Prepared for the 26th IUSSP Conference, Marrakech, September 2009

Session 037: Measuring Maternal Mortality through the 2010 round of population censusesg y g f p p

Maternal Mortality in South Africa:Maternal Mortality in South Africa:update from Community Survey 2007update from Community Survey 2007update from Community Survey, 2007update from Community Survey, 2007

Michel Garenne Michel Garenne (IRD/Institut Pasteur, Paris)(IRD/Institut Pasteur, Paris)

Robert McCaaRobert McCaa (MPC/IPUMS, Minneapolis(MPC/IPUMS, Minneapolis))Robert McCaa Robert McCaa (MPC/IPUMS, Minneapolis(MPC/IPUMS, Minneapolis))

Kourtoum NacroKourtoum Nacro ((UNPFA, AngolaUNPFA, Angola))

Updated: September 17, 2009

Maternal mortality in Maternal mortality in South AfricaSouth Africa

Controversial issueControversial issue Several sources:Several sources:

Vital registration Vital registration Census and surveys Census and surveys Demographic Surveillance SystemDemographic Surveillance System

Hospital dataHospital data Hospital data Hospital data Levels, Trends, DifferentialsLevels, Trends, Differentials

Major discrepancies on levelsMajor discrepancies on levelsMajor discrepancies on levels Major discrepancies on levels Agreement about recent increaseAgreement about recent increase Very large differences (regional, socioVery large differences (regional, socio--economic status …)economic status …)

Issues related with maternal Issues related with maternal mortality in developing countriesmortality in developing countries

Case definitionsCase definitions Demographic: “Pregnancy related death” (any death during Demographic: “Pregnancy related death” (any death during

maternal period) = direct + indirect + fortuitousmaternal period) = direct + indirect + fortuitous Medical: “Direct obstetric causes”Medical: “Direct obstetric causes”Medical: Direct obstetric causesMedical: Direct obstetric causes Major issue in case of high young adult mortality Major issue in case of high young adult mortality

(HIV/AIDS + external causes)(HIV/AIDS + external causes) Changing relationship with socioChanging relationship with socio economic statuseconomic status Changing relationship with socioChanging relationship with socio--economic status, economic status,

because of the HIV/AIDS epidemicbecause of the HIV/AIDS epidemic General issue for causes of deathGeneral issue for causes of death

i l l l f l lii l l l f l li Particularly relevant for maternal mortalityParticularly relevant for maternal mortality Earlier publication based on 2001 census data, in: Earlier publication based on 2001 census data, in:

Population Health MetricsPopulation Health Metrics, 2008 (4):1, 2008 (4):1--1313pp , ( ), ( )

Census data on maternal mortality Census data on maternal mortality in South Africain South Africa

Recent sources: Recent sources: Census, 2001 (1/10 sample available)Census, 2001 (1/10 sample available) Community Survey, 2007 (1/43 sample)Community Survey, 2007 (1/43 sample)

Both include:Both include: Births in past 12 monthsBirths in past 12 months

Deaths in past 12 monthsDeaths in past 12 months Deaths in past 12 months Deaths in past 12 months Maternal deaths, for women aged 12Maternal deaths, for women aged 12--50 / demographic 50 / demographic

definition = Deaths during pregnancy, delivery or within 6 definition = Deaths during pregnancy, delivery or within 6 k f d li / i f i di d i dik f d li / i f i di d i diweeks of delivery / No information on direct and indirect weeks of delivery / No information on direct and indirect

causescauses Deaths from external causes (accidents and violence)Deaths from external causes (accidents and violence)( )( )

Potential of census data in South Potential of census data in South Africa (2001 & 2007)Africa (2001 & 2007)

Allows to compute all maternal mortality indicatorsAllows to compute all maternal mortality indicatorsp yp y MMR: maternal mortality ratioMMR: maternal mortality ratio MDR: maternal death rateMDR: maternal death rate MMR: life time risk (maternal mortality quotient)MMR: life time risk (maternal mortality quotient)

Allows differential analysisAllows differential analysisVariety of socioVariety of socio economic factors in censuseconomic factors in census Variety of socioVariety of socio--economic factors in censuseconomic factors in census

Available only at household level for maternal deathsAvailable only at household level for maternal deaths Allows multivariate analysisAllows multivariate analysisAllows multivariate analysisAllows multivariate analysis

Compares cases (maternal deaths) with controls (women Compares cases (maternal deaths) with controls (women who delivered in past 12 months and survived)who delivered in past 12 months and survived)

Results: fertility and mortalityResults: fertility and mortalityResults: fertility and mortalityResults: fertility and mortality

Census, 2001Census, 2001 CS, 2007CS, 2007Census, 2001Census, 2001 CS, 2007CS, 2007

