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

Effect of early detection and treatment on malaria related maternal mortality on the north-western border of Thailand 1986-2010

INTRODUCTION

Maternal mortality is high in developing countries, but there are few data in high-risk groups such as migrants and refugees in malaria-endemic areas. Trends in maternal mortality were followed over 25 years in antenatal clinics prospectively established in an area with low seasonal transmission on the north-western border of Thailand.

METHODS AND FINDINGS

All medical records from women who attended the Shoklo Malaria Research Unit antenatal clinics from 12(th) May 1986 to 31(st) December 2010 were reviewed, and maternal death records were analyzed for causality. There were 71 pregnancy-related deaths recorded amongst 50,981 women who attended antenatal care at least once. Three were suicide and excluded from the analysis as incidental deaths. The estimated maternal mortality ratio (MMR) overall was 184 (95%CI 150-230) per 100,000 live births. In camps for displaced persons there has been a six-fold decline in the MMR from 499 (95%CI 200-780) in 1986-90 to 79 (40-170) in 2006-10, p<0.05. In migrants from adjacent Myanmar the decline in MMR was less significant: 588 (100-3260) to 252 (150-430) from 1996-2000 to 2006-2010. Mortality from P. falciparum malaria in pregnancy dropped sharply with the introduction of systematic screening and treatment and continued to decline with the reduction in the incidence of malaria in the communities. P. vivax was not a cause of maternal death in this population. Infection (non-puerperal sepsis and P. falciparum malaria) accounted for 39.7 (27/68) % of all deaths.

CONCLUSIONS

Frequent antenatal clinic screening allows early detection and treatment of falciparum malaria and substantially reduces maternal mortality from P. falciparum malaria. No significant decline has been observed in deaths from sepsis or other causes in refugee and migrant women on the Thai-Myanmar border.

Estimating obstetric mortality from pregnancy-related deaths recorded in demographic censuses and surveys

Demographic surveys and censuses often record pregnancy-related deaths, defined as those occurring during the maternal risk period (pregnancy, delivery, and six weeks postpartum), but do not include cause of death. This study presents a method for estimating obstetric mortality from pregnancy-related deaths data. Calculations are based on multiple-decrement life tables, and data needed are simply age-specific fertility and mortality rates that are commonly available in Demographic and Health Survey (DHS) or census data, and an estimate of the relative risk of death from nonobstetric causes during the maternal risk period. The method is tested on 59 DHS surveys from Africa. Results show that, on average, less than half of the pregnancy-related deaths are attributable to obstetric causes. This proportion varies with the level of mortality and fertility, and in particular with the prevalence of HIV in the population.

Tracking progress towards safe motherhood: meeting the benchmark yet missing the goal? An appeal for better use of health-system output indicators with evidence from Zambia and Sri Lanka

OBJECTIVES

Indicators of health-system outputs, such as Emergency Obstetric Care (EmOC) density, have been proposed for monitoring progress towards reducing maternal mortality, but are currently underused. We seek to promote them by demonstrating their use at subnational level, evaluating whether they differentiate between a high-maternal-mortality country (Zambia) and a low-maternal-mortality country (Sri Lanka) and assessing whether benchmarks are set at the right level.

METHODS

We compared national and subnational density of health facilities, EmOC facilities and health professionals against current benchmarks for Zambia and Sri Lanka. For Zambia, we also examined geographical accessibility by linking health facility data to population data.

RESULTS

Both countries performed similarly in terms of EmOC facility density, implying this indicator, as currently used, fails to discriminate between high- and low-maternal-mortality settings. In Zambia, the WHO benchmarks for doctors/midwives were met overall, but distribution between provinces was highly unequal. Sri Lanka overshot the suggested benchmarks by three times for midwives and over 30 times for doctors. Geographical access in Zambia--which is much less densely populated than Sri Lanka--was poor, less than half the population lived within 15 km of an EmOC facility.

