Measuring maternal mortality in MSF programs

1. Measuring maternal mortalityin MSF programs

2. 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 Background: A maternal death is the 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 birth). Between 11% and 17% of maternal deaths happen during childbirth itself and between 50% and 71% in the postpartum period[1]. 99% in developing countries. E.g.Lifetime risks of pregnant women dying in Africa is 1 in 16 while the lifetime risks of pregnant women in North America is 1 in 3,700 Maternal mortality is the health indicator with the greatest disparity between developed and developing nations, and between rich and poor within developing. Reducing maternal mortality by 75% within the next 25 years is one of the millennium development goals, but aside from a few exceptions, it is unclear what progress, if any, has been made in achieving this in developing countries, which carry 99% of the global burden of maternal mortality. [1] World Health Report 2005. WHO 2006 Background: A maternal death is the 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 birth). Between 11% and 17% of maternal deaths happen during childbirth itself and between 50% and 71% in the postpartum period[1]. 99% in developing countries. E.g.Lifetime risks of pregnant women dying in Africa is 1 in 16 while the lifetime risks of pregnant women in North America is 1 in 3,700 Maternal mortality is the health indicator with the greatest disparity between developed and developing nations, and between rich and poor within developing. Reducing maternal mortality by 75% within the next 25 years is one of the millennium development goals, but aside from a few exceptions, it is unclear what progress, if any, has been made in achieving this in developing countries, which carry 99% of the global burden of maternal mortality. [1] World Health Report 2005. WHO 2006

3. 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

4. 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. The countries that have successfully managed to make motherhood safer have three things in common. First, policy-makers and managers were informed: they were aware that they had a problem, knew that it could be tackled, and decided to act upon that information. Second, they chose a common-sense strategy that proved to be the right one: not just antenatal care, but also professional care at and after childbirth for all mothers, by skilled midwives, nurse-midwives or doctors, backed up by hospital care. Third, they made sure that access to these services – financial and geographical – would be guaranteed for the entire population (3). 3) Van Lerberghe W, De Brouwere V. Of blind alleys and things that have worked: history’s lessons on reducing maternal mortality. In: De Brouwere V, Van Lerberghe W, eds. Safe motherhood strategies: a review of the evidence. Antwerp, ITG Press, 2001 (Studies in Health Services Organisation and Policy, 17:7–33). The countries that have successfully managed to make motherhood safer have three things in common. First, policy-makers and managers were informed: they were aware that they had a problem, knew that it could be tackled, and decided to act upon that information. Second, they chose a common-sense strategy that proved to be the right one: not just antenatal care, but also professional care at and after childbirth for all mothers, by skilled midwives, nurse-midwives or doctors, backed up by hospital care. Third, they made sure that access to these services – financial and geographical – would be guaranteed for the entire population (3). 3) Van Lerberghe W, De Brouwere V. Of blind alleys and things that have worked: history’s lessons on reducing maternal mortality. In: De Brouwere V, Van Lerberghe W, eds. Safe motherhood strategies: a review of the evidence. Antwerp, ITG Press, 2001 (Studies in Health Services Organisation and Policy, 17:7–33).

