Setting a Target for Maternal Mortality

Marjorie Koblinsky, USAIDThomas Pullum, MEASURE DHS

Tessa Wardlaw, Danzhen You, UNICEFLale Say, Doris Chou (WHO)

Sam Whipple (KMS)

Sept 1, 2013

1

Outline of talk

1. Setting a target for maternal mortality: the indicator

2. Absolute target for MMR: 50 by 2035 Historical MMR trends: Annual rates of reduction (ARRs)

3. Relative target for MMR: 75% and 85%, 20354. Key points and questions

2

1. Setting a target for maternal mortality

Characteristics : ambitious but plausible; should accelerate progress

Four key components to target setting:

– End year: Focus here on 2035, but actual value is TBD (MDG 5: 1990-2015)

– Indicator: MMR or # maternal deaths, LTR, other? (MDG 5: MMR)

– Annual Rate of Reduction (ARR) does not have to be constant, but the average value should be feasible, aggressive

(MDG 5: ARR of 5.5%)

– End value: Determined by the choice of end year and ARR, with rounding (MDG 5: 25% of the start value, or a decline of 75%--a relative target—over 25 year period) 3

1. Indicator: NMR versus MMR

• NMR is an age specific rate whereas the MMR is a cause specific ratio.

• The Neonatal Mortality Rate is the number of infants under 1 month who died per 1,000 live births.

• The MMR is a ratio of maternal deaths per 100,000 live births –note the extra factor of 100 in the denominator -- rare event, sparse data.

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1. Indicator: MMR Numerator- maternal deaths

The death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management but not from accidental or incidental causes. WHO International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, 1992 (ICD-10)

Need to know: • Pregnancy status of the woman • Timing of death • Medical cause of death

How: Surveys or Census, + VA; Estimations (2010) Measurement is a challenge!

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• Global MMR: 210 maternal deaths per 100,000 live births in 2010

• Global number of maternal deaths: 287,000 in 2010• 77 countries already reached an MMR of 50 or lower; among

them, 58 already reached an MMR of 30 or lower• 26 countries still had an MRR more than 400 deaths per

100,000 live births

Statistics & Monitoring Section/DPS

Table 1: Number of Countries with specific ranges of MMR in 2010 (n=189)

MMR≤30 30<MMR≤50

50<MMR≤100

100<MMR≤200

200<MMR≤500

MMR>400

Number of countries

58 19 35 16 35 26

1. Indicator: Present MMR

7

1990 1995 2000 2005 2010 2015 2020 2025 2030 20350

50

100

150

200

250

300

350

400

450

Ma

tern

al M

ort

alit

y R

ati

o (

pe

r 1

00

,00

0 li

ve

bir

ths

)

543,000 deaths annually

287,000 deaths annually

4.1% Annual Rate of MMR Reduc-

tion 2000-2010

5.6% Annual Rate of MMR

Reduction 2010-2035

Accelerated Trend

4.1% Annual Rate of MMR

Reduction 2010-2035

Current trend

Global MMR

OECD Upper Limit MMR

2015 MDGMMR=100

Source: UN Estimates for Trends in Maternal Mortality 1990-2010.World Health Organization, 2012.

74

50

2. Absolute Target: Historical trends and projections, MMR = 50 by 2035, worldwide

8

1990 1995 2000 2005 2010 2015 2020 2025 2030 20350

100

200

300

400

500

600

700

800

900

1000

Mat

erna

l Mor

talit

y Ra

tion

(per

100

,000

live

birt

hs)

Asia, excl. India and China

India

Sub-Saharan Africa

Global MMR

OECD Countries - Upper Limit

Asia: Afghanistan, Bhutan, Cambodia, Indonesia, Iran, Iraq, Kyrgyzstan, Lao, Morocco, Myanmar, Nepal, Pakistan, Papua New Guinea, Philippines, Solomon Islands, Tajikistan, Turkmenistan, Uzbekistan, VietNam, YemenAfrica: Angola, Benin, Botswana, Burkina Faso, Burundi, Cameroon, Central African Republic, Chad, Congo, Cote d'Ivoire, Democratic Republic of the Congo, Equatorial Guinea, Eritrea, Ethiopia, Gabon, Gambia, Ghana, Guinea, Guinea-Bissau, Kenya, Lesotho, Liberia, Madagascar, Malawi, Mali, Mauritania, Mozambique, Niger, Nigeria, Rwanda, Sao Tome and Principe, Senegal, Sierra Leone, Somalia, South Africa, Sudan, Swaziland, Togo, Uganda, Tanzania, Zambia, Zimbabwe

