Maternal mortality for 181 countries

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Maternal mortality for 181 countries

  1. 1. Maternal mortality for 181 countries, 1980-2008 <ul><li>A systematic analysis of progress towards Millennium Development Goal 5 </li></ul>
  2. 2. Opportunities for a Robust Reassessment of Maternal Mortality <ul><li>Global Burden of Disease (GBD) study has undertaken a comprehensive analysis of misclassification of maternal death in vital registration data </li></ul><ul><li>Methodological advances in correcting sibling history data for known biases (survivor bias, recall bias) – Obermeyer et al 2010, PLoS Medicine </li></ul><ul><li>Growing body of population-based verbal autopsy studies </li></ul><ul><li>New estimates of all-cause reproductive-aged female mortality -- Rajaratnam et al, 2010, The Lancet </li></ul><ul><li>Methodological developments in other fields provide improved statistical tools to detect spatial-temporal patterns </li></ul>
  3. 3. Clarifying the Definition of the MMR <ul><li>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) </li></ul><ul><li>For inter-temporal and international comparisons, ICD and MDG manual recommend A+B+C excluding D+E+F </li></ul><ul><li>Maternal mortality ratio: number of maternal deaths per 100,000 live births </li></ul>  Direct Indirect HIV Incidental Early maternal (<42 days) A B C D Late maternal (> 42 days & < 1 year) E F    
  4. 4. Systematic Identification of Data <ul><li>Vital registration data </li></ul><ul><ul><li>Naghavi et al ( Population Health Metrics 2010) have undertaken a detailed study of the misclassification of maternal deaths in ICD coded vital registration data; correcting for misclassification increased maternal deaths in vital registration data on average by 42%. </li></ul></ul><ul><li>Sibling history data from surveys </li></ul><ul><ul><li>Apply the Gakidou-King correction for survival bias </li></ul></ul><ul><li>Deaths in the household from censuses and surveys </li></ul><ul><li>National and sub-national verbal autopsy </li></ul><ul><ul><li>Literature review to identify published estimates from national and sub-national population-based studies of maternal mortality </li></ul></ul>
  5. 5. Final Database by Source <ul><li>No data for 21 countries, representing 2.2% of births </li></ul><ul><li>Each sibling history data point covers a 5-year period </li></ul>
  6. 6. Sibling History Data Needs to be Corrected for Survivor Bias Obermeyer et al 2010, PLoS Medicine
  7. 7. Analytical Approach <ul><li>Extract proportion of all female deaths due to maternal causes from all data sources </li></ul><ul><li>Apply proportion to new adult female adult mortality time series (Rajaratnam et al, The Lancet , 2010) to arrive at maternal mortality rates by age. </li></ul><ul><li>Two stage analysis, modeling the age-specific maternal mortality rate </li></ul><ul><ul><li>Stage 1: Linear model </li></ul></ul><ul><ul><li>Stage 2: Spatial temporal model </li></ul></ul>
  8. 8. Model Validation: An Essential Test <ul><li>More sophisticated models can improve measurement but it is essential that the validity of any modeling strategy be rigorously evaluated. </li></ul><ul><li>Validity of alternative models tested using four types of predictive validity: </li></ul><ul><ul><li>Hold out 20% of country-years </li></ul></ul><ul><ul><li>Hold out 20% of countries </li></ul></ul><ul><ul><li>Hold out the first 20% of years of data for all countries </li></ul></ul><ul><ul><li>Hold out the last 20% of years of data for all countries </li></ul></ul><ul><li>Two stage modeling strategy reduces median error by 50-60% </li></ul>
