UNITED NATIONS POPULATION INFORMATION NETWORK (POPIN)
UN Population Division, Department of Economic and Social Affairs,
with support from the UN Population Fund (UNFPA)

Guidelines on Tracking Child and Maternal Mortality

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This document has been prepared by the Secretariat of the United Nations 

Inter-Agency Task Force on the Implementation of the ICPD Programme of 

Action.  For further information please contact the United Nations 

Population Fund, Task Force on ICPD Implementation, 220 East 42nd Street, 

New York, NY 10017 USA, or send E-mail to: pierce@unfpa.org

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                     GUIDELINES ON A COMMON APPROACH

                TO NATIONAL CAPACITY BUILDING IN TRACKING

                      CHILD AND MATERNAL MORTALITY

                 FOR THE UN RESIDENT COORDINATOR SYSTEM





INTRODUCTION



1.   At the request of the UNDP Administrator, on behalf of the

Secretary General of the UN, a first meeting of the Inter-agency

task force on the implementation of the ICPD programme of action

was convened.  This meeting, held on December 13, 1994, at UN

headquar-ters in New York, was attended by representatives of 12 UN

agencies and organizations.  It agreed to establish four working

groups on: child and maternal mortality data; basic education and

gender disparities; social policy-related issues; and women's

empowerment.



2.   These guidelines are the main outcome of the Working Group on

a Common Approach to National Capacity Building in Tracking Child

and Maternal Mortality which met at UNICEF Headquarters in New York

on May 4, 1995.  They are intended to provide a succinct and

readable summary of the relevance of child and maternal mortality

to human development, how the indicators are measured and who in

the UN system can provide what specific kinds of assistance at the

country level to governments, and more broadly civil society, in

their efforts to assess infant, child and maternal mortality as

they act to effect improvements.  A list of key references for both

child and maternal mortality is attached.





I.   CHILD MORTALITY



Child mortality - an ongoing concern





3.   Under-five mortality and its major component, infant

mortality, have been used as measures of childrenūs well-being for

many years.  However, it was the International Conference on

Primary Health Care held in Alma Ata in 1978 which first considered

how child mortality could be reduced world-wide by a systematic

development of a primary health care system.



4.   The number of under-five deaths are huge, 12 or more million

annually.  But this number only tells part of the problem.  These

12 million represent over 700 million years of productive life lost

annually.  And by far the majority of these lives being lost could

be saved.  The following table lists the causes of under-five

deaths for developing countries.  It shows that over 70% of these

deaths are caused by diseases for which practical, low cost inter-

ventions exist - involving immunization, ORT use, antibiotics and

the like.



------------------------------------------------------------------- 

      Table 1: Under-five deaths 1993, developing world

        Cause                                % of total



        ARI (mostly pneumonia)                 25

        Diarrhoea alone                        23

        Malaria alone                           6

        ARI-measles                             5

        Neonatal tetanus                        5

        Tuberculosis                            2

        ARI-pertussis                           2

        Measles alone                           2

        Diarrhoea - measles                     2

        Pertussis alone                         1

                                                                  

        Total                                  73

                                                                  

 Source: WHO, The World health report 1995, Geneva, 1995



5.   In this context, it is not surprising that child mortality

measures are of key relevance in assessing progress in overall

national development as well as progress for children.  Both U5MR

and IMR measure an end result of the development process rather

than an input such as school enrolment ratio, per capita calorie

availabili-ty, or the numbers of doctors per thousand population -

all of which are a means to an end.



6.   Furthermore, child mortality is known to be the result of a

wide variety of inputs: the nutritional health and the health

knowledge of mothers; the level of immunization and ORT use; access

to maternal and child health services (including prenatal care);

income and food availability in the family; the availability of

clean water and safe sanitation; and the overall safety of the

child's environment.



International conferences



7.   Specific mention of action to be taken on child mortality can

be found in paragraph 8.16 of the Report of the international

conference on population and development (UN ref. A/CONF.171/13, 18

October 1994).  In particular this paragraph includes the

following.



     Countries should strive to reduce their infant and under-    

     five mortality rates by one third, or to 50 and 70 per 1000  

     live births, respectively, whichever is less, by the year    

     2000, with appropriate adaptation to the particular situa-   

     tion of each country.  By 2005, countries with inter-mediate 

     mortality levels should aim to achieve an infant mortality   

     rate below 50 deaths per 1000 and an under-five mortality rate 

     below 60 deaths per 1000 births.  By 2015, all countries     

     should aim to achieve an infant mortality rate below 35 per  

     1000 live births and an under-five mortality rate below 45 per 

     1000.  Countries that achieve these levels earlier should    

     strive to lower them further.



8.   In the context of UN sponsored international conferences,

these same goals for the year 2000 were first mentioned in the

World Summit for Children, which was held in New York in 1990. 

Subsequently, the United Nations Conference on Environment and

Development, held in Rio de Janeiro in June 1992 repeated these

goals, as did the World Summit for Social Development in Copenhagen

in March 1995.  Thus the target of reducing child mortality has

both broad-based and long-term support.



Definitions



9.   The generally accepted definitions for under-five and infant

mortality rates come from demography, are cohort based and can be

stated as follows.



     Under-five mortality rate (U5MR): The probability of dying   

     between birth and the fifth birthday (exact age 5 years),    

     expressed per 1000 live births.



     Infant mortality rate (IMR): The probability of dying between 

     birth and the first birthday (exact age 1 year), expressed   

     per 1000 live births.



10.  The infant mortality rate is often computed as the ratio of

deaths of children under one year of age occurring during a given

period and births in the same period.  The difference between this

and the above stated cohort measure are very small.  However, a

similar period based estimate cannot be used for the under-five

mortality rate.



Data sources and estimation methods



11.  In the developed countries, measures of child mortality at the

national level have traditionally come from the registration of

births and deaths.  If births and deaths are completely recorded,

and the compilation of statistics from the registration system are

timely, then these are the preferred mortality estimates.



