Maternal mortality in South Africa: an update from the 2007 Community Survey

The 2007 Community Survey conducted in South Africa included questions on maternal deaths in the previous 12 months (pregnancy-related deaths). The Maternal Mortality Ratio (MMR) was estimated at 702 per 100,000 live births, some 30% more than at the 2001 census. This high level occurred despite a low proportion of maternal deaths (4.3%) among deaths of women aged 15–49 years, which is even lower than the proportion of time spent in the maternal risk period (7.6%). The high level of MMR was due to the astonishingly high level of adult mortality, which increased by 46% since 2001. The main reasons for these excessive levels were HIV/AIDS and external causes of death (accidents and violence). Differentials in MMR were very marked, and similar to those found in 2001 with respect to urban residence, race, province, education, income, and wealth. Provincial levels of MMR correlated primarily with HIV/AIDS prevalence. Maternal mortality defined as ‘pregnancy-related death’ appears no longer as a proper indicator of ‘safe motherhood’ in this situation.     

Maternal mortality in South Africa: lessons from a case study in the use of deaths reported by households in censuses and surveys

South Africa is unique in being a developing country which has asked questions on pregnancy-related deaths in both its 2001 census and 2007 household survey, and monitors maternal and pregnancy-related mortality through vital registration and a confidential enquiry into maternal deaths. These sources of data provide a wide range of estimates of maternal mortality for the country. This paper examines these estimates to assess to what extent the differences between them are due to data deficiencies, methodological deficiencies or definitional differences. The results show that since maternal deaths are relatively rare it is fairly difficult to establish the maternal mortality rate with a great degree of accuracy in a setting where data are less than perfect. They also show that to some extent the differences are due to differences and errors in processing of data but that pregnancy-related mortality should not be treated as synonymous with maternal mortality. However, after adjustment, pregnancy-related mortality from vital registration was comparable with the level that may be expected using several alternative approaches, while the rate reported by households in census and surveys was about double that from vital registration. Nonetheless, all the data indicate an upward trend in maternal mortality that is in keeping with the impact of the HIV/AIDS epidemic, which is likely to have contributed to the discrepancies.     

Purposive concealment of death in household surveys in Misamis Oriental Province

Summary The randomized response technique was used in a household survey of approximately 2,000 rural and 2,000 urban households in Misamis Oriental Province in the southern Philippines in order to determine the extent of purposive concealment of death. The estimated number of deaths deliberately not revealed to the interviewers was 50 per cent or higher. Adjusted crude death rates of 11.5 and 13.4 per 1,000 population were computed for urban and rural areas, respectively, by adding estimated concealed deaths to deaths reported to the interviewers. Application of stable population techniques and of model life tables suitable to the Philippine setting, while not permitting definite conclusions, provided reasons for believing that these adjusted death rates are close to the true mortality situation in the study areas. Randomized response data further indicate that approximately 75 per cent of urban deaths and 47 per cent of rural deaths of the population studied were not registered with municipal authorities. The authors postulate that failure to register deaths with municipal authorities, together with fear of legal involvement if this failure becomes known outside the immediate neighbourhood, is a major reason for the purposive concealment of death in household surveys.     

Mrs Stone and Dr Smellie: British eighteenth-century birth attendance and long-run levels and trends in maternal mortality discussed in a north European context

This is a book review turned research paper. The aim is to estimate the differences in the maternal mortality rate (MMR) between untrained midwives, expert midwives, and the famous obstetrician Dr Smellie in eighteenth-century Britain. The paper shows that the birth attendance practices of the expert midwife Mrs Stone and of Dr Smellie were very similar, though Stone used her hands whereas Smellie used forceps. Both applied the same invasive techniques to successfully deliver women with similar fatal complications, techniques that untrained midwives and most surgeons of the time could not perform. However, the same procedures, if used for normal births, would have increased the MMR. So, the key to the low MMR of both was that they kept interventions away from the majority of births that were normal. The paper quantifies the likely MMR for a ‘Stone and Smellie style’ birth attendance and concludes that the wider dissemination of their techniques can explain the decline in the British MMR.     

