1
Measuring progress in reducing maternal mortality

https://doi.org/10.1016/j.bpobgyn.2007.12.001Get rights and content

The need to monitor progress in reducing maternal mortality has a long history, which can be traced back to the 1700s in some parts of the Western world. Today, however, this need is felt most acutely in developing countries, where the priority is to stimulate, evaluate and sustain action to prevent these essentially avoidable deaths. Over the last two decades, considerable efforts have been made to understand and overcome the measurement challenges of maternal mortality in the context of weak information systems, and new and enhanced methods and tools have emerged.

Introduction

Today, the desire to show progress in reducing the burden of mortality is universal: across developing and developed countries; at international, national and local levels; and for all causes and conditions. What is also universal is the challenge this presents. Capturing deaths and assigning causes is not straightforward, and this alone makes showing changes – increases or decreases – problematic.1 Two-thirds of the world's population reside where routine registration of deaths is missing, and for the remaining third, misclassification of particular causes or circumstances can sometimes lead to spurious trends and conclusions about progress.2 It is important to acknowledge this wider reality of mortality measurement even when specific subgroups are the focus of attention. In this chapter, the focus is on maternal mortality and a reminder of the wider challenge is particularly relevant. Measuring maternal mortality is often regarded as one of the most problematic outcomes to track, especially in developing countries.3 There certainly are significant challenges, but also many distinctive characteristics to maternal deaths, which aid reporting and measurement, as illustrated later. The aim of our paper is to introduce the various approaches that are possible in different country settings, and so illustrate the comparative wealth of opportunities for measuring maternal mortality. Why is this illustration important now?

2007 marked the twentieth anniversary year of the international Safe Motherhood Initiative, which was launched to galvanize action to reduce maternal mortality.4 2007/08 also marks the mid-point to achieving the Millennium Development Goals (MDG), one of which – MDG5 – will be judged on the basis of a 75% reduction in maternal mortality by 2015.5 Together, these events have shone a spotlight on the weaknesses of existing statistics, nationally and thus internationally, on the magnitude and trends in maternal mortality. Ironically, the weaknesses are often discussed together with apparent conclusions that no progress has been made and that MDG5 is ‘off-track’.6 Confusing ‘no progress’ with ‘no measurement of progress’ is the fundamental problem here, as is confusing ‘no options for measurement’ and ‘no resources to do so’. Such confusions have repercussions at local, national and international levels, leading in the extreme to disillusionment and disinvestment in actions to reduce these deaths, because ‘what you count is what you do’.7 Currently, there are indeed no standardized methods and sources for measuring maternal mortality that can be universally applied and are universally reliable for the purposes of international monitoring of maternal mortality. This does not, however, mean that at subnational and national levels there are no options for measurement. There is currently a high demand and need within countries to measure maternal mortality to stimulate, evaluate and sustain action to prevent these essentially avoidable deaths.

This chapter synthesizes the published literature and draws on key resource materials (Box 1) to present the current range of measurement options, and to highlight the scope for further improvement and innovation. The definitions and common indicators for maternal mortality are introduced. The main reasons for, and history of, measurement is then discussed. Next, the challenges to measurement are outlined, followed by the specific issues raised by tracking progress. An overview is then given of the measurement approaches for finding deaths and for categorizing them as maternal. The final section proposes priority areas for research and development.

Section snippets

Definitions

There are two main bases for defining maternal death: cause of death and time of death relative to pregnancy status.8 These have direct implications for the choice and suitability of alternative data sources and methods for measuring maternal mortality, such as civil registration, routine health information systems or population-based household surveys. For example, in many developing countries only deaths occurring in health facilities are assigned a medical cause, as certification of deaths

Why measure maternal mortality?

Information on maternal mortality is needed for a wide range of purposes and at local, national and international levels.17 These purposes can be broadly grouped into four:

  • 1.

    To establish levels, trends and differentials in maternal mortality.

  • 2.

    To identify characteristics and determinants of maternal deaths.

  • 3.

    To monitor and evaluate the effectiveness of activities designed to reduce maternal mortality.

  • 4.

    To monitor progress towards international development targets, such as MDG5.

However, in reality these

History of measuring maternal mortality

The history of measuring maternal mortality – ‘deaths in childbed’ – goes back over three centuries in some developed countries.19 Here, the measurement of mortality usually evolved with the overall civil registration system, moving from being primarily a means of ensuring legal transference of inheritance rights at death to being used for statistical purposes. However, in some settings, maternal deaths were initially recorded as part of the maternity service, with healthcare providers

What are the challenges in measuring maternal mortality?

