Transcript PPT
The new UN interagency maternal mortality estimates Agbessi Amouzou and Holly Newby Data & Analytics Section, DPS, UNICEF 1 May 2014 Will be released on Tuesday, 6 May 2014 Levels and trends of maternal mortality between 1990 and 2013 for 183 countries Includes MMR, lifetime risk of maternal death and numbers of maternal deaths Will replace current UN interagency estimates pertaining to 2010 Outline of the Presentation Why UN Inter-Agency estimate of maternal mortality Summary of issues in maternal mortality measurement How the UN Inter-Agency estimates are produced Highlights of new estimates WHY UN INTER-AGENCY ESTIMATES? Why Inter-Agency MM Estimates? MMR is key indicator for MDG 5 Global monitoring and reporting requires a harmonized measure of MMR that is comparable across countries Need to obtain a measure that has same reference year across all countries Maternal mortality is challenging to measure Similar initiative is done for under-five mortality (see www.childmortality.org) Maternal Mortality Estimation Interagency Group (MMEIG) The UN interagency estimates are produced by the Maternal Mortality Estimation Interagency Group (MMEIG): • • • • • WHO (Lead) UNICEF UNFPA The World Bank Lead technical consultant (Leontine Alkema, National University of Singapor) • Technical Advisory Group MATERNAL MORTALITY MEASUREMENT Definitions Definition Implications Maternal death The death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management but not from accidental or incidental causes. Pregnancy-related death The death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the cause of death. Death must be attributed directly or indirectly to pregnancy or childbirth Requires medical certification or verbal autopsy Cannot be obtained through surveys or censuses No deaths beyond 42 days due to pregnancy complications accounted for Cause of death certification not needed Can be obtained through surveys or censuses UN Interagency maternal mortality estimates conform to the definition of maternal death Sources of maternal mortality data and their limitations Maternal mortality data can come from a variety of sources: – Vital registration • Considered gold standard • Good in only about a third of countries • Extensive under-reporting and misclassification • Even in countries with complete vital registration, maternal deaths may be underreported by a factor of 1.5 – 3.0 Sources of maternal mortality data and their limitations Maternal mortality data can come from a variety of sources: – Vital registration – Household surveys (sisterhood method) • Pregnancy-related deaths • MMR very imprecise, large confidence intervals • Doe not produce recent estimate: MMR refers to 7 to 9 years in the past Sources of maternal mortality data and their limitations Maternal mortality data can come from a variety of sources: – Vital registration – Household surveys (sisterhood method) – Censuses • Pregnancy-related deaths • Conducted every 10 years • Need adjustment for completeness of births and deaths Sources of maternal mortality data and their limitations Maternal mortality data can come from a variety of sources: – Vital registration – Household surveys (sisterhood method, etc.) – Censuses – Reproductive-age mortality studies (RAMOS) • Complicate, time-consuming and expensive • Under-report of maternal deaths • Under report of number of live births Sources of maternal mortality data and their limitations Maternal mortality data can come from a variety of sources: – Vital registration – Household surveys (sisterhood method, etc.) – Censuses – Reproductive-age mortality studies (RAMOS) – Verbal autopsy • Misclassification of cause of death • Under report of maternal deaths • Recall issues Sources of maternal mortality data and their limitations Maternal mortality data can come from a variety of sources: Bottom line: – Vital registration Each source surveys has advantages limitations. – Household (sisterhoodand method, etc.) Measurement is challenging regardless of – Censuses source. – Reproductive-age mortality studies (RAMOS) There is need to adjust and harmonize – Verbal autopsy available data for cross country comparability and global reporting Issues to keep in mind Survey estimates of MMR are averages over periods of 7 or 9 years in the past, so not comparable to UN Interagency estimates MMR generally have large uncertainty ranges Maternal death is a rare event; MMR is expressed in per 100,000 live births and therefore creates a false sense of precision – 300/100,000 = 0.30/100 – 330/100,000 = 0.33/100 MMR of 300 may not be different from MMR of 330 Trend Estimation from Sibling Histories with 95% Confidence Intervals (Namibia) 600 500 400 300 200 The 2007 MMR refers to period 1998 -2007 100 0 1985 1990 1995 Year 1992 DHS 2007 DHS 2000 2005 2000 DHS Estimates are averages over long periods (here 7 or 9 years) and 95% confidence intervals are large Source: Ken Hill – UN maternal mort workshop, Nairobi December 2010 Trend Estimation from Sibling Histories with 95% Confidence Intervals (Namibia) 600 500 400 300 200 100 0 1985 1990 1995 Year 1992 DHS 2007 DHS The 2000 MMR has 95%CI ranging from 2000 90 to 450 2005 2000 DHS Estimates are averages over long periods (here 7 or 9 years) and 95% confidence intervals are large Source: Ken Hill – UN maternal mort workshop, Nairobi December 2010 Trend Estimation from Sibling Histories with 95% Confidence Intervals (Namibia) 600 500 400 300 200 100 0 1985 1990 1995 Year Note2000 that this2005 is at the 1992 DHS 2000 DHS national level! It’s not possible 2007 DHS to disaggregate by region or other like Estimates are averages over long periods (here 7characteristics or 9 years) and 95% confidence intervals are large household wealth! Source: Ken Hill – UN maternal mort workshop, Nairobi December 2010 HOW ARE THE UN INTER-AGENCY ESTIMATES DONE? Source of data for the 2013 MMR estimates Group Source of maternal mortality data Number of countries/ territories % of % of births countries/ in 183 territories in countries/te each category rritories covered A Civil registration characterized as complete, with good attribution of cause of death 67 37 17 B Incomplete civil registration and/or other types of data 96 52 81 C No national data on maternal mortality 20 11 2 183 100 100 Total General methodology of estimation Little change from methodology used for 2010 estimates 1. Compile and review all available nationally representative maternal mortality data 2. Adjust available maternal mortality data for misclassification and underreporting General methodology of estimation 3. Use one of two approaches depending on country – Countries with adequate civil registration data • Calculate MMR directly with adjusted – All other countries: • Use multilevel linear regression model • Covariates: GDP, general fertility rate and skilled attendant at birth • Separate model component for AIDS deaths that are indirect maternal deaths 4. Compute uncertainty ranges through simulations Methodological changes from the 2010 estimates? Increased data availability – 5% increase in available data Update in the estimate of female deaths in the reproductive age by WHO Update of series of live births and general fertility rates from World Population Prospects Update in AIDS adjustment parameters Methodological changes from the 2010 estimates? Data availability – 5% increase in available data Update in the estimate of female deaths in the reproductive age by WHO Update of series of live births and general fertility rates from World Population Prospects Update in AIDS adjustment parameters Little change from methodology used for 2010 estimates Review process Reviewed by the Technical Advisory Group with experts from academic institutions: Harvard University, Johns Hopkins University, University of Aberdeen, and others Country consultation led by WHO allowed countries to provide feedback and provide new data STOP! The 2013 UN interagency estimates REPLACE the previous estimates and should not be compared or interpreted together with them The 2013 estimates are NOT comparable to estimates from other sources Maternal mortality estimates generated by countries At the global level, we use the interagency estimates for MDG reporting and official monitoring UNICEF presents both nationally reported estimates and UN interagency estimates in State of the World’s Children TABLE 8 Trends in Maternal Mortality Ratio (Embargoed until May 6, 2014) By UNICEF regions 1200 940 990 1000 610 1990 380 430 2005 12 11 15 270 210 300 230 36 27 65 140 93 85 170 100 74 0 200 140 110 440 550 190 200 Embargoed until May 6, 2014 ---------------------280 400 510 600 680 800 2013 Source: Trends in Maternal Mortality: 1990-2013 (WHO, UNICEF, UNFPA, World Bank) Resources More information on new estimates available (from May 6) at: Data.unicef.org Complete methodological details and all data available on: www.who.int/reproductivehealth/publications/monitoring/xxxxxxxxx/en/ind ex.html and MME Info: www.maternalmortalitydata.org We are in process of updating the MMEIG website MM Info (maternalmortalitydata.org) To be released on 6 May 2014! Contacts Agbessi Amouzou [email protected] Holly Newby [email protected]