Maternal Mortality

Liliana Carvajal
Vibeke Oestreich Nielsen
Armando H. Seuc
UNICEF
Statistics Norway
WHO
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 BACKGROUND
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 MDG 5: Improve Maternal Health
Target 5.A: Reduce by three quarters, between
1990 and 2015, the maternal mortality ratio
– 5.1 Maternal mortality ratio (MMR)
– 5.2 Proportion of births attended by skilled health
personnel (SAB)
Target 5.B: Achieve, by 2015, universal access
to reproductive health
– 5.3 Contraceptive prevalence rate
– 5.4 Adolescent birth rate
– 5.5 Antenatal care coverage
at least one visit and at least four visits
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– 5.6 Unmet need for family planning

 Maternal Mortality
Target 5.A: Reduce by three quarters, between
1990 and 2015, the maternal mortality ratio
– 5.1 Maternal mortality ratio
– 5.2 Proportion of births attended by skilled health
personnel
Initially updates every 5 year since 1990 by WHO,
UNICEF, UNFPA – The World Bank joined in 2005
– 2008 update – An academic team at University of Berkeley in
collaboration with MMEIG
– 2010 update – idem
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 MEASURING MATERNAL
MORTALITY
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 Trends in Maternal Mortality:
1990 to 2008
Reviewed by the technical
advisory group (TAG) with
experts from academic
institutions: Berkeley,
Harvard, Hopkins, Texas,
Aberdeen, Umea, Statistics
Norway
Countries consulted for
comments on methodology
and additional input
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 Trends in Maternal Mortality:
1990 to 2010
Reviewed by the technical
advisory group (TAG) with
experts from academic
institutions: Berkeley,
Harvard, Hopkins, Texas,
Aberdeen, Umea, Statistics
Norway
Countries consulted for
comments on methodology
and additional input
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 General framework of the maternal mortality
estimates 1990-2008 and 1990-2010
Levels and trends of maternal mortality between 1990
and 2008 for 172 countries (1990-2010 for 181
countries)
Hierarchical/multilevel linear regression model
The model input data is the PMDF (proportion
maternal among all female deaths 15-49) adjusted for
completeness and definition
Covariates: the log(GDP), log(GFR) and SAB
The final output takes into account the maternal
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mortality related with the HIV/AIDS

 Definitions used
Maternal death: “the death of a woman while
pregnant or within 42 days of termination of
pregnancy, irrespective of the duration and the
site of the pregnancy, from any cause related to
or aggravated by the pregnancy or its
management but not from accidental or
incidental causes.” ICD-10, WHO,1994
Pregnancy-related death: “the death of a woman
while pregnant or within 42 days of termination
of pregnancy”
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 Estimated measures
Maternal Mortality Ratio (MMR): Ratio of maternal
deaths in a period to live births (proxy for risky
events) in the same period (x 100,000).
Number of maternal deaths
PMDF: Proportion of maternal among female
deaths 15-49
Lifetime risk of a maternal death: An estimate of
the likelihood that a woman who survives to age
15 will die of maternal causes
– proportion of women reaching reproductive age who
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would die of maternal causes, taking into account

competing causes
 Input data to the model: PMDF
– PMDF is considered less subject to under-reporting
than MMR (maternal and non-maternal deaths likely
to be under-reported to similar degree)
– Maternal deaths as defined by ICD is difficult to
capture – usually all deaths in pregnancy measured
– Efforts have been made to adjust for:
under reporting
definition
– For the model the HIV/AIDS component was taken
out from the PMDF; the HIV/AIDS component is
then added back after the model fitting
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 Input database
1990-2008: Database of 172 countries -
territories, from 1985 onwards
1990-2010: Database of 181 countries -
territories, from 1985 onwards
Nationally representative data
=> focusing on sources where PMDF is
possible to compute
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 METHODS OF DATA
COLLECTION, ESTIMATION
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 Sources of Data
Civil registration systems with cause of death
assigned by attending physician
Household surveys with sibling histories
Sample vital registration systems
Reproductive Age Mortality Surveys (RAMOS): not
very common
Population censuses with questions on household
deaths
Hospital- or facility-based studies
Other
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 Data on maternal mortality:
availability
Sources Number Number of
of surveys country-years
Civil Registration 1891 1891 (2125*)
Surveys with Sibling 105 819 (895*)
Histories
Population Censuses 18 19 (19*)
Other (eg special surveys, 80 113 (161*)
verbal autopsies,
surveillance)
Total 2094 2842 (3200*)
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*: 1990-2010 estimations
 Data available in the Region:
Group
Afghanistan B A. Civil registration
Bangladesh B characterized as
Bhutan B
complete, with good
Cambodia B
attribution of cause
China B
Indonesia B
of death
Iran B B. Countries lacking
Lao B good complete
Mongolia C registration data but
Myanmar B where other types of
Nepal B data are available
Pakistan B
Philippines B
C. No national data on
Thailand B maternal mortality
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Papua New Guinea C