7. 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. Very little data exists regarding current levels of maternal mortality in those areas in which MSF works. Even where data exists, reported figures are based on estimates at the national level. Although these reported figures are high, it is likely that these national or regional figures greatly underestimate the actual burden of maternal mortality in those sub-regions and populations at most risk. Some studies in remote and difficult areas have attempted to look at maternal mortality linked to patients presenting to health facilities. Results from such hospital or health facility based studies cannot give accurate information on what is occurring in the population which they service, as either the women who deliver, the women who die, or more often both, are not representative of the general population[1]. It is likely that the burden of maternal death is borne by those women who lived too distant from a health facility to access it at the time of delivery, and evaluating outcomes within a health facility ignores these women. A very few studies have looked at sub-regional estimates in settings similar to those in which in which MSF works using community based survey methods. A recent paper measuring maternal mortality in Afghanistan found 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]. This evidence suggests that in those areas where MSF is working, sub-regional estimates are needed to reliable quantify maternal mortality levels. It also suggests that MSF is working in many of those regions where maternal mortality is likely to be the highest. But at present, we have very little information on maternal mortality in any of these areas. [1] Royston, E. and AbouZahr, C. Measuring maternal mortality. British Medical Journal, 1992, 99 (7):540-543.   [2] Linda A Bartlett, Shairose Mawji, Sara Whitehead, Chadd Crouse, Suraya Dalil, Denisa Ionete, Peter Salama, and the Afghan Maternal Mortality Study Team, Where giving birth is a forecast of death: Maternal mortality in four districts of Afghanistan, 1999–2002, Lancet 2005; 365: 864–70   Very little data exists regarding current levels of maternal mortality in those areas in which MSF works. Even where data exists, reported figures are based on estimates at the national level. Although these reported figures are high, it is likely that these national or regional figures greatly underestimate the actual burden of maternal mortality in those sub-regions and populations at most risk. Some studies in remote and difficult areas have attempted to look at maternal mortality linked to patients presenting to health facilities. Results from such hospital or health facility based studies cannot give accurate information on what is occurring in the population which they service, as either the women who deliver, the women who die, or more often both, are not representative of the general population[1]. It is likely that the burden of maternal death is borne by those women who lived too distant from a health facility to access it at the time of delivery, and evaluating outcomes within a health facility ignores these women. A very few studies have looked at sub-regional estimates in settings similar to those in which in which MSF works using community based survey methods. A recent paper measuring maternal mortality in Afghanistan found 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]. This evidence suggests that in those areas where MSF is working, sub-regional estimates are needed to reliable quantify maternal mortality levels. It also suggests that MSF is working in many of those regions where maternal mortality is likely to be the highest. But at present, we have very little information on maternal mortality in any of these areas.

8. 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.