Over the last 25 years, considerable experience has accumulated in understanding and grappling with the challenges of measuring maternal mortality in the context of weak or non-existent routine reporting of deaths. This experience has been widely publicized*7, 17, 29, 30, 31, giving a higher level of awareness of the problems than exists in many other areas of mortality estimation.32 Broadly speaking, the challenges fall into two interrelated categories: problems with meeting the definition of

What do we mean by progress?

Defining progress might seem obvious, implying at its simplest reduced burden or increased health gain. However, progress is a multidimensional concept39 and can be discussed on four main, interrelated bases: the type of outcome in which progress is measured, the scale or scope of the population of interest, the criteria and metric used for judging progress, and the reliability and attribution of apparent progress.

What are the options for measuring maternal mortality?

This section provides an introduction to the principal methods, techniques and approaches to measuring maternal mortality. These are best grouped according to a hierarchy of considerations that are more easily conveyed using interactive devices, such as the web-based guideline in the main resource referred to earlier (http://www.maternal-mortality-measurement.org). The first level of consideration distinguishes between empirical and analytical approaches, with the former relying on new data on

Conclusions

The need to monitor progress in reducing maternal mortality has a long history, which can be traced back to the 1700s in some parts of the Western world. Today, however, this need is felt most acutely in developing countries. By drawing attention to these avoidable maternal deaths, the international Safe Motherhood Initiative, marked the beginning of two decades of efforts to understand and overcome the measurement challenges in the context of weak information systems. Evidence of the success

Acknowledgements

W.J.G. is funded partially by the University of Aberdeen. O.M.R.C. is funded partially by the London School of Hygiene and Tropical. W.J.G. and O.M.R.C. are also partially funded, and L.B.F., E.H and L.D. fully funded by an international research programme – Immpact (http://www.immpact-international.org) supported by the Bill & Melinda Gates Foundation, the Department for International Development, the European Commission and USAID. The funders have no responsibility for the information

References (101)

  • W.J. Graham et al.

    A new method for linking maternal death with poverty: the familial technique

    Lancet

    (2004)
  • L. Milne et al.

    Safe motherhood program evaluation: theory and practice

    J Midwifery Women's Health

    (2004)
  • M.E. Chowdhury et al.

    Determinants of reduction in maternal mortality in Matlab, Bangladesh: a 30-year cohort study

    Lancet

    (2007)
  • K. Hill et al.

    Measuring maternal mortality

    Lancet

    (2006)
  • W. Graham et al.

    The right to count

    Lancet

    (2004)
  • P.F. Thonneau et al.

    Distribution of causes of maternal mortality during delivery and post-partum: results of an African multicentre hospital-based study

    Eur J Obstet Gynecol Reprod Biol

    (2004)
  • S. Jocums et al.

    Monitoring maternal mortality using vital records linkage

    Am J Prev Med

    (1995)
  • J.M. Smith et al.

    Conceiving and dying in Afghanistan

    Lancet

    (2005)
  • K. Hill

    Making deaths count

    Bull World Health Organ

    (2006)
  • C.D. Mathers et al.

    Counting the dead and what they died from: an assessment of the global status of cause of death data

    Bull World Health Organ

    (2005)
  • A.S. Yazbak

    Comment: challenges in measuring maternal mortality

    Lancet

    (2007)
  • World Health Organization

    Health and the Millennium Development Goals

    (2005)
  • Lancet. Editorial

    Women: more than mothers

    Lancet

    (2007)
  • UNFPA

    Issues in measuring and monitoring maternal mortality: implications for programmes

    (1998)
  • C. Ronsmans et al.

    A comparison of three verbal autopsy methods to ascertain levels and causes of maternal deaths in Matlab, Bangladesh

    Int J Epidemiol

    (1998)
  • International statistical classification of diseases and related health problems, 10th Revision. 2nd edition, Volume 2...
  • R. Laurenti et al.

    Maternal and child health indicators: implications of the tenth revision of the International Classification of Diseases

    Pan American Journal of Public Health/Revista Panamericana de Salud Publica

    (1997)
  • K. Hill et al.

    How should we measure maternal morality in the developing world? A comparison of household deaths and sibling history approaches

    Bull World Health Organ

    (2006)
  • W.J. Graham et al.

    Estimating maternal mortality: the sisterhood method

    Stud Fam Plann

    (1989)
  • P.W. Setel et al.

    Sample registration of vital events with verbal autopsy: a renewed commitment to measuring and monitoring vital statistics

    Bull World Health Organ

    (2005)
  • C. Deneux-Tharaux et al.

    Underreporting of pregnancy-related mortality in the United States and Europe

    Obstet Gynecol

    (2005)
  • C. AbouZahr

    Maternal mortality overview

  • World Health Organization

    Beyond the numbers: reviewing maternal deaths and complications to make pregnancy safer

    (2004)
  • I. Loudon

    Death in Childbirth. An international study of maternal care and maternal mortality 1800–1950

    (1992)
  • F. Poppel et al.

