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Maternal health

Modified on 2013/05/16 15:11 by Haoyi Chen Paths: Read in Order Categorized as Chapter 2 - Health
From gender issues to gender statistics on maternal health: illustrative examples

Policy-relevant questions Data needed Sources of data
Has the maternal mortality declined? Maternal deaths and number of live births for at least two periods of time Civil registration system
Population censuses
Household surveys based on large samples
Has women’s access to prenatal care increased? Pregnant women by number of visits to a health facility or health care provider. Data needed for at least two points in time. Household surveys
Are birth deliveries increasingly attended by skilled personnel? What groups of women are most disadvantaged? Births by type of personnel attending the delivery for at least two points in time. Data should be disaggregated by: age, marital status and educational attainment of the mother; urban/rural areas; geographic areas; and wealth status of the household. Household surveys

  • + Gender issues
    • Women in developing countries face a high risk of dying while pregnant, during delivery, in the period immediately following delivery or from an unsafe termination of pregnancy. Maternal mortality remains very high in developing countries, although it has declined overall (WHO, 2010). In a small number of countries, maternal mortality, already at high levels, it increased even further (WHO, 2010). In general, the risk of dying is increased by several factors more often affecting women in developing countries, such as anaemia, HIV or other infections, complications from unsafe abortions, and sepsis (WHO, 2009). Female genital mutilation or cutting, prevalent in many African countries, also increases the risk of complications at delivery. The decline in maternal mortality is often associated with increased proportion of deliveries attended by skilled health personnel; improved access to emergency obstetric care; increased proportion of pregnant women who received antenatal care; and increased proportion of women using contraceptive methods (WHO, 2009).

      Many pregnant women in developing countries do not receive adequate prenatal care. Prenatal care provides opportunities for regular check-ups to assess risks as well as to screen for and treat conditions that could affect both the pregnant woman and her baby (WHO, 2009). For example, many women have nutritional deficiencies when they start their pregnancy. Iron deficiency anaemia and deficiencies of vitamin A and iodine, with negative effects on the health of the mother and her baby, are common but, at the same time, they are not difficult to counteract. As another example, in countries where malaria is endemic, pregnant women may be provided with intermittent preventive treatment. Also, women who are HIV-positive may receive help in avoiding transmission of the virus to their babies. While access to prenatal care has increased in all regions, the proportion of pregnant women with at least four prenatal visits to maternal care facilities, as recommended by WHO, remains low in the less developed regions, particularly in sub-Saharan Africa and southern Asia (United Nations, 2011c).

      Many women in developing countries lack adequate care during delivery and are at risk to a number of disabling sequelae, including infertility, severe anaemia, uterine prolapse and vaginal fistula. Lack of skilled personnel or health facilities, combined with inadequate transportation infrastructure, often prevents pregnant women from receiving the emergency care they need. Although the proportion of deliveries attended by skilled personnel has increased, in many developing countries with high fertility rates and high maternal mortality, women’s access to adequate care during delivery remains limited. In particular, poor women and women from rural areas in developing countries are more likely to lack access to appropriate obstetric services at delivery. (United Nations, 2011a; 2011c; UNICEF, 2009; WHO 2009)

      Lack of access to contraceptives reduces women’s ability to plan the number and timing of their births and increases the health risks associated with pregnancy. Use of contraceptive methods has increased in all regions, but remains relatively low in countries with high maternal mortality (United Nations, 2011a). Women face several barriers in satisfying their unmet need for family planning, such as lack of services or difficulties accessing them, lack of awareness and information about family planning methods, or high cost of contraceptives (United Nations, 2009). Younger, poorer, less educated and rural segments of the population tend to face greater barriers to access family planning services (United Nations, 2011a).

      Unintended pregnancies followed by unsafe abortions cause a significant proportion of maternal deaths. In developing countries, many of the women at risk of maternal death are adolescents lacking access to contraceptives. Abortions performed in an illegal context are likely to be provided by unskilled persons in unhygienic conditions, increasing the risk of death and illness. When abortion procedures are performed by qualified health professionals using appropriate techniques and sanitary protocols, the risk of death or injury from elective abortion is low. However, induced abortions are in many countries allowed only on restricted grounds, and when complications from abortions arise, access to appropriate post-abortion care is not easily accessible. (United Nations, 2011a; WHO, 2009)

  • + Data needed
    • Maternal deaths by age

      Number of live births by age of mother

      Number of women of reproductive age by age

      Number of deaths of women of reproductive age

      Number of abortions

      Contraceptive use by type of contraceptive method, age and marital status

      Number of pregnant women receiving prenatal care by number of visits

      Number of live births by type of attendance (skilled or not) at delivery

      Number of deliveries in health facilities

      Additional breakdowns should be considered. Data on maternal mortality collected in population censuses and from civil registration systems with complete coverage should be further disaggregated by other characteristics, such as urban/rural areas and geographic areas. Data on prenatal care, deliveries in health facilities and by type of attendance should also be disaggregated by urban/rural areas and geographic areas, as well as by other characteristics related to the pregnant women and her household, such as the woman’s educational attainment and wealth of the household.