225

50

Current AAR 2000-2010

AAR to Reach MMR = 50

Sub-Saharan Africa -3.7% -8.9%India -6.5% -5.4%

Asia, excluding India and China -4.8% -5.1%Global -4.1% -5.6%

2. Absolute Target: Historical trends and projections

MMR = 50 by 2035, regions

Statistics & Monitoring Section/DPS

ARR≤1 1<ARR≤2 2<ARR≤3 3<ARR≤4 4<ARR≤5 5<ARR≤6 ARR>6

Number of countries

20 36 40 32 23 10 20

Table 2: Number of Countries with specific ranges of ARR in 2000-2010

• Global ARR: 3.1% in 1990-2010; 4.1% in 2000-2010

• Only 20 countries had an ARR more than 6%; among them, only 5 countries had an ARR more than 8%

• Plausible ARR range: 5-7%

2. Absolute target: Annual rates of reduction (ARR)

Source: UN Estimates for Trends in Maternal Mortality 1990-2010.World Health Organization, 2012. 10

Thailand

Pakistan

Indonesia

China

Sri Lanka

Bangladesh

India

Nepal

Afghanistan

World

0.0% 1.0% 2.0% 3.0% 4.0% 5.0% 6.0% 7.0% 8.0%

3.1%

3.7%

4.3%

4.9%

4.9%

5.0%

6.5%

7.2%

7.5%

4.1%

Annual Rate of Reduction (%)

MDG TargetARR=5.5%

2. Absolute target: ARR 2000-2010, Asian countries

11

50

1990 1995 2000 2005 2010 2015 2020 2025 2030 20350

200

400

600

800

1000

1200

1400

Mat

erna

l Mor

talit

y Ra

tio (p

er 1

00,0

00 li

ve b

irths

)

Current ARR ARR to Reach 2000-2010 MMR=50Afghanistan -7.5% -8.5%Bangladesh -5.0% -6.1%Nepal -7.2% -4.8%Pakistan -3.7% -6.4%

Afghanistan

Pakistan

Nepal

Bangladesh

Source: UN Estimates for Trends in Maternal Mortality 1990-2010.World Health Organization, 2012.

2. Absolute target: Afghanistan, Bangladesh, Nepal, Pakistan

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1990 1995 2000 2005 2010 2015 2020 2025 2030 2035-10

10

30

50

70

90

110

130

Mat

erna

l Mor

talit

y Ra

tio (p

er 1

00,0

00 li

ve b

irths

)

Current ARR ARR to Reach 2000-2010 MMR=50Sri Lanka -4.9% 1.4%Thailand -3.1% 0.2%Sri Lanka

Thailand50

10

22

Source: UN Estimates for Trends in Maternal Mortality 1990-2010.World Health Organization, 2012.

2. Absolute target: Sri Lanka & Thailand

3. Relative targets

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Statistics & Monitoring Section/DPS

3. Relative target for MMR: 75% by 2035 (ARR=5.5%)

15Source: UN Estimates for Trends in Maternal Mortality 1990-2010.World Health Organization, 2012.

2010 2015 2020 2025 2030 20350

50

100

150

200

250

300

Mat

erna

l Mor

talit

y Ra

tio (p

er 1

00,0

00 li

ve b

irths

)

58

75% ReductionARR=5.5%

Bangladesh 2010 MMR=240, ARR=5.0%

36

85% ReductionARR=7.3%

41

Nepal 2010 MMR=170, ARR=7.2%

26

3. Relative target for MMR: Bangladesh & Nepal--75% and 85%

16Source: UN Estimates for Trends in Maternal Mortality 1990-2010.World Health Organization, 2012.

2010 2015 2020 2025 2030 20350

5

10

15

20

25

30

35

40

Mat

erna

l Mor

talit

y Ra

tio (p

er 1

00,0

00 li

ve b

irths

)

9

China 2010, MMR=37, ARR=4.9%

6

Sri Lanka 2010 MMR=35ARR=4.9%

5

75% ReductionARR=5.5%

85% ReductionARR=7.3%

3. Relative target for MMR: China & Sri Lanka --75% and 85%

4. Key points and questions

• Indicator: Should we continue with the MMR? • Absolute Target depends on current MMR, end year

– Does a GLOBAL indicator make sense? Absolute country targets make achieving goals difficult for high MMR countries, particularly sub-Saharan African countries.

– ARR trajectory: Depends on country’s current MMR• Should high MMR countries aim for higher MMR in 2035 (MMR=100)? • Should low MMR countries focus on equity (high MMR subpopulations)? • Should we set 5 year milestones?

• Plausible Relative Target will depend on the end year– 2035: 80% decline, global MMR target=50– 2030: 70% decline, global MMR target=60 – 2025: 60% decline, global MMR target=80 or 90

• How has the MDG 5 target (75% reduction over 25 years) been used in country?– Has the MDG 5 target been useful for policy?

Programming? Monitoring? • What does it take to implement a new target

for reducing maternal mortality?

• Many thanks!!

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4. Key points and questions