hhhhhh

1. Workshop on
Demographic Analysis
and Evaluation
‫الديمغرافي‬ ‫التحليل‬ ‫بشأن‬ ‫عمل‬ ‫حلقة‬
‫والتقييم‬

2. Maternal Mortality
Estimation from the Census
‫التعداد‬ ‫من‬ ‫األمهات‬ ‫وفيات‬ ‫تقدير‬
2

3. Maternal Mortality(‫األمومة‬ ‫وفيات‬ ‫)معدل‬
In this lesson, we consider the following questions:
1. Why are we interested in maternal mortality?
2. What is a maternal death?
3. What are the key measures of maternal mortality?
4. Where do maternal mortality estimates come from?
5. How can we calculate maternal mortality ratio from the census?
‫التالية‬ ‫األسئلة‬ ،‫الدرس‬ ‫هذا‬ ‫في‬ ‫نعتبر‬
:
.1
‫األمهات؟‬ ‫وفيات‬ ‫في‬ ‫مهتمون‬ ‫نحن‬ ‫لماذا‬
.2
‫األمهات؟‬ ‫وفاة‬ ‫حالة‬ ‫هي‬ ‫ما‬
.3
‫النفاس؟‬ ‫أثناء‬ ‫األمهات‬ ‫لوفيات‬ ‫الرئيسية‬ ‫التدابير‬ ‫هي‬ ‫ما‬
.4
‫النفاس؟‬ ‫أثناء‬ ‫األمهات‬ ‫وفيات‬ ‫من‬ ‫التقديرات‬ ‫تأتي‬ ‫أين‬
.5
‫السكان؟‬ ‫تعداد‬ ‫من‬ ‫األمهات‬ ‫وفيات‬ ‫نسبة‬ ‫بحساب‬ ‫نقوم‬ ‫أن‬ ‫يمكن‬ ‫كيف‬
3

4. Why We are Interested in Maternal Mortality
‫األمهات‬ ‫بوفيات‬ ‫مهتمين‬ ‫نحن‬ ‫لماذا‬
Increasing international attention:
 1990 World Summit for Children
 1994 International Conference on Population and Development
 1995 World Conference for Women
 2000 – United Nations identified maternal mortality as the 5th of 8 Millennium
Development Goals (MDGs)
‫الدولي‬ ‫االهتمام‬ ‫زيادة‬
:

‫اال‬ ‫ل‬ ‫العالمي‬ ‫القمة‬ ‫مؤتمر‬
‫طفال‬
‫لعام‬
1990

‫الدولي‬ ‫المؤتمر‬
"
‫لعام‬ ‫والتنمية‬ ‫بالسكان‬ ‫المعني‬
1994

‫عام‬ ‫في‬ ‫للمرأة‬ ‫العالمي‬ ‫المؤتمر‬
1995

2000
–
‫من‬ ‫كالخامس‬ ‫األمهات‬ ‫وفيات‬ ‫معدل‬ ‫حددت‬ ‫المتحدة‬ ‫األمم‬
"
‫اإلنمائية‬ ‫األهداف‬
"
‫لأللفية‬ ‫الثمانية‬
(
‫اإلنمائية‬ ‫األهداف‬
‫لأللفية‬
)
4

5. Introduction (
‫مقدمة‬
)
The fifth MDG calls for the improvement of maternal health and,
specifically, for the reduction of maternal mortality ratios (maternal
deaths per 100,000 live births (MMR)) by three quarters between
1990 and 2015 (UNDP 2010?).
We will use maternal mortality analysis for Namibia as an example of
how to estimate and evaluate maternal mortality.
Estimates of maternal mortality for Namibia have varied from
 225 for the period preceding the 1992 NDHS, to
 271 for the period leading up to the 2000 NDHS, to
 449 maternal deaths per 100,000 live births for the decade preceding the
latest NDHS.
5

