THE WORLD BANK

IMPROVING NATIONAL CAPACITY TO TRACK MATERNAL MORTALITY TOWARDS

THE ATTAINMENT OF THE MDG5

Report on a World Bank/UNICEF/WHO/UNFPA Workshop December 7-8, 2010 (English session) December 9-10, 2010 (French session)

Nairobi, Kenya

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CONTENTS

ACKNOWLEDGEMENTS ...................................................................................................................................... III

ACRONYMS AND ABBREVIATIONS .....................................................................................................................IV

INTRODUCTION................................................................................................................................................... 1

1.1 OBJECTIVES AND EXPECTED OUTCOMES........................................................................................................2

1.1.1 Specific objectives ...............................................................................................................................2

1.1.2 Expected outcomes..............................................................................................................................2 1.2 OPENING SESSION .............................................................................................................................................2

2 PRESENTATIONS BY TECHNICAL EXPERTS................................................................................................... 3

2.1 SEXUAL AND REPRODUCTIVE HEALTH AND THE MDGS: WHO/UNICEF/UNFPA/WORLD BANK (H4) MATERNAL MORTALITY

ESTIMATES – OVERVIEW, HISTORY ..................................................................................................................................3 2.1.1 Discussion and observations ...............................................................................................................4

2.2 METHODS FOR MEASURING MATERNAL MORTALITY................................................................................................4

2.3 GLOBAL MATERNAL MORTALITY ESTIMATES AND TRENDS, 1990-2008 ........................................................................5

2.3.1 Discussion and observations ...............................................................................................................5 2.4 DEMONSTRATION OF PROPOSED MATERNAL MORTALITY ESTIMATION DASHBOARD ......................................................6

2.4.1 Discussions and observations..............................................................................................................6

3 GROUP SESSIONS AND THE WAY FORWARD.............................................................................................. 6

3.1 HOUSEHOLD SURVEY GROUP ...............................................................................................................................6

3.1.1 Presentation: Estimating Maternal or Pregnancy-Related Mortality Using Household Surveys ........6

3.1.2 Discussions and practice .....................................................................................................................7

3.2 CENSUS GROUP ................................................................................................................................................7 3.2.1 Presentation: Estimating Pregnancy-Related Mortality from the Census...........................................7

3.2.2 Discussions and Practice .....................................................................................................................8

3.3 HEALTH FACILITY GROUP ....................................................................................................................................8

3.3.1 Presentation: Measuring Maternal Mortality: The Potential of Health Facility Data.........................8 3.3.2 Presentation: The WHO Classification of during Pregnancy, Childbirth, and the Puerperium............9

3.3.3 Presentation: Implementing maternal death and near miss reviews to make pregnancy safer ........9

3.3.4 Maternal Mortality Audit: Botswana Experience..............................................................................10 3.3.5 Discussions and Practice ...................................................................................................................10

4 WORKSHOP SUMMARY ........................................................................................................................... 10

THE HOTEL INTERCONTINENTAL, NAIROBI, KENYA, 7-10 DECEMBER, 2010 ................................ 12

INTERCONTINENTAL NAIROBI, KENYA........................................................................................ 18

7-10 DECEMBER 2010 ........................................................................................................................... 18

7-8 DECEMBER 2010 (ANGLOPHONE)........................................................................................... 18

Annexes ANNEX 1. LIST OF PARTICIPANTS...............................................................................................................................12 ANNEX 2. AGENDA ....................................................................................................................................................18

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Acknowledgements

The workshop was coordinated by Eduard Bos, Emi Suzuki, Samuel Mills, and Bahie Rassekh

of the World Bank, Holly Newby and Liliana Carvajal of UNICEF, Ralph Hakkert of UNFPA,

and Lale Say and Doris Chou of WHO. Special thanks to Real Useful Travel and Marketing

Company for organizing the meeting in Nairobi, Kenya. Many thanks to the resource persons

listed in Annex 1 for facilitating the workshop. The contributions and participation of the

country experts listed in Annex 1 are much appreciated. Bahie Rassekh and Emi Suzuki

prepared the initial draft of this report, along with input from the UNICEF, WHO, and UNFPA

workshop coordinators and the workshop facilitators. The report was edited and translated into

French by the General Services Translation and Interpretation Unit, The World Bank

Contact persons:

Emi Suzuki, Human Development Network, World Bank. E-mail: esuzuki1@worldbank.org

Bahie Mary Rassekh, Human Development Network, World Bank. E-mail:

bmrassekh@worldbank.org

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Acronyms and Abbreviations

AIDS Acquired Immunodeficiency Syndrome

AMDF AIDS adjusted PMDF

DHS Demographic and Health Survey

GFR General Fertility Rate

HIS Health Information Systems

HIV Human Immunodeficiency Virus

ICD-10 International Statistical Classification of Diseases and Related Health Problems

(10th Revision)

ICPD International Conference on Population and Development

IHME Institute for Health Metrics and Evaluation

LTR Lifetime Risk

MDG Millennium Development Goal

MMR Maternal Mortality Ratio

MMRate Maternal Mortality Rate

PMDF Proportion of Maternal among female deaths 15-49

PRMRatio Pregnancy-Related Mortality Ratio

RAMOS Reproductive Age Mortality

RAPID Rapid Ascertainment Process for Institutional Deaths

TAG Technical Advisory Group

UC Berkeley University of California, Berkeley

UN United Nations

UNFPA United Nations Population Fund

UNICEF United Nations Children’s Fund

VR Vital Registration

WHO World Health Organization

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1

INTRODUCTION

Improving sexual and reproductive health, which includes reducing maternal mortality, has

been a key concern of several international summits and conferences since the late 1980s,

including the International Conference on Population and Development (ICPD) in 1994 in

Cairo and the subsequent Fourth World Women’s Conference in 1995 in Beijing, which firmly

placed sexual and reproductive health and women’s health at the centre of social and economic

development. Their importance was again underlined at the Millennium Summit in 2000 when

one of the eight Millennium Development Goals (MDG) adopted was improving maternal

health (MDG5). Within the MDG monitoring framework (including 2005 World Summit

recommendations), the targets for improving maternal health are providing universal access to

sexual and reproductive health and reducing the maternal mortality ratio (MMR) by three-

fourths between 1990 and 2015.

