Maternal Mortality Panorama in the Americas

Maternal Mortality Panorama in the Americas

Fatima Marinho, MD, MPH, PhDHealth and Analysis (HSD/HA)

Pan American Health Organization (PAHO/WHO)

Topics

• Background

– Quality of maternal death information in The Americas

Issues with definition and measurement

• Maternal mortality trend by selected countries

• Point for discussion

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.

Direct obstetric deaths

• those resulting from obstetric complications of the pregnant state (pregnancy, delivery, and postpartum), from interventions, omissions, incorrect treatment, or from a chain of events resulting from any of the above.

for example:• haemorrhage,• pre-eclampsia/eclampsia • or those due to complications

of anaesthesia or caesarean section are classified as direct obstetric deaths

Indirect obstetric deaths

• those resulting from previous existing disease, or diseases that developed during pregnancy,

• and which were not due to direct obstetric causes but aggravated by physiological effects of pregnancy.

for example: deaths due to aggravation of

an existing cardiac or renal disease are indirect obstetric deaths.

Opportunities and options for Measuring Maternal Mortality

Routine Opportunities Special Opportunities

1.DeathRegistrationA)CivilRegistration**B)Sample VitalRegistration*/**

2. HealthFacilityStatistics**

3. DecennialCensus*

4. Surveys*A) Household surveyasking about deaths inHousehold

B) Indirect Sisterhood –household survey askingabout deaths of sisters,without dates

C) Direct Sisterhood –household survey, asking about deaths of sisters, with dates

D) Sampling at ServiceSites (SSS) – usingdirect sisterhood method

5. Surveillance*A) DemographicSurveillance Systems

B) Prospective study

C) Sample VitalRegistration, with VerbalAutopsy (SAVVY)

D) Active surveillance of reproductive age female deaths

E) Active surveillance ofpregnancy-related ormaternal deaths(Confidential Enquiries)

6. RAMOS*: In-depth review of reproductive-age female deaths identified from routine &/or special opportunities, & follow-up investigation of maternal deaths

Empirical measurement Analytical

Birth-death recordlinkage: to findMaternal deaths

Dual methodor capture – recapture:corrects forunder - reporting

UN models:Estimate levelsof maternalmortality usingregression

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

How many maternal deaths occur annually in the Region?

Source: PAHO/WHO. Mortality Information System

0.0 50.0 100.0 150.0 200.0 250.0 300.0

ARGBHSBLZBOLBRABRBCANCHLCOLCRI

CUBDOMECUGTMGUYHNDJAMMEXNIC

PANPERPRI

PRYSLVSURTTOURYUSAVEN

OMS

OPS(país)

WHO, UNICEF, UNFPA, WB

PAHO (countries)

• 8000 deaths (mortality database)

• 12 000 deaths (estimated)

Maternal mortality Ratio (MMR 100 000 lb)

Which are the main causes of maternal deaths?


Tendencia de la razón de mortalidad materna en los países con serie temporal disponible.

Región de las Américas, 2000 a 2009

0

10

20

30

40

50

60

0 10 20 30 40

Infa

nt m

orta

lity

rate

[per

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00 lb

] (E

stim

ated

less

tha

n 1

year

) 200

6

Highest 20%/Lowest 20% income ratio [Ratio] 2002-2006

In Bolivia the highest 20% receives 36 times the lowest 20%

More inequality is related to higher infant and maternal mortality rates

0

50

100

150

200

250

0 10 20 30 40

Mat

erna

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Highest 20%/Lowest 20% income ratio [Ratio] 2002-2006

Maternal Mortality Ratio

Infant and Maternal Mortality Rates are higher in more unequal countries

Infant Mortality Ratio

Source: PAHO Basic Indicators

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

Republica Dominicana* 190 202 6.3Uruguay* 4 16 300.0

Chile 41 43 4.9Costa Rica 19 10 -47.4

El Salvador 18 14 -22.2Guatemala 335 340 1.5Panama 41 29 -29.3

Change in Maternal Mortality in 2009 in countries with decling tendencies in previous years

Source: PAHO/WHO. Mortality Information System *Rep. Dominicana y Uruguay dato reportado por la vigilancia

Pandemic Impact?