12.  However, the major problem with vital registration as a data

source is its quality.  In many developing countries, birth

registra-tion is incomplete  In a still larger number of countries,

the recording of child deaths is incomplete.  Registration of

deaths after infancy is, in general, more complete than in infancy,

but the recording of the population by age in childhood is also

subject to error.  A further problem with vital registration

systems is the frequent delay in compilation and publication.



13.  Experience with programmes to improve vital registration

coverage have been rather discouraging.  Work in this area suggests

that complete vital registration evolves over time with general

administrative development and as the importance of records becomes

evident to, and used by, the general population.



14.  However, sample registration is proving valuable in some of

the world's largest countries.  A successful example is the Indian

sample registration system, introduced in some states in the 1960s,

and currently operating throughout the country.  Bangladesh has

developed a similar system which, after some uncertainty, appears

to be stabilizing.  China has recently embarked on a related sample

system.



15.  In countries where the vital registration system as a basis

for child mortality estimates is of uncertain or unacceptable

quality, as is the case for most developing countries, information

from some type of household survey is required to validate,

calibrate or substitute for vital registration estimates.  A

distinction can be drawn between prospective and retrospective

surveys.



16.  The essential characteristic of a prospective survey is that

a defined population is followed over time, with the vital events

occurring to the population being recorded.  A typical prospective

survey involves the initial recording of populations in a sample of

areas.  The population is then resurveyed at regular intervals,

with the reported events checked against changes in household

composition between rounds in order to minimize omission.  With

careful fieldwork, prospective surveys can provide relatively

accurate estimates of child mortality.  Such surveys, however,

require careful fieldwork over an extended period of time to

estimate trends, and because of sample size limitations, may have

to be extended over several years to provide stable estimates of

child mortality levels.  This continuity of effort can be difficult

to achieve in some developing country settings.



17.  Retrospective surveys typically obtain information from

mothers on the survival of their children.  Such surveys provide

the main source of estimates for most developing countries.



18.  Response errors, which arise during data collection, are a

major source of poor quality mortality data from all sources.  This

is of particular concern in retrospective surveys where questions

require adequate specification and interviewers must be well

trained and supervised.  In addition to such response errors, the

retrospective survey techniques are affected to a greater or lesser

extent by potential selection bias, because in order for a child to

be reported the mother must be a member of the study population at

the time of the survey.  Thus, either death or emigration of the

mother can affect the reporting coverage. 



19.  The most extensively utilized retrospective survey techniques

are: questions to women on aggregate numbers of children born and

dead, often referred to as the 'Brass' questions; and questions to

elicit maternity histories, where each woman is asked for the date

of birth and, if applicable, the age at death of each of her live-

born children.  Brass questions have been used in most developing

countries and are the simplest and least costly of the two

techniques to apply.  They have worked well in a wide variety of

social contexts and of data collection vehicles, including

censuses.   



20.  Maternity history data have provided a wealth of information

on child mortality in developing countries.  Complete maternity

histories, such as those utilized by the Demographic and Health

Surveys, are more onerous to collect than data from Brass

questions, and hence have been generally limited to national

household surveys where sample sizes are insufficient to provide

detailed sub-national mortality estimates.  Maternity history data

have made a particular contribution to the exploration of differen-

tials and associations in child mortality.



21.  There are other retrospective survey techniques, such as

asking about recent household deaths by age, or questions on the

survival of a motherūs previous birth.  However, for these

techniques either the experiences have been mixed, or they apply

more appropriately to population sub-groups - such as mothers who

give birth in health centres.



22.  More information on these and other survey techniques can be

found in Child mortality since the 1960s, and in Approaches to the

measurement of childhood mortality: a comparative review.



Helping countries track child mortality



23.  The activities involved in tracking child mortality at the

country level can be usefully divided into three components:

determine what mortality data exist; generate reasonable time

series of mortality estimates; and fill data gaps.  These

components are further detailed in the following.



Determine what mortality data exist



24.  This task can generally be done by local demographers.  A good

example of what should be done to describe these data and to

provide an updateable record is provided in Child mortality since

the 1960s (see references).  A typical country profile in this

publication presents the key features: the available data listed

and referenced, and all data graphed.  These latter charts (one

each for under-five mortality and infant mortality) provide a very

useful visual assessment of the amount of data, the consistency of

data from different sources, and the trend of mortality over time.



Generate reasonable time series of mortality estimates



25.  There are two important aspects to generating time series

estimates (separately) of the under-five and infant mortality rates

for period 1960 to 1995.  The first is the ensuing result of a

single set of estimates.  The second is the process of obtaining

the time series, which requires assessment of the existing data and

discussion among experts.



26.  There are often several different estimates of child mortality

used by different national bodies, be they in the government,

public or private sectors.  Different estimates of child mortality

for the same or similar time period are almost always detrimental

to concerted efforts to reduce child mortality, since the lack of

agreement is often associated  with a lack of a coordinated effort

on reducing child mortality.  Different mortality estimates can

also lead to different, and separate, programme strategies for

mortality reduction.  The aim should be to minimize differences

between mortality estimates and to obtain very broad country-wide

support for a single and consistent set of under-five and infant

mortality estimates.



27.  Arriving at a single set of under-five or infant mortality

estimates is not an easy task, since there is no unique best method

and the country situations can differ widely.  For example, the

data from seven data sets for Bolivia, shown in figure 1, display

a very consistent trend and coherency over the period 1960-92.  The

situation in figure 2, for Papua New Guinea, shows the other

extreme.  The country has only two data sets, with a very low data

consistency since in the period 1965-67 the 1980 census reports an

under-five mortality rate of just over 100 per 1000 live births,

whereas the 1970 census reports a mortality rate of around 200 for

the same period.



28.  In the case of Bolivia, fitting a line representing a single

time series of mortality estimates from 1960 to 1995 appears

feasible, and most reasonable attempts could be expected to fall

within a narrow band (see the annex for further information on line

fitting).  Fitting such a line to the data in figure 2 for Papua

New Guinea would give very questionable results since possible

lines would fall within a very wide mortality range, from a line

through the 1970 census data projected to 1995 with the same trend

as that given by the 1970 census, to a line through the 1980 census

data projected both backwards to 1960 and forward to 1995 with the

same trend as the 1980 census.



