Agbessi Amouzou and Holly Newby Data amp Analytics Section DPS UNICEF 1 May 2014 Will be released on Tuesday 6 May 2014 Levels and trends of maternal mortality between 1990 and 2013 for ID: 734868
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Slide1
The new UN interagency maternal mortality estimates
Agbessi Amouzou and Holly Newby Data & Analytics Section, DPS, UNICEF1 May 2014Slide2
Will be released on Tuesday, 6 May 2014Levels and trends of maternal mortality between 1990 and
2013 for 183 countriesIncludes MMR, lifetime risk of maternal death and numbers of maternal deathsWill replace current UN interagency estimates pertaining to 2010Slide3
Outline of the PresentationWhy UN Inter-Agency estimate of maternal mortality
Summary of issues in maternal mortality measurementHow the UN Inter-Agency estimates are producedHighlights of new estimatesSlide4
WHY UN inter-agency estimates?Slide5
Why Inter-Agency MM Estimates?
MMR is key indicator for MDG 5Global monitoring and reporting requires a harmonized measure of MMR that is comparable across countriesNeed to obtain a measure that has same reference year across all countries
Maternal mortality is challenging to measure
Similar initiative is done for under-five mortality (see www.childmortality.org) Slide6
Maternal Mortality Estimation Interagency Group (MMEIG)
The UN interagency estimates are produced by the Maternal Mortality Estimation Interagency Group (MMEIG):
WHO (Lead)
UNICEF
UNFPA
The World Bank
Lead technical consultant (
Leontine
Alkema
, National University of
Singapor
)
Technical Advisory GroupSlide7
Maternal mortality measurementSlide8
Definitions
Maternal deathThe death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and site of the pregnancy, from
any cause related to or aggravated by the pregnancy or its management
but not from accidental or incidental causes.
Death must be
attributed directly or indirectly to
pregnancy or childbirth
Requires
medical certification or verbal autopsy
Cannot be obtained through surveys or censuses
No deaths beyond 42 days due to pregnancy complications accounted for
Definition
Implications
Pregnancy-related death
The death of a woman
while pregnant or within 42 days
of termination of pregnancy, irrespective of the cause of death
.
Cause of death certification not needed
Can be obtained through surveys or censuses
UN Interagency maternal mortality estimates conform to the definition of maternal deathSlide9
Sources of maternal mortality data and their limitations
Maternal mortality data can come from a variety of sources:Vital registration
Considered
gold
standard
Good in only about a third of countries
Extensive
under-reporting and misclassification
Even
in countries with complete vital registration, maternal deaths may be underreported by a factor of 1.5 – 3.0Slide10
Sources of maternal mortality data and their limitations
Maternal mortality data can come from a variety of sources:Vital registrationHousehold surveys (sisterhood method)
Pregnancy-related deaths
MMR
very imprecise
, large confidence intervals
Doe not produce recent estimate: MMR
refers to 7
to 9 years
in the pastSlide11
Sources of maternal mortality data and their limitations
Maternal mortality data can come from a variety of sources:Vital registrationHousehold surveys (sisterhood method)Censuses
Pregnancy-related
deaths
Conducted every 10 years
Need adjustment for
completeness of births and deathsSlide12
Sources of maternal mortality data and their limitations
Maternal mortality data can come from a variety of sources:Vital registrationHousehold surveys (sisterhood method, etc.)
Censuses
Reproductive-age mortality studies (RAMOS)
Complicate, time-consuming and expensive
Under-report of maternal deaths
Under report of number of live birthsSlide13
Sources of maternal mortality data and their limitations
Maternal mortality data can come from a variety of sources:Vital registrationHousehold surveys (sisterhood method, etc.)
Censuses
Reproductive-age mortality studies (RAMOS)
Verbal autopsy
Misclassification of cause of death
Under report of maternal deaths
Recall issuesSlide14
Sources of maternal mortality data and their limitations
Maternal mortality data can come from a variety of sources:Vital registrationHousehold surveys (sisterhood method, etc.)CensusesReproductive-age mortality studies (RAMOS)Verbal autopsy
Bottom line:
Each
source has advantages and limitations.
Measurement is challenging regardless of source
.