Brasil

0

100

200

300

400

500

600

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

Abortion

Oedema, proteinuria and hypertensivedisorders in pregnancy, childbirth and thepuerperium

Haemorrhage in pregnancy, childbirth and thepuerperium

Sepsis and another puerperal infecctions

Complications predominantly related to thepregnacy and childbirth

Complications predominantly related to thepuerperium


Obstetric death of unspecified cause

Maternal Deaths from from any obstetriccause occurring more than 42 days but lessthan one year after delivery and sequelae

Mate

rnal d

eath

s


Brasil


Maternal mortality: proportion by causes and MMR

Brasil


Mexico

0

50

100

150

200

250

300

350

400

450

500

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

Abortion


Haemorrhage in pregnancy, childbirth andthe puerperium








Mate

rnal d

eath

s

Mexico


Maternal mortality: proportion by causes and MMR

Mexico


Ecuador

0

10

20

30

40

50

60

70

80

90

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

Abortion

Oedema, proteinuria and hypertensivedisorders in pregnancy, childbirth andthe puerperium

Haemorrhage in pregnancy, childbirthand the puerperium


Complications predominantly related tothe pregnacy and childbirth

Complications predominantly related tothe puerperium



Maternal Deaths from from any obstetriccause occurring more than 42 days butless than one year after delivery andsequelae


Mate

rnal d

eath

s

Chile


0

2

4

6

8

10

12

14

16

18

20

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

Abortion


Haemorrhage in pregnancy, childbirthand the puerperium


Complications predominantly related tothe pregnacy and childbirth

Complications predominantly related tothe puerperium



Maternal Deaths from from any obstetriccause occurring more than 42 days butless than one year after delivery andsequelae

Mate

rnal d

eath

s

Guatemala


0

20

40

60

80

100

120

140

160

2005 2006 2007 2008 2009

Abortion


Haemorrhage in pregnancy, childbirth and thepuerperium







Mate

rnal d

eath

s

Guatemala Maternal mortality: proportion by causes and MMR

Mortality data base

%

Mortality data base

(Direct Obstetric)Data reported by the country

http://health.gov.bz/www/attachments/565_annual%20report%202009-2011%20-%202.pdf

Belize

http://health.gov.bz/www/attachments/565_annual%20report%202009-2011%20-%202.pdf

Year MMR Death2008 86.2 132008 92.9 142007 106.0 162007 132.3 20

MMR with different number of death

• 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?

Under-reporting of maternal deaths was more common among the following

• Early pregnancy deaths, which cannot be linked to a reportable birth outcome.

• Deaths in the later postpartum period (these were less likely to be reported than early postpartum deaths).

• Deaths at extremes of maternal age (youngest and oldest).

• Miscoding by ICD-9 or ICD-10, most often seen in cases of deaths caused by:

––cerebrovascular diseases;––cardiovascular diseases.

Potential reasons cited for under reporting/misclassification include the following

•Inadequate understanding of ICD rules (either ICD-9 or ICD-10).

• Death certificates completed without mention of pregnancy status.

• Desire to avoid litigation.

• Desire to suppress information (especially as related to abortion deaths).

¿Qué progresos y debilidades existen?

Panorama Heterogéneo en la Región• Compromiso político de los países

• Establecimiento de intervenciones

• Elaboración de informes de monitoreo de avances de los países

• Fortalecimiento de los sistemas de información

• Aplicación de metodologías para la búsqueda intencionada de muertes maternas (Brasil, México, Paraguay)

• Involucramiento de la comunidad y organizaciones sociales

• Falta de empleo correcto de

definiciones internacionalmente

aceptadas muerte materna obstétrica

directa e indirecta (CIE-10)

• Estimaciones por Agencias (diferentes

resultados para un país)

• Inconsistencias en el indicador (RMM)

• Dificultad para el monitoreo y

evaluación del avance de 1990 a 2010

• Desconocimiento de las verdaderas

causas de las muertes maternas

Points for Discussion

•How are countries investigating maternal deaths?

Maternal Mortality Panorama in the Americas

Health & Medicine

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