Academic journal article Bulletin of the World Health Organization

Community-Based Surveillance of Maternal Deaths in Rural Ghana/Systeme De Surveillance Communautaire De la Mortalite Maternelle En Milieu Rural Au Ghana/Seguimiento De Ambito Comunitario De la Mortalidad Materna En la Ghana Rural

Academic journal article Bulletin of the World Health Organization

Community-Based Surveillance of Maternal Deaths in Rural Ghana/Systeme De Surveillance Communautaire De la Mortalite Maternelle En Milieu Rural Au Ghana/Seguimiento De Ambito Comunitario De la Mortalidad Materna En la Ghana Rural

Article excerpt

Introduction

Ascertainment of cases of maternal death depends on a health information system that accurately identifies and records the causes of death. Most low-income countries do not have systems for certifying births and deaths and the estimates of maternal mortality used in decision-making are based on surveys, data on fertility rates and hospital records. (1) However, these data sources produce estimates with wide confidence intervals and their usefulness for guiding specific local interventions is limited. Demographic and Health Surveys and Multiple Indicator Cluster Surveys use the direct sisterhood method, which identifies pregnancy-related deaths rather than maternal deaths. (1) Moreover, the resulting estimates are retrospective and have wide confidence intervals. National census data are more accurate but censuses are carried out only every 10 years and highly trained enumerators are required to collect the wide range of information covered. (1) Reproductive-age mortality surveys (RAMOSs) have been used in several settings to improve the ascertainment of maternal deaths. (2,3) Typically, such surveys involve asking 39 questions that span the many possible causes of death in women of reproductive age, including the causes of maternal death (details available from the corresponding author). A confidential enquiry into maternal deaths undertaken in Accra, Ghana, in 2002 applied the reproductive-age mortality surveys methods at health facilities and morgues in Accra and found that maternal deaths had been under-reported by 44%. (4) However, the reproductive-age mortality survey has limited usefulness at the population or national level, where it is necessary to identify all deaths in women of reproductive age and to examine several sources of information. A large-scale, national reproductive-age mortality survey can be complicated, time-consuming and expensive and the resulting maternal mortality ratios (MMRs) may not be accurate in settings where most women deliver at home. (1)

In 2010, community-based surveillance of maternal deaths was conducted in the Sene district of Ghana using a modified reproductive-age mortality survey. (5) Researchers selected the 10 questions from the survey that were most likely to identify a maternal death and that could be used by community health volunteers in interviews of the family members of women of reproductive age who had died. A maternal mortality review committee investigated all cases in which a respondent gave a positive answer to at least one of the 10 questions. Using the committee's determination of maternal death as the gold standard, four questions emerged as the best predictors of a maternal death: (i) Was she pregnant when she died? (ii) Was she pregnant recently? (iii) Did she have a child younger than one year when she died? and (iv) Did she die from a miscarriage or abortion? (5) These four simple yes-no questions were found to have a high predictive value for identifying a maternal death. Moreover, the number of maternal deaths ascertained almost doubled in the year community-based surveillance took place. A similar study in Eritrea reported comparable results. (3)

The hypothesis of the current study was that MMRs derived from community-based surveillance of maternal deaths using the four yes-no questions in a modified reproductive-age mortality survey would be higher than those determined using current techniques. In addition, we aimed to demonstrate that a simple four-question survey conducted by community health workers is feasible in rural communities and is an effective way of increasing knowledge about the current burden and causes of maternal death in these communities.

Methods

The public health director of Bosomtwe district in Ghana decided to conduct a modified reproductive-age mortality survey in four subdistricts with the aim of increasing understanding of maternal mortality beyond that provided by currently available hospital-based MMRs. …

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