Informe Muerte Materna

8/20/2019 Informe Muerte Materna

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Trends in

Maternal Mortality:

1990 to 2015Estimates by WHO, UNICEF, UNFPA, World Bank Group

and the United Nations Population Division


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Trends in maternal mortality:

1990 to 2015

Estimates by WHO, UNICEF, UNFPA, World Bank Group

and the United Nations Population Division


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WHO Library Cataloguing-in-Publication Data

Trends in maternal mortality: 1990 to 2015: estimates by WHO, UNICEF, UNFPA, World Bank Group and the United

Nations Population Division.

1.Maternal Mortality - trends. 2.Maternal Welfare. 3.Data Collection - methods. 4.Models, Statistical. I.World Health

Organization. II.World Bank. III.UNICEF. IV.United Nations Population Fund.

ISBN 978 92 4 156514 1 (NLM classification: WQ 16)

PRE-PUBLICATION VERSION

© World Health Organization 2015

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Box 2Estimating trends for countries with improving data quality

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0454 J72/51 5K-7IPK7I5 5K. :;;


21/199

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Box 2

Estimating trends for countries with improving data quality

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22/199

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?8 R7I/5-8S

Box 3

Categorization of VR data retrieved from CRVS systems (country-year records) based

on usability and availability

"2%&.#5? "51%&512

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23/199

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28/199

15

Box 4

Accurately interpreting point-estimates and uncertainty intervals

the true value lies below 216.

• There is an 80% chance that the true 2015 global MMR lies between 207 and 249.

• There is still a 10% chance that the true 2015 global MMR lies above 249, and a 10% chance

that the true value lies below 207.

Other accurate interpretations include:

• We are 90% certain that the true 2015 global MMR is at least 207.

• We are 90% certain that the true 2015 global MMR is 249 or less.

The amount of data available for estimating an indicator and the quality of that data determine the width

of an indicator’s UI. As data availability and quality improve, the certainty increases that an indicator’s

true value lies close to the point-estimate.


29/199

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Latin Americai B> B >>> $ @$ >#=

Caribbeanm

$D@ $ 5>> 5 "> $#@

Oceanian $LD @>> $ 5 >#B

4S TT& .152345.1 K4M. ?../ -7I/0.0 4RR7-02/P 57 5K. V7667`2/P 1RK.3.9 u :


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[1.95& CJ =Z 57 :[ 57 ;_ U K4M. 67` TT&S

,K-.. R7I/5-2.1 7I5120. 5K. 1I?QO4K4-4/ )V-2R4/ -.P27/ K4M. K2PK TT&9 )VPK4/2154/ ]W;\c CE =>W 57\=c CE =ZX 57 >[=_ 4/0 A4252 ]W>;c CE =W\ 57 \[


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O2.--4 N.7/. `25K 4/ 4JJ-7f2345. 62V.523. -21H 7V : 2/ :ZB 4/0 "K40 `25K 4/ 4JJ-7f2345. 62V.523. -21H

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T2@,& UJ "#/;251'#$ #4 /2%&5$2, /#5%2,1%? 52%1# Q

Developed

regionsd "5 5 @>> $" $ D>> :L "#B 5#5 "#"

Developing

regions :5> @"= >>> "5= 5>" >>> :: "#: $#5 5#$

Northern Africae $D$ B :>> D> 5 $>> @= 5#B :#$ 5#"

Sub-Saharan

Africaf =LD ""5 >>> @:B ">$ >>> :@ "#: $#@ "#=

Eastern Asiag =@ "B >>> "D : L>> D" @#> :#L @#>

Eastern Asia

excluding

China @$ @=> :5 5L> $B >#D ?5#> 5#$

Southern Asia @5L "$> >>> $DB BB >>> BD :#@ 5#B @#$

Southern Asia

excluding

India :=@ @D L>> $L> "$ >>> B: :#$ "#@ @#$

South-eastern

Asiai 5"> 5= >>> $$> $5 >>> BB :#5 :#D :#>

Western Asia $B> B D>> =$ : D>> :5 "#" "#D $#=

Caucasus and

Central Asiak B= $ 5>> 55 B$> @" 5#> 5#$ "#=

Latin America

and the $5@ $B >>> BD D 5>> @> "#L 5#$ "#B


37/199

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TL* -.P27/ :;;< = o RK4/P.

