Maternal Mortality Panorama     in the Americas      Fatima Marinho, MD, MPH, PhD         Health and Analysis (HSD/HA)  Pa...
Topics • Background   – Quality of maternal death information in The Americas      Issues with definition and measurement ...
Concepts and definitions ICD-10 - Maternal death definition The death of a woman while pregnant or within 42 days of termi...
Direct obstetric                       Indirect obstetricdeaths                                 deaths•   those resulting ...
Opportunities and options for Measuring Maternal Mortality                           Empirical measurement                ...
How many maternal deaths occur annuallyin the Region? • 8000 deaths (mortality database)                                  ...
Which are the main causes of maternaldeaths?Source: PAHO/WHO. Mortality Information System
Tendencia de la razón de mortalidad materna en los      países con serie temporal disponible.      Región de las Américas,...
Infant and Maternal Mortality Rates are higher in                                 more unequal countries                  ...
Change in Maternal Mortality in 2009in countries with decling tendencies inprevious years                                 ...
Brasil                  600                                                                                       Abortion...
Brasil         Maternal mortality: proportion by causes and MMRSource: PAHO/WHO. Mortality Information System
BrasilSource: PAHO/WHO. Mortality Information System
Mexico                    500                                                                              Abortion       ...
Mexico      Maternal mortality: proportion by causes and MMRSource: PAHO/WHO. Mortality Information System
MexicoSource: PAHO/WHO. Mortality Information System
Ecuador                                                                                                Abortion           ...
Chile                    20                                                                                               ...
Guatemala             160                                                                                         Abortion...
Guatemala Maternal mortality: proportion by causes and MMR
Mortality data base                      %
Belize                                                                     Mortality data base                            ...
MMR with differentnumber of death Year MMR Death 2008  86.2  13 2008  92.9  14 2007 106.0  16 2007 132.3  20
• Do we all use the same definition?• Do we all agree on how to measure it?• Do we use the same data collection  instrumen...
Under-reporting of maternal               Potential reasons cited for underdeaths was more common among              repor...
¿Qué progresos y debilidades existen?       Panorama Heterogéneo en la Región•   Compromiso político de los países      • ...
Points for Discussion • How are countries   investigating maternal deaths?
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Maternal Mortality Panorama in the Americas

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Maternal Mortality Panorama in the Americas

  1. 1. Maternal Mortality Panorama in the Americas Fatima Marinho, MD, MPH, PhD Health and Analysis (HSD/HA) Pan American Health Organization (PAHO/WHO)
  2. 2. Topics • Background – Quality of maternal death information in The Americas Issues with definition and measurement • Maternal mortality trend by selected countries • Point for discussion
  3. 3. Concepts and definitions ICD-10 - Maternal death definition The 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. This definition allows identification of maternal deaths, based on their causes as either direct or indirect.
  4. 4. Direct obstetric Indirect obstetricdeaths deaths• those resulting from obstetric • those resulting from previous complications of the pregnant existing disease, or diseases state (pregnancy, delivery, that developed during and postpartum), from pregnancy, interventions, omissions, • and which were not due to incorrect treatment, or from a direct obstetric causes but chain of events resulting from aggravated by physiological any of the above. effects of pregnancy. for example: for example:• haemorrhage, deaths due to aggravation of an• pre-eclampsia/eclampsia existing cardiac or renal disease are indirect obstetric deaths.• or those due to complications of anaesthesia or caesarean section are classified as direct obstetric deaths