CONCLUSIONS

Current health-system output indicators and benchmarks on EmOC need revision to enhance discriminatory power and should be adapted for different population densities. Subnational disaggregation and assessing geographical access can identify gaps in EmOC provision and should be routinely considered. Increased use of an improved set of output indicators is crucial for guiding international efforts towards reducing maternal mortality.

Field test results of the motherhood method to measure maternal mortality

BACKGROUND & OBJECTIVES

Measuring maternal mortality in developing countries poses a major challenge. In Nepal, vital registration is extremely deficient. Currently available methods to measure maternal mortality, such as the sisterhood method, pose problems with respect to validity, precision, cost and time. We conducted this field study to test a community-based method (the motherhood method), to measure maternal and child mortality in a developing country setting.

METHODS

Motherhood method was field tested to derive measures of maternal and child mortality at the district and sub-regional levels in Bara district, Nepal. Information on birth, death, risk factors and health outcomes was collected within a geographic area as in an unbiased census, but without visiting every household. The sources of information were a vaccination registry, focus group discussions with local health workers, and most importantly, interview in group setting with women who share social bonds formed by motherhood and aided by their peer memory. Such groups included all women who have given birth, including those whose babies died during the measurement period.

RESULTS

A total of 15,161 births were elicited in the study period of two years. In the same period 49 maternal deaths, 713 infant deaths, 493 neonatal deaths and 679 perinatal deaths were also recorded. The maternal mortality ratio was 329 (95%CI: 243-434)/100,000 live birth, infant mortality rate was 48 (44-51)/1000LB, neonatal mortality rate was 33 (30-36)/1000LB, and perinatal mortality rate was 45 (42-48)/1000 total birth.

INTERPRETATION & CONCLUSIONS

The motherhood method estimated maternal, perinatal, neonatal and infant mortality rates and ratios. It has been field tested and validated against census data, and found to be efficient in terms of time and cost. Motherhood method can be applied in a time and cost-efficient manner to measure and monitor the progress in the reduction of maternal and child deaths. It can give current estimates of mortalities as well as averages over the past few years. It appears to be particularly well-suited to measuring and monitoring programmes in community and districts levels.

Maternal mortality estimation at the subnational level: a model-based method with an application to Bangladesh

OBJECTIVE

To provide a model-based method of estimating maternal mortality at the subnational level and illustrate its use in estimating maternal mortality rates (MMrates) and maternal mortality ratios (MMRs) in all 64 districts of Bangladesh.

METHODS

Knowing that mortality is more pronounced among the poorer segments of a population, in rural areas and in areas with poor availability and utilization of maternal care, we used an empirical Bayesian prediction method to estimate maternal mortality at the subnational level from the spatial distribution of such factors.

FINDINGS

MMRs varied significantly by district in Bangladesh, from 158 maternal deaths per 100,000 live births at Dhaka district to 782 in the northern coastal regions. Maternal mortality was consistently higher in the eastern and northern regions, which are known to be culturally conservative and to have poor transportation systems.

CONCLUSION

Bangladesh has made noteworthy strides in reducing maternal mortality since 1990, even though the utilization of skilled birth attendants has increased very little. However, several areas still show alarmingly high maternal mortality figures and need to be prioritized and targeted by health administrators and policy-makers.

A lost cause? Extending verbal autopsy to investigate biomedical and socio-cultural causes of maternal death in Burkina Faso and Indonesia