2/ TT&

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]:[ .fJ.-2./R.0 4 0.R62/. 2/ TT& ?.5`../ :;;< 4/0 =S F7- 5K. -.342/2/P

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J72/5Q.152345.1 1IPP.15 5K45 == 7V 5K.3 62H.68 .fJ.-2./R.0 4 0.R-.41. 4/0 X 62H.68 .fJ.-2./R.0 4/

2/R-.41.S

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= 7V Z>o 7- 37-. K4M. 4RK2.M.0 TL* >) U 5K.8 K4M. ?../ J64R.0 2/ 5K. V2-15 R45.P7-8S ,K.

1.R7/0 R45.P7-8B 5K71. R7I/5-2.1 5K45 4-. 34H2/P J-7P-.11B 2/R6I0.1 W; R7I/5-2.1 `25K 4/ .152345.0

TT& -.0IR527/ 7V > ,K. TT& RI5Q7VV 7V :


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.152345.0 TT& -.0IR527/ 7V =>o 7- 37-.B 4/0 45 6.415 4 ;oB 7- 4 P-.45.- 5K4/ :) 54-P.5S

)//.f :[ 021J6481 R45.P7-8 64?.61 V7- 466 ;> R7I/5-2.1S

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GKI54/B "43?7024B "4?7 $.-0.B 5K. E16432R &.JI?62R 7V E-4/B 5K. N47 (.7J6.d1 L.37R-452R &.JI?62RB

T4602M.1B T7/P7624B &`4/04 4/0 ,237-QN.15.S n.5B 437/P 5K.1. R7I/5-2.1 5K.-. 21 1I?154/5246

M4-24527/ 2/ 5K. 6.M.6 7V R.-542/58 7V 5K21 4RK2.M.3./5S )1 2/02R45.0 ?8 I/R.-542/58 2/5.-M461 ]7/68

"43?7024 4/0 T4602M.1 K4M. 4 P-.45.- 5K4/ ;o

7- 37-.S F7- 5K. 75K.- 1.M./B 4 :o ]1.. ,4?6. X_B 466

0.37/15-45.0 1I?154/5246 J-7P-.11B J4-52RI64-68 4V5.- 4//7I/R.3./5 7V 5K. TL*1 2/ =


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@K26. 02VV.-2/P R7/5.f51 34H. 211I2/P J-.1R-2?.0 -.0IR527/ 15-45.P2.1 23J7112?6.B .f432/2/P 5K.

15-45.P2.1 .3J678.0 ?8 1IRR.11VI6 R7I/5-2.1 R4/ 266I32/45. -7I5.1 5K45 75K.- R7I/5-2.1 348 V2/0

I1.VI6S A7`.M.-B 5K. W< R7I/5-2.1 `25K 5K. K2PK.15 TT&1 2/ = `266 K4M. 57 4RK2.M. 1I?154/524668

K2PK.- 4//I46 -45.1 7V -.0IR527/ 57 45542/ TT&1 ?.67` :X< 2/ =


43/199

30

Box 6

Strategies driving success in reducing maternal mortality

UVWg4 0&.&2'+< 679+-4(&* '()*(+,-+. (/0*)1. +21-2, 3)+4+2(*56+ 7*(+)2*6 7/)(*6-(8

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/2* 9*$"C& @#02>() ": %0$& 0., &@#>()

• %)2,)+-/ -2'0)*7.&* 60).&*70&4 /' '(& 1/.-+-'


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K.465K 1815.31 4/0 2/V-415-IR5I-.B 2/ 4002527/ 57 251 02-.R5 K.465K 23J4R51S %3.-P./5 KI34/254-24/

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E/0..0B Z\o 7V K2PK 345.-/46 37-546258 R7I/5-2.1 ]5K71. `25K TT& w W


45/199

32

Box 7

Tools for improving data collection

H".:>,&.(>02 F.@#>$) >.(" I0(&$.02 J&0(;- KHFIJL

U-'(-2 &4'/9+-4(&* .-8-+ 0&,-4'0/'-)2 /2* 8-'/+ 4'/'-4'-.4 H;T_AI 4c 3)0& 3/'&02/+ *&/'(4O 0&46&.'-8&+220.%& 0., M&-*".-& KIJ!ML

M' '(& (&/+'(S./0& 1/.-+-'< +&8&+O %FAT 4.."C0(>".-

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2/'-)2/+ (&/+'( 4H@S

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F2/4668B 0454 5K45 R4/ ?. 0214PP-.P45.0 57 .f432/. 5-./01 4/0 3.41I-. 5K. 37-546258 ?I-0./ `25K2/

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UJS ( )2,, %# 2)%1#$

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0&4&5&$)&'

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=_S

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=


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D7M.3?.- =_S

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G4/P640.1K9 4 "7I/507`/ 57 = R7I/5-8 R41. 15I08S N4/R.5S =:_9:W\\QZXS

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D7M.3?.- =_S

=;S T45.-/46 4/0 (.-2/4546 T7-?20258 4/0 T7-546258 &.M2.` "733255..S T45.-/46 0.45K1 2/ 5K.

