Measurement Of Maternal Mortality Research Articles

Measurement of maternal mortality

Context: Accurate measurement of maternal mortality is an imperative for policy and planning on maternal health care. Objective: The objective of this review is to focus attention on the various methods of measuring maternal mortality, advantages, and drawbacks. Source of materials for this article are from learned journals and reports on the subject. Conclusion: The measurement of maternal mortality poses unique challenges in resource-poor settings in developing countries. In these settings, though various methods may be employed, a census, cumbersome as it may be, offers the best possible source of data.

Medical provision and urban-rural differences in maternal mortality in late nineteenth century Scotland

This paper examines the effect of variable reporting and coding practices on the measurement of maternal mortality in urban and rural Scotland, 1861–1901, using recorded causes of death and women who died within six weeks of childbirth. This setting provides data (n = 604 maternal deaths) to compare maternal mortality identified by cause of death with maternal mortality identified by record linkage and to contrast urban and rural settings with different certification practices. We find that underreporting was most significant for indirect causes, and that indirect causes accounted for a high proportion of maternal mortality where the infectious disease load was high. However, distinguishing between indirect and direct maternal mortality can be problematic even where cause of death reporting appears accurate. Paradoxically, underreporting of maternal deaths was higher in urban areas where deaths were routinely certified by doctors, and we argue that where there are significant differences in medical provision and reported deaths, differences in maternal mortality may reflect certification practices as much as true differences. Better health services might therefore give the impression that maternal mortality was lower than it actually was. We end with reflections on the interpretation of maternal mortality statistics and implications for the concept of the obstetric transition.

Acknowledging uncertainty about maternal mortality estimates.

Differences between estimates of maternal mortality from different research groups have been much debated. (1-3) The data that are included or omitted and the choice of models have been discussed, but the uncertainty of the estimates has not received much attention. Attempts to estimate the maternal mortality ratio (MMR) for South Africa published in the past five years illustrate the large variability of estimates and the tendency to underestimate uncertainty, particularly when MMR is low. Fig. 1 shows the three most recent estimates of MMR published by the Institute for Health Metrics and Evaluation (IHME) (4-6) and the two most recent estimates published by the World Health Organization (WHO). (7,8) In addition, two sets of estimates derived from local data are shown: (i) the confidential enquiry based on maternal deaths recorded in health facilities and births at those facilities; (9) and (ii) the indicator used by the Health Data Advisory and Coordination Committee (HDACC) of the Department of Health. (10) The latter is based on registered maternal deaths from vital registration, corrected for general incompleteness of reporting of death plus 50% to allow for maternal deaths incorrectly attributed to other causes. (11) Neither of the estimates based on local data purports to produce an accurate estimate of maternal mortality, but both attempt to track changes over time on a reasonably consistent basis. Fig. 1 includes the 95% uncertainty intervals about the WHO estimates and Fig. 2 the 95% uncertainty intervals about the IHME estimates. These intervals supposedly indicate the uncertainty about the estimates. The most recent estimates from IHME and WHO lie outside the respective 95% uncertainty intervals about their previous estimates. In the case of IHME, even though the most recent estimates acknowledge a much greater degree of uncertainty, the uncertainty intervals don't overlap those about the immediately preceding estimates. The most striking feature of these estimates is the wide range spanned by the WHO and IHME estimates. The second feature is the difference between the most recent and second most recent published estimates. The third is that where the IHME estimates now lie above the other estimates, the WHO estimates lie below the others, in contrast to their previous estimates. Unless a country has a nationally representative system to track maternal deaths, there is likely to be a great deal of uncertainty about maternal mortality. Currently this uncertainty is not being fully acknowledged by those attempting to estimate MMR indirectly, particularly as part of efforts to track maternal mortality globally. This, together with the fact that estimates of MMR can change significantly from one set of estimates to the next, make them useless for informing countries about what is or is not working to combat maternal mortality. Countries should monitor the effectiveness of policy and interventions using an index for tracking changes over time, such as the institutional MMR, even if this does not necessarily produce an accurate estimate of the absolute level of the maternal mortality in the country. The global initiatives that produce country-specific estimates should allow for greater model uncertainty and balance in-depth evaluation of country-specific data against finding one model that fits all. Given that the target 3.1 of the Sustainable Development Goals is to reduce the global maternal mortality ratio to less than 70 per 100000 live births by 2030, (12) maternal mortality will be a key indicator to measure target progress. Therefore, investment is needed in civil registration and vital statistics for improved measurement of maternal mortality by low- and middle-income countries. (13) Competing interests: None declared. References (1.) AbouZahr C. New estimates of maternal mortality and how to Interpret them: choice or confusion? …