HouseholdsHouseholds 991,543991,543 246,618246,618

Fertility (CBR)Fertility (CBR) 22.822.8 24.024.0

Mortality (CDR)Mortality (CDR) 9.39.3 15.315.3

MaleMale qq 440440 606606Male, Male, 4545qq1515 440440 606606

Female, Female, 4545qq1515 320320 501501

Results: maternal mortalityResults: maternal mortalityResults: maternal mortalityResults: maternal mortality

Census, 2001Census, 2001 CS, 2007CS, 2007Census, 2001Census, 2001 CS, 2007CS, 2007

Nb maternal deathsNb maternal deaths 508508 168168

Percent time in Percent time in maternal periodmaternal period

7.1%7.1% 7.6%7.6%maternal period maternal period Proportion of Proportion of maternal deathsmaternal deaths

6.4%6.4% 4.3%4.3%

MMR / 100,000MMR / 100,000 542542 702702

95% CI95% CI 497497--591591 603603--816816

Levels and trends in Levels and trends in maternal mortalitymaternal mortality

LevelsLevels Abnormally high adult mortality (3 to 5 times that of model Abnormally high adult mortality (3 to 5 times that of model

life tables with same elife tables with same e°°(60)(60)D t h i i f ti HIV/AIDS d PTBD t h i i f ti HIV/AIDS d PTB Due to chronic infections: HIV/AIDS and PTBDue to chronic infections: HIV/AIDS and PTB

And to external causes (accidents, violence)And to external causes (accidents, violence) TrendsTrends TrendsTrends

Increasing trend in adult mortality from 2001 to 2007Increasing trend in adult mortality from 2001 to 2007 Increasing trend in maternal mortality (+29%; P<0.004)Increasing trend in maternal mortality (+29%; P<0.004) Decreasing proportion in maternal deathsDecreasing proportion in maternal deaths

Risk attributable to Risk attributable to the maternal periodthe maternal period

ComparisonComparisonpp Deaths expected from mortality among nonDeaths expected from mortality among non--pregnant pregnant

women women Deaths during maternal periodDeaths during maternal periodDeaths during maternal period Deaths during maternal period

Attributable riskAttributable risk Observed / Expected number of deathsObserved / Expected number of deaths

C 2001 AR 0 69C 2001 AR 0 69 Census, 2001: AR= 0.69Census, 2001: AR= 0.69 Community Survey, 2007: AR= 0.57Community Survey, 2007: AR= 0.57 No increased risk associated with pregnancy and delivery! No increased risk associated with pregnancy and delivery!

(pregnancy and delivery are protective)(pregnancy and delivery are protective) New situation, very different from preNew situation, very different from pre--AIDS era, where AIDS era, where

AR = 1.5 to 2.0AR = 1.5 to 2.0

Differential analysisDifferential analysisDifferential analysisDifferential analysis Household characteristics / SocioHousehold characteristics / Socio--economic statuseconomic status

Urban / RuralUrban / Rural ProvinceProvince RaceRace EducationEducation IncomeIncome IncomeIncome WealthWealth

Community variables / Provincial levelCommunity variables / Provincial levelyy HIV/AIDS prevalenceHIV/AIDS prevalence External causesExternal causes

H d li iH d li i Home deliveriesHome deliveries

MMR, by area of residenceMMR, by area of residenceMMR, by area of residenceMMR, by area of residence

1000888

800

1000

hs

20012007

604

505 539600

100,

000

birt

h

200

400

MM

R p

er

0

200

Rural UrbanRural Urban

MMR, by province of residenceMMR, by province of residenceMMR, by province of residenceMMR, by province of residence

245175Western Cape

415

347

245

509

445

Northern Cape

Limpopo

Western Cape 20072001

654

519

395

860

414

555

Free State

Mpumalanga

Gauteng

751

712

654

642

1236

North-West

Eastern Cape

ee State

772912

0 200 400 600 800 1000 1200 1400

Kwazulu Natal

MMR, per 100,000 live births, p ,

MMR, by population group (race)MMR, by population group (race)MMR, by population group (race)MMR, by population group (race)

1000

784800

1000

hs

20012007

614600

100,

000

birt

h

284 310

200200

400

MM

R, p

er

67

0

200

Black/African Coloured Indian/Asian White/EuropeanBlack/African Coloured Indian/Asian White/European

MMR, by level of educationMMR, by level of educationMMR, by level of educationMMR, by level of education9931000

899

753703

800

900

1000

ths

703

598 595

500

600

700

100,

000

birt

382

258

200

300

400

MM

R, p

er

0

100

200

0-4 years 5-8 years 9-11 years 12+ yearsy y y y

MMR, by income per capitaMMR, by income per capitaMMR, by income per capitaMMR, by income per capita1200

800

1000

1200

birt

hs

20012007

400

600

800

per

100,

000

200

400

MM

R,

0 None

declared < 2400 < 4800 < 9600 < 28800 >=28800

Income per capita (ZAR)Income per capita (ZAR)

MMR, by absolute wealth indexMMR, by absolute wealth indexMMR, by absolute wealth indexMMR, by absolute wealth index1200