29.  Even in the case of Bolivia - and this is an example of a very

consistent set of data - there would be individual variations if

different experts attempted to produce a mortality time series. 

For countries with less consistent data the derivation of a single

time series becomes more variable, and an explicit methodology for

obtaining a consistent and repeatable time series is needed.  



30.  The work of Hill and Yazbeck in Trends in child mortality

provides a model for generating such a time series at the country

level.  This important work is summarized in an annex to these

guidelines.  A key consideration in this model is that it be

repeatable and useable by others, particularly at the country

level.  Hence countries can understand, adopt and implement this

methodology themselves, leading to a greater awareness and

commitment within each country.



31.  The Hill and Yazbeck methodology aids data assessment, since

the choice of regression weights explicitly assigns assessments of

data source quality (see Annex).  Assessment approaches which  rely

on comparisons between data sources can be found in Child mortality

since the 1960s (pages 12 to 15).  At the same time, the quality of

individual sources can and should be explored.  Such assessments

are helped if separate quality studies have been implemented as

part of the data collection process.  But fairly simple data

analyses, such as the calculation of male/female ratios and their

comparison against known standards, can throw useful light on data

limitations.



Fill data gaps



32.  A data ūgapū is used here to identify country situations where

there are either no mortality data referenced to a year within the

last five or, where there are such data, they are inconsistent or

refer to a time before a catastrophic occurrence of national impact

- such as civil conflict or major natural disaster.



33.  Measured mortality, referenced within the last five years, is

considered the minimum requirement which all countries should be

able to meet.  A more frequent measurement of mortality is advan-

tageous in general, preferably annually, but care has to be taken

to balance frequency of mortality measurement with the capacity of

a country.  For example, if a country is facing economic hardships

and has a high child mortality level, attempting to measure

mortality every year will absorb significant country resources,

resources which could be better used in reducing child mortality

rather than its frequent measurement.  This example fits the

situations in many African countries.



34.  Having identified a mortality data gap exists, how it should

be filled depends on the country situation.  Countries with gaps to

fill can be divided into two groups: those which have (or had) an

adequate vital registration system, and countries without.  An

"adequate" vital registration system is defined here as one which

covers over nearly all births and under five deaths in a country. 

The term "nearly all" is used deliberately; it could have been

replaced with 'at least 80% of births and under-five deaths'. 

However, a more relevant specification is whether vital regis-

tration can play the major role in tracking child mortality. 

Clearly a vital registration system which covers all births and

under five deaths meets this specification.  But so also does a

system which covers enough of the births and deaths so that

periodic censuses or large surveys can be used to derive an

adjustment factor.  This adjustment is then applied to the annual

vital registration system estimates to arrive at good quality

national child mortality estimates.



a)   Countries which have (had) an adequate vital registration    

     system



35.  Countries which had an adequate vital registration but now

have data gaps, are few in number.  But this situation can arise

when existing systems have been run down or, as in the case of man-

made or natural catastrophes, when country infrastructures have

been adversely affected.  Systems may not have stopped functioning,

but their coverage of births or deaths may have declined, or the

reporting lag between occurrence and reported estimate may have

increased considerably.  



36.  Filling such data gaps requires a review of the vital

registration system to determine what the problems are, and a

support project initiated to correct them.  In some situations,

where there are no mortality data for the last five years, or since

a catastro-phe, a survey may be required to provide more current

data until the vital registration system is functioning adequately

again.



b)   Countries without an adequate vital registration system



37.  Countries without an adequate vital registration system

comprise the majority of developing countries.  An ultimate, long-

term aim is to have complete vital registration for all countries. 

However, as noted earlier, experience indicates that complete vital

registration evolves over time, with general administrative deve-

lopment and public use.  This is not to say the development of

complete systems should not be supported, but they do not get built

quickly.  Projects for vital registration development need to

recognize both the several years for which support will likely be

required, as well as the implementation of household surveys to

provide mortality data in the interim.



38.  For those countries where adequate registration systems are

sometime in the future, either retrospective or prospective surveys

need to be used to fill data gaps.  In general the technique of

choice is the Brass questions in retrospective surveys, since these

are the easiest and least costly to implement over a wide range of

data collection vehicles.  Where correlations of mortality with

other factors are particularly sought, maternity history questions

should be considered.



39.  In situations where the primary source of retrospective survey

data, mothers, are likely to introduce a significant selection

bias, prospective surveys can be considered for filling data gaps. 

But such situations require careful review, balancing the country

capacity to carry out such a logistically demanding survey against

the degree to which other less costly and simpler techniques may

suffice.



40.  Any action on filling data gaps must take into account

feasible data accuracy and the use to which the data are to be put.

In the case of feasible data accuracy, and including both sampling

and non-sampling error components, a useful general rule is that

mortality measurements have an uncertainty of at least plus or

minus 10% of the measurement value.  For example, if an under-five

mortality rate of 100 is measured, the actual rate should be

interpreted as being, at best, somewhere in the range 90 to 110,

and is often outside this range.  Reducing the uncertainty of

measurement below this 10% level is both difficult and costly.



41.  Measurement is of little value if the data are not used. 

Hence consideration should be given to how mortality data can be

used to more effect.  As noted earlier in these guidelines,

exploring cause of death is useful in helping to better target

programme interven-tions.  Additionally, it is beneficial to get

users as well as producers together, not only to discuss existing

data systems and additional data needs, but particularly to clarify

how existing data are presently used, and how new mortality data

will be used.  In this the guideline should be that where a cost is

incurred in measuring child mortality, this cost should produce a

greater benefit in mortality reduction, and not solely result in a

measurement report, however imposing and official it may look.