However, assessment of the extent of the progress of MDG5 has been a challenge because of

lack of reliable data on sexual and reproductive health, and maternal mortality in particular.

This is of particular concern in countries in sub-Saharan Africa where maternal mortality is

high and the routine health information systems (HIS) are weak. Since the 1990s, the WHO,

UNICEF, UNFPA, and recently the World Bank have jointly developed five-yearly global

maternal mortality estimates using an approach that reconciles data from different sources, such

as facility-based data and population-based studies such as Demographic Health Surveys

(DHS), in order to obtain valid and internationally comparable country estimates. The approach

also involves the prediction of maternal mortality levels by using a statistical model for

countries where no nationally representative data drawn from standard methodologies exist.

The methodological challenges faced when estimating country-specific MMR point to a clear

need for generation of reliable and valid data to facilitate future estimates of sexual and

reproductive health indicators, particularly MMR in sub-Saharan where the existing data

sources are deficient. Accurate estimates of MMR require (i) complete records of all deaths in a

population, (ii) accurate attribution of the causes of death, and (iii) knowledge of the pregnancy

status of deceased women of reproductive age. However, none of the countries in sub-Saharan

Africa meet these criteria; the MMR for most countries in sub-Saharan Africa were either

derived from statistical models or entailed adjustment of the direct sisterhood estimates arising

from the DHS.

An estimated 358 000 maternal deaths occurred worldwide in 2008, a 34% decline from the

levels of 1990. Despite this decline, developing countries continued to account for 99% (355

000) of the deaths. Sub-Saharan Africa, alone accounted for 57% (204 000) of global maternal

deaths.

Overall, it was estimated that there were 42 000 deaths due to HIV/AIDS among pregnant

women in 2008. About half of those were assumed to be maternal. The contribution of

HIV/AIDS was highest in sub-Saharan Africa where 9% of all maternal deaths were due to

HIV/AIDS. Without these deaths, the MMR for sub-Saharan Africa would have been 580

maternal deaths per 100 000 live births instead of 640.

The MMR in 2008 was highest in developing regions (290) in stark contrast to developed

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regions (14) and countries of the Commonwealth of Independent States (40). Among

developing regions, sub-Saharan Africa had the highest MMR at 640 maternal deaths per 100

000 live births in 2008. And three Sub Saharan countries, Chad, Guinea-Bissau, and Somalia,

have extremely high MMR (MMR ≥1000). Globally, the adult lifetime risk of maternal death

(the probability that a 15-year-old female will die eventually from a maternal cause) as

measured in 2008 is highest in sub-Saharan Africa (at 1 in 31).

The workshop, which took place in Nairobi, Kenya, was a joint World Bank, WHO, UNICEF

and UNFPA activity. It was composed of two 2-day meetings (back-to-back), separately

organized for 54 participants from 19 countries for the English session (December 7-8, 2010)

and 32 participants from 16 countries for the French session (December 9-10, 2010) in Africa.

The countries that participated in the English session were Botswana, Eritrea, Ethiopia, Ghana,

Kenya, Lesotho, Liberia, Malawi, Mozambique, Namibia, Nigeria, Somalia, South Africa,

Sudan, Swaziland, Tanzania, Uganda, Zambia, and Zimbabwe. The countries that participated

in the French session were Angola, Benin, Burkina Faso, Burundi, Cameroon, Central African

Republic, Chad, Côte d'Ivoire, Gabon, Guinea, Madagascar, Mali, Mauritania, Niger, São

Tomé and Principe, and Senegal. This report combines the proceedings of both the Anglophone

and Francophone sessions.

1.1 OBJECTIVES AND EXPECTED OUTCOMES

The objective of the workshop was to strengthen the capacity of national statisticians in each of

the participating countries on the approaches for improving data quality for estimating maternal

mortality.

The specific objectives and expected outcomes were as follows:

1.1.1 Specific objectives

• To establish a common understanding between UN agencies and national counterparts

on the approaches used for the recently developed 2008 maternal mortality estimates;

• To strengthen capacity of country statisticians in collecting, analyzing and use of

maternal mortality data;

• To identify needs and gaps in the generation, analysis, and use of data for estimating

maternal mortality.

1.1.2 Expected outcomes

• Common understanding between UN agencies and national counterparts on the

approaches used for the 2008 maternal mortality estimates;

• Improved technical expertise at country level in using methodologies and approaches to

measure maternal mortality.

1.2 OPENING SESSION

The workshop was officially opened by representatives from the four organizing agencies,

Khama Rogo for the World Bank, Richmond Tiemoko for UNFPA, Bo Pederson for UNICEF,

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and Doris Chou for WHO, followed by opening remarks by Eduard Bos from the World Bank.

Dr. Bos conveyed the importance of the subject of improving reproductive and maternal health,

which has been the key concern of several international summits and conferences since the late

1980s. He defined MDG 5 and explained that WHO, UNICEF, UNFPA, and the World Bank

collaborated on a round of country-level estimates of maternal deaths. He provided some

background on the workshop, presented the workshop’s overall and specific objectives,

expected outcomes, and agenda.

