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

Current Approaches to Following Up Women and Newborns After Discharge From Childbirth Facilities: A Scoping Review

INTRODUCTION

The postpartum period is critical for the health and well-being of women and newborns, but there is limited research on the most effective methods of post-childbirth follow-up. This scoping review synthesizes evidence from high-, middle-, and low-income countries on approaches to following up individuals after discharge from childbirth facilities.

METHODS

Using a systematic search in Ovid MEDLINE, we identified quantitative studies describing post-discharge follow-up methods deployed up to 12 months postpartum. We searched for English-language, peer-reviewed articles published between January 1, 2007 and November 2, 2022, with search terms covering 2 broad areas: "postpartum/postnatal period" and "surveillance." We single-screened titles and abstracts and double-extracted all included articles, recording study design and location, population, health outcome, method, timing and frequency of data collection, and percentage of study participants reached.

RESULTS

We identified 1,654 records, of which 31 studies were included. Eight studies used in-person visits to follow up participants, 10 used telephone calls, 7 used self-administered questionnaires, and 6 used multiple methods. Across studies, the minimum length of follow-up was 1 week after delivery, and up to 4 contacts were made within the first year after delivery. Follow-up (response) rates ranged from 23% to100%. Postpartum infection was the most common outcome investigated. Other outcomes included maternal (ill-)health, neonatal (ill-)health and growth, maternal mental health and well-being, care-giving/-seeking behaviors, and knowledge and intentions.

CONCLUSION

Our scoping review identified multiple follow-up methods after discharge, ranging from home visits to self-administered electronic questionnaires, which could be implemented with high response rates. The studies demonstrated that post-discharge follow-up of women and newborns was feasible, well received, and important for identifying postpartum illness or complications that would otherwise be missed. Therefore, the identified methods have the potential to become an important component of fostering a continuum of care and measuring and addressing postpartum morbidity.

Approaches to improve and adapt maternal mortality estimations in low- and middle-income countries: A scoping review

BACKGROUND

In the absence of robust vital registration systems, many low- and middle-income countries (LMICs) rely on national surveys or routine surveillance systems to estimate the maternal mortality ratio (MMR). Although the importance of MMR estimates in ending preventable maternal deaths is acknowledged, there is limited research on how different approaches are used and adapted, and how these adaptations function.

OBJECTIVES

To assess methods for estimating maternal mortality in LMICs and the rationale for these modifications.

SEARCH STRATEGY

A literature search with the terms "maternal death", "surveys" and "low- and middle-income countries" was performed in Medline, Embase, Web of Science, Scopus, CINAHL, APA PsycINFO, ERIC, and IBSS from January 2013 to March 17, 2023.

SELECTION CRITERIA

Studies were eligible if their main focus was to compare, adapt, or assess methods to estimate maternal mortality in LMICs.

DATA COLLECTION AND ANALYSIS

Titles and abstracts were screened using Rayyan. Relevant articles were independently reviewed by two reviewers against inclusion criteria. Data were extracted on mortality measurement methods, their context, and results.

MAIN RESULTS

Nineteen studies were included, focusing on data completeness, subnational estimates, and community involvement. Routinely generated MMR estimates are more complete when multiple data sources are triangulated, including data from public and private health facilities, the community, and local authorities (e.g. vital registration, police reports). For subnational estimates, existing (e.g. the sisterhood method and reproductive-age mortality surveys [RAMOS]) and adapted methods (e.g. RAMOS 4 + 2 and Pictorial Sisterhood Method) provided reliable confidence intervals. Community engagement in data collection increased community awareness of maternal deaths, provided local ownership, and was expected to reduce implementation costs. However, most studies did not include a cost-effectiveness analysis.

CONCLUSION

Household surveys with community involvement and RAMOS can be used to increase data validity, improve local awareness of maternal mortality estimates, and reduce costs in LMICs.

Simulation-based estimates and projections of global, regional and country-level maternal mortality by cause, 1990-2050

Maternal mortality is a major global health challenge. Although progress has been made globally in reducing maternal deaths, measurement remains challenging given the many causes and frequent underreporting of maternal deaths. We developed the Global Maternal Health microsimulation model for women in 200 countries and territories, accounting for individual fertility preferences and clinical histories. Demographic, epidemiologic, clinical and health system data were synthesized from multiple sources, including the medical literature, Civil Registration Vital Statistics systems and Demographic and Health Survey data. We calibrated the model to empirical data from 1990 to 2015 and assessed the predictive accuracy of our model using indicators from 2016 to 2020. We projected maternal health indicators from 1990 to 2050 for each country and estimate that between 1990 and 2020 annual global maternal deaths declined by over 40% from 587,500 (95% uncertainty intervals (UI) 520,600-714,000) to 337,600 (95% UI 307,900-364,100), and are projected to decrease to 327,400 (95% UI 287,800-360,700) in 2030 and 320,200 (95% UI 267,100-374,600) in 2050. The global maternal mortality ratio is projected to decline to 167 (95% UI 142-188) in 2030, with 58 countries above 140, suggesting that on current trends, maternal mortality Sustainable Development Goal targets are unlikely to be met. Building on the development of our structural model, future research can identify context-specific policy interventions that could allow countries to accelerate reductions in maternal deaths.

Birth and Death Notifications for Improving Civil Registration and Vital Statistics in Bangladesh: Pilot Exploratory Study

Background

Effective health policy formulation requires sound information of the numerical data and causes of deaths in a population. Currently, in Bangladesh, neither births nor deaths are fully and promptly registered. Birth registration in Bangladesh is around 54% nationally. Although the legal requirements are to register within 45 days of an event, only 4.5% of births and 35.9% of deaths were reported within the required time frame in 2020. This study adopted an innovative digital notification approach to improve the coverage of registration of these events at the community level.

Objective

Our primary objective was to assess (1) the proportion of events identified by the new notification systems (success rate) and the contribution of the different notifiers individually and in combination (completeness) and (2) the proportion of events notified within specific time limits (timeliness of notifications) after introducing the innovative approach.

Methods

We conducted a pilot study in 2016 in 2 subdistricts of Bangladesh to understand whether accurate, timely, and complete information on births and deaths can be collected and notified by facility-based service providers; community health workers, including those who routinely visit households; local government authorities; and key informants from the community. We designed a mobile technology–based platform, an app, and a call center through which the notifications were recorded. All notifications were verified through the confirmation of events by family members during visits to the concerned households. We undertook a household survey–based assessment at the end of the notification period.

Results

Our innovative system gathered 13,377 notifications for births and deaths from all channels, including duplicate reports from multiple sources. Project workers were able to verify 92% of the births and 93% of the deaths through household visits. The household survey conducted among a subsample of the project population identified 1204 births and 341 deaths. After matching the notifications with the household survey, we found that the system was able to capture over 87% of the births in the survey areas. Health assistants and family welfare assistants were the primary sources of information. Notifications from facilities were very low for both events.

Conclusions

The Global Civil Registration and Vital Statistics: Scaling Up Investment Plan 2015-2024 and the World Health Organization reiterated the importance of building an evidence base for improving civil registration and vital statistics. Our pilot innovation revealed that it is possible to coordinate with the routine health information system to note births and deaths as the first step to ensure registration. Health assistants could capture more than half of the notifications as a stand-alone source.

Assessment of Effective Coverage of Antenatal Care and Associated Factors in Squatter Settlements of Islamabad Capital Territory, Pakistan: An Analytical Cross-Sectional Study

Background: Effective coverage of antenatal care (ANC) goes beyond contact coverage and assesses the quality of service provided. We used World Health Organization’s recommended positive pregnancy guidelines to assess effective coverage and factors associated with the utilization of ANC among women in squatter settlements of Islamabad Capital Territory.

Methods:We conducted a household survey in the study area with 416 women who had given birth in the past one year. Face-to-face interviews were conducted after the selection of study subjects was done through a systematic random sampling approach. Statistical analysis was carried out using Statistical Package for the Social Sciences 22 (SPSS 22; IBM corp. Armonk, NY). Effective ANC coverage was defined as four or more ANC visits along with all WHO-recommended interventions received at least once during ANC. Adjusted odds ratios (adjOR) with 95% CI were calculated using binary logistic regression to determine the independent effects of all associated factors on the outcome.

Results: Of the 416 women interviewed, 399 (95.6%) had availed ANC services at least once. The coverage of 4+ ANC visits was 92% but effective coverage was only received by 35% women. The proportion of women who received nutritional interventions, maternal and fetal assessment and other preventive measures was 68%, 51% and 80.8% respectively. Maternal education (adjOR, 95% CI = 4.8[2.4-9.3]), family income (2.3[1.1-5.1]), multiparity (1.7[1.1-2.9]), place of first ANC visit (4.2[1.7-10.5]) and distance from a health facility (2.2[1.3-3.6]) were independently associated with the non-utilization of effective ANC.