II.MATERNAL MORTALITY



Maternal mortality reduction - an overarching goal



42.  Deaths of women due to pregnancy or childbirth is a major

public health problem in developing countries.  On average, 500,000

women die from maternity-related causes every year -approximately

one maternal death every minute.  99 percent of these deaths occur

in developing countries with the majority concentrated in Africa

and South Asia.  Although there has been a significant decline in

child mortality in recent years, the gap between maternal mortality

ratios in the developing and the developed countries remains wider

than for any other health indicator.  While the absolute number of

maternal deaths may seem small in comparison with the number of

infants dying, the risk of death accumulates for women with each

pregnancy.  For example, the life-time risk of death from pregnancy

and child birth for a woman in Africa is 1 in 20 while this risk is

1 in 10,000 for a woman in northern Europe.  The lack of attention

that has been paid to this problem is a reflection of the lack of

importance given to women's health issues in general.



International conferences



43.  The first time that the international health community's

attention was clearly focussed on maternal deaths was in 1987, when

the International Conference on Maternal Mortality was held in

Nairobi, Kenya.  This conference reflected a consensus that the

number of maternal deaths in the developing world was too high,

unnecessarily so, and could be prevented or reduced considerably. 

A second important moment for the Safe Motherhood Initiative was

the 1990 World Summit for Children.  The Summit Declaration and

Plan of Action included the reduction of maternal mortality by half

as one of the seven major goals to be achieved between 1990 and the

year 2000.  



44.  Most recently, the International Conference on Population and

Development (ICPD) in Cairo, and the World Summit for Social

Development held in Copenhagen in March 1995, reiterated the

maternal mortality reduction goal set forth in Nairobi and the

World Summit for Children, and expanded it to include a further

reduction in maternal mortality of 50% by the year 2015.  In

addition, the ICPD Programme of Action recommends that 



     ... Countries with intermediate levels of mortality should aim 

     to achieve by the year 2005 a maternal mortality rate below  

     100 per 100,000 live births and by 2015 a maternal mortality 

     rate below 60 per 100,000 live births.  Countries with the   

     highest levels of mortality should aim to achieve by 2005 a  

     maternal mortality rate below 125 per 100,000 live births and 

     by 2015 a maternal mortality rate below 75 per 100,000 live  

     births. However, all countries should reduce maternal

     morbidity and mortality to levels where they no longer     

     constitute a public health problem.  Disparities within     

     countries and between geographical regions, socio-economic and 

     ethnic groups should be narrowed...



45.  Countries which have formally committed themselves to

achieving the maternal mortality reduction goal are also res-

ponsible for monitoring progress toward that end.  To accomplish

this, close collaboration among international and national

agencies, governments and non-governmental organizations is

essential.



Indicators



46.  In the context of the World Summit for Children, UNICEF, WHO,

UNESCO and others have worked closely together to agree on a basic

set of indicators to recommend to countries for monitoring progress

toward the goals. In relation to the World Summit for Children and

Health for All maternal mortality reduction goals, the two

monitoring indicators agreed upon by WHO and UNICEF are the

Maternal Mortality Rate (ratio)(MMR): Annual number of maternal

deaths per 100,000 live births and the Annual Number of Maternal

Deaths.



Measurement problems



47.  There are several features of maternal mortality, however,

that make it technically difficult to measure.  First, as compared

to other commonly measured demographic events (such as births or

under five deaths), it is a relatively rare event.  Second,

maternal deaths are often not reported, or when they are, they are

not correctly classified as maternal deaths.  As a result, most

official measures of maternal mortality are under-estimates.



48.  The relative infrequency of maternal deaths means that large

populations need to be studied which makes such studies very

costly.  If the study population or sample is too small, the number

of deaths will not be large enough to yield reliable, stable

estimates.  WHO has calculated that to establish a maternal

mortality ratio of 300 (per 100,000 live births), correct to within

20% (95% confidence intervals) would require a sample size of

50,000 births.  Of course, many more households would have to be

interviewed to yield 50,000 births. 



49.  Maternal mortality estimates generally have wide margins of

error.  This presents a particular problem in measuring trends over

time because, even if consecutive studies showed a decline over

time, it may not be possible to rule out chance as an explanation

for this finding.  Figure 1 illustrates this point using data from

a direct household survey.  Scenario B assumes a 50% reduction in

maternal mortality and Scenario C a 25% reduction.  In both cases

the 95% confidence limits overlap with the baseline estimate and it

is therefore not possible to measure a statistically significant

difference between the two estimates.  In summary, measuring trends

is much more difficult than generally believed, even using the new

sisterhood and network methods.



50.  Vital registration is usually relatively complete in most

developed and a few developing countries.  However, in most deve-

loping countries, this is not the case. One of the reasons why many

deaths in developing countries are not registered is that they do

not occur in health facilities, where health personnel would be

required to report them.  Many deaths occur in the home or on the

way to a hospital and are consequently not recorded. 



51.  Even in countries with relatively complete vital registration

systems, misreporting of maternal deaths is a serious problem.  The

mis-reporting of maternal deaths means that they were reported but

not properly classified as a maternal death.  A maternal death is

defined as 



     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 or 

     incidental causes.  



52.  Therefore, to properly report a maternal death, it is

necessary to know not only that the woman died but the timing and

the cause of the death as well.  Few maternal deaths actually take

place in obstetric wards because when a life-threatening situation

arises, the patient is moved to another department and the cause of

death is not certified by an obstetrician or the death certificate

may not mention the obstetric cause which triggered the series of

complica-tions leading to death.  Even in the United States,

studies have shown misreporting of between 25% and 70% of maternal

deaths.



Data sources



53.  In addition to vital registration systems, the main sources of

data on maternal mortality are household surveys, reproductive age

mortality surveys (RAMOS), hospital data and community studies. 

The RAMOS studies are likely to produce the most reliable estimates

of maternal mortality but are too costly to implement at the

national level on a regular basis.  While data from hospitals and

health centres can be informative, they can also be misleading -

this is particularly true when data come primarily from hospitals

which specialize in maternal care, where mortality rates can be

much higher than in the general population.  On the other hand,

under reporting and mis-classification can lead to gross under-

estimates of maternity-related mortality, even in countries where

all or most deaths are medically certified.  Health systems in a

large number of developing countries do not have adequate popu-

lation coverage.  Community studies of maternal mortality are more

common in many developing countries, but these are for very limited

geographical areas, and the quality varies enormously.