2 PRESENTATIONS BY TECHNICAL EXPERTS

On the first day of the workshop, international experts made several presentations on the

approaches and methods for measuring maternal mortality. Annex 2 presents the agenda of the

meeting for the Anglophone and Francophone sessions. A summary of the presentations is

below.

2.1 SEXUAL AND REPRODUCTIVE HEALTH AND THE MDGS: WHO/UNICEF/UNFPA/WORLD BANK (H4) MATERNAL MORTALITY

ESTIMATES – OVERVIEW, HISTORY

Dr. Doris Chou presented an overview and history of the WHO/UNICEF/UNFPA/World Bank

maternal mortality estimates.

Dr. Chou described the health MDGs 4, 5, and 6, including indicators used to monitor progress.

She explained that there have been five-yearly estimates, separately for 1990, 1995, 2000, and

2005, that were based on an approach that encompassed different sources of data. There was a

decision to make more frequent updates, increasing the number of studies available from

countries. There was a review and revision of the previous approach and model. The

methodology changed, modeling maternal mortality over space and time. There was also a

hierarchical / multilevel linear regression model. A maternal mortality estimation interagency

group (MMEIG) was put in place.

Dr. Chou explained that a critical aspect of the Inter-Agency estimates of maternal mortality

was the technical collaboration with experts from academic institutions including University of

California, Berkeley, Harvard University, Johns Hopkins University, University of Texas,

Aberdeen, Umea University, and Statistics Norway. Another critical aspect was the country

consultation element. During this period of interaction with countries the estimates and

modeling methods are shared. Additional data are obtained and data quality reviewed, the

estimates are improved. The consultation improves the estimation process and builds a shared

understanding of country level activities in monitoring maternal mortality and the process

undertaken to derive internationally comparable estimates to enhance country use of the

estimates. This is a preliminary step in which countries have the opportunity to provide inputs

and share national data. Often it is found that the inter-agency best estimate and the country

reported figures may differ. In one country example, the Minister of Health said that the UN

estimate was much too high and that it was wrong. WHO sent a team of experts and an in-depth

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study was conducted to review the data, uncover new data, analyze and discuss the results with

government and academic in the country. The result was an improved estimate.

Dr. Chou explained that following the consultation, continuous interaction with countries is

envisaged to strengthen capacity in data collection, reviewing data quality, updating the

database, supporting the use of data for decision making. Regional workshops are organized to

discuss these issues and the methodology of model based estimates. The technical

collaboration continues, such as during the upcoming TAG meeting in January 2011 during

which comments received during country consultation are reviewed for action. Lastly, the Inter

Agency maintains transparency in its work by making the database and the model publically

available

(www.who.int/reproductivehealth/publications/monitoring/9789241500265/en/index.html).

2.1.1 Discussion and observations

Following the introduction and background presentation, several participants raised concern on

the maternal mortality estimates for their individual countries. It was mutually agreed to move

forward with discussions on the methodology to address these concerns.

2.2 METHODS FOR MEASURING MATERNAL MORTALITY

Professor Kenneth Hill made a presentation regarding methods for measuring maternal

mortality. He defined a “maternal death” as the death of a woman while pregnant (or within 42

days of termination of pregnancy), irrespective of the duration and the site of the pregnancy,

from any cause related to or aggravated by the pregnancy or its management but not from

accidental causes (source: WHO 1993, 10th

revision of the ICD). He explained the difference

between a maternal death and a pregnancy-related death, where both have a temporal

relationship to the pregnant state, but a maternal death also has a causal relationship to the

pregnant state. The data collection method determines whether one measures maternal or

pregnancy-related deaths, since identifying maternal deaths requires either death certification

by an attending physician or a verbal autopsy. Household survey methods frequently used in

low/middle income countries simply ask time of death relative to pregnancy and thus measure

pregnancy-related death.

Dr. Hill then defined and provided characteristics of the MMR and explained that it is designed

to express direct or indirect obstetric risk, as opposed to the maternal mortality rate (MMRate),

which is a cause-specific death rate. He defined the Lifetime Risk (LTR) and Proportion

Maternal (PMDF) and how to calculate them.

Dr. Hill then explained the sources of data for measuring maternal mortality, including vital

registration, reproductive age mortality surveys (RAMOS), large population-based surveys,

national population censuses, facility-based studies, and statistical models. For large

population-based surveys, three survey methods of data collection/estimation were described:

The original sisterhood method, sibling history-based method, and identification of all female

deaths in the household in some reference period, which can be used in a census or large

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survey. General problems with MMR measurement were explained, including that they are rare

events, that certain types of maternal death are hard to identify (especially abortion-related),

and that nonvital registration (VR) methods generally measure pregnancy-related mortality

ratio (PRMRatio).

He concluded by summarizing that maternal mortality is difficult to measure accurately, even

in countries with a complete VR, that in countries lacking complete VR, no approach is

guaranteed to give accurate estimates, and finally, that in the long run, it is essential to improve

VR.

2.3 GLOBAL MATERNAL MORTALITY ESTIMATES AND TRENDS, 1990-2008

Dr. John Wilmoth’s presentation had three parts: 1. Data and methods used for creating the new

UN estimates; 2. Key findings regarding levels and trends of maternal mortality (especially for

Sub-Saharan Africa (SSA); and 3. Comparison to other estimates (including national sources).

