Search

Abstract Current methods for estimating maternal mortality lack precision, and are not suitable for monitoring progress in the short run. In addition, national maternal mortality ratios (MMRs) alone do not provide useful information on where the greatest burden of mortality is located, who is concerned, what are the causes, and more importantly what sub-national variations occur. This paper discusses a maternal death surveillance and response (MDSR) system. MDSR systems are not yet established in most countries and have potential added value for policy making and accountability and can build on existing efforts to conduct maternal death reviews, verbal autopsies and confidential enquiries. Accountability at national and sub-national levels cannot rely on global, regional and national retrospective estimates periodically generated from academia or United Nations organizations but on routine counting, investigation, sub national data analysis, long term investments in vital registration and national health information systems. Establishing effective maternal death surveillance and response will help achieve MDG 5, improve quality of maternity care and eliminate maternal mortality (MMR ≤ 30 per 100,000 by 2030).

Abstract Background Clean birth practices can prevent sepsis, one of the leading causes of both maternal and newborn mortality. Evidence suggests that clean birth kits (CBKs), as part of package that includes education, are associated with a reduction in newborn mortality, omphalitis, and puerperal sepsis. However, questions remain about how best to approach the introduction of CBKs in country. We set out to develop a practical decision support tool for programme managers of public health systems who are considering the potential role of CBKs in their strategy for care at birth. Methods Development and testing of the decision support tool was a three-stage process involving an international expert group and country level testing. Stage 1, the development of the tool was undertaken by the Birth Kit Working Group and involved a review of the evidence, a consensus meeting, drafting of the proposed tool and expert review. In Stage 2 the tool was tested with users through interviews (9) and a focus group, with federal and provincial level decision makers in Pakistan. In Stage 3 the findings from the country level testing were reviewed by the expert group. Results The decision support tool comprised three separate algorithms to guide the policy maker or programme manager through the specific steps required in making the country level decision about whether to use CBKs. The algorithms were supported by a series of questions (that could be administered by interview, focus group or questionnaire) to help the decision maker identify the information needed. The country level testing revealed that the decision support tool was easy to follow and helpful in making decisions about the potential role of CBKs. Minor modifications were made and the final algorithms are presented. Conclusion Testing of the tool with users in Pakistan suggests that the tool facilitates discussion and aids decision making. However, testing in other countries is needed to determine whether these results can be replicated and to identify how the tool can be adapted to meet country specific needs.

Abstract Background The maternal mortality ratio (MMR) remains high in most developing countries. Local, recent estimates of MMR are needed to motivate policymakers and evaluate interventions. But, estimating MMR, in the absence of vital registration systems, is difficult. This paper describes an efficient approach using village informant networks to capture maternal death cases (Maternal Deaths from Informants/Maternal Death Follow on Review or MADE-IN/MADE-FOR) developed to address this gap, and examines its validity and efficiency. Methods MADE-IN used two village informant networks - heads of neighbourhood units (RTs) and health volunteers (Kaders). Informants were invited to attend separate network meetings - through the village head (for the RT) and through health centre for the kaders. Attached to the letter was a form with written instructions requesting informants list deaths of women of reproductive age (WRA) in the village during the previous two years. At a 'listing meeting' the informants' understanding on the form was checked, informants could correct their forms, and then collectively agreed a consolidated list. MADE-FOR consisted of visits relatives of likely pregnancy related deaths (PRDs) identified from MADE-IN, to confirm the PRD status and gather information about the cause of death. Capture-recapture (CRC) analysis enabled estimation of coverage rates of the two networks, and of total PRDs. Results The RT network identified a higher proportion of PRDs than the kaders (estimated 0.85 vs. 0.71), but the latter was easier and cheaper to access. Assigned PRD status amongst identified WRA deaths was more accurate for the kader network, and seemingly for more recent deaths, and for deaths from rural areas. Assuming information on live births from an existing source to calculate the MMR, MADE-IN/MADE-FOR cost only $0.1 (US) per women-year risk of exposure, substantially cheaper than alternatives. Conclusions This study shows that reliable local, recent estimates of MMR can be obtained relatively cheaply using two independent informant networks to identify cases. Neither network captured all PRDs, but capture-recapture analysis allowed self-calibration. However, it requires careful avoidance of false-positives, and matching of cases identified by both networks, which was achieved by the home visit.

