Journal club preesentation

1. Field test results of the motherhood method
to measure maternal mortality
Mahesh K. Maskey1, Kedar P. Baral 2, Rajani Shah3 , Bhagawan D. Shrestha4, Janet
Lang5, & Kenneth J. Rothman6
1Nepal Public Health Foundation, Kathmandu, 2 PatanAcademy of Health sciences,
3 CTEVT, Bharatpur, 4 Plan Nepal, Nepal 5 Watson Institute for International studies, Brown University, Providence RI,
USA and 6 RTI Health solutions, Research Triangle Park, NC & Boston University school of Public Health, USA
Indian J Med Res 133, January 2011, pp 64-69
Presented by
Dr. Fredrick Stephen
P.G in community Medicine

2. About The Journal
• Scope : Technical and clinical studies related to health, ethical and social issues in field
of biomedical research
• Frequency : Monthly, in two volumes and 12 issues per year
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• Impact factor : 2.061
• Editor : Dr Anju Sharma

3. Introduction
• The current estimate of global maternal deaths is 3429001*
• Over the past decade, reduction in maternal deaths has attained a high priority in
global health movements
• MDG5 has set a target of reducing the maternal mortality ratio by 75 % between 1990
and 2015.
• The most widely used measure of maternal mortality is the maternal mortality ratio
• Developing countries - vital registration of medically-certified births and deaths is non-existent
/ incomplete, validity or feasibility of other purely records-based approaches is
questionable
* Hogan MC, Foreman KJ, Naghavi M, Ahn SY, MengruW, Makela SM, et al. Maternal mortality for
181 countries, 1980-2008: a systematic analysis of progress towards Millennium Development Goal
5. Lancet. 2010;375:1609–23. [PubMed]

4. Aims & Objectives
• To test a community-based method (the motherhood method) and measure
maternal and child mortality in a developing country setting.

5. Maternal Mortality Estimation
Maternal Mortality
Empirical
Methods
Analytical Methods
Routine
opportunity
Measurements
Special
opportunity
Measurements
Main Approach
Composite
Approach

6. Routine Opportunity
Empirical
Measurements
Special Opportunity
Empirical Measurements
• Vital
Registration
System
• Census
• Facility Based
Health Services
Records
• Sisterhood
Methods
• Demographic
Surveillance
Systems
Empirical Methods

7. Analytical Methods
Main Approach
• Birth & death
Record Linkage
• Capture
Recapture
• Statistical
Modelling used
by UN systems
Composite
Approach
• Reproductive
Age Mortality
Study (RAMOS)
• Motherhood
Method

8. Reproductive Age Mortality study
(RAMOS)
• It uses multiple sources such as records from hospital, police, public-health
department and vital data registries to identify and investigate the cause of
deaths for each woman of reproductive age in a defined population
• Interviews with household members and health care providers provide a basis
to classify the deaths as maternal or otherwise.
• Is considered to be the most complete estimation of maternal mortality
• Complex, because information regarding the number of births must come
from separate sources

9. Sisterhood Method
• Was originally developed during the late 1980’s
• The approach was designed to overcome the problem of large sample
sizes and thus reduce costs
• It is an indirect measurement technique of the kind frequently used to
measure a variety of demographic parameters (such as child or adult
mortality), which has been adapted for the measurement of maternal
mortality.
• The method reduces sample size requirements because it obtains
information by interviewing respondents about the survival of all their
adult sisters.

10. When to Use
• When there is no reliable estimate of the level of maternal mortality
• An approximate level of maternal mortality needed for advocacy
purposes and to draw attention to the problem
• Poor Resources
• A starting point is needed for more detailed follow-up of maternal
deaths identified during the recent past.
Not appropriate for
Measuring progress towards safe motherhood in the short term
Evaluating programme impact
Comparing geographic areas or studying trends
Allocating resources.

11. Approximate Sample Size Requirements for Indirect Applications
of the Sisterhood Method
(*) Assuming 2 adults available for interviewing per household
(**) Maternal mortality ratios from about 200 per 100 000 live births for "intermediate" level to more than
1000 for "extremely high" level.
In settings with high levels of maternal mortality (over 500 maternal deaths per 100,000 live births, sample
sizes needed can be of the order of 4,000 households or less

12. Time Location of Estimates from Indirect Sisterhood Method
Reports cover deaths occurring over a large interval time, hence results
generate an overall estimate of maternal mortality for a point centred around 10
to 12 years before the survey

13. Method Strengths Limitations
Original indirect method
 Four simple questions can be added
to ongoing household survey
 Minimal time requirements
 Minimal sample size requirements
 Simple calculations to estimate
ratios
 Additional information can be
gathered on place/time/cause of
death
 Care needed in the use
understanding of the
questions
 Provides retrospective
estimate (10-12 years prior to
the survey)
 Not appropriate for use in
settings with high levels of
migration
 Not appropriate for use in
settings with declining or low
fertility (TFR<3)
Direct Method
 Can be added to ongoing
multipurpose household survey
 Smaller sample size requirements
than household surveys but larger
than indirect methods
 Can be used to provide more recent
estimates than the indirect method
 Relatively inexpensive
 Data collection more
complex & longer than
indirect method
 Not appropriate for use in
settings with high levels of
migration
 Not appropriate for use in
settings with low fertility
(TFR<3)
 Not appropriate for
monitoring in the short term

14. Number of respondents needed to establish a maternal mortality ratio
of 300 per 1,00,000 live births correct to within 20%
MMR Indirect
Method
Direct Method Household
Survey
300 4,000* 5,000* 50,000**
* Adult respondents
** Births

15. THE ORIGINAL SISTERHOOD METHOD'S FOUR QUESTIONS
1. How many sisters (born to the same mother) have you ever had who were
ever-married (including those who are now dead)?
2. How many of these ever-married sisters are alive now?
3. How many of these ever-married sisters are dead?
4.
How many of these dead sisters died while they were pregnant
or during childbirth, or during the six weeks after the end of
pregnancy?