T4602M.19 =


50/199

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J0V B 4RR.11.0 > D7M.3?.- =_S

W;S T.K6 *B N4?-2aI. )S (-27-252Y2/P 2/5.P-45.0 3A.465K 15-45.P2.1 V7- I/2M.-146 K.465K

R7M.-4P.S OR2./R.S =]\=


51/199

38

($$&B&'


52/199

Annex 1. Summary of the country consultations 2015

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53/199

Annex 2. Measuring maternal mortality

Concepts and definitions

In the International statistical classification of diseases and related health problems, 10th revision

(ICD-10),1 WHO defines maternal death 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 (from direct or indirect obstetric death), but not from accidental or incidental

causes.

This definition allows identification of maternal deaths, based on their causes, as either direct or

indirect. Direct maternal deaths are those resulting from obstetric complications of the pregnant

state (i.e. pregnancy, delivery and postpartum), interventions, omissions, incorrect treatment, or a

chain of events resulting from any of the above. Deaths due to, for example, obstetric

haemorrhage or hypertensive disorders in pregnancy, or those due to complications ofanaesthesia or caesarean section are classified as direct maternal deaths. Indirect maternal deaths

are those resulting from previously existing diseases, or from diseases that developed during

pregnancy and that were not due to direct obstetric causes but aggravated by physiological

effects of pregnancy. For example, deaths due to aggravation of an existing cardiac or renal

disease are considered indirect maternal deaths.

The concept of death during pregnancy, childbirth and the puerperium is included in the ICD-10

and is defined as any death temporal to pregnancy, childbirth or the postpartum period, even if it

is due to accidental or incidental causes (this was formerly referred to as “pregnancy-related

death”, see Box 1). This alternative definition allows measurement of deaths that are related to

pregnancy, even though they do not strictly conform to the standard “maternal death” concept, in

settings where accurate information about causes of death based on medical certificates is

unavailable.

For instance, in population-based surveys, respondents provide information on the pregnancy

status of a reproductive-aged sibling at the time of death, but no further information is elicited on

the cause of death. These surveys – for example, the Demographic and Health Surveys and

Multiple Indicator Cluster Surveys – therefore, usually provide measures of pregnancy-related

deaths rather than maternal deaths.

Further, complications of pregnancy or childbirth can lead to death beyond the six weeks

postpartum period, and the increased availability of modern life-sustaining procedures and

technologies enables more women to survive adverse outcomes of pregnancy and delivery, and to

delay death beyond 42 days postpartum. Despite being caused by pregnancy-related events,

these deaths do not count as maternal deaths in routine civil registration systems. Specific codes

for “late maternal deaths” are included in the ICD-10 (O96 and O97) to capture delayed maternal

deaths occurring between six weeks and one year postpartum (see Box A2.1). Some countries,

particularly those with more developed civil registration systems, use this definition.

1 International statistical classification of diseases and related health problems, tenth revision. Vol. 2: Instruction manual.

Geneva: World Health Organization; 2010.


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Box A2.1

Definitions related to maternal death in ICD-10

Maternal death

The death of a woman while pregnant or within 42 days of termination ofpregnancy, irrespective of the duration and site of the pregnancy, from any cause

related to or aggravated by the pregnancy or its management (from direct or

indirect obstetric death), but not from accidental or incidental causes.

Pregnancy-related death

The death of a woman while pregnant or within 42 days of termination of

pregnancy, irrespective of the cause of death.

Late maternal deathThe death of a woman from direct or indirect obstetric causes, more than 42 days,

but less than one year after termination of pregnancy.

Coding of maternal deaths

Despite the standard definitions noted above, accurate identification of the causes of maternal

deaths is not always possible. It can be a challenge for medical certifiers to correctly attribute

cause of death to direct or indirect maternal causes, or to accidental or incidental events,

particularly in settings where most deliveries occur at home. While several countries apply the ICD-

10 in civil registration systems, the identification and classification of causes of death during

pregnancy, childbirth and the puerperium remain inconsistent across countries.