Under the first topic, Data and Methods for Estimating Maternal Mortality, several areas were

discussed. These include coverage of estimates, sources of maternal mortality data used for the

2008 estimates, data types worldwide and in SSA, definitions of maternal death and pregnancy-

related death, PMDF, Mortality from all causes, envelope adjustment, data on live births, data

adjustments, underreporting of maternal or pregnancy-related deaths, and multilevel regression

models. With regards to the regression model, the model was specified, including dependent

variables, covariates, and offset terms. Three variants of the model were explored, using

PMDFna

, AMDFna

, and MMRna

as the dependent variable. It was explained that for each

covariate or offset variable, complete annual data series were either obtained or created. For the

regression model, average values of covariates and offset variables were computed over time

intervals matched to each PMDF observation. The final model included random effects for both

countries and regions to provide a simple means of depicting those components of the

variability in PMDFna

that are not well described by the simple model with three covariates.

He also presented the key findings of the 2008 MMR estimates and explained why the

estimates may differ from national estimates.

2.3.1 Discussion and observations

Participants suggested the addition of other maternal health variables to the model, for example

indicators related to emergency care. Some participants also expressed interest in having

information on national policies reflected on the model. Dr. Wilmoth explained that the lack of

cross country data on additional variables or national policies would make it difficult for them

to be included.

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2.4 DEMONSTRATION OF PROPOSED MATERNAL MORTALITY ESTIMATION

DASHBOARD

Holly Newby proposed the idea of the maternal mortality estimation dashboard and provided a

demonstration for participants. As an example, she showed several graphs with the 2008

estimates and trends, with the information on inputs used, including Gross Domestic Product,

skilled birth attendance and general fertility rate(GFR).

2.4.1 Discussions and observations

• In general, participants and facilitators thought having the dashboard was a good idea

because it was informative for countries for both inputs and outputs.

• Although the prototype did not include country-generated MMR data (directly obtained

from surveys, etc.), the final version of the dashboard will include both the MMR

estimates from the country as well as the interagency estimates.

• A suggestion was made for the dashboard to include other indicators related to maternal

health to provide a larger context for interpreting trends. Although the initial version of

the dashboard will not include data beyond maternal mortality, the model input

variables of GDP, skilled birth attendance and GFR will be included. This idea will be

explored for inclusion in a subsequent version of the dashboard.

• A number of participants noted that because the maternal mortality estimation

dashboard is based on the DevInfo platform, it would be ideal to be able to link the

dashboard with their own country’s DevInfo application. This idea can be explored,

although it is important to note that even if an individual country has new input data, the

model is based on all available data globally and thus cannot be rerun at the country

level using a single country’s input data.

3 GROUP SESSIONS AND THE WAY FORWARD

There were three groups in the group sessions, with a focus on the following themes: census,

household surveys, and routine health data.

3.1 HOUSEHOLD SURVEY GROUP

3.1.1 Presentation: Estimating Maternal or Pregnancy-Related Mortality Using Household Surveys

In this session, Dr. John Wilmoth discussed the three survey methods of data collection,

including the original sisterhood methods (only listed, not discussed), the sibling history-based

method, and the identification of all female deaths in the household in some reference period.

This presentation focused on the full sibling history, including background information of this

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method, data collected, and examples. The presentation then introduced data evaluation and

adjustment, including definitions and acronyms, information regarding sampling errors, data

quality indicators, recall bias, selection bias, the Gakidou-King Estimation Method and

adjustments. After this, data evaluation was introduced. This included potential data

evaluations, mortality level, Coale-Demeny Model Life Tables, sex differentials in adult

mortality, age patterns of adult mortality, and proportions of pregnancy-related deaths by age

group. The presentation ended with a section on computations. The following steps were

outlined: Calculate pregnancy-related mortality rates, age-standardize overall pregnancy-related

mortality rate, standardize the total pregnancy-related death rate to the household female

population, use the general fertility rate to calculate the pregnancy-related mortality ration per

100,000 live births, calculate pregnancy-related mortality ration using GFR, age-standardize

overall proportion of deaths pregnancy-related 15-49 years, calculate age-standardized

proportion of pregnancy-related deaths of women 15-49 years, and the last step, which was to

estimate the risk that a woman surviving to age 15 will die a pregnancy-related death. There

was an explanation of the LTR equation, and the session concluded with practice calculations

completed by participants.

3.1.2 Discussions and practice

After Dr. Wilmoth’s presentation, participants worked on an exercise which involved

identifying the right data from DHS reports on-line, or in copies of the report provided by

participants. They entered the data in worksheets and calculated the various maternal mortality

indicators. Participants were guided through the process of calculation and interpretation of the

results. A volunteer from the group was selected to present conclusions from the household

survey analysis to all the participants during the subsequent plenary session.

3.2 CENSUS GROUP

3.2.1 Presentation: Estimating Pregnancy-Related Mortality from the Census

Dr. Kenneth Hill’s presentation focused on ways of estimating pregnancy-related mortality

from the census. There are three components of PRMRatio: 1. Deaths of women of

reproductive age (D); 2. The proportion of those deaths that were pregnancy-related (PPR); and

3. Births (B). The formula for the PRMRatio is (D*PPR*100,000)/B. Therefore the evaluation

focuses on D, PPR and B.

Dr. Hill used the example of South Africa to illustrate ways to use data from the various

censuses to evaluate the numbers of deaths of women of reproductive age. He explained that

this involves evaluating female deaths at all ages post-childhood. It is most important that

deaths of older women are recorded. Numbers of deaths are evaluated by comparison with the

population age distribution. He explained the key assumptions: The methods assume that the

errors of reporting (deaths and population) are distributed proportionately by age, that the

population is closed to migration, the Brass Growth Balance method assumes that the

population is demographically stable, and the General Growth Balance method replaces the

assumption of stability by using data from two censuses, but assumes that the age pattern of

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deaths in the intercensal interval is approximated by the observed pattern. The General Growth

Balance Method was then explained in greater detail and illustrated using Honduras as an

example. Dr. Hill then discussed the calculations, including the entry rate, the growth rate, the

observed death rate and the computation of adjustment factor for deaths. He went over

spreadsheets, graphs, and interpretations.