There is need to adjust and harmonize available data for cross country comparability and global reportingSlide15
Issues to keep in mind
Survey estimates of MMR are averages over periods of 7 or 9 years in the past, so not comparable to UN Interagency estimatesMMR generally have large uncertainty ranges Maternal death is a rare event; MMR is expressed in per 100,000 live births and therefore creates a false sense of precision300/100,000 = 0.30/100330/100,000 = 0.33/100
MMR of 300 may not be different from MMR of 330Slide16
Trend Estimation from Sibling Histories with 95% Confidence Intervals (Namibia)
Estimates are averages over long periods (here 7 or 9 years) and 95% confidence intervals are large
Source: Ken Hill – UN maternal mort workshop, Nairobi December 2010
The 2007 MMR refers to period 1998 -2007Slide17
Trend Estimation from Sibling Histories with 95% Confidence Intervals (Namibia)
Estimates are averages over long periods (here 7 or 9 years) and 95% confidence intervals are large
Source: Ken Hill – UN maternal mort workshop, Nairobi December 2010
The 2000 MMR has 95%CI ranging from 90 to 450Slide18
Trend Estimation from Sibling Histories with 95% Confidence Intervals (Namibia)
Estimates are averages over long periods (here 7 or 9 years) and 95% confidence intervals are large
Source: Ken Hill – UN maternal mort workshop, Nairobi December 2010
Note that this is at the national level! It’s not possible to disaggregate by region or other characteristics like household wealth!Slide19
How are the UN inter-agency estimates done?Slide20
Source of data for the 2013 MMR estimates
Group
Source of maternal mortality data
Number of countries/ territories
% of countries/ territories in each category
% of births in 183 countries/territories covered
A
Civil registration
characterized as complete, with good attribution of cause
of
death
67
37
17
B
Incomplete civil registration and/or other types of data
96
52
81
C
No national
data on maternal
mortality 20112
Total
183
100
100Slide21
General methodology of
estimationLittle change from methodology used
for 2010 estimates
Compile and review all available nationally representative maternal mortality data
Adjust available maternal
mortality data
for
misclassification and underreportingSlide22
3. Use one of two approaches depending on country
Countries with adequate civil registration dataCalculate MMR directly with adjustedAll other countries: U
se m
ultilevel
linear regression model
C
ovariates
: GDP,
general fertility rate
and
skilled attendant at birth
Separate model component for AIDS deaths that are indirect maternal deaths
4. Compute uncertainty ranges through simulations
General methodology of estimationSlide23
Methodological changes from the 2010 estimates?
Increased data availability5% increase in available dataUpdate in the estimate of female deaths in the reproductive age by WHOUpdate of series of live births and general fertility rates from World Population ProspectsUpdate in AIDS adjustment parameters Slide24
Methodological changes from the 2010 estimates?
Data availability5% increase in available dataUpdate in the estimate of female deaths in the reproductive age by WHOUpdate of series of live births and general fertility rates from World Population ProspectsUpdate in AIDS adjustment parameters
Little change from methodology used
for
2010
estimates Slide25
Review processReviewed by the
Technical Advisory Group with experts from academic institutions: Harvard University, Johns Hopkins University, University of Aberdeen, and othersCountry consultation led by WHO allowed countries to provide feedback and provide new dataSlide26
STOP!
The 2013 UN interagency estimates REPLACE the previous estimates and should not be compared or interpreted together with themThe 2013 estimates are NOT
comparable to estimates from other sourcesSlide27
Maternal mortality estimates generated by countries
At the global level, we use the interagency estimates for MDG reporting and official monitoring
UNICEF
presents both
nationally reported
estimates and UN interagency
estimates in
State of the World’s Children
TABLE 8Slide28
Embargoed
until May 6, 2014 ----------------------
Trends in Maternal Mortality
Ratio
(Embargoed until May 6, 2014)
By UNICEF regions
Source:
Trends in Maternal Mortality: 1990-2013
(WHO, UNICEF, UNFPA, World Bank) Slide29
Resources
Complete methodological details and all data available on:www.who.int/reproductivehealth/publications/monitoring/xxxxxxxxx/en/index.html and MME Info: www.maternalmortalitydata.org
More information on new estimates available (from May 6) at:
Data.unicef.org
We are in process of updating the MMEIG website MM Info (
maternalmortalitydata.org
)Slide30
To be released on
6 May 2014!
Contacts
Agbessi Amouzou
aamouzou@unicef.org
Holly Newby
hnewby@unicef.org
Slide31
Issues to keep in mind
Maternal mortality is difficult to measureNeed to have information on pregnancy status, timing and causeRare eventAvailable data suffer from serious limitations
Sparse
Suffer from under-reporting and misclassification of deaths
May have definitional
differences
Goal – adjust for lack of
data,
misclassification and
under-reporting to
provide the best possible estimatesSlide32
Things to think about
Note that the 2012 UN interagency estimates are not comparable to estimates from other sourcesSerious limitations regarding maternal mortality estimation
Underlying data are sparse and suffer from under-reporting and misclassification
Lots of assumptions needed for modeled global estimates
Estimates are bracketed by a wide range of
uncertainty
Need to use a broad range of evidence and indicators for tracking progress