Influencing Maternal and Child Health Policies in Resource-poor Countries
Submitting InstitutionUniversity of Southampton
Unit of AssessmentSocial Work and Social Policy
Summary Impact TypeHealth
Research Subject Area(s)
Medical and Health Sciences: Public Health and Health Services
Summary of the impact
Research by the University of Southampton into maternal and child health
in the developing world has contributed significantly to the design of
better health policies by governments, international agencies, and
non-governmental organisations. The research broke new ground in
identifying the urban poor in developing countries as among the groups
most at risk of poor maternal and child health. Its findings have informed
policy and funding priorities at national and international organisations
including the Department for International Development (DFID) and the
United Nations; influenced health practitioners in Africa and Asia; and
led to better health care outcomes in countries which were the focus of
Reducing maternal mortality worldwide remains among the most elusive of
the Millennium Development Goals (MDGs). Every day, approximately 800
women worldwide die from preventable causes related to pregnancy and
childbirth. 99% of them live in developing countries, particularly
sub-Saharan Africa and South Asia. The majority of these women could be
saved with adequate reproductive health and maternity care. Similarly,
over 3 million newborns die needlessly every year. It is on these areas
that the Centre for Global Health, Population, Poverty, and Policy (GHP3)
at the University of Southampton and its predecessor, Opportunities
and Choices DFID Reproductive Health Knowledge Programme (1999-2005)
have focused much of their research. Over the past two decades, Zoë
Matthews, Professor of Global Health and Co-Director of GHP3 (1993-), and
Nyovani Madise, Professor of Demography and Social Statistics (1993-) and
founding director of GHP3, and their teams have produced a number of high
quality research outputs on access to reproductive and maternal health
care and the quality of that care.
a) In a paper published in the Lancet [3.1], Matthews et al found
that the lack of skilled providers (doctors and midwives) was one of the
key barriers to stemming the tide of maternal and newborn deaths, and that
teams of midwives and midwife assistants working in facilities (as opposed
to solo health workers assisting with home deliveries) are the most
efficient option for increasing the availability of maternity care. This
work commenced while Matthews was on secondment to the World Health
Organisation (WHO) in 2003-2005 where she carried out global policy
overviews on maternal and newborn health and survival through structured
literature reviews informed by medical and other health staff worldwide [3.2].
The results were reported in the World Health Report 2005. During her
secondment, Matthews retained her Reader position at Southampton where she
had access to research facilities and funding from the Opportunities and
Choices DFID-funded programme, to enable her to continue to work on
b) Madise and her collaborators at the African Population Health Research
Centre conducted pioneering empirical research among the urban poor in
Kenya and other Africa countries from 2004 to 2012 [3.3-3.4]. This
body of research, funded by the World Bank and the Wellcome Trust, showed
that the residents of urban informal settlements (or slums) often lack
access to formal health care despite their close physical proximity to
health services, challenging the notion that urban residents have better
health outcomes than their rural counterparts. In the Kenya study, slum
residents had as much as 25% higher maternal mortality than the national
rate and poorer child health outcomes than the national population.
Matthews, Madise, Dr Amos Channon (lecturer since 2008) and their
collaborators from UCL and Agha Khan University strengthened these
findings in 2010 through an analysis of data from 30 poor countries which
again showed that no urban `advantage' in health care and child survival
exists for poor people [3.5]. The work was published in leading
journals including PLoS Medicine, American Journal of Public Health,
Demography, and Social Science and Medicine.
c) Matthews et al, with funding from the Wellcome Trust, also conducted a
situation analysis of the quality of care within institutional maternity
services in a slum area in Mumbai in India, developing a framework [3.6]
which can be used as a flexible quality assessment tool in similar
settings in developing countries. Key findings included evidence that care
quality is far from optimal in either municipal or private facilities,
with quality issues including a lack of essential drugs, the use of
inappropriate procedures, and women being left unsupported, among others.
References to the research
3.1 Koblinsky M, Van Lerberghe, W, Matthews Z et
al. (2006) Going to scale with professional skilled care. The Lancet,
3.2 World Health Organisation (2005) World Health Report 2005. W.
Van Lerberghe (Editor in Chief) with Matthews Z, Manuel A.
and Wolfheim C, WHO, Geneva.
3.3 Stephenson R, Bascheiri A, Clements S, Hennink M, and Madise NJ
(2006) Contextual influences on the use of health facilities for
childbirth in Africa. Am. J. Public Health, 96 (1): 84-93.