Dr. Hill then discussed evaluating the proportion of deaths that were pregnancy-related, and

evaluating the numbers of births. He explained that the evaluation is of recent fertility against

lifetime fertility (P/F Ratios), and then explained the P/F Ratios in further detail, including the

principle, application, complications. He explained the interpretation of the data, and concluded

with the Pregnancy-Related Mortality Ratio (PRMRatio).

3.2.2 Discussions and Practice

After Dr. Hill’s presentation, participants spent the remaining time practicing the methods by

entering data into the excel file provided by Dr. Hill. Dr. Hill guided the participants so they

could visually examine the results in the graph. Dr. Hill answered questions and accompanied

participants as they interpreted the results. Dr. Hill and the participants prepared the

presentations on key findings and recommendations from the group.

3.3 HEALTH FACILITY GROUP

3.3.1 Presentation: Measuring Maternal Mortality: The Potential of Health Facility Data

Dr. Carla Abou-Zahr’s presentation included the following topics: principles for using facility

data; advantages and limitations of facility data; data requirements; data quality assessment and

adjustment; methods to improve data completeness and quality; technical resources; and

country examples.

She began by defining maternal death and pregnancy-related death, and explained that the data

sources that identify “true” maternal deaths require medical determination of cause. She

discussed health facility records and health management information systems (HMIS) as well

as strengths and limitations of facility-based HMIS data. She discussed how we can further tap

the potential of facility data and some of the reasons for the weakness of routine HMIS

reporting. She introduced a tool called RAPID (Rapid Ascertainment Process for Institutional

Deaths) to review hospital records for all deaths of women aged 15 to 49 years in order to

improve identification of all maternal deaths in facilities. Dr. Abou-Zahr then discussed

identifying maternal deaths in communities and options for identifying home deaths,

reconciling facility data and community reporting (capture-recapture), and conditions for using

routine HMIS reports from health facilities for monitoring. She discussed country strategies for

improving maternal mortality data, technical resources, and major categories of MMR data

sources.

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3.3.2 Presentation: The WHO Classification of during Pregnancy, Childbirth, and the Puerperium

Dr. Doris Chou presented work on the WHO Classification of during Pregnancy, Childbirth,

and the Puerperium. She explained that inconsistency in death attribution leads to

misclassification of maternal deaths extracted from vital registration, which in turn may bias

the understanding of the magnitude and causes of maternal death. The WHO Classification of

maternal deaths is intended to simplify and standardize the capture of maternal deaths from VR

and other sources of data. The current version is based upon ICD 10 codes. She explained

principles of the classification system, defined maternal death in relation to the ICD 10 and

explained the overall structure of classification. Dr. Chou defined and explained the

relationship between contributing conditions and underlying cause and immediate causes of

death, and provided examples. She closed her presentation with conclusions and one

recommendation, that once the maternal death classification system is published, it should be

adopted by all countries.

3.3.3 Presentation: Implementing maternal death and near miss reviews to make pregnancy safer

Professor Gwyneth Lewis had six main parts to her presentation: 1. Underlying principles; 2.

The Beyond the Numbers approaches; 3. Which deaths? Which approach?; 4. Steps in the

process; 5. Other issues to consider; 6. Detailed descriptions of community based death

reviews, facility based deaths reviews and near miss reviews.

She explained that a large percentage of maternal deaths occur due to substandard care and

preventable causes. The MMR is a crude estimate, does not give causes of death, does not

address intra-country variations, and is often out of date. It often appears overwhelming to

policy makers or health care planners and does not have insight into avoidable or remediable

factors. She stressed that we need to look beyond the numbers at why mothers really die.

There are three types of delays/barriers to care: socio-cultural (status of women, traditional

beliefs, practices); lack of access to care (availability, transport); and poor quality care, poor

resources. Professor Lewis talked about the five approaches to look “Beyond the Numbers” and

shared characteristics between all these approaches. She discussed the maternal mortality

surveillance cycle, as well as investigations into causes of deaths such as verbal autopsy,

facility based death reviews, learning from near miss case reviews, and Confidential Enquiries

into Maternal Deaths, and factors in deciding which approach to adopt. She discussed types of

maternal deaths and methods to identify and review maternal deaths. She went through steps in

the process, including setting up an overview committee at the start, collecting data including

issues of confidentiality, legal and ethical considerations, analyzing the results both

quantitatively and qualitatively, and disseminating findings. Professor Lewis then discussed

deaths in the community, community-based reviews, and community data collection. She

discussed facility based reviews, types, scope, and potential difficulties and gains. She

discussed “near-miss” cases, why to review them, uses of these data, approaches to reviewing

these cases, including card based surveillance systems. Professor Lewis closed by giving some

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reference sites: www.cmace.org.uk, www.nice.org.uk, www.ukoss@npeu.ox.ac.uk,

www.dh.gov.uk, www.npsa.org.uk, www.rcog.org.uk, www.cqc.org.uk

3.3.4 Maternal Mortality Audit: Botswana Experience

Boitumelo Thipe, the National Safe Motherhood Program coordinator, Botswana, made this

presentation regarding the Botswana experience with Maternal Mortality Audits. She described

the health system of Botswana and some of the history of the maternal death review process.

