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

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

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

WHY UN inter-agency estimates?

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 www.childmortality.org)

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.

Maternal mortality measurement

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

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

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

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

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

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

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

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

The 2007 MMR refers to period 1998 -2007 Trend Estimation from Sibling Histories with 95% Confidence Intervals (Namibia) The 2007 MMR refers to period 1998 -2007 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

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

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

How are the UN inter-agency estimates done?

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

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

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

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

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

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

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

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

Trends in Maternal Mortality Ratio (Embargoed until May 6, 2014) By UNICEF regions Embargoed until May 6, 2014 ---------------------- Source: Trends in Maternal Mortality: 1990-2013 (WHO, UNICEF, UNFPA, World Bank)

Resources More information on new estimates available (from May 6) at: Data.unicef.org Complete methodological details and all data available on: www.who.int/reproductivehealth/publications/monitoring/xxxxxxxxx/en/index.html and MME Info: www.maternalmortalitydata.org We are in process of updating the MMEIG website MM Info (maternalmortalitydata.org)

To be released on 6 May 2014! Contacts Agbessi Amouzou aamouzou@unicef.org Holly Newby hnewby@unicef.org

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

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