With the publication of the ICD-10, WHO recommended adding a checkbox on the death

certificate for recording a woman’s pregnancy status at the time of death.2 This was to help

identify indirect maternal deaths, but it has not been implemented in many countries. For

countries using ICD-10 coding for registered deaths, all deaths coded to the maternal chapter (O

codes) and maternal tetanus (A34) are counted as maternal deaths.

In 2012, WHO published Application of ICD-10 to deaths during pregnancy, childbirth and the

puerperium: ICD maternal mortality (ICD-MM) to guide countries to reduce errors in coding

maternal deaths and to improve the attribution of cause of maternal death.3 The ICD-MM is to beused together with the three ICD-10 volumes. For example, the ICD-MM clarifies that the coding of

maternal deaths among HIV-positive women may be due to one of the following.

• Obstetric causes: Such as haemorrhage or hypertensive disorders in pregnancy – these should

be identified as direct maternal deaths.

• The interaction between human immunodeficiency virus (HIV) and pregnancy : In these cases,

there is an aggravating effect of pregnancy on HIV and the interaction between pregnancy

2 International statistical classification of diseases and related health problems, tenth revision. Vol. 2: Instruction manual.


3 Application of ICD-10 to deaths during pregnancy, childbirth and the puerperium: ICD maternal mortality (ICD-MM).



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and HIV is the underlying cause of death. These deaths are considered as indirect maternal

deaths. In this report, they are referred to as “AIDS-related indirect maternal deaths”, and in the

ICD those deaths are coded to O98.7 and categorized in Group 7 (non-obstetric complications)

in the ICD-MM.

• Acquired immunodeficiency syndrome ( AIDS): In these cases, the woman’s pregnancy status is

incidental to the course of her HIV infection and her death is a result of an HIV complication, as

described by ICD-10 codes B20–24. These are not considered maternal deaths. Thus, proper

reporting of the mutual influence of HIV or AIDS and pregnancy in Part 1 of the death

certificate will facilitate the coding and identification of these deaths.

Measures of maternal mortality

The extent of maternal mortality in a population is essentially the combination of two factors:

(i) The risk of death in a single pregnancy or a single live birth.

(ii) The fertility level (i.e. the number of pregnancies or births that are experienced by women ofreproductive age).

The MMR is defined as the number of maternal deaths during a given time period per 100 000 live

births during the same time period. It depicts the risk of maternal death relative to the number of

live births and essentially captures (i) above.

By contrast, the maternal mortality rate (MMRate) is defined as the number of maternal deaths in a

population divided by the number of women aged 15–49 years (or woman-years lived at ages 15–

49 years). The MMRate captures both the risk of maternal death per pregnancy or per total birth

(live birth or stillbirth), and the level of fertility in the population. In addition to the MMR and the

MMRate, it is possible to calculate the adult lifetime risk of maternal mortality for women in the

population (see Box A2). An alternative measure of maternal mortality, the proportion of maternal

deaths among deaths of women of reproductive age (PM), is calculated as the number of maternal

deaths divided by the total deaths among women aged 15–49 years.

Box A2.2

Statistical measures of maternal mortality

Maternal mortality ratio (MMR)

Number of maternal deaths during a given time period per 100 000 live births during the

same time period.

Maternal mortality rate (MMRate)

Number of maternal deaths divided by person-years lived by women of reproductive age.4

4 Wilmoth J, Mizoguchi N, Oestergaard M, Say L, Mathers C, Zureick-Brown S, et al. A new method for deriving global

estimates of maternal mortality: supplemental report. Stat Politics Policy. 2012;3(2):1–38.


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Box A2.2

Statistical measures of maternal mortality

Adult lifetime risk of maternal death

The probability that a 15-year-old woman will die eventually from a maternal cause.

The proportion of maternal deaths among deaths of women of reproductive age (PM)

The number of maternal deaths in a given time period divided by the total deaths among

women aged 15–49 years.

Approaches for measuring maternal mortality

Ideally, civil registration systems with good attribution of cause of death provide accurate data on

the level of maternal mortality and the causes of maternal deaths. In countries with incomplete

civil registration systems, it is difficult to accurately measure levels of maternal mortality. First, it is

challenging to identify maternal deaths precisely, as the deaths of women of reproductive age

might not be recorded at all. Second, even if such deaths were recorded, the pregnancy status or

cause of death may not have been known and the deaths would therefore not have been reported

as maternal deaths. Third, in most developing-country settings where medical certification of

cause of death does not exist, accurate attribution of a female death as a maternal death is

difficult.