She explained that for purposes of counter-checking, maternal mortality is captured by two

parallel systems, one based in SRH and the other in HSU, and then described both processes

and the SRH/HSU system linkages. She outlined the maternal death notification process for

audit purposes, the composition of the maternal mortality committees, and described the 2008

national maternal mortality report. Finally, she discussed the maternal deaths by age, by direct

and indirect causes, the proportion of pregnancy complications, the MMR and MDG trend over

the past five years, and contributory factors per cause of death. She concluded by discussing

the improvement of clinical care using maternal death audits, some challenges, and areas that

need strengthening.

3.3.5 Discussions and Practice

The participant from Madagascar shared some approaches taken at country level to standardize

and improve cause of death attribution. This results in improved cause of death attribution.

Further improvements is anticipated with an international standard on maternal cause of death

attribution, such as proposed in the WHO Classification of Deaths in Pregnancy, Childbirth and

the Puerperium.

4 WORKSHOP SUMMARY

Holly Newby from UNICEF presented a recap of the experiences in the working groups and

draft recommendations. Her summary included the following points:

1. General technical issues

a. Definitions are important

i. MMR versus MMRate

ii. Maternal deaths versus pregnancy-related deaths

b. The MMR gives a false sense of precision

c. Maternal mortality data comes from a variety of sources

i. Each source has advantages and limitations

ii. Even vital registration, misreporting well-documented

iii. All maternal mortality data require careful, critical evaluation

2. UN interagency estimates

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a. UN interagency estimates address data limitations and provide comparable trend

estimates for 172 countries

b. To produce the UN interagency estimates, a series of decisions had to be made

i. Use (adequate) civil registration data directly for trend estimation

ii. Model PMDF (not MMR) for all other countries

iii. Choice of covariates

iv. How to handle HIV

v. Envelope of all cause female deaths; births

c. UN estimates: Special efforts made to:

i. Document all decisions

ii. Make all data and calculations publically available

3. Working groups

a. Household survey group (Direct sisterhood method)

i. Important source of data for sub-Saharan Africa

ii. Mortality underestimated overall

iii. Confidence intervals very wide (difficult to interpret trends)

iv. Recommendations—

1. Improve data collection

2. Necessary to review data quality, perform critical checks

b. Census group

i. A number of sub-Saharan African countries have (or will) include

questions on deaths in household (and whether pregnancy related)

ii. Recommendations –

1. Data collection should be standardized

2. Need to evaluate all data carefully

3. Even if they appear implausible, keep original data because may

be possible to adjust

4. Need mechanisms for continued exchange and technical

assistance

c. Health facility group

i. Strength -- Provides information on cause of death; produced regularly

and all over country

ii. Weakness -- Facility data often incomplete; problems with

denominators; bias because only based on facility deliveries

iii. How to strengthen

1. Need to regularly review and evaluate facility data

2. Health care providers: Need to increase skills and understanding

3. Audits important – help improve data and take you beyond

numbers to underlying causes and circumstances

4. Main concluding points:

a. Critical data reviews are essential

b. Look across all potential data sources

c. Important to look beyond the MMRatio

12

Annex 1. List of participants

THE WORLD BANK

Improving national capacity to track maternal mortality towards the attainment of the MDGs

The Hotel Intercontinental, Nairobi, Kenya, 7-10 December, 2010

English Session Participants (December 7-8, 2010)

Botswana Boitumelo Thipe, Sexual Reproductive Health Division, Department Public Health, Ministry of Health

Botswana Babuang Tlhomelang, Central Bureau of Statistics

Botswana Kelebetse Mbiganyi, Central Bureau of Statistics

Botswana Lucy Sejo Maribe, Nurse, DPM/FRH, WHO Botswana

Botswana Peter Beat Gross, Social Policy Specialist, UNICEF

Eritrea Mismay Ghebrehiwet, Advisor to Minister of Health (MOH)

Eritrea Yodit Hiruy, UNICEF

Ethiopia Gebeyehu Horjo, Central Bureau of Statistics

Ethiopia Sahelu Gelaye, Central Bureau of Statistics

Ghana Philomena Efua Nyarko, Deputy Government Statistician, Statistical Service

Kenya Andrew Imbwaga, Kenya National Bureau of Statistics

Kenya Henry Osoro, Kenya National Bureau of Statistics

Kenya Patricia Elung'ata, DSS Data Manager, African Population and Health Research Center

Lesotho Nonkosi Tlale, UNFPA

13

Lesotho Thabelo Ramatlapeng, UNFPA

Liberia Woseh Gobeh, Reproductive Health Commodity Officer at the MOH

Malawi George Chapotera, Principal Economist, MOH Central M&E Division

Malawi Mylen Mahowe, Demography and Social Statistics, NSO

Mozambique Carlos Arnaldo, Centro de Estudos Africanos (Centre for African Studies)

Mozambique Cassiano Soda Chipembe, Instituto Nacional de Estatistia (National Institute of Statistics)

Namibia Mutambani Mwakamui, Ministry of Health

Namibia Ndapandula Ndiknetepo, Central Bureau of Statistics

Nigeria Agosa Olusegun, Statistician, Dept of Health Planning, Research and Stats, Ministry of Health

Nigeria Denis Jobin, Chief Planning, M&E Coordinator, UNICEF

Nigeria Godwin A. Iro, National Bureau of Statistics

Nigeria Ossideko Olusola, National Population Commission

Nigeria Utibe.Abasi Essien Urua, National Primary Health Care Development Agency

Somalia Ahmed D. Farah, Ministry of Planning

Somalia Rogaia Abuelgasim, UNFPA

Somalia Stephen Macharia, UNFPA

South Africa Bjorn Gelders, M&E Officer, UNICEF South Africa

South Africa Khangelani Zuma, Human Sciences Research Council

South Africa Maletela Tuoane-Nkhazi, Health and Vital Statistics Division, Statistics South Africa