Conclusion: Despite a very high crude coverage of ANC services, the study shows a very low proportion of women receiving effective coverage. This stresses the importance of measuring the proportion of the population that receives health services with quality to monitor progress toward achieving universal health coverage.

Protocol for analysing the epidemiology of maternal mortality in Zimbabwe: A civil registration and vital statistics trend study

BACKGROUND

Sub-Saharan Africa (SSA) carries the highest burden of maternal mortality, yet, the accurate maternal mortality ratios (MMR) are uncertain in most SSA countries. Measuring maternal mortality is challenging in this region, where civil registration and vital statistics (CRVS) systems are weak or non-existent. We describe a protocol designed to explore the use of CRVS to monitor maternal mortality in Zimbabwe-an SSA country.

METHODS

In this study, we will collect deliveries and maternal death data from CRVS (government death registration records) and health facilities for 2007-2008 and 2018-2019 to compare MMRs and causes of death. We will code the causes of death using classifications in the maternal mortality version of the 10th revision to the international classification of diseases. We will compare the proportions of maternal deaths attributed to different causes between the two study periods. We will also analyse missingness and misclassification of maternal deaths in CRVS to assess the validity of their use to measure maternal mortality in Zimbabwe.

DISCUSSION

This study will determine changes in MMR and causes of maternal mortality in Zimbabwe over a decade. It will show whether HIV, which was at its peak in 2007-2008, remains a significant cause of maternal deaths in Zimbabwe. The study will recommend measures to improve the quality of CRVS data for future use to monitor maternal mortality in Zimbabwe and other SSA countries of similar characteristics.

Methods used to measure maternal mortality in Sub-Saharan Africa from 1980 to 2020: A systematic literature review

BACKGROUND

Gobally, Sub-Saharan Africa (SSA) has the largest maternal mortality burden, but the region lacks accurate data.

OBJECTIVE

To review methods historically used to measure maternal mortality in SSA to inform future study methods.

SEARCH STRATEGY

We searched databases: PubMed, Medline, WorldCat and CINHAL, using keywords "maternal mortality," "pregnancy-related death," "reproductive age mortality," "ratio," "rate," and "risk," using Boolean operators "OR" and "AND" to combine the search terms.

SELECTION CRITERIA

We searched for empirical and analytical studies that: (1) measured maternal mortality levels, (2) were in SSA, (3) reported original results, and (4) were not duplicate studies. We included studies published in English since 1980.

DATA COLLECTION AND ANALYSIS

We screened the studies using titles and abstracts, reading the full text of selected studies. We analyzed the estimates and strengths, and limitations of the methods.

MAIN RESULTS

We identified 96 studies that used nine methods: demographic surveillance (n = 4), health record reviews (n = 18), confidential enquiries and maternal death surveillance and response (n = 7), prospective cohort (n = 9), reproductive age mortality survey (RAMOS) (n = 6), sisterhood method (n = 35), mixed methods (n = 4), and mathematical modeling (n = 13).

CONCLUSION

Sisterhood method studies and RAMOS studies that combined institutional records and community data produced maternal mortality ratios more comparable with WHO estimates.

What is meant by validity in maternal and newborn health measurement? A conceptual framework for understanding indicator validation

BACKGROUND

Rigorous monitoring supports progress in achieving maternal and newborn mortality and morbidity reductions. Recent work to strengthen measurement for maternal and newborn health highlights the existence of a large number of indicators being used for this purpose. The definitions and data sources used to produce indicator estimates vary and challenges exist with completeness, accuracy, transparency, and timeliness of data. The objective of this study is to create a conceptual overview of how indicator validity is defined and understood by those who develop and use maternal and newborn health indicators.

METHODS

A conceptual framework of validity was developed using mixed methods. We were guided by principles for conceptual frameworks and by a review of the literature and key maternal and newborn health indicator guidance documents. We also conducted qualitative semi-structured interviews with 32 key informants chosen through purposive sampling.

RESULTS

We categorised indicator validity into three main types: criterion, convergent, and construct. Criterion or diagnostic validity, comparing a measure with a gold standard, has predominantly been used to assess indicators of care coverage and content. Studies assessing convergent validity quantify the extent to which two or more indicator measurement approaches, none of which is a gold-standard, relate. Key informants considered construct validity, or the accuracy of the operationalisation of a concept or phenomenon, a critical part of the overall assessment of indicator validity.

CONCLUSION

Given concerns about the large number of maternal and newborn health indicators currently in use, a more consistent understanding of validity can help guide prioritization of key indicators and inform development of new indicators. All three types of validity are relevant for evaluating the performance of maternal and newborn health indicators. We highlight the need to establish a common language and understanding of indicator validity among the various global and local stakeholders working within maternal and newborn health.

Implementation of an individual patient prospective database of hospital births in Sri Lanka and its use for improving quality of care

OBJECTIVES

This study was aimed at piloting a prospective individual patient database on hospital deliveries in Colombo, Sri Lanka, and at exploring its use for developing recommendations for improving quality of care (QoC).

DESIGN

Observational study.

SETTING

De Soysa Maternity Hospital, the largest referral hospital for maternity care in Sri Lanka.

DATA COLLECTION AND ANALYSIS

From July 2015 to June 2017, 150 variables were collected for each delivery using a standardised form and entered into a database. Data were analysed every 8 months, and the results made available to local staff. Outcomes of the study included: technical problems; data completeness; data accuracy; key database findings; and use of data.

RESULTS

7504 deliveries were recorded. No technical problem was reported. Data completeness exceeded that of other existing hospital recording systems. Less than 1% data were missing for maternal variables and less than 3% for newborn variables. Mistakes in data collection and entry occurred in 0.01% and 0.09% of maternal and newborn data, respectively. Key QoC indicators identified in comparison with international standards were: relatively low maternal mortality (0.053%); relatively high maternal near-miss cases (3.4%); high rate of induction of labour (24.6%), caesarean section (30.0%) and episiotomy (56.1%); relatively high rate of preterm births (9.4%); low birthweight rate (16.5%); stillbirth (0.97%); and of total deaths in newborn (1.98%). Based on key indicators identified, a list of recommendations was developed, including the use checklists to standardise case management, training, clinical audits and more information for patients. A list of lessons learnt with the implementation of the data collection system was also drawn.

CONCLUSIONS

The study shows that the implemented system of data collection can produce a large quantity of reliable information. Most importantly, this experience provides an example on how database findings can be used for discussing hospital practices, identifying gaps and to agree on recommendations for improving QoC.

Health Indicators Related to Disease, Death, and Reproduction

One of the primary goals of epidemiology is to quantify various aspects of a population’s health, illness, and death status and the determinants (or risk factors) thereof by calculating health indicators that measure the magnitudes of various conditions. There has been some confusion regarding health indicators, with discrepancies in usage among organizations such as the World Health Organization the, Centers for Disease Control and Prevention (CDC), and the CDC of other countries, and the usage of the relevant terminology may vary across papers. Therefore, in this review, we would like to propose appropriate terminological definitions for health indicators based on the most commonly used meanings and/or the terms used by official agencies, in order to bring clarity to this area of confusion. We have used appropriate examples to make each health indicator easy for the reader to understand. We have included practical exercises for some health indicators to help readers understand the underlying concepts.

Assessment of implementation of the health management information system at the district level in southern Malawi

Background

Despite Malawi's introduction of a health management information system (HMIS) in 1999, the country's health sector still lacks accurate, reliable, complete, consistent and timely health data to inform effective planning and resource management.

Methods

A cross-sectional survey was conducted wherein qualitative and quantitative data were collected through in-depth interviews, document review, and focus group discussions. Study participants comprised 10 HMIS officers and 10 district health managers from 10 districts in the Southern Region of Malawi. The study was conducted from March to April 2012. Quantitative data were analysed using Microsoft Excel and qualitative data were summarised and analysed using thematic analysis.

Results

The study established that, based on the Ministry of Health's minimum requirements, 1 out of 10 HMIS officers was qualified for the post. The HMIS officers stated that HMIS data collectors from the district hospital, health facilities, and the community included medical assistants, nurse-midwives, statistical clerks, and health surveillance assistants. Challenges with the system included inadequate resources, knowledge gaps, inadequacy of staff, and lack of training and refresher courses, which collectively contribute to unreliable information and therefore poorly informed decision-making, according to the respondents. The HMIS officers further commented that missing values arose from incomplete registers and data gaps. Furthermore, improper comprehension of some terms by health surveillance assistants (HSAs) and statistical clerks led to incorrectly recorded data.

Conclusions

The inadequate qualifications among the diverse group of data collectors, along with the varying availability and utilisation different data collection tools, contributed to data inaccuracies. Nevertheless, HMIS was useful for the development of District Implementation Plans (DIPs) and planning for other projects. To reduce data inconsistencies, HMIS indicators should be revised and data collection tools should be harmonised.