16. THE "DIRECT" SISTERHOOD METHOD'S QUESTIONS
1. How many children did yourmother give birth to?
2. How many of these births did your mother have before you were born?
3. What was the name given to your oldest (next oldest) brother or sister?
4. Is (NAME) male or female?
5. Is (NAME) still alive?
6. How old in (NAME)?
7. In what year did (NAME) die?OR How many yeas ago did (NAME) die?
8. How old was (NAME) when she died?
For dead sisters only:
9. Was (NAME) pregnant when she died?
10.Did (NAME) die during childbirth
11.Did (NAME) die within two months after the end of pregnancy or childbirth?

17. Motherhood Method
• It is a direct technique for deriving local population-based estimates of
maternal mortality.
• The method involves estimating the same information within a
geographic area as would be collected in a census, but without visiting
every household.
• It is a targeted census of births and deaths within a defined study period.
• Evolutionary variant of the Participatory Community Survey method - for
neonatal tetanus and the perinatal mortality rate in rural Nepal
• It shares features with the Boerma and Mati’s “networking” approach of
eliciting maternal deaths and

18. • MIMF (Maternal death from Informants and Maternal
death Follow-on review)
• It differs, however, in eliciting deaths through group discussion of
listed mothers and community health care providers.
• To implement the method, the local health volunteers assist in
facilitating group discussions related to maternal and child health.
• Information on total births and maternal death during pregnancy,
childbirth or puerperium is elicited through immunization
registries, group discussions (FGD), peer memory, memory aids
and verbal autopsy.

19. Materials and Methods
• Motherhood method was pretested in a small, relatively well-off community of
about 8000 population (MMR 140/100000)
• The method was tested in a larger sample of 15161 births in the Bara district of
Nepal
• The sample size was expected to provide estimate of MMR within 30 % o
margin of error.
• This study employed the pregnant women group (PWG) approach
• The PWG comprised 7-15 pregnant women living in the same village or wards.
• They met once a month to discuss issues related to mother and child health.
The female community health volunteers (FCHVs) facilitated these meetings

20. Materials & Methods
Bara District, Nepal
(Total predicted population for 2005=6,15,933)
[1,30,578 women of reproductive age (15-49)]
Divided into 7 sectors
7 VDC* with population of 6000 were
selected
Total 49 VDC selected
* - Village Development Committees

21. • Study Period : 2 yr from 17th July 2003 to 16 July 2005
• Information : Births, Maternal Death, Infant Death & PWG status
• Survey Period : 12 weeks
• The data were checked every day for omissions and errors and
corrected in the
field by revisits when necessary.
• Sub-sample of 49 wards was randomly selected, one from each VDC, to
conduct a census to validate the information obtained from the
motherhood method.

22. • Training : 2 days training was provided to supervisors and enumerators
to enable them to elicit required information from BCG and TT
vaccination registries and from the group discussion.
• Limitations of BCG registries were partially compensated for by
augmenting the list from TT vaccination registries.
• FGD : The typical group comprised 10-15 mothers and the local health
workers
• Deliveries outside the study period were excluded from the list of
counted pregnancies

23. • Each group had four data collectors with 3 enumerators and one
supervisor.
• On an average one group took five days to cover one VDC.
• The total cost of the evaluation was $ 10,896
• It was found that doing a census was 10 times more costly than
collecting data from motherhood method
(per unit cost $ 50.5 and $ 4.4)

24. RESULTS
Table 1 Total Births and Deaths by Study Groups, Bara District

25. Table 2: Mortality Indices of Bara District Compared with National
Estimates

26. Results
• The results compared well with national data.
• A comparison with the census results in 49 wards showed 100 per
cent agreement with MM in detecting maternal and child deaths.
• There was about a 0.25 per cent under-reporting of births.
• The maternal, infant, neonatal and perinatal indicators in PWG
women were lower than the non-PWG women and the national
statistics.

27. Discussion
• Motherhood method demonstrated - MMR can be directly measured if
the BCG and TT vaccination registers are in place and local health
workers are properly mobilized and supervised for data collection
• Proper motivation of community key informants, health volunteers,
and mobilizers is crucial for the accuracy of data
• The motherhood method can be applied in a time and cost-efficient
manner to measure and monitor the progress in the reduction of
maternal and child deaths
• It can give current estimates of maternal mortality as well as averages
over the past few years

28. Discussion
• It appears to be particularly well-suited in measuring and
monitoring programmes in sub-national regions and districts
• Group discussion counteracted the disinclination of mothers
to talk about the death of their child, and enhanced collective
memory for recalling details
• The motherhood method appears to be effective regarding
problems induced by migration.
• The group discussion could elicit which mothers migrated to
the village to live or came to their mother’s home for delivery

29. Limitations
• Requires proper training of field assistants to moderate the group
discussion among mothers and health volunteers
• Motivation of key community informants and health volunteers is crucial
to the accuracy of data, and mothers need to be aware of the need for
accuracy
• The effort in collecting data depends on the duration of the study period,
the longer the study period, the greater the potential for inaccurate
recall

30. Limitations
• Reporting of maternal deaths in early pregnancy and those
related to abortion as non-maternal deaths may occur.
• Maternal Deaths related to “Hidden pregnancy” among teens
can be missed.
• The method would need further adaptation to measure births
and deaths in urban areas.

31. THANK YOU