South Africa Nat Khaole, National Department of Health

South Africa Mosidi Sarah Nhlapo, Demographer,

South Africa Sean Jooste, Human Sciences Research

14

Statistics South Africa, Census Analysis

Council

Sudan Barbara Akita Kibos, MOH- Government of South Sudan

Sudan Majak Makal Adhil, Southern Sudan Centre for Census Statistics and Evaluation

Sudan Richard Lino Laku, Director, Monitoring and Evaluation, MOH-GOSS (Govt of Southern Sudan)

Swaziland Dlamini Nombulelo, Statistician, Central Bureau of Statistics

Swaziland Duduzile Dlamini, National Population Unit

Swaziland Phumzile Mabuza, SRHU, MNCH Manager

Swaziland Simelane Zanela, HMIS Coordinator, Ministry of Health

Tanzania Aldegunda Komba, Statistician / Demographer, National Bureau of Statistics

Tanzania Asia Hussein, UNICEF

Tanzania Edith Mbatia, UNICEF

Tanzania Mayasa Mwinyi, Office of Chief Gov. Statistics

Uganda Anthony Mbonye, Commissioner, Health Services, Ministry of Health

Uganda Mark Kajubi, Sr Statistician, Uganda Bureau of Statistics

Uganda Miriam Sentongo, Reproductive Health Division, Ministry of Health

Uganda Vincent Ssenono, Uganda Bureau of Statistics

Zambia Sheila Mudenda, Central Bureau of Statistics

Zimbabwe Godfrey Matsinde, ZIMSTAT

Zimbabwe Winston Chirombe, Ministry of Health and Child Welfare

French Session Participants (December 9-10, 2010)

Angola Helga de Freitas, Médica de Saúde Pública, Revitalização do Sistema Municipal de Saúde

Benin Ahovey A Elise C, Ingeneur demographe, Institut National de la Statistique et de l'Analyse Economieque / Ministry of

15

Development

Benin Hyacinthe Ahomlanto, Médecin Gynécologue- Obstétricien, Direction de la Santé de la Mère et de l’Enfant/service Santé Maternelle et Infantile

Burkina Faso Doamba Jean Edouard, Direction generale de l'information et des statistiques sanitaires

Burkina Faso Tingueri Rose Koirine, Ingenieure Demographe-Geographe

Burundi Deogratias Buzingo (Chief Section of Demographic studies and Statistics at the National Institute of Statistics)

Burundi Noe Nduwabike, Chef Division Traitement et Analyse, RGPH

Burundi Dionis Nizigiyimana, EPISTA, MoH

Cameroun KAMGHO TEZANOU Bruno Magloire, Institut National de la Statistique

Cameroun Ndong Ngoe Constant, Epidemiologist from Ministry of Public Health

Côte d'Ivoire Yao Koffi Edmond, Chief of Demographic and Social Statistics at the National Statistics Institute

Côte d'Ivoire Youan Rodolphe Tian Bi, Assistant Suivi-Evaluation, UNFPA 01 BP 1747, Abidjan 01

Gabon Yolande Vierin, Ministère de la santé

Guinée Diallo M.D. Dile, Ministère du plan

Madagascar Eugene Kongnyuy, CTA Maternal Health

Madagascar Randretsa Iarivony, Director of Demography and Social Statistics from the National Institute of Statistics in Madagascar

Mali Mamadou Diop, Chef Unite Statistique, CPS/Secteur Sante

Mauritanie Brahim Ould Mohamed ould Amar, Chef de Service des Methodes et du Suivi des Indicateurs (MOH), focal point

Niger Abduol Rachid Fatima, Departement centrale de la sante maternelle et infantile,

Niger Argoze Moussa, Direction des Statistiques et des Etudes Demographiques et Sociales

16

MOH

(DSEDS)

Niger Haladou Moussa, Technicien Supérieur en Santé Publique, DSS/RE-MSP, Div. Formation et Recherche

Niger Mariama Djakounda Pascal, UNFPA

Niger Sani Oumaro, Direction des Statistiques et des Etudes Demographiques et Sociales (DSEDS)

Niger Yaroh Asma Galo, Departement centrale de la sante maternelle et infantile, MOH

République Centre-Africaine Aguide Soumouk, Responsable suivi évaluation, DSFP, Ministère Santé RCA

République Centre-Africaine Ali Blaise Bienvenu, StatALI Blaise Bienvenu, Statisticien-Démographe, Chef de Service des Statistiques Démographiques

São Tomé and Principe Agostinho Miguel Soares Batista de Sousa, Ministère de la santé

Sénégal Aida Tall, Médecin, en service à la DSR du Ministère de la Santé et de la Prévention

Tchad Fatime Marthe Koulassengar, UNICEF

Tchad Gnayam An Koumtingue, Chargee du Suivi et Evaluation, UNICEF N'Djamena, Unite Suivi et Evaluation

Tchad Lam nee Mai Service, UNICEF

Tchad Prosper Lawe Ngaindandji, Demographe, INSEED

Resource Persons

Carla Abou-Zahr Consultant, WHO 6 chemin des Fins, le Grand Saconnex, 1218 Geneva, Switzerland

Kenneth Hill Harvard University SPH, Harvard Init on Global Health Third Floor 104 Mt Auburn St Cambridge MA 02138

Gwyneth Lewis National Clinical Director for Maternal Health and Maternity Services, Department of Health, England 202 Wellington House, 133-155 Waterloo

John Wilmoth Associate Professor in the Department of Demography, University of California, Berkeley Department of Demography

17

Road, London SE1 8UG

University of California, Berkeley 2232 Piedmont Avenue Berkeley, California 94720-2120

