Every Death Counts: Measurement of Maternal Mortality Via a Census

By Stanton, Cynthia; Hobcraft, John et al. | Bulletin of the World Health Organization, July 2001 | Go to article overview

Every Death Counts: Measurement of Maternal Mortality Via a Census


Stanton, Cynthia, Hobcraft, John, Hill, Kenneth, Kodjogbe, Nicaise, Mapeta, W. T., Munene, Francis, Naghavi, Moshen, Rabeza, Victor, Sisouphanthong, Bounthavy, Campbell, Oona, Bulletin of the World Health Organization


Voir page 663 le resume en francais. En la pagina 664 figura un resumen en espanol.

Introduction

High levels of maternal mortality in the developing world have been increasingly recognized as an urgent public health concern during the past decade. The 1987 Safe Motherhood Conference in Nairobi, Kenya, drew attention to the fact that maternal mortality ratios in the developing world are at least 100 times greater than those found in industrialized countries, identifying maternal mortality as the health indicator with the greatest disparity between rich and poor countries. Subsequently, several international forums including the 1990 World Summit for Children, the 1994 International Conference on Population and Development (ICPD), and the 1996 International Conference on Women in Beijing, China, included a 50% reduction in maternal mortality over the following decade among its stated goals. This emphasis was reaffirmed by the Programme of Action approved by the 1999 ICPD + 5 in The Hague, Netherlands (1).

This heightened attention to maternal health has greatly increased demand for measures of maternal mortality at the national and subnational level. Such data serve well as broad indicators of progress but cannot be linked to specific interventions. However, the public health community has been slow to accept the fact that maternal mortality data cannot be used to evaluate the impact of the Safe Motherhood programme (2, 3). Using such data to assess specific interventions can be dangerous. In Matlab, Bangladesh, for example, where there has been a recently reported decline in maternal mortality, efforts to link the decline to specific interventions failed when it was shown that similar decreases in maternal mortality occurred in both intervention and control areas (4).

Regardless of the intended use of the data, methods for measuring and monitoring maternal mortality lag far behind the demand for such statistics. In the industrialized world, civil registration systems generate the needed data on maternal mortality, albeit with substantial, and often acknowledged, underreporting (5-7). In the majority of developing countries, however, civil registration data are simply too incomplete to be useful, leading a growing number of countries to turn to sample surveys as a means of measuring maternal mortality.

Disadvantages of surveys for determining maternal mortality

Survey methods which attempt to identify recent maternal deaths in households require prohibitively large sample sizes because maternal deaths are relatively rare events. Demographic surveillance systems, though valuable for research purposes, cannot safely be generalized to a national population. Direct estimation techniques based on survey questions concerning the survival of each respondent's sisters are able to increase the sample size at relatively low cost (8, 9). Even using this methodology, however, sample sizes of 5000-15 000 female respondents, such as is common in the Demographic and Health Surveys (DHS) programme, still generate highly imprecise direct estimates of maternal mortality with confidence limits of plus or minus 30%, even for reference periods that include events occurring over 7 or more years (10). Indirect sisterhood estimates have similarly wide confidence intervals. Given this imprecision, survey-based methods can only provide a national-level estimate, cannot provide information on differentials in maternal mortality, and can only give an estimate for a period that often covers 7 or more years. The degree of imprecision can be seen from the maternal mortality ratios and 95% confidence intervals (CI) from recent surveys: Central African Republic 1451 (95% CI: 1194-1709); Indonesia 454 (95% CI: 378-529); and Peru 218 (95% CI: 148-288) (10). Given the shortcomings of the more commonly used approaches summarized above for the measurement of maternal mortality, the attributes of an ideal methodology are outlined in Box 1. …

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