 General Problems with
Maternal Mortality Measurement
Rare events
– National trends unstable
– For household surveys requires very large samples
Certain types of maternal deaths hard to identify
(especially abortion-related)
Non-VR methods tend to measure pregnancy-
related mortality PRMR
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 Civil Registration Data
WHO estimates that approx. 72 (out of 193)
member states have complete recording of
deaths
– But not all have adequate cause of death data
Even in countries with complete VR,
classification of deaths as maternal is
problematic
– Recent increase in MMR (47% 2002 to 2004) in US
due to change of death certificate
Issues:
– 14 studies (confidential enquiries, record linkages) of
countries with complete registration: a median
underestimation of 0.5 true maternal deaths were
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incorrectly recorded as non-maternal

 Household Surveys
With Sibling Histories
Key questions for sibling history:
– Each sibling listed individually
– Record sex
– Record age in completed years for surviving sibs
– Record year of death, age at death for dead sibs
– For deaths of women of reproductive age, 3 questions
about timing of death relative to pregnancy
Widely used by DHS program (41countries,65 surveys)
Issues:
– Measures pregnancy-related mortality
– Estimates are usually made for 7 years before survey
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– May under-estimate overall mortality

 Sample Vital Registration Systems
Special procedures in random sample of areas
(4,000+ in India, 160 in China)
Continuous monitoring of vital events plus 6-
monthly household survey (India)
Cause of death identified by verbal autopsy (VA)
(India) or case records plus VA (China)
Issues:
– Requires considerable administrative sophistication
– Cannot be implemented rapidly
– Needs periodic evaluation
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 RAMOS Studies
Starting point is complete listing of deaths of women
of reproductive age
– Best starting point is close to complete VR
– Key feature is triangulation among data sources (eg
church records, burial grounds) to identify missed deaths
– May be done for a sample (but has to be large)
Each death is investigated in detail to determine
whether or not it was maternal
– Hospital, health facility records
– Household interviews
Issues:
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– Results may be no better than the frame of deaths

– MMR also needs number of births
 Censuses with Questions on Deaths
Population censuses can include questions on
deaths in households in defined recent reference
period
Reported deaths of reproductive aged women
trigger questions about the timing of death relative
to pregnancy
Issues:
– Pregnancy-related mortality
– Census misses deaths in single-person households
– Death of head of household may result in household breakup
– Experience suggests there is almost always some under-
reporting
– Need to evaluate carefully
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– No consensus as to the quality of the data obtained

 Facility-Based Studies
Useful for identifying areas for improved care
(confidential enquiries)
Potential for gold standard case identification
(case notes)
Facility deaths (and births) are selected on
characteristics that may not be known
Not readily generalizable to a national MMR
estimate
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 ESTIMATION (MODELLING)
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 Modelling