9. 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. Pilot assessment: This lack of information applicable to MSF contexts is due to the difficulties in measuring maternal mortality, particularly at sub-regional levels. If levels reported in the study above for remote areas of Afghanistan are also likely in many MSF settings, we considered that it might be possible to measure maternal mortality in a useful way with relatively small sample sizes and simple methodology. MSF carries out rapid health and mortality assessments in many settings, and these are both feasible and simple to implement. As an initial step towards developing feasible strategies for assessing maternal mortality levels, we attempted to pilot some measures of maternal mortality in the context of a study that was designed to measure morbidity and crude mortality. Issues that needed to be addressed included reliability of self-report, the lack of a system to validate reported deaths, and the need for simplified and short questionnaires. The survey was carried out in order to obtain data on levels of morbidity and mortality in the Pool region of Congo-Brazzaville, in those districts in which MSF currently has health projects (Mindouli and Kindamba districts). MSF has been working in this region for several years, as it is an area that was severely affected during the civil war and still is one of the most under-serviced areas of Congo-Brazzaville. The majority of this region is rural, with some semi urban areas surrounding the main towns. Both districts are similar, however Mindouli, due to the presence of a train line and proximity to larger towns in surrounding districts, is slightly better serviced and accessible. The survey was carried out in the 2 districts using stratified cluster sample methodology. Mortality was assessed over a 6-month recall period preceding the survey, and cause of death was assessed through self-report. Maternal mortality for the purpose of the survey was defined as a maternal death during or immediately after delivery, as reported by the family to the interviewer. It was considered that families could more reliably report a maternal death linked to the actual delivery than a death during pregnancy. Permission to conduct the survey was obtained from the Ministry of Health at national and local level, and oral informed consent of all respondents was obtained and documented. The sampling frame was based on the most updated population estimates available, and was the same sampling frame used for the Congo-Brazzaville Demographic and Health Survey (DHS) conducted in 2005-2006[1], as well as prior surveys conducted in 2005, including a UNDP/World Bank Household Poverty Survey conducted in the same year. Residents of Mindouli and Kindamba townships were excluded from the sampling frame, as the objective was to evaluate rural populations outside the main towns. For the purpose of this survey, a household was defined as a group of persons living together and sharing the same meals (living in one or several closely grouped shelters). Visitors (defined as persons who have been in the household less than one month) were excluded from the survey, with the exception of those children born during the recall period covered by the survey. The WHO 30 by 30-cluster survey methodology was used to select households. 30 clusters in Mindouli and 28 clusters in Kindamba were sampled, with approximately 30 households per cluster, and weighting was applied to estimates to adjust for unequal cluster size. In Mindouli, 905 households, with 4579 individuals were surveyed, and in Kindamba, 855 households with 4435 individuals. We found 11 maternal deaths linked closely to the delivery in our study population (7 in Kindamba and 4 in Mindouli). The number of live births recorded was 218 for the survey period (97 in Kindamba and 121 in Mindouli). The estimated maternal mortality ratio within the survey population by district for the study period was 4600 (95%CI: 340 – 8,900) per 100,000 live births in Mindouli and 7700 (95%CI: 2400 – 13,100) per 100,000 live births in Kindamba. The estimate for the survey region as a whole was 5200 (95%CI: 1500 –8,900) per 100,000 live births (all estimates adjusted for clustering and weighted). The levels of maternal mortality found in our [1] Enquete Demographique et Sante du Congo (EDSC-I) 2005 Ministère du Plan, de l’Aménagement du Territoire, de l’Intégration Économique et du NEPAD Centre National de la Statistique et des Études Économiques (CNSEE), Brazzaville et ORC Macro, Calverton, Maryland, Juillet 2006 Pilot assessment: This lack of information applicable to MSF contexts is due to the difficulties in measuring maternal mortality, particularly at sub-regional levels. If levels reported in the study above for remote areas of Afghanistan are also likely in many MSF settings, we considered that it might be possible to measure maternal mortality in a useful way with relatively small sample sizes and simple methodology. MSF carries out rapid health and mortality assessments in many settings, and these are both feasible and simple to implement. As an initial step towards developing feasible strategies for assessing maternal mortality levels, we attempted to pilot some measures of maternal mortality in the context of a study that was designed to measure morbidity and crude mortality. Issues that needed to be addressed included reliability of self-report, the lack of a system to validate reported deaths, and the need for simplified and short questionnaires. The survey was carried out in order to obtain data on levels of morbidity and mortality in the Pool region of Congo-Brazzaville, in those districts in which MSF currently has health projects (Mindouli and Kindamba districts). MSF has been working in this region for several years, as it is an area that was severely affected during the civil war and still is one of the most under-serviced areas of Congo-Brazzaville. The majority of this region is rural, with some semi urban areas surrounding the main towns. Both districts are similar, however Mindouli, due to the presence of a train line and proximity to larger towns in surrounding districts, is slightly better serviced and accessible. The survey was carried out in the 2 districts using stratified cluster sample methodology. Mortality was assessed over a 6-month recall period preceding the survey, and cause of death was assessed through self-report. Maternal mortality for the purpose of the survey was defined as a maternal death during or immediately after delivery, as reported by the family to the interviewer. It was considered that families could more reliably report a maternal death linked to the actual delivery than a death during pregnancy. Permission to conduct the survey was obtained from the Ministry of Health at national and local level, and oral informed consent of all respondents was obtained and documented. The sampling frame was based on the most updated population estimates available, and was the same sampling frame used for the Congo-Brazzaville Demographic and Health Survey (DHS) conducted in 2005-2006[1], as well as prior surveys conducted in 2005, including a UNDP/World Bank Household Poverty Survey conducted in the same year. Residents of Mindouli and Kindamba townships were excluded from the sampling frame, as the objective was to evaluate rural populations outside the main towns. For the purpose of this survey, a household was defined as a group of persons living together and sharing the same meals (living in one or several closely grouped shelters). Visitors (defined as persons who have been in the household less than one month) were excluded from the survey, with the exception of those children born during the recall period covered by the survey. The WHO 30 by 30-cluster survey methodology was used to select households. 30 clusters in Mindouli and 28 clusters in Kindamba were sampled, with approximately 30 households per cluster, and weighting was applied to estimates to adjust for unequal cluster size. In Mindouli, 905 households, with 4579 individuals were surveyed, and in Kindamba, 855 households with 4435 individuals. We found 11 maternal deaths linked closely to the delivery in our study population (7 in Kindamba and 4 in Mindouli). The number of live births recorded was 218 for the survey period (97 in Kindamba and 121 in Mindouli). The estimated maternal mortality ratio within the survey population by district for the study period was 4600 (95%CI: 340 – 8,900) per 100,000 live births in Mindouli and 7700 (95%CI: 2400 – 13,100) per 100,000 live births in Kindamba. The estimate for the survey region as a whole was 5200 (95%CI: 1500 –8,900) per 100,000 live births (all estimates adjusted for clustering and weighted). The levels of maternal mortality found in our [1] Enquete Demographique et Sante du Congo (EDSC-I) 2005 Ministère du Plan, de l’Aménagement du Territoire, de l’Intégration Économique et du NEPAD Centre National de la Statistique et des Études Économiques (CNSEE), Brazzaville et ORC Macro, Calverton, Maryland, Juillet 2006