Maternal mortality in developing countries is characterised by disadvantage and exclusion. Women who die whilst pregnant are typically poor and live in low-income and rural settings where access to quality care is constrained and where deaths, within and outside hospitals, often go unrecorded and unexamined. Verbal autopsy (VA) is an established method of determining cause(s) of death for people who die outside health facilities or without proper registration. This study extended VA to investigate socio-cultural factors relevant to outcomes. Interviews were conducted with relatives of 104 women who died during pregnancy, childbirth or postpartum in two rural districts in Indonesia and for 70 women in a rural district in Burkina Faso. Information was collected on medical signs and symptoms of the women prior to death and an extended section collected accounts of care pathways and opinions on preventability and cause of death. Illustrative quantitative and qualitative analyses were performed and the implications for health surveillance and planning were considered. The cause of death profiles were similar in both settings with infectious diseases, haemorrhage and malaria accounting for half the deaths. In both settings, delays in seeking, reaching and receiving care were reported by more than two-thirds of respondents. Relatives also provided information on their experiences of the emergencies revealing culturally-derived systems of explanation, causation and behaviour. Comparison of the qualitative and quantitative results suggested that the quantified delays may have been underestimated. The analysis suggests that broader empirical frameworks can inform more complete health planning by situating medical conditions within the socio-economic and cultural landscapes in which healthcare is situated and sought. Utilising local knowledge, extended VA has potential to inform the relative prioritisation of interventions that improve technical aspects of life-saving services with those that address the conditions that underlie health, for those whom services typically fail to reach.

Maternal mortality for 181 countries, 1980-2008: a systematic analysis of progress towards Millennium Development Goal 5

BACKGROUND

Maternal mortality remains a major challenge to health systems worldwide. Reliable information about the rates and trends in maternal mortality is essential for resource mobilisation, and for planning and assessment of progress towards Millennium Development Goal 5 (MDG 5), the target for which is a 75% reduction in the maternal mortality ratio (MMR) from 1990 to 2015. We assessed levels and trends in maternal mortality for 181 countries.

METHODS

We constructed a database of 2651 observations of maternal mortality for 181 countries for 1980-2008, from vital registration data, censuses, surveys, and verbal autopsy studies. We used robust analytical methods to generate estimates of maternal deaths and the MMR for each year between 1980 and 2008. We explored the sensitivity of our data to model specification and show the out-of-sample predictive validity of our methods.

FINDINGS

We estimated that there were 342,900 (uncertainty interval 302,100-394,300) maternal deaths worldwide in 2008, down from 526,300 (446,400-629,600) in 1980. The global MMR decreased from 422 (358-505) in 1980 to 320 (272-388) in 1990, and was 251 (221-289) per 100,000 livebirths in 2008. The yearly rate of decline of the global MMR since 1990 was 1.3% (1.0-1.5). During 1990-2008, rates of yearly decline in the MMR varied between countries, from 8.8% (8.7-14.1) in the Maldives to an increase of 5.5% (5.2-5.6) in Zimbabwe. More than 50% of all maternal deaths were in only six countries in 2008 (India, Nigeria, Pakistan, Afghanistan, Ethiopia, and the Democratic Republic of the Congo). In the absence of HIV, there would have been 281 500 (243,900-327,900) maternal deaths worldwide in 2008.

INTERPRETATION

Substantial, albeit varied, progress has been made towards MDG 5. Although only 23 countries are on track to achieve a 75% decrease in MMR by 2015, countries such as Egypt, China, Ecuador, and Bolivia have been achieving accelerated progress.

FUNDING

Bill & Melinda Gates Foundation.

What you count is what you target: the implications of maternal death classification for tracking progress towards reducing maternal mortality in developing countries

The first target of the fifth United Nations Millennium Development Goal is to reduce maternal mortality by 75% between 1990 and 2015. This target is critically off track. Despite difficulties inherent in measuring maternal mortality, interventions aimed at reducing it must be monitored and evaluated to determine the most effective strategies in different contexts. In some contexts, the direct causes of maternal death, such as haemorrhage and sepsis, predominate and can be tackled effectively through providing access to skilled birth attendance and emergency obstetric care. In others, indirect causes of maternal death, such as HIV/AIDS and malaria, make a significant contribution and require alternative interventions. Methods of planning and evaluating maternal health interventions that do not differentiate between direct and indirect maternal deaths may lead to unrealistic expectations of effectiveness or mask progress in tackling specific causes. Furthermore, the need for additional or alternative interventions to tackle the causes of indirect maternal death may not be recognized if all-cause maternal death is used as the sole outcome indicator. This article illustrates the importance of differentiating between direct and indirect maternal deaths by analysing historical data from England and Wales and contemporary data from Ghana, Rwanda and South Africa. The principal aim of the paper is to highlight the need to differentiate deaths in this way when evaluating maternal mortality, particularly when judging progress towards the fifth Millennium Development Goal. It is recommended that the potential effect of maternity services failing to take indirect maternal deaths into account should be modelled.

