Download - Motherhood method 12 9-13
Field test results of the motherhood method to measure maternal mortality
Mahesh K. Maskey1, Kedar P. Baral 2, Rajani Shah3 , Bhagawan D. Shrestha4, Janet Lang5, & Kenneth J. Rothman6
1Nepal Public Health Foundation, Kathmandu, 2 Patan Academy of Health sciences,
3 CTEVT, Bharatpur, 4 Plan Nepal, Nepal 5 Watson Institute for International studies, Brown University, Providence RI,
USA and 6 RTI Health solutions, Research Triangle Park, NC & Boston University school of Public Health, USA
Indian J Med Res 133, January 2011, pp 64-69
Presented by
Dr. Fredrick Stephen
P.G in community Medicine
About The Journal
• Scope : Technical and clinical studies related to health, ethical and social issues in field
of biomedical research
• Frequency : Monthly, in two volumes and 12 issues per year
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Introduction
• The current estimate of global maternal deaths is 3429001*
• Over the past decade, reduction in maternal deaths has attained a high priority in
global health movements
• MDG5 has set a target of reducing the maternal mortality ratio by 75 % between 1990
and 2015.
• The most widely used measure of maternal mortality is the maternal mortality ratio
• Developing countries - vital registration of medically-certified births and deaths is non-
existent / incomplete, validity or feasibility of other purely records-based approaches is
questionable
* Hogan MC, Foreman KJ, Naghavi M, Ahn SY, Mengru W, Makela SM, et al. Maternal mortality for 181 countries, 1980-2008: a systematic analysis of progress towards Millennium Development Goal 5. Lancet. 2010;375:1609–23. [PubMed]
Aims & Objectives
• To test a community-based method (the motherhood method) and measure maternal and child mortality in a developing country setting.
Maternal Mortality Estimation
Maternal Mortality
Empirical Methods
Analytical Methods
Routine opportunity
Measurements
Special opportunity
Measurements
Main ApproachComposite Approach
Routine Opportunity Empirical
Measurements
Special OpportunityEmpirical Measurements
• Vital
Registration
System
• Census
• Facility Based
Health Services
Records
• Sisterhood
Methods
• Demographic
Surveillance
Systems
Empirical Methods
Analytical Methods
Main Approach
• Birth & death
Record Linkage
• Capture
Recapture
• Statistical
Modelling used
by UN systems
Composite Approach
• ReproductiveAge Mortality
Study (RAMOS)
• Motherhood Method
Reproductive Age Mortality study (RAMOS)
• It uses multiple sources such as records from hospital, police, public-health
department and vital data registries to identify and investigate the cause of
deaths for each woman of reproductive age in a defined population
• Interviews with household members and health care providers provide a basis
to classify the deaths as maternal or otherwise.
• Is considered to be the most complete estimation of maternal mortality
• Complex, because information regarding the number of births must come
from separate sources
Sisterhood Method
• Was originally developed during the late 1980’s
• The approach was designed to overcome the problem of large sample
sizes and thus reduce costs
• It is an indirect measurement technique of the kind frequently used to
measure a variety of demographic parameters (such as child or adult
mortality), which has been adapted for the measurement of maternal
mortality.
• The method reduces sample size requirements because it obtains
information by interviewing respondents about the survival of all their
adult sisters.
When to Use
• When there is no reliable estimate of the level of maternal mortality
• An approximate level of maternal mortality needed for advocacy purposes and to draw attention to the problem
• Poor Resources
• A starting point is needed for more detailed follow-up of maternal deaths identified during the recent past.
Not appropriate for
Measuring progress towards safe motherhood in the short term
Evaluating programme impact
Comparing geographic areas or studying trends
Allocating resources.
Approximate Sample Size Requirements for Indirect Applications of the Sisterhood Method
(*) Assuming 2 adults available for interviewing per household(**) Maternal mortality ratios from about 200 per 100 000 live births for "intermediate" level to more than 1000 for "extremely high" level.In settings with high levels of maternal mortality (over 500 maternal deaths per 100,000 live births, sample sizes needed can be of the order of 4,000 households or less
Time Location of Estimates from Indirect Sisterhood Method
Reports cover deaths occurring over a large interval time, hence results generate an overall estimate of maternal mortality for a point centred around 10 to 12 years before the survey
Method Strengths Limitations
Original indirect method
Four simple questions can be added to ongoing household survey
Minimal time requirements Minimal sample size requirements Simple calculations to estimate
ratios Additional information can be
gathered on place/time/cause of death
Care needed in the use understanding of the questions
Provides retrospective estimate (10-12 years prior to the survey)
Not appropriate for use in settings with high levels of migration
Not appropriate for use in settings with declining or low fertility (TFR<3)
Direct Method
Can be added to ongoing multipurpose household survey
Smaller sample size requirements than household surveys but larger than indirect methods
Can be used to provide more recent estimates than the indirect method
Relatively inexpensive
Data collection more complex & longer than indirect method
Not appropriate for use in settings with high levels of migration
Not appropriate for use in settings with low fertility (TFR<3)
Not appropriate for monitoring in the short term
Number of respondents needed to establish a maternal mortality ratio of 300 per 1,00,000 live births correct to within 20%
MMR Indirect Method
Direct Method Household Survey
300 4,000* 5,000* 50,000**
* Adult respondents** Births
THE ORIGINAL SISTERHOOD METHOD'S FOUR QUESTIONS
1. How many sisters (born to the same mother) have you ever had who were ever-married (including those who are now dead)?
