UNIVERSITY OF WASHINGTON

Maternal Mortality Estimates: Global Progress on Levels and Trends

August 30, 2010

Rafael Lozano, MD MSc

Professor of Global Health

Outline• Background

• Data sources and methods

• Results

• Lessons learned and next steps

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Broader context• Important momentum for new estimates

o Need to assess progress given international commitment to Millennium Development Goal 5.

• Opportunities for robust reassessmento WHO sponsored development of country estimates for 1990, 1995, 2000,

2005.

o Most recent assessment (Hill et al, 2007) reported 576,300 maternal deaths in 1990 and 535,900 in 2007; 0.48% annual rate of decline in the global maternal mortality ratio.

• Methodological advances

• More data than ever before

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Outline• Background

• Data sources and methods

• Results

• Lessons learned and next steps

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Definitions• Maternal death: “death of a woman while pregnant or

within 42 days of termination of pregnancy…from any cause related to the pregnancy or its management, but not from accidental or incidental causes” (ICD-10)

• For inter-temporal and international comparisons, ICD and MDG manual recommend A+B+C excluding D+E+F

• Maternal mortality ratio: number of maternal deaths per 100,000 live births

  Direct Indirect HIV Incidental

Early maternal (<42 days)   A B C D

Late maternal (> 42 days & < 1 year) E F    

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Density of site-years of observation, 1980-2008

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Systematic identification of data• Vital registration data

o Naghavi et al.* have undertaken a correction of the registration data, increasing maternal deaths in vital registration countries by 40% on average.

• Sibling history datao Survey respondents report on survival of siblings

and whether deaths of sisters 15-49 occurred during pregnancy, childbirth, or period after birth.

o Apply the Gakidou-King correction for survival bias.

• Deaths in the household

• National and sub-national verbal autopsyo Literature review to identify published estimates

from national and sub-national population-based studies of maternal mortality.

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* Naghavi M, et al. Algorithms for enhancing public health utility of cause s of death data, Population Health Metrics, 2010.

Source of DataSite-Years of Observation

Vital registration 2,186Sibling Histories 204

Surveillance Systems 20Census/Survey Deaths in 

Household 26National VA 35

Subnational VA 180Total 2,651

No data for 21 countries, representing 2.2% of births

Analytical approach

• Extract the proportion of all female deaths due to maternal causes for five-year age groups (15-49).

• Apply proportion to new adult female mortality time series (Rajaratnam et al, 2010) to arrive at maternal mortality rates by country, year, and age groups.

• Two-stage analysis, modeling the age-specific maternal mortality rate:o Stage 1: Linear model

o Stage 2: Spatial-temporal model

• HIV counterfactual analysis

• Model validation

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Criteria for better and consistent estimates

• Continued increase in quantity and quality of data

• Use of models with improved predictive validity

• Quantify uncertainty using statistical methods

• Transparency of data sources and methods

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Outline• Background

• Data sources and methods

• Results

• Lessons learned and next steps

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Maternal deaths by region, 1980-2008

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Regional trends in the MMR

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MMR with and without HIV

India: Predicted MMR per 100,000 live births with uncertainty

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MMR per 100,000 live births, 2008

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Annualized rate of decline in MMR, 1990 to 2008

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Outline• Background

• Data sources and methods

• Results

• Lessons learned and next steps

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Lessons learned• Gaining ground

o Global maternal deaths down to 342,900 in 2008

o Global trend is a 1.4% decline per year since 1990

o 23 countries are on track to meet MDG 5, achieving an annual rate of decline of 5.5%

• Progress undocumented but not unexpectedo Global total fertility rate has dropped from 3.70 in 1980 to 2.56 in 2008

o Income per capita has been rising over the period, particularly in Asia and Latin America

o Maternal education has been increasing as well; in Sub-Saharan Africa, the average years of schooling for women aged 25-44 rose from 1.5 years in 1980 to 4.4 years in 2008

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Lessons learned• Adverse Impact of HIV

o Progress on reducing maternal mortality would have been much greater in the absence of HIV, especially in sub-Saharan Africa

o Important implications for intervention policy

• Communication with countries and local researcherso Letters to the editor: Argentina. Jamaica, Iran, Burkina Faso, Peru,

Philippines, Indonesia

o Letters to correspondence author: Turkey, Jamaica, Centro America, Cambodia

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Next steps

• Research o Continue updates

o Evaluation

• Data disseminationo Reports

o Web page http://www.healthmetricsandevaluation.org

• Organization of regional workshops

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KNOWING IS NOT ENOUGH; WE MUST APPLY.

WILLING IS NOT ENOUGH; WE MUST DO.

JOHANN W. VON GOETHE (1749-1832)

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