1. The new UN interagency maternal mortality estimates
Agbessi Amouzou and Holly Newby
Data & Analytics Section, DPS, UNICEF
1 May 2014

2. Will be released on Tuesday, 6 May 2014
Levels and trends of maternal mortality between 1990 and 2013 for 183 countries
Includes MMR, lifetime risk of maternal death and numbers of maternal deaths
Will replace current UN interagency estimates pertaining to 2010

3. Outline of the Presentation
Why UN Inter-Agency estimate of maternal mortality
Summary of issues in maternal mortality measurement
How the UN Inter-Agency estimates are produced
Highlights of new estimates

4. WHY UN inter-agency estimates?

5. Why Inter-Agency MM Estimates?
MMR is key indicator for MDG 5
Global monitoring and reporting requires a harmonized measure of MMR that is comparable across countries
Need to obtain a measure that has same reference year across all countries
Maternal mortality is challenging to measure
Similar initiative is done for under-five mortality (see

6. Maternal Mortality Estimation Interagency Group (MMEIG)
The UN interagency estimates are produced by the Maternal Mortality Estimation Interagency Group (MMEIG):
WHO (Lead)
UNICEF
UNFPA
The World Bank
Lead technical consultant (Leontine Alkema, National University of Singapor)
Technical Advisory Group
This inter-agency group began working together in the mid-1990s with the goal of providing a more accurate assessment of the global maternal mortality burden, as well as comparable estimates across countries. The MMEIG has produced peer reviewed sets of estimates that have been critical for MDG5 monitoring and reporting.

7. Maternal mortality measurement

8. Definitions Definition Implications Maternal death
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.
Death must be attributed directly or indirectly to pregnancy or childbirth
Requires medical certification or verbal autopsy
Cannot be obtained through surveys or censuses
No deaths beyond 42 days due to pregnancy complications accounted for
Pregnancy-related death
The death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the cause of death.
Cause of death certification not needed
Can be obtained through surveys or censuses
UN Interagency maternal mortality estimates conform to the definition of maternal death

9. Sources of maternal mortality data and their limitations
Maternal mortality data can come from a variety of sources:
Vital registration
Considered gold standard
Good in only about a third of countries
Extensive under-reporting and misclassification
Even in countries with complete vital registration, maternal deaths may be underreported by a factor of 1.5 – 3.0
Vital registration: Considered gold standard, however….
Relatively few countries have complete vital registration and good attribution of cause of death
Extensive under-reporting and misclassification
Even in countries with complete vital registration, maternal deaths may be underreported by a factor of 1.5 – 3.0

10. Sources of maternal mortality data and their limitations
Maternal mortality data can come from a variety of sources:
Vital registration
Household surveys (sisterhood method)
Pregnancy-related deaths
MMR very imprecise, large confidence intervals
Doe not produce recent estimate: MMR refers to 7 to 9 years in the past
Vital registration: Considered gold standard, however….
Relatively few countries have complete vital registration and good attribution of cause of death
Extensive under-reporting and misclassification
Even in countries with complete vital registration, maternal deaths may be underreported by a factor of 1.5 – 3.0
Household surveys (sisterhood method): Only source of information in many developing countries, however….
Estimates refer to a period 0-6 or 0-9 years before the survey
Wide confidence intervals

11. Sources of maternal mortality data and their limitations
Maternal mortality data can come from a variety of sources:
Vital registration
Household surveys (sisterhood method)
Censuses
Pregnancy-related deaths
Conducted every 10 years
Need adjustment for completeness of births and deaths
Household surveys (sisterhood method): Only source of information in many developing countries, however….
Estimates refer to a period 0-6 or 0-9 years before the survey
Wide confidence intervals

12. Sources of maternal mortality data and their limitations
Maternal mortality data can come from a variety of sources:
Vital registration
Household surveys (sisterhood method, etc.)
Censuses
Reproductive-age mortality studies (RAMOS)
Vital registration: Considered gold standard, however….
Relatively few countries have complete vital registration and good attribution of cause of death
Extensive under-reporting and misclassification
Even in countries with complete vital registration, maternal deaths may be underreported by a factor of 1.5 – 3.0
Household surveys (sisterhood method): Only source of information in many developing countries, however….
Estimates refer to a period 0-6 or 0-9 years before the survey
Wide confidence intervals
Complicate, time-consuming and expensive
Under-report of maternal deaths
Under report of number of live births

13. Sources of maternal mortality data and their limitations
Maternal mortality data can come from a variety of sources:
Vital registration
Household surveys (sisterhood method, etc.)
Censuses
Reproductive-age mortality studies (RAMOS)
Verbal autopsy
Vital registration: Considered gold standard, however….
Relatively few countries have complete vital registration and good attribution of cause of death
Extensive under-reporting and misclassification
Even in countries with complete vital registration, maternal deaths may be underreported by a factor of 1.5 – 3.0
Household surveys (sisterhood method): Only source of information in many developing countries, however….
Estimates refer to a period 0-6 or 0-9 years before the survey
Wide confidence intervals
Misclassification of cause of death
Under report of maternal deaths
Recall issues

