International maternal health indicators and middle-income countries: RussiaBMJ 2005; 331 doi: http://dx.doi.org/10.1136/bmj.331.7515.510 (Published 01 September 2005) Cite this as: BMJ 2005;331:510
- 1 Health Systems Development Programme, London School of Hygiene and Tropical Medicine, London WC1E 7HT
- 2 Moscow Medical Academy, Ferganski Prospect 14-3-55, Moscow 109507, Russian Federation
- Correspondence to: J O Parkhurst
Maternal mortality is a key indicator of a country's progress in improving health, forming the basis for one of the United Nations' millennium development goals. It is an area where, despite substantial gains in the post-war period, the countries of the former Soviet Union have made only limited progress since gaining their independence in the early 1990s. Yet a failure to reduce maternal mortality does not indicate what action is needed for improvement. Interest is focusing on other measures, many of which examine the provision of the various elements of delivery of care.1 2 But in the post-Soviet context, how useful are these process indicators in guiding policy development?
Russia's overall maternal mortality ratio was estimated to be 34 deaths per 100 000 live births in 2002. This is significantly higher than the ratio in western Europe, where ratios of 10 or lower are common.3 4 This figure is also higher than in the other former communist countries of central and eastern Europe.4 Yet, despite the international focus on maternal mortality as one of the millennium development goals, little analysis has been done on what action is needed in the former Soviet Union to tackle this problem, still less on the quality of services provided, or the access to care by different groups in the population.
This paper reviews the maternal health situation in Russia, looking at commonly used measures of maternal care. We draw on a range of information sources (table 1), as well as using primary data collection in one Russian oblast (an administrative region or province of the Russian Federation with its own government).5
The international community has not agreed a set of indicators of the process of maternal care, but table 2 lists a series of indicators identified by four international bodies. On the basis of Ronsmans' classifications,11 we have grouped these indicators into measures of service provision, service use, use by groups in need, quality, and “other measures.”
International indicators in Russia
Although the maternal mortality ratio is the most widely used indicator of maternal health outcomes, the very high rates of induced abortion in Russia can undermine the use of the ratio as it is expressed as number of deaths per 100 000 live births. Abortion related deaths are included in the numerator, but aborted pregnancies are not counted in the denominator. This could inflate the ratio by up to 60% compared with a hypothetical country in which there were very few abortions. Even though abortion is legal and easily available, abortion complications account for about a quarter of maternal deaths,4 with two thirds of these reportedly resulting from illegal abortions.12–14
National figures say nothing about the distribution of outcomes among population groups. Key informants (see table 1) identified migrants and young mothers as especially at risk, but whether more general socioeconomic inequalities exist is not known. There are certain methodological problems in tracking health outcomes by socioeconomic status, but Diamond and colleagues have suggested ways of circumventing some of these problems, including ecological analyses combining census and health survey data.15 This may be one way forward in Russia.
Access to and availability of care
Russia has an extensive, though underfunded, network of antenatal and emergency maternal care facilities, with high staffing levels.16 As table 2 shows, unlike in low income countries, in Russia virtually all women give birth in institutions, with a trained attendant. The infrastructure that permits this near universal access was established before the recent decline in fertility (now 1.2 children per woman4), so there is considerable overprovision.
There are, however, grounds for concern. Although Russia has a compulsory health insurance system, in practice about 10% of the population fall outside it.17 Key informants identify certain groups as being at particular risk. Mothers aged under 18 remain under the care of paediatric services, which have poor links to sexually transmitted infections services and to maternal and reproductive services. Migrants and those who lack registration documents with local addresses face barriers in accessing care in some places owing to bureaucratic obstacles and informal pressure to pay for care.5 Modern contraception is, in practice, not always accessible, reflected by high levels of awareness of different contraception methods but low contraception use and high rates of abortion.18
The widespread use of indicators of service provision in international comparisons appropriately reflects the situation in developing countries faced with severe shortages of health professionals. In contrast, most countries of the former Soviet Union have extensive health infrastructures, with Russia reporting twice as many midwives per 100 000 population than many Western countries.4 A study in the Tula region, however, showed that the official number of budgeted posts often substantially exceeds the number of individuals employed.
Use of services
Indicators of service use are widely used in policy documents. Their value is greatest, however, where the concern is with low use. With nearly all births in Russia attended by skilled staff, aggregate measures provide little insight into health system failures. Instead, researchers need to identify the few women within populations who do not receive skilled care, as well as explore the issue of over-medicalisation.
