These include:
- lack of knowledge or understanding of the civil registration
process among large sections of the population.
- insufficient staff numbers and among them relatively low
qualification levels.
- insufficient number of civil registration centres to adequately
serve remote populations.
- lack of computerization of the civil registration procedures,
to mention a few.
- relativiely intractable problems
- data resources
- quality issues
- laxk of staff resources
- lack of adequate financial resourses
- insufficient technical capabilities
- insufficient relevance
Sources of Data to measure--
- Vital registration
- Sample vital registration
- Reproductive Age Mortality Studies (RAMOS)
- Large population-based surveys
- National population censuses
- Facility-based studies
- Statistical models (UNICEF/UNFPA/WHO/World Bank estimates)
1. Vital Registration
Systems:-
Advantage
- Some data exist in most countries (not all report to UN
agencies)
- Continuous recording
- Relatively large numbers of events.
Disadvantage
- Well documented under-reporting in both High Income (HIC) and
Low or Middle Income (LMIC) countries
- Reasons vary by setting
- Provided MMRs for only 15% of global births in global
estimates
Low or Middle Income Countries
- Frequently female deaths from all causes are underrecorded
- Lack of incentive to report vital events
- Differential under-reporting by sex
- Even with complete reporting of deaths, poor classification of
cause of death
2. Sample Vital Registration
Systems
- Requires considerable administrative sophistication
- Cannot be implemented rapidly
- Needs periodic evaluation
3. Reproductive Age
Mortality Studies (RAMOS)
Relies on multiple sources of data to identify adult female
deaths:
- Vital registration, medical records, undertaker, TBA, mother’s
groups, market, newspaper, verbal autopsy (“triangulation”)
- Almost impossible without reasonable
Once adult female deaths have been identified, a verbal autopsy
or medical records or a combination of both are used to determine
cause of death
Advantages
- More complete reporting of maternal deaths
- Allows for important data collection on avoidable causes of
death both in facilities and at home (care-seeking behavior).
Disadvantages
- Expensive and labor-intensive
- Should be considered generally in settings with 60%+
completeness of reporting for adult female deaths in vital
registration
- Rarely carried out at a national level.
- Approach to data collection varies by country
- Does not provide number of births (for MM Ratio).
4. Large Population-Based
Surveys three method:-1. The original sisterhood
method,
2. Sibling history-based method:-
- Relies on direct estimation—demographic techniques in which all
required data to produce an estimate are available
- Consists of an additional module added to women’s individual
survey
- More demanding data requirements.
Advantages
- Provides all information required to estimate pregnancy-related
mortality, including fertility
- Also provides estimates of male and female allcause mortality
between ages 15 and 50
- Relatively inexpensive
Disadvantages
- Given “standard” sample sizes, generates large sampling
errors
- Only produces national level estimate
- May preclude use of other modules (“crowding out”)
- Requires complex data processing
- Evidence of under-reporting of adult deaths in recent period—
unclear how to adjust
3. Identification of all female deaths in the household in some
reference period:-
- Measures pregnancy-related mortality (PRMR) (No realistic
possibility for verbal autopsy).
- May under-estimate overall mortality (and hence PR mortality
also): under-records high mortality sibships
- Even in surveys of 30,000 households, estimates are generally
made for 7 years before survey (small numbers)
5. Censuses with Questions on
Deaths
- Population censuses can include questions on deaths in
households in defined recent reference period.
- Reported deaths of women of reproductive age trigger additional
questions about the timing of death relative to pregnancy.
- Issues:
- Pregnancy-related mortality (unless
combined with Verbal Autopsy)
- Census misses deaths in
single-person households Death of leading household figure may
result in breakup of household
- Experience suggests there is almost
always some underreporting
- Need to evaluate carefully,
6.
Facility-Based Studies
- Useful for identifying areas for
improved care (confidential enquiries)
- Potential for gold standard case
identification (case notes)
- Facility deaths (and births) are
selected on characteristics that may not be known
- Not readily generalizable to a
national MMR estimate (unless selection probabilities are
known)
General Problems with MM
Measurement
- Rare events (only ~ 5% of child
deaths)
- National trends unstable over short
periods
- For household surveys requires very
large samples
- Certain types of maternal death
hard to identify (especially abortion-related)
- Non-VR methods generally measure
pregnancyrelated mortality PRMR
-------Maternal mortality is
difficult to measure accurately, even in countries with complete
VR
-------In countries lacking complete
VR, no approach is guaranteed to give accurate estimates
- Data need careful evaluation
- Periodic measurement by multiple
methods is recommended
- Estimation of short-term trends not
feasible
- In absence of verbal autopsy,
estimates are of pregnancy-related mortality
------In the long run, essential to
improve Vital Registration.