Timing of maternal death: Levels, trends, and ecological correlates using sibling data from 34 sub-Saharan African countries

Millennium Development Goal 5 has not been universally achieved, particularly in sub-Saharan Africa. Understanding whether maternal deaths occur during pregnancy, childbirth, or puerperium is important to effectively plan maternal health programs and allocate resources. Our main research objectives are to (1) describe the proportions and rates of mortality for the antepartum, intrapartum, and postpartum periods; (2) document how these trends vary by sub-region; and (3) investigate ecological correlations between these rates and maternal care interventions. We used data from the Demographic and Health Survey program, which comprises 84 surveys from 34 sub-Saharan African countries conducted between 1990 and 2014. We calculated age-standardized maternal mortality rates and time-specific maternal mortality rates and proportions, and we assessed correlations with maternal care coverage. We found high levels of maternal mortality in all three periods. Time-specific maternal mortality rates varied by country and region, with some showing an orderly decline in all three periods and others exhibiting alarming increases in antepartum and postpartum mortality. Ecological analysis showed that antenatal care coverage was significantly associated with low antepartum mortality, whereas the presence of a skilled attendant at childbirth was significantly associated with low postpartum mortality. In sub-Saharan Africa, maternal deaths occur at high rates in all three risk periods, and vary substantially by country and region. The provision of maternal care is a predictor of time-specific maternal mortality. These results confirm the need for country-specific interventions during the continuum of care to achieve the global commitment to eliminating preventable maternal mortality.

The influence of the social and cultural environment on maternal mortality in Nigeria: Evidence from the 2013 demographic and health survey

Introduction

Reducing maternal mortality remains a priority for global health. One in five maternal deaths, globally, are from Nigeria.

Objective

This study aimed to assess the sociocultural correlates of maternal mortality in Nigeria.

Methods

We conducted a retrospective analysis of nationally representative data from the 2013 Nigeria Demographic and Health Survey. The analysis was based on responses from the core women’s questionnaire. Maternal mortality was categorized as ‘yes’ for any death while pregnant, during delivery or two months after delivery (as reported by the sibling), and ‘no’ for deaths of other or unknown causes. Multilevel logistic regression analysis was conducted to test for association between maternal mortality and predictor variables of sociocultural status (educational attainment, community women’s education, region, type of residence, religion, and women’s empowerment).

Results

Region, Religion, and the level of community women’s education were independently associated with maternal mortality. Women in the North West were more than twice as likely to report maternal mortality (OR: 2.14; 95% CI: 1.42–3.23) compared to those in the North Central region. Muslim women were 52% more likely to report maternal deaths (OR: 1.52; 95% CI: 1.10–2.11) compared to Christian women. Respondents living in communities where a significant proportion of women have at least secondary schooling were 33% less likely to report that their sisters died of pregnancy-related causes (OR: 0.67; 95% CI: 0.48–0.95).

Conclusion

Efforts to reduce maternal mortality should implement tailored programs that address barriers to health-seeking behavior influenced by cultural beliefs and attitudes, and low educational attainment. Strategies to improve women’s agency should be at the core of these programs; they are essential for reducing maternal mortality and achieving sustainable development goals towards gender equality. Future studies should develop empirically evaluated measures which assess, and further investigate the association between women’s empowerment and maternal health status and outcomes.

DECOMPOSING THE SOCIOECONOMIC INEQUALITY IN UTILIZATION OF MATERNAL HEALTH CARE SERVICES IN SELECTED COUNTRIES OF SOUTH ASIA AND SUB-SAHARAN AFRICA

The gap in access to maternal health care services is a challenge of an unequal world. In 2015, each day about 830 women died due to complications of pregnancy and childbirth. Almost all of these deaths occurred in low-resource settings, and most could have been prevented. This study quantified the contributions of the socioeconomic determinants of inequality to the utilization of maternal health care services in four countries in diverse geographical and cultural settings: Bangladesh, Ethiopia, Nepal and Zimbabwe. Data from the 2010-11 Demographic and Health Surveys of the four countries were used, and methods developed by Wagstaff and colleagues for decomposing socioeconomic inequalities in health were applied. The results showed that although the Concentration Index (CI) was negative for the selected indicators, meaning maternal health care was poorer among lower socioeconomic status groups, the level of CI varied across the different countries for the same outcome indicator: CI of -0.1147, -0.1146, -0.2859 and -0.0638 for <3 antenatal care visits; CI of -0.1338, -0.0925, -0.1960 and -0.2531 for non-institutional delivery; and CI of -0.1153, -0.0370, -0.1817 and -0.0577 for no postnatal care within 2 days of delivery for Bangladesh, Ethiopia, Nepal and Zimbabwe, respectively. The marginal effects suggested that the strength of the association between the outcome and explanatory factors varied across the different countries. Decomposition estimates revealed that the key contributing factors for socioeconomic inequalities in maternal health care varied across the selected countries. The findings are significant for a global understanding of the various determinants of maternal health care use in high-maternal-mortality settings in different geographical and socio-cultural contexts.

Measuring facility capability to provide routine and emergency childbirth care to mothers and newborns: An appeal to adjust for delivery caseload of facilities

Background

Measurement of Emergency Obstetric Care capability is common, and measurement of newborn and overall routine childbirth care has begun in recent years. These assessments of facility capabilities can be used to identify geographic inequalities in access to functional health services and to monitor improvements over time. This paper develops an approach for monitoring the childbirth environment that accounts for the delivery caseload of the facility.

Methods

We used data from the Kenya Service Provision Assessment to examine facility capability to provide quality childbirth care, including infrastructure, routine maternal and newborn care, and emergency obstetric and newborn care. A facility was considered capable of providing a function if necessary tracer items were present and, for emergency functions, if the function had been performed in the previous three months. We weighted facility capability by delivery caseload, and compared results with those generated using traditional “survey weights”.

Results

Of the 403 facilities providing childbirth care, the proportion meeting criteria for capability were: 13% for general infrastructure, 6% for basic emergency obstetric care, 3% for basic emergency newborn care, 13% and 11% for routine maternal and newborn care, respectively. When the new caseload weights accounting for delivery volume were applied, capability improved and the proportions of deliveries occurring in a facility meeting capability criteria were: 51% for general infrastructure, 46% for basic emergency obstetric care, 12% for basic emergency newborn care, 36% and 18% for routine maternal and newborn care, respectively. This is because most of the caseload was in hospitals, which generally had better capability. Despite these findings, fewer than 2% of deliveries occurred in a facility capable of providing all functions.

Conclusion

Reporting on the percentage of facilities capable of providing certain functions misrepresents the capacity to provide care at the national level. Delivery caseload weights allow adjustment for patient volume, and shift the denominator of measurement from facilities to individual deliveries, leading to a better representation of the context in which facility births take place. These methods could lead to more standardized national datasets, enhancing their ability to inform policy at a national and international level.

Evaluation of the maternal mortality surveillance system in Mutare district, Zimbabwe, 2014-2015: a cross sectional study

Introduction

In Zimbabwe the integrated disease surveillance and response guidelines include maternal mortality as a notifiable event reported through the Maternal Mortality Surveillance System (MMSS). A preliminary review of the MMSS data for Mutare district for the period January to June 2014 revealed that there were some discrepancies in cases notified and those captured on the T5 monthly return form. There were also delays in reporting of some maternal deaths. Poor reporting indicated shortcomings in the MMSS in Mutare district and we therefore sought to assess the performance of the maternal mortality surveillance system in Mutare district.

Methods

A descriptive cross sectional study was conducted using Centers for Disease Control and Prevention updated guidelines for evaluating public health surveillance systems. A total of 64 health workers were enrolled into the study from 19 selected health facilities in Mutare district and 32 maternal death notification forms submitted in 2014 to the provincial office were reviewed to assess the quality of information on the forms. Interviewer administered questionnaires were used to collect information from enrolled health workers, the system's attributes namely usefulness, acceptability, simplicity, stability, data quality, timeliness and completeness were assessed and a checklist was used to assess availability of resources for the implementation of the maternal mortality surveillance. We also determined the cost of reporting each maternal death in Mutare district.

Results

Half of the study participants gave the correct definition of a maternal death. All health workers participated and were willing to continue participating in the maternal mortality surveillance. Majority of health workers, 79.7% used data generated from the surveillance system and 59.5% found it easy to implement the system. A total of 32 death notification forms were reviewed and of these, 31 forms were forwarded to the national office and all did not reach the national office on time. Average completeness of notification forms was 76.0% and 53.1% of the forms had all the necessary accompanying documents. Reporting each maternal death was estimated to cost $28.65 in Mutare district.

Conclusion

The strongest components of the maternal mortality surveillance system in Mutare district were usefulness and acceptability. Timeliness and completeness were the weaker components of the system. The system was found to be simple; however, resources were not adequately available in all health facilities.

