Immpact Toolkit: Module 4
Version 2
Maternal Death from Informants and Maternal Death Follow-on Review (MADE-IN / MADE-FOR)
In many developing countries, vital registration systems are inadequate for obtaining accurate and reliable health-related data. In many cases, these systems are poorly maintained or unused by the local community. Where they do exist, the causes of deaths related to pregnancy, childbirth and the puerperium are often poorly recorded. In these circumstances, different approaches have been used to measure levels and causes of mortality. The problems with most of the commonly used methods are outlined in the World Health Organization (WHO) publication Maternal Mortality in 2000 (WHO, 2004a). Large-scale surveys, in particular, are often used as an alternative way of gaining reliable data, and modules to measure rates of maternal mortality have often been added to other major health surveys such as the Demographic and Health Surveys (DHSs) (Stanton et al, 1997) or censuses (Stanton et al, 2001). These surveys, however, are not always an 'easy' solution: they usually only take place every five to ten years, are costly to implement, and do not permit useful estimates to be made at sub-national levels.
The difficulty in measuring maternal mortality, including problems associated with costs, validity and reliability of existing methods, has led Immpact to develop methods that are cheaper, more reliable or easier to undertake in developing country contexts. The Sampling at Service Sites (SSS) tool in this toolkit has outlined one method for collecting data for measuring rates of maternal mortality in the community using a survey approach. This useful tool, however, does not examine the causes of maternal deaths. Furthermore, it is not suitable for obtaining very precise estimates or for highly intensive surveys (since it uses the 'sisterhood method'). Where maternal mortality ratios (MMRs) have fallen substantially below 500 per 100,000 live births, any method based on interviewing a population-based sample of households or women becomes increasingly expensive and inefficient. In order to develop strategies and interventions in maternal health that are evidence-based and targeted on local problems, it is also important to tell the 'story' of how women die in order to analyse the underlying factors that lead to deaths (WHO, 2004b).
The Maternal Death from Informants / Maternal Death Follow-On Review (MADE-IN / MADE-FOR) is an approach that allows the measurement of maternal mortality down to the community level, together with an analysis of the causes of maternal deaths. Where there are suitable networks of informants available, this tool is not only suitable for intensive surveys or even censuses, but can also be used in large surveys to give precise estimates. In addition, the tool is less costly than household surveys or SSS, especially in lower-fertility, lower-mortality contexts. It goes beyond simply counting deaths, it develops an understanding of why they happened and how they can be averted. Where large numbers of women die outside of health care facilities in the community, identifying the main causes of, and factors contributing to, deaths can be particularly difficult. Investigating these deaths, however, is very important since they shed light on the medical and non-medical factors and barriers to care that lead to women dying (Lewis and Berg, 2004). Action based on the results of community-based research can save lives not only through introducing or refocusing health education messages and improving community awareness and knowledge, but also by adopting changes in clinical practice and reconfiguring local services to make them more acceptable, accessible and available.
To date, MADE-IN / MADE-FOR has been conducted by Immpact in two districts of Indonesia and the guidance contained in this tool is based on that study. The lessons learned from the experience are also discussed.