It is difficult and costly to accurately measure maternal mortality (see below), and the results are not actionable. However, process indicators are monitoring tools that can provide information about where interventions are needed.
One example of a process indicator is whether there is skilled attendance at birth. This particular indicator will be used as a global benchmark to monitor progress towards the goal of maternal mortality reduction, as agreed at ICPD + 5.
Process indicators to guide programmes and policies
A series of process indicators published in 1997 by UNICEF, WHO and UNFPA focuses specifically on monitoring whether women who develop serious obstetric complications receive the services they need. This information can guide programmes and policies.
Obstetric service indicators
|Indicator||Minimal Acceptable Level|
|Facilities||For every 500,000 people, 4 facilities that provide basic EOC, and one that offers more comprehensive care.|
|Number of all births in EOC facilities||At least 15 per cent of all births.|
|Met needs||All women with complications receive EOC.|
|Number of Caesarian sections||Between 5 and 15 per cent of all births.|
|Case fatalities||Less than 1 per cent.|
Indicators include the number of facilities offering emergency obstetric care, their geographic distribution, the percentage of women with complications treated in emergency obstetric care facilities, the Caesarean-section rate and the case fatality rate, an indicator of the quality of care provided.
This series of process indicators is now often used to assess the outcome of interventions at district and facility level and may be included in national management information systems. Maternal deaths audits, undertaken withfamilies, communities and health providers, are also a powerful way of improving the delivery of services.
The difficulty of measuring maternal mortality
Maternal morality rates and ratios are difficult and expensive to obtain and often inaccurate. Maternal mortality tends to be under-reported because people in developing countries often die outside the health system, which makes accurate registration of deaths difficult. In some studies, the actual number of maternal deaths was double or triple what was initially reported.
Maternal mortality is also misclassified, because health workers may not know why a woman died, or whether she was or had recently been pregnant. Deaths are sometimes intentionally misclassified, especially if they are associated with clandestine abortions.
Methods used to calculate maternal death rates are often complex and costly to use. The actual number of maternal deaths in a specific place at a specific time is relatively small. Therefore, very large populations must be surveyed in order to get accurate estimates, which is costly. The relative infrequency of maternal deaths over a short period also means that the rates will appear to jump around, making interpretation of trends over time difficult. In addition, some of the poorest countries do not have adequate vital registration systems.
A much more detailed discussion of the difficulties and methodologies used to gauge the incidence of maternal mortality is available in this joint publication.