Measure for Measure

We can make dramatic progress in lowering maternal mortality -- but we need better data, and more of it.

Bill and I are used to journalists calling us data nerds. Sometimes it's meant as a compliment, sometimes it's not, but we always take it in a positive way. At Microsoft, we analyzed mountains of data to make the best possible business decisions. We have tried to bring the same culture to our foundation. However, we've had to come to terms with the fact that in certain areas of global health, the data just aren't very good.

My primary focus is women and children's health. I'm enthusiastic when I look at child health statistics because child mortality is declining steadily. When I look at maternal health statistics, though, it's more frustrating. For years, the number of maternal deaths worldwide remained relatively constant at just above 500,000 per year. In 2005, a big World Health Organization study put it at 536,000. It was agonizing watching the numbers hold steady. The Millennium Development Goals (MDGs) had set a very ambitious target of a 75 percent reduction in maternal deaths by 2015 (compared to the 1990 figure). The problem wasn't just that we were going to fall short of the target. It was that we weren't making any progress toward it whatsoever.

Then, in 2010, a new study in The Lancet put the number of maternal deaths at 342,000. The change reflected a new and better methodology for doing the estimates. According to more up-to-date statistical techniques, we'd been making gradual progress on maternal health for years; we just hadn't been able to measure it. Now, there is consensus in the field that maternal mortality is down by about a third in the past three decades -- well short of the MDG target, but much better than total stagnation.

Obviously, everyone is pleased with the newer estimates. Fewer mothers dying is the goal. But the data are still far from perfect, and our ongoing difficulty in accurately measuring maternal mortality also makes it harder for us to know how best to prevent it.

In his annual letter, which came out Wednesday, Bill explains "how important measurement is to improving the human condition." When we set a clear goal, intervene in the ways we think will best help us achieve the goal, and then measure the impact of the intervention as we go, Bill argues, we essentially have a report card. We can see which interventions work and which don't, and we can keep doing what works and fix what's not working. When measurement is public, as it is with the MDGs, countries have a strong incentive to focus on important global health goals. No country wants to be in last place on the list of maternal deaths.

But if we don't know how many mothers are dying, where, or why, then we have to make educated guesses about which interventions to pursue.  And if we can't measure the impact of those interventions, then we can't identify best practices in a rigorous way.

The poor maternal health data is not for lack of trying. Fundamentally, thankfully, maternal mortality is a rare event, so the sample sizes are low. It's also systematically underreported. Many countries with high maternal mortality rates also have poor systems of registering deaths. As a result, we have to produce estimates using multiple data sets and complicated statistical modeling, but the confidence intervals are large enough to belie the use of the word confidence.

In response to these problems, the maternal health community has pioneered innovative survey techniques to obtain more accurate mortality data. One of these techniques is a relatively low-cost survey called the "sisterhood method," which involves asking women questions about the health status of their siblings. During these interviews, participants often recall deaths that occurred a decade or longer before, providing surveyors with valuable historical data. Eventually, the goal is to replace these surveys with better registration and certification of deaths, or where this is not possible, maternal mortality estimates based on census data.

Now, we are getting better at using proxies for maternal mortality -- basically counting important steps toward better maternal health that are easier to count, like how many women give birth with a skilled attendant. The field needs to focus on understanding which proxies are most reliable. Figuring out how many women have access to prenatal care, to take another example, is measurable, and if we can establish how that's correlated to better health for mothers and their children, then we can track prenatal care access in real time to help inform our decision-making in the short and medium term.

One possible proxy is the number of women giving birth at health facilities instead of in the home, and the data show that this number is going up globally. There is a good reason for health systems to encourage facility births. Research shows that it is virtually impossible to predict obstetric emergencies. For example, numerically, more women without risk factors have atonic postpartum hemorrhage compared to those with risk factors.

Any woman giving birth is at risk of serious complications. Since mothers with quick access to expert, high-quality care are more likely to survive emergency situations, it makes sense to ensure that mothers have access to that kind of care.

Still, recent data suggest that in poor countries the quality of care in many health facilities is so low that not enough women, especially the most disadvantaged, are getting the care they need. As more women choose to give birth in facilities, the issue of improving the quality of care is and should be a top priority for maternal and child health advocates.

The tragedy of women dying uncounted -- their invisibility to members of the global health research community -- is a reflection of their invisibility in the societies they call home. The lives -- and deaths -- of women and children often go unseen.