6. The maternal mortality rate can be converted to a maternal mortality
ratio and expressed per 100,000 live births by dividing the rate by the
general fertility rate. This general fertility rate that prevailed during this
period was 0.117. Using this procedure, the maternal mortality ratio
during the 10-year period before the survey is estimated at 449
maternal deaths per 100,000 live births. This figure should be
viewed with caution because the number of female deaths that
occurred during pregnancy, at delivery, or within two months of
delivery is small (86). As a result, the maternal mortality estimates are
subject to large sampling errors; the 95 percent confidence intervals
indicate that the maternal mortality ratio varies from 341 to 557.
6
From the 2006/07 NDHS

7. Maternal mortality ratios have been estimated for comparable 10-year
periods preceding the 1992 and 2000 NDHS surveys. The maternal
mortality ratio appears to have increased substantially since the mid-
1980s. Over the past seven years it increased from 271 maternal
deaths per 100,000 live births for the period 1991-2000 to 449 for the
period 1998-2007. The methodology used and the sample sizes
implemented in these three surveys do not allow for precise estimates
of maternal mortality. While the sampling errors around each of the
estimates are large, the confidence intervals around the estimates from
the 2000 NDHS and 2006-07 NDHS do not overlap. Thus, it is
possible to say with reasonable confidence that maternal mortality
in Namibia increased in the recent past.
-- 2006/2007 NDHS, p.113
7
From the 2006/07 NDHS

8. Using the Census to Measure Maternal Mortality
The 2011 census offers an opportunity to measure
maternal mortality without the small numbers of observed
deaths and sampling error associated with surveys.
The census asked questions about adult mortality and
maternal mortality (questionnaire section G). The 2011
census attempts to use a measurement system offering
more observations and, in principle, a more accurate
result than the NDHS series.
8

9. What is a Maternal Death?
9
In the International Classification of Diseases and
Related Health Problems, Tenth Revision, 1992 (ICD-
10), WHO defines maternal death as:
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.

10. Using the Census to Measure Maternal Mortality
The census attempts to measure maternal mortality by
modifying a time-defined measure of maternal death
corresponding to what ICD-10 refers to as a “pregnancy-
related death” )PRD(, defined as any death of a woman
while pregnant or within 42 days of termination of
pregnancy, irrespective of cause.
A PRD, then, may include deaths during pregnancy, at
time of childbirth, or following childbirth from unrelated
causes.
A PRD is easier to measure than a maternal death since
it does not require determination of cause of death.
10

11. Using the Census to Measure Maternal Mortality
11

12. Introduction
 G4 and G5 identify the deceased as female (G4) and
age 12-54 (G5)
 Adjustment for not-stated age cases follows standard
procedure (cf. Wilmoth et al. 2010:4, Hill et al. 2001
chapter 4.1)
 G6 allows for removal of all non-illness causes; that is,
removal of accident, injury, suicide, violence,
witchcraft, and other.
12

13. Using the Census to Measure Maternal Mortality
 G6 and G7 define the death as pregnancy-related. If
G6 (What was the cause of his or her death) OR G7
(Did the death occur while pregnant, during childbirth,
or within 2 months after childbirth) is yes, then this is a
PRD but, having eliminated accidents etc., this is also
a maternal death.
13

14. Measures of Maternal Mortality
(
‫االمومة‬ ‫أثناء‬ ‫األمهات‬ ‫وفيات‬ ‫مقاييس‬
)
14
Maternal mortality ratio (MRR) - Number of maternal deaths during a
given time period per 100,000 live births during the same time period
Maternal mortality rate - Number of maternal deaths in a given period
per 100,000 women of reproductive age during the same time period
Adult lifetime risk of maternal death - The probability of dying from a
maternal cause during a woman’s reproductive lifespan
‫األمهات‬ ‫وفيات‬ ‫نسبة‬
(
MRR
)
-
‫لكل‬ ‫معينة‬ ‫زمنية‬ ‫فترة‬ ‫خالل‬ ‫األمهات‬ ‫وفيات‬ ‫عدد‬
100000
‫حية‬ ‫والدة‬
‫الوقت‬ ‫نفس‬ ‫خالل‬
‫األمهات‬ ‫وفيات‬ ‫معدل‬
-
‫لكل‬ ‫معينة‬ ‫فترة‬ ‫في‬ ‫األمهات‬ ‫وفيات‬ ‫عدد‬
000
100
‫خالل‬ ‫اإلنجاب‬ ‫سن‬ ‫في‬ ‫امرأة‬
‫الوقت‬ ‫نفس‬
‫الكبار‬ ‫العمر‬ ‫فترة‬ ‫خالل‬ ‫األمهات‬ ‫وفيات‬ ‫خطر‬
-
‫اإلنجاب‬ ‫العمر‬ ‫خالل‬ ‫األمومة‬ ‫بسبب‬ ‫الوفاة‬ ‫احتمال‬
‫ل‬ ‫ي‬
‫المرأة‬