Maternal Mortality in Bangladesh

Summary Background Bangladesh is one of the only nine Countdown countries that are on track to achieve the primary target of Millennium Development Goal (MDG) 5 by 2015. It is also the only low-income or middle-income country with two large, nationally-representative, high-quality household surveys focused on the measurement of maternal mortality and service use. Methods We use data from the 2001 and 2010 Bangladesh Maternal Mortality Surveys to measure change in the maternal mortality ratio (MMR) and from these and six Bangladesh Demographic and Health Surveys to measure changes in factors potentially related to such change. We estimate the changes in risk of maternal death between the two surveys using Poisson regression. Findings The MMR fell from 322 deaths per 100 000 livebirths (95% CI 253–391) in 1998–2001 to 194 deaths per 100 000 livebirths (149–238) in 2007–10, an annual rate of decrease of 5·6%. This decrease rate is slightly higher than that required (5·5%) to achieve the MDG target between 1990 and 2015. The key contribution to this decrease was a drop in mortality risk mainly due to improved access to and use of health facilities. Additionally, a number of favourable changes occurred during this period: fertility decreased and the proportion of births associated with high risk to the mother fell; income per head increased sharply and the poverty rate fell; and the education levels of women of reproductive age improved substantially. We estimate that 52% of maternal deaths that would have occurred in 2010 in view of 2001 rates were averted because of decreases in fertility and risk of maternal death. Interpretation The decrease in MMR in Bangladesh seems to have been the result of factors both within and outside the health sector. This finding holds important lessons for other countries as the world discusses and decides on the post-MDG goals and strategies. For Bangladesh, this case study provides a strong rationale for the pursuit of a broader developmental agenda alongside increased and accelerated investments in improving access to and quality of public and private health-care facilities providing maternal health in Bangladesh. Funding United States Agency for International Development, UK Department for International Development, Bill & Melinda Gates Foundation.

Predictive value of institutional impact factor as an indirect measure of maternal mortality in Nigeria: A systematic review

Background: This study developed a novel measure termed as an institutional impact factor (IIF), which was used for predicting the trends of maternal mortality ratio (MMR) resulting from poor management of the health system. Methods: A total of 3518 publications from Nigeria in PubMed from 1975 to 2005, were used to obtain IIF for each institution studied. The study periods compared, were period A (1975-1989), period B (1990-2004), and period C (1990-2005). Results: The public health sector period A mean ± standard error (SE) IIF was 1.423 ± 0.09, and dropped significantly in period B, to IIF of 0.704 ± 0.024, P < 0.001. Conversely, in period A, the mean ± SE MMR, was 508.8 ± 115.7/100,000 live births, and rose significantly in period B to MMR of 1895.5 ± 363.7/100,000 live births, P < 0.05. The linear regression model suggested a negative correlation between IIF and MMR. The overall, F (1,18) =15.5, P < 0.001, R2 was 0.463, BETA coefficient was − 0.68, P < 0.0001. The intercept 2957.6 was significant, P < 0.0001. We predicted that the Millennium Development Goals 5 required a 75% drop in MMR to 127/100,000 live births, and IIF rise to 1.69, in 2015. Conclusion: The IIF may be a health metric index for monitoring efficiency of the health workforce.