10. Methodology and results Methodology : 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 We used a stratified WHO 30x30 cluster sample methodology. Mortality was assessed over a 6-month recall period; cause of death was assessed through self-report. Maternal mortality was defined as a maternal death during or immediately after delivery, as reported by the family to the interviewer. We considered that families could more reliably report a maternal death linked to the delivery than a death during pregnancy. Permission was obtained from the Ministry of Health and oral informed consent was obtained. The sampling frame was that used for the 2005-2006 Congo-Brazzaville Demographic and Health Survey.   Results: 905 households (4579 individuals) were surveyed in Mindouli, and 855 households (4435 individuals) in Kindamba. 11 maternal deaths were linked closely to delivery (7 in Kindamba, 4 in Mindouli). 218 live births were recorded (97 in Kindamba, 121 in Mindouli). Maternal mortality ratios were 4600 (95%CI: 340–8900) in Mindouli and 7700 (95%CI: 2400–13 100) in Kindamba. The estimate for the survey region as a whole was 5200 (95%CI: 1500-8900). We used a stratified WHO 30x30 cluster sample methodology. Mortality was assessed over a 6-month recall period; cause of death was assessed through self-report. Maternal mortality was defined as a maternal death during or immediately after delivery, as reported by the family to the interviewer. We considered that families could more reliably report a maternal death linked to the delivery than a death during pregnancy. Permission was obtained from the Ministry of Health and oral informed consent was obtained. The sampling frame was that used for the 2005-2006 Congo-Brazzaville Demographic and Health Survey.   Results: 905 households (4579 individuals) were surveyed in Mindouli, and 855 households (4435 individuals) in Kindamba. 11 maternal deaths were linked closely to delivery (7 in Kindamba, 4 in Mindouli). 218 live births were recorded (97 in Kindamba, 121 in Mindouli). Maternal mortality ratios were 4600 (95%CI: 340–8900) in Mindouli and 7700 (95%CI: 2400–13 100) in Kindamba. The estimate for the survey region as a whole was 5200 (95%CI: 1500-8900).