Even in developed countries where routine registration of deaths is in place, maternal deaths may

be underreported due to misclassification of ICD-10 coding, and identification of the true numbersof maternal deaths may require additional special investigations into the causes of death. A

specific example of such an investigation is the Confidential Enquiry into Maternal Deaths (CEMD),

a system established in England and Wales in 1928.5,6,7 The most recent report of the CEMD (for

2009–2011) identified 79% more maternal deaths than were reported in the routine civil

registration system.8 Other studies on the accuracy of the number of maternal deaths reported in

civil registration systems have shown that the true number of maternal deaths could be twice as

high as indicated by routine reports, or even more.9,10 Annex 6 summarizes the results of a

5 Lewis G, editor. Why mothers die 2000–2002: the confidential enquiries into maternal deaths in the United Kingdom.

London: RCOG Press; 2004.

6 Lewis G, editor. Saving mothers’ lives: reviewing maternal deaths to make motherhood safer 2003–2005. The seventh

report on confidential enquiries into maternal deaths in the United Kingdom. London: Confidential Enquiry into

Maternal and Child Health (CEMAH); 2007.

7 Centre for Maternal and Child Enquiries (CMACE). Saving mothers’ lives: reviewing maternal deaths to make

motherhood safer: 2006–2008. The eighth report on confidential enquiries into maternal deaths in the United Kingdom.

BJOG. 2011;118(Suppl.1):1–203. doi:10.1111/j.1471-0528.2010.02847.x.

8 Knight M, Kenyon S, Brocklehurst P, Neilson J, Shakespeare J, Kurinczuk JJ, editors (on behalf of MBRRACE-UK). Saving

lives, improving mothers’ care – lessons learned to inform future maternity care from the UK and Ireland Confidential

Enquiries into Maternal Deaths and Morbidity 2009–12. Oxford: National Perinatal Epidemiology Unit, University of

Oxford; 2014.

9 Deneux-Tharaux C et al. Underreporting of pregnancy-related mortality in the United States and Europe. Obstet

Gynecol. 2005;106:684–92.

10 Atrash HK, Alexander S, Berg CJ. Maternal mortality in developed countries: not just a concern of the past. Obstet


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literature review (updated January 2014) for such studies where misclassification on coding in civil

registration could be identified.

These studies are diverse in terms of the definition of maternal mortality used, the sources

considered (death certificates, other vital event certificates, medical records, questionnaires or

autopsy reports) and the way maternal deaths are identified (record linkage or assessment fromexperts). In addition, the system of reporting causes of death to a civil registry differs from one

country to another, depending on the death certificate forms, the type of certifiers and the coding

practice. These studies have estimated underreporting of maternal mortality due to

misclassification in death registration data, ranging from 0.85 to 5.0, with a median value of 1.5 (i.e.

a misclassification rate of 50%).

Underreporting of maternal deaths was more common among:

• early pregnancy deaths, including those not linked to a reportable birth outcome;

• deaths in the later postpartum period (these were less likely to be reported than early

postpartum deaths);

• deaths at extremes of maternal age (youngest and oldest);

• miscoding by the ICD-9 or ICD-10, most often seen in cases of deaths caused by:

o cerebrovascular diseases;

o cardiovascular diseases.

Potential reasons cited for underreporting and/or misclassification include:

• inadequate understanding of the ICD rules (either ICD-9 or ICD-10);

• death certificates completed without mention of pregnancy status;

• desire to avoid litigation;

• desire to suppress information (especially as related to abortion deaths).

The definitions of misclassification, incompleteness and underreporting of maternal deaths areshown in Box A2.3.

Box A2.3

Definitions of misclassification, incompleteness and underreporting

Misclassification

Refers to incorrect coding in civil registration, due either to error in the medical certification

of cause of death or error in applying the correct code.

Incompleteness

Refers to incomplete death registration. Includes both the identification of individual deaths

in each country and the national coverage of the register.

Gynecol. 1995;86(4 pt 2):700–5.


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Box A2.4

Approaches to measuring maternal mortality

period approximately five years prior to the survey); the analysis is more complicated.

Census14,15

A national census, with the addition of a limited number of questions, could produce estimates of

maternal mortality. This approach eliminates sampling errors (because all women are covered)

and hence allows a more detailed breakdown of the results, including trend analysis, geographic

subdivisions and social strata.

• This approach allows identification of deaths in the household in a relatively short reference

period (1–2 years), thereby providing recent maternal mortality estimates, but is conducted at

10-year intervals and therefore limits monitoring of maternal mortality.