Joining the dots: a plea for precise estimates of the maternal mortality ratio in sub-Saharan Africa

Monitoring of maternal mortality levels in sub-Saharan Africa (SSA) to assess the achievements of safe motherhood programmes and for MDG-5 has been made difficult because of the lack of precise estimates of the maternal mortality ratio (MMR). Projections based on the slow rate of decline of the MMR indicate that MDG-5 may not be reached before the end of this century in this region. Measurements done using demographical and health surveys, statistical modelling and censuses are imprecise and do not allow trends in individual countries to be established. SSA countries should be encouraged to measure mortality levels from their own resources, using methods that produce precise estimates such as population-based surveys. Establishment of the trends will lead to country-specific program targets. The less frequent but more precise measurements can be afforded by SSA countries, as a case study from Zimbabwe shows.

Surviving pregnancy and childbirth is a human right: the silent tragedy of maternal mortality

More than two decades after the launch of the Safe Motherhood Initiative (Nairobi 1987) , maternal health in many developing countries has shown little or no improvement. Year after year, more than half a million mothers continue to die in silence. The specificities of the complex cross-cutting issue only partly explain why tireless efforts have led to insufficient progress so far. While some success stories prove that results can be obtained quickly, the dissensions and deficiencies the Initiative has encountered have strongly weakened its impact. However, recent developments over the past 3 years allow to foresee the silence will soon be -broken. While advocacy begins to subsequently raise awareness, more financial means are mobilized. As a consensus on priority interventions has finally been reached, more coordinated actions and initiatives are being developed. The strive for achieving the Millennium Development Goals helps to create the political momentum strongly needed to generate new leadership, and to develop and implement adequate strategies. Sensible focus on resources and structures as well as innovative management will be crucial in that process.

Unsafe abortion: unnecessary maternal mortality

Every year, worldwide, about 42 million women with unintended pregnancies choose abortion, and nearly half of these procedures, 20 million, are unsafe. Some 68,000 women die of unsafe abortion annually, making it one of the leading causes of maternal mortality (13%). Of the women who survive unsafe abortion, 5 million will suffer long-term health complications. Unsafe abortion is thus a pressing issue. Both of the primary methods for preventing unsafe abortion-less restrictive abortion laws and greater contraceptive use-face social, religious, and political obstacles, particularly in developing nations, where most unsafe abortions (97%) occur. Even where these obstacles are overcome, women and health care providers need to be educated about contraception and the availability of legal and safe abortion, and women need better access to safe abortion and postabortion services. Otherwise, desperate women, facing the financial burdens and social stigma of unintended pregnancy and believing they have no other option, will continue to risk their lives by undergoing unsafe abortions.

An introduction to maternal mortality

Approximately 529,000 women die from pregnancy-related causes annually and almost all (99%) of these maternal deaths occur in developing nations. One of the United Nations' Millennium Development Goals is to reduce the maternal mortality rate by 75% by 2015. Causes of maternal mortality include postpartum hemorrhage, eclampsia, obstructed labor, and sepsis. Many developing nations lack adequate health care and family planning, and pregnant women have minimal access to skilled labor and emergency care. Basic emergency obstetric interventions, such as antibiotics, oxytocics, anticonvulsants, manual removal of placenta, and instrumented vaginal delivery, are vital to improve the chance of survival.