given context
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