Space-time patterns in maternal and mother mortality in a rural South African population with high HIV prevalence (2000-2014): results from a population-based cohort

Background

International organs such as, the African Union and the South African Government view maternal health as a dominant health prerogative. Even though most countries are making progress, maternal mortality in South Africa (SA) significantly increased between 1990 and 2015, and prevented the country from achieving Millennium Development Goal 5. Elucidating the space-time patterns and risk factors of maternal mortality in a rural South African population could help target limited resources and policy guidelines to high-risk areas for the greatest impact, as more generalized interventions are costly and often less effective.

Methods

Population-based mortality data from 2000 to 2014 for women aged 15–49 years from the Africa Centre Demographic Information System located in the Umkhanyakude district of KwaZulu-Natal Province, South Africa were analysed. Our outcome was classified into two definitions: Maternal mortality; the death of a woman while pregnant or within 42 days of cessation of pregnancy, regardless of the duration and site of the pregnancy, from any cause related to or exacerbated by the pregnancy or its management but not from unexpected or incidental causes; and ‘Mother death’; death of a mother whilst child is less than 5 years of age. Both the Kulldorff and Tango spatial scan statistics for regular and irregular shaped cluster detection respectively were used to identify clusters of maternal mortality events in both space and time.

Results

The overall maternal mortality ratio was 650 per 100,000 live births, and 1204 mothers died while their child was less than or equal to 5 years of age, of a mortality rate of 370 per 100,000 children. Maternal mortality declined over the study period from approximately 600 per 100,000 live births in 2000 to 400 per 100,000 live births in 2014. There was no strong evidence of spatial clustering for maternal mortality in this rural population. However, the study identified a significant spatial cluster of mother deaths in childhood (p = 0.022) in a peri-urban community near the national road. Based on our multivariable logistic regression model, HIV positive status (Adjusted odds ratio [aOR] = 2.5, CI 95%: [1.5–4.2]; primary education or less (aOR = 1.97, CI 95%: [1.04–3.74]) and parity (aOR = 1.42, CI 95%: [1.24–1.63]) were significant predictors of maternal mortality.

Conclusions

There has been an overall decrease in maternal and mother death between 2000 and 2014. The identification of a clear cluster of mother deaths shows the possibility of targeting intervention programs in vulnerable communities, as population-wide interventions may be ineffective and too costly to implement.

High maternal mortality in Jigawa State, Northern Nigeria estimated using the sisterhood method

BACKGROUND

Maternal mortality is extremely high in Nigeria. Accurate estimation of maternal mortality is challenging in low-income settings such as Nigeria where vital registration is incomplete. The objective of this study was to estimate the lifetime risk (LTR) of maternal death and the maternal mortality ratio (MMR) in Jigawa State, Northern Nigeria using the Sisterhood Method.

METHODS

Interviews with 7,069 women aged 15-49 in 96 randomly selected clusters of communities in 24 Local Government Areas (LGAs) across Jigawa state were conducted. A retrospective cohort of their sisters of reproductive age was constructed to calculate the lifetime risk of maternal mortality. Using most recent estimates of total fertility for the state, the MMR was estimated.

RESULTS

The 7,069 respondents reported 10,957 sisters who reached reproductive age. Of the 1,026 deaths in these sisters, 300 (29.2%) occurred during pregnancy, childbirth or within 42 days after delivery. This corresponds to a LTR of 6.6% and an estimated MMR for the study areas of 1,012 maternal deaths per 100,000 live births (95% CI: 898-1,126) with a time reference of 2001.

CONCLUSIONS

Jigawa State has an extremely high maternal mortality ratio underscoring the urgent need for health systems improvement and interventions to accelerate reductions in MMR.

TRIAL REGISTRATION

The trial is registered at clinicaltrials.gov ( NCT01487707 ). Initially registered on December 6, 2011.

Use of Rapid Ascertainment Process for Institutional Deaths (RAPID) to identify pregnancy-related deaths in tertiary-care obstetric hospitals in three departments in Haiti

Background

Accurate assessment of maternal deaths is difficult in countries lacking standardized data sources for their review. As a first step to investigate suspected maternal deaths, WHO suggests surveillance of “pregnancy-related deaths”, defined as deaths of women while pregnant or within 42 days of termination of pregnancy, irrespective of cause. Rapid Ascertainment Process for Institutional Deaths (RAPID), a surveillance tool, retrospectively identifies pregnancy-related deaths occurring in health facilities that may be missed by routine surveillance to assess gaps in reporting these deaths.

Methods

We used RAPID to review pregnancy-related deaths in six tertiary obstetric care facilities in three departments in Haiti. We reviewed registers and medical dossiers of deaths among women of reproductive age occurring in 2014 and 2015 from all wards, along with any additional available dossiers of deaths not appearing in registers, to capture pregnancy status, suspected cause of death, and timing of death in relation to the pregnancy. We used capture-recapture analyses to estimate the true number of in-hospital pregnancy-related deaths in these facilities.

Results

Among 373 deaths of women of reproductive age, we found 111 pregnancy-related deaths, 25.2% more than were reported through routine surveillance, and 22.5% of which were misclassified as non-pregnancy-related. Hemorrhage (27.0%) and hypertensive disorders (18.0%) were the most common categories of suspected causes of death, and deaths after termination of pregnancy were statistically significantly more common than deaths during pregnancy or delivery. Data were missing at multiple levels: 210 deaths had an undetermined pregnancy status, 48.7% of pregnancy-related deaths lacked specific information about timing of death in relation to the pregnancy, and capture-recapture analyses in three hospitals suggested that approximately one-quarter of pregnancy-related deaths were not captured by RAPID or routine surveillance.

Conclusions

Across six tertiary obstetric care facilities in Haiti, RAPID identified unreported pregnancy-related deaths, and showed that missing data was a widespread problem. RAPID is a useful tool to more completely identify facility-based pregnancy-related deaths, but its repeated use would require a concomitant effort to systematically improve documentation of clinical findings in medical records. Limitations of RAPID demonstrate the need to use it alongside other tools to more accurately measure and address maternal mortality.

Trends and causes of maternal mortality in Ethiopia during 1990-2013: findings from the Global Burden of Diseases study 2013

Background

Maternal mortality is noticeably high in sub-Saharan African countries including Ethiopia. Continuous nationwide systematic evaluation and assessment of the problem helps to design appropriate policy and strategy in Ethiopia. This study aimed to investigate the trends and causes of maternal mortality in Ethiopia between 1990 and 2013.

Methods

We used the Global Burden of Diseases and Risk factors (GBD) Study 2013 data that was collected from multiple sources at national and subnational levels. Spatio-temporal Gaussian Process Regression (ST-GPR) was applied to generate best estimates of maternal mortality with 95% Uncertainty Intervals (UI). Causes of death were measured using Cause of Death Ensemble modelling (CODEm). The modified UNAIDS EPP/SPECTRUM suite model was used to estimate HIV related maternal deaths.

Results

In Ethiopia, a total of 16,740 (95% UI: 14,197, 19,271) maternal deaths occurred in 1990 whereas there were 15,234 (95% UI: 11,378, 19,871) maternal deaths occurred in 2013. This finding shows that Maternal Mortality Ratio (MMR) in Ethiopia was still high in the study period. There was a minimal but insignificant change of MMR over the last 23 years. The results revealed Ethiopia is below the target of Millennium Development Goals (MGDs) related to MMR. The top five causes of maternal mortality in 2013 were other direct maternal causes such as complications of anaesthesia, embolism (air, amniotic fluid, and blood clot), and the condition of peripartum cardiomyopathy (25.7%), complications of abortions (19.6%), maternal haemorrhage (12.2%), hypertensive disorders (10.3%), and maternal sepsis and other maternal infections such as influenza, malaria, tuberculosis, and hepatitis (9.6%). Most of the maternal mortality happened during the postpartum period and majority of the deaths occurred at the age group of 20–29 years. Overall trend showed that there was a decline from 708 per 100,000 live births in 1990 to 497 per 100,000 in 2013. The annual rate of change over these years was -1.6 (95% UI: -2.8 to -0.3).

Conclusion

The findings of the study highlight the need for comprehensive efforts using multisectoral collaborations from stakeholders for reducing maternal mortality in Ethiopia. It is worthwhile for policies to focus on postpartum period.

Reducing Maternal Deaths in Ethiopia: Results of an Intervention Programme in Southwest Ethiopia

Background

In a large population in Southwest Ethiopia (population 700,000), we carried out a complex set of interventions with the aim of reducing maternal mortality. This study evaluated the effects of several coordinated interventions to help improve effective coverage and reduce maternal deaths. Together with the Ministry of Health in Ethiopia, we designed a project to strengthen the health-care system. A particular emphasis was given to upgrade existing institutions so that they could carry out Basic (BEmOC) and Comprehensive Emergency Obstetric Care (CEmOC). Health institutions were upgraded by training non-clinical physicians and midwives by providing the institutions with essential and basic equipment, and by regular monitoring and supervision by staff competent in emergency obstetric work.