54.  Household surveys require large sample sizes, even with the

new sisterhood and network methods.  While careful field work can

produce good quality estimates, large surveys have often produced

poor results.  The sisterhood method has been developed more

recently and minimizes the number of households that need to be

visited in order to obtain information on a large number of women. 

The method asks all adult women in a household about the survival

of their sisters: how many sisters they had who survived to

adulthood and how many died of pregnancy-related causes.  This

information is then converted into a life-time risk of dying from

maternal causes and maternal mortali-ty.  Questions based on the

sisterhood method have been successfully added to many of the

Demographic and Health Surveys.  However, the sisterhood method

produces estimates which reflect maternal mortality levels of ten

years or more in the past. Therefore, they cannot be used for

monitoring progress toward the maternal mortality reduction goal

during the current decade.  They also do not provide information on

cause of death. Nonetheless, estimates of maternal mortality

derived from the sisterhood technique are valuable, particularly in

places where no reliable community studies are available and/or

where vital registration is inadequate.



55.  Maternal mortality epidemiologic surveillance systems may be

appropriate in countries where civil registration is relatively

more complete and where most births take place in health

facilities.  The Pan American Health Organization (PAHO) has been

working to develop this methodology further.  However, trade-offs

should be considered on the return of investment in this type of

approach since the improvement of civil registration systems is a

long-term undertaking and even in the best systems the measurement

of maternal mortality presents specific problems and this type of

surveillance does not provide information relevant to programme

planners.  



56.  Because of the measurement problems described above, many of

the national level maternal mortality estimates regularly reported

by international agencies, and used by national governments, are

not accurate reflections of the present situation and are of

limited value in measuring trends over time.  This raises a serious

problem for monitoring the maternal mortality reduction goal since

it is set relative to a 1990 baseline.  This does not imply that

all attempts to measure maternal mortality should be abandoned. 

However, it is important that the limitations of using these

estimates for monitoring progress in maternal mortality reduction

be fully recognized: they are costly to produce, may not be

nationally representative or, in the case of sisterhood estimates,

provide estimates which are not current.  Finally, maternal

mortality ratios alone do not provide the information needed for

development of programme interventions or policy formulation. 



Model-based estimates



57.  An alternative method is to base estimates of maternal

mortality on a mathematical model using widely available predictor

variables.  At present, the WHO Maternal Health and Safe Motherhood

Programme and the UNICEF Planning Office are collaboratively

pursuing this option, at least for those countries which are known

to have weak data or no data at all on maternal mortality.



58.  Preliminary results are promising, although the predicted MMRs

resulting from a mathematical model may be somewhat imprecise

because of wide margins of error.  Given the weakness of the

existing data on maternal mortality, however, the model-based

estimates will likely be an improvement.  For countries which lack

accurate national level estimates, the model-based estimates offer

a sound alternative to investment in large-scale surveys.  They

provide, at minimum, an indication of the order of magnitude of the

problem which can be used to stimulate action to reduce maternal

mortality.  



59.  Work on the development of model-based estimates is continuing

and final results are expected to be available by the Fall of 1995.



In addition to UNICEF and WHO, UNDP and The World Bank have

expressed interest in using the model-based estimates for those

countries which have no reliable estimates for maternal mortality.



Process indicators



60.  An important alternative to monitoring the impact of

programmes is to monitor the processes which are known to reduce

maternal mortality.  There are several distinct advantages to this

approach.  First, it avoids the substantial expense involved in

generating maternal mortality rates, which in many cases may not be

accurate, or reflect a situation ten years or more in the past. 

Second, process indicators can provide information essential for

guiding policies and programmes.



61.  In 1992, UNICEF issued a set of guidelines for monitoring

progress toward maternal mortality reduction which proposed a

series of process indicators [D. Maine, et al., Guidelines for

Monitoring Progress in the Reduction of Maternal Mortality.  (A

Workin Prog-ress). UNICEF Statistics and Monitoring Section,

October 1992].  These process indicators are based on the

assumption that the most effective strategy for reducing maternal

mortality is to increase access to prompt, adequate emergency

obstetric care (EOC) and therefore are designed to measure progress

toward improving access to, utilization of and the quality of EOC

services.   Using process indicators will help programme planners

identify priority interventions and areas, as well as aspects of

the programme that need strengthening.  Thus, monitoring of process

indicators serves a variety of purposes - not just data gathering

for its own sake.



62.  Following this pioneering work on indicator development, WHO

convened a technical working group, in 1993, to make recommen-

dations on data collection and analysis for monitoring the

maternal mortality and coverage of care goals.  The technical

working group met at a time of growing consensus on the content of

programmes for improving maternal health, growing convergence on

the essential package of indicators for monitoring progress, and

growing need for guidance for the collection and utilization of

these indicators.  The main conclusion of the Technical Working

Group meeting was that 



     ... there is a need to recognize that, at the national     

     and subnational levels, impact indicators are much less likely 

     to be useful for programme management than process indicators 

     and are insufficiently accurate for monitoring purposes.  From 

     an international perspective, impact indicators are probably 

     still needed, principally for advocacy purposes, but the     

     uncertainty over their usefulness at lower levels and the    

     difficulties and cost in collecting the necessary information 

     make it difficult to attach any sense of priority to the two 

     mortality indicators.  Consumer information is needed in order 

     to enable countries and programme managers to make a decision 

     on this issue...(p. 26)



63.  The outcome of the meeting included a series of recommen-

dations on specific indicators and methodologies [See Indicators to

Monitor Maternal Health Goals.  Report of a Technical Working

Group.  Geneva, 8-12 November 1993.  WHO Division of Family

Health].  



