UN Population Division, Department of Economic and Social Affairs,
with support from the UN Population Fund (UNFPA)
|
| UN Population Division, Department of Economic and Social Affairs, with support from the UN Population Fund (UNFPA) |
|
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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.
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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.
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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].
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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.
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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.
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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.
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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.