1000

1200

birt

hs

20012007

600

800

per

100,

000

b

200

400

MM

R, p

0'0-1 '2-3 '4-5 '6-7 '8-9 '10-11 '12+

Wealth index (number of modern items in household)( )

MMR, by HIV prevalenceMMR, by HIV prevalenceprovinces of South Africaprovinces of South Africa

1000

1200

1400

CS-2001r= 0,73

1000

1200

1400

CS-2007r= 0,59

NWFSEC

KZN

600

800

1000

per

100,

000

birt

hs

FSKZN

600

800

1000

per

100,

000

birt

hs

LP

MP

GTNC

WC

200

400

600

MM

R, p

LP MP

GTNC

WC200

400

600

MM

R, p

0

200

0 10 20 30 40 50

Percent HIV+ (antenatal clinics)

WC

0

200

0 10 20 30 40 50

Percent HIV+ (antenatal clinics)

MMR, by external cause mortality, MMR, by external cause mortality, provinces of South Africaprovinces of South Africa

1000

1200

1400

rths

CS-2001r= 0,80

EC1200

1400

ths

CS-2007r= 0,59

MP

NWFS EC

KZN

600

800

1000

er10

0,00

0bi

r

NW

FSKZN

600

800

1000

r10

0,00

0bi

rt

LP

MPGT NC

WC200

400

600

MM

R,p

e

LPMP

GT NC

WC200

400

600

MM

R,p

e

0100 200 300 400 500

Mortality from external causes (per 10,000)

WC

0100 200 300 400

Mortality from external causes (per 10,000)y (p , ) y (p , )

MMR, by proportion of home MMR, by proportion of home deliveries, provinces of South Africadeliveries, provinces of South Africa

1000

NWFS EC

KZN

800

1000

birt

hs

CS-2001r= +0,29

LP

MPGT NC

400

600

er10

0,00

0

LPWC

200

400

MM

R,p

00% 5% 10% 15% 20% 25% 30%

Proportion of home deliveriesp

Conclusions (I)Conclusions (I)Conclusions (I)Conclusions (I) MMR much higher than previously thoughtMMR much higher than previously thoughtg p y gg p y g

Consistent with findings from Agincourt (same MMR)Consistent with findings from Agincourt (same MMR) Still within the range of other countries in AfricaStill within the range of other countries in Africa Unlikely to be overUnlikely to be over--estimated because of the low estimated because of the low

proportion of maternal deaths among women 15proportion of maternal deaths among women 15--4949 MMR has increased in recent years due toMMR has increased in recent years due to MMR has increased in recent years, due to MMR has increased in recent years, due to

HIV/AIDS & PTB, Accidents & ViolenceHIV/AIDS & PTB, Accidents & Violence Many hospital studies show a high proportion of maternal Many hospital studies show a high proportion of maternal

d h d HIV/AIDS PTBd h d HIV/AIDS PTBdeaths due to HIV/AIDS or PTBdeaths due to HIV/AIDS or PTB Evidence of increase in MMR in Cape Town peninsula Evidence of increase in MMR in Cape Town peninsula Evidence from the vital registration systemEvidence from the vital registration systemEvidence from the vital registration system Evidence from the vital registration system

Conclusions (II)Conclusions (II)Conclusions (II)Conclusions (II)

Very pronounced maternal mortalityVery pronounced maternal mortality Very pronounced maternal mortality Very pronounced maternal mortality differentials in South Africadifferentials in South Africa By race, ethnicity , provinceBy race, ethnicity , provincey , y , py , y , p Milder by level of educationMilder by level of education

Complex relationship with income and wealth:Complex relationship with income and wealth:p pp p middle income / average wealth have the highest middle income / average wealth have the highest

risksrisks Risks decline with distance from average, except Risks decline with distance from average, except

for the poorest for the poorest

Conclusions (III)Conclusions (III)Conclusions (III)Conclusions (III) Potential of population censuses for maternal Potential of population censuses for maternal p pp p

mortality:mortality: Exhaustive and unbiasedExhaustive and unbiased Large number of deaths and small confidence intervalsLarge number of deaths and small confidence intervals Large number of deaths, and small confidence intervalsLarge number of deaths, and small confidence intervals Potential for differential analysisPotential for differential analysis Potential for multivariate analysis at household levelPotential for multivariate analysis at household level

C b h i d b idi d ilC b h i d b idi d il Can be much improved by providing more details on Can be much improved by providing more details on causes of maternal deaths:causes of maternal deaths: Separate direct cause, indirect causes, external causesSeparate direct cause, indirect causes, external causesp , ,p , , Provide more details on timing of death (early pregnancy, Provide more details on timing of death (early pregnancy,

late pregnancy, delivery, postlate pregnancy, delivery, post--partum, postpartum, post--abortum)abortum) Question the actual “demographic” definition of MMRQuestion the actual “demographic” definition of MMRQuestion the actual demographic definition of MMRQuestion the actual demographic definition of MMR

South Africa, Rock Art