Setting a Target for Maternal Mortality Marjorie Koblinsky, USAID Thomas Pullum, MEASURE DHS Tessa Wardlaw, Danzhen You, UNICEF Lale Say, Doris Chou (WHO) Sam Whipple (KMS) Sept 5, 2013 Original presentation condensed 1

1. Setting a target for maternal mortality Characteristics : ambitious but plausible; should accelerate progress Four 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) 2

Global MMR: 210 maternal deaths per 100,000 live births in 2010 Global number of maternal deaths: 287,000 in countries already reached an MMR of 50 or lower; among them, 58 already reached an MMR of 30 or lower 26 countries still had an MRR more than 400 deaths per 100,000 live births Statistics & Monitoring Section/DPS Table 1: Number of Countries with specific ranges of MMR in 2010 (n=189) MMR≤30 30<MMR ≤50 50<MMR≤ <MMR≤ <MMR≤ 500 MMR>400 Number of countries Indicator: Present MMR

4 2. Absolute Target: Historical trends and projections, MMR = 50 by 2035, worldwide

5 Asia: Afghanistan, Bhutan, Cambodia, Indonesia, Iran, Iraq, Kyrgyzstan, Lao, Morocco, Myanmar, Nepal, Pakistan, Papua New Guinea, Philippines, Solomon Islands, Tajikistan, Turkmenistan, Uzbekistan, VietNam, Yemen Africa: 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 Current AAR AAR to Reach MMR = 50 Sub-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% 2. Absolute Target: Historical trends and projections MMR = 50 by 2035, regions

Statistics & Monitoring Section/DPS ARR≤11<ARR≤22<ARR≤33<ARR≤44<ARR≤55<ARR≤6ARR>6 Number of countries Table 2: Number of Countries with specific ranges of ARR in Global ARR: 3.1% in ; 4.1% in Only 20 countries had an ARR more than 6%; among them, only 5 countries had an ARR more than 8% Plausible ARR range: 5-7% 2. Absolute target: Annual rates of reduction (ARR)

Source: UN Estimates for Trends in Maternal Mortality World Health Organization, Absolute target: ARR , Asian countries

8 50 Source: UN Estimates for Trends in Maternal Mortality World Health Organization, Absolute target: Afghanistan, Bangladesh, Nepal, Pakistan

9 3. Relative Target: 2010 and 2035 MMR Estimates (85% Reduction; ARR=7.3%) MMR<15 15≤MMR<30 30≤MMR<60 MMR≥60 MMR< ≤MMR< ≤MMR<400 MMR≥ Estimate 2035 Target

10 Already achieved MMR≤50 0≤ARR<4% 4%≤ARR<8% ARR≥8% Required ARR to Reach MMR=50 2. Absolute target: Countries Require Different Annual Rates of Reduction to Achieve MMR=50 by 2035

Afghanistan*: 460  69 Angola: 450  68 Bangladesh*: 240  36 Burundi: 800  120 Cameroon: 690  104 Central African Republic: 890  134 Chad: 1100  165 Congo: 560  84 DRC*: 540  81 Ethiopia*: 350  53 Ghana: 350  53 Guinea: 610  92 Guinea-Bissau: 790  119 Haiti*: 350  53 India*: 200  30 Indonesia*: 220  33 Ivory Coast*: 400  60 Kenya*: 360  54 Laos: 470  71 Lesotho: 620  Relative Target: MCH Priority Countries with 2035 Projection (85% Reduction, ARR=7.3%) Liberia*: 770  116 Madagascar*: 240  36 Malawi*: 460  69 Mali*: 540  81 Mauritania: 510  77 Mozambique*: 490  74 Nepal*: 170  26 Niger: 590  89 Nigeria*: 630  95 Pakistan*: 260  39 Rwanda*: 340  51 Senegal*: 370  56 Sierra Leone: 890  134 Somalia: 1000  150 Sudan*: 730  110 Tanzania*: 460  69 Uganda*: 310  47 Yemen*: 200  30 Zambia*: 440  66 Zimbabwe*: 570  86 Source: UN Estimates for Trends in Maternal Mortality World Health Organization, * MCH Priority Country

4. Key points and questions Indicator: Should we continue with the MMR? Absolute Target depends on current MMR, end year – Does 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 MMR Should 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 year – 2035: 80% decline, global MMR target=50 – 2030: 70% decline, global MMR target=60 – 2025: 60% decline, global MMR target=80 or 90

Setting a Target for Maternal Mortality In LAC Peg Marshall, USAID Kelsey Wright (KMS) November 14,

Trends shown in these slides include: - Projections to 2035 using current ARR -Projections to 2035 using goal of MMR=50 by Projections to 2035 using goal of 50% reduction in MMR -Projections to 2035 using goal of 75% reduction in MMR 14 Current ARRs are based on estimates Regional Averages are weighted by live births from

Weighted Regional Projections 15

*Countries included in weighted analysis are: Bolivia, Brazil, Canada, Colombia, Costa Rica, Dominican Republic, Guatemala, Guyana, Haiti, Jamaica, Paraguay, United States Sources: (1) MMR data from WHO (2012). Trends in Maternal Mortality: 1990 to 2010; (2) Live births data from U.S. Census Bureau International Data Base; (3) Census Bureau Table of Live Births ( Weighted Average of Selected LAC Countries*

Select LAC Countries where Current MMR ARR is Positive (MMR is increasing) 17

Positive MMR ARRs in the LAC Region Source: Trends in maternal mortality: 1990 to WHO, UNICEF, UNFPA and The World Bank estimates. World Health Organization,