3.4 Ziraba AK, Madise NJ, Mills S, Kyobutungi C
& Ezeh A (2009) Maternal Mortality in the informal settlements of
Nairobi city: What do we know? Reproductive Health, 6:6.
3.5 Matthews Z, Channon A, Neal S, Osrin D, Madise
NJ et al. (2010) Examining the `urban advantage' in maternal
healthcare in developing countries, PLOS Medicine 7(9), e1000327.
3.6 Hulton L, Matthews Z & Stones RW (2007) Applying a
framework for assessing quality of maternal health services in urban
India. Soc Sci Med, 64(10): 2083-2095.
1) Diamond I, Stones RW, Black T, Matthews Z, Madise NJ,
Falkingham, JC et al. Improving peoples' benefit of reproductive health
services, DFID, 1999-2005. £2.3 million. Funding for Opportunities and
Choices DFID Reproductive Health Knowledge programme.
2) Stones RW, Ramasubbon R & Matthews Z, Maternal
health seeking in the slums of Mumbai, Wellcome Trust, 1999 - 2002,
3) Madise, NJ, Ezeh, A, Fotso, JC, Ziraba, A et al. Averting
preventable maternal mortality: Delays and barriers to the utilization of
emergency obstetric care in Kenya. World Bank, 2005- 2006, $100,000. Also
core grants for the demographic surveillance (PIs Ezeh, A, Zulu, E, Madise,
NJ), 2002-2006, Rockefeller Foundation ($687K) and William and Flora
Hewlett Foundation ($1.5m).
4) Zulu E, Madise NJ, Falkingham JC, Cleland J, Ezeh A, Fotso JC.
Urbanization, Poverty, and Health Dynamics in Sub-Saharan Africa, Wellcome
Trust, 2006-2010, £2.4m.
5) Evidence for Action to Reduce Maternal and Neonatal Mortality in
Africa. 2012-2016. £560,000. DFID. Sub-grant from Options to Matthews
Z, Madise, NJ, Amoako Johnson, F, and Bailey C.
Details of the impact
As a direct result of their research, Matthews and Madise have advised
leading national and international policy makers throughout the impact
assessment period, with their findings informing policy development on
maternal and child health in developing countries.
In 2008, the WHO's World Health Report of which Matthews was one of four
main authors — and which remains the most comprehensive document of its
kind — was disseminated to the House of Commons International Development
Committee. The findings from this report on maternal health skilled
providers, alongside several other research outputs by Matthews et al.
were cited as written evidence in the Committee's report on Maternal
Health in February 2008 [5.1, 5.7]. Both Matthews and Madise act as
advisors regularly for DFID and other international agencies. For example,
in 2010 Madise and Matthews were invited to contribute to the development
of DFID's Strategy for Reproductive, Maternal, and Newborn Health (RMNH),
which is used in prioritising the nearly £200 million funding in these
areas. The strategy document `Choices for women: Planned Pregnancies, Safe
Births and Healthy Newborns' uses evidence from the Atlas of Birth (see
details below) and papers by Matthews and Madise on urban health in the
rationale for investment [5.2].
Also in 2008, Matthews was commissioned by the Norwegian Prime Minister,
Jens Stoltenberg, to report on the progress of MDGs 4 and 5 on child and
maternal health. Her report was presented to the network of global
leaders, including Gordon Brown, Bill Gates, and the then World Bank
President Paul Zoellick, at a UN high level event in September 2008
leading to renewed focus on maternal and child health and a `Call to
Action' campaign led by Gordon Brown which asked for renewed global
commitments to accelerate progress of the two MDGs [5.3]. Matthews'
research input into the co-authored work, The State of the World's
Midwifery 2011: Delivering Health, Saving Lives [5.4], the
first global data collection of midwifery services from 68 resource-poor
countries, was presented in September 2011 at a UN special retreat on
women and children as part of the recommendations of UN Secretary-General
Ban Ki Moon's new Accountability Commission for the health of Women and
As a direct result of her research, Madise was invited to the United
Nations Expert Group organised by the UN Population Division in January
2008 to discuss lessons from her work on maternal and child health in
urban poor settings. The proceedings from this meeting were published and
disseminated to member states by the United Nations [5.5]. Also,
since 2005, Madise has been contacted to advise the William and Flora
Hewlett Foundation and the Packard Foundations on priority areas for
funding in the African continent. In 2012, she was approached by the Bill
and Melinda Gates Foundation to advise them on how to improve access to
reproductive health services among poor African women. Melinda Gates used
some of Madise' s research findings in her speech at the TedX event in
Berlin on 5th April 2012, which was attended by more than 300
people and broadcast online to millions worldwide [5.10].