  5. 5. Opportunities and options for Measuring Maternal Mortality Empirical measurement Analytical Routine Opportunities Special Opportunities Birth-death record 4. Surveys* 5. Surveillance* 1.Death A) Household survey linkage: to find 3. Decennial A) Demographic Registration asking about deaths in Surveillance Systems Maternal deaths Census* Household A)Civil B) Prospective study Registration** B) Indirect Sisterhood – Dual method B)Sample Vital household survey asking C) Sample Vital or capture – Registration*/ 2. Health about deaths of sisters, Registration, with recapture: Facility Verbal ** without dates Autopsy (SAVVY) corrects for Statistics** under - reporting C) Direct Sisterhood – D) Active surveillance household survey, of reproductive asking about deaths of age female deaths UN models: sisters, with dates Estimate levels E) Active surveillance of pregnancy-related or of maternal D) Sampling at Service Sites (SSS) – using maternal deaths mortality using (Confidential Enquiries) regression direct sisterhood method 6. RAMOS*: In-depth review of reproductive-age female deaths identified from routine &/or special opportunities, & follow-up investigation of maternal deathsColour key: Green = longitudinal & continuous capture of deaths; Red= cross-sectional capture; Grey = mixed capture; Teal= no newcapture of deaths* Deaths actively sought by measurement ** Deaths passively recorded, as dependent on relatives or health providers to notify death
  6. 6. How many maternal deaths occur annuallyin the Region? • 8000 deaths (mortality database) • 12 000 deaths (estimated) VEN USA URY TTO OMS UNICEF, UNFPA, WB WHO, SUR SLV OPS(país) PAHO (countries) PRY PRI PER PAN NIC MEX JAM HND GUY GTM ECU DOM CUB CRI COL CHL CAN BRB BRA BOL BLZ BHS ARG Maternal mortality Ratio (MMR 100 000 lb) 0.0 50.0 100.0 150.0 200.0 250.0 300.0Source: PAHO/WHO. Mortality Information System
  7. 7. Which are the main causes of maternaldeaths?Source: PAHO/WHO. Mortality Information System
  8. 8. Tendencia de la razón de mortalidad materna en los países con serie temporal disponible. Región de las Américas, 2000 a 2009
  9. 9. Infant and Maternal Mortality Rates are higher in more unequal countries Maternal Mortality Ratio 250 200 Infant Mortality Ratio -2 6 0 150 60 100 50 50 b 2 0 1 ] , l 40 0 M m o d p n e a y r t [ , i l 30 0 10 20 30 40 Highest 20%/Lowest 20% income ratio [Ratio] 2002-2006 20 10 m In Bolivia the highest 20% receives 36m n h d 6 0 2 1 e a E y s r tobpn01e ) (ay l irt][fI,il 0 0 10 20 30 40 times the lowest 20% Highest 20%/Lowest 20% income ratio [Ratio] 2002-2006 More inequality is related to higher Source: PAHO Basic Indicators infant and maternal mortality rates
  10. 10. Change in Maternal Mortality in 2009in countries with decling tendencies inprevious years 2008 2009 % CambioArgentina 322 422 31.1Brasil 1679 1878 11.9Ecuador 165 208 26.1Mexico 1135 1229 8.3Paraguay 115 128 11.3Cuba 57 66 15.8 PandemicRepublica Dominicana* 190 202 6.3 Impact?Uruguay* 4 16 300.0Chile 41 43 4.9Costa Rica 19 10 -47.4El Salvador 18 14 -22.2Guatemala 335 340 1.5Panama 41 29 -29.3Source: PAHO/WHO. Mortality Information System *Rep. Dominicana y Uruguay dato reportado por la vigilancia
  11. 11. Brasil 600 Abortion 500 Oedema, proteinuria and hypertensive disorders in pregnancy, childbirth and the puerperium Haemorrhage in pregnancy, childbirth and the puerperium 400Maternal deaths Sepsis and another puerperal infecctions Complications predominantly related to the 300 pregnacy and childbirth Complications predominantly related to the puerperium 200 Indirect obstetric deaths Obstetric death of unspecified cause 100 Maternal Deaths from from any obstetric cause occurring more than 42 days but less than one year after delivery and sequelae 0 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 Source: PAHO/WHO. Mortality Information System
  12. 12. Brasil Maternal mortality: proportion by causes and MMRSource: PAHO/WHO. Mortality Information System
  13. 13. BrasilSource: PAHO/WHO. Mortality Information System
  14. 14. Mexico 500 Abortion 450 Oedema, proteinuria and hypertensive disorders in pregnancy, childbirth and the 400 puerperium Haemorrhage in pregnancy, childbirth and Maternal deaths 350 the puerperium Sepsis and another puerperal infecctions 300 250 Complications predominantly related to the pregnacy and childbirth 200 Complications predominantly related to the puerperium 150 Indirect obstetric deaths 100 Obstetric death of unspecified cause 50 Maternal Deaths from from any obstetric cause occurring more than 42 days but less 0 than one year after delivery and sequelae 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009Source: PAHO/WHO. Mortality Information System
