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MDG 5 indicators: Concepts and Methodologies


MDG 5 indicators: Concepts and Methodologies Lale Say MD, MSc and Doris Chou, MD Department of Reproductive Health and Research World Health Organization – PowerPoint PPT presentation

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Title: MDG 5 indicators: Concepts and Methodologies

MDG 5 indicators Concepts and Methodologies
  • Lale Say MD, MSc and Doris Chou, MD
  • Department of Reproductive Health and Research
  • World Health Organization

MDG 5 improve maternal health
  • Target 5.A Reduce by three quarters, between
    1990 and 2015, the maternal mortality ratio
  • 5.1 Maternal mortality ratio
  • 5.2 Proportion of births attended by skilled
    health personnel
  • Target 5.B Achieve, by 2015, universal access to
    reproductive health
  • 5.3 Contraceptive prevalence rate
  • 5.4 Adolescent birth rate
  • 5.5 Antenatal care coverage
  • at least one visit and at least four visits
  • 5.6 Unmet need for family planning

Target 5.A Reduce by three quarters, between
1990 and 2015, the maternal mortality ratio
  • 5.1 Maternal mortality ratio

  • Updates every 5 year since 1990 by WHO, UNICEF,
    UNFPA The World Bank joined in 2005 updates
  • 2008 update An academic team at University of
    Berkeley developed/applied in collaboration with

Trends in Maternal Mortality 1990 to 2008
  • Reviewed by the technical advisory group with
    experts from academic institutions Berkeley,
    Harvard, Hopkins, Texas, Aberdeen, Umea,
    Statistics Norway in current update
  • Countries consulted for comments on methodology
    and additional input

General framework of the maternal mortality
estimates 1990-2008
  • Levels and trends of maternal mortality between
    1990 and 2008 for 172 countries
  • Hierarchical/multilevel linear regression model
  • The input data is the PMDF (proportion maternal
    among all female deaths 15-49) adjusted for
    completeness and definition
  • Covariates the log(GDP), log(GFR) and SAB
  • The final output takes into account the maternal
    mortality related with the HIV/AIDS

Definition used
  • gt Maternal death the 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.
    ICD-10, WHO,1994
  • Pregnancy-related death the death of a woman
    while pregnant or within 42 days of termination
    of pregnancy

Estimated measures
  • Maternal Mortality Ratio (MMR) Ratio of maternal
    deaths in a period to live births (proxy for
    risky events) in the same period (x 100,000).
  • Number of maternal deaths
  • PMDF Proportion of maternal among female deaths
  • Lifetime risk of a maternal death An estimate of
    the likelihood that a woman who survives to age
    15 will die of maternal causes
  • proportion of women reaching reproductive age who
    would die of maternal causes, taking into account
    competing causes

Input data to the model PMDF
  • PMDF is considered less subject to
    under-reporting than MMR (maternal and
    non-maternal deaths likely to be under-reported
    to similar degree)
  • Maternal deaths as defined by ICD is difficult to
    capture usually all deaths in pregnancy
  • Efforts have been made to adjust for
  • under reporting
  • definition
  • For the model the HIV/AIDS component was taken
    out from the PMDF the HIV/AIDS component is
    added back after the model fitting

Input database
  • Database of 172 countries, from 1985 onwards
  • Nationally representative data
  • gt focusing on sources where PMDF is possible to

Sources of Data
  • Civil registration systems with cause of death
    assigned by attending physician (generally not
    complete in developing world)
  • Sample vital registration systems
  • Reproductive Age Mortality Surveys (RAMOS) not
    very common
  • Household surveys with sibling histories
  • Population censuses with questions on household
  • Hospital- or facility-based studies
  • Other

Civil Registration Data
  • WHO estimates that 72 (out of 193) member states
    have complete recording of deaths
  • But not all have adequate cause of death data
  • Even in countries with complete VR,
    classification of deaths as maternal is
  • Recent increase in MMR (47 2002 to 2004) in US
    due to change of death certificate
  • Issues
  • 14 studies (confidential enquiry, record linkage)
    of countries with complete registration a median
    underestimation of 0.5) (true maternal deaths
    were incorrectly recorded as non-maternal)

Sample Vital Registration Systems
  • Special procedures in random sample of areas
    (4,000 in India, 160 in China)
  • Continuous monitoring of vital events plus
    6-monthly household survey (India)
  • Cause of death identified by verbal autopsy (VA)
    (India) or case records plus VA (China)
  • Issues
  • Requires considerable administrative
  • Cannot be implemented rapidly
  • Needs periodic evaluation

RAMOS Studies
  • Starting point is complete listing of deaths of
    women of reproductive age
  • Best starting point is close to complete VR
  • Key feature is triangulation among data sources
    (eg church records, burial grounds) to identify
    missed deaths
  • May be done for a sample (but has to be large)
  • Each death is investigated in detail to determine
    whether or not it was maternal
  • Hospital, health facility records
  • Household interviews
  • Issues
  • Results may be no better than the frame of deaths
  • MMR also needs number of births