Abstract Background The effect of the recent world recession on population health has featured heavily in recent international meetings. Maternal health is a particular concern given that many countries were already falling short of their MDG targets for 2015. Methods We utilise 20th century time series data from 14 high and middle income countries to investigate associations between previous economic recession and boom periods on maternal and infant outcomes (1936 to 2005). A first difference logarithmic model is used to investigate the association between short run fluctuations in GDP per capita (individual incomes) and changes in health outcomes. Separate models are estimated for four separate time periods. Results The results suggest a modest but significant association between maternal and infant mortality and economic growth for early periods (1936 to 1965) but not more recent periods. Individual country data display markedly different patterns of response to economic changes. Japan and Canada were vulnerable to economic shocks in the post war period. In contrast, mortality rates in countries such as the UK and Italy and particularly the US appear little affected by economic fluctuations. Conclusions The data presented suggest that recessions do have a negative association with maternal and infant outcomes particularly in earlier stages of a country's development although the effects vary widely across different systems. Almost all of the 20 least wealthy countries have suffered a reduction of 10% or more in GDP per capita in at least one of the last five decades. The challenge for today's policy makers is the design and implementation of mechanisms that protect vulnerable populations from the effects of fluctuating national income.

Abstract Background Substantial reductions in maternal mortality are called for in Millennium Development Goal 5 (MDG-5), thus assuming that maternal mortality is measurable. A key difficulty is attributing causes of death for the many women who die unaided in developing countries. Verbal autopsy (VA) can elicit circumstances of death, but data need to be interpreted reliably and consistently to serve as global indicators. Recent developments in probabilistic modelling of VA interpretation are adapted and assessed here for the specific circumstances of pregnancy-related death. Methods A preliminary version of the InterVA-M probabilistic VA interpretation model was developed and refined with adult female VA data from several sources, and then assessed against 258 additional VA interviews from Burkina Faso. Likely causes of death produced by the model were compared with causes previously determined by local physicians. Distinction was made between free-text and closed-question data in the VA interviews, to assess the added value of free-text material on the model's output. Results Following rationalisation between the model and physician interpretations, cause-specific mortality fractions were broadly similar. Case-by-case agreement between the model and any of the reviewing physicians reached approximately 60%, rising to approximately 80% when cases with a discrepancy were reviewed by an additional physician. Cardiovascular disease and malaria showed the largest differences between the methods, and the attribution of infections related to pregnancy also varied. The model estimated 30% of deaths to be pregnancy-related, of which half were due to direct causes. Data derived from free-text made no appreciable difference. Conclusion InterVA-M represents a potentially valuable new tool for measuring maternal mortality in an efficient, consistent and standardised way. Further development, refinement and validation are planned. It could become a routine tool in research and service settings where levels and changes in pregnancy-related deaths need to be measured, for example in assessing progress towards MDG-5.