11. Discussion of Congo-B findings Plausible ? The levels are several fold higher than published rates for Congo-Brazzaville. 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. estimates adjusted for clustering and weighted). The levels of maternal mortality found in our study are extremely high; several fold higher than published rates for Congo-Brazzaville. Maternal mortality for the country as a whole is reported as 510 per 100,000 live births[1], but this is based on extrapolations from life table estimates and is likely to be an underestimate. A paper assessing maternal mortality in Brazzaville in 1996 using death registrations found a ratio of 645 per 100,000, in the context of a major city 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 we found appear however, to be consistent with those reported in the paper from Afghanistan. There were many limitations to what we did. We used a narrower definition of maternal mortality than that used in calculating maternal mortality data. 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. As this was a rapid health assessment, it was also not possible to obtain more detailed data such as socio-economic data or information on type or level of care. As our sample size was relatively small, the confidence intervals around the estimates we obtained were very wide. [1] World Health Statistics 2006, World Health Organization, 2006 [2] Le Coeur S, Pictet G, M'Pele P, Lallemant M. Direct estimation of maternal mortality in Africa, Lancet. 1998 Nov 7;352(9139):1525-6 estimates adjusted for clustering and weighted). The levels of maternal mortality found in our study are extremely high; several fold higher than published rates for Congo-Brazzaville. Maternal mortality for the country as a whole is reported as 510 per 100,000 live births[1], but this is based on extrapolations from life table estimates and is likely to be an underestimate. A paper assessing maternal mortality in Brazzaville in 1996 using death registrations found a ratio of 645 per 100,000, in the context of a major city 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 we found appear however, to be consistent with those reported in the paper from Afghanistan. There were many limitations to what we did. We used a narrower definition of maternal mortality than that used in calculating maternal mortality data. 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. As this was a rapid health assessment, it was also not possible to obtain more detailed data such as socio-economic data or information on type or level of care. As our sample size was relatively small, the confidence intervals around the estimates we obtained were very wide.

12. 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

13. Utility of confidence intervals

14. 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

15. 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. Accepted methodologies and their limitations : It is generally accepted that to measure maternal mortality directly, very large sample sizes are needed. This can be done, for example, through census data or through civil 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. However, such vital registration systems are non-existent in those countries with current high maternal mortality levels, and are unlikely to be in place for some time. In an effort to address this, WHO has recommended use of the sisterhood method[1]. Both the original indirect sisterhood method, and the adapted direct sisterhood method, estimate maternal mortality by asking women of reproductive age about pregnancy related deaths in their sisters. These methods require smaller sample sizes than direct respondent household surveys, but have major limitations. The indirect method, which is simple to implement and requires the smallest sample sizes, gives an estimate of maternal mortality centred around 12 years prior to the date of the survey. The indirect method gives a measure centred around 7 years prior, but achieves this with a much more complex questionnaire and analysis, and with considerably larger samples sizes. Although some reports from direct sisterhood studies have attempted to give levels centred closer to the survey date, there are persistent anomalies in the result which suggest it is not valid to extrapolate sisterhood, even direct sisterhood, survey results, to more recent periods. Another major drawback of both is that they cannot be used in regions where there is high migration, including war-torn areas or refugee populations. Another weakness is the validity of reported cause of death. As was the case for our rapid assessment, which ever form of the sisterhood method is used, it must still rely on reported cause of death. [1] Graham, W., Brass, W. and Snow, R.W. Indirect estimation of maternal mortality: the sisterhood method. Studies in Family Planning, 1989, 20 (3):125-135.   Accepted methodologies and their limitations : It is generally accepted that to measure maternal mortality directly, very large sample sizes are needed. This can be done, for example, through census data or through civil 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. However, such vital registration systems are non-existent in those countries with current high maternal mortality levels, and are unlikely to be in place for some time. In an effort to address this, WHO has recommended use of the sisterhood method[1]. Both the original indirect sisterhood method, and the adapted direct sisterhood method, estimate maternal mortality by asking women of reproductive age about pregnancy related deaths in their sisters. These methods require smaller sample sizes than direct respondent household surveys, but have major limitations. The indirect method, which is simple to implement and requires the smallest sample sizes, gives an estimate of maternal mortality centred around 12 years prior to the date of the survey. The indirect method gives a measure centred around 7 years prior, but achieves this with a much more complex questionnaire and analysis, and with considerably larger samples sizes. Although some reports from direct sisterhood studies have attempted to give levels centred closer to the survey date, there are persistent anomalies in the result which suggest it is not valid to extrapolate sisterhood, even direct sisterhood, survey results, to more recent periods. Another major drawback of both is that they cannot be used in regions where there is high migration, including war-torn areas or refugee populations. Another weakness is the validity of reported cause of death. As was the case for our rapid assessment, which ever form of the sisterhood method is used, it must still rely on reported cause of death.

