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Discussion Questions for Case 1: Saving Mothers’ Lives in Sri Lanka 4. In Sri Lanka, the...

Discussion Questions for Case 1: Saving Mothers’ Lives in Sri Lanka 4. In Sri Lanka, the government’s ability to track trends in maternal deaths through the vital registration system was important to the implementation of their program. What are some of the difficulties that poor countries face in developing such systems? What alternatives to vital registration are used to measure maternal mortality? What are the pros and cons of alternative approaches?

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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

  1. Some data exist in most countries (not all report to UN agencies)
  2. Continuous recording
  3. Relatively large numbers of events.

Disadvantage

  1. Well documented under-reporting in both High Income (HIC) and Low or Middle Income (LMIC) countries
  2. Reasons vary by setting
  3. 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

  1. More complete reporting of maternal deaths
  2. Allows for important data collection on avoidable causes of death both in facilities and at home (care-seeking behavior).

Disadvantages

  1. Expensive and labor-intensive
  2. Should be considered generally in settings with 60%+ completeness of reporting for adult female deaths in vital registration
  3. Rarely carried out at a national level.
  4. Approach to data collection varies by country
  5. 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:
  1. Pregnancy-related mortality (unless combined with Verbal Autopsy)
  2. Census misses deaths in single-person households Death of leading household figure may result in breakup of household
  3. Experience suggests there is almost always some underreporting
  4. 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.


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