Measuring Maternal Health

What is Maternal Health?

Maternal health is health at the time of pregnancy, childbirth or postpartum period. It is pleasant experience to women and families; however, some women die or develop some complications that affect quality of life. Some even develop maternal complications causing chronic morbidities such as obstetric fistula (it is the condition where there is hole between rectum and vagina or between urinary bladder and vagina and the women suffering with it, are ostracized and secluded from family and the society in many cases), dyspareunia (painful sexual intercourse), prolapse (the pelvic organ is prolapsed down from vagina, women having such condition are stigmatized in the society and women consider it as shameful condition and hides it instead of seeking medical help) and they might be stigmatized and ostracized from the society just because she doesn’t get appropriate intervention at the time of childbirth. Some might have normal childbirth and may not need any assistance but no pregnancy can be considered free of risk as complications can arise at any point of time so there should be availability of appropriate, affordable health care service for each pregnant woman.

How can we measure maternal health?

Maternal health can be measured with specific indicators.

We can use the various indicators to understand the status of anything in any group or population. These are also useful in measuring progress towards predefined objectives. Depending upon the type of indicator, Indicator provides information regarding a health outcome or management process. Indicators are the markers to understand our own position on the pathway to our goal. If we want to cover 1000 km, the covered distance at particular time is the indicator to have understanding of our own progress. To assess the status of maternal health we can use impact indicators, Process indicator and outcome indicator. Impact indicators provide information on the end result, but may not provide understanding into how the outcome was achieved. Process and outcome indicators provide insight into the program activities carried out to achieve the objectives.

Maternal health is measured using such multiple indicators. Those indicators can be broadly categorized as Impact indicator, Outcome Indicator and Process indicator. Impact indicator is the indicator, which reflects the final expected change in the status. It expresses how much programmes have brought a change in the health status.

Outcome and process indicators are used to measure access to and use of care, as well as quality of care. Outcome and process indicators are generally easier to measure than impact indicators. However, the scope of outcome and process indicators is limited in that they do not measure the event of primary importance: maternal mortality. Nevertheless, if we don’t have quality data of maternal deaths, and other required information, then these outcome and process indicators can also be utilized to evaluate maternal health status and programmes. The most recent NDHS 2011 too evaluated outcome and process indicators instead of maternal mortality.

Indicators	Example
Impact indicator	Maternal mortality rate/ratios, Life time risk of maternal death
Outcome Indicator and Process indicator	Proportion of Deliveries by skilled personnel, proportion of birth by site, Met need for essential obstetrics Referral rate

Why do we need the Indicator?

1. To find out whether the implemented programmed are effective or not

2. To find out progress

3. To decide resource allocation

4. To explore the barriers and challenges in achieving the goal or objectives

Impact indicator is commonly used for evaluation of maternal health status and to assess the effectiveness of the maternal health programmes.

1. Maternal mortality ratio (MMR): is the total number of maternal deaths per 100,000 live births. The MMR is calculated as follows:

WHO recommends including maternal deaths that occur within 42 days of the end of pregnancy. The numerator includes deaths due to direct obstetric complications of pregnancy, labor, and the puerperium and deaths from a previously existing condition that develops during or is aggravated by the pregnancy (Indirect obstetric deaths). Deaths, resulted from accidental or incidental causes, such as an automobile accident, are generally not included in the numerator.  This indicator is used to measure obstetric risk once a woman becomes pregnant and useful to gauge the progress in maternity services.

The maternal mortality ratio measures risk of maternal death once a woman becomes pregnant. This is especially useful to measure progress in maternity services.

2. Maternal Mortality rate: The maternal mortality rate is the maternal deaths per 1,000 women of reproductive age. The maternal mortality rate measures the risk of dying and also includes the likelihood of both becoming pregnant and dying the pregnancy or the puerperium. 

 

3. Lifetime risk of maternal death

This enumerates a woman’s probability of dying from maternal causes over her reproductive life span, usually given as 30-35 years. This measure is determined by the probability of becoming pregnant and the risk of death once pregnant.This is the life time risk of a girl reaching to the age of 15 years. If some region have higher fertility rate, then the lifetime risk also increases as the woman is exposed to risk multiple times in her reproductive age and if the fertility is less the lifetime risk of maternal death is less.

4. Case Fatality rate

The case fatality rate is the proportion of death of women with obstetric complications in a specific facility providing emergency obstetric care. The CFR is calculated as follows:

For example, if the department of obstetrics and gynecology receives 100 cases of hemorrhage, 50 cases of prolonged or obstructed labor, 100 cases of postpartum sepsis, 100 cases of complications of abortion, 50 cases of preeclampsia/eclampsia, 100 cases of ectopic pregnancy and 100 cases of ruptured uterus in one month. Two hundred women die of such complications during this duration of one month.

The CFR would be

200                

______ = 0.33

600

The case fatality rate is an indicator of the likelihood that a woman with an obstetric complication will survive after admission to the medical facility. CFR can be calculated for specific complications as well as in whole.

This measure will be affected by the quality and promptness of medical care provided, and the condition of the woman upon admission to the facility.

5. Proportionate maternal mortality

Proportionate mortality is a useful measure of the percentage of deaths among women of reproductive age that are due to pregnancy.

6. Cause specific proportionate maternal mortality rate: we can also enumerate cause specific proportionate maternal mortality rate.

7. Proportion of maternal morbidity: It can be estimated to measure effectiveness and efficiency of maternal health care program as well as burden of diseases. Maternal morbidity refers to any physical, mental illness caused by pregnancy or childbirth. Prevalence or incidence of maternal complications and sequelae: we can also estimate the prevalence or incidence of maternal complications to get scenario of maternal health and quality, efficiency of maternal health care services.

• Acute maternal morbidity
• Postpartum maternal morbidity and disabilities
• Chronic morbidity

Process and outcome indicators

These indicators give clear picture of maternal health service. We can also have understanding about how much we are investing on maternal health programme and how many are getting the appropriate services. Number of trained skilled birth attendants, number of birthing centers per population, Proportion of Deliveries by skilled personnel, proportion of birth by site, Met need for essential obstetrics, Referral rate are such indicators.

Some terminologies