Censuses with Questions on Deaths
  • Population censuses can include questions on
    deaths in households in defined recent reference
  • Reported deaths of reproductive aged women
    trigger questions about the timing of death
    relative to pregnancy
  • Issues
  • Pregnancy-related mortality
  • Census misses deaths in single-person households
  • Death of head of household may result in
    household breakup
  • Experience suggests there is almost always some
  • Need to evaluate carefully
  • No consensus as to the quality of the data

Facility-Based Studies
  • Useful for identifying areas for improved care
    (confidential enquiries)
  • Potential for gold standard case identification
    (case notes)
  • Facility deaths (and births) are selected on
    characteristics that may not be known
  • Not readily generalizable to a national MMR

Household Surveys With Sibling Histories
  • Key questions for sibling history
  • Each sibling listed individually
  • Record sex
  • Record age in completed years for surviving sibs
  • Record year of death, age at death for dead sibs
  • For deaths of women of reproductive age, 3
    questions about timing of death relative to
  • Widely used by DHS program (41countries,65
  • Issues
  • Measures pregnancy-related mortality
  • Even in surveys of 30,000 households, estimates
    are made for 7 years before survey
  • May under-estimate overall mortality

General Problems with Maternal Mortality
  • Rare events (only 5 of child deaths)
  • National trends unstable
  • For household surveys requires very large samples
  • Certain types of maternal death hard to identify
    (especially abortion-related)
  • Non-VR methods tend to measure pregnancy-related
    mortality PRMR

Input data to the model Adjustment by type of
  • Adjustment for completeness of reporting
    specified in relation to the type of data
  • CR system Review of recent literature on
    underestimation of maternal deaths in CR systems
  • adjustment by a factor of 1.5
  • Sibling histories age-standardization,
  • 1.1 upward adjustment (underestimation of early
    pregnancy deaths)
  • 0.9, 0.85 downward adjustment (remove accidental
  • Other special studies (e.g., RAMOS)
  • 1.1 upward adjustment

Data on maternal mortality availability
Sources Number of surveys Number of country-years
Civil Registration 1891 1891
Surveys with Sibling Histories 105 819
Population Censuses 18 19
Other (eg special surveys, verbal autopsies, surveillance) 80 113
Total 2094 2842
24 countries had no nationally representative
data that met inclusion criteria
  • GDP gross domestic product PPP per capita, in
    constant 2005 international dollar the World
    Bank series, complemented by other sources
  • GFR general fertility rate, the number of births
    in a population divided by the number of women at
    reproductive ages UNPD World Population
    Prospects the 2008 revision
  • SAB the proportion of deliveries with a skilled
    attendant at birth from UNICEF database

Covariates and the model
  • A time series of these three covariates were
    constructed for the 1985-2008 period
  • Time-matched average values of the covariates for
    time intervals corresponding to the period of
    each observation of the dependent variable PMDF
    were computed
  • A hierarchical/multilevel model with three main
    covariates, plus random effects for countries and
    regions and an offset which will adjust the
    denominator of PMDF for AIDS.

Input data to the model Definition and HIV/AIDS
  • Observed PMDF were grouped into 3 categories
    according to the definition
  • Maternal mortality
  • Pregnancy-related
  • Pregnancy-related without accident

Maternal, non-AIDS-related Maternal, AIDS-related
Accidental/incidental, non-AIDS-related Accidental/incidental, AIDS-related
Input data to the model Addressing HIV/AIDS
  • The fraction of AIDS deaths among women aged
    15-49 that occur during pregnancy (v)
  • v ckGFR / ( 1 c(k-1)GFR)
  • c average period of exposure-to-risk associated
    with each live birth
  • k relative risk of dying from HIV/AIDS for a
    pregnant versus non-pregnant woman
  • u the fraction of AIDS deaths that were
    presumably included in a PMDF or MMR observation.
  • 1 if pregnancy-related definition (with or
    without accidents)
  • 0.5 otherwise
  • PMDF observations adjusted to remove estimated
    included AIDS deaths before running regression
  • PMDF u v a
  • where a proportion of AIDS deaths among all
    deaths in age range 15-49 for women

Fitting and add back HIV/AIDS
  • The model fitted to the complete set of
    observations for 172 countries
  • Add back a fraction, u, of the total number of
    AIDS deaths estimated to have occurred during
  • Predicted PMDF converted to MMRs
  • D N female deaths 15-49 estimated from WHO life
  • B N live births from UN Population Division

Country consultation
  • Focal point identification and review
  • Comments received during consultation
  • Accepted amendments to data input
  • source of reference clearly identified

Maternal mortality in 2008 and average annual
change between 1990 and 2008
  MMR Lower estimate Upper estimate Maternal deaths Average annual change
WORLD TOTAL 260 200 370 358,000 -2.3
DEVELOPED REG. 14 13 16 1700 -0.8
COUNTRIES OF THE CIS 40 34 48 1500 -3.0
DEVELOPING REG. 290 220 410 355,000 -2.3
North Africa 92 60 140 3400 -5.0
Sub-Saharan Africa 640 470 930 204,000 -1.7
Asia 190 130 270 139,000 -4.0
Latin America and the Caribbean 85 72 100 9200 -2.9
Oceania 230 100 500 550 -1.4
Numbers are rounded
Maternal mortality ratios 1990-2008
  • Components of uncertainty include
  • Any remaining bias in adjusted PMDF values
  • Uncertainty in model parameters (c, k, u, and pi)
  • Regression prediction uncertainty within the PMDF
  • Possible error in MMR conversion (estimated
    births and deaths)
  • Alternative models, covariates, etc.

