Academic journal article Bulletin of the World Health Organization

Estimates of Maternal Mortality for 1995

Academic journal article Bulletin of the World Health Organization

Estimates of Maternal Mortality for 1995

Article excerpt

Voir page 192 le resume en francais. En la pagina 193 figura un resumen en espanol.


Maternal mortality is notoriously difficult to measure (1). The most widely used measure, the Maternal Mortality Ratio (MMRatio), expresses maternal deaths per 100 000 live births, but MMRatios rarely exceed 1000 or 1 per 100 live births. Maternal deaths are thus relatively rare events and they are also hard to identify precisely, both of which limit the applicability of sample survey measurement methods. In countries with well-developed statistical services, the conventional source of information about maternal mortality is the civil registration system, which records both live births and deaths, by cause, on a continuous basis. Even in such settings, however, maternal deaths are invariably found to be under-recorded in official statistics owing to misclassification of the cause of death (2-4). In countries with less well developed statistical services, the outright omission of deaths contributes an additional source of error.

Despite the difficulties in measuring maternal mortality, interest in obtaining estimates has increased. The MMRatio varies by a factor of over 100 between the highest and lowest mortality settings, making it the health outcome with the largest gap between developed and developing countries. Interest has also increased because one of the main targets of the Programme of Action, which was developed at the International Conference on Population and Development in Cairo in 1994 (5), is reproductive health. One specific goal of the Programme of Action called for quantified reductions in maternal mortality. However, although the goal was phrased in terms of a 1990 baseline, no global estimates of the situation in 1990 were available. To try to bridge the gap between the need for reliable data and the quality of conventional data sources, alternative approaches to measurement have been explored.

In 1996, WHO and UNICEF prepared model-based estimates of maternal mortality for about the year 1990 in developing countries, for which adequate empirical information had not been identified (6, 7). The model caused considerable controversy, particularly in countries which did have relevant information and for which the model-based estimates were often substantially higher than the existing figures. The resulting controversy, however, had at least three positive outcomes: 1) it increased general awareness of the problems surrounding the measurement of the MMRatio; 2) it drew attention to the various strengths and weaknesses of the different measurement approaches; and 3) it brought to light relevant data hitherto unavailable to the international community, or stimulated new data collection, or both. This paper updates the 1996 exercise using a revised methodology, incorporating new data as available, and presents the maternal mortality, estimates, by countries and regions, for 1995.

The basis of the estimates

The estimation strategy was developed in response to concerns in three major areas, which were expressed in international forums about the 1996 exercise: 1) failure to use country data where they were available and which are believed to be of good quality; 2) concern about the choice of a dependent variable in the statistical model; and 3) rigidities in the model that limited the range of possible values of estimates of maternal mortality (8-11).

For the present estimation exercise, every attempt was made to use country data where available and of adequate quality. Using the available data, countries, areas, and territories were placed in one of the following six categories, according to whether they had:

(a) complete death registration data, with generally good cause of death attribution;

(b) complete death registration data, but uncertain cause of death attribution;

(c) information from a survey on deaths of sisters, with timing of death related to pregnancy;

(d) recent results from a Reproductive Age Mortality Study (RAMOS);

(e) other available relevant data;

(f) no relevant data available for a recent period. …

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