Measuring Maternal Mortality

By: Umakant Singh

Reduction in the Maternal Mortality is one of the six health related MDG. In 2008, there were an estimated 358 000 maternal deaths in the world, or a maternal mortality ratio (MMR) of 260 maternal deaths per 100 000 live births.  India had the largest number of maternal deaths (63 000), followed by Nigeria (50 000).

Maternal mortality is an indicator of

–      Disparity and inequity between men and women.

–       It implies the place of women in society

–       Women’s opportunity with regard to health-care access and economic activity.

–      Weakness of overall health system

WHO defines maternal death as “ The death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management but not from accidental or incidental causes”. Accurate identification of the causes of maternal deaths by differentiating the extent to which they are due to direct or indirect obstetric causes, or due to accidental or incidental events, is not always possible – particularly in settings where deliveries occur mostly at home, and/or where civil registration systems with correct attribution of causes of death are inadequate.

Statistical measures of maternal mortality

Maternal mortality ratio	Number of maternal deaths during a given time period per 100 000 live births during the same time-period.
Maternal mortality rate	Number of maternal deaths in a given period per 100 000 women of reproductive age during the same time-period.

Approaches to measuring maternal mortality

Civil registration systems	Involves routine registration of births and deaths. Ideally, maternal mortality statistics should be obtained through civil registration data. However,  maternal deaths may be missed or misclassified;
Household surveys	Where civil registration data are not available, household surveys provide an alternative however require large sample size, expensive, uncertainty (wide confidence interval)
Sisterhood methods  (Cambodia)	obtain information by interviewing a representative sample of respondents about the survival of all their adult sisters (number of ever-married sisters, how many are alive, how many are dead, and how many died during pregnancy, delivery, or within six weeks of pregnancy). reduces the sample size, but it provides a retrospective rather than a current maternal mortality estimate (over 5 years prior to the survey);
Reproductive-age mortality studies	This approach involves identifying and investigating the causes of all deaths of women of reproductive age in a defined area/population by using multiple sources of data (e.g. interviews of family members, vital registrations, health facility records, burial records, traditional birth attendants)
Verbal autopsy15	cause of death through interviews with family or community members, where medical certification of cause of death is not available.
Census	A national census, with the addition of a limited number of questions, could produce estimates of maternal mortality; this approach eliminates sampling errors . Allows identification of deaths in the household in a relatively short  period (1–2 years), thereby providing recent maternal mortality estimates,

Causes of Maternal Mortality: Three Delays Model

The causes of maternal and child deaths are largely multidimensional and multidisciplinary

 Phase 1 delay. Delay in decision to seek care

–      Failure to recognize complications

–      Acceptance of maternal death

–      Low status of women

–      Socio-cultural barriers to seeking care: women's mobility, ability to command resources, decision-making abilities, beliefs and practices surrounding childbirth and delivery, nutrition and education

Phase 2 delay. Delay in reaching care

           

–      Poor roads, mountains, islands, rivers - poor organization

Phase 3 delay. Delay in receiving care

–      Inadequate facilities, supplies, personnel

–      Poor training and demotivation of personnel

–      Lack of finances

Maternal Mortality:  Socio-economic Determinants

Evidence and Community level experience show that Maternal Mortality is influenced by

–      Poverty

–      Women’s Literacy

–      Social Exclusion faced eg. rural and minority section

–      Better access to food and nutrition (anemia as a consequence)

–      Age at marriage and childbirth

–      Access to health services – including contraceptive and abortion services

 Some Contributing Factors to Maternal Deaths

• Adolescent pregnancy
• HIV among pregnant women
• Malaria
• Malnutrition
• Harmful traditional practices

What is needed to reduce Maternal Mortality?

• More resources for Maternal Health and health system.
• Better monitoring.
• Ensuring staffing in rural areas for EmOC.
• Efforts to improve quality.
• Addressing policy barriers - delegation & posting and transfers.
• Newer thinking - social health insurance, Voucher and Health Equity fund
• Maternity  Waiting Room
• Strong commitment to maternal  and newborn survival and health by political leaders and decision makers at national and local levels
• Community involvement, Resource mobilization and Partnership
• Realistic and appropriate investment in women’s education, health and economic empowerment
• Male involvement and participation in Reproductive Health issues and services
•  Implementation framework with clearly defined supervision, monitoring and evaluation mechanisms.

Any country can reduce MMR, but it needs political & societal commitment.  Country should invest in women to fulfill their potential to deliver as mothers, individuals, family members, and citizens.  My recommendation to all implementers and practitioners of maternal health is “Knowing is not enough,  we must apply;  Willing is not enough, We must do.” Geothe