• It identifies pregnancy-related deaths (not maternal deaths); however, if combined with

verbal autopsy, maternal deaths could be identified.

• Training of enumerators is crucial, since census activities collect information on a range of

other topics unrelated to maternal deaths.

• Results must be adjusted for characteristics such as completeness of death and birth

statistics and population structures, in order to arrive at reliable estimates.

Reproductive-age mortality studies (RAMOS)11,12

This approach involves identifying and investigating the causes of all deaths of women of

reproductive age in a defined area or population, by using multiple sources of data (e.g.

interviews of family members, civil registrations, health-care facility records, burial records,

traditional birth attendants), and has the following characteristics.

• Multiple and diverse sources of information must be used to identify deaths of women of

reproductive age; no single source identifies all the deaths.

• Interviews with household members and health-care providers and reviews of facility records

are used to classify the deaths as maternal or otherwise.

• If properly conducted, this approach provides a fairly complete estimation of maternal

mortality (in the absence of reliable routine registration systems) and could provide

subnational MMRs. However, inadequate identification of all deaths of reproductive-aged

women results in underestimation of maternal mortality levels.

• This approach can be complicated, time-consuming and expensive to undertake –

particularly on a large scale.

• The number of live births used in the computation may not be accurate, especially in settings

where most women deliver at home.

14 Stanton C et al. Every death counts: measurement of maternal mortality via a census. Bull World Health Organ.

2001;79:657–64.15 WHO guidance for measuring maternal mortality from a census. Geneva: World Health Organization; 2013.


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Box A2.4

Approaches to measuring maternal mortality

Verbal autopsy16,17,18

This approach is used to assign cause of death through interviews with family or communitymembers, where medical certification of cause of death is not available. Verbal autopsies may be

conducted as part of a demographic surveillance system maintained by research institutions that

collect records of births and deaths periodically among small populations (typically in a district).

This approach may also be combined with household surveys or censuses. In special versions,

and in combination with software that helps to identify the diagnosis, verbal autopsy is suitable

for routine use as an inexpensive method in populations where no other method of assessing the

cause of death is in place. The following limitations characterize this approach.

• Misclassification of causes of deaths in women of reproductive age is not uncommon with

this technique.

• It may fail to identify correctly a group of maternal deaths, particularly those occurring early in

pregnancy (e.g. ectopic, abortion-related) and indirect causes of maternal death (e.g.

malaria).

• The accuracy of the estimates depends on the extent of family members’ knowledge of the

events leading to the death, the skill of the interviewers, and the competence of physicians

who do the diagnosis and coding. The latter two factors are largely overcome by the use of

software.

• Detailed verbal autopsy for research purposes that aims to identify the cause of death of an

individual requires physician assessment and long interviews. Such systems are expensive

to maintain, and the findings cannot be extrapolated to obtain national MMRs. This limitation

does not exist where simplified verbal autopsy is aiming to identify causes at a population

level and where software helps to formulate the diagnoses.

16 Chandramohan D et al. The validity of verbal autopsies for assessing the causes of institutional maternal death. Stud

Fam Plann. 1998;29:414–22.

17 Chandramohan D, Stetal P, Quigley M. Misclassification error in verbal autopsy: can it be adjusted? Int J Epidemiol.

2001;30:509–14.

18 Leitao J et al. Revising the WHO verbal autopsy instrument to facilitate routine cause-of-death monitoring. Global

Health Action. 2013;6:21518.


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Annex 3. Methods used to derive a complete series of annual

estimates for each covariate, 1985–2015

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19 GDP per capita measured in purchasing power parity (PPP) equivalent dollars, reported as constant 2011 international

dollars, based on estimates published by World Bank Group. International Comparison Program database. Washington

(DC): World Bank Group; 2014.

20 World population prospects: the 2015 revision. New York: United Nations, Department of Economic and Social Affairs,

Population Division; 2015.

21 UNICEF Data: Monitoring the Situation of Children and Women [website]. New York: United Nations Children’s Fund;

2015 (http://data.unicef.org/).

22 Making pregnancy safer: the critical role of the skilled attendant: a joint statement by WHO, ICM and FIGO. Geneva:

World Health Organization; 2014.


