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What having a baby taught me about indicators

Last year a story in the Guardian emphasised the importance of being sensitive to how we collect monitoring data – and the impact of receiving a "would you recommend our service" SMS on a couple who had just lost their baby.

More recently, Maria and I had our own experience that emphasised the importance of the indicators that we choose. It started in very much the same way as the story in the Guardian, with the loss of our baby in a late miscarriage in November 2014.

As a result of this, our subsequent pregnancy has been heavily monitored under the direct supervision of a specialist consultant in fetal medicine. This supervision included the decision on whether Maria was to give birth through an elective caesarian or naturally.

Given that her first birthing experience was an emergency caesarian, and second was to 'complete the miscarriage' (to use the terminology), her strong preference was for an elective caesarian. At least once, she wanted to determine the circumstances of her birth.

However, securing an elective caesarian ended up being a long fight with the health system. A fight that was, ultimately, driven by the indicators we choose to measure.

Whilst the European Court of Justice established that women have a right to determine the circumstances in which they give birth, their is no explicit right to a caesarian birth. The (non-binding) guidance to the medical profession is that a woman's preference should be respected unless it is in the medical interest of the woman and the baby to do otherwise.

Our local hospital is one that has a policy of strongly preferring natural births as a follow-on from a first caesarian birth. Natural birth after a first caesarian is associated with small but significant reductions in maternal morbidity among the general population.

We experienced this policy first hand. After expressing her preference for an elective caesarian, Maria was forcefully lobbied by the fetal medicine team to change her preference to attempt a natural birth. This created an enormous level of anxiety in a pregnancy that was already riddled with stress because of our previous loss.

We soon discovered that Maria's experience was not unique, and came across multiple stories of women who were persuaded to abandon their choice for an elective caesarian, and to attempt a natural birth. Among our unrepresentative sample, at least 80% of the women seemed to regret this decision and resent the experience of the birth that they had. The numerous online forums speak of a similar trend.

It was puzzling to us that such an outcome should be the intentional policy of a group of highly expert and dedicated professionals. As we learned more, however, it became apparent why: indicators.

The indicators currently used in the medical debate on post-caesarian birth include:

  1. whether a natural birth was 'successful' or not. Success is defined simply as whether the baby came out the birth canal, and nothing more;
  2. whether the mother or baby died;
  3. whether the mother or baby suffered morbidity;
  4. whether the mother had post natal depression; and
  5. some long term health effects.

We found that data on these indicators leads to a logical recommendation by the medical profession: to attempt a natural birth after caesarian. Rates of mortality and depression are the same for both groups, morbidity is lower for natural birth, and there is some evidence that there are long term health benefits to the child from a natural birth.

So what is missing? Why did we come across so many unhappy women?

There is no patient-centred indicator. In other words, nobody measures women's own perspective on their birthing experience, and whether they were happy with it or not. Whilst depression is measured, there exists a large and invisible spectrum of experiences between happy and clinically depressed.

Women's own perceptions of their experiences are not counted. As a result, birthing plans that seem to be in their own best interest are not experienced this way. And, in arriving at those birthing plans, many women felt their preferences and the value of their opinions counted for very little.

When we dug into this issue more with our medical team, we found they acknowledged that, in their qualitative experience, women tend to be happier about their birth when they get the plan they want. Without an indicator to measure it, however, it does not figure in the hospital's policy.

The whole experience brought home how important indicators can be – both the ones we choose and the one's that we don't.

Very often we hear complaints that international development management is not 'results-based' enough: that management decisions are not based on performance indicators. Perhaps, however, this looseness is also a form of protection. In my practice, I have rarely come across monitoring and evaluation frameworks with intentional, precise and comprehensive sets of indicators that I would feel confident in being the only data used to make management decisions. Yet, ultimately, this is exactly what results-based management is.

Our personal experience reflects what happens, and what some of the unintended consequences are, when a highly effective professional team does make decisions based on indicators. Fortunately, we fought to have Maria's preference recognised, she had a positive experience of elective caesarian, and we now have a healthy baby boy in our family. But, I will never again make light of the outcome indicators we choose.

This blog post originally appeared on ImpactReady's Blog, where both Maria and Joseph are Senior Partners.

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Comment by Marguerite Berger on October 27, 2015 at 21:06

Good comment, Jolanda.  We try to use open-ended questions for that purpose.

Comment by Jolanda on October 27, 2015 at 16:38

It was what I expressed when starting the course Gender Mainstreaming in Development Programs this morning; what hampers just to ask men and women what the outcome indicator should be? Instead of the actual practice using often lousy indicators affecting heavily the desired dialogue on social change in gender relations if we seriously practice monitoring for learning.

Comment by Marguerite Berger on October 21, 2015 at 2:39

Congratulations on becoming a father, Joseph.  I totally agree that participants' perspective is something we need to measure and take into account. That's basic ethics, and maybe there is even a relationship with medical outcomes that needs to be tested. As I mentioned on your website, a crucial missing indicator on your list--from a public health perspective--is cost.  Generally, the cost of vaginal delivery is way lower than C-section.  If a better sample than a group of your friends shows that outcomes are equal or better under the the less expensive procedure, it's better to use society's scarce resources in other ways.  The medical and pharmaceutical industries are very aware that patient requests can sway doctors toward more costly options. That's why they bombard us with ads! I think we should prioritize extending safer deliveries to more women ahead of giving more expensive options to the few.  The indicators that are being used tend to reflect this.  Another lesson about indicators--they are not distribution neutral!

Comment by Krinna Shah on October 20, 2015 at 16:17

Dear Joseph,

To me knowledge and insight emerging out of experience in life hold more value than anything else. I sincerely appreciate this sharing.

Thanks and regards,


Comment by Jyotsna Sivaramayya on October 20, 2015 at 8:30

Congratulations on a safe delivery and wish you all well.

Your post is a reminder on what one is likely to forget while doing evaluations. The necessity for participatory evaluations could not have been expressed in better words.

Comment by Simren Singh on October 19, 2015 at 21:27
Thanks for sharing your experience. Congratulations to you and your wife.
Your experience throws light onto many things such as choice, individual autonomy vs state and its regulations, and more importantly like you mentioned, the subjective and flexible nature of indicators.

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