Positive MMR ARRs in the LAC Region Source: Trends in maternal mortality: 1990 to WHO, UNICEF, UNFPA and The World Bank estimates. World Health Organization,

Canada MMR Projections Source: Trends in maternal mortality: 1990 to WHO, UNICEF, UNFPA and The World Bank estimates. World Health Organization,

Costa Rica MMR Projections Source: Trends in maternal mortality: 1990 to WHO, UNICEF, UNFPA and The World Bank estimates. World Health Organization,

Guyana MMR Projections Source: Trends in maternal mortality: 1990 to WHO, UNICEF, UNFPA and The World Bank estimates. World Health Organization,

Jamaica MMR Projections Source: Trends in maternal mortality: 1990 to WHO, UNICEF, UNFPA and The World Bank estimates. World Health Organization,

U.S. MMR Projections Source: Trends in maternal mortality: 1990 to WHO, UNICEF, UNFPA and The World Bank estimates. World Health Organization,

Select LAC Countries where 50% Reduction by 2035 is equal to or below MMR=50 25

50% Reduction by 2035 is ≤MMR=50 Source: Trends in maternal mortality: 1990 to WHO, UNICEF, UNFPA and The World Bank estimates. World Health Organization, ARR 2035 MMR Current MMR= % Reduction % Reduction

Brazil MMR Projections Source: Trends in maternal mortality: 1990 to WHO, UNICEF, UNFPA and The World Bank estimates. World Health Organization,

Colombia MMR Projections Source: Trends in maternal mortality: 1990 to WHO, UNICEF, UNFPA and The World Bank estimates. World Health Organization,

Paraguay MMR Projections Source: Trends in maternal mortality: 1990 to WHO, UNICEF, UNFPA and The World Bank estimates. World Health Organization,

30 Select LAC Countries where 75% Reduction by 2035 is equal to or below MMR=50

75% Reduction by 2035 is ≤MMR=50 Source: Trends in maternal mortality: 1990 to WHO, UNICEF, UNFPA and The World Bank estimates. World Health Organization, ARR 2035 MMR Current MMR= % Reduction % Reduction

Bolivia MMR Projections Source: Trends in maternal mortality: 1990 to WHO, UNICEF, UNFPA and The World Bank estimates. World Health Organization,

Dominican Republic MMR Projections Source: Trends in maternal mortality: 1990 to WHO, UNICEF, UNFPA and The World Bank estimates. World Health Organization,

Guatemala MMR Projections Source: Trends in maternal mortality: 1990 to WHO, UNICEF, UNFPA and The World Bank estimates. World Health Organization,

Select LAC countries where no projections for 2035 are below MMR=50 35

Haiti MMR Projections Source: Trends in maternal mortality: 1990 to WHO, UNICEF, UNFPA and The World Bank estimates. World Health Organization,

Maternal Mortality Ratio (MMR) in Selected LAC Countries Source: Trends in maternal mortality: 1990 to WHO, UNICEF, UNFPA and The World Bank estimates. World Health Organization, 2012.

Projected Maternal Mortality Ratio (MMR) in Selected LAC Countries (Current ARR) Source: Trends in maternal mortality: 1990 to WHO, UNICEF, UNFPA and The World Bank estimates. World Health Organization, 2012.

Projected Maternal Mortality Ratio (MMR) in Selected LAC Countries (ARR to reach 50% reduction in MMR) Source: Trends in maternal mortality: 1990 to WHO, UNICEF, UNFPA and The World Bank estimates. World Health Organization, 2012.

Projected Maternal Mortality Ratio (MMR) in Selected LAC Countries (ARR to reach 75% reduction in MMR) Source: Trends in maternal mortality: 1990 to WHO, UNICEF, UNFPA and The World Bank estimates. World Health Organization, 2012.

2010 MMR Estimates vs MMR Projections in Selected LAC Countries 2010 MMR Estimates2035 MMR Projections (Current ARR) Source: Trends in maternal mortality: 1990 to WHO, UNICEF, UNFPA and The World Bank estimates. World Health Organization, 2012.

MMR Projections (ARR to reach 75% Reduction) 2035 MMR Projections (ARR to reach 50% Reduction) 2035 MMR Projections in Selected LAC Countries: 50% vs. 75% reduction Source: Trends in maternal mortality: 1990 to WHO, UNICEF, UNFPA and The World Bank estimates. World Health Organization, 2012.

ARR in Selected LAC Countries Source: Trends in maternal mortality: 1990 to WHO, UNICEF, UNFPA and The World Bank estimates. World Health Organization, 2012.

Our recommendations for future targets which include the diversity and special needs of the region are??? 44

Thank you! 45

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48 Source: UN Estimates for Trends in Maternal Mortality World Health Organization, Absolute target: Sri Lanka & Thailand

49 3. Relative Target: 2010 and 2035 MMR Estimates (75% Reduction; ARR=5.5%) MMR< ≤MMR< ≤MMR<400 MMR≥400 MMR<25 25≤MMR<50 50≤MMR<100 MMR≥ Estimate 2035 Target

50 Source: UN Estimates for Trends in Maternal Mortality World Health Organization, Relative target for MMR: Bangladesh & Nepal--75% and 85%

51 Source: UN Estimates for Trends in Maternal Mortality World Health Organization, Relative target for MMR: China & Sri Lanka --75% and 85%

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