Correspondence
1
2
3
4
5
Langer A, Horton R, Chalamilla G. A manifesto for maternal health post-2015. Lancet 2013; 381: 601–02. Hatem M, Sandall J, Devane D, Soltani H, Gates S. Midwife-led versus other models of care for childbearing women. Cochrane Database Syst Rev 2008; 4: CD004667. WHO. The World Health Report 2005: make every mother and child count. Geneva, World Health Organization, 2005. Rath AD, Basnett I, Cole M, Subedi HN, Thomas D, Murray SF. Improving emergency obstetric care in a context of very high maternal mortality: the Nepal Safer Motherhood Project 1997–2004. Reprod Health Matters 2007; 15: 72–80. UNFPA. The state of the world’s midwifery 2011: delivering health, saving lives. New York, United Nations Population Fund, 2011.
The recommendations for maternal health1 are an excellent framework to build on to improve maternal health. I believe that without strong political will and stewardship, these activities will be difficult to implement. In addition, male partner involvement in securing women’s access to health services cannot be underestimated.2 Their buy-in for acknowledging and accepting the rights of women will be critical to ensure healthy outcomes. I encourage the Maternal Health Task Force to include these additional points in the manifesto. I declare that I have no conflicts of interest.
manifesto. The correction has now been made. We want to take this opportunity to acknowledge the critical role midwives play in maternal health. Midwives are key to improving women’s health and wellbeing through pregnancy, childbirth, and beyond. Additionally, in response to Harry Strulovici’s concerns, we heartily agree that working with men is key to changing the odds for women. With men’s support of women’s access and choices in reproductive, maternal, and neonatal health, as well as in the broader context of their lives, progress can be made and sustained that will benefit entire families. As the global community defines the next set of development goals, the need to work with men is a given. We declare that we have no conflicts of interest.
*Ana Langer, Guerino Chalamilla, Richard Horton
[email protected] Women and Health Initiative, Maternal Health Task Force, Harvard School of Public Health, Boston, MA 02115, USA (AL); Management and Development for Health, Dar es Salaam, Tanzania (GC); and The Lancet, London, UK (RH) 1
Langer A, Horton R, Chalamilla G. A manifesto for maternal health post-2015. Lancet 2013; 381: 601–02.
Harry Strulovici
[email protected] Life for Mothers Policy, New York, NY, USA
Science Photo Library
1
2
Langer A, Horton R, Chalamilla G. A manifesto for maternal health post-2015. Lancet 2013; 381: 601–02. Barker G, Ricardo C, Nascimento M. Engaging men and boys in changing gender-based inequity in health: evidence from programme interventions. Geneva, World Health Organization, 2007.
Authors’ reply A note of appreciation to Jim Campbell and colleagues for recognising the error in the manifesto1 published as a result of the Global Maternal Health Conference held on Jan 15–17, 2013, in Arusha, Tanzania. The Maternal Health Task Force, Management and Development for Health, and The Lancet Editor sincerely regret the omission of midwives in the 1718
Maternal death reviews We are concerned that the new overarching Maternal Death Surveillance and Response (MDSR) programme,1 could have an adverse effect on current and future Maternal Death Reviews (MDRs). Over the past 10 years, the rights of pregnant women to receive respectful and skilled care from well-trained health professionals have become more prominent. The responsibility of maternity health-care staff to continually evaluate and improve the care and services they provide is now widely accepted. Facility-based MDRs start from the principle that every maternal death, avoidable or not, provides useful
lessons to be learnt.2 In most resource limited countries, the reviews are mainly conducted at facility level, and, when possible, in the community, using verbal autopsy. They achieve improvements through implementation of recommendations arising from investigation and identification of the barriers women might have faced, the resources available, and the care received, where possible benchmarked against standards of best practice. They go beyond the search for technical excellence, they contribute to making health professionals accountable for ongoing self-assessment, encouraging professionalism.3 MDRs are not necessarily expensive (US$154 per session in Burkina Faso and US$217 in Benin). Confidentiality is essential in facilitybased MDRs. Accountability and legal process can be maintained in parallel. The UK Confidential Enquiries into Maternal Death is a successful example. Today, however, nationwide MDSR is proposed to countries by key UN organisations as the new best buy option, although it might be too early for full implementation. MDSR eventually aims to identify most—if not all—maternal deaths, and uses facility and community based reviews, together with other surveillance methods, to feed a national database with a more limited analysis of causes (medical and other), circumstances, and determinants of maternal mortality. It is hoped that the rapid analysis of maternal deaths will prompt immediate actions to improve maternal health.4 MDSRs seem to focus on national or regional strategic leverages to reduce maternal mortality such as the organisation of national blood banks or the training or recruitment of health personnel. They also will develop systems of accountability by creating feedback mechanisms from district to national level. However, because the focus is on creating changes by improving accountability—as opposed to local improvement of quality of care— MDSRs might threaten confidentiality, www.thelancet.com Vol 381 May 18, 2013
Correspondence
essential for facility-based MDRs. Without confidentiality and openness in reporting, valuable insights and lessons are lost. We declare that we have no conflicts of interest.