Maternal mortality in Bangladesh: a Countdown to 2015 country case study

Bangladesh is one of the only nine Countdown countries that are on track to achieve the primary target of Millennium Development Goal (MDG) 5 by 2015. It is also the only low-income or middle-income country with two large, nationally-representative, high-quality household surveys focused on the measurement of maternal mortality and service use. We use data from the 2001 and 2010 Bangladesh Maternal Mortality Surveys to measure change in the maternal mortality ratio (MMR) and from these and six Bangladesh Demographic and Health Surveys to measure changes in factors potentially related to such change. We estimate the changes in risk of maternal death between the two surveys using Poisson regression. The MMR fell from 322 deaths per 100,000 livebirths (95% CI 253-391) in 1998-2001 to 194 deaths per 100,000 livebirths (149-238) in 2007-10, an annual rate of decrease of 5·6%. This decrease rate is slightly higher than that required (5·5%) to achieve the MDG target between 1990 and 2015. The key contribution to this decrease was a drop in mortality risk mainly due to improved access to and use of health facilities. Additionally, a number of favourable changes occurred during this period: fertility decreased and the proportion of births associated with high risk to the mother fell; income per head increased sharply and the poverty rate fell; and the education levels of women of reproductive age improved substantially. We estimate that 52% of maternal deaths that would have occurred in 2010 in view of 2001 rates were averted because of decreases in fertility and risk of maternal death. The decrease in MMR in Bangladesh seems to have been the result of factors both within and outside the health sector. This finding holds important lessons for other countries as the world discusses and decides on the post-MDG goals and strategies. For Bangladesh, this case study provides a strong rationale for the pursuit of a broader developmental agenda alongside increased and accelerated investments in improving access to and quality of public and private health-care facilities providing maternal health in Bangladesh. United States Agency for International Development, UK Department for International Development, Bill & Melinda Gates Foundation.

Measuring maternal mortality: an overview of opportunities and options for developing countries.

BackgroundThere is currently an unprecedented expressed need and demand for estimates of maternal mortality in developing countries. This has been stimulated in part by the creation of a Millennium Development Goal that will be judged partly on the basis of reductions in maternal mortality by 2015. MethodsSince the launch of the Safe Motherhood Initiative in 1987, new opportunities for data capture have arisen and new methods have been developed, tested and used. This paper provides a pragmatic overview of these methods and the optimal measurement strategies for different developing country contexts.ResultsThere are significant recent advances in the measurement of maternal mortality, yet also room for further improvement, particularly in assessing the magnitude and direction of biases and their implications for different data uses. Some of the innovations in measurement provide efficient mechanisms for gathering the requisite primary data at a reasonably low cost. No method, however, has zero costs. Investment is needed in measurement strategies for maternal mortality suited to the needs and resources of a country, and which also strengthen the technical capacity to generate and use credible estimates.ConclusionOwnership of information is necessary for it to be acted upon: what you count is what you do. Difficulties with measurement must not be allowed to discourage efforts to reduce maternal mortality. Countries must be encouraged and enabled to count maternal deaths and act.

A prospective key informant surveillance system to measure maternal mortality – findings from indigenous populations in Jharkhand and Orissa, India

BackgroundIn places with poor vital registration, measurement of maternal mortality and monitoring the impact of interventions on maternal mortality is difficult and seldom undertaken. Mortality ratios are often estimated and policy decisions made without robust evidence. This paper presents a prospective key informant system to measure maternal mortality and the initial findings from the system.MethodsIn a population of 228 186, key informants identified all births and deaths to women of reproductive age, prospectively, over a period of 110 weeks. After birth verification, interviewers visited households six to eight weeks after delivery to collect information on the ante-partum, intra-partum and post-partum periods, as well as birth outcomes. For all deaths to women of reproductive age they ascertained whether they could be classified as maternal, pregnancy related or late maternal and if so, verbal autopsies were conducted.Results13 602 births were identified, with a crude birth rate of 28.2 per 1000 population (C.I. 27.7–28.6) and a maternal mortality ratio of 722 per 100 000 live births (C.I. 591–882) recorded. Maternal deaths comprised 29% of all deaths to women aged 15–49. Approximately a quarter of maternal deaths occurred ante-partum, a half intra-partum and a quarter post-partum. Haemorrhage was the commonest cause of all maternal deaths (25%), but causation varied between the ante-partum, intra-partum and post-partum periods. The cost of operating the surveillance system was US$386 a month, or US$0.02 per capita per year.ConclusionThis low cost key informant surveillance system produced high, but plausible birth and death rates in this remote population in India. This method could be used to monitor trends in maternal mortality and to test the impact of interventions in large populations with poor vital registration and thus assist policy makers in making evidence-based decisions.

