1. 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 1, 2013

2. Outline of talk Setting a target for maternal mortality: the indicator
Absolute target for MMR: 50 by 2035
Historical MMR trends: Annual rates of reduction (ARRs)
Relative target for MMR: 75% and 85%, 2035
Key points and questions

3. 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)
Most common indictors of maternal mortality are # mat deaths, MMRatio, LTR, the proportion of women’s deaths that are maternal
Process indicators:–  Provides information on actions to be taken and how to improve
existing 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 progress
Use 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 woman
Timing of death
Medical cause of death
How: 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) – Other
Each 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 2010
Global number of maternal deaths: 287,000 in 2010
77 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
Table 1: Number of Countries with specific ranges of MMR in 2010 (n=189)
Start with a brief overview of current levels and trends in MMR
Table shows distribution
(could we get map?)
MMR≤30
30<MMR≤50
50<MMR≤100
100<MMR≤200
200<MMR≤500
MMR>400
Number of countries 58 19 35 16 26
Statistics & 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 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%
225 50
With 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 2.5Xs
India would slow down from 6.5% to 5.4%--In such countries, we would need to look at subregional variation
ARR: 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, 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

9. 2. Absolute target: Annual rates of reduction (ARR)
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%
Table 2: Number of Countries with specific ranges of ARR in
ARR≤1
1<ARR≤2
2<ARR≤3
3<ARR≤4
4<ARR≤5
5<ARR≤6
ARR>6
Number of countries 20 36 40 32 23 10
Statistics & 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 point 50
Source: 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.

13. 3. Relative targets

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 them
Statistics & 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 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

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?