title: Tracking progress towards safe motherhood: meeting the benchmark yet missing the goal? An appeal for better use of health-system output indicators with evidence from Zambia and Sri Lanka.
abstract: OBJECTIVE
  Indicators of health-system outputs, such as Emergency Obstetric Care (EmOC) density, have been proposed for monitoring progress towards reducing maternal mortality, but are currently underused. We seek to promote them by demonstrating their use at subnational level, evaluating whether they differentiate between a high-maternal-mortality country (Zambia) and a low-maternal-mortality country (Sri Lanka) and assessing whether benchmarks are set at the right level.
  
  
  METHODS
  We compared national and subnational density of health facilities, EmOC facilities and health professionals against current benchmarks for Zambia and Sri Lanka. For Zambia, we also examined geographical accessibility by linking health facility data to population data.
  
  
  RESULTS
  Both countries performed similarly in terms of EmOC facility density, implying this indicator, as currently used, fails to discriminate between high- and low-maternal-mortality settings. In Zambia, the WHO benchmarks for doctors/midwives were met overall, but distribution between provinces was highly unequal. Sri Lanka overshot the suggested benchmarks by three times for midwives and over 30 times for doctors. Geographical access in Zambia--which is much less densely populated than Sri Lanka--was poor, less than half the population lived within 15 km of an EmOC facility.
  
  
  CONCLUSIONS
  Current health-system output indicators and benchmarks on EmOC need revision to enhance discriminatory power and should be adapted for different population densities. Subnational disaggregation and assessing geographical access can identify gaps in EmOC provision and should be routinely considered. Increased use of an improved set of output indicators is crucial for guiding international efforts towards reducing maternal mortality.
authors.affiliation: Institute of Public Health, Ruprecht-Karls-Universität, Heidelberg, Germany. sabine.gabrysch@uni-heidelberg.de
authors.forename: Sabine
authors.initials: S
authors.lastname: Gabrysch
authors.forename: Philipp
authors.initials: P
authors.lastname: Zanger
authors.forename: Harshalal R
authors.initials: HR
authors.lastname: Seneviratne
authors.forename: Reuben
authors.initials: R
authors.lastname: Mbewe
authors.forename: Oona M R
authors.initials: OM
authors.lastname: Campbell
mesh_terms: D019985:Benchmarking; D001723:Birth Rate; D003906:Developing Countries; D019317:Evidence-Based Medicine / Q000379:methods; D005260:Female; D040362:Geographic Information Systems; D006268:Health Facilities / Q000600:supply & distribution; D006297:Health Services Accessibility; D006302:Health Services Research / Q000379:methods; D006801:Humans; D007231:Infant, Newborn; D008427:Maternal Health Services / Q000592:standards*; D011156:Population Density; D011247:Pregnancy; D019984:Quality Indicators, Health Care; D013188:Sri Lanka / Q000453:epidemiology; D000078329:Workforce; D015024:Zambia / Q000453:epidemiology