Undertaking a complex evaluation of safe motherhood in rural Burkina Faso Wendy J. Graham 1 , S. Ghislaine Conombo 2 , D. Sosthe ` ne Zombre ´ 2 , Nicolas Meda 3 , Peter Byass 1 and Vincent De Brouwere 4 1 Immpact, University of Aberdeen, Aberdeen, Scotland, UK 2 World Health Organisation, Ouagadougou, Burkina Faso 3 Immpact, Centre Muraz, Bobo-Dioulasso, Burkina Faso 4 Immpact, Institute of Tropical Medicine, Antwerp, Belgium Summary Evaluations of composite health interventions, such as those attempting to make motherhood safer, are by definition complex, but nevertheless regarded as essential to informing progress in global health. This paper introduces a series of reports which set out the basis of Family Care International’s Skilled Care Initiative in rural Burkina Faso, go on to describe strategies and methods for evaluating it, and present evaluation findings in terms of pregnancy outcomes, utilisation and effects of the intervention and economics. Although there were encouraging findings, no ‘magic bullets’ emerged from these studies, illustrating the reality that sustained and increasing resources are needed to achieve safe motherhood for all. There is no cheap or short-cut solution. keywords complex evaluation, safe motherhood strategies, skilled attendance at delivery Introduction There are many discrete interventions which can help to prevent the tragedy of maternal death. These differ enormously and in many respects: their modes of working, resource requirements, timing, consequences and effec- tiveness. These interventions, however, also share a com- mon inadequacy: none alone can achieve a significant impact on maternal mortality at a population level. By 2015, the target of Millennium Development Goal 5 is to achieve a 75% reduction in maternal mortality. History provides examples of such dramatic progress (De Brouwere et al. 1998) and also clear indications that composites of interventions are needed, delivered through functioning health systems. These major composite intervention strat- egies are necessarily challenging to design and implement, and to robustly evaluate for effectiveness and cost-effec- tiveness (Milne et al. 2004). The importance of evaluating all major health initiatives is now undisputed. Indeed, it is advocated that around 10% of the budget for such initiatives is devoted to evaluation (Savedoff et al. 2006). Most interventions for composite health problems require complex evaluations to capture the multiple inputs, processes, outputs and out- comes as well as the context of implementation. Such complexity to an assessment is a natural reflection of the real world and not necessarily a bad thing. There are, however, risks arising from the sheer volume and layering of information from complex evaluations. Inconclusive findings may, for example, be misinterpreted as evidence that the health problem is intractable or the interventions ineffective or undeliverable. Decision-makers who could have used the evidence may be unwilling or unable to navigate the labyrinths of conclusions, and the value-for- money of the evaluation may rightly be called into question. These negative risks can be reduced by taking the extra step of distilling the mass of findings into policy- relevant messages (Campbell Collaboration, 2005). This distillation process is necessarily simplifying, and should reflect a dialogue between the generators of the evidence and those who may act upon it (Bryce et al. 2005). In this Supplement, the experience and findings of a complex evaluation in Burkina Faso are reported. Safe motherhood was the complex problem being targeted, and the intervention strategy focused on skilled attendance at delivery (Graham et al. 2008). Complex evaluations are, by definition, major under- takings, from conception through to translation and communication. The experience reported here reflects a study period of over 4 years. More than half this time was devoted to planning and set-up: clarifying the key ques- tions, ensuring ownership of the evaluation by Government decision-makers, and forging relations with the imple- menting partners – Family Care International and the study Tropical Medicine and International Health doi:10.1111/j.1365-3156.2008.02081.x volume 13 suppl. 1 pp 1–5 july 2008 ª 2008 The Authors Journal compilation ª 2008 Blackwell Publishing Ltd, 13 (Suppl. 1), 1–5 1