64.  USAID and The World Bank have also conducted in-depth

reviews of indicators for monitoring and evaluation of repro-

ductive health programmes and there is now a growing consensus on

the use of process indicators for monitoring progress.



65.  It should be noted, however, that there is relatively little

experience in the use of these indicators and additional field

testing (of the indicators and data collection protocols) is

required.  Further guidance is also needed on the use and

interpretation of all these indicators.  



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SELECTED BIBLIOGRAPHY 

CHILD MORTALITY





Child Mortality Estimates:



UNICEF, The State of the Worldūs Children 1995, UNICEF, New York.



DIESA, Mortality of children under age 5 - World estimates and

projections 1950-2025, ST/ESA/SER.A/105, United Nations, New York,

1988.



DESIPA, World population prospects - the 1994 revision, United

Nations, New York, 1995 forthcoming.



Estimation Methods:



DIESA, Step-by-step guide to the estimation of child mortality,

ST/ESA/SER.A/107, United Nations, New York, 1990.



DIESA, Manual X. Indirect techniques for demographic estimation,

ST/ESA/SER.A/81, United Nations, New York, 1983.



DHS, Model A questionnaire, DHS-II Basic documentation, Macro

International, Columbia, USA, 1990.



K. Hill, Approaches to the measurement of child mortality: a

comparative review, Population Index, Vol. 57, No. 3.



P. H. David et al, Measuring childhood mortality: A guide for

simple surveys, UNICEF, Amman, Jordan, 1990



Child Mortality Databases:



DESD, Child mortality since the 1960s - A database for developing

countries, ST/ESA/SER.A/128, United Nations, New York, 1992.



K. Hill and A. Yazbeck, Trends in child mortality, 1960-90:

Estimates for 83 developing countries,  Background paper number 6,

October 1994.



Source Key for Figures 1 and 2



Figure 1: Bolivia under-5 mortality



EDNi75    - Encuesta demogr fica nacional, 1975, indirect estimates

CENSi76   - Census, 1976, indirect estimates

EDNi80    - Encuesta demogr fica nacional, 1980, indirect estimates

ENPVi88   - Encuesta nacional de poblacion y vivienda, 1988,      

            indirect estimates

ENDSd89   - Enquesta nacional de demogr fia y salud, 1989, direct 

            estimates

ENDSi89   - Encuesta nacional de demogr fia y salud, 1989, direct 

            estimates

DHSi94    - Encuesta nacional de demogr fia y salud, 1994, direct 

            estimates



Figure 2: Papua New Guinea under-5 mortality



CENSi71   - Census, 1971, indirect estimates

CENSi80   - Census, 1980, indirect estimates



All data from Child mortality since the 1960s - A database for

developing countries, except for DHSi94 data, which come from the

published DHS report on Bolivia.



-------------------------------------------------------------------



                    SELECTED BIBLIOGRAPHY 

                      MATERNAL MORTALITY





General:



WHO, Maternal Health and Safe Motherhood Programme, Division of

Family Health.  Mother-Baby Package:  Implementing Safe Motherhood

in Countries.  Practical Guide. (WHO/FHE/MSM/94.11), 1994.



Maine, D.  Safe Motherhood Programs: Options and Issues.  Columbia

University, Center for Population and Family Health, 1990.



Measurement of Maternal Mortality:



Campbell, O. and W. J. Graham.  Measuring Maternal Mortality and

Morbidity:  Levels and Trends.  Maternal and Child Epidemiology

Unit Publication No.2, London: London School of Tropical Medicine

and Hygiene, 1990.



Graham, W. J., "The Sisterhood Method for Estimating the Level of

Maternal Mortality:  Seven Years' Experience."  The Kangaroo,

December, 1994, p.82-87.



Graham, W. J. and P. Airey.  "Measuring Maternal Mortality:  Sense

and Sensitivity."  Health Policy and Planning 2:323-333, 1987.



Indicators for Monitoring Maternal Mortality Reduction:



Maine, D. et al., Guidelines for Monitoring Progress in the

Reduction of Maternal Mortality. (A Work in Progress). UNICEF

Statistics and Monitoring Section, October 1992. (Update forth-

coming in Fall 1995).



WHO, Maternal Health and Safe Motherhood Programme. Indicators to

Monitor Maternal Health Goals.  Report of a Technical Working

Group.  Geneva, 8-12 November 1993.



Bulatao, R. A. and L. B. Shrestha.  Key Indicators for

Reproductive Health Projects.  Draft 5 June, 1995.  The World Bank.



Graham, W. J. and V. Filippi.  Monitoring Maternal Health Goals: 

How Well Do the Indicators Perform?  Maternal and Child

Epidemiology Unit Publication No.2, London: London School of

Hygiene and Tropical Medicine, 1990.



International Data Sets on Maternal Mortality Ratios:



WHO, Division of Family Health.  Maternal Mortality.  A Global

Factbook.  Compiled by Carla AbouZahr and Erica Royston, Geneva,

1991, and the WHO Database on Maternal Mortality.



Pan American Health Organization (PAHO). Regional Plan of Action

for the Reduction of Maternal Mortality in the Americas (CE111/11),

27 May 1993.



The State of the World's Children Report,  Human Development

Report, World Development Report.



Model-based Estimates of Maternal Mortality:      

     

Stanton, C. And K. Hill.  Model-Based Estimates of Maternal

Mortality.  Report to UNICEF/WHO.  July 28, 1994 Department of

Population Dynamics, John Hopkins University School of Public

Health. [A final report on this work is forthcoming from UNICEF and

WHO].



-------------------------------------------------------------------

                        BRIEF SUMMARY OF 

               TRENDS IN CHILD MORTALITY, 1960-90: 

              ESTIMATES FOR 83 DEVELOPING COUNTRIES

                   BY K. HILL AND A. YAZBECK





A1.  The report describes a methodology for trend fitting, applies

it to the data for 83 countries, presents the results in text and

charts country by country, and draws some general conclusions about

the rates of decline of child mortality since 1960.     