15. Calculating MMR
‫األمهات‬ ‫وفيات‬ ‫معدل‬ ‫حساب‬
Hill et al. (2001 chapter 4) provide a step-by-step guide to maternal mortality
estimation involving data quality evaluation and adjustment in four steps:
1. Adjustment of population age structure
2. Evaluation of the completeness of death reporting and adjustment of
reported deaths
3. Evaluation of the completeness of birth reporting and adjustment of
reported births
4. Evaluation of the classification of adult female deaths as maternal
‫هيل‬
et al. (2001
‫الفصل‬
4
)
‫تق‬ ‫على‬ ‫تنطوي‬ ‫التي‬ ‫األمهات‬ ‫وفيات‬ ‫لتقدير‬ ‫بخطوة‬ ‫خطوة‬ ‫دليل‬ ‫تقديم‬
‫نوعية‬ ‫ييم‬
‫خطوات‬ ‫أربع‬ ‫في‬ ‫والتكيف‬ ‫البيانات‬
:
.1
‫للسكان‬ ‫العمري‬ ‫الهيكل‬ ‫تعديل‬
.2
‫عنها‬ ‫المبلغ‬ ‫الوفيات‬ ‫من‬ ‫والتكيف‬ ‫الوفيات‬ ‫عن‬ ‫اإلبالغ‬ ‫اكتمال‬ ‫مدى‬ ‫تقييم‬
.3
‫الوالدات‬ ‫عن‬ ‫اإلبالغ‬ ‫من‬ ‫والتكيف‬ ‫المواليد‬ ‫عن‬ ‫اإلبالغ‬ ‫اكتمال‬ ‫لمدى‬ ‫التقييم‬
.4
‫كاألمهات‬ ‫الكبار‬ ‫اإلناث‬ ‫وفيات‬ ‫لتصنيف‬ ‫التقييم‬
15

16. Step 1
‫الخطوة‬
1
Adjustment of the age distribution, involves working with
the raw age distribution, adjusting each age group
proportionately for cases where age is not reported (Hill
et al. 2001 section 4.1).
We can use PAS spreadsheet ADJAGE.xls.
‫وضب‬ ،‫الخام‬ ‫العمر‬ ‫توزيع‬ ‫مع‬ ‫العمل‬ ‫على‬ ‫ينطوي‬ ،‫العمري‬ ‫التوزيع‬ ‫تعديل‬
‫فئة‬ ‫كل‬ ‫ط‬
‫ذكرت‬ ‫ال‬ ‫العمر‬ ‫فيها‬ ‫يكون‬ ‫التي‬ ‫للحاالت‬ ً‫ا‬‫تناسبي‬ ‫عمرية‬
(
‫القسم‬
4.1
‫هيل‬ ‫من‬
et al. 2001).
‫األداء‬ ‫تقييم‬ ‫بيانات‬ ‫جدول‬ ‫استخدام‬ ‫يمكننا‬
ADJAGE.xls.
16

