1. Measuring maternal mortality using census data in developing countries Tiziana Leone LSE Department of Social Policy

2. Outline  Definitions  Background  Objectives and rationale  Lesotho and Nicaragua  Methods  Results  Discussion and future work

3. Definition A maternal death is the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and the site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management but not from accidental causes. WHO, 1993

4. Measures of Maternal Mortality

5. Background  Pressure to get the indicators right to measure progress of MDG 5  Vital registration not sufficient to record maternal deaths  Maternal mortality ‘rare’ event: sample surveys need big sample in order to collect enough information  Census has been recommended in countries that lack complete vital registration

6. Advantages and Disadvantages using Census Data to Estimate MMRate Advantages: No problems with sample size It is possible to study differentials Evaluation methods are well developed It’s cheap! Disadvantages: Basic data need evaluation and adjustments Only every 10 years (normally) Methods Have Strong Assumption (e.g.:no migration) Estimates are for intercensal period, not a specific period

7. Objectives  Apply methodology to two different settings : Nicaragua and Lesotho  Analyse feasibility of methods  Develop methods in order to estimate differential mortality

8. Lesotho and Nicaragua PopulationTFRMMRGDP per capita Net migration HIV prevalence Lesotho1.8m3.5730$1,300-0.78 ‰ 23% Nicaragua5.7m3.283-170$2,600-1.13‰0.2%

9. Data  Nicaragua 1995-2005 census  Lesotho 1986-1996 census

10. Questions included in Lesotho census questionnaire

11. Questions included in Nicaragua census questionnaire

12. Methods Series of evaluations methods based on demographic ‘indirect techniques’ with adjustments when needed. Hill et al 2001. Check degree of death coverage in the population General Growth Balance Check quality of fertility data P/F Ratio Check quality of information on pregnancy related deaths No formal methods.

13. General growth balance Based on the balance population equation r = b – d or (rearranging) b – r = d b=crude birth rate r=growth rate d=crude death rate. Assumes absence of migration and that the completeness of coverage of the deaths is c, constant at all ages. The observed age-specific mortality rates are therefore equal to the true rates multiplied by c, or that the true rates are equal to the observed rates divided by c: b(x+) – r(x+) = {1/c}*dobs(x+) C=adjustment factor calculated using regression models

14. Mortality Check Regression line fitted for (5+)-(65+)

15. Fertility Check

16. Plausibility checks

17. MMR CensusUNICEF estimate UNDP Lesotho532 (1996)550 (2000)530 (1996) Nicaragua135 (2005)170 (2005)230 (2000)

18. Age specific PRMR

19. Discussion We are estimating an intercensal value and not a specific period Careful interpretation of results We need to explore more ways to get formal methods to estimate pregnancy related deaths Census data give reasonable estimates Best way forward in absence of Vital registration Very little additional information needed Need for more advocacy and training

20. Future plans  Apply the same methodology to more countries (e.g. South Africa and Zimbabwe)  Two points in time  Differential (e.g.: wealth, residence, region) mortality applying smoothing functions