  15. 15. Mexico Maternal mortality: proportion by causes and MMRSource: PAHO/WHO. Mortality Information System
  16. 16. MexicoSource: PAHO/WHO. Mortality Information System
  17. 17. Ecuador Abortion 90 Oedema, proteinuria and hypertensive 80 disorders in pregnancy, childbirth and the puerperium 70 Haemorrhage in pregnancy, childbirth and the puerperium 60 Sepsis and another puerperal infecctionsMaternal deaths 50 Complications predominantly related to the pregnacy and childbirth 40 Complications predominantly related to the puerperium 30 Indirect obstetric deaths 20 Obstetric death of unspecified cause 10 Maternal Deaths from from any obstetric 0 cause occurring more than 42 days but less than one year after delivery and 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 sequelae Source: PAHO/WHO. Mortality Information System
  18. 18. Chile 20 Abortion 18 Oedema, proteinuria and hypertensive 16 disorders in pregnancy, childbirth and the puerperium Haemorrhage in pregnancy, childbirth 14 and the puerperium Maternal deaths 12 Sepsis and another puerperal infecctions 10 Complications predominantly related to the pregnacy and childbirth 8 Complications predominantly related to the puerperium 6 Indirect obstetric deaths 4 Obstetric death of unspecified cause 2 0 Maternal Deaths from from any obstetric cause occurring more than 42 days but 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 less than one year after delivery and sequelaeSource: PAHO/WHO. Mortality Information System
  19. 19. Guatemala 160 Abortion 140 Oedema, proteinuria and hypertensive disorders in pregnancy, childbirth and the puerperium 120 Haemorrhage in pregnancy, childbirth and the puerperium 100 Sepsis and another puerperal infecctionsMaternal deaths Complications predominantly related to the 80 pregnacy and childbirth Complications predominantly related to the puerperium 60 Indirect obstetric deaths 40 Obstetric death of unspecified cause 20 Maternal Deaths from from any obstetric cause occurring more than 42 days but less than one year after delivery and sequelae 0 2005 2006 2007 2008 2009 Source: PAHO/WHO. Mortality Information System
  20. 20. Guatemala Maternal mortality: proportion by causes and MMR
  21. 21. Mortality data base %
  22. 22. Belize Mortality data base (Direct Obstetric) Data reported by the countryhttp://health.gov.bz/www/attachments/565_annual%20report%202009-2011%20-%202.pdf
  23. 23. MMR with differentnumber of death Year MMR Death 2008 86.2 13 2008 92.9 14 2007 106.0 16 2007 132.3 20
  24. 24. • Do we all use the same definition?• Do we all agree on how to measure it?• Do we use the same data collection instrument for measurement?• What do we want to measure?
  25. 25. Under-reporting of maternal Potential reasons cited for underdeaths was more common among reporting/misclassification includethe following the following• Early pregnancy deaths, which •Inadequate understanding of ICD cannot be linked to a reportable rules (either ICD-9 or ICD-10). birth outcome. • Death certificates completed• Deaths in the later postpartum without mention of pregnancy period (these were less likely to be reported than early postpartum status. deaths). • Desire to avoid litigation.• Deaths at extremes of maternal age (youngest and oldest). • Desire to suppress information (especially as related to abortion• Miscoding by ICD-9 or ICD-10, most deaths). often seen in cases of deaths caused by:––cerebrovascular diseases;––cardiovascular diseases.
  26. 26. ¿Qué progresos y debilidades existen? Panorama Heterogéneo en la Región• Compromiso político de los países • Falta de empleo correcto de definiciones internacionalmente• Establecimiento de intervenciones aceptadas muerte materna obstétrica directa e indirecta (CIE-10)• Elaboración de informes de monitoreo de avances de los países • Estimaciones por Agencias (diferentes resultados para un país)• Fortalecimiento de los sistemas de información • Inconsistencias en el indicador (RMM)• Aplicación de metodologías para la • Dificultad para el monitoreo y búsqueda intencionada de muertes maternas (Brasil, México, Paraguay) evaluación del avance de 1990 a 2010• Involucramiento de la comunidad y • Desconocimiento de las verdaderas organizaciones sociales causas de las muertes maternas
  27. 27. Points for Discussion • How are countries investigating maternal deaths?

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