Complications during pregnancy and childbirth are a leading cause of death and disability for women in developing countries. Millennium Development Goal (MDG) 5, to improve maternal health, is the goal with the least progress. An indicator of progress towards MDG 5 is maternal mortality ratio (MMR), the proportion of maternal deaths per 100,000 live births.

Tracking progress to MDG 5 in the PacificLittle has been published on maternal outcomes of pregnancy in the Pacific.1,2 Discrepancies in available UN estimates of MMR and national figures are a challenge for reporting progress towards MDG 5. Additionally, where reporting is incomplete or infrequent, MMR estimates are unreliable for tracking change over time. Western Pacific Regional Office of the World Health Organization (WHO) has highlighted these challenges, recommending improved data validation and analysis, based on stronger Health Management Information Systems (HMIS).3 In small populations it is particularly challenging to use MMR to track progress in MDG 5; for example, even where vital registration systems provide accurate and timely information, extrapolating an MMR from 10,000 live births per year, is misleading.

Measuring maternal outcomes in the PacificIn small populations it may be more relevant to use quality of care as an indicator of improved maternal health outcomes, by measuring the frequency with which women face any risk related to pregnancy and childbirth.4 WHO recently defined a maternal near-miss as a situation in which a woman survives a life-threatening complication of pregnancy, childbirth or in the first 42 days following delivery.

As 2015 approaches, policy makers in the Pacific should be directing their attention to strengthening both the vital registration systems and the monitoring of quality of care for all pregnancies and deliveries. A range of approaches and tools have been developed to better both count maternal deaths and severe acute maternal morbidity (SAMM).

Approaches and tools to track progress to MDG 5 in the PacificAlison MorganNossal Institute for Global Health, University of Melbourne, Australia, and Associate, Burnet Institute, Australia

KNOWLEDGE HUBS FOR HEALTH STRENGTHENING HEALTH SYSTEMS THROUGH EVIDENCE IN ASIA AND THE PACIFIC

MARCH 2013POLICY BRIEF

COMPASSWOMEN'S AND CHILDREN'S HEALTHKNOWLEDGE HUB

Key Messages• Maternal mortality ratio (MMR), the number of maternal

deaths per 100,000 live births, is used as an indicator of progress towards MDG 5.

• It is particularly challenging to use MMR to track progress to MDG 5 in countries with small populations.

• In settings where a majority of deliveries occur in hospitals and health facilities, health information systems should document the progress and outcome of all pregnancies. Where home deliveries are more common, community-based audits should be introduced.

A mother holds her child, Papua New Guinea. © 2012 Brett Ballalas

This research has been funded by AusAID. The views represented are not necessarily those of AusAID or the Australian Government

KNOWLEDGE HUBS FOR HEALTH STRENGTHENING HEALTH SYSTEMS THROUGH EVIDENCE IN ASIA AND THE PACIFIC KNOWLEDGE HUBS FOR HEALTH STRENGTHENING HEALTH SYSTEMS THROUGH EVIDENCE IN ASIA AND THE PACIFIC KNOWLEDGE HUBS FOR HEALTH STRENGTHENING HEALTH SYSTEMS THROUGH EVIDENCE IN ASIA AND THE PACIFIC

For further information please contact Jane Hawtin, Communications Officer, Burnet Institute: jhawtin@burnet.edu.au

References1. Tran L, Bauze A, Nguyen H, Firth S, Jimenez-Soto E.J. (2011) Under-five

mortality Analysis for Papua New Guinea: University of Queensland.2. Sanga K, de Costa C, Mola G. (2010) A review of maternal deaths at Goroka

General Hospital, Papua New Guinea 2005-2008. The Australian & New Zealand Journal Of Obstetrics & Gynaecology, 50(1), 21-24.

3. WHO (2010a) Achieving the health-related MDGs in the Western Pacific Region: Western Pacific Regional Office WHO.

4. AbouZahr C (2011) New estimates of maternal mortality and how to interpret them: choice or confusion? Reproductive Health Matters, 19(37) 117-128.

5. Haddad S, Cecatti J, Parpinelli M, Souza J, Costa M, Sousa M, et al. (2011) From planning to practice: building the National Network for the Surveillance of Severe Maternal Morbidity. BMC public health, 11(1), 283.

6. Say L, Chou D. (2011). Better understanding of maternal deaths: the new WHO cause classification system. BJOG: An International Journal of Obstetrics & Gynaecology, 118, 15-17.

7. Pirkle CM, Dumont A, Zunzunegui MV. Criterion-based clinical audit to assess quality of obstetrical care in low- and middle-income countries: a systematic review. Int J Qual Health Care. 2011;23(4):456-63.

In the absence of complete vital registration, countries should review their current mechanisms to strengthen alternative programs to measure complications, deaths and quality of care. Suggested steps in instituting national reviews include:1. Review of existing studies;2. Review of existing HMIS reporting;3. Review national survey data (eg. Demographic Health

Survey);4. Create a national network for surveillance of severe maternal

complications.

National networks for surveillance of severe maternal complications enlist health care facilities and community-based organisations in ongoing and systematic collection, analysis and interpretation of health data on maternal complications and quality of care.5 The table below provides a summary of context-specific approaches and tools that national networks could use to better track maternal outcomes and quality of care in the Pacific.

Potential context-specific approaches in the Pacific to measuring maternal outcomes

Hig

h pr

opor

tion

of

faci

lity-

base

d de

liver

ies

>80%

Requirements in all settings

Settings where population is less than 250,000 Settings where population is greater than 250,000

Strengthen vital registration – add a box to check on all death certificates as to whether the woman was pregnant at the time of death or delivered within the last 42 days.6

Establish maternal morbidity and mortality surveillance committee and a national network.

Severe Acute Maternal Morbidity (SAMM): Identifying and exploring the cases where women survived severe obstetric complications.Clinical Audit: An assessment of service quality, through the review of particular aspects of care, usually against a pre-determined set of criteria.7 Skilled Attendance Index (SAI): to measure the quality of the care provided for each delivery. A criterion based audit to review the proportion of critical components of quality delivery care that were performed during a given delivery.

Confidential enquiries (CE): Systematic and confidential investigation of either all or a representative number of maternal deaths, at facility, regional or national level. Data is pooled and so anonymity retained.Methods applicable for settings where the population is less than 250,000 are also applicable in larger populations.

E.g. Vanuatu E.g. Fiji

Low

pro

port

ion

of fa

cilit

y-ba

sed

deliv

erie

s

Not applicable Reproductive Age Mortality Studies (RAMOS): Documenting all deaths of women of reproductive age in a given period and geographical area and determining the maternal death fraction through review of available medical records or conducting verbal autopsy.Community-based maternal death reviews (verbal autopsy): Interviews with family and community members to describe the events leading to a death outside of a medical facility.Facility-based maternal deaths review (FMDR): In-depth qualitative analysis of circumstances leading up to a maternal death in a facility.E.g. PNG, Solomon Islands, Timor Leste

Compass: Women's and Children's Health Knowledge Hub is a partnership between the Burnet Institute, Menzies School of Health Research and the Centre for International Child Health, University of Melbourne. The Knowledge Hubs for Health are an Australian Agency for International Development (AusAID) initiative that aims to build knowledge, evidence and expertise and inform health policy dialogue relevant to Asia and the Pacific.

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