Results

In this implementation study, the maternal mortality ratio (MMR) was the primary outcome. The study was carried out from 2010 to 2013 in three districts, and we registered 38,312 births. The MMR declined by 64% during the intervention period from 477 to 219 deaths per 100,000 live births (OR 0.46; 95% CI 0.24–0.88). The decline in MMR was higher for the districts with CEmOC, while the mean number of antenatal visits for each woman was 2.6 (Inter Quartile Range 2–4). The percentage of pregnant women who attended four or more antenatal controls increased by 20%, with the number of women who delivered at home declining by 10.5% (P<0.001). Similarly, the number of deliveries at health posts, health centres and hospitals increased, and we observed a decline in the use of traditional birth attendants. Households living near to all-weather roads had lower maternal mortality rates (MMR 220) compared with households without roads (MMR 598; OR 2.72 (95% CI 1.61–4.61)).

Conclusions

Our results show that it is possible to achieve substantial reductions in maternal mortality rates over a short period of time if the effective coverage of well-known interventions is implemented.

Measuring maternal mortality: a systematic review of methods used to obtain estimates of the maternal mortality ratio (MMR) in low- and middle-income countries

Background

The new global target for maternal mortality ratio (MMR) is a ratio below 70 maternal deaths per 100 000 live births by 2030. We undertook a systematic review of methods used to measure MMR in low- and middle-income countries.

Sources of data

Systematic review of the literature; 59 studies included.

Areas of agreement

Civil registration (5 studies), census (5) and surveys (16), Reproductive Age Mortality Studies (RAMOS) (4) and the sisterhood methods (11) have been used to measure MMR in a variety of settings.

Areas of controversy

Middle-income countries have used civil registration data for estimating MMR but it has been a challenge to obtain reliable data from low-income countries with many only using health facility data (18 studies).

Growing points and areas for further research

Based on the strengths and feasibility of application, RAMOS may provide reliable and contemporaneous estimates of MMR while civil registration systems are being introduced. It will be important to build capacity for this and ensure implementation research to understand what works where and how.

Measuring maternal, foetal and neonatal mortality: Challenges and solutions

Levels and causes of mortality in mothers and babies are intrinsically linked, occurring at the same time and often to the same mother-baby dyad, although mortality rates are substantially higher in babies. Measuring levels, trends and causes of maternal, neonatal and foetal mortality are important for understanding priority areas for interventions and tracking the success of interventions at the global, national, regional and local level. However, there are many measurement challenges. This paper provides an overview of the definitions and indicators for measuring mortality in pregnant and post-partum women (maternal and pregnancy-related mortality) and their babies (foetal and neonatal mortality). We then discuss current issues in the measurement of the levels and causes of maternal, foetal and neonatal mortality, and present options for improving measurement of these outcomes. Finally, we illustrate some important uses of mortality data, including for the development of models to estimate mortality rates at the global and national level and for audits.

Reclassifying causes of obstetric death in Mexico: a repeated cross-sectional study

Objective

To describe causes of maternal mortality in Mexico over eight years, with particular attention to indirect obstetric deaths and socioeconomic disparities.

Methods

We conducted a repeated cross-sectional study using the 2006–2013 Búsqueda intencionada y reclasificación de muertes maternas (BIRMM) data set. We used frequencies to describe new cases, cause distributions and the reclassification of maternal mortality cases by the BIRMM process. We used statistical tests to analyse differences in sociodemographic characteristics between direct and indirect deaths and differences in the proportion of overall direct and indirect deaths, by year and by municipality poverty level.

Findings

A total of 9043 maternal deaths were subjected to the review process. There was a 13% increase (from 7829 to 9043) in overall identified maternal deaths and a threefold increase in the proportion of maternal deaths classified as late maternal deaths (from 2.1% to 6.9%). Over the study period direct obstetric deaths declined, while there was no change in deaths from indirect obstetric causes. Direct deaths were concentrated in women who lived in the poorest municipalities. When compared to those dying of direct causes, women dying of indirect causes had fewer pregnancies and were slightly younger, better educated and more likely to live in wealthier municipalities.

Conclusion

The BIRMM is one approach to correct maternal death statistics in settings with poor resources. The approach could help the health system to rethink its strategy to reduce maternal deaths from indirect obstetric causes, including prevention of unwanted pregnancies and improvement of antenatal and post-obstetric care.

Rural-urban differentials in pregnancy-related mortality in Zambia: estimates using data collected in a census

BACKGROUND

The use of census data to measure maternal mortality is a recent phenomenon, implemented in settings with non-functional vital registration systems and driven by needs for trend data. The 2010 round of population and housing censuses recorded a significant increase in the number of countries collecting maternal mortality data. The objective of this study was to estimate rural-urban differentials in pregnancy-related mortality in Zambia using census data.

METHODS

We used data from the Zambia 2000 and 2010 censuses. Both censuses recorded the female population by age, the number of children ever born, and live births 12 months prior to the census. The 2010 census further recorded, by age, household, and pregnancy-related deaths 12 months prior to the census. We evaluated and adjusted recorded live births using the cohort Parity Fertility ratio method, and household deaths using deaths distribution methods (General Growth Balance and Synthetic Extinct Generation). Adult female mortality and pregnancy-related mortality for rural and urban areas were estimated for the period October 2009 to October 2010.

RESULTS

Data evaluation showed errors in recorded population age, age-at-death, live births, and deaths, and appropriate adjustments were made. Adjusted adult female mortality was high; an adolescent aged 15 years had a one-in-three chance of dying before her 50th birthday in rural areas and one-in-four chance in urban areas. Pregnancy-related deaths comprised 15.3 % of all deaths among reproductive-age women overall; 17.9 % in rural areas and 9.8 % in urban areas. The pregnancy-related mortality ratio for the period was 789 deaths/100,000 live births overall: 960/100,000 live births in rural areas and 470/100,000 live births in urban areas.

CONCLUSIONS

Census-based estimates show very high adult female mortality and particularly high pregnancy-related mortality in both rural and urban areas of Zambia 12 months prior to the 2010 census. Future censuses should pay greater attention to strategies for improving data quality.

Impact of Pregnancy-Related Deaths on Female Life Expectancy in Zambia: Application of Life Table Techniques to Census Data

INTRODUCTION

Since 2000, the world has been coalesced around efforts to reduce maternal mortality. However, few studies have estimated the significance of eliminating maternal deaths on female life expectancy. We estimated, based on census data, the potential gains in female life expectancy assuming complete elimination of pregnancy-related mortality in Zambia.

METHODS

We used data on all-cause and pregnancy-related deaths of females aged 15-49 reported in the Zambia 2010 census, and evaluated, adjusted and smoothed them using existing and verified techniques. We used associated single decrement life tables, assuming complete elimination of pregnancy-related deaths to estimate the potential gains in female life expectancy at birth, at age 15, and over the ages 15-49. We compared these gains with the gains from eliminating deaths from accidents, injury, violence and suicide.

RESULTS

Complete elimination of pregnancy-related deaths would extend life expectancy at birth among Zambian women by 1.35 years and life expectancy at age 15 by 1.65 years. In rural areas, this would be 1.69 years and 2.19 years, respectively, and in urban areas, 0.78 years and 0.85 years. An additional 0.72 years would be spent in the reproductive age group 15-49; 1.00 years in rural areas and 0.35 years in urban areas. Eliminating deaths from accidents, injury, suicide and violence among women aged 15-49 would cumulatively contribute 0.55 years to female life expectancy at birth.

CONCLUSION

Eliminating pregnancy-related mortality would extend female life expectancy in Zambia substantially, with more gains among adolescents and females in rural areas. The application of life table techniques to census data proved very valuable, although rigorous evaluation and adjustment of reported deaths and age was necessary to attain plausible estimates. The collection of detailed high quality cause-specific mortality data in future censuses is indispensable.

Maternal mortality in rural south Ethiopia: outcomes of community-based birth registration by health extension workers

INTRODUCTION

Rural communities in low-income countries lack vital registrations to track birth outcomes. We aimed to examine the feasibility of community-based birth registration and measure maternal mortality ratio (MMR) in rural south Ethiopia.

METHODS

In 2010, health extension workers (HEWs) registered births and maternal deaths among 421,639 people in three districts (Derashe, Bonke, and Arba Minch Zuria). One nurse-supervisor per district provided administrative and technical support to HEWs. The primary outcomes were the feasibility of registration of a high proportion of births and measuring MMR. The secondary outcome was the proportion of skilled birth attendance. We validated the completeness of the registry and the MMR by conducting a house-to-house survey in 15 randomly selected villages in Bonke.

RESULTS

We registered 10,987 births (81·4% of expected 13,492 births) with annual crude birth rate of 32 per 1,000 population. The validation study showed that, of 2,401 births occurred in the surveyed households within eight months of the initiation of the registry, 71·6% (1,718) were registered with similar MMRs (474 vs. 439) between the registered and unregistered births. Overall, we recorded 53 maternal deaths; MMR was 489 per 100,000 live births and 83% (44 of 53 maternal deaths) occurred at home. Ninety percent (9,863 births) were at home, 4% (430) at health posts, 2·5% (282) at health centres, and 3·5% (412) in hospitals. MMR increased if: the male partners were illiterate (609 vs. 346; p= 0·051) and the villages had no road access (946 vs. 410; p= 0·039). The validation helped to increase the registration coverage by 10% through feedback discussions.