But I see signs that women themselves are starting to fight against this invisibility. When I talk to women in places like Kenya about their desire to plan the number of children they have, I hear evidence that they're starting to believe they can and should have power over their futures and the future of their families. When I talk to women in self-help groups, I hear evidence that they're finding powerful role models among their peers.

In Bill's letter, he tells the story of Sebsebila Nassir, an Ethiopian mother who recently gave birth to her second daughter. When her first daughter was born several years ago, Sebsebila followed the Ethiopian custom of waiting to give her a name, for fear of becoming attached to a child who might not survive her first month. But because the Ethiopian health system is improving, mothers are starting to abandon the tradition. Sebsebila named her daughter Amira on her birthday. It's a powerful story about a revolution in child survival and the commitment and innovation of the Ethiopian government. It's also the story of one mother's growing sense of empowerment and optimism.

Measurement in the field of maternal health will continue to be a massive challenge. The recent, lower estimates of maternal mortality show that years of work by dedicated maternal health advocates and practitioners had a greater impact than we understood. They also show that poor women themselves are full of ambition and have been doing the hard work of saving their own lives. If we invest in better measurement, we will get a lot more impact out of all that courageous effort.


National Security

Atomic Bond

Does Hagel’s nomination mean Obama will cut the nuclear arsenal?

Since word first leaked in mid-December that Chuck Hagel was President Obama's likely choice for secretary of defense, opponents of his nomination have sought to paint him as anti-Israel, soft on Iran, and a supporter of sweeping defense budget reductions. The intensity of most of those charges has waned, with the Israel issue being dealt a seemingly fatal blow by Sen. Chuck Schumer's support for the nominee. But there is another potential hurdle -- one that sounds more appropriate to 1983 than 2013: is Hagel hawkish enough on nuclear weapons?

Hagel's Republican critics have claimed that he is "an outspoken supporter of nuclear disarmament" and "seeks a world free of nuclear weapons." Conservative media outlets have parroted these charges in their continuing attacks on Hagel and Senate Republicans are poised to make an issue out of them at his January 31 confirmation hearing. They are unlikely to succeed -- Hagel's nuclear views are mainstream. The real question is whether he'll have the opportunity to do anything about them.

As it begins its second term, the Obama administration faces a number of key nuclear and budget decisions left over from its first term that will have profound consequences for U.S. national security. If confirmed, Secretary of Defense Hagel would be a key player in formulating and implementing those choices. While it remains to be seen how vigorously the Obama administration will pursue nuclear threat reduction over the next four years, Hagel's past writings and affiliations suggest that he would strongly support reshaping U.S. nuclear strategy and spending to address today's threats and the budget crunch. Indeed, few Americans, including secretaries of defense, have thought as seriously about the appropriate role of nuclear weapons as Chuck Hagel.

Obama and Hagel actually go way back when it comes to nuclear weapons. In August 2007, when they were both senators, they co-sponsored S. 1977, known as the Nuclear Weapons Threat Reduction Act. The bill's purpose was "To provide for sustained United States leadership in a cooperative global effort to prevent nuclear terrorism, reduce global nuclear arsenals, stop the spread of nuclear weapons and related material and technology, and support the responsible and peaceful use of nuclear technology." The legislation was inspired in part by George Shultz, William Perry, Henry Kissinger, and Sam Nunn, who earlier that year had published a now famous op-ed in the Wall Street Journal outlining a step-by-step plan to ultimately rid the world of nuclear weapons.

Though the Senate never voted on S. 1977, the bill served as the framework for Obama's first major foreign policy speech as president -- in April 2009 in Prague, where he pledged America's commitment to work toward a world free of nuclear weapons and laid out a series of interim steps that the United States must take to reduce the risk of a nuclear catastrophe. In his first term, Obama issued a Nuclear Posture Review that moderately reduced the role of nuclear weapons in U.S. policy, removed some 1,380 kilograms of highly enriched uranium and plutonium from around the world (enough material for approximately 55 nuclear weapons), and signed the New START agreement reducing U.S. and Russian arsenals. But key elements of this ambitious agenda remain unfinished, and the views of the next secretary of defense on how to move forward will carry significant weight.