17. Step 2
‫الخطوة‬
2
The second step, evaluation and adjustment of deaths recorded in a census,
may involve a similar adjustment for missing-age deaths, but the primary
objective of this step involves evaluation of completeness of death recording
using either the Brass Growth Balance Equation or the General Growth
Balance technique (United Nations 1983, Hill 1987, Hill et al. 2001)
We can use PAS spreadsheet GRBAL.xls.
‫مم‬ ‫تعديل‬ ‫على‬ ‫تنطوي‬ ‫قد‬ ،‫تعداد‬ ‫في‬ ‫المسجلة‬ ‫الوفيات‬ ‫من‬ ‫والتكيف‬ ‫والتقييم‬ ،‫الثانية‬ ‫الخطوة‬
‫سن‬ ‫لوفيات‬ ‫اثل‬
‫باست‬ ‫الوفاة‬ ‫تسجيل‬ ‫اكتمال‬ ‫مدى‬ ‫تقييم‬ ‫على‬ ‫تنطوي‬ ‫الخطوة‬ ‫هذه‬ ‫من‬ ‫األساسي‬ ‫الهدف‬ ‫ولكن‬ ،‫مفقود‬
‫خدام‬
"
‫معادلة‬
‫النحاس‬ ‫النمو‬ ‫توازن‬
"
‫العامة‬ ‫النمو‬ ‫توازن‬ ‫تقنية‬ ‫أو‬
(
‫عام‬ ‫المتحدة‬ ‫األمم‬
1983
،
1987
‫هيل‬ ،‫هيل‬
et al.
2001)
‫األداء‬ ‫تقييم‬ ‫بيانات‬ ‫جدول‬ ‫استخدام‬ ‫يمكننا‬
GRBAL.xls.
17

18. The third step, evaluating the completeness of birth recording and
adjustment of number of births in order to calculate an adjusted GFR, is
described in Hill et al. 2001 section 4.3. A corrected GFR is required for the
conversion of MMR into MMRate.
We can use PFRatio.xls, ARFE-2.xls, or ARFE-3.xls to implement the
adjustment of reported ASFRs, reported births
‫الوال‬ ‫لعدد‬ ‫والتكيف‬ ‫المواليد‬ ‫تسجيل‬ ‫اكتمال‬ ‫مدى‬ ‫تقييم‬ ،‫الثالثة‬ ‫الخطوة‬
‫أجل‬ ‫من‬ ‫دات‬
‫حساب‬
GFR
‫الفرع‬ ‫في‬ ‫يرد‬ ،‫معدل‬
4
-
3
‫هيل‬ ‫من‬
et al. 2001.
‫مطلوب‬
GFR
‫االختطار‬ ‫إلى‬ ‫األمهات‬ ‫وفيات‬ ‫معدل‬ ‫لتحويل‬ ‫المصوبة‬
.
‫نس‬ ‫أن‬ ‫يمكن‬
‫تخدم‬
PFRatio.xls
،
‫عارف‬
-
2
.
xls
،
‫عارف‬ ‫ذكرت‬ ‫وذكرت‬ ،‫أسفرس‬ ‫أو‬
-
3
.
xls
‫الوالدات‬ ‫في‬ ‫التعديالت‬ ‫تنفيذ‬
18
Step 3
‫الخطوة‬
3

19. The fourth step described by Hill et al. 2001 involves evaluation of the classification of
adult female deaths as pregnancy-related. Hill et al. suggest plotting the distribution
of proportion of deaths due to maternal causes and the MMR by age.
‫هيل‬ ‫وصف‬ ‫الرابعة‬ ‫الخطوة‬
et al. 2001
‫كالمتعل‬ ‫الكبار‬ ‫اإلناث‬ ‫وفيات‬ ‫لتصنيف‬ ‫تقييم‬ ‫على‬ ‫ينطوي‬
‫بالحمل‬ ‫قة‬
.
‫هيل‬ ‫وتوحي‬
et al.
‫ح‬ ‫األمهات‬ ‫وفيات‬ ‫ومعدل‬ ‫األمهات‬ ‫أسباب‬ ‫عن‬ ‫الناجمة‬ ‫الوفيات‬ ‫من‬ ‫نسبة‬ ‫توزيع‬ ‫التآمر‬
‫سب‬
‫العمر‬
.
19
Step 4
‫الخطوة‬
4

