From gender issues to gender statistics on maternal health: illustrative examples
||Sources of data
|Has maternal mortality declined?
||Maternal deaths and live births for at least two periods of time.
||Civil registration systems.
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.
|Are 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, geographical areas and wealth status of the household.
- + 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, has increased even further (WHO, 2010). In general, the risk of dying is increased by several factors that more often affect 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 an increase in the proportion of deliveries being attended by skilled health personnel, improved access to emergency obstetric care, an increase in the proportion of pregnant women receiving antenatal care and an increase in the proportion of women using contraceptives (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, which have negative effects on the health of the mother and her baby, are common but, at the same time, not difficult to counteract. By way of 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 preventing the transmission of the virus to their babies. While access to prenatal care has increased in all regions, the proportion of pregnant women who have had 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 of a number of disabling sequelae, including infertility, severe anaemia, uterine prolapse and vaginal fistula. A lack of skilled personnel or health facilities combined with inadequate transportation infrastructure often prevents pregnant women from receiving the emergency care that 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 rates, 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, Economic and Social Council, 2011; UN, 2011c; UNICEF, 2008; 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 contraceptives has increased in all regions, but remains relatively low in countries with high maternal mortality (United Nations, Economic and Social Council, 2011). Women face several barriers in satisfying their unmet need for family planning, such as a lack of services or difficulties accessing services, a lack of awareness and information about family planning methods, and the high cost of contraceptives (United Nations, Economic and Social Council, 2009). Younger, poorer, less educated and rural segments of the population tend to face greater barriers in accessing family planning services (United Nations, Economic and Social Council, 2011).
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, thereby 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, in many countries induced abortions are allowed only on restricted grounds and, when complications arise, access to appropriate post-abortion care is not easily accessible (United Nations, Economic and Social Council, 2011; WHO, 2009)
- + Data needed
- Data needed to analyse maternal health are:
(a) Maternal deaths by age;
(b) Live births by age of the mother;
(c) Women of reproductive age by age;
(d) Deaths of women of reproductive age;
(f) Contraceptive use by contraceptive method, age and marital status;
(g) Pregnant women receiving prenatal care by number of visits to a health facility;
(h) Live births by type of attendance (skilled or not) at delivery;
(i) Deliveries in health facilities.
Additional breakdowns should be considered. Data on maternal mortality collected through population censuses and from civil registration systems with complete coverage should be further disaggregated by other characteristics, such as urban/rural areas and geographical areas. Data on prenatal care, deliveries in health facilities and type of attendance should also be disaggregated by urban/rural areas and geographical areas, as well as by other characteristics related to the pregnant women and her household, such as the woman’s educational attainment and the 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 proportion of maternal deaths among all deaths of women of reproductive age.
Population censuses that are used to collect data on deaths in the household in the past 12 or 24 months may have additional questions on the pregnancy status of women of reproductive age who have died. Therefore, 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 a breakdown of maternal mortality data by individual, household or geographical characteristics.
Household surveys can provide data on pregnancy-related deaths using the direct or indirect sisterhood method, whereby respondents are asked about the survival of their adult sisters. The information needed for indirect estimates of maternal mortality includes the number of ever-married sisters, the number who are still alive, the number who are dead and, for those who are dead, the number who died during pregnancy, at 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 of maternal mortality based on sisterhood method require, for each sibling, information related to age, age at death and year of death and information on whether the death was pregnancy-related. The direct method is used in DHS surveys.
Household surveys of very large samples may also provide direct estimates of maternal mortality based on deaths reported for the past 12 or 24 months and live births during the same period. However, such surveys have limited value in providing the 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, such as prenatal care visits, deliveries attended by skilled health personnel, deliveries in health facilities and use of contraceptives.
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 on the basis of interviews with family members (a method known as “verbal autopsy”). Although such studies are very useful, they are expensive and time-consuming to conduct.
Reproductive-age mortality studies involve the identification of the 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 owing to underreporting and misclassification 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 data on deaths are derived from a civil registration system with complete coverage, maternal deaths may be missed or may not be correctly identified, thereby compromising the reliability of such statistics. In this context, underreporting or misclassification may be due to such reasons as an inadequate understanding of International Classification of Diseases rules, the completion of death certificates without a mention of pregnancy status, a desire to avoid litigation and a 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. Moreover, deaths in the later post-partum period are less likely to be reported than early post-partum deaths. Maternal deaths at the youngest and oldest ages are also more likely to remain unidentified.
When data on maternal deaths are derived from censuses, surveys or demographic surveillance systems and when the causes of such deaths are identified on the basis of interviews with family or community members, misclassification is common. For example, some deaths may be identified as maternal deaths even when 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, the proportion of maternal deaths among all deaths of women of reproductive age is not considered to be significantly underreported and may therefore 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 of being inadequate, it is important to interpret indicators of maternal mortality the context of other maternal health indicators, such as presence of skilled health personnel at delivery and antenatal care.
Use of contraceptives may be underreported, especially where use of traditional methods or use of contraceptive sterilization are common. In order to reduce underreporting, respondents should be reminded of various types of contraceptives.
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.