Countries in Group A Countries in Groups B

– No modelling was and C
used – Multilevel model was
– Essentially data from used to predict PMDF
CR were adjusted by a with GDP, GFR and
1.5 factor SAB as predictors
– Group C countries
«borrowed» from other
countries in the region
– PMDF was converted
into MMR
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 Input data to the model:
Adjustment by type of source
Adjustment for completeness of reporting
specified in relation to the type of data
– CR system: Review of recent literature on
underestimation of maternal deaths in CR systems
adjustment by a factor of 1.5
– Sibling histories: age-standardization,
1.1 adjustment (underestimation of early pregnancy
deaths)
0.9, 0.85 adjustment (remove accidental deaths)
– Other special studies (e.g., RAMOS):
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1.1 adjustment
 Covariates
GDP: gross domestic product PPP per capita, in
constant 2005 international dollar; the World
Bank series, complemented by other sources
GFR: general fertility rate, the number of births
in a population divided by the number of women
at reproductive ages; UNPD World Population
Prospects
SAB: the proportion of deliveries with a skilled
attendant at birth from UNICEF database
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 Covariates and the model
A time series of these three covariates were
constructed for the 1985-2008 (1985-2010) period
Time-matched average values of the covariates for
time intervals corresponding to the period of each
observation of the dependent variable PMDF were
computed
A hierarchical/multilevel model with three main
covariates, plus random effects for countries and
regions and an offset which will adjust the
denominator of PMDF for AIDS.
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 Input data to the model:
Definition and HIV/AIDS adjustment
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 MODELLING OF PMDFna
PMDF=Y=dependent variable;
datapoints collected (n=680)
Covariates: GDP, GFR, SAB
Cleaning process

Datapoints included (n=484) Cleaning, adjustments,

inter/extra-polations

unadjusted PMDF MMR Adjusted GDP, GFR, SAB

Adjustments:
1. For all countries:
- including under-
reporting / misclassifications
(1.5 for VR; 1.1 for others) adjusted/observed
2. For Groups B-C countries: Multilevel
- excluding AIDS-related PMDFna modelling
[from numerator (*) and from
denominator (**)], and excluding
non-maternal from numerator validation
using π=10% or 15% (**) Model fitting
(*): PMDFadj1=(PMDFadj0 – ũ v a) (1-π)δ
(**): offset term, i.e.
log(PMDFadj1) = b0 + j + k
+ b1 log(GDP) + b2 log(GFR)
PMDFna
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+ b3 SAB + log(1‐a) + ε
predictions 1
 Excluding AIDS-related
deaths from PMDF:
PMDFadj1=(PMDFadj0 – ũ v a) (1-π)δ
o removes from numerator
a = fraction of AIDS deaths among deaths to women aged 15-49
v = proportion of such AIDS deaths that occur during pregnancy (or within 42
days after delivery)
ũ = fraction “actually" counted as maternal

log(PMDFadj1) = b0 + j + k
+ b1 log(GDP) + b2 log(GFR)
+ b3 SAB + log(1‐a) + ε
o removes from denominator
AMDF = AIDS-adjusted (denominator) PMDF = (PMDFadj1)/(1-a)
 Final estimates of PMDF:

 PMDFa : splitting the UNAIDS estimate of total

AIDS deaths among women aged 15‐49;
PMDFa = u v a
a = fraction of AIDS deaths among deaths to women
aged 15-49
v = proportion of such AIDS deaths that occur during
pregnancy (or within 42 days after delivery)
u = fraction that “should be" counted as maternal
 PMDF = PMDFna + PMDFa
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 Uncertainty
Components of uncertainty include:
Any remaining bias in adjusted PMDF values
Uncertainty in model parameters (c, k, u, and pi)
Regression prediction uncertainty within the
PMDF model
Possible error in MMR conversion (estimated
births and deaths)
Alternative models, covariates, etc.
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 What is new in 2008 and 2010
compared with 2005

Trend estimates for countries

=> bigger database
Definition issue addressed
Maternal deaths related with HIV/AIDS taken
into account
Statistical model – more detailed
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 What is new in 2010 compared with 2008

Data availability:
– 3200 country-years of data in 2010 compared
with 2842 in 2008 (13% increase)
– Total female deaths in the reproductive age
were updated backward (routine updating
process by WHO)
Countries included:
– 181 in 2010 vs. 172 in 2008. The population
cut-off for country inclusion was 100000 in
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2010 vs. 250000 in 2008

 COUNTRY CONSULTATION
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 Country consultation
CL.33.2011 (8 December 2011):
– “Following WHO’s quality standards for data
publication and prior to the official release of the
above estimates, WHO is consulting with its Member
States to review each individual country estimate in
order to identify and make use of primary data
sources that may not have been previously identified.”
Focal point identification and review. Comments
received during consultation.
Accepted amendments to data input
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– source of reference clearly identified