2Measuring maternal, foetal and neonatal mortality: Challenges and solutions
Introduction
Monitoring levels of maternal mortality has been a priority on the global health agenda. Millennium development goal (MDG) 5 aimed to reduce the maternal mortality ratio (MMR) by 75% between 1990 and 2015. However, measuring progress over this time period was challenging, primarily because of the scarcity of empirical data. Global tracking relied instead on modelled estimates to monitor the success [1]. These estimates suggested that maternal mortality decreased by 44% worldwide in the MDG era [2]. Similar challenges were faced in tracking foetal and neonatal mortality. Neonatal deaths were not explicitly mentioned in MDG 4, which sought to reduce under-5 child mortality by two-thirds, but they were increasingly recognised as comprising almost half of child mortality globally and progressing more slowly. Neonatal mortality was estimated to have decreased by 47% worldwide during this period [3]. Stillbirths (late foetal deaths) were excluded from the MDG targets, and consequently received less attention, although the major associated burden has been quantified more recently [4]. At the end of the MDG era, the number of deaths, albeit based on modelled estimates, remains unacceptably high: 303,000 maternal deaths [2], 2.6 million stillbirths (late foetal deaths) [5] and 2.7 million neonatal deaths [3].
Measuring the levels and trends of maternal, neonatal and foetal mortality is important for quantifying disease burden, understanding risk factors and determinants, identifying priority areas for interventions, programmes and policies, and evaluating the success of interventions at the global, national, regional and local level [6], [7]. Knowing the biomedical causes of mortality in pregnant or recently delivered women, or in their babies, is essential to direct interventions to prevent such deaths. Unfortunately, there are many challenges to measurement, but there are also numerous potential options and solutions.
This paper provides an overview of current issues and options in measuring the levels and causes of maternal, foetal and neonatal mortality. We define these deaths and associated indicators, and then focus on the measurement methods, challenges and solutions, and where possible, present potential opportunities to improve measurement of maternal, neonatal and foetal deaths.
Section snippets
Definitions
To compare maternal, foetal and neonatal mortality across populations or over time requires standardised definitions for each outcome. These definitions were included in the 10th revision of the International Classification of Diseases (ICD-10) [8], as summarised in Table 1 and described below. Various dimensions of these definitions require an ability to assess pregnancy status of women, the timing of death in relation to delivery, gestational age (or alternatively birth weight or birth
Indicators
Counting numbers of maternal, foetal and neonatal deaths can identify countries, regions or subgroups with the largest numeric burden, but often we are also interested in knowing where the risk of such deaths is highest. For example, due to its large population, India has a much greater number of maternal deaths than Sierra Leone, yet the risk of a woman in India dying of maternal causes is much lower than in Sierra Leone [2]. Identifying the risk faced by individual women or babies requires
Current issues in measuring mortality
Despite the existence of definitions and indicators, measuring mortality can be problematic. First, deaths need to be identified, and then categorised and counted. Deaths may be misclassified because aspects of their definitions (including pregnancy/post-partum status, incidental/accidental cause of death, gestational age, survival status at the start of labour and at delivery and day of death post partum) are difficult to recognise, determine, capture or remember. They can also be
Using and interpreting mortality data
Maternal, foetal and neonatal mortality data are used for numerous purposes including examining the burden of mortality and trends in this over time, for identification of risk factors for mortality and for exploring effects of mortality on other outcomes (e.g., effect of a foetal death on maternal mental health or effect of maternal death on infant survival). It can be useful to adopt a life course perspective on health problems; for example, the effect of maternal health on long-term outcomes
Conclusion
Accurate and timely measurement is important to achieve change and inhibit preventable maternal, neonatal and foetal mortality. However, as we have illustrated in this paper, there are numerous obstacles to achieving this goal, particularly in high-burden settings. These challenges range from conceptual difficulties in the definitions of maternal and foetal mortality, to challenges faced in data collection systems making it impossible to count each birth and death, to problems of intentional or
Conflict of interest
The authors declare that they have no conflict of interest.
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