16. Accepted methodologies and their limitations DHS data : National DHS surveys Provide national or regional estimates, do not give sub-regional 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 Accepted methodologies and their limitations : It is generally accepted that to measure maternal mortality directly, very large sample sizes are needed. This can be done, for example, through census data or through civil 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. However, such vital registration systems are non-existent in those countries with current high maternal mortality levels, and are unlikely to be in place for some time. In an effort to address this, WHO has recommended use of the sisterhood method[1]. Both the original indirect sisterhood method, and the adapted direct sisterhood method, estimate maternal mortality by asking women of reproductive age about pregnancy related deaths in their sisters. These methods require smaller sample sizes than direct respondent household surveys, but have major limitations. The indirect method, which is simple to implement and requires the smallest sample sizes, gives an estimate of maternal mortality centred around 12 years prior to the date of the survey. The indirect method gives a measure centred around 7 years prior, but achieves this with a much more complex questionnaire and analysis, and with considerably larger samples sizes. Although some reports from direct sisterhood studies have attempted to give levels centred closer to the survey date, there are persistent anomalies in the result which suggest it is not valid to extrapolate sisterhood, even direct sisterhood, survey results, to more recent periods. Another major drawback of both is that they cannot be used in regions where there is high migration, including war-torn areas or refugee populations. Another weakness is the validity of reported cause of death. As was the case for our rapid assessment, which ever form of the sisterhood method is used, it must still rely on reported cause of death. [1] Graham, W., Brass, W. and Snow, R.W. Indirect estimation of maternal mortality: the sisterhood method. Studies in Family Planning, 1989, 20 (3):125-135.   Accepted methodologies and their limitations : It is generally accepted that to measure maternal mortality directly, very large sample sizes are needed. This can be done, for example, through census data or through civil 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. However, such vital registration systems are non-existent in those countries with current high maternal mortality levels, and are unlikely to be in place for some time. In an effort to address this, WHO has recommended use of the sisterhood method[1]. Both the original indirect sisterhood method, and the adapted direct sisterhood method, estimate maternal mortality by asking women of reproductive age about pregnancy related deaths in their sisters. These methods require smaller sample sizes than direct respondent household surveys, but have major limitations. The indirect method, which is simple to implement and requires the smallest sample sizes, gives an estimate of maternal mortality centred around 12 years prior to the date of the survey. The indirect method gives a measure centred around 7 years prior, but achieves this with a much more complex questionnaire and analysis, and with considerably larger samples sizes. Although some reports from direct sisterhood studies have attempted to give levels centred closer to the survey date, there are persistent anomalies in the result which suggest it is not valid to extrapolate sisterhood, even direct sisterhood, survey results, to more recent periods. Another major drawback of both is that they cannot be used in regions where there is high migration, including war-torn areas or refugee populations. Another weakness is the validity of reported cause of death. As was the case for our rapid assessment, which ever form of the sisterhood method is used, it must still rely on reported cause of death.