Holly Newby Division of Policy and Planning Strategic Information Section UNICEF Three United Nations Plaza, New York, NY 10017

Liliana Carvajal Division of Policy and Planning Strategic Information Section UNICEF Three United Nations Plaza, New York, NY 10017

Ralph Hakkert Technical Advisor Population and Development Branch 220 East 42nd Street 17st Floor, New York

Lale Say MD and Epideomiologist, Department of Reproductive Health and Research, World Health Organization HQ Avenue Appia, 1211 Geneva 27, Switzerland

Doris Chou Medical Officer, World Health Organization HQ, Geneva Avenue Appia, 1211 Geneva 27, Switzerland

Eduard Bos Lead Population Specialist (AFTHE) Washington D.C. The World Bank MSN J10-1004 1818 H Street NW Washington, DC 20433

Samuel Mills Health, Nutrition & Population (HDNHE) The World Bank MSN G7-701 1818 H Street NW Washington, DC 20433

Emi Suzuki Research Analyst (HDNHE) The World Bank MSN G7-701 1818 H St NW Washington, DC 20433

Khama Odera Rogo Lead Health Specialist, The World Bank (IFC) Nairobi The World Bank, Nairobi, Kenya (IFC) Mail Stop: NBOWB

Bahie Mary Rassekh Health Consultant (HDNHE) The World Bank MSN G7-701 1818 H St NW Washington, DC 20433

18

Annex 2. Agenda

THE WORLD BANK

Improving national capacity to track maternal mortality towards the attainment of the MDG5

InterContinental Nairobi, Kenya 7-10 December 2010 7-8 December 2010 (Anglophone) 9-10 December 2010 (Francophone)

Agenda

Day One

Time Description Presenter

08:30-09:00

Registration Susan Oloo-Oruya

09:00-09:30

Welcome/introductory remarks Khama Rogo, World Bank; Richmond Tiemoko, UNFPA Bo Pederson, UNICEF Doris Chou, WHO

09:30-

09:45

Background & agenda

Objectives/expected outcomes

Eduard Bos, World Bank

09:45-10:00

Sexual and reproductive health and the MDGs

Maternal mortality - overview, history, why the five-yearly inter-agency maternal mortality estimates

Discussion

Doris Chou, WHO

10:00-

11:15

Methods for Measuring Maternal Mortality -- Definitions -- Sources of data to estimate maternal mortality

-- Methods of data collection, estimation

Discussion

Kenneth Hill, Harvard University

11:15-11:30

Tea break

11:30-12:30

Global maternal mortality estimates & trends, 1990-2008

-- Data and methods used for creating the new UN estimates

-- Key findings regarding levels and trends of maternal mortality (especially for Sub-Saharan

John Wilmoth, UC Berkeley

19

Africa)

-- Comparison to other estimates (including national sources)

Discussion

12:30-13:45

Lunch

13:45- 14:30

Global maternal mortality estimates & trends, 1990-2008 (continued)

John Wilmoth, UC Berkeley

14:30-14:45

Demonstration of Proposed Maternal Mortality Estimation Dashboard

Holly Newby, UNICEF

14:45-15:00

Group Photo / Tea break

15:00-17:30

Working groups - Measuring maternal mortality (3 groups)

1. Household survey group

-- Advantages and limitations -- Questionnaire/data required -- Data Evaluation and adjustment -- Resources available to developing countries -- Country examples

2. Census group

-- 2010 Principles and Recommendations for Population and Housing Censuses

-- Advantages and limitations

-- Questionnaire/data required

-- Data Evaluation and adjustment

-- Resources available to developing countries

-- Country examples

3. Health facility group

--Presentation of attributes of health facility data

--Maternal health audits

-- Country examples and application of health facility data and death audits (Botswana)

-- Death classification discussion

-- Discussion and preparation of recommendations

John Wilmoth, UC Berkeley

Holly Newby, UNICEF

Liliana Carvajal, UNICEF

Kenneth Hill, Harvard University Richmond Tiemoko, UNFPA

Emi Suzuki, World Bank

Bahie Rassekh, World Bank

Carla Abou-Zahr, WHO Consultant

Gwyneth Lewis, Dept of Health, UK

Doris Chou, WHO

Eduard Bos, World Bank

18:00 Cocktail

20

Day Two

Time Description Presenter

09:00-12:00

Working groups (continued)

1. Household survey group

2. Census group

3. Health facility group

John Wilmoth, UC Berkeley

Holly Newby, UNICEF

Liliana Carvajal, UNICEF

Kenneth Hill, Harvard University Richmond Tiemoko, UNFPA

Emi Suzuki, World Bank

Bahie Rassekh, World Bank

Carla Abou-Zahr, WHO Consultant

Gwyneth Lewis, Dept of Health, UK

Doris Chou, WHO

Eduard Bos, World Bank

12:00-13:30

Lunch

13:30-14:15

Working group presentations, discussions and recommendations (Household survey group)

Group rapporteurs

14:15-15:00

Working group presentations, discussions and recommendations (Census group)

Group rapporteurs

15:00-15:15

Tea Break

15:15-16:00

Working group presentations, discussions and recommendations (Health facility group)

Group rapporteurs

16:00-

17:20

Recap of the experiences in the working groups and draft recommendations

Discussion of the recommendations on how to improve maternal mortality estimation at country level

Wrap-up /way forward

Holly Newby, UNICEF

WHO

UNICEF

World Bank

UNFPA

17:20-17:30

Closing remarks 4 Agency representatives

Chairperson:

Tuesday, 07 December 2010 Morning session: Khama Rogo, World Bank Wednesday, 08 December 2010

21

Afternoon session: Carla Abou-Zahr, WHO Consultant