14. Sources of maternal mortality data and their limitations
Maternal mortality data can come from a variety of sources:
Vital registration
Household surveys (sisterhood method, etc.)
Censuses
Reproductive-age mortality studies (RAMOS)
Verbal autopsy
Bottom line:
Each source has advantages and limitations.
Measurement is challenging regardless of source.
There is need to adjust and harmonize available data for cross country comparability and global reporting
Vital registration: Considered gold standard, however….
Relatively few countries have complete vital registration and good attribution of cause of death
Extensive under-reporting and misclassification
Even in countries with complete vital registration, maternal deaths may be underreported by a factor of 1.5 – 3.0
Household surveys (sisterhood method): Only source of information in many developing countries, however….
Estimates refer to a period 0-6 or 0-9 years before the survey
Wide confidence intervals

15. MMR of 300 may not be different from MMR of 330
Issues to keep in mind
Survey estimates of MMR are averages over periods of 7 or 9 years in the past, so not comparable to UN Interagency estimates
MMR generally have large uncertainty ranges
Maternal death is a rare event; MMR is expressed in per 100,000 live births and therefore creates a false sense of precision
300/100,000 = 0.30/100
330/100,000 = 0.33/100
MMR of 300 may not be different from MMR of 330

16. The 2007 MMR refers to period 1998 -2007
Trend Estimation from Sibling Histories with 95% Confidence Intervals (Namibia)
The 2007 MMR refers to period
Estimates are averages over long periods (here 7 or 9 years) and 95% confidence intervals are large
Source: Ken Hill – UN maternal mort workshop, Nairobi December 2010

17. The 2000 MMR has 95%CI ranging from 90 to 450
Trend Estimation from Sibling Histories with 95% Confidence Intervals (Namibia)
The 2000 MMR has 95%CI ranging from 90 to 450
Estimates are averages over long periods (here 7 or 9 years) and 95% confidence intervals are large
Source: Ken Hill – UN maternal mort workshop, Nairobi December 2010

18. Trend Estimation from Sibling Histories with 95% Confidence Intervals (Namibia)
Note that this is at the national level! It’s not possible to disaggregate by region or other characteristics like household wealth!
Estimates are averages over long periods (here 7 or 9 years) and 95% confidence intervals are large
Source: Ken Hill – UN maternal mort workshop, Nairobi December 2010

19. How are the UN inter-agency estimates done?

20. Source of data for the 2013 MMR estimates
Group
Source of maternal mortality data
Number of countries/ territories
% of countries/ territories in each category
% of births in 183 countries/territories covered A
Civil registration characterized as complete, with good attribution of cause of death 67 37 17 B
Incomplete civil registration and/or other types of data 96 52 81 C
No national data on maternal mortality 20 11 2
Total
183
100

21. General methodology of estimation
Little change from methodology used
for 2010 estimates
Compile and review all available nationally representative maternal mortality data
Adjust available maternal mortality data for misclassification and underreporting

22. General methodology of estimation
3. Use one of two approaches depending on country
Countries with adequate civil registration data
Calculate MMR directly with adjusted
All other countries:
Use multilevel linear regression model
Covariates: GDP, general fertility rate and skilled attendant at birth
Separate model component for AIDS deaths that are indirect maternal deaths
4. Compute uncertainty ranges through simulations

23. Methodological changes from the 2010 estimates?
Increased data availability
5% increase in available data
Update in the estimate of female deaths in the reproductive age by WHO
Update of series of live births and general fertility rates from World Population Prospects
Update in AIDS adjustment parameters

24. Methodological changes from the 2010 estimates?
Data availability
5% increase in available data
Update in the estimate of female deaths in the reproductive age by WHO
Update of series of live births and general fertility rates from World Population Prospects
Update in AIDS adjustment parameters
Little change from methodology used
for 2010 estimates

25. Review process
Reviewed by the Technical Advisory Group with experts from academic institutions: Harvard University, Johns Hopkins University, University of Aberdeen, and others
Country consultation led by WHO allowed countries to provide feedback and provide new data

26. STOP!
The 2013 UN interagency estimates REPLACE the previous estimates and should not be compared or interpreted together with them
The 2013 estimates are NOT comparable to estimates from other sources

27. Maternal mortality estimates generated by countries
At the global level, we use the interagency estimates for MDG reporting and official monitoring
UNICEF presents both nationally reported estimates and UN interagency estimates in State of the World’s Children
TABLE 8
Official MDG5 estimates
Countdown to 2015

28. Trends in Maternal Mortality Ratio (Embargoed until May 6, 2014)
By UNICEF regions
Embargoed until May 6,
Source: Trends in Maternal Mortality: (WHO, UNICEF, UNFPA, World Bank)

29. Resources More information on new estimates available (from May 6) at:
Data.unicef.org
Complete methodological details and all data available on:
and MME Info:
We are in process of updating the MMEIG website MM Info (maternalmortalitydata.org)

30. To be released on 6 May 2014! Contacts Agbessi Amouzou
Holly Newby

31. Issues to keep in mind Maternal mortality is difficult to measure
Need to have information on pregnancy status, timing and cause
Rare event
Available data suffer from serious limitations
Sparse
Suffer from under-reporting and misclassification of deaths
May have definitional differences
Goal – adjust for lack of data, misclassification and under-reporting to provide the best possible estimates

32. Things to think about
Note that the 2012 UN interagency estimates are not comparable to estimates from other sources
Serious limitations regarding maternal mortality estimation
Underlying data are sparse and suffer from under-reporting and misclassification
Lots of assumptions needed for modeled global estimates
Estimates are bracketed by a wide range of uncertainty
Need to use a broad range of evidence and indicators for tracking progress