The 2012 UN MDG Report highlights that in 2008, 63% of women world-wide delivered their babies attended by skilled health personnel. The good side: this is up from 53% in 1990, but it still leaves 37% of women in developing countries without sufficient care.  And, it falls short of the fifth MDG, which aims to reduce maternal mortality by 75% (for which the “proportion of births attended by skilled health personnel” was adopted as the primary indicator of progress).  Recent analysis by the World Bank, WHO, and others confirms that only ten countries have succeeded in meeting the fifth MDG, and just nine additional countries are on track to achieve it by 2015.

We asked ourselves why?

IEG recently completed a systematic review of impact evaluations on maternal and child mortality to review the evidence.  We learned that there is no credible impact evaluation evidence that investments in skilled birth attendance by themselves have succeeded in reducing maternal or neonatal mortality.  On the other hand, the mortality rate for children under five declined by 41% from 1990 to 2011. We find that non-health investments—from energy and education, to governance and income generating activities—along with health interventions that simultaneously improve both provision and utilization, have been essential.

The challenge, as we prepare for the post 2015 period will be: how do we get all the players around the same table and develop shared ideas and strategies that will deliver greater benefits to people?  The new WBG Strategy speaks to addressing this challenge: solutions that bring together partners and instruments – across sectors – to generate sustainable results.

And how about areas where evidence is insufficient to guide policy and action?  For instance, we know that we don't know enough – with sufficient certainty – about investments in early child health care. Should policy-makers or WHO in its role to establish a normative framework, wait until enough high-quality evidence is available?  

Of course not.  Instead, I suggest a coalition that entails:

  • Policy-makers at WHO and elsewhere develop hypotheses of the norms they believe should be set based on their experience to date;
  • Evaluators undertake a series of purposeful evaluations – RCT, quasi-experimental, descriptive and qualitative – to evaluate whether these hypothesis hold based on experience with past programs.  This will require involving independent evaluation to take an arms-length look at existing programs, and real-time evaluations undertaken as part of new and ongoing programs, to learn what works and correct what doesn't, while recording feedback to inform normative and policy-making decisions;
  • Researchers test those aspects of the hypotheses that have not yet been tried and search for opportunities for cross-learning from other sectors; and
  • Policy-makers and implementers in the countries work in tandem with ongoing evaluations and researchers in piloting policy and service delivery options.

As we move to establish the post-MDG agenda, policy-makers, evaluators, and researchers should jointly develop meaningful indicators for the next round of global development goals.  These should be based in sound normative frameworks and be established by robust field-based evidence. This way, we can advance progress, drawing on each other’s strengths for better informed decisions and actions.



Im a current graduate student a University of Southern California. Im working on my thesis which is focus on Improving Maternal Health and decreasing mortality in Nicaragua. Thanks to your blog I will be able to add some input to my thesis. Thank you (

It is evident that investing in skilled health personnel alone can not significanlty contribute to reduction in Maternal deaths. What developing countries need is an intergarted approach and combined actions by all stakeholders. Not to forget is the change in attitude and quick action among health personnel. Recently, my sister in low collapsed immediately after giving birth because she had lost alot of blood. Hadnt it been for quick intervention and follow up, she would have left this world. Maternal death is real, we see it and read about it every day.

Joyce, thanks for reinforcing the important point that the findings of evaluation work -- such as the need for an integrated approach to MCH -- can make a direct contribution to improving the lives of our families, friends, and neighbors. Given the slow progress on some of the health MDGs, IEG is scaling up our work in this area -- you may be interested to look at the approach paper for an upcoming evaluation on health financing in improving health systems performance (

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