Maternal and Reproductive Health

Multiple Indicator Cluster SurveysData Interpretation, Further Analysis and Dissemination Workshop Maternal and Reproductive Health

Overview of presentation • Fertility (1 table) • Childbearing among adolescents (3 tables) • Contraception (2 tables) • Antenatal care (3 tables) • Delivery care (2 tables) • Post-natal health care (6 tables) • Adult and maternal mortality (3 tables)

Fertility Table may be produced if using either: Fertility module (WITH Birth History) Fertility module (WITHOUT Birth History) Age-specific fertility rate: Number of live births per 1,000 women in a specific age for a specific point in time (e.g. three years) 15-19 - Adolescent birth rate Total Fertility Rate (TFR): Average number of children to which a woman will have given birth by the end of her reproductive years (by age 50) if current fertility rates prevailed The total fertility rate (TFR) is calculated by summing the age-specific fertility rates calculated for each of the 5-year age groups of women, from age 15 through to age 49. General Fertility Rate (GFR): Number of births per 1,000 women of reproductive ages Crude Birth Rate (CBR): Number of live births per 1,000 population

Fertility If the Fertility module (which excludes the Birth History) is used: Date of last birth (CM12) is used for calculations Rates are based on the one-year period (1-12 months) preceding the survey. Numerators and denominators should be carefully checked for the total and urban-rural samples to ensure that they are based on sufficient numbers of cases. Use of a one-year estimation period may result in very small denominators

Childbearing among adolescents Calculations based on data from the child mortality module (Brass questions) or birth history Pay attention to sample sizes, especially for breakdowns by background variables

Childbearing among adolescents Sum of first two columns

Childbearing among adolescents • Two indicators - Note that each indicator has a different denominator • Data from different cohorts provides trends

Adolescent childbearing – comparison of indicators Example from MICS4

Contraception Modern MDG Indicator Traditional Should have been customized in-country e.g. LAM

Defining unmet need……… • Women with an unmet need for family planning are women who: • are married or in union • are fecund • report not wanting any more children or wanting to delay the birth of their next child for at least two years • not using any method of contraception

Defining unmet need……… • The following are also considered to have unmet need: • Women* who are pregnant, but whose current pregnancy unwanted or mistimed • Postpartum amenorrheic women* (not using contraception) whose last birth was unwanted or mistimed *Married/in union

Key indicator elements Marital status Fecundity Desire for future births Current use of contraception (any method) Pregnant or amenorrheic Desire for last birth Large amount of data needed to estimate unmet need, with a complex algorithm

Unmet need Women married or in a union who are fecund but are not using any method of contraception, and report not wanting any more children (limiting) or wanting to delay the next child (spacing). Note that met need for contraception includes both traditional and modern methods

Country example

Country example Use of contraception Note that met need for contraception includes both traditional and modern methods

Antenatal care Only the most qualified provider is considered in cases where more than one provider was reported Key indicator: At least one ANC visit (MDG) • MICS5 standard -- Normally, skilled providers includes doctors, nurses and midwives. Auxilliary midwife may or may not be considered skilled personnel. Provider categories: Should have been modified in country

Antenatal care MDG indicator • Watch out for: • Indicator definition (any provider) • “don’t knows”

Antenatal care Second part of table on timing of antenatal care visits Important information on timing of antenatal visits

Antenatal care

Delivery Care • MDG indicator • MICS5 standard -- Normally, skilled attendantincludes doctors, nurses and midwives. Auxiliary midwife may or may not be considered skilled personnel.

Delivery Care • This is new in MICS – to establish emergency ceasarians • C-section should be within 5%-15%

Delivery Care • Place of delivery categories should have been modified in country • Possible to present additional categories.

Continuum of reproductive and maternal health interventions

Continuum of reproductive and maternal health interventions Gap! Gap!

Post-natal health • 6 tables covering post-natal health checks for both mother and child • Post-partum stay in health facility • Post-natal health checks for newborns • Post-natal care (PNC) visits for newborns • Post-natal health checks for mothers • Post-natal care (PNC) visits for mothers • Post-natal health checks for mothers and newborns

Post-natal health terminology • MICS developed the module to capture information on: • Health checks after delivery • While in health facility after delivery or before the birth attendant leaves the mother and baby • Post-natal visits • Contact of providers with mothers and babies after discharge from health facility, or after the attendant leaves the mother and baby • Post-natal health checks • Encompassing both – the global indicator

Post-natal health – indicators, definitions

PNC Data from Ghana MICS 2011

PNC Data from Ghana MICS 2011 • More PNC visits for newborns than mothers – both for home and facility deliveries

To conclude • Substantial increase in PNC data availability due to inclusion in MICS • 18 surveys in 2009-2012 • Many more in MICS5 • Large amount of data now to perform secondary analysis

Adult and maternal mortality Standard MICS questionnaires include the maternal mortality module that collect data for the direct sisterhood method (survivorship of all siblings) Data is collected on survivorship of all siblings of interviewed women, including ages at death and since death (MM8) of the respondents' brothers and sisters and this information is used to re-construct cohorts in the recent past and calculate mortality rates. Total number of years lived by all surviving and deceased brothers and sisters (that is, exposure years) during the 7 years preceding the survey are calculated to form the denominators.

Adult and maternal mortality • Three tables are generated • On adult mortality rates • On adult mortality probabilities • On maternal mortality

Adult mortality rates Mortality rates for males and females, for ages 15 to 49, during the last 7 years

Adult mortality probabilities Age-specific mortality rates in the previous table are then converted to probabilities of dying from age 15 to 50 – a summary measure of the force of mortality during adulthood, for use in life tables

Maternal mortality MMRate: Expressed per 1,000 woman-years of exposure LTR: 1-(1-MMR)TFR where MMR is the maternal mortality ratio, and TFR represents the total fertility rate for the seven years preceding the survey Deaths during pregnancy or childbirth or deaths within 2 months after the termination of a pregnancy or childbirth Additional questions on when female deaths occurred (pregnancy, delivery or post-partum periods) make it possible to calculate maternal mortality rates and ratios GFR and TFR should be estimated from the survey results, or from external sources - should refer to the 7-year period preceding the survey

Limitations Reference period usually 7 years or 10 years before the survey Confidence intervals are very wide Studies indicate that both male and female mortality underestimated But know that maternal mortality is underestimated even in countries with good vital registration systems

Trend Estimation with 95% Confidence Intervals (Namibia) Estimates are averages over long periods (here 7 or 9 years) and 95% confidence intervals are large Source: Ken Hill – UN maternal mort workshop, Nairobi December 2010

Further use of the data

Coverage of interventions varies across the continuum of care Source: Countdown to 2015: The 2012 report

Tracking Progress on Child and Maternal Nutrition

Brainstorming • Focus on adolescents – coverage of maternal health services • Maternal health… • Fertility desires by background characteristics • HIV and maternal care (knowledge, testing during ANC) • Malaria in pregnancy (provision of IPTp during ANC visits)

Maternal and Reproductive Health