    Methodology

    

A2.  There are many ways in which a set of estimates can be

obtained from a series of observations, and in which extrapolations

forward or backward to any time point can be made.  The simplest

procedure is hand smoothing: drawing a freehand curve through a set

of observations, and extending its general trend onwards to some

time point for which an estimate or projection is required.  Such

a procedure is unlikely to be objective - different analysts would

almost inevitably draw different lines, particularly for extrapola-

tions beyond the latest observations.

     

A3.  Regression analysis offers a set of possible approaches:

robust regression, locally-weighted least squares, weighted least

squares, or ordinary least squares.  Such regression techniques

offer a greater degree of objectivity than hand smoothing, but

still require the choice of model specification.

    

A4.  The approach adopted in the Hill and Yazbeck report is to fit

a regression line to the relationship between child mortality

indicators and their reference dates using weighted least squares. 

The basic model assumes that the rate at which child mortality

changes is linear in time, that is, that child mortality changes at

a constant annual percentage rate over some specific time period. 

The simplest model maintains a constant rate of change in child

mortality over the entire period studied.  The most complex model

used in the report allows the rate of change of child mortality to

alter every five years.  The choice of model depends on the number

of mortality observations by time period.     



A5.  Weighted least squares is used because a substantial body of

evidence suggests different validity weights for different types of

observations.  For example, it is generally thought that the

quality of retrospectively reported information deteriorates with

the length of time since the events reported.  All estimates from

vital registration or prospective surveys are given initial weights

of 1.0; in the former case, the weight is justified by the

typically large number of events involved and by the lack of any

substantial lag between event and report; in the latter case, the

high weight is justified by the lack of lag and by the accuracy

enforced by the data collection methodology.



A6.  Estimates derived from maternity histories are assigned

weights that vary with the length of time before the survey to

which the estimate refers.  Specifically, estimates for the five

years before the survey are given a weight of 1.0, for periods five

to nine years before the survey, 0.8, and periods 10 to 14 years

before the survey, 0.6, and for yet longer periods, 0.4.  Weights

for indirect estimates based on the proportions dead of children

ever born vary by age group of mother; estimates based on reports

of young women are given low weight, zero for women aged 15 to 19,

and 0.2 for women aged 20 to 24, because of the selection problems

which affect such estimates - early childbearing is highest among

the poor, who also suffer the highest child mortality rates. 

Estimates based on reports of women aged 25 to 29 (0.9) and 30 to

34 (1.0) get the highest weights.  Then, as age increases, the

weights decline slowly, on the grounds that information about

events longer ago is more prone to error.     



A7.  The observation-specific weights described in the foregoing

are essentially based on the authorsū judgement and experience. 

However, regression techniques can be used to estimate robust

weights for particular types of observation.  These techniques have

been applied by the authors on a subset of 13 countries with a

large number of different types of observation - particularly

indirect estimates based on the Brass questions and direct

estimates based on birth histories.  They find broad agreement

between the robust regression weights and those described earlier. 

    

     Applying the methodology

     

A8.  For each country, step one of the smoothing and extrapolation

process fits the regression model using appropriate date variables

and the weights described earlier.  The infant mortality rate and

the under-five mortality rate are fitted independently.  The only

subjective element in the process is in the decision concerning how

many slope variables to include in the model.  The observations and

fitted line are displayed graphically.  In step two, the step one

results are examined, and data sets that are clearly aberrant are

identified - such as vital registration sequences that fall consis-

tently below all other infant mortality estimates, or indirect

estimates that are clearly inconsistent with the bulk of the other

mortality estimates.  In general, the weights for that entire data

set are reduced by a constant factor that is usually zero.



A9.  Egypt provides an interesting example of the application of

the methodology.  Figure A1 shows the observations and final

regression estimates for infant mortality.  The vital registration

and observa-tions from the 1976 and 1986 population censuses are

clearly out of line with all other survey estimates.  The step one

regression line (not shown) is pulled down by the registration

data, particularly for the 1960s, giving the almost certainly

erroneous impression of rising infant mortality in the 1960s.     

  

A10. In addition, and generally applied throughout the report, it

is assumed that response errors are more likely to result in under-

estimates of child mortality than in overestimates.  Thus when two

data sets indicate very different levels, that set indicating

higher mortality is assumed, other things being equal, to be more

likely to be right.  In step two in the case of Egypt, the

registration and census data were all given zero weights.



A11. The intention of the methodology is to provide a transparent

and partially objective way of fitting a smoothed trend to a set of

observations, and of extrapolating the trend to cover the period

from 1960 to the present.  However, there are subjective judgements

which still have to be made.  Step one depends on the weights

selected for different types of data.  At the same time, while

analysts might choose different weights, the weights used in the

report are broadly supported by robust regression results.  It is

in the second step that subjective judgements are likely to have a

significant impact - primarily in the decision as to whether, and

if so by how much, to underweight entire data sets.



    Country specific results

    

A12. Each of the 83 countries reported has its own two page section

which is divided into four parts.  The first part lists the data

sets used in the analysis, and gives both the initial and final

weights utilized in the model fitting.  The second part notes any

unusual characteristics of the application, such as overriding an

apparent trend when extrapolating child mortality on the basis of

known periods of civil disruption.  The third part summarizes the

results of the model in the form of estimates of under-five

mortality and infant mortality for the period 1960 to 1992.  In

addition to the mortality estimates, the time period coefficients

estimated by the model and the implied annual rates of change for

five year periods are also given.  The fourth section presents

graphs showing all available observations of infant and under-five

mortality by source, together with the fitted trend line.



-------------------------------------------------------------------

Source Key for Figure A1



Figure A1: Egypt infant mortality



CENSi76   - Census, 1976, indirect estimates

EFSd80    - Egyptian fertility survey, 1980, direct estimates

EFSi80    - Egyptian fertility survey, 1980, indirect estimates

ECPSi84   - Egypt contraceptive prevalence survey, 1984, indirect 

            estimates 

CENSi86   - Census, 1986, indirect estimates

EDHSd89   - Egypt demographic and health survey, 1988-89, direct  

            estimates 

EDHSi89   - Egypt demographic and health survey, 1988-89, indirect 

            estimates 

EPSd91    - Egypt papchild survey, 1991, direct estimates

EPSi91    - Egypt papchild survey, 1991, indirect estimates Vital 

            reg.- Vital registration, 1960-87

Estimates - Regression estimates from step two.