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Annex 4. Adjustment factor to account for misclassification of

maternal deaths in civil registration, literature review of

reports and articles

Country Period/year Adjustment factor

Australiaa 1994–1996 1.23

Australiab 1997–1999 1.80

Australiac 2000–2002 1.97

Australiad 2003–2005 2.03

Austriae 1980–1998 1.61

Brazilf 2002 1.40

Canadag 1988–1992 1.69

Canadah 1997–2000 1.52

Denmark i 1985–1994 1.94

Denmark j 2002–2006 1.04

Finlandk 1987–1994 0.94

Francel Dec 1988 to

March 1989

2.38

Francem 1999 1.29

Francen 2001–2006 1.21

Franceo 2007–2009 1.21

Guatemalap 1989 1.84

Guatemalap 1996–1998 1.84

Guatemalaq 2000 1.88

Guatemalar

2007 1.73

Irelands 2009–2011 3.40

Japant 2005 1.35

Mexicou 2008 0.99

Netherlandsv 1983–1992 1.34

Netherlandsx 1993–2005 1.48

New Zealandy 2006 1.11

New Zealandz

2007 0.85

New Zealandaa 2008 1.00


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Country Period/year Adjustment factor

New Zealandbb 2009 0.92

New Zealandcc 2010 1.00

Portugaldd 2001–2007 2.04

Serbiaee 2007–2010 1.86

Singaporeff 1990–1999 1.79

Sloveniagg 2003–2005 5.00

South Africahh 1999–2001 0.98

South Africaii 2002–2004 1.16

South Africaii 2005–2007 0.90

Sweden jj 1997–2005 1.33

Swedenkk 1988–2007 1.68

United Kingdomll 1988–1990 1.39







United Statesmm 1991–1997 1.48

United Statesnn 1995–1997 1.54

United Statesoo 1999–2002 1.59

United Statesoo 2003–2005 1.41

Median 1.5

a AIHW, NHMRC. Report on maternal deaths in Australia 1994–96. Cat. no. PER 17. Canberra: AIHW; 2001 ().

b Slaytor EK, Sullivan EA, King JF. Maternal deaths in Australia 1997–1999. Cat. No. PER 24. Sydney: AIHW National

Perinatal Statistics Unit; 2004 (Maternal Deaths Series, No. 1).

c Sullivan EA, King JF, editors. Maternal deaths in Australia 2000–2002. Cat. no. PER 32. Sydney: AIHW National


d Sullivan EA, Hall B, King JF. Maternal deaths in Australia 2003–2005. Cat. no. PER 42. Sydney: AIHW National


e Johnson S, Bonello MR, Li Z, Hilder L, Sullivan EA. Maternal deaths in Australia 2006–2010. Cat. no. PER 61. Canberra:

AIHW; 2014 (Maternal Deaths Series, No. 4).


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f Brasil Ministério da Saúde, Secretaria de Atenção à Saúde, Departamento de Ações Programáticas Estratégicas. Estudo da

mortalidade de mulheres de 10 a 49 anos, com ênfase na mortalidade materna: relatório final. Brasilia: Ministério da Saúde,

Secretaria de Atenção à Saúde, Departamento de Ações Programáticas Estratégicas, Editora do Ministério da Saúde; 2006.

g Turner LA et al. Underreporting of maternal mortality in Canada: a question of definition. Chronic Dis Can. 2002;23:22–

30.

h Health Canada. Special report on maternal mortality and severe morbidity in Canada – enhanced surveillance: the path to

prevention. Ottawa: Minister of Public Works and Government Services Canada; 2004.

i Andersen BR et al. Maternal mortality in Denmark 1985–1994. Eur J Obstet Gynecol Reprod Biol. 2009;42:124–8.

j Bødker B et al. Maternal deaths in Denmark 2002–2006. Acta Obstet Gynecol Scand. 2009;88:556–62.

k Gissler M et al. Pregnancy-associated deaths in Finland 1987–1994 definition problems and benefits of record linkage.

Acta Obstet Gynecol Scand. 1997;76(7):651–7.

l Bouvier-Colle MH et al. Reasons for the underreporting of maternal mortality in France, as indicated by a survey of all

deaths among women of childbearing age. Int J Epidemiol. 1991;20:717–21.

m Bouvier-Colle MH et al. Estimation de la mortalité maternelle en France : une nouvelle méthode. J Gynecol Obstet Biol

Reprod. 2004;33(5):421–9.

n Rapport du Comité national d’experts sur la mortalité maternelle (CNEMM) 2001–2006. Saint-Maurice: Institut de veille

sanitaire; 2010.

o Rapport du comité national d’experts sur la mortalité maternelle (CNEMM). Enquête nationale confidentielle sur les morts

maternelles France, 2007–2009 Inserm, France: Institut national de la santé et de la recherche médicale; 2013.

p Schieber B, Stanton C. Estimación de la mortalidad materna en Guatemala período 1996–1998. Guatemala; 2000.

q

Línea basal de mortalidad materna para el año 2000. Informe final. Guatemala: Ministerio de Salud Pública y AsistenciaSocial; 2003.

r Estudio nacional de mortalidad materna. Informe final. Guatemala: Secretaría de Planificación y Programación de la

Presidencia Ministerio de Salud Pública y Asistencia Social; 2011.

s Confidential Maternal Death Enquiry in Ireland, report for triennium 2009–2011. Cork: Maternal Death Enquiry; 2012.

t Health Sciences Research Grant. Analysis and recommendations of the causes of maternal mortality and infant mortality.

