Child and Maternal Mortality
in Islamic Countries
17
2.2. Challenges of estimating maternal mortality in developing country settings and
implications for tracking and targeting MMR reduction
A difficult challenge for monitoring progress towards MDG-5 and subsequently SDG-3.1 is the
problem of maternal mortality estimation itself. An accurate estimation of maternal mortality is
notoriously difficult in developing countries, primarily because complete vital registration
systems are absent. In the absence of complete vital registration with good attribution of causes
of deaths, the most commonly employed methods for maternal mortality estimation are
household surveys with direct death inquiry, indirect and direct sisterhood methods, and
reproductive age mortality surveys (RAMOS). Because maternal deaths are rare events relative
to births or child deaths, a reliable maternal mortality survey needs exceptionally large sample
size, which deters its implementation in resource poor countries. Moreover, none of the current
estimation methods are suitable for measuring maternal mortality in small geographical areas
where safe motherhood programs are often targeted and implemented. Similarly, the estimation
of MMRs for the subgroups of population is not feasible in currently available most national
surveys. As a result, health administrators and programmanagers working on safe motherhood
programs are often frustrated because they cannot monitor progress towards maternal
mortality reduction in their area and target specific population group.
The global and national maternal mortality estimation for low- and middle-income countries
(LMIC) are primarily based on regression-based methods. These results are available at a
national level. Often the results of MMR estimates across different sources are vastly diverse28,
which make it difficult for tracking progress. As an example, the model-based UN MMEIG
estimate of MMR in Afghanistan was 396 deaths per 100,000 live births in 2015 (Table 2.1); in
contrast, the Afghanistan Demographic and Health Survey in 2015 estimated MMR of 1291
deaths per 100,000 live births. This illustrates a major problem for tracking maternal mortality,
especially by the government officials: Which number to trust? Which number is more reliable
than the other? Which number to use for tracking progress? There may be conflicts of interest
to prefer the lower estimated numbers for showing progress or to prefer higher numbers as the
baseline estimate.
In the absence of reliable death reporting and vital registration, the countries rely on survey
methods for collecting data on maternal deaths and often the causes of maternal deaths are
derived with the verbal autopsy method. Misreporting and misclassification of deaths are likely
to bias the MMR estimates. The regression methods for maternal mortality estimation are also
challenging. The UN method relies on three covariates (GDP, skilled birth attendance and
general fertility rate) and does not take in to account other factors, such as health system
deficiencies, that also affect maternal mortality. The method at best attempts to fill the maternal
mortality data gaps for the countries where maternal mortality estimates are not available or
considered not reliable.
In selected OIC countries, the Demographic and Health Surveys (DHS) collected data on
maternal mortality based on direct sisterhood method. The Demographic and Health Surveys
are the major source of data for maternal mortality estimations in low- and middle-income
countries. The estimation of maternal mortality with the sisterhood method is currently used in
the standard DHS surveys that include the maternal mortality module (sibling history). This
method is an extension of the original sisterhood method, now referred to as indirect sisterhood
method, which was the first method used in the DHS maternal mortality module initiated in