The research cited in Section 3 has also contributed to raising public
awareness. In 2009 members of GHP3 were invited to collaborate with the
White Ribbon Alliance (an international coalition promoting health care
for women and newborns) to co-produce the global `Atlas of Birth', an
advocacy tool featuring powerfully communicated coloured maps. The Atlas
was disseminated globally in 2009/10, including at the G8, Canadian
Parliamentarians' meeting, the African Union Summit, the International
Parliamentarians Annual meeting in Bangkok, and the `Women Deliver'
Conference. The Atlas of Birth is cited repeatedly in DFID's RMNH strategy
Madise et al's research on maternal health in urban poor settings in
Nairobi has had a direct impact in influencing service provision in the
slum communities where it was undertaken. Madise disseminated the results
of her research on maternal health among women in Nairobi slums to
District Medical Officers of Health (DMOH) in the Nairobi province and as
a direct result, the DMOH of Kasarani district in 2012 persuaded the
Government of Kenya to build two maternity facilities in one of the slums.
These facilities, expected to be opened in July 2013, will serve a
population of over 200,000 [5.8]. In addition, the DMOH's office
has reviewed the way they record the causes of maternal deaths as a direct
result of Madise et al's work.
Similarly, Matthews' framework for assessing the quality of care in
institutional settings in developing countries has been used in Nepal
where the Family Health Division in the Ministry of Health has developed
the `Monitoring of Quality of Care in Maternity Services' guidelines based
on the Southampton research and on the WHO Mother Baby Package. The
guidelines, which have been implemented in 14 health facilities, have
resulted in changes in hospital working modalities in maternity care and
improved the care for millions of pregnant women [5.6].
The research by GHP3 on maternal health has had significant impact on
policies of governments and international agencies, and indirectly led to
millions of women's and children's lives saved. With new funding, Matthews
and Madise are continuing to engage with research users to translate their
work into policies and actions (for example DFID funding mentioned in
Section 3 to work with governments in six African countries to improve
women's and children's health, and Wellcome Trust funding to engage with
Kenya Ministry of Health).
Sources to corroborate the impact
5.1 House of Commons International Development Committee. Maternal
Health: Fifth report of Session 2007-2008, Volume II, Oral and Written
Evidence. See reports' pages EV105- EV108: Written evidence
uses the 2005 World Health Report co-authored by Matthews, her
Lancet paper 2006; and work published by Moore, Madise et al. 2007 on
adolescents and coerced sex.
5.2 `Choices for women: Planned pregnancies, safe births and healthy
The UK's Framework for Results for improving reproductive, maternal and
newborn health in the developing world, DFID 2010. See pages 12-13
which use the Atlas of Birth and evidence from Ziraba, Madise
et al (2009) on maternal mortality ratio in Nairobi slums).
5.3 Network of Global Leaders Annual Reports: Leading by Example —
Protecting the most vulnerable during the economic crisis, The Global
Campaign for the Health Millennium Development Goals 2009. Contact:
Director, Global Health and AIDS Department, Norwegian Agency for
5.4 The State of the World's Midwifery 2011: Delivering Health, Saving
Lives. UNFPA. Named contributors include Zoe Matthews
(editorial member) and also Sarah Neal, Nyovani Madise from
5.5 United Nations Expert Group Meeting on Population Distribution,
Urbanization, Internal Migration and Development, New York, 21-23.
Department of Economic and Social Affairs, Population Division.
ESA/P/WP.206, March 2008: New York. Madise's contribution to this
UN document is on pp 231-247.
Contacts who can corroborate impact claims:
5.6 Email from Reproductive Health Coordinator, Family Health
Division, Nepal, confirming the incorporation of Southampton research into
the `Monitoring of Quality of Care in Maternity Services' guidelines.
5.7 The Director of Department for Global Health, Education and Research,
Norwegian Agency for Development Cooperation (NORAD).
5.8 Letter from District Medical Officer of Health — Kasarani,
Nairobi is available on request.
5.9 DFID contact: Health Adviser, Department for International
Development, Policy and Research Division, DFID.
5.10 Bill and Melinda Gates Foundation: Co-Chair or Head of
Speechwriting. Email acknowledgement from Co-Chair available on