1. Maternal Mortality Panorama
in the Americas
Fatima Marinho, MD, MPH, PhD
Health and Analysis (HSD/HA)
Pan American Health Organization (PAHO/WHO)

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. 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. Direct obstetric Indirect obstetric
deaths 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. 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 deaths
Colour key: Green = longitudinal & continuous capture of deaths; Red= cross-sectional capture; Grey = mixed capture; Teal= no new
capture of deaths
* Deaths actively sought by measurement ** Deaths passively recorded, as dependent on relatives or health providers to notify death

6. How many maternal deaths occur annually
in 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 50.0 100.0 150.0 200.0 250.0 300.0
Source: PAHO/WHO. Mortality Information System

7. Which are the main causes of maternal
deaths?
Source: PAHO/WHO. Mortality Information System

8. Tendencia de la razón de mortalidad materna en los
países con serie temporal disponible.
Región de las Américas, 2000 a 2009

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 36
m
n
h
d
6
0
2
1
e
a
E
y
s
r
t
o
b
p
n
0
1
e
)
(
a
y
l
i
r
t
]
[
f
I
,
i
l
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. Change in Maternal Mortality in 2009
in countries with decling tendencies in
previous years
2008 2009 % Cambio
Argentina 322 422 31.1
Brasil 1679 1878 11.9
Ecuador 165 208 26.1
Mexico 1135 1229 8.3
Paraguay 115 128 11.3
Cuba 57 66 15.8 Pandemic
Republica Dominicana* 190 202 6.3
Impact?
Uruguay* 4 16 300.0
Chile 41 43 4.9
Costa Rica 19 10 -47.4
El Salvador 18 14 -22.2
Guatemala 335 340 1.5
Panama 41 29 -29.3
Source: PAHO/WHO. Mortality Information System
*Rep. Dominicana y Uruguay dato reportado por la vigilancia

11. Brasil
600
Abortion
500 Oedema, proteinuria and hypertensive
disorders in pregnancy, childbirth and the
puerperium
Haemorrhage in pregnancy, childbirth and the
puerperium
400
Maternal 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. Brasil
Maternal mortality: proportion by causes and MMR
Source: PAHO/WHO. Mortality Information System

13. Brasil
Source: PAHO/WHO. Mortality Information System

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 2009
Source: PAHO/WHO. Mortality Information System

15. Mexico
Maternal mortality: proportion by causes and MMR
Source: PAHO/WHO. Mortality Information System

16. Mexico
Source: PAHO/WHO. Mortality Information System

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 infecctions
Maternal 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. 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
sequelae
Source: PAHO/WHO. Mortality Information System

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 infecctions
Maternal 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. Guatemala
Maternal mortality: proportion by causes and MMR

21. Mortality data base
%

22. Belize
Mortality data base
(Direct Obstetric)
Data reported by the
country
http://health.gov.bz/www/attachments/565_annual%20report%202009-2011%20-%202.pdf

23. MMR with different
number of death
Year MMR Death
2008 86.2 13
2008 92.9 14
2007 106.0 16
2007 132.3 20

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. Under-reporting of maternal Potential reasons cited for under
deaths was more common among reporting/misclassification include
the 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. ¿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. Points for Discussion
• How are countries
investigating maternal deaths?