CONCLUSION

It is possible to obtain a high-coverage birth registration and measure MMR in rural communities where a functional system of community health workers exists. The MMR was high in rural south Ethiopia and most births and maternal deaths occurred at home.

Comparability of sociodemographic and pregnancy characteristics of pregnancy-related deaths identified via the sisterhood method versus the household/verbal autopsy method

OBJECTIVE

To compare sociodemographic and pregnancy characteristics of pregnancy-related deaths identified by the direct sisterhood and the verbal autopsy with household mortality (HHVA) methods.

METHODS

Nationally representative data for 1997-2001 were obtained from the household, verbal autopsy, and women's questionnaires of the Bangladesh Maternal Health Services and Maternal Mortality Services Survey, 2001. Sociodemographic and pregnancy characteristics were compared for maternal deaths identified by the two methods. Characteristics of deceased women were reported directly with HHVA, but extrapolated in the direct sisterhood method using the reporting sister as proxy.

RESULTS

Overall, 201 pregnancy-related deaths were identified via HHVA and 388 through DS reporting. There were no significant differences between reporting sister characteristics and deceased women's characteristics in educational attainment, working status, husband's educational attainment, and spouse educational parity. However, timing of death relative to pregnancy phase, number of previous live births, and years since death did differ (P<0.05).

CONCLUSION

The sociodemographic characteristics of women with pregnancy-related deaths identified via the two methods were similar. However, some pregnancy characteristics differed significantly, suggesting that different policy interventions are required. Before considering using sister proxy characteristics to target services, issues responsible for these differences should be resolved, and generalizability of evaluated indicators must be considered.

Using the unmet obstetric needs indicator to map inequities in life-saving obstetric interventions at the local health care system in Kenya

BACKGROUND

Developing countries with high maternal mortality need to invest in indicators that not only provide information about how many women are dying, but also where, and what can be done to prevent these deaths. The unmet Obstetric Needs (UONs) concept provides this information. This concept was applied at district level in Kenya to assess how many women had UONs and where the women with unmet needs were located.

METHODS

A facility based retrospective study was conducted in 2010 in Malindi District, Kenya. Data on pregnant women who underwent a major obstetric intervention (MOI) or died in facilities that provide comprehensive Emergency Obstetric Care (EmOC) services in 2008 and 2009 were collected. The difference between the number of women who experienced life threatening obstetric complications and those who received care was quantified. The main outcome measures in the study were the magnitude of UONs and their geographical distribution.

RESULTS

566 women in 2008 and 724 in 2009 underwent MOI. Of these, 185 (32.7%) in 2008 and 204 (28.1%) in 2009 were for Absolute Maternal Indications (AMI). The most common MOI was caesarean section (90%), commonly indicated by Cephalopelvic Disproportion (CPD)-narrow pelvis (27.6% in 2008; 26.1% in 2009). Based on a reference rate of 1.4%, the overall MOI for AMI rate was 1.25% in 2008 and 1.3% in 2009. In absolute terms, 22 (11%) women in 2008 and 12 (6%) in 2009, who required a life saving intervention failed to get it. Deficits in terms of unmet needs were identified in rural areas only while urban areas had rates higher than the reference rate (0.8% vs. 2.2% in 2008; 0.8% vs. 2.1% in 2009).

CONCLUSIONS

The findings, if used as a proxy to maternal mortality, suggest that rural women face higher risks of dying during pregnancy and childbirth. This indicates the need to improve priority setting towards ensuring equity in access to life saving interventions for pregnant women in underserved areas.

The projected effect of scaling up midwifery

We used the Lives Saved Tool (LiST) to estimate deaths averted if midwifery was scaled up in 78 countries classified into three tertiles using the Human Development Index (HDI). We selected interventions in LiST to encompass the scope of midwifery practice, including prepregnancy, antenatal, labour, birth, and post-partum care, and family planning. Modest (10%), substantial (25%), or universal (95%) scale-up scenarios from present baseline levels were all found to reduce maternal deaths, stillbirths, and neonatal deaths by 2025 in all countries tested. With universal coverage of midwifery interventions for maternal and newborn health, excluding family planning, for the countries with the lowest HDI, 61% of all maternal, fetal, and neonatal deaths could be prevented. Family planning alone could prevent 57% of all deaths because of reduced fertility and fewer pregnancies. Midwifery with both family planning and interventions for maternal and newborn health could avert a total of 83% of all maternal deaths, stillbirths, and neonatal deaths. The inclusion of specialist care in the scenarios resulted in an increased number of deaths being prevented, meaning that midwifery care has the greatest effect when provided within a functional health system with effective referral and transfer mechanisms to specialist care.

Estimação da razão de mortalidade materna no Brasil, 2008-2011

Neste trabalho, propõe-se uma metodologia de estimação da razão de mortalidade materna (RMM), no Brasil, 2008-2011, por meio das informações do Ministério da Saúde. O método proposto leva em consideração, o sub-registro geral de óbitos, as proporções de investigação de mortes de mulheres em idade fértil, bem como as proporções de óbitos maternos que foram atribuídos, indevidamente, a outras causas antes da investigação. A RMM foi estimada por Unidade de Federação no triênio de 2009-2011. No Brasil, a RMM atinge o valor mínimo em 2011 (60,8/100 mil nascidos vivo) e o máximo em 2009 (73,1/100 mil nascidos vivos), explicado, provavelmente, pela epidemia de influenza A (H1N1). Os maiores valores da RMM foram encontrados no Maranhão e no Piauí, ultrapassando 100/100 mil nascidos vivos, e o menor foi apresentado por Santa Catarina, o único estado com magnitude inferior a 40/100 mil nascidos vivos. Os resultados indicaram valores superiores aos que deveriam ter sido alcançados de acordo com a quinta meta do milênio, mas apontaram para um decréscimo significativo no período de 1990-2011, se as estimativas anteriores da RMM forem consideradas.

Acknowledging HIV and malaria as major causes of maternal mortality in Mozambique

OBJECTIVE

To review national data on HIV and malaria as causes of maternal death and to determine the importance of looking at maternal mortality at a subnational level in Mozambique.

METHODS

Three national data surveys were used to document HIV and malaria as causes of maternal mortality and to assess HIV and malaria prevention services for pregnant women. Data were collected between 2007 and 2011, and included population-level verbal autopsy data and household survey data.

RESULTS

Verbal autopsy data indicated that 18.2% of maternal deaths were due to HIV and 23.1% were due to malaria. Only 19.6% of recently pregnant women received at least two doses of sulfadoxine-pyrimethamine for intermittent preventive treatment, and only 42.3% of pregnant women were sleeping under an insecticide-treated net. Only 37.5% of recently pregnant women had been counseled, tested, and received an HIV test result. Coverage of prevention services varied substantially by province.

CONCLUSION

Triangulation of information on cause of death and coverage of interventions can enable appropriate targeting of maternal health interventions. Such information could also help countries in Sub-Saharan Africa to recognize and take action against malaria and HIV in an effort to decrease maternal mortality.

Mortality risk associated with surgical treatment of female genital fistula

OBJECTIVE

To describe the mortality risk associated with surgical treatment of female genital fistula and the contributory and contextual factors.

METHODS

In a descriptive study, confidential inquiries and clinical audits were conducted at 14 fistula repair sites in seven resource-poor countries between January 2005 and March 2013. Data collection included interviews with key personnel involved in the clinical management of the deceased, and a review of hospital records and patient files following an audit protocol.

RESULTS

Overall, 26060 fistula repairs were performed at 44 sites located in 13 countries; 30 deaths were reported in this period. Twenty-one deaths were attributable to surgery, yielding a case fatality of 0.08 per 100 procedures. The cause of death in nearly half of the cases was various manifestations of sepsis and inflammation.

CONCLUSION

The case fatality rate for fistula repair surgery in resource-poor countries was in the same range as that for comparable gynecologic operations in high-resource settings. Clinical and systemic issues to be addressed to reduce the case fatality rate include improvement of perioperative care and follow-up, assuring prudent referral or deferral of difficult cases, and maintaining better records.

Application of Capture-Recapture for Fine-tuning Uncertainties About National Maternal Mortality Estimates

BACKGROUND

Maternal mortality ratio (MMR) is one of the main indicators of the millennium development goals and its accurate estimation is very important for the countries concerned. The objective of this study is to evaluate the applicability of capture-recapture (CRC) as an analytical method to estimate MMR in countries.

