2 Outline of talk Setting a target for maternal mortality: the indicator Absolute target for MMR: 50 by 2035Historical MMR trends: Annual rates of reduction (ARRs)Relative target for MMR: 75% and 85%, 2035Key points and questions
3 1. Setting a target for maternal mortality Characteristics : ambitious but plausible; should accelerate progressFour key components to target setting:End year: Focus here on 2035, but actual value is TBD(MDG 5: )Indicator: MMR or # maternal deaths, LTR, other? (MDG 5: MMR)Annual Rate of Reduction (ARR) does not have to be constant, but the average value should be feasible, aggressive(MDG 5: ARR of 5.5%)End value: Determined by the choice of end year and ARR, with rounding (MDG 5: 25% of the start value, or a decline of 75%--a relative target—over 25 year period)Most common indictors of maternal mortality are # mat deaths, MMRatio, LTR, the proportion of women’s deaths that are maternalProcess indicators:– Provides information on actions to be taken and how to improveexisting programmes– Less expensive, Can be measured more frequently– Can reflect changes immediately, which permits feedback to programme activities– Can be used for an initial situation analysis and to monitor progressUse historical trends to determine ARRs, and end value?
4 1. Indicator: NMR versus MMR NMR is an age specific rate whereas the MMR is a cause specific ratio.The Neonatal Mortality Rate is the number of infants under 1 month who died per 1,000 live births.The MMR is a ratio of maternal deaths per 100,000 live births –note the extra factor of 100 in the denominator -- rare event, sparse data.
5 1. Indicator: MMR Numerator- maternal deaths 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.WHO International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, 1992 (ICD-10)Need to know:Pregnancy status of the womanTiming of deathMedical cause of deathHow: Surveys or Census, + VA; Estimations (2010)Measurement is a challenge!How to get m death:– Vital registration – Household surveys (sisterhood method, etc.) with VA, Censuses, Reproductive-age mortality studies (RAMOS) – OtherEach source has advantages and limitations; Measurement is challenging regardless of source.
6 1. Indicator: Present MMR Global MMR: 210 maternal deaths per 100,000 live births in 2010Global number of maternal deaths: 287,000 in 201077 countries already reached an MMR of 50 or lower; among them, 58 already reached an MMR of 30 or lower26 countries still had an MRR more than 400 deaths per 100,000 live birthsTable 1: Number of Countries with specific ranges of MMR in 2010 (n=189)Start with a brief overview of current levels and trends in MMRTable shows distribution(could we get map?)MMR≤3030<MMR≤5050<MMR≤100100<MMR≤200200<MMR≤500MMR>400Number of countries5819351626Statistics & Monitoring Section/DPS
7 2. Absolute Target: Historical trends and projections, MMR = 50 by 2035, worldwide Between 1990 and 2010, the maternal mortality ratio declined by nearly half—from 543,000 deaths to 287,000 deaths. While the first decade saw a rate of decline of approx 3.1% per year, the decade rate increased to over 4% globally. But to reach a MMR of 50 by 2035—the upper limit of the MMR among OECD countries—the ann rate of reduction worldwide must increase to %
8 2. Absolute Target: Historical trends and projections MMR = 50 by 2035, regions Current AARAAR to Reach MMR = 50Sub-Saharan Africa-3.7%-8.9%India-6.5%-5.4%Asia, excluding India and China-4.8%-5.1%Global-4.1%-5.6%22550With the historical ARRs in mind by subregion, we now relook at the target of 50 by 2035.To reach 50 by 2035, SSA would have to increase its ARR by 2.5XsIndia would slow down from 6.5% to 5.4%--In such countries, we would need to look at subregional variationARR: Plausible range 5-7%, MDG 5 ARR=5.5%Asia: Afghanistan, Bhutan, Cambodia, Indonesia, Iran, Iraq, Kyrgyzstan, Lao, Morocco, Myanmar, Nepal, Pakistan, Papua New Guinea, Philippines, Solomon Islands, Tajikistan, Turkmenistan, Uzbekistan, VietNam, YemenAfrica: Angola, Benin, Botswana, Burkina Faso, Burundi, Cameroon, Central African Republic, Chad, Congo, Cote d'Ivoire, Democratic Republic of the Congo, Equatorial Guinea, Eritrea, Ethiopia, Gabon, Gambia, Ghana, Guinea, Guinea-Bissau, Kenya, Lesotho, Liberia, Madagascar, Malawi, Mali, Mauritania, Mozambique, Niger, Nigeria, Rwanda, Sao Tome and Principe, Senegal, Sierra Leone, Somalia, South Africa, Sudan, Swaziland, Togo, Uganda, Tanzania, Zambia, Zimbabwe
9 2. Absolute target: Annual rates of reduction (ARR) Global ARR: 3.1% in ; 4.1% inOnly 20 countries had an ARR more than 6%; among them, only 5 countries had an ARR more than 8%Plausible ARR range: 5-7%Table 2: Number of Countries with specific ranges of ARR inARR≤11<ARR≤22<ARR≤33<ARR≤44<ARR≤55<ARR≤6ARR>6Number of countries203640322310Statistics & Monitoring Section/DPS
10 2. Absolute target: ARR 2000-2010, Asian countries Source: UN Estimates for Trends in Maternal Mortality World Health Organization, 2012.
11 2. Absolute target: Afghanistan, Bangladesh, Nepal, Pakistan Future ARR needed really depends on the level of the MMR at start point50Source: UN Estimates for Trends in Maternal Mortality World Health Organization, 2012.
12 2. Absolute target: Sri Lanka & Thailand In countries with already low MMR, the absolute target would not make sense as a national target—so we have talked of having the absolute target be that for the world. And in such countries with low MMRs—then ensuring equity in the MMR across all areas and groups of women would be important.Source: UN Estimates for Trends in Maternal Mortality World Health Organization, 2012.
14 3. Relative target for MMR: 75% by 2035 (ARR=5.5%)If continued with the MDG 5 target of 75% reduction to 2035, then what we see is that many of the SSA countries would reach a MMR>100, where as most Asian countries would be in the range which is relatively easy for themStatistics & Monitoring Section/DPS
15 3. Relative target for MMR: Bangladesh & Nepal--75% and 85% Source: UN Estimates for Trends in Maternal Mortality World Health Organization, 2012.
16 3. Relative target for MMR: China & Sri Lanka --75% and 85% Source: UN Estimates for Trends in Maternal Mortality World Health Organization, 2012.
17 4. Key points and questions Indicator: Should we continue with the MMR?Absolute Target depends on current MMR, end yearDoes a GLOBAL indicator make sense? Absolute country targets make achieving goals difficult for high MMR countries, particularly sub-Saharan African countries.ARR trajectory: Depends on country’s current MMRShould high MMR countries aim for higher MMR in 2035 (MMR=100)?Should low MMR countries focus on equity (high MMR subpopulations)?Should we set 5 year milestones?Plausible Relative Target will depend on the end year2035: 80% decline, global MMR target=502030: 70% decline, global MMR target=602025: 60% decline, global MMR target=80 or 90
18 4. Key points and questions How has the MDG 5 target (75% reduction over 25 years) been used in country?Has the MDG 5 target been useful for policy? Programming? Monitoring?What does it take to implement a new target for reducing maternal mortality?Many thanks!!
19 4. Key points and questions What are necessary next steps and timeline for target setting for NMR and MMR globally?How was the target for MMR (MDG 5) used in country over the last decade?What would need to be done in country to make the targets useful for policy and programs?