Measuring maternal mortality in MSF programs

1. Measuring maternal mortalityin MSF programs Kamalini Lokuge

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 [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 [1] World Health Report 2005. WHO 2006.

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.

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. [2] Bartlett A et al, Lancet 2005; 365: 864–70

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. [1] World Health Report 2005. WHO 2006.

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. [1] World Health Report 2005. WHO 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

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. [1] World Health Report 2005. WHO 2006.

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 [1] World Health Report 2005. WHO 2006.

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 [1] World Health Report 2005. WHO 2006.

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. [1] World Health Report 2005. WHO 2006.

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 [1] World Health Report 2005. WHO 2006.

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 [1] World Health Report 2005. WHO 2006.

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. [1] World Health Report 2005. WHO 2006.

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. [1] World Health Report 2005. WHO 2006.