METHODS

We used the CRC method to estimate MMR in Iran for 2004 and 2005, using two data sources: The maternal mortality surveillance system and the National Death Registry (NDR). Because the data registry contains errors, we defined three levels of matching criteria to enable matching of cases between the two systems. Increasing the matching level makes the matching criteria less conservative. Because NDR data were missing or incomplete for some provinces, we calculated estimates for two conditions: With and without missing/incomplete data.

RESULTS

According to the CRC method, MMR in 2004 and 2005 were 33 and 25 in the best-case scenarios respectively and 86 and 59 in the worst-case scenarios respectively. These estimates are closer to the ones reported by United Nations Agencies published in 2010, 38 and Hogan's study, 30 in 100,000 live births in 2005.

CONCLUSIONS

The MMR estimation by CRC method is slightly different from the international studies. CRC can be considered as a cost-effective method, in comparison with cross-sectional studies or improvement of vital registration systems, which are both costly and difficult. However, to achieve accurate estimates of MMR with CRC method and decrease the uncertainty we need to have valid databases and the absence of such capacities will limit the applicability of this method in developing countries with poor quality health databases.

Maternal and neonatal mortality in south-west Ethiopia: estimates and socio-economic inequality

Introduction

Ethiopia has achieved the fourth Millennium Development Goal by reducing under 5 mortality. Nevertheless, there are challenges in reducing maternal and neonatal mortality. The aim of this study was to estimate maternal and neonatal mortality and the socio-economic inequalities of these mortalities in rural south-west Ethiopia.

Methods

We visited and enumerated all households but collected data from those that reported pregnancy and birth outcomes in the last five years in 15 of the 30 rural kebeles in Bonke woreda, Gamo Gofa, south-west Ethiopia. The primary outcomes were maternal and neonatal mortality and a secondary outcome was the rate of institutional delivery.

Results

We found 11,762 births in 6572 households; 11,536 live and 226 stillbirths. There were 49 maternal deaths; yielding a maternal mortality ratio of 425 per 100,000 live births (95% CI:318–556). The poorest households had greater MMR compared to richest (550 vs 239 per 100,000 live births). However, the socio-economic factors examined did not have statistically significant association with maternal mortality. There were 308 neonatal deaths; resulting in a neonatal mortality ratio of 27 per 1000 live births (95% CI: 24–30). Neonatal mortality was greater in households in the poorest quartile compared to the richest; adjusted OR (AOR): 2.62 (95% CI: 1.65–4.15), headed by illiterates compared to better educated; AOR: 3.54 (95% CI: 1.11–11.30), far from road (≥6 km) compared to within 5 km; AOR: 2.40 (95% CI: 1.56–3.69), that had three or more births in five years compared to two or less; AOR: 3.22 (95% CI: 2.45–4.22). Households with maternal mortality had an increased risk of stillbirths; OR: 11.6 (95% CI: 6.00–22.7), and neonatal deaths; OR: 7.2 (95% CI: 3.6–14.3). Institutional delivery was only 3.7%.

Conclusion

High mortality with socio-economic inequality and low institutional delivery highlight the importance of strengthening obstetric interventions in rural south-west Ethiopia.

Potential gains in reproductive-aged life expectancy by eliminating maternal mortality: a demographic bonus of achieving MDG 5

Objective

We assessed the change over time in the contribution of maternal mortality to a life expectancy calculated between ages 15 and 49, or Reproductive-Aged Life Expectancy (RALE). Our goal was to estimate the increase in RALE in developed countries over the twentieth century and the hypothetical gains in African countries today by eliminating maternal mortality.

Methods

Analogous to life expectancy, RALE is calculated from a life table of ages 15 to 49. Specifically, RALE is the average number of years that women at age 15 would be expected to live between 15 and 49 with current mortality rates. Associated single decrement life tables of causes of death other than maternal mortality are explored to assess the possible gains in RALE by reducing or eliminating maternal mortality. We used population-based data from the Human Mortality Database and the Demographic and Health Surveys.

Findings

In developed countries, five years in RALE were gained over the twentieth century, of which approximately 10%, or half a year, was attributable to reductions in maternal mortality. In sub-Saharan African countries, the possible achievable gains fluctuate between 0.24 and 1.47 years, or 6% and 44% of potential gains in RALE.

Conclusions

Maternal mortality is a rare event, yet it is still a very important component of RALE. Averting the burden of maternal deaths could return a significant increase in the most productive ages of human life.

The neighbourhood method for measuring differences in maternal mortality, infant mortality and other rare demographic events

In the absence of reliable systems for registering rare types of vital events large surveys are required to measure changes in their rates. However some events such as maternal deaths are widely known about in the community. This study examined the utility of asking respondents about events in their neighbourhood as an efficient method for measuring relative rates of rare health events such as maternal and infant deaths. A survey was conducted in the health and demographic surveillance system (HDSS) in Matlab, Bangladesh, which includes two areas with different health care regimes. Adult women were asked about any maternal deaths; multiple births; infant deaths, live births and some other events they knew of in a small specified area around their home. Agreement between HDSS records and survey responses was moderate or better (kappa≥0.44) for all the events and greatest for maternal deaths (kappa = 0.77) with 84% being reported. Most events were more likely to be reported if they were recent (p<0.05). Infant mortality rate in one area was 0.56 times that in the other which was well reflected by the ratio of survey results (0.53). Simulations were used to study the ability of the method to detect differences in maternal mortality ratio. These suggested that a sample size around 5000 would give 80% power to detect a 50% decrease from a baseline of 183 which compared well with an estimated sample size around 10 times larger using the direct sisterhood method. The findings suggest that the Neighbourhood Method has potential for monitoring relative differences between areas or changes over time in the rates of rare demographic events, requiring considerably smaller sample sizes than traditional methods. This raises the possibility for interventions to demonstrate real effects on outcomes such as maternal deaths where previously this was only feasible by indirect methods.

Maternal Mortality in Burkina Faso: A Method from Population Census 2006

BACKGROUND

Estimating maternal mortality level is constantly challenging researchers and planners both in rich and poor countries. In developing countries, particularly in Burkina Faso where the registration system is not working properly, censuses and surveys are the main providers of maternal mortality estimates. However, censuses provide more reliable data about maternal mortality especially at sub-national level. Strength of this situation, the census 2006 of Burkina Faso collected information about maternal mortality. Unfortunately, the census also under reported the phenomenon. In this regard, a methodology was developed to provide adjusted estimates of the phenomenon.

METHODS

This paper aims to assess the census 2006 estimates of maternal mortality through a critical review of the questionnaire, data quality, adjustment technique and outputs. Incoherencies, duplicated cases and missing data were the key aspects of the data quality assessment. The assumptions and outputs of the method were examined and comparison made with existent estimates.

RESULTS

Findings highlighted weaknesses regarding the assumptions of the method and showed that the levels of the phenomenon were still under-estimated. In this research, propositions have been made concerning data cleaning, situations of adjustment coefficients less than 1 and the problem of weak assumptions. Findings led to a MMRatio of 331 [293-402] maternal deaths per 100 000 live births.

CONCLUSION

The level of maternal mortality as published in the census 2006 report (MMRatio of 307) is acceptable because falling in the range 293-402. However, the questionnaire, data and method used needed improvements.

Maternal mortality in rural South Africa: the impact of case definition on levels and trends

Background

Uncertainty in the levels of global maternal mortality reflects data deficiencies, as well as differences in methods and definitions. This study presents levels and trends in maternal mortality in Agincourt, a rural subdistrict of South Africa, under long-term health and sociodemographic surveillance.

Methods

All deaths of women aged 15 years–49 years occurring in the study area between 1992 and 2010 were investigated, and causes of death were assessed by verbal autopsy. Two case definitions were used: “obstetrical” (direct) causes, defined as deaths caused by conditions listed under O00–O95 in International Classification of Diseases-10; and “pregnancy-related deaths”, defined as any death occurring during the maternal risk period (pregnancy, delivery, 6 weeks postpartum), irrespective of cause.

Results

The case definition had a major impact on levels and trends in maternal mortality. The obstetric mortality ratio averaged 185 per 100,000 live births over the period (60 deaths), whereas the pregnancy-related mortality ratio averaged 423 per 100,000 live births (137 deaths). Results from both calculations increased over the period, with a peak around 2006, followed by a decline coincident with the national roll-out of Prevention of Mother-to-Child Transmission of HIV and antiretroviral treatment programs. Mortality increase from direct causes was mainly due to hypertension or sepsis. Mortality increase from other causes was primarily due to the rise in deaths from HIV/AIDS and pulmonary tuberculosis.

Conclusion

These trends underline the major fluctuations induced by emerging infectious diseases in South Africa, a country undergoing rapid and complex health transitions. Findings also pose questions about the most appropriate case definition for maternal mortality and emphasize the need for a consistent definition in order to better monitor and compare trends over time and across settings.