17. 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 Recommendations on measuring maternal mortality in MSF settings - The best ongoing method for monitoring maternal mortality is reliable vital registration data, which has the 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 and potential interventions would add to the utility of such systems. - In settings where maternal mortality might be high, the potential may exist for carrying out rapid health assessments that include a component measuring maternal mortality. Careful consideration should be given to not so much to the likely point estimate, but to the utility of the range of the estimate (its confidence interval). As our initial pilot study in Congo-Brazzaville demonstrated, although the confidence intervals around our estimates were wide, these results still provided very useful information for program purposes. As they were a direct measure of levels over the 6-month recall period of the survey, they reflected current levels. They provided sub-regional estimates that were significantly different to national and urban estimates, and therefore provided a strong tool for use in advocating for greater resources to a comparatively under-serviced population. These results support the fact that in areas with very high maternal mortality, even relatively small surveys may be useful in establishing current levels sufficiently precisely to be of value in programmatic decision-making. Such surveys may also be useful in monitoring effectives of interventions, and even progress towards targets such as the MDG goal of 75% reduction in maternal mortality. - Implement the WHO recommended process indicators (Guidelines for monitoring the availability and use of obstetric services)[1], in particular access to all components of essential obstetric care (i.e essential obstetric services actually provide by health facilities). Essential obstetric care is the term used to describe the elements of obstetric care needed for the management of normal and complicated pregnancy, delivery and the postpartum period, and specifies requirements at both the health centre and district hospital level. For the services at a facility to be considered functional, the elements of care must have been provided during the 6 months previous to data collection. We currently look at one process indicator, antenatal coverage, but this does not provide the information needed to look at overall obstetric services. Our delivery and post-natal coverage rates are too low in all areas to give useful information on population level outcomes. Considering that most maternal deaths are likely to be due deaths during delivery or in the post-partum period, and that the majority of these will be related to causes that cannot be addressed through adequate antenatal care alone, simply providing and reporting on comprehensive antenatal services cannot give a reliable measure of delivery outcomes. [1] UNICEF/WHO/UNFPA. Guidelines for monitoring the availability and use of obstetric services. October 1997.   Recommendations on measuring maternal mortality in MSF settings - The best ongoing method for monitoring maternal mortality is reliable vital registration data, which has the 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 and potential interventions would add to the utility of such systems. - In settings where maternal mortality might be high, the potential may exist for carrying out rapid health assessments that include a component measuring maternal mortality. Careful consideration should be given to not so much to the likely point estimate, but to the utility of the range of the estimate (its confidence interval). As our initial pilot study in Congo-Brazzaville demonstrated, although the confidence intervals around our estimates were wide, these results still provided very useful information for program purposes. As they were a direct measure of levels over the 6-month recall period of the survey, they reflected current levels. They provided sub-regional estimates that were significantly different to national and urban estimates, and therefore provided a strong tool for use in advocating for greater resources to a comparatively under-serviced population. These results support the fact that in areas with very high maternal mortality, even relatively small surveys may be useful in establishing current levels sufficiently precisely to be of value in programmatic decision-making. Such surveys may also be useful in monitoring effectives of interventions, and even progress towards targets such as the MDG goal of 75% reduction in maternal mortality. - Implement the WHO recommended process indicators (Guidelines for monitoring the availability and use of obstetric services)[1], in particular access to all components of essential obstetric care (i.e essential obstetric services actually provide by health facilities). Essential obstetric care is the term used to describe the elements of obstetric care needed for the management of normal and complicated pregnancy, delivery and the postpartum period, and specifies requirements at both the health centre and district hospital level. For the services at a facility to be considered functional, the elements of care must have been provided during the 6 months previous to data collection. We currently look at one process indicator, antenatal coverage, but this does not provide the information needed to look at overall obstetric services. Our delivery and post-natal coverage rates are too low in all areas to give useful information on population level outcomes. Considering that most maternal deaths are likely to be due deaths during delivery or in the post-partum period, and that the majority of these will be related to causes that cannot be addressed through adequate antenatal care alone, simply providing and reporting on comprehensive antenatal services cannot give a reliable measure of delivery outcomes.