    The development of cause-of-death registration in the Netherlands, 1865–1955

    Contin Chang

    (1997)
  • A. Macfarlane

    Enquiries into maternal deaths during the 20th century

  • WHO

    Maternal mortality ratios and rates: a tabulation of available information

    (1991)
  • C. Stanton et al.

    DHS maternal mortality indicators: an assessment of data and implications for data use

    (September 1997)
  • Immpact, University of Aberdeen

    Sampling at Service Sites (SSS), Module 4, Tool 1

  • C. Stanton et al.

    Every death counts: measurement of maternal mortality via a census

    Bull World Health Organ

    (2001)
  • S.C. Amstrup et al.

    Handbook of Capture-Recapture Analysis

    (2005)
  • World Health Organization

    Studying maternal mortality in developing countries: a guidebook

    (1987)
  • C. AbouZahr et al.

    Maternal mortality at the end of a decade: signs of progress?

    Bull World Health Organ

    (2001)
  • E. Gakidou et al.

    Adult mortality: time for a reappraisal

    Int J Epidemiol

    (2004)
  • A.P. Betrán et al.

    National estimates for maternal mortality: an analysis based on the WHO systematic review of maternal mortality and morbidity

    BMC Public Health

    (2005)
  • S. Saleh et al.

    Maternal mortality in Menoufia: a study of reproductive age mortality

    (1987)
  • WHO

    The sisterhood method for estimating maternal mortality: guidance notes for potential users

    (1997)
  • United Nations

    Household sample surveys in developing and transition countries

    (2005)
  • O.M.R. Campbell

    Measuring progress in safe motherhood programmes: uses and limitations of health outcome indicators

    Reprod Health Matters

    (1999)
  • G. Bicego et al.

    The effect of AIDS on maternal mortality in Zimbabwe and Malawi

    Aids

    (2002)
  • Cited by (26)

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

      2015, International Journal of Gynecology and Obstetrics
      Citation Excerpt :

      Millennium Development Goal 5A aims to reduce the maternal mortality ratio by three-quarters between 1990 and 2015. However, accurate accounting of maternal deaths has been a primary challenge in the estimation of pregnancy-related mortality in low-resource countries and the collection of data to advocate for policy change around maternal heath [1–3]. The quality and consistency of available data vary substantially owing to inadequate vital registration systems and death misclassification [4–6].

    • Estimation of maternal and neonatal mortality at the subnational level in Liberia

      2014, International Journal of Gynecology and Obstetrics
      Citation Excerpt :

      In accordance with the 10th revision of the International Classification of Diseases, a pregnancy-related death was defined as “the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the cause of death” [14]. The main indicators of maternal mortality measured were: the maternal mortality ratio (MMR), defined as the number of maternal deaths for every 100 000 live births [15]; the maternal mortality rate, defined as the number of maternal deaths over a period in women of reproductive age; the lifetime risk of maternal death, defined as the probability of a woman dying of maternal causes over her reproductive life span; and the proportion of maternal deaths among deaths of females of reproductive age, which measures the contribution of maternal deaths to overall female deaths of reproductive age [9]. MMR was calculated as the maternal mortality rate divided by the general fertility rate [4].

    • An innovative approach to measuring maternal mortality at the community level in low-resource settings using mid-level providers: A feasibility study in Tigray, Ethiopia

      2012, Reproductive Health Matters
      Citation Excerpt :

      Vital registration systems in such contexts can miss a significant proportion of vital events, including the large majority of maternal deaths.5,11 In order to improve upon the measurement of births and deaths in low-resource settings, stronger, more comprehensive, vital registration systems are needed to link vital events at both the community and facility levels.12 The development of such systems on a global scale will necessitate reliance upon existing health infrastructures, and will require the involvement of low and mid-level health providers and community members in the collection of vital events data.13,14

    • Achieving millennium development goal 5, the improvement of maternal health

      2010, JOGNN - Journal of Obstetric, Gynecologic, and Neonatal Nursing
    • Maternal mortality for 181 countries, 1980-2008: a systematic analysis of progress towards Millennium Development Goal 5

      2010, The Lancet
      Citation Excerpt :

      Acceleration of progress in maternal mortality has received renewed policy attention in the USA through the Obama administration's proposed Global Health Initiative,10 and high-profile civil society groups such as the White Ribbon Alliance continue to bring further attention. The need for accurate monitoring of maternal mortality has long been recognised, both to advocate for resources and policy attention and to track progress.11–13 Maternal mortality, however, is considered very difficult to measure.14–17

    View all citing articles on Scopus
    View full text