20. Once adjustments to raw data have been made,
wherever they can be made, MMR is calculated as the
ratio of adjusted maternal deaths to adjusted live births.
،‫جعلوا‬ ‫يمكن‬ ‫حيثما‬ ،‫الخام‬ ‫البيانات‬ ‫على‬ ‫تعديالت‬ ‫أدخلت‬ ‫قد‬ ‫واحدة‬ ‫مرة‬
MMR
‫المعدلة‬ ‫الحية‬ ‫للوالدات‬ ‫المعدلة‬ ‫األمومة‬ ‫وفيات‬ ‫كالنسبة‬ ‫يحسب‬
.
20
Step 4
‫الخطوة‬
4

21. Finally (
‫وأخيرا‬
)
Lifetime risk (LTR), the hypothetical lifetime risk of maternal deaths to a
cohort of women passing through their reproductive ages at the levels of
MMR and fertility prevailing, is the final calculation. LTR takes into account
the chances of maternal death each time a woman becomes pregnant.
MMRate = MMR*GFR
and
LTR = MMRate*35
‫الحياة‬ ‫مدى‬ ‫االختطار‬
(
‫لتر‬
)
‫الن‬ ‫أثناء‬ ‫األمهات‬ ‫لوفيات‬ ‫افتراضية‬ ‫خطر‬ ‫أن‬ ،
‫إلى‬ ‫فاس‬
‫ومعدل‬ ‫األمهات‬ ‫وفيات‬ ‫معدل‬ ‫مستويات‬ ‫في‬ ‫اإلنجاب‬ ‫سن‬ ‫مرورا‬ ‫نساء‬ ‫فوج‬
‫النهائي‬ ‫الحساب‬ ‫هو‬ ،‫السائدة‬ ‫الخصوبة‬
.
‫احتماالت‬ ‫االعتبار‬ ‫في‬ ‫يأخذ‬ ‫لتر‬
‫وفاة‬
‫حامل‬ ‫امرأة‬ ‫يصبح‬ ‫مرة‬ ‫كل‬ ‫في‬ ‫األمهات‬
.
MMRate = MMR*GFR ‫و‬ LTR = MMRate*35
21

22. MMR calculation.xls
‫حساب‬
MMR
‫بالجدول‬
Calculation.xls
22

23. References (
‫مراجع‬
)
Hill, Kenneth. 1987. “Estimating Census and Death Registration
Completeness,” Asian and Pacific Population Forum, 1(3):8-13, 23-
24.
_____, Stanton, Cynthia, Gupta, Neeru. 2001. Measuring Maternal
Mortality from a Census: Guidelines for Potential Users.
MEASURE Evaluation Manual Series, No. 4.. Carolina Population
Center, University of North Carolina at Chapel Hill.
23

24. References
MMEIG et al. 2010. Trends in maternal mortality: 1990 to 2008.
Estimates developed by WHO, UNICEF, UNFPA and The World
Bank. Geneva: WHO. By the Maternal Mortality Estimation Inter-
Agency Group (MMEIG), together with Professor John Wilmoth,
Nobuko Mizoguchi, Sarah Zureick, and Reid Hamel.
.http://www.childinfo.org/files/Trends_in_Maternal_Mortality_1990_to_2
008.pdf
Namibia. 2004. Namibia 2004 Millennium Development Goals.
Windhoek: Office of the President, National Planning Commission.
United Nations Development Programme (UNDP). [2010?] Millennium
Development Goals. “What are the Millennium Development Goals?”
http://www.undp.org/mdg/basics.shtml. Downloaded November 17,
2011.
24

25. References
Wilmoth, John, Sarah Zureick, Nobuko Mizoguchi, Mie Inoue, and
Mikkel Oestergaard. 2010. “Levels and Trends of Matenral Mortality in
the World: The development of new estimates by the United Nations.”
http://www.who.int/reproductivehealth/publications/monitoring/MMR_tec
hnical_report.pdf
World Health Organization (WHO). 1992. International Statistical
Classification of Diseases and Related Health Problems, tenth
revision, 2nd ed. Geneva: WHO.
25