Maternal deaths due to HIV/AIDS
  • Overall, it was estimated that there were 42 000
    deaths due to HIV/AIDS among pregnant women in
  • About half of those were assumed to be maternal
  • The contribution of HIV/AIDS was highest in
    sub-Saharan Africa where 9 of all maternal
    deaths were estimated to be due to HIV/AIDS
  • Globally, 6 of maternal deaths estimated to be
    due to HIV/AIDS

Maternal mortality ratios at country level
CEE/CIS countries
What is new compared with the 2005 analysis
  • Trend estimates for countries
  • gt bigger database
  • Definition issue addressed
  • Maternal deaths related with HIV/AIDS taken into
  • Statistical model more detailed

Differences with IHME analysis
  • The data used by IHME and MMEIG are very similar
  • Global totals for 2008 similar, differences in
    1990 estimates and individual countries likely to
    be due to technical differences in the methods
  • adjustments made to data from various sources
    differed, in some cases use of sub-national data
  • modelling strategies
  • different covariates used
  • IHME TFR, GDP, HIV prevalence, NMR, female
  • addressing HIV IHME used HIV prevalence as a
  • adult mortality databases

Next steps
  • Database and the statistical programme available
    on web
  • January TAG meeting call for inputs and
  • Review feedback and continuous interaction with
    countries in
  • strengthening capacity in using the model
  • reviewing data quality
  • updating the database
  • supporting the use of data for decision making
  • Regional workshops

Target 5.A Reduce by three quarters, between
1990 and 2015, the maternal mortality ratio
  • 5.2 Proportion of births attended by skilled
    health personnel

Births attended by Skilled Health Personnel
  • Health service coverage indicator
  • Measurement as a percentage
  • Numerator births attended by SBA
  • Denominator total live births in time pd
  • Skilled birth attendant
  • an accredited health professional (midwife,
    nurse, doctor) trained and able to manage
    uncomplicated pregnancy, childbirth, postnatal
    period, and able to identify, manage, refer
    complications of women and newborns
  • Definition excludes traditional birth attendants
    (with or without training)

SBA Data Sources
  • Household surveys
  • Respondents asked about each live birth and who
  • Facility based records
  • Where high proportion of births occur in
  • Used in Latin America
  • Data issues
  • Some survey reports may present a total of
    births attended by a type of provider (eg
    includes community health workers)
  • Standardization of definition of SBA is difficult
    because of training differences

SBA reporting
  • Data reported annually by UNICEF and WHO
  • Weighted averages of country data using number
    live births for reference year in country
  • No figures are reported if less than 50 live
    births in region covered
  • Disaggregation
  • Location
  • Education level
  • Wealth quintile
  • Health personnel
  • Place of delivery
  • Administrative region
  • Health region

Target 5.B Achieve, by 2015, universal access to
reproductive health
  • 5.5 Antenatal care coverage
  • at least one visit
  • at least four visits

Antenatal Coverage
  • Health service coverage
  • Measurement as a percentage
  • Numerator women aged 15-49 with live birth in
    time pd who received ANC (at least once or at
    least 4 times) during pregnancy
  • Denominator total of women aged 15-49 with
    live birth in time pd

ANC Data Sources
  • Household surveys
  • Based upon standard questions that ask if, and
    how many times, and by whom the health of woman
    was checked in pregnancy
  • Facility reporting systems
  • Used where coverage is high
  • Data issues
  • Receiving ANC does not guarantee all
    interventions to improve maternal health
  • Indicator for at least one visit refers to
    skilled provider
  • Indicator for 4 or more visits measures any
  • Standardization of definition of SBA is difficult
    because of training differences

Antenatal Care reporting
  • Data reported annually by UNICEF and WHO
  • Population weighted averages weighted by total
    number live births
  • No figures are reported if less than 50 live
    births in region covered
  • Disaggregation
  • Location
  • Education level
  • Wealth quintile
  • Administrative region
  • Health region

  • Indicators are markers of health status, service
    provision, resource availability
  • Indicators are designed to monitor service
    performance or programme goals
  • Indicators have inherent limitations

  • Interpretation of indicators is challenging due
    to variability
  • Lack of reliable statistics for measuring
    progress results in an evolving understanding of
    the interpretation

  • Gradual but variable decline of maternal
    mortality, globally off the pace required by the
    MDG 5 target
  • Preventable maternal deaths occur every day
  • Need for real and better numbers
  • Maternal deaths must be counted to guide action
    and monitoring progress
  • Estimates are imprecise, but important as a means
    to assess progress and engage countries
  • Not knowing the exact numbers of women dying
    should not deflect anyone's attention from
    stepping up our efforts to reduce maternal