Rationale for Exemplar Studies in Maternal and Neonatal Mortality Reductions

During years 2000-2017, the global maternal mortality ratio (MMR) declined 38% and the global neonatal mortality rate (NMR) declined 41%. Low and middle income countries have recorded large variability in the pace of decline; considerable uncertainty also exists due to lack of data. Several countries have surpassed average progress relative to their socio-economic progress. These countries were selected as Exemplar countries. Funded by Gates Ventures and the Bill & Melinda Gates Foundation, Exemplars in Global Health asks: Can we research and document drivers of success in these exemplar countries to provide evidence and learning for other countries?

Researchers in the xxemplar countries:

  • Documented and analyzed the contribution of health system policy and programs, financing, human resources, intervention coverage, quality of care and contextual factors to the rapid decline in NMR and MMR;
  • Explored the effects of identified successful drivers in a range of countries within a geographic cluster; and
  • Synthesized and disseminated the findings in the countries and globally.

In 2023, results will be published on the exemplars website and in a peer-reviewed journal.

Selection of Exemplar Countries

Selection of exemplars was based on MMR and NMR decline since 2000, adjusted for gross national income; other considerations included data availability, region of the world, and feasibility (partnerships). Challenges in identifying true exemplars, and the need to ensure good counterfactual analysis and generalizability, led to cluster approach with selected in-depth countries. The selected countries were Bangladesh, Nepal, India, Ethiopia, Morocco, Niger, and Senegal. The clusters were South Asia (Bangladesh, Nepal, India); North African & Middle East (Morocco); Eastern Africa (Ethiopia); West Africa (Niger, Senegal).

On the graphs below, each point plots a country’s annual percentage increase in gross national income (GNI) during the years 2000-2017, compared with its annual rate of reduction in maternal mortality ratio or neonatal mortality. Therefore, all countries below the line measured a greater reduction in maternal mortality than would be expected from GNI increase alone. Only the exemplar countries are labeled. Not pictured are countries with missing GNI data (Eritrea, Iraq, Liberia, Myanmar, North Korea, Somalia, South Sudan, and Syria) and countries that recorded no annual decrease in maternal mortality (Dominican Republic [0.01%], Haiti [0.005%], and Jamaica [0.002%]).


Study Design

The study design in a case study approach with mixed methods and multiple components based on a comprehensive framework:

  1. Focus on national and subnational levels.
  2. Analysis of MNH service readiness, quality of care and intervention coverage trends and equity through  literature reviews, facility surveys, routine data, and population surveys.
  3. Mortality analysis: analysis of trends in stillbirths, perinatal and neonatal mortality rates and maternal mortality ratios; assessment of contribution of changes in family planning, fertility, legalization of abortion and other social determinants; decomposition analysis; assessment of equity gaps as data permitted.
  4. Lives Saved Analysis: assessment of the contribution of changes in coverage and quality of care to maternal and neonatal lives saved.
  5. Health system, policy, and financing analysis: Literature review on drivers of neonatal and maternal mortality decline; documentation of health system inputs, policies, programs and financing, and outputs over the past two decades; qualitative interviews with key informants of policy and programs implementation.
  6. Mapping of contextual factors: mapping of contextual factors, such as socioeconomic status, road networks, and natural crises.
  7. Triangulation of all data.
  8. Extension through comparison of main findings to other countries.


Holistic Conceptual Framework

The study team has published a holistic conceptual framework which integrates theories and frameworks from different disciplines to include the range of factors that explain reductions in maternal, late foetal and neonatal mortality and improvements in health. The framework includes:

  • Health policy and system levers,
  • Service delivery and coverage of interventions across the continuum of care, and
  • Epidemiological and behavioral risk factors
  • Contextual factors’ the individual/household, community, national and transnational levels

The framework is applicable for using varied methods to study how different factors work together to influence maternal and newborn health outcomes.