-------------------------------------------------------------------

                     AGENCY PROFILES





The World Bank (IBRD)



     In the area of common data systems for monitoring child and

maternal mortality, the World Bank uses the indicators published by

UNICEF and WHO.  Both the under-five mortality rate and the

maternal mortality ratio are considered "priority poverty

indicators" that are required by the Bank's Operational Directives

to be included in Bank country economic reports. The Bank has also

started to incorporate surveillance of both outcome and process

indicators for reproductive health into project design and imple-

mentation for several projects currently under preparation.  A

paper on indicators for reproductive health projects is currently

in the final stages of preparation.  The difficulties in measuring

under-five and maternal mortality described in the report of the

working group are well recognized, and the Bank endorses the

efforts of WHO and UNICEF to improve the data, including the use of

model-based maternal mortality estimates.





United Nations Population Fund (UNFPA)



     Since its inception, UNFPA has encouraged and supported

national efforts to formulate and implement population policies,

helping developing countries to establish population planning units

and has funded population analysis and research, as well as data

collection activities.  It has also provided support for national

capacity building through training programmes at the national,

regional and global levels.  Establishing a common approach to

national capacity building in tracking child and maternal mortality

form an integral part of UNFPA's support to data collection and

analysis activities.  UNFPA provides support to numerous population

and housing censuses.  This is crucial in sub-Saharan Africa, where

such support has enabled newly independent countries to undertake

their first modern population censuses.  Additionally, the Fund

supported demographic surveys, such as the World Fertility Survey

(WFS) programme, and more recently the PAPCHILD surveys undertaken

in the Arab States.  UNFPA's future strategy with regards to a

common approach to national capacity building will maintain its

emphasis on strengthening national data systems and analytical

capabilities to provide timely and relevant information for policy

formulation, programme development and monitoring, including

support to intersectoral and  inter-disciplinary efforts to

streamline existing national and international approaches to

generate and disseminate data.  Special emphasis will be given to

the development of innovative methodologies to generate,

disseminate and use data in population and related areas.  UNFPA

will support the development of data systems that generate

information that is disaggregated by gender as well as by

geographic areas.  UNFPA has, post ICPD, undertaken a number of

initiatives directed at the improvement of monitoring reproductive

health and family planning activities.  The Fund is currently

undertaking a pilot project aimed at establishing the feasibility

of a system for the global monitoring of key indicators of family

planning and reproductive health programmes.  UNFPA is also

spearheading an international initiative, with the active

participation of the United Nations and bilateral agencies and

organisations, to help establish comprehensive national and

international data bases on reproductive health and family

planning, inter alia, to facilitate the assessment of needs and the

development of indicators including those measures agreed upon to

track child and maternal mortality.



-------------------------------------------------------------------

United Nations Children's Fund (UNICEF)



     In response to the ICPD Programme of Action recommendations,

UNICEF will build on its on-going work, with other United Nations

agencies, in assisting countries to strengthen their capacity to

monitor progress toward the World Summit for Children goals and

thus better address the ICPD goals.  Most recently, UNICEF, in

collabora-tion with WHO, UNFPA, UNESCO, the UN Statistical Division

and regional centres of excellence, has been helping countries to

build a statistical base for reporting progress towards specific

goals at mid-decade.  A key objective in monitoring has been to

bring together the users and producers of data and to ensure that

policy makers have access to understandable and current information

to make decisions for programme and policy formulation, development

and implementation.  This has been a particular concern of UNICEF

in tracking child mortality levels.  In tracking maternal mortality

particular emphasis is being placed on process indicators (i.e.,

indicators which monitor the processes which are known to reduce

maternal mortality, including indicators which measure improvements

in access to, utilization of and the quality of Emergency Obstetric

Care services). UNICEF has issued a  set of guidelines for

monitoring progress in maternal mortality reduction which include

a detailed description of the measurement issues and proposes a

series of process indicators with a methodology for collecting the

data needed to calculate these indicators.  In addition, UNICEF, in

collaboration with WHO, is in the process of developing model-based

estimates of maternal mortality for those countries which have no

data at all or very weak data on maternal mortality.



-------------------------------------------------------------------

World Health Organization (WHO)



     WHO maintains global bibliographic and indicator databases on

maternal mortality and associated women's health issues including

coverage of maternity care, unsafe abortion, infertility, anemia in

pregnancy, and fertility.  The maternal mortality database

comprises studies bringing together information on a country-by-

country basis of all that is known about maternal mortality - the

dimensions of the problem, causes and avoidable factors and the

populations most at risk.  This information provides the

foundations upon which the regional and global estimates of

maternal mortality and morbidity are made.  The databases are

available on diskette and have been widely distributed to

countries, WHO Regional Offices, international agencies and

researchers around the world.  Tabulations of the indicators are

reissued at regular intervals.  WHO also convenes meetings of

experts and produces guidelines on measurements issues, including

methods for assessing maternal mortality at community level,

indicators for monitoring progress towards the attainment of

maternal health goals,  and methodologies for measuring maternal

morbidity.  Guidelines on verbal autopsy for maternal deaths and

conducting maternal death audits at facility level are currently in

preparation.  WHO is working with developing countries to improve

health information systems in general and in particular to increase

national capacity to gather and analyse basic information on

births, deaths and cause of death.  WHO's philosophy is that all

data collection should be seen as a means towards an end rather

than an end in itself.  It is, therefore, recommended that in the

context of maternal health indicators, countries focus increasingly

on perfor-mance-based measures such as maternal audit, surveillance

and other process measures.  Such programme indicators should be

useful for policy-making and be generated through data collection

procedures that are useful for programme management at the level at

which the data are collected.




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