measuring maternal mortality using census data in developing countries tiziana leone lse department...
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Measuring maternal mortality using census
data in developing countries
Tiziana LeoneLSE
Department of Social Policy
Outline
Definitions Background Objectives and rationale Lesotho and Nicaragua Methods Results Discussion and future work
Definition
A maternal death is 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 causes.
WHO, 1993
Measures of Maternal Mortality
000,100#
#X
livebirths
athsmaternaldeMMRatio
000,14915#
#X
women
athsmaternaldeMMRate
Background
Pressure to get the indicators right to measure progress of MDG 5
Vital registration not sufficient to record maternal deaths
Maternal mortality ‘rare’ event: sample surveys need big sample in order to collect enough information
Census has been recommended in countries that lack complete vital registration
Advantages and Disadvantages using Census Data to Estimate
MMRateAdvantages:
• No problems with sample size• It is possible to study differentials• Evaluation methods are well developed• It’s cheap!
Disadvantages:
• Basic data need evaluation and adjustments• Only every 10 years (normally)• Methods Have Strong Assumption (e.g.:no migration) • Estimates are for intercensal period, not a specific period
Objectives
Apply methodology to two different settings : Nicaragua and Lesotho
Analyse feasibility of methods Develop methods in order to
estimate differential mortality
Lesotho and Nicaragua
Population TFR MMR GDP per capita
Net migration
HIVprevalence
Lesotho 1.8m 3.5 730 $1,300 -0.78 ‰ 23%
Nicaragua
5.7m 3.2 83-170 $2,600 -1.13‰ 0.2%
MethodsSeries of evaluations methods based on demographic ‘indirect techniques’ with adjustments when needed. Hill et al 2001.
Check degree of death coverage in the population
General Growth BalanceCheck quality of fertility data
P/F RatioCheck quality of information on pregnancy related deaths
No formal methods.
General growth balanceBased on the balance population equation
r = b – d or (rearranging) b – r = d
b=crude birth rater=growth rated=crude death rate.
Assumes absence of migration and that the completeness of coverage of the deaths is c, constant at all ages.The observed age-specific mortality rates are therefore equal to the true rates multiplied by c, or that the true rates are equal to the observed rates divided by c:
b(x+) – r(x+) = {1/c}*dobs(x+)
C=adjustment factor calculated using regression models
Mortality CheckGeneral Growth Balance - Lesotho, female, 1986-1996
0.0000
0.0100
0.0200
0.0300
0.0400
0.0500
0.0600
0.0000 0.0050 0.0100 0.0150 0.0200 0.0250 0.0300
Death Rate x+
En
try -
Gro
wth
Rate
x+
Observed values
Fitted values
General Growth Balance - Nicaragua, female, 1995-2005
0.0000
0.0100
0.0200
0.0300
0.0400
0.0000 0.0100 0.0200 0.0300 0.0400 0.0500
Death Rate x+
En
try
- G
row
th R
ate
x+
Observed values
Fitted values
Regression line fitted for (5+)-(65+)
Fertility Check
ASFR, Lesotho 1996
0.0000
0.0200
0.0400
0.0600
0.0800
0.1000
0.1200
0.1400
0.1600
0.1800
0.2000
15-19 20-24 25-29 30-34 35-39 40-44 45-49
Age specific fertility rates Nicaragua, 2005
0.0000
0.0200
0.0400
0.0600
0.0800
0.1000
0.1200
0.1400
15-19 20-24 25-29 30-34 35-39 40-44 45-49
Plausibility checks
Proportions of Births and Pregnancy-Related Deaths, Lesotho 1996
0.00
0.05
0.10
0.15
0.20
0.25
0.30
0.35
0.40
0 1 2 3 4 5 6
Age Group
Pro
po
rtio
n
Births
Preg-Related Deaths
Proportions of Births and Pregnancy-Related Deaths, Nicaragua 2005
0.00
0.05
0.10
0.15
0.20
0.25
0.30
0.35
0.40
0 2 4 6 8
Age Group
Pro
po
rtio
n
Births
Preg-Related Deaths
MMR
Census UNICEF estimate
UNDP
Lesotho 532 (1996) 550 (2000) 530 (1996)
Nicaragua 135 (2005) 170 (2005) 230 (2000)
Age specific PRMR
Age specific PRMR, Lesotho 1996
0
200
400
600
800
1000
15-19 20-24 25-29 30-34 35+
Age
PR
MR
Age Specific PRMR, Nicaragua 2005
0
500
1000
1500
2000
2500
15-19 20-24 25-29 30-34 35-39 40-44 45-49
Age
PR
MR
Age spefic PRMP, Nicaragua 2005-shorter age range
0
50
100
150
200
250
300
15-19 20-24 25-29 30-34 35-39
Series1
DiscussionWe are estimating an intercensal value and not a specific period
Careful interpretation of results
We need to explore more ways to get formal methods to estimate pregnancy related deaths
Census data give reasonable estimatesBest way forward in absence of Vital registration
Very little additional information needed
Need for more advocacy and training
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