The first target of the fifth United Nations Millennium Development Goal is to reduce maternal mortality by 75% between 1990 and 2015. This target is critically off track. Despite difficulties inherent in measuring maternal mortality, interventions aimed at reducing it must be monitored and evaluated to determine the most effective strategies in different contexts. In some contexts, the direct causes of maternal death, such as haemorrhage and sepsis, predominate and can be tackled effectively through providing access to skilled birth attendance and emergency obstetric care. In others, indirect causes of maternal death, such as HIV/AIDS and malaria, make a significant contribution and require alternative interventions. Methods of planning and evaluating maternal health interventions that do not differentiate between direct and indirect maternal deaths may lead to unrealistic expectations of effectiveness or mask progress in tackling specific causes. Furthermore, the need for additional or alternative interventions to tackle the causes of indirect maternal death may not be recognized if all-cause maternal death is used as the sole outcome indicator. This article illustrates the importance of differentiating between direct and indirect maternal deaths by analysing historical data from England and Wales and contemporary data from Ghana, Rwanda and South Africa. The principal aim of the paper is to highlight the need to differentiate deaths in this way when evaluating maternal mortality, particularly when judging progress towards the fifth Millennium Development Goal. It is recommended that the potential effect of maternity services failing to take indirect maternal deaths into account should be modelled. La premiere cible du cinquieme objectif du Millenaire pour le developpement fixe par les Nations Unies est de reduire des deux tiers, entre 1990 et 2015, le taux de mortalite maternelle. L'evolution actuelle s'ecarte gravement de cet objectif. Malgre les difficultes inherentes a la mesure de la mortalite maternelle, les interventions visant a reduire cette mortalite doivent etre suivies et evaluees pour determiner les strategies les pius efficaces dans differentes situations. Dans certains contextes, les causes directes de deces maternels telles que les hemorragies et les accidents septiques, sont predominantes et peuvent etre contrees efficacement en permettant aux femmes de beneficier d'une assistance a l'accouchement par du personnel qualifie et de soins obstetricaux d'urgence. Dans d'autres contextes, des causes indirectes de deces maternels telles que le VIH/sida et le paludisme contribuent notablement a la mortalite des meres et necessitent d'autres types d'interventions. Les methodes de planification et d'evaluation des interventions en faveur de la sante maternelle qui ne font pas la distinction entre deces maternels directs et indirects peuvent conduire a des attentes irrealistes quant a l'efficacite des interventions ou masquer les progres dans la maitrise de certaines causes. En outre, la necessite d'interventions supplementaires ou alternatives pour faire face aux causes indirectes de deces maternels peut ne pas etre reconnue si le nombre de deces maternels toutes causes confondues est utilise comme seul indicateur de resultat. Le present article illustre l'importance de la differenciation entre deces maternels directs et indirects a travers l'analyse de donnees historiques provenant d'Angleterre et du Pays de Galle et de donnees contemporaines provenant du Ghana, du Rwanda et d'Afrique du Sud. Il vise principalement a attirer l'attention sur la necessite de cette distinction lors de l'evaluation des deces maternels, notamment lorsqu'il s'agit de juger les progres realises vers le cinquieme objectif du Millenaire pour le developpement. Il est recommande de modeliser les effets potentiels de la non-prise en compte des deces maternels indirects par les services de maternite. La primera meta del quinto Objetivo de Desarrollo del Milenio de las Naciones Unidas, consistente en reducir la mortalidad materna en un 75% entre 1990 y 2015, parece cada dia mas inalcanzable. Pese a las dificultades inherentes a la medicion de la mortalidad materna, es preciso vigilar y evaluar las intervenciones encaminadas a reduciria si se desea determinar las estrategias mas eficaces en los diferentes contextos. En algunos entornos predominan las causas directas de defuncion materna, como las hemorragias y la septicemia, que pueden abordarse eficazmente proporcionando acceso a atencion de parteria cualificada y atencion obstetrica de urgencia. En otros casos, las causas indirectas, como el VIH/sida y la malaria, contribuyen de forma importante y exigen otro tipo de intervenciones. Los metodos de planificacion y evaluacion de las intervenciones de salud materna que no distinguen las defunciones maternas directas de las indirectas pueden dar lugar a expectativas poco realistas sobre la eficacia, o bien encubrir los progresos en relacion con causas especificas. Ademas, a veces no se reconoce la necesidad de emprender intervenciones adicionales o alternativas para abordar las causas de mortalidad materna indirecta debido a que el unico indicador de resultado empleado es la mortalidad materna por todas las causas. Este articulo muestra la importancia de diferenciar la mortalidad materna directa y la indirecta a partir de un analisis de datos historicos de Inglaterra y Gales y datos recientes de Ghana, Rwanda y Sudafrica. El principal objetivo del articulo es subrayar la necesidad de distinguir las defunciones de ese modo al evaluar la mortalidad materna, sobre todo a la hora de calibrar los progresos hacia el quinto Objetivo de Desarrollo del Milenio. Se recomienda establecer modelos del efecto potencial de la no consideracion de las defunciones maternas indirectas por los servicios de maternidad., Introduction Despite long-term efforts to reduce maternal mortality by providing antenatal care, emergency obstetric care and skilled attendance at delivery, (1) the risk of dying during pregnancy or childbirth remains [...]

Maternal and perinatal mortality reduction has remained a priority on the international health agenda for nearly 2 decades. During this time, strategies for achieving these goals have shifted in emphasis from prevention of pregnancies to provision of care. Robust evidence is limited, particularly regarding what works best in delivering care in specific health system settings and at the population level. We describe the limited evidence base using a framework that highlights the consequences of the major gaps in measurement, evidence, and action, and we discuss existing opportunities for bridging these gaps at the policy level. Capitalizing on current global policy interests and generating demand-driven evidence is a priority for enabling documentation of progress toward reaching the United Nations Millennium Development Goals for 2015. doi:10.2105/AJPH.2005.073692