2. How many of these ever-married sisters are alive now?
3. How many of these ever-married sisters are dead?
4.How many of these dead sisters died while they were pregnantor during childbirth, or during the six weeks after the end of pregnancy?
THE "DIRECT" SISTERHOOD METHOD'S QUESTIONS
1. How many children did your mother give birth to?
2. How many of these births did your mother have before you were born?
3. What was the name given to your oldest (next oldest) brother or sister?
4. Is (NAME) male or female?
5. Is (NAME) still alive?
6. How old in (NAME)?
7. In what year did (NAME) die? OR How many yeas ago did (NAME) die?
8. How old was (NAME) when she died?
For dead sisters only:
9. Was (NAME) pregnant when she died?
10.Did (NAME) die during childbirth
11.Did (NAME) die within two months after the end of pregnancy or childbirth?
Motherhood Method• It is a direct technique for deriving local population-based estimates of
maternal mortality.
• The method involves estimating the same information within a
geographic area as would be collected in a census, but without visiting
every household.
• It is a targeted census of births and deaths within a defined study period.
• Evolutionary variant of the Participatory Community Survey method - for
neonatal tetanus and the perinatal mortality rate in rural Nepal
• It shares features with the Boerma and Mati’s “networking” approach of
eliciting maternal deaths and
• MIMF (Maternal death from Informants and Maternal
death Follow-on review)
• It differs, however, in eliciting deaths through group discussion of
listed mothers and community health care providers.
• To implement the method, the local health volunteers assist in
facilitating group discussions related to maternal and child health.
• Information on total births and maternal death during pregnancy,
childbirth or puerperium is elicited through immunization
registries, group discussions (FGD), peer memory, memory aids
and verbal autopsy.
Materials and Methods
• Motherhood method was pretested in a small, relatively well-off community of
about 8000 population (MMR 140/100000)
• The method was tested in a larger sample of 15161 births in the Bara district of
Nepal
• The sample size was expected to provide estimate of MMR within 30 % o
margin of error.
• This study employed the pregnant women group (PWG) approach
• The PWG comprised 7-15 pregnant women living in the same village or wards.
• They met once a month to discuss issues related to mother and child health.
The female community health volunteers (FCHVs) facilitated these meetings
Materials & Methods
Bara District, Nepal (Total predicted population for 2005=6,15,933)[1,30,578 women of reproductive age (15-49)]
Divided into 7 sectors
7 VDC* with population of 6000 were selected
Total 49 VDC selected
* - Village Development Committees
• Study Period : 2 yr from 17th July 2003 to 16 July 2005
• Information : Births, Maternal Death, Infant Death & PWG status
• Survey Period : 12 weeks
• The data were checked every day for omissions and errors and
corrected in the
field by revisits when necessary.
• Sub-sample of 49 wards was randomly selected, one from each VDC, to
conduct a census to validate the information obtained from the
motherhood method.
• Training : 2 days training was provided to supervisors and enumerators
to enable them to elicit required information from BCG and TT
vaccination registries and from the group discussion.
• Limitations of BCG registries were partially compensated for by
augmenting the list from TT vaccination registries.
• FGD : The typical group comprised 10-15 mothers and the local health
workers
• Deliveries outside the study period were excluded from the list of
counted pregnancies
• Each group had four data collectors with 3 enumerators and one
supervisor.
• On an average one group took five days to cover one VDC.
• The total cost of the evaluation was $ 10,896
• It was found that doing a census was 10 times more costly than
collecting data from motherhood method
(per unit cost $ 50.5 and $ 4.4)
Table 1 Total Births and Deaths by Study Groups, Bara District
RESULTS
Table 2: Mortality Indices of Bara District Compared with National Estimates
Results
• The results compared well with national data.
• A comparison with the census results in 49 wards showed 100 per
cent agreement with MM in detecting maternal and child deaths.
• There was about a 0.25 per cent under-reporting of births.
• The maternal, infant, neonatal and perinatal indicators in PWG
women were lower than the non-PWG women and the national
statistics.
Discussion
• Motherhood method demonstrated - MMR can be directly measured if
the BCG and TT vaccination registers are in place and local health
workers are properly mobilized and supervised for data collection
• Proper motivation of community key informants, health volunteers,
and mobilizers is crucial for the accuracy of data
• The motherhood method can be applied in a time and cost-efficient
manner to measure and monitor the progress in the reduction of
maternal and child deaths
• It can give current estimates of maternal mortality as well as averages
over the past few years
Discussion
• It appears to be particularly well-suited in measuring and
monitoring programmes in sub-national regions and districts
• Group discussion counteracted the disinclination of mothers
to talk about the death of their child, and enhanced collective
memory for recalling details
• The motherhood method appears to be effective regarding
problems induced by migration.
• The group discussion could elicit which mothers migrated to
the village to live or came to their mother’s home for delivery
Limitations
• Requires proper training of field assistants to moderate the group
discussion among mothers and health volunteers
• Motivation of key community informants and health volunteers is crucial
to the accuracy of data, and mothers need to be aware of the need for
accuracy
• The effort in collecting data depends on the duration of the study period,
the longer the study period, the greater the potential for inaccurate
recall
Limitations
• Reporting of maternal deaths in early pregnancy and those
related to abortion as non-maternal deaths may occur.
• Maternal Deaths related to “Hidden pregnancy” among teens
can be missed.
• The method would need further adaptation to measure births
and deaths in urban areas.
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