Improving the measurement of maternal mortality: the sisterhood method revisited

BACKGROUND

Over the past several decades the efforts to improve maternal survival and the consequent demand for accurate estimates of maternal mortality have increased. However, measuring maternal mortality remains a difficult task especially in developing countries with weak information systems. Sibling histories included in household surveys (most notably the Demographic and Health Surveys (DHS)) have emerged as an important source of maternal mortality data. Data have been mainly collected from women and have not been widely collected from men due to concerns about data quality. We assess data quality of histories obtained from men and the potential to improve the efficiency of surveys measuring maternal mortality by collecting such data.

METHODS AND FINDINGS

We used data from 10 Demographic and Health Surveys (DHS) that have included a full sibling history in both their women's and men's questionnaires. We estimated adult and maternal mortality indicators from histories obtained from men and women. We assessed the completeness and accuracy of these histories using several indicators of data quality. Our study finds that mortality estimates based on sibling histories obtained from men do not systematically or significantly differ from those obtained from women. Quality indicators were similar when comparing data from men and women. Pooling data obtained from men and women produced narrower confidence intervals.

CONCLUSION

From experience across nine developing countries, sibling history data obtained from men appear to be a reliable source of information on adult and maternal mortality. Given that there are no significant differences between mortality estimates based on data obtained from men and women, data can be pooled to increase efficiency. This finding improves the feasibility for countries to generate robust empirical estimates of adult and maternal mortality from surveys. Further we recommend that male sibling histories be collected from all sample households rather than from a subsample.

Existence and functionality of emergency obstetric care services at district level in Kenya: theoretical coverage versus reality

Background

The knowledge on emergency obstetric care (EmOC) is limited in Kenya, where only partial data from sub-national studies exist. The EmOC process indicators have also not been integrated into routine health management information system to monitor progress in safe motherhood interventions both at national and lower levels of the health system. In a country with a high maternal mortality burden, the implication is that decision makers are unaware of the extent of need for life-saving care and, therefore, where to intervene. The objective of the study was to assess the actual existence and functionality of EmOC services at district level.

Methods

This was a facility-based cross-sectional study. Data were collected from 40 health facilities offering delivery services in Malindi District, Kenya. Data presented are part of the “Response to accountable priority setting for trust in health systems” (REACT) study, in which EmOC was one of the service areas selected to assess fairness and legitimacy of priority setting in health care. The main outcome measures in this study were the number of facilities providing EmOC, their geographical distribution, and caesarean section rates in relation to World Health Organization (WHO) recommendations.

Results

Among the 40 facilities assessed, 29 were government owned, seven were private and four were voluntary organisations. The ratio of EmOC facilities to population size was met (6.2/500,000), compared to the recommended 5/500,000. However, using the strict WHO definition, none of the facilities met the EmOC requirements, since assisted delivery, by vacuum or forceps was not provided in any facility. Rural–urban inequities in geographical distribution of facilities were observed. The facilities were not providing sufficient life-saving care as measured by caesarean section rates, which were below recommended levels (3.7% in 2008 and 4.5% in 2009). The rates were lower in the rural than in urban areas (2.1% vs. 6.8%; p < 0.001 ) in 2008 and (2.7% vs. 7.7%; p < 0.001) in 2009.

Conclusions

The gaps in existence and functionality of EmOC services revealed in this study may point to the health system conditions contributing to lack of improvements in maternal survival in Kenya. As such, the findings bear considerable implications for policy and local priority setting.

mHealth for midwives: a call to action

The use of mobile phones has grown exponentially in the last decade including in some of the most remote and low-resource regions of the world. With the geographic expansion of mobile phone use, information and communication technology for development (ICT4D) was born, and innovative uses for mobile technologies in various fields including health care have emerged. This use of mobile technology in health care is known as mHealth. mHealth interventions are being used internationally to improve maternal and child health. Be it the use of a mobile phone to call for emergency transport, remote consultation, or large-scale short message service (SMS)-based community education programs, mHealth is demonstrating its utility in reproductive health programs throughout the world. This article describes the evolution and challenges of mHealth, discusses the role of mHealth in achieving Millennium Development Goals 4 and 5, and addresses the potential impact of mHealth for midwives. mHealth represents a new area of global health that warrants the attention of midwifery advocates. Midwifery leadership in the field of mHealth at this early stage of its development will ensure future health programming that is relevant to the needs of women and the midwives who care for them.

Measuring unsafe abortion-related mortality: a systematic review of the existing methods

BACKGROUND

The WHO estimates that 13% of maternal mortality is due to unsafe abortion, but challenges with measurement and data quality persist. To our knowledge, no systematic assessment of the validity of studies reporting estimates of abortion-related mortality exists.

STUDY DESIGN

To be included in this study, articles had to meet the following criteria: (1) published between September 1(st), 2000-December 1(st), 2011; (2) utilized data from a country where abortion is "considered unsafe"; (3) specified and enumerated causes of maternal death including "abortion"; (4) enumerated ≥100 maternal deaths; (5) a quantitative research study; (6) published in a peer-reviewed journal.

RESULTS

7,438 articles were initially identified. Thirty-six studies were ultimately included. Overall, studies rated "Very Good" found the highest estimates of abortion related mortality (median 16%, range 1-27.4%). Studies rated "Very Poor" found the lowest overall proportion of abortion related deaths (median: 2%, range 1.3-9.4%).

CONCLUSIONS

Improvements in the quality of data collection would facilitate better understanding global abortion-related mortality. Until improved data exist, better reporting of study procedures and standardization of the definition of abortion and abortion-related mortality should be encouraged.

Pregnancy registration systems can enhance health systems, increase accountability and reduce mortality

As many low- to middle-income countries strive to achieve targets of reduced maternal, neonatal and infant mortality set by the Millennium Development Goals, health system innovations which can accelerate progress are being carefully examined. Among these are technologies and systems which aim to strengthen frontline health workers and the health systems within which they work, by enabling the registration of pregnancies, births and outcomes. Accurate, population-based numerators and denominators can help to improve accountability of the health system to provide expected routine antenatal and post-natal care, as well as emergency support and referral, as needed. The enumeration of women of reproductive age, followed by prospective, voluntary registration of pregnancies has the potential to support governments, health agencies, and the populations they serve, to ensure public health service delivery and to guide informed policies.

High maternal mortality in rural south-west Ethiopia: estimate by using the sisterhood method

BACKGROUND

Estimation of maternal mortality is difficult in developing countries without complete vital registration. The indirect sisterhood method represents an alternative in places where there is high fertility and mortality rates. The objective of the current study was to estimate maternal mortality indices using the sisterhood method in a rural district in south-west Ethiopia.

METHOD

We interviewed 8,870 adults, 15-49 years age, in 15 randomly selected rural villages of Bonke in Gamo Gofa. By constructing a retrospective cohort of women of reproductive age, we obtained sister units of risk exposure to maternal mortality, and calculated the lifetime risk of maternal mortality. Based on the total fertility for the rural Ethiopian population, the maternal mortality ratio was approximated.

RESULTS

We analyzed 8503 of 8870 (96%) respondents (5262 [62%] men and 3241 ([38%] women). The 8503 respondents reported 22,473 sisters (average = 2.6 sisters for each respondent) who survived to reproductive age. Of the 2552 (11.4%) sisters who had died, 819 (32%) occurred during pregnancy and childbirth. This provided a lifetime risk of 10.2% from pregnancy and childbirth with a corresponding maternal mortality ratio of 1667 (95% CI: 1564-1769) per 100,000 live births. The time period for this estimate was in 1998. Separate analysis for male and female respondents provided similar estimates.

CONCLUSION

The impoverished rural area of Gamo Gofa had very high maternal mortality in 1998. This highlights the need for strengthening emergency obstetric care for the Bonke population and similar rural populations in Ethiopia.

Achieving the millennium development goal of reducing maternal mortality in rural Africa: an experience from Burundi

OBJECTIVES

To estimate the reduction in maternal mortality associated with the emergency obstetric care provided by Médecins Sans Frontières (MSF) and to compare this to the fifth Millennium Development Goal of reducing maternal mortality.

METHODS

The impact of MSF's intervention was approximated by estimating how many deaths were averted among women transferred to and treated at MSF's emergency obstetric care facility in Kabezi, Burundi, with a severe acute maternal morbidity. Using this estimate, the resulting theoretical maternal mortality ratio in Kabezi was calculated and compared to the Millennium Development Goal for Burundi.

RESULTS

In 2011, 1385 women from Kabezi were transferred to the MSF facility, of whom 55% had a severe acute maternal morbidity. We estimated that the MSF intervention averted 74% (range 55-99%) of maternal deaths in Kabezi district, equating to a district maternal mortality rate of 208 (range 8-360) deaths/100,000 live births. This lies very near to the 2015 MDG 5 target for Burundi (285 deaths/100,000 live births).

CONCLUSION

Provision of quality emergency obstetric care combined with a functional patient transfer system can be associated with a rapid and substantial reduction in maternal mortality, and may thus be a possible way to achieve Millennium Development Goal 5 in rural Africa.