*Vincent De Brouwere, Gwyneth Lewis, Véronique Filippi, Thérèse Delvaux, Jolly Beyeza-Kashesya, Yirgu Gebrehiwot, Cassimo Bique, David Taylor
[email protected] Institute of Tropical Medicine, Antwerp, Belgium (VDB, TD); London School of Hygiene and Tropical Medicine, London, UK (VF); Mulago National Referral Hospital, Kampala, Uganda (JB-K); Institute of Women’s Health, University College London (GL); Addis Ababa University, School of Medicine, Addis Ababa, Ethiopia (YG); Hospital Central de Maputo, Maputo, Mozambique (CB); and International Federation of Obstetrics and Gynaecology, London, UK (DT) 1
2
3
4
Hounton S, de Bernis L, Hussein J, et al. Towards elimination of maternal deaths: maternal deaths surveillance and response. Reprod Health 2013; 10: 1. WHO. Beyond the numbers. Reviewing maternal deaths and complications to make pregnancy safer. Geneva: World Health Organization; 2004. Swick HM, Szenas P, Danoff D, Whitcomb ME. Teaching professionalism in undergraduate medical education. JAMA 1999; 282: 830–32. Danel I, Graham WJ, Boerma T. Maternal death surveillance and response. Bull World Health Organ 2011; 89: 779A.
Counting the dead: properly and promptly Registration of deaths in England and Wales is not fit for purpose, as the Royal Statistical Society makes clear1 with ten arguments against late registration, and calls to action by national statisticians, health and social care information centres, and ministers. Late registrations, mainly of inquest deaths, occur because the fact of death is not even registered in England and Wales until the inquest verdict has determined cause of death. Legislation is needed to uncouple registration of the fact of death from registering cause. Without exception, all deaths in Scotland must be registered within 8 days of death having been ascertained. www.thelancet.com Vol 381 May 18, 2013
The Chief Medical Officer’s first report on public health in England failed to differentiate between registrationyear and death-year for deaths from illicit drugs. Of drug-related deaths registered in 2011, half occurred in preceding years.2 Differentiation also failed in the European Monitoring Centre for Drugs and Drug Addiction (EMCDDA)’s annual report.3 Carefully chosen words in the Editorial on suicides in the UK (Feb 2, p 348)4 disguised the problem: “6045 suicides were recorded in UK in 2011”. Most readers would not realise that nearly half the suicides registered in England and Wales in 2011 had occurred in preceding years.5 Only around 10 000 of the half million deaths per year in England and Wales have a registration delay of at least 6 months.1 Parliamentary questions by Patrick Mercer revealed that one in five deaths of people aged 5–44 years is subject to at least 6 months registration delay.1 Indeed, registration delay varies by cause of death, age and sex,1 and have lengthened in the past decade. Record linkage is a powerful means of making discoveries about public health, including at the interface with other jurisdictions. But in England and Wales, this is challenged by our being unable to correctly establish the survival status of study participants. Paid-for checks against the death register in England and Wales on whether study participants have died by a specified date yielded information on deaths that have both occurred and been registered by the check date, while Scotland’s statistical system would retrieve all deaths that occurred. As a consequence, in England and Wales, analyses have to be delayed to allow for registration delays, and the discovery potential from NHS record linkage is held back. Reports on deaths in England and Wales should differentiate registration-year from death-year. Researchers doing death registration checks in England and Wales should
specify both analysis date and check date because participants who died before the analysis date, but whose death was not registered before the check date, could be analysed wrongly as alive at the analysis date. I lead for the Royal Statistical Society on late registration of deaths.
Sheila M Bird
[email protected] Biostatistics Unit, Medical Research Council, Cambridge, CB2 0SR, UK 1
2
3
4 5
Royal Statistical Society. Late registration of deaths in England and Wales—further statement. http://www.rss.org.uk/site/cms/newsarticle. asp?chapter=15&nid=79 (accessed May 1, 2013). Office for National Statistics. Deaths related to drug poisoning in England and Wales, 2011. http://www.ons.gov.uk/ons/rel/subnationalhealth3/deaths-related-to-drug-poisoning/ 2011/stb-deaths-related-to-drugpoisoning-2011.html (accessed May 1, 2013). EMCDDA. 2012 Annual report on the state of the drugs problem in Europe.http://www. emcdda.europa.eu/publications/annualreport/2012 (accessed May 1, 2013). The Lancet. Suicide in the UK: questioning ourselves. Lancet 2013; 381: 348. Office for National Statistics. Suicides in the United Kingdom, 2011. http://www.ons.gov. uk/ons/rel/subnational-health4/suicides-inthe-united-kingdom/2011/stb-suicidebulletin.html (accessed May 1, 2013).
EU Clinical Trials Regulation The upcoming debate on the proposal for European regulation on clinical trials will have to unravel many knots. In addition to removing any reference to Ethics Committees, the proposal, released by the EU Commission, established ground for a single scientific assessment for the authorisation to conduct a clinical trial. This one-entry evaluation, which will then be valid for all concerned member states, has been artificially dissociated from national ethical assessments.1 Other deregulation measures were also put forward, introducing provisions that will negatively impact on the protection of trial participants, such as narrowing the definition of a clinical trial. This change would allow some post-authorisation trials to fall outside the scope of the new regulation 1719