One of the first major tasks is the revision of high-level nuclear policy guidance that could pave the way for further reductions in the arsenal below the levels agreed to in New START, which limits the United States and Russia to no more than 1,550 deployed strategic warheads and 700 deployed delivery systems. The 2010 Nuclear Posture Review did not reevaluate the existing nuclear employment and targeting strategy; the New START levels were based on the George W. Bush administration's guidance. Despite reports last summer indicating that there was interagency consensus about reducing the number of deployed warheads to about 1,000, Obama postponed a decision on new nuclear policy guidance and force levels until after the election.

Once the president settles on new guidance, he will then need to decide how to implement further reductions. Options include a new treaty with Russia that limits all types of nuclear warheads, a new treaty that limits only deployed warheads (or an amendment to the New START treaty), or scrapping the treaty process altogether and seeking Russian buy-in for non-binding, reciprocal cuts -- as previous Republican presidents have done. For its part Russia, which is already below the New START limits on deployed warheads and delivery systems, has linked new treaty-based reductions to its concerns about U.S. missile defense plans in Europe, and efforts to reach a cooperative agreement with Moscow on missile defense have so far been unsuccessful.

Related to the issue of further reductions is the fiscal challenge posed by sustaining and modernizing U.S. nuclear weapons. For example, over the next 10 to 15 years the departments of defense and energy plan to spend over $100 billion to build 12 new ballistic missile submarines and $10 billion to refurbish the B61 nuclear gravity bomb. A smaller arsenal could obviate the need to build as many new delivery systems and free funding for higher priority programs in a time of budget austerity.

Where should we expect Hagel to come down on these issues?  Since leaving the Senate in 2009, Hagel has remained active and outspoken on the importance of reducing the nuclear threat, in particular through his work with Global Zero, an international movement for the elimination of nuclear weapons that is supported by some 300 world leaders. Hagel was a member of Global Zero's U.S. Nuclear Policy Commission, chaired by former Vice Chairman of the Joint Chiefs of Staff Gen. James Cartwright. In May 2012, the commission published a report calling on the United States to move away from a Cold War-era nuclear posture, including an illustrative proposal to reduce the US nuclear stockpile to 900 total warheads by the end of the decade. Though the Commission argued that such cuts should be undertaken via a treaty with Russia, it sensibly noted, "Some unilateral steps, or parallel reciprocal steps along the lines of the 1991 Presidential Nuclear Initiatives, could facilitate the effort."

The area where Hagel would be positioned to have the biggest impact is on nuclear weapons spending -- especially plans for the next generation of nuclear delivery systems. Most experts agree that the Pentagon budget is slated for a haircut well below the initial $487 billion reduction scheduled to be implemented over the next decade -- with or without sequestration (which would require an additional $500 billion cut). Such reductions could force changes to U.S. nuclear weapons levels that exceed those recommended by the guidance review process and also prompt more serious discussion inside the Pentagon about whether to eliminate a leg of the nuclear triad.  Indeed, in a Nov. 14 letter to Senators John McCain and Lindsey Graham, Secretary of Defense Leon Panetta stated that sequestration could force the Pentagon to delay the next generation nuclear ballistic missile submarine and reduce the buy from 12 to 10 subs, terminate until the mid-2020s the next generation strategic bomber, and eliminate the ICBM leg of the triad.

As the overseer of the impending drawdown, the next secretary of defense will be confronted with a number of stark budget choices between nuclear forces and other major investments. While small pockets of the Navy and Air Force and Republicans in Congress are likely to view nuclear spending as sacrosanct, much of the military views nuclear weapons as a waste of time and resources. As Colin Powell once put it: "We have every incentive to reduce the number [of nuclear weapons]. These are expensive. They take away from soldier pay. They take away from O and M [operations and maintenance] investments. They take away from lots of things. There is no incentive to keep more than you believe you need for the security of the Nation."

In response to questions in advance of tomorrow's Senate Armed Services Committee hearing on his nomination, Hagel pledged his support for the president's commitment to a safe, secure, and effective nuclear deterrent as long as nuclear weapons exist and stated that "providing necessary resources for nuclear modernization of the Triad should be a national priority." However, Hagel was careful not to tie himself to a specific number of nuclear weapons or level of nuclear spending. If President Obama plans to make further strides on nuclear threat reduction in his second term, he's likely to have a willing partner in Chuck Hagel.  

Mark Wilson/Getty Images