Research process
The Exemplars in Neonatal and Maternal Mortality study aims to systematically and comprehensively evaluate factors associated with rapid reductions in neonatal and maternal mortality. Selected countries demonstrated success at reducing neonatal and maternal mortality beyond what would be expected based on economic progress alone—as measured by changes in the gross national income per capita from 2000 to 2017. Data availability, regional representation, and existing in-country partnerships were also considered in the country selection process. The countries identified as Exemplar countries were Bangladesh, Ethiopia, India, Morocco, Nepal, Niger, and Senegal.
Figure 45: NMR/MMR Exemplar country selection
WHO, UNICEF, UNFPA, World Bank Group and UNPD (MMEIG). https://www.who.int/data/gho/data/indicators/indicator-details/GHO/maternal-mortality-ratio-(per-100-000-live-births) ; United Nations Inter-agency Group for Child Mortality Estimation (2021). https://www.who.int/data/gho/data/indicators/indicator-details/GHO/neonatal-mortality-rate-(per-1000-live-births); World Bank. GDP per capita (constant 2015 US$)]. https://data.worldbank.org/indicator/NY.GDP.PCAP.KD
Summary of methods
A mixed-methods approach was used to assess key drivers of progress. Findings were synthesized across five methods of inquiry: literature review, quantitative analysis of country-level data, qualitative analysis, policy and program review, and financing analysis. The research in Nepal was completed in collaboration with a consortium of research partners, which are listed below.
The study methods are outlined in Table 2 below.
Table 2: Exemplars in Neonatal and Maternal Mortality study methods
Method | Data Sources | Short Description of methods |
Literature search | Peer-reviewed literature databases (PubMed, Scopus) | Comprehensive search of policy and program literature focused on Nepal and MNH. |
Analysis of mortality rates: national and stratified | IGME, national IHME, national MMEIG, national DHS (1996 – 2022), stratified | Trends analysis using modeled estimates from IGME, MMEIG, and IHME. Analysis of pooled survey data for trends and inequalities |
Review of causes of death | WHO/MCEE IHME Nepal Maternal Mortality Study 2021 | Causes of maternal death were obtained from IHME, and additional information was from the Nepal Maternal Mortality Study 2021. Causes of neonatal deaths came from recent estimates from the WHO/MCEE. |
Analysis of coverage and equity | DHS (1996–2022) | National, subnational, and equity-stratified data were reanalyzed for consistency in the coverage indicator definitions across surveys. Calculation of absolute and relative changes. |
Hierarchical decomposition | DHS 2001 and 2022 | Hierarchical regression of neonatal mortality on proximate, intermediate, and distal determinants. Extraction of effects of change in each factor of neonatal mortality change, controlling for upper-level factors. |
Fertility decomposition | IGME and MMEIG’s estimates of maternal and neonatal mortality United Nations Population Division’s estimate of population, total births, and crude birth rates | Use of Jain’s decomposition of maternal lives saved between 2000 and 2017 into components due to decline in birthrates, changes in birth-risk composition, and strengthening of maternal health programs. Adaptation of the method to decompose neonatal mortality reduction on the same period. |
Analysis with the Lives Saved Tool | IGME and MMEIG estimates of maternal and neonatal mortality DHS and national surveys for coverage estimates SPA for differences in coverage by facility type | Lives saved analysis to determine the contribution of changes in health interventions coverage to decline in maternal and neonatal mortality between 2000 and 2022. |
Policy and program review | Country reports Annual statistical yearbook | Desk review of health systems organization, programs and policies, and human resources for health; development of a policy timeline; analysis of qualitative interviews. |
Qualitative interviews | Key informant interviews | In-depth key informant interviews on the health system context and organization, policy and program development, and successes and challenges. |
Abbreviations: ANC, antenatal care; DHS, Demographic and Health Surveys; IGME, United Nations Inter-agency Group for Child Mortality Estimation; IHME, Institute for Health Metrics and Evaluation; MICS, Multiple Indicator Cluster Surveys; MMEIG, United Nations Maternal Mortality Estimation Inter-agency Group; MNH, maternal and newborn health; SPA, Service Provision Assessment; WHO/MCEE, World Health Organization Maternal and Child Epidemiology Estimation Group.
Data Source: Exemplars in Global Health