Antenatal care provides an example of over-medicalisation. In Russia almost all mothers receive a highly intensive package of antenatal care, involving 15 to 19 visits according to one study.19 Admission to hospital during pregnancy is increasingly common (38-50% of mothers are admitted at some stage in their pregnancy), in part to compensate for reduced need for postnatal beds. Of those admitted, about 40% remain for 30 nights or longer.20
Met and unmet need
Rather less information is available for generating indicators that relate use to specific needs, although some indicators, such as access to care by mothers with complications, are less appropriate because of the over-medicalisation.
In seeking to identify those in greatest need, it is necessary to take account of certain definition issues.21 The traditional Soviet medical paradigm was quite different from that in the West. The reasons for this difference are complex and go beyond the scope of this paper, but they encompass differences in ideology, incentives, and adaptations to circumstances (such as a large pool of health professionals with few drugs or modern equipment).16 22 For example, many deliveries are recorded as “imperfection of labour activity,” yet there is no clear definition of what this means. Interviews with obstetricians in the Tula and Moscow regions suggest that this terminology is popular for three reasons: physicians can obtain gratuities or informal payments for managing “complicated” cases; the risk of litigation or complaints by patents is reduced; and length of stay can be extended, leading to higher reimbursement for the facility.
Quality and variability of care
Table 2 shows that few quality based indicators are regularly collected in Russia. As with other types of indicator, however, their potential use is limited by Russian contextual factors, with variation among facilities in the way different conditions are treated. For example, in the Tula region even quite basic practices such as episiotomy or amniocentesis show marked differences. Whereas variations in obstetric practices have been well documented in many countries,23 the extent of variation in Russia appears much larger than might be expected for some procedures, possibly reflecting the lack of any national consensus.
A way forward?
Given the many problems with quantitative measures in Russia, is there an alternative? Many countries already do regular audits of maternal deaths.11 Russia has such a system, but it is largely an administrative formality. It is hampered by lack of transparency, investigative expertise, and established procedures, and there is little evidence of tangible improvements in practice.24 A detailed investigation of nine maternal deaths in the Tula region between 2001 and 2003 identified errors in anaesthesia as a contributing factor in four cases, thus identifying an area in need of attention. This would have been missed in inspection of routine data, which focus on specific complications such as haemorrhage, sepsis, or eclampsia.
A problem in trying to identify useful indicators for guiding policies for reducing Russia's unduly high level of maternal mortality is that systems for data collection have not changed much since Soviet times, when information was primarily geared towards the needs of central planning, with little attention to quality and accessibility. However, although international bodies have identified a set of indicators that can be used to assess maternal care, these have been designed primarily for low income countries and are not especially helpful in a situation characterised by high use, extensive infrastructure, and evidence of over-medicalisation.
The challenge is to find measures that track quality rather than quantity and to indicate when services are being used appropriately. Some indicators that have been developed elsewhere—though not yet widely used—may prove useful in settings such as Russia. These indicators include the “observed versus expected ratio” (OVER) of complications25 or ones that overcome the current system of incentives to over-treat, such as monitoring time from admission to treatment. The Russian Federation has the capacity to capture detailed health indicators; the question is therefore to decide what is appropriate. Any improved quantitative indicators should be supplemented, however, with approaches such as maternal death audits.
This analysis shows how, although some existing indicators can be useful for international comparisons, others may be needed for tackling particular regional or country contexts. Only by using measures suited to their specific needs will countries such as Russia be able to improve maternal health.
The countries of the former Soviet Union, and Russia in particular, are lagging behind the rest of Europe in terms of maternal health outcomes
The most common international indicators look at quantity and use of health services
High levels of infrastructure, over-medicalisation, and practice variation in Russia are not captured well by existing indicators
Approaches for looking at quality and differential access to care, as well as maternal death audits, may be more useful for guiding maternal health policy in Russia
Contributors and sources All authors contributed to the conception and design of the study, collection of data, and writing of the manuscript. KD and DB reviewed the Russian language sources and collected the Russian data. JOP reviewed the maternal health literature and took lead responsibility for drafting and editing the manuscript. All authors contributed tothe analysis and the writing, editing, and final review of the manuscript. KD is the guarantor. All authors are members of a collaborative health systems development research programme that has used maternal health as one possible probe to understand health systems functioning in several low and middle income countries. These findings result from both literature review and dataset analysis in Russia. Statistical information was derived from the State Statistical Committee from the Ministry of Health annual statistical publications, and from the Tula Oblast Statistics Office. Relevant information from empirical studies conducted by the authors in 2002-3 has also been reported, including a study of maternal care provision in Tula and analysis of a dataset including all births in Tula in 2000. Competing interests: None declared.
Ethical approval Not needed.