  • + Sources of data
    • Civil registration systems with complete coverage can provide data on total deaths, maternal deaths and live births. These data can be used to calculate some maternal mortality indicators such as maternal mortality ratio and the proportion of maternal deaths among all female deaths of reproductive age.

      Population censuses collecting data on deaths in the household in the last 12 or 24 months may have additional questions on the pregnancy status of female deaths of reproductive age. Thus, population censuses may be used to capture pregnancy-related deaths. Other data needed to calculate indicators on maternal mortality may also be collected, such as number of live births (during the same interval of 12 or 24 months), and number of women of reproductive age by age. Population censuses have the advantage of eliminating sampling errors and allowing for breakdown of maternal mortality data by some individual, household or geographic characteristics.

      Household surveys can provide data on pregnancy-related deaths using the direct or indirect sisterhood method, where the respondents are asked about the survival of their adult sisters. The information needed for the indirect estimate of maternal mortality are the number of ever-married sisters; number of those still alive; number of those who are dead; and, of those dead, the number who died during pregnancy, delivery, or within six weeks of termination of pregnancy. The indirect sisterhood method should be used only in contexts of high fertility with limited migration. Direct estimates based on sisterhood method require for each of the siblings information related to age, age at death and year of death, and whether the death was pregnancy-related. The direct method is used in Demographic and Health Surveys.

      Household surveys of very large samples may also provide direct estimates of maternal mortality based on deaths reported for the last 12 or 24 months, and live births during the same period. However, they have limited value in providing data necessary to assess trends in maternal mortality or the status of specific groups of population.

      Household surveys such as DHS and MICS also provide data on important factors in reducing maternal mortality: prenatal care visits; deliveries attended by skilled health personnel; deliveries in health facilities; use of contraceptive methods.

      Demographic surveillance systems usually maintained by research institutions in developing countries may provide information on births and deaths by cause of death in small populations of selected areas, such as a community, or a district. Where death certificates are not available, a cause of death is assigned based on interviews with family members (a method called “verbal autopsy”). Although these studies are very useful, they are expensive and time-consuming to conduct.

      Reproductive-age mortality studies (RAMOS) involve identification of causes of all deaths of women of reproductive age in a selected population by using multiple sources of data for a defined area or population. Civil records, health facility records, burial records and interviews with traditional birth attendants and family members are used to identify deaths of women of reproductive age and to classify those deaths as maternal or otherwise.

  • + Conceptual and measurement issues
    • Reliable data on maternal mortality are lacking in many countries due to underreporting and misclassifications of deaths. Maternal death is defined 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. Even where deaths are derived from a civil registration system with complete coverage, maternal deaths may be missed or not correctly identified, thus compromising the reliability of such statistics. In that context, underreporting or misclassification may be due to reasons such as inadequate understanding of ICD (International Classification of Diseases) rules; death certificates completed without mention of pregnancy status; desire to avoid litigation; desire to suppress information (especially as related to abortion deaths). Underidentification of maternal deaths is more common among early pregnancy deaths because they are not linked to reportable birth outcome. Also, deaths in the later postpartum period are less likely to be reported than early postpartum deaths. Maternal deaths at youngest and oldest ages are also more likely to remain unidentified.

      When maternal deaths are derived from data collected in censuses, surveys, or demographic surveillance and the causes of reproductive-aged female deaths are identified based on interviews with family or community members, misclassification is common. For example, some deaths may be identified as maternal deaths even if they were due to accidents or injuries.

      Results based on censuses or surveys may need to be adjusted for underreporting of births and deaths declared in the census and for distortions in the age structure. However, it is considered that the proportion of maternal deaths among all deaths of females of reproductive age is not significantly underreported, and therefore, this proportion may be used to estimate maternal mortality.

      Estimates of maternal mortality obtained from household surveys have wide confidence intervals, making it difficult to monitor changes over time and to assess differences between population groups.

      In countries where data on maternal mortality are suspected to be inadequate, it is important to interpret indicators of maternal mortality within the context of other maternal health indicators, such as presence of skilled health personnel at delivery and antenatal care.

      Use of contraceptive methods may be underreported, especially where use of traditional methods or use of contraceptive sterilization are common. In order to reduce underreporting, the respondents should be reminded of various types of contraceptive methods.

      Reliable statistics on abortions are not easily available. Abortions that are spontaneous and do not result in further complications are rarely reported. Induced abortions are also underreported, especially in countries with laws that restrict access to abortion.

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