MEASURING MATERNAL MORTALITY IN MALAYSIA

There has been a significant decline in maternal mortality in Malaysiasince independence. The issue of measuring maternal mortality accurately is a problem in all countries. Another major problem is whether we can reduce the mortality further. The definition of maternal mortality includes two major components, which are causation of death and the time of death. To improve data collection on maternal deaths, we need to collect all data on maternal deaths, which are omitted or misclassified. Deaths from accidental causes that are not normally used in the calculations of maternal mortality need to be carefully reexamined to be excluded. The time of death means that in maternal mortality calculations, it includes up to six weeks after delivery, but recent World Health Organization (WHO) publication (ICD-10) suggests that the collection of maternal deaths even after six weeks should be reviewed because there are many maternal deaths which occur after six weeks. Measuring maternal mortality rate should be encouraged rather than maternal mortality ratio. Another measurement of maternal mortality is the lifetime risk of the women. The lifetime risk is the measure of maternal mortality that takes into account the probability of becomingpregnant and the probability of dying as a result of pregnancy. Many countries have started reporting the lifetime risk, which is considered to be better indicator to measure maternal health.

Maternal Mortality in Islamic and Arabic Countries

Maternal deaths have been recognized as an area of maternal care that requires urgent attention. Every minute of every day, somewhere in the world, a woman dies as a result of complications arising during pregnancy and childbirth. The majority of these deaths are avoidable. The estimated number of maternal deaths in 2000 for the world was 529,000 according to WHO, UNICEF, UNFPA estimates. These deaths were almost equally divided between Africa (251,000) and Asia (253,000), with about (22,000) occurring in Latin America and the Caribbean, and less than (2,500) in the more developed regions of the world. DEFINITIONS AND MEASURES OF MATERNAL MORTALITY

Reflections on the measurement of maternal mortality

The maternal mortality rate is a highly sensitive indicator for the health level of both women and the general population in a given geographical area. There is extensive variability among different countries, and rates are high in underdeveloped or developing areas, as in Brazil. Health authorities from various countries have launched programs aimed at reducing maternal deaths and have thus needed to estimate the actual rates to allow for a proper assessment and to control the programs' progress. However, there are many obstacles and difficulties in obtaining the real values of these measures, mainly because of incomplete data. The aim of this paper is to present some of the proposed methodologies for estimating maternal mortality rates and to call attention to the limits and biases of these methods. Based on the Brazilian case, the article also recommends an improvement in the quality and coverage of the Civil Registry, the official source of data on births and deaths.

Why Perinatal Mortality Cannot be a Proxy for Maternal Mortality

In recent years, the perinatal mortality rate (PNMR) has been proposed as a proxy measure of maternal mortality, because perinatal deaths are more frequent and potentially more easily measured. This report assesses evidence for an association between these two statistics. This study, based upon data from Matlab, Bangladesh, shows that the maternal mortality ratio (MMR) and the PNMR do not vary together over time, and that the PNMR does not reliably indicate either the magnitude or the direction of change in the MMR from year to year. Statistical analysis shows that the correlation between the PNMR and the MMR is not significantly different from zero. An examination of the major causes of maternal and perinatal deaths indicates that the two measures cannot be expected to vary together. Almost half of perinatal deaths result from causes that do not pose a threat to the mother's life, and almost half of maternal deaths result from causes that do not lead to perinatal death. Monitoring of the PNMR can give an inaccurate picture of maternal mortality and should not be used as a proxy.