maternal mortality
TRANSCRIPT
Maternal Mortality and Morbidity
+ we are starting our conference today
why is it important?● Pregnancy and childbirth remain unsafe● MM is relatively high● MM is avoidable and preventable● The necessary interventions are well known● A case of MM produces a widower and at least one orphan
Key facts about MM● Every day, nearly 830 women die from preventable causes
related to pregnancy and childbirth. ● 99% of all maternal deaths occur in developing countries. ● Maternal mortality is higher in women living in rural areas and
among poorer communities. ● Young adolescents face a higher risk of complications and death
as a result of pregnancy than other women. ● Skilled care before, during and after childbirth can save the lives
of women and newborn babies. ● Between 1990 and 2015, maternal mortality worldwide dropped
by about 44% [not ¾ as in MDG]
Outline● Definitions● Indicators● Registration● Data and Estimates● Level● Causes● Trends● Interventions
DefinitionThe death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and the site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management, but not from accidental or incidental causes
(International Statistical Classification of Diseases, ICD 10, O95, a part of CHAPTER XV - Pregnancy, childbirth and the puerperium (O00-O99))
Direct obstetric deathsDirect obstetric deaths are those resulting from obstetric complications of the pregnancy state (pregnancy, labour and the puerperium), from interventions, omissions, incorrect treatment, or from a chain of events resulting from any of the above.
Indirect obstetric deathsIndirect obstetric deaths are those resulting from previous existing disease or disease that developed during pregnancy and which was not due to direct obstetric causes, but which was aggravated by physiologic effects of pregnancy.
OtherCoincidental maternal deaths
Deaths from unrelated causes which happen to occur in pregnancy or the puerperium
Late Maternal Deaths
The death of a woman from direct or indirect obstetric causes, more than 42 days, but less than 1 year after termination of pregnancy
Pregnancy related deathsNearly similar to the above definitions.
Used mostly outside vital statistics domain, but in censuses, surveys, verbal autopsy, etc. when pregnancy histories and the like events of the past are collected.
Maternal Mortality Ratiois the number of maternal deaths in a given time period divided by the number of live births during the same period:
MMRatio=m.Deaths/l.Births (per 100 000)
It is often used as a measure of the quality of a health care system, and gender equality
It reflects the risk of dying during a single pregnancy
Maternal Mortality Rateis defined as the number of maternal deaths divided by person-years lived by women of reproductive age in a population
MMRate=m.Deaths/f(15-49).P
It reflects not only the risk of dying during a single pregnancy, but also how many times a woman faces this risk (i.e., her fertility level)
rates and ratiosThe MMRatio is generally regarded as the preferred measure of maternal mortality because it describes the frequency of maternal death relative to its risk pool, as measured (imperfectly, but not badly) by the number of live births. In practice, however, the MMRatio is prone to measurement bias because data for the numerator and denominator are often collected through different means.
proportion of maternal deaths Also useful
PM=m.Deaths/All.15-49.Deaths
Even if a given data source yields an underestimate of the number of maternal deaths (as occurs quite frequently due to under-reporting of events), it is plausible that the reported proportion of maternal deaths is more reliable (Hill et al., 2007).
MMrate is MMRatio+fertilityMMrate=MMRatio*GFR
the MMRate reflects both the risk of maternal death per live birth (MMRatio) and the level of fertility (GFR).
Lifetime risk of maternal deathrefers to the probability that a 15-year-old female will die eventually from a maternal cause if she experiences throughout her lifetime the risks of maternal death and the overall levels of fertility and mortality that are observed for a given population. The adult lifetime risk of maternal mortality can be derived using either the maternal mortality ratio (MMRatio), or the maternal mortality rate (MMRate).
It supposes that we have age-specific data, sometimes we have, then see here.
otherwise the lifetime risk of maternal death is
LR=MMRate*(T50-T15)/l15
MetricsAre they adequate?
Do they adequately reflect the definition?
Civil registration: availability of data(A) countries with relatively complete civil registration systems and good attribution of causes of death (%% countries/births 37/15)
(B) countries that lack complete registration systems but for which other nationally representative data are available for measuring maternal mortality (49/82), and
(C) countries with no available national-level data on maternal mortality (14/4)
data beyond registration:sample surveys, censuses, periodic inquiries (often called “reproductive-age mortality studies” or RAMOS), and various ongoing surveillance systems (including “sample registration” in India). Censuses and some surveys have been used to collect data on the number of recent deaths occurring in a household, along with some information about cause of death (sometimes a complete verbal autopsy). A more common survey technique is the (direct) sisterhood method, which gathers detailed information about all past deaths among sisters of respondents, including whether they occurred during the maternal risk period (but typically without additional information about the underlying cause of death). More information about the different data sources is available in (Wilmoth et al., 2012).
for instance Lao census (1995)Q Did any deaths occur in the household in the last 12 months?
4I If yes: Was the deceased male or female?
Q How old was the deceased (age in completed years)?
4I For women aged 15–49 years and for deaths other than caused by an accident:
Q Did she die while pregnant, while giving birth, or within 42 days after giving birth?
Data and estimate● what is the difference?● Rosstat practice
Bureaucracy, Millennium Development Goal
5The Millennium Development Goals (MDGs) are eight international development goals that were officially established following the Millennium Summit of the United Nations in 2000
Two major sources of information
● the UN family● Institute for Health Metrics and Evaluation, University of
Washington, Seattle, WA, USA● other sources are less influential but more doubtful
the UN family
UN Maternal Mortality Estimation Inter-agency Group
(during two weeks : HTTP Error 404. The requested resource is not found. May be due to MDG program is over, thus the site is over)
A Bayesian approach to the global estimation of maternal mortality
is a good topic to make a presentation at our conference, esp for those whose topic is far from RH+FP
IHMEMaternal mortality estimates:global progress on levels and trends
UN, IHME estimates and national data (2012)
Maternal Mortality Ratio
Orange - IHMEViolet - UN MMEIGRed - National Data
● Uzbekistan● Kazakhstan● Ukraine● Russia● Germany● Belarus
Levels
TrendsPakistan is making progress
Kenya and Nigeria — no
why ?
CausesGlobal causes of maternal death: a WHO systematic analysis
InterventionsWomen’s access to high-quality health services during pregnancy and childbirth is crucial to save lives.
Essential health interventions include:
● practising good hygiene to reduce the risk of infection; ● injecting oxytocin immediately after childbirth to reduce the
risk of severe bleeding; ● identifying and addressing potentially fatal conditions like
pregnancy-induced hypertension; and ● ensuring access to sexual and reproductive health services and
family planning for women.
Resume● Very popular in advocacy, but very difficult in observation● Data are scarce, what is published — model driven estimates● Incompatibility of indicators in many cases● Lack of events, esp in a developed country or dealing with
national regions ● Easily preventable