Tomoaki I, principal investigator. Research Report 2006–2008. Osaka: Department of Perinatology, National Cardiovascular

Center; 2009 [in Japanese].

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gynaecology]. 2009;99(1):85–95 [in Japanese].

u Búsqueda intencionada de muertes maternas en México. Informe 2008. Mexico, DF: Dirección General de Información en

Salud, Secretaría de Salud; 2010.

v Schuitemaker N et al. Confidential enquiry into maternal deaths in the Netherlands 1983–1992. Eur J Obstet Gynecol

Reprod Biol. 1998;79(1):57–62.

x Schutte J et al. Rise in maternal mortality in the Netherlands. BJOG. 2010;117(4):399–406.

y PMMRC. Perinatal and maternal mortality in New Zealand 2006: second report to the Minister of Health. Wellington:

Ministry of Health; 2009.

z PMMRC. Perinatal and maternal mortality in New Zealand 2007: third report to the Minister of Health July 2008 to June

2009. Wellington: Ministry of Health; 2009.


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aa PMMRC. Perinatal and maternal mortality in New Zealand 2008: fourth report to the Minister of Health July 2009 to June

2010. Wellington: Ministry of Health; 2010.

bb PMMRC. Fifth annual report of the Perinatal and Maternal Mortality Review Committee: reporting mortality 2009.

Wellington: Health Quality and Safety Commission; 2011.

cc PMMRC. Sixth annual report of the Perinatal and Maternal Mortality Review Committee: reporting mortality 2010.

Wellington: Health Quality and Safety Commission; 2012.

dd Gomes MC, Ventura MT, Nunes RS. How many maternal deaths are there in Portugal? J Matern Fetal Neonatal Med.

2012;25(10):1975–9.

ee Krstic M et al. Maternal deaths – methodology for cases registration and reporting. Belgrade; 2008 [unpublished paper].

ff Lau G. Are maternal deaths on the ascent in Singapore? A review of maternal mortality as reflected by coronial casework

from 1990 to 1999. Ann Acad Med Singapore. 2002;31(3):261–75.

gg Kralj E, Mihevc-Ponikvar B, Premru-Sr !enc T, Bala"ica J. Maternal mortality in Slovenia: case report and the method of

identifying pregnancy-associated deaths. Forensic Sci Int Suppl Ser. 2009;1(1):52–7.

hh Moodley J. Saving mothers: 1999–2001. S Afr Med J. 2003;93(5):364–6.

ii Saving mothers 2008–2010: fifth report on the confidential enquiries into maternal deaths in South Africa. Comprehensive

report. South Africa: Department of Health, National Committee on Confidential Enquires into Maternal Deaths; 2012.

jjGrunewald C et al. Modradodligheten underskattad i Sverige. Lakartidningen. 2008;34(105):2250–3.

kk Esscher A et al., Maternal mortality in Sweden 1988–2007: more deaths than officially reported. Acta Obstet Gynecol

Scand. 2012;92:40–6.

ll Centre for Maternal and Child Enquiries (CMACE). Saving mothers’ lives: reviewing maternal deaths to make motherhood

safer: 2006–2008. The eighth report on confidential enquiries into maternal deaths in the United Kingdom. BJOG.2011;118(Suppl.1):1–203.

mm Berg CJ et al. Pregnancy-related mortality in the United States, 1991–1997. Obstet Gynecol. 2003;101(2):289–96.

nn MacKay AP et al. An assessment of pregnancy-related mortality in the United States. Paediatr Perinat Epidemiol.

2005;19(3):206–14.

oo MacKay AP et al. Changes in pregnancy mortality ascertainment United States, 1999–2005. Obstet Gynecol.

2011;118:104–10.


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Annex 5. Usability assessment of civil registration data for

selected years (1990, 1995, 2000, 2005, 2010 and latest

available year)

Assessment of civil registration data (VR data) quality – usability

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