Midterm evaluation of the Latin American and the Caribbean maternal mortality initiative

Interim evaluation covers the period 12/96-9/99. The LAMM initiative had a somewhat unusual beginning because it did not have a Project Paper, had a staggered start-up, and had three implementing agencies and various contracting mechanisms. Despite considerable efforts to overcome these obstacles, conceptual clarity is still lacking in key elements of the initiative, leaving LAMM implementers without the guidance needed to weigh technically complex programming and intervention alternatives. Also, giving each partner exclusive responsibility for one intermediate results (IR) has produced clear lines of responsibility but has unduly separated the three components. Also, four strategic EOC issues are not yet included in the LAMM results package -- holistically oriented service models, unmet need, and improvements in obstetric data collection and in training of nurses and auxiliary nurses. Findings regarding IRs are as follows: (1) In IR 1 -- increased community capacity to recognize and respond to pregnancy-related complications by accessing health services -- LAMM is making substantial progress in one pilot country in increasing the percentage of adults who can name danger signs during pregnancy and who specify an intent to use services in the event of an obstetric emergency. Also, progress is being made in preparing community emergency evacuation plans and improving linkages between community groups and health workers. In other pilot countries, the quality of information, education, and communication (IEC) materials is high, but community mobilization is not far advanced. (2) In IR2 -- improved quality of care at the first level of obstetric referral -- learning is taking place in one pilot country in developing, testing, and disseminating protocols, standards, and guidelines, and significant, replicable gains are occurring in improved EOC. In another country, fewer gains are being achieved, although activities are underway to improve patient reception and flow. Energetic Ministry of Health (MOH) commitment to the improvement process is essential; where it exists, gains will likely take place. Also, some projects seem to be addressing peripheral rather than substantive obstetric issues. Additional focus on the four essential obstetric emergencies -- hemorrhage, sepsis, hypertension/eclampsia, and obstructed delivery -- would help address this. (3) In IR 3 -- intensive implementation of the EOC aspects of the Regional Plan for the Reduction of Maternal Mortality -- substantial gains have been achieved in high-level political support to reduced maternal mortality at the country level. Adequate progress is being made in reviewing existing strategies and legislative/regulatory policy changes, though country coordinating committees need to be strengthened. Enhanced communication between PAHO country program managers and better informed regional program staff are areas needing improvement. Also, except in isolated cases, PAHO staff appears to be concerned with pure policy formulation and is disconnected from what is taking place in the field. Success stories should be given wide exposure throughout LAMM, and the four neglected strategic EOC issues mentioned above should receive additional policy attention. (Author abstract, modified)