18. 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. Recommendations on measuring maternal mortality in MSF settings - The best ongoing method for monitoring maternal mortality is reliable vital registration data, which has the 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 and potential interventions would add to the utility of such systems. - In settings where maternal mortality might be high, the potential may exist for carrying out rapid health assessments that include a component measuring maternal mortality. Careful consideration should be given to not so much to the likely point estimate, but to the utility of the range of the estimate (its confidence interval). As our initial pilot study in Congo-Brazzaville demonstrated, although the confidence intervals around our estimates were wide, these results still provided very useful information for program purposes. As they were a direct measure of levels over the 6-month recall period of the survey, they reflected current levels. They provided sub-regional estimates that were significantly different to national and urban estimates, and therefore provided a strong tool for use in advocating for greater resources to a comparatively under-serviced population. These results support the fact that in areas with very high maternal mortality, even relatively small surveys may be useful in establishing current levels sufficiently precisely to be of value in programmatic decision-making. Such surveys may also be useful in monitoring effectives of interventions, and even progress towards targets such as the MDG goal of 75% reduction in maternal mortality. - Implement the WHO recommended process indicators (Guidelines for monitoring the availability and use of obstetric services)[1], in particular access to all components of essential obstetric care (i.e essential obstetric services actually provide by health facilities). Essential obstetric care is the term used to describe the elements of obstetric care needed for the management of normal and complicated pregnancy, delivery and the postpartum period, and specifies requirements at both the health centre and district hospital level. For the services at a facility to be considered functional, the elements of care must have been provided during the 6 months previous to data collection. We currently look at one process indicator, antenatal coverage, but this does not provide the information needed to look at overall obstetric services. Our delivery and post-natal coverage rates are too low in all areas to give useful information on population level outcomes. Considering that most maternal deaths are likely to be due deaths during delivery or in the post-partum period, and that the majority of these will be related to causes that cannot be addressed through adequate antenatal care alone, simply providing and reporting on comprehensive antenatal services cannot give a reliable measure of delivery outcomes. [1] UNICEF/WHO/UNFPA. Guidelines for monitoring the availability and use of obstetric services. October 1997.   Recommendations on measuring maternal mortality in MSF settings - The best ongoing method for monitoring maternal mortality is reliable vital registration data, which has the 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 and potential interventions would add to the utility of such systems. - In settings where maternal mortality might be high, the potential may exist for carrying out rapid health assessments that include a component measuring maternal mortality. Careful consideration should be given to not so much to the likely point estimate, but to the utility of the range of the estimate (its confidence interval). As our initial pilot study in Congo-Brazzaville demonstrated, although the confidence intervals around our estimates were wide, these results still provided very useful information for program purposes. As they were a direct measure of levels over the 6-month recall period of the survey, they reflected current levels. They provided sub-regional estimates that were significantly different to national and urban estimates, and therefore provided a strong tool for use in advocating for greater resources to a comparatively under-serviced population. These results support the fact that in areas with very high maternal mortality, even relatively small surveys may be useful in establishing current levels sufficiently precisely to be of value in programmatic decision-making. Such surveys may also be useful in monitoring effectives of interventions, and even progress towards targets such as the MDG goal of 75% reduction in maternal mortality. - Implement the WHO recommended process indicators (Guidelines for monitoring the availability and use of obstetric services)[1], in particular access to all components of essential obstetric care (i.e essential obstetric services actually provide by health facilities). Essential obstetric care is the term used to describe the elements of obstetric care needed for the management of normal and complicated pregnancy, delivery and the postpartum period, and specifies requirements at both the health centre and district hospital level. For the services at a facility to be considered functional, the elements of care must have been provided during the 6 months previous to data collection. We currently look at one process indicator, antenatal coverage, but this does not provide the information needed to look at overall obstetric services. Our delivery and post-natal coverage rates are too low in all areas to give useful information on population level outcomes. Considering that most maternal deaths are likely to be due deaths during delivery or in the post-partum period, and that the majority of these will be related to causes that cannot be addressed through adequate antenatal care alone, simply providing and reporting on comprehensive antenatal services cannot give a reliable measure of delivery outcomes.

19. 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. 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 useful and feasible ways of measuring and monitoring what happens to their mothers. 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 useful and feasible ways of measuring and monitoring what happens to their mothers.