Maternal Mortality – resources, Topic 1

You should start by looking at this presentation from the Geneva Foundation for Medical Education and Research by Dr Karim Abawi, Measuring Maternal Mortality, which provides an introduction to the ways to measure maternal mortality.

There is also a document from the WHO Maternal mortality: Evidence Brief, which is a clear summary of the size of the problem and some of the causes. We will return to causes later in the course.

You can see data in this executive summary of Maternal Mortality: Levels and trends - taken from the WHO website Sexual and reproductive health. The data here are from 2000 to 2017, and the site should be providing access to regular updates. You can see data for different countries in the report. The introduction to the report on the website states:

"In anticipation of the launch of the Sustainable Development Goals, the World Health Organization (WHO) and partners released a consensus statement and full strategy paper on ending preventable maternal mortality (EPMM). The EPMM target for reducing the global maternal mortality ratio (MMR) by 2030 was adopted as Sustainable Development Goal target 3.1: to reduce global MMR to less than 70 per 100 000 live births by 2030. To enable monitoring of the achievement of the goals, this report presents internationally comparable global, regional and country-level estimates and trends for maternal mortality between 2000 and 2017.

Having targets for mortality reduction is important, but accurate measurement of maternal mortality remains challenging and many deaths still go uncounted. Many countries still lack well functioning civil registration and vital statistics (CRVS) systems, and where such systems do exist, reporting errors – whether incompleteness (unregistered deaths, also known as “missing”) or misclassification of cause of death – continue to pose a major challenge to data accuracy."

The UNICEF website, headed Maternal mortality declined by 38 per cent between 2000 and 2017 shows a nice picture of the global patterns.

Sustainable Development Goals: Reducing maternal mortality is an important goal:

Goal 3: Ensure healthy lives and promote well-being for all at all ages

Target 3.1: By 2030, reduce the global maternal mortality ratio to less than 70 per 100,000 live births Indicator 3.1.1: Maternal mortality ratio

You can find details of the various goals on this SDG website. Please look through the details of the maternal mortality indicator here

Identify the most important problems resulting in gaps and inaccuracy of data, and discuss potential solutions to improve data accuracy.
- can explain why the currency of that data / how and why it was collected affects how it can be interpreted
- can discuss what is needed to improve the quality / timeliness of data collection

Here is a presentation about some of the problems in measuring maternal mortality. It is rather out of date in terms of numbers and rates, but the methodological issues are well described.
Methodological issues in measuring maternal mortality.

A paper Measuring maternal mortality: a systematic review of methods used to obtain estimates of the maternal mortality ratio (MMR) in low- and middle-income countries from 2017 approaches this in more depth and is well worth reading through. [Note: in addition to the information on maternal mortality, the paper describes a very good systematic review of the literature - a skill that you will come across in the Evidence Based Practice module and is required for the Dissertation.] The paper covers these methods: "Civil registration (5 studies), census (5) and surveys (16), Reproductive Age Mortality Studies (RAMOS) (4) and the sisterhood methods (11) have been used to measure MMR in a variety of settings." The authors state the problem: "Reliable data are needed so that adequate resources can be allocated to maternal health programmes for countries (or regions in countries) that are not yet accelerating the annual reduction in maternal deaths. These data are also needed to monitor progress toward the targets set for the new Sustainable Development Goals (SDG). Assessing progress has been a challenge because <40% of countries currently have complete civil registration (CR) systems in place or other methods to provide accurate and contemporaneous MMR data. Similarly, although Maternal Death Surveillance and Review is promoted and being implemented in many settings, attribution and reporting of cause of maternal death is not yet systematically in place. Only 2 of the 49 least developed countries have >50% coverage with regard to death registration.^"

Discuss the possible effects of maternal mortality and morbidity on the overall development of your country.

The paper The true cost of maternal death: individual tragedy impacts family, community and nations, discusses ‘the true costs of maternal mortality’ and provides more information and evidence (from various countries in Africa) on these implications/consequences. The paper summarises: "It is important in this period of post-MDG strategy planning period that donors, governments, and NGOs be aware not only of the individual level tragedy of the loss of a mother’s life, but also the financial and health costs associated with maternal mortality, and to keep the focus on maternal health as a key issue in all aspects of development, not just health."

Optional resource:

A provocative critique of the international attention to get the measurement of maternal mortality ‘right’ can be found here: “Guilty until proven innocent”: the contested use of maternal mortality indicators in global health: it is important to understand that work towards progress in maternal health can very well coexist with rough estimates, and that developments in civil registration in countries is more sustainable than exhaustive efforts to measure maternal mortality exactly at population level. Locally appropriate proxy indicators might provide sufficient information for continuous monitoring (for example, maternal mortality ratios calculated with institutional childbirth data when coverage is high).