  9. 9. Sources of Uncertainty <ul><li>Multiple measurements for the same year often differ substantially. </li></ul><ul><li>Measurements only available for selected years </li></ul><ul><li>Models used to integrate data from multiple sources have uncertainty associated with them. </li></ul><ul><li>Methods for uncertainty estimation for global health not yet standardized. Our estimates of uncertainty for technical reasons are likely to be too large. </li></ul>
  10. 10. India: Available Studies and Predicted MMR With Uncertainty
  11. 11. Mali: Available Studies and Predicted MMR With Uncertainty
  12. 12. Trend in Global Maternal Deaths
  13. 13. MMR in 2008
  14. 14. Top 21 Countries: 80% of Maternal Deaths Order Country Deaths in 1000s (UI) % Cumulative % Births (%) Cumulative % 1 India 68.3 (41.6-106.2) 19.9 19.9 19.7 19.7 2 Nigeria 36.7 (22.4-57.0) 10.7 30.6 4.4 24.1 3 Pakistan 20.1 (12.3-31.3) 5.9 36.5 3.9 28.0 4 Afghanistan 20.0 (7.5-43.1) 5.8 42.3 0.9 28.9 5 Ethiopia 18.2 (11.1-28.8) 5.3 47.6 2.3 31.2 6 Congo, the Democratic Republic of the 15.4 (9.0-24.7) 4.5 52.1 2.1 33.3 7 Bangladesh 11.6 (6.7-18.7) 3.4 55.5 2.5 35.8 8 Indonesia 9.6 (5.6-16.0) 2.8 58.3 3.1 38.9 9 Tanzania, United Republic of 8.0 (4.8-12.8) 2.3 60.6 1.3 40.2 10 China 7.3 (6.4-8.3) 2.1 62.7 13.3 53.5 11 Malawi 6.8 (4.0-10.9) 2.0 64.7 0.4 53.9 12 Côte d'Ivoire 6.8 (4.1-10.8) 2.0 66.7 0.5 54.4 13 Kenya 6.2 (3.6-10.2) 1.8 68.5 1.1 55.5 14 Chad 5.3 (3.3-8.2) 1.5 70.0 0.4 55.9 15 Mozambique 5.2 (3.1-8.4) 1.5 71.5 0.6 56.5 16 Uganda 5.2 (3.1-8.2) 1.5 73.0 1.1 57.6 17 Cameroon 5.0 (2.8-8.1) 1.4 74.4 0.5 58.1 18 Niger 4.7 (3.0-7.3) 1.4 75.8 0.6 58.7 19 Angola 4.6 (1.8-9.9) 1.3 77.1 0.6 59.3 20 Sudan 4.0 (2.5-6.0) 1.2 78.3 0.9 60.2 21 Mali 3.6 (2.3-5.5) 1.1 79.4 0.4 60.6 All other countries (160) 70.3 (43.0-112.2) 20.5 100.0 39.3 100.0 Total   342.9 100.0 100.0 100.0 100.0
  15. 15. Annualized Rate of Decline in MMR, 1990 to 2008
  16. 16. Progress Undocumented But Not Unexpected <ul><li>Global maternal deaths down to 342,900 in 2008 </li></ul><ul><li>Global total fertility rate has dropped from 3.70 in 1980 to 2.56 in 2008 </li></ul><ul><li>Income per capita has been rising over the period, particularly in Asia and Latin America </li></ul><ul><li>Maternal education has been increasing as well </li></ul><ul><ul><li>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 </li></ul></ul><ul><li>The steady, slow rise in skilled birth attendance coverage may also have contributed </li></ul>
  17. 17. Improving Maternal Mortality Measurement in the Future <ul><li>There is more data on maternal mortality than any other cause of death. </li></ul><ul><li>Improved measurement can come from three strategies: </li></ul><ul><ul><li>Reduced misclassification of maternal deaths in complete vital registration systems – check boxes on death certificates, follow-up studies for probable maternal deaths </li></ul></ul><ul><ul><li>Expanded coverage of incomplete vital registration systems – e.g. South Africa raised VR coverage in a short period </li></ul></ul><ul><ul><li>Wider and repeated collection of sibling history data in household surveys </li></ul></ul>
  18. 18. Progress on MDG4 and MDG5 Can be Different Equivalence Line
  19. 19. Global Progress Toward Reducing Maternal and Child Mortality

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