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

4 Sep 2008

Maria Victoria Valero

Source: BMC Medicine (see original article)

Citation: Graham WJ, Ahmed S, Stanton C, Abou-Zahr C, Campbell OM (2008). Measuring maternal mortality: an overview of opportunities and options for developing countries. BMC Med; 6:12. Review.

© 2008 Graham et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

A reduction in the maternal mortality ratio (MMR) by three-quarters, to 140 or less per 100,000 live births, is one of six health-related Millennium Development Goals (MDGs) (1,2). MMR is highest in less developed economies – i.e. low and middle income countries.

An autopsy study of maternal mortality in Mozambique found that in a tertiary hospital, infectious diseases accounted for at least half of all maternal deaths, even though effective treatment is available for the four leading causes: HIV/AIDS, pyogenic bronchopneumonia, severe malaria, and pyogenic meningitis (3).

Since the launch of the Safe Motherhood Initiative in 1987, new opportunities for data capture have arisen and new methods have been developed, tested and used. However, there is no consensus on how to measure MMR in the many countries that do not have complete registration of deaths and accurate ascertainment of cause of death maternal mortality (2,4).

In a review article, Graham et al. aim to raise awareness of the alternatives among all who commission and act upon information on maternal mortality. The authors define MMR as the number of maternal deaths during a given time period per 100,000 live births during the same time period.

The authors summarize the main opportunities and options for generating empirical estimates, describe their evolution and evaluation, and propose optimal measurement strategies for different country contexts. As the investigators state: ‘It is timely to emphasize these opportunities for a number of reasons, and not just because one of the two indicators for MDG-5 is maternal mortality.’

They consider three main objectives for measuring maternal mortality:

To further help empower countries to measure maternal mortality and ‘own’ their national estimates
To challenge the prevailing view of measurement stagnation: that maternal mortality is too difficult or too expensive to measure
To respond to the heightened need for health outcome data that has resulted from results-based financing of maternity services in developing countries.

The methodology focuses primarily on measuring the magnitude and trends in maternal mortality at national and major sub-national levels. The authors do not address approaches whose main rationale is to identify or improve interventions to prevent maternal deaths. Also they do not discuss approaches and indicators which may act as alternative measures of maternal mortality.

The authors highlight the use of civil registration statistics and demographic and health surveys as the main platform (measurement opportunity) for gathering the data, and the method (measurement option) used to identify maternal deaths and derive estimates of mortality. They identify five major data-gathering opportunities: (i) death registration, (ii) health facilities, (iii) decennial censuses, (iv) surveys, and (v) surveillance.

The article describes how these five opportunities for measuring maternal mortality have evolved over last 20 years, in response to the demand generated initially by the Safe Motherhood Initiative (1987) and sustained by the advent of MDG-5 (2005). These initiatives (and some measurement methodologies) have been transformed or modified in developing countries since the mid-1980s. Unfortunately, in spite of these efforts, there remains considerable underreporting of maternal deaths. Routine collection of data often takes places without contact with health systems. In addition, there have been insufficient studies to validate the methods used, which could be affected by bias.

There are many difficulties and limitations which need to be addressed in research studies and development priority programmes, according to local conditions. Each country bears the enormous responsibility of developing appropriate strategies to strengthen the national registration system, in order to guarantee complete and accurate coverage in data collection.

References

1. Hill K, El Arifeen S, Koenig M, Al-Sabir A, Jamil K, Raggers H (2006). How should we measure maternal mortality in the developing world? A comparison of household deaths and sibling history approaches. Bull World Health Organ; 84(3):173-180. Available from: http://www.ncbi.nlm.nih.gov/pubmed/16583075

2. Stanton C, Hobcraft J, Hill K, Kodjogbé N, Mapeta WT, Munene F, Naghavi M, Rabeza V, Sisouphanthong B, Campbell O (2001). Every death counts: measurement of maternal mortality via a census. Bull World Health Organ; 79(7):657-664. Available from: http://www.ncbi.nlm.nih.gov/pubmed/11477969

3. Menendez C, Romagosa C, Ismail MR et al (2008). An autopsy study of maternal mortality in Mozambique: the contribution of infectious diseases. PLoS Med; 5(2):e48. Available from: http://www.ncbi.nlm.nih.gov/pubmed/18288887

4. Shiffman J (2007). Generating political priority for maternal mortality reduction in 5 developing countries. Am J Public Health; 97:796-803. Available from: http://www.ncbi.nlm.nih.gov/pubmed/17395848

Note: This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited