Transcript Measures of maternal mortality

Measuring maternal mortality
in MSF programs
Kamalini Lokuge
What is maternal mortality?
• Maternal death : death of a woman from pregnancy-related
complications occurring at anytime throughout pregnancy, labour, and
childbirth or in the postpartum period (up to the 42nd day after the end of
pregnancy, regardless of duration of pregnancy).
• When do maternal deaths occur?
– 11% - 17% occur during childbirth, 50% - 71% in the postpartum period [1].
– Late maternal death
• Where do they occur?
– 99% in developing countries.
– Maternal mortality is the human development indicator with the greatest
disparity between developed and developing countries.
• Measures of maternal mortality
– Maternal mortality ratio : No. maternal deaths / No. live births
– Maternal mortality rate : No. maternal deaths / Women aged 15-49 years
[1] World Health Report 2005. WHO 2006.
Why measure maternal mortality or
related indicators?
• Maternal mortality can be prevented by
– Immediate access to emergency obstetric care
(EOC).
– helping women avoid unwanted pregnancies
through family planning
– Skilled birth attendants, i.e., doctors, nurses, and
midwives, providing appropriate ante-natal and
post-natal care, essential obstetric care, effective
post-abortion care.
• There ARE interventions we can implement.
• Information allows us to prioritise our programs,
advocate internally and externally
[1] World Health Report 2005. WHO 2006.
Can we address maternal mortality ?
• Has been done, and been done by developing countries, including
those with very limited resources (e.g. Sri Lanka)
• The countries that have successfully managed to make motherhood
safer have three things in common [3].
– First, policy-makers and managers were informed that there was a
problem.
– Second, they chose a strategy that included all essential components : not
just antenatal care, but also professional care at and after childbirth,
backed up by hospital care.
– Third, they made sure that the entire population had access (financial and
geographical) to these services.
• 2 & 3 require significant resource commitments. This commitment
began with quantifying the problem. This presentation will cover how
we can reach this first step in MSF.
Maternal mortality in MSF settings
• Existing data
– Very little data regarding current levels
– Where data exists, reported figures usually based on estimates at
the national/regional level.
– Although these reported figures are high, likely they greatly
underestimate actual levels in those sub-regions and populations
at most risk.
• Likely levels
– Recent study in Afghanistan : Maternal mortality ratios of 6507
(range 5026-7988) in the most remote province, compared to a
maternal mortality ratio of 418 (235–602) in Kabul, the capital [2].
– Suggests that where MSF is working, sub-regional estimates are
needed
– Also suggests that MSF is working in many of those regions
where maternal mortality is likely to be very high.
[2] Bartlett A et al, Lancet 2005; 365: 864–70
What MSF measures now
• Antenatal care and coverage
– Essential component, but MUST be linked to emergency
obstetric services to be effective
– Measuring antenatal care and coverage cannot equate to
measures of obstetric risk.
• Outcomes for deliveries in MSF facilities: very low
coverage, and we cannot aim to achieve coverage
through this alone.
• Postnatal consultations: coverage very low, and based
on passive data collection at health facilities, therefore
does not reflect community outcomes.
[1] World Health Report 2005. WHO 2006.
Pilot survey in Congo-Brazzaville
• Justification for survey
– To obtain data on levels of morbidity and mortality in the Pool
region of Congo-Brazzaville.
• Justification for maternal mortality component
– MSF carries out rapid health and mortality assessments in many
settings, and these are both feasible and simple to implement.
– Initial attempt to pilot some feasible direct measures of maternal
mortality
• Objectives :
– Levels reported in the study above for remote areas of
Afghanistan are also likely in MSF settings with poor access and
services
– With very high levels, can measure maternal mortality in a useful
way with relatively small sample sizes and simple methodology.
[1] World Health Report 2005. WHO 2006.
Methodology and results
• Methodology :
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Stratified WHO cluster survey methodology, each district a stratum
Sampling frame : 2005-2006 DHS survey frame
All estimates weighted and adjusted for clustering
6-month recall period
Definition “maternal death during or immediately after delivery” ( up to 1
week)
• Results :
– 905 households in Mindouli, and 855 households in Kindamba.
– 11 maternal deaths (7 in Kindamba, 4 in Mindouli). Crude birth rate of
5.53% and 4.45 % (Kindamba and Mindouli respectively).
• Maternal mortality ratios
– 4600 (95%CI: 340–8900) in Mindouli
– 7700 (95%CI: 2400–13100) in Kindamba.
– 5200 (95%CI: 1500-8900) in survey region as a whole
Discussion of Congo-B findings
• Plausible ?
– The levels are several fold higher than published rates for CongoBrazzaville. E.g.
• MMR nationally 510 per 100,000 live births[1],
• 645 in Brazzaville, where 90% of women have access to antenatal care and
most deliveries occur in a hospital[2].
– The levels in a region such as the Pool, where levels of access to such
services are much lower, would be expected to be higher. The levels (and
gradient between urban and remote rural areas) we found appear are
consistent with those found in Afghanistan.
• Limitations
– Narrower definition of maternal mortality : maternal death during delivery or
immediately after delivery ( to improve reliability of reported cause)
– It was not possible to validate such reports with death registration or
certificates, as the vital registration system in this area is very poor.
– It was also not possible to conduct more detailed evaluations of each
reported death to determine causative factors .
– As our sample size was relatively small, the confidence intervals around the
estimates we obtained were very wide.
[1] World Health Report 2005. WHO 2006.
Impact of survey findings
• Despite wide confidence intervals, team was able to
convey meaning of results to stakeholders (MoH etc)
• External advocacy tool to demonstrate disparities between
country as a whole and Pool region:
– Advocate for more and for skilled health staff
– Advocate for investment in infrastructure
• Internal advocacy tool : human resources (midwife), gave
team incentive to look into why women were not accessing
maternity services, opened maternity house
• Figures on access to EOC etc, were not as useful for
advocacy
[1] World Health Report 2005. WHO 2006.
Utility of confidence intervals
Survey, Congo-Brazzaville
95% confidence intervals of maternal mortality ratios
14,000
12,000
WHO national estimates
MMR
10,000
8,000
6,000
4,000
2,000
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Impact of survey findings (cont’d)
Future utility : measuring program impact, progress
towards MDG target.
• Sample sizes needed to demonstrate a MDG
target-type 75% reduction, assuming a stable birth
rate and age/sex distribution :
– 6 month recall (as we used)
• Mindouli : 5052 households
• Kindamba: 1860 households
• Area as a whole : 3341 households
– 12 month recall
• Mindouli : 2526 households
• Kindamba: 930 households
• Area as a whole : 1671 households
[1] World Health Report 2005. WHO 2006.
Accepted methodologies and their
limitations
• Direct and indirect sisterhood surveys : estimate maternal
mortality by asking women of reproductive age about
pregnancy related deaths in their sisters.
– Require smaller sample sizes than direct respondent household
surveys
• Limitations.
– Period to which estimate applies : Gives estimates of maternal
mortality centred around 12 ( indirect) and 7 (direct) years prior to
the date of the survey.
– Cannot therefore be used to measure program impact
– Require stable populations therefore not useful in displaced
populations etc
– Both methods rely on reported cause of death.
[1] World Health Report 2005. WHO 2006.
Accepted methodologies and their
limitations
• DHS data : National DHS surveys
– Provide national or regional estimates, do not give subregional figures for highest risk areas.
• Vital registration systems : Those few developing
countries that have made real progress in reducing
maternal mortality this century have had reliable vital
registration systems that allowed them to monitor
levels.
– Requirements for vital registration system
[1] World Health Report 2005. WHO 2006.
Feasible strategies
• Surveillance / outreach worker programs
– Gold standard is reliable vital registration data
– Added advantage of providing information on other deaths and on
births in the population.
– Improving the use of outreach workers in identifying and
investigating possible maternal deaths would in effect be a vital
registration system covering those areas in which we work.
– Validation of reported deaths with verbal autopsies done by skilled
health workers, and qualitative assessments to ascertain possible
causes.
– Outreach worker program of good quality and coverage can
equate to a vital registration system
[1] World Health Report 2005. WHO 2006.
Feasible strategies (cont’d)
• Process indicators
– Access to essential obstetric care
– Useful in settings where mortality levels require large sample
sizes, and where there is already a commitment to implementing
interventions.
• Rapid health assessments
– Useful in areas where levels are likely to be very high, and there is
no existing data, or to which national or regional estimates are not
generalisable.
– Consider it as an initial step, should be aiming towards instituting
ongoing surveillance where possible
– Evaluate utility not so much of point measure, but the range,
especially the lower bound of the confidence interval.
[1] World Health Report 2005. WHO 2006.
Conclusion:
"I am going to the sea to fetch a new baby, but the journey
is long and dangerous and I may not return".
• Conclusion: The death of a mother of reproductive age is a
devastating occurrence in any setting. In the areas we work, it
automatically equates to a much higher risk of death and morbidity
in all children she leaves behind. The community loses a
productive member in the prime of her life. An essential step in
addressing maternal mortality in the populations we work with is
devising and implementing useful and feasible ways of measuring
and monitoring what happens to their mothers.
[1] World Health Report 2005. WHO 2006.