Diversity and change in Cambodian households, 1998–2006

Extant ethnographic studies suggest that the nuclear family has been the predominant living arrangement in Cambodia, and the country’s rapid socioeconomic transformation since the early 1990s may have accentuated that dominance. To examine these claims, we analyse here household structure in Cambodia between 1998 and 2006, based on data from the 1998 Census, two nationally-representative surveys (2000 and 2005), and a continuing demographic surveillance system (from 2000 on). Our analysis confirms the large prevalence of nuclear families, but not an unequivocal trend toward their increasing prevalence. First, nuclear families are less prevalent in urban than in rural areas, and nationwide, they appear to have receded slightly between 2000 and 2005. We find that increases in the prevalence of extended households correspond to periods of faster economic growth, and interpret these contrasted trends as signs of tensions during this transitional period in Cambodia. While the nuclear family may still be the cultural norm, a high degree of pragmatism is also evident in the acceptance of other living arrangements, albeit temporary, as required by economic opportunities and housing shortage in urban areas.     

孕产妇死亡健康公平性分析

文章利用2000～2005年全国卫生统计年报中孕产妇死亡情况有关资料,计算了以孕产妇死亡率为基础的一系列健康公平性指标,分析了2000～2005年间我国孕产妇死亡的健康公平性。研究结果从人群归因危险度百分比、集中指数、集中曲线等指标反映出在我国孕产妇死亡存在分布的不均衡。2000～2005年我国孕产妇死亡在地区间及省际的差距没有明显变化,即不公平现象6年间没有得到改善。     

Household income and child survival in Egypt

This article uses household-level economic and fertility survey data to examine the relationship between household income and child survival in Egypt. Income has little effect on infant mortality but is inversely related to mortality in early childhood. The relationship persists with other associated socioeconomic variables controlled. The mechanisms underlying the income effects are not evident from this analysis: income differentials in sources of household drinking water, type of toilet facilities, and maternal demographic characteristics do not explain the net impact of income on child mortality. The absence of effects on child survival of the size of the place of residence and the relatively weak effects of maternal schooling are also notable.     

Famine,Disease, and Mortality Patterns in the Parish of Borshevka,Russia, 1830–1912

Scholars have projected a dismal image of nineteenth-century, rural Russia as a society repeatedly punctuated by crop failures, famine, starvation, and epidemics of famine-related diseases. But there has been no rigorous attempt, using appropriate methods, to assess the nature of demographic crises in Russia and their contribution to overall mortality and population growth. The pattern of mortality evident in the parish under examination is distinguished by an extremely high incidence of infant, diarrhoeal diseases and childhood, infectious diseases. This unfavourable disease environment and resulting high rates of infant and early childhood mortality were more closely related to fertility levels, household size, housing conditions, and weaning practices than to annual or seasonal food availability and the nutritional status of the population. In a disease-driven society, the susceptibility to infection and the force of infection can, to a considerable extent, be determined by demographic factors, familial norms, and climatic constraints.     

India's National Family Health Survey provides new information on maternal and child health and AIDS awareness

Teams surveyed a sample of 88,562 households, drawn from 99% of the population of India in 24 states plus the National Capital Territory of Delhi, between April 1992 and September 1993 to collect a basic set of information on all 500,492 household members, with more details on the 89,777 women in the households who had ever been married and were aged 13-49 years. This National Family Health Survey (NFHS) collected information from the women on a range of health topics including child immunization, women's knowledge of AIDS, services and facilities use during pregnancy and childbirth, infant feeding and treatment for diarrhea, and infant, child, and maternal mortality. Levels of infant and child mortality declined in India, but 8% of all children still die before their first birthday and 11% die before reaching age 5. As for maternal mortality, there are an estimated 420 maternal deaths per 100,000 live births annually. That rate implies that at least 100,000 Indian women die each year due to causes related to pregnancy and childbirth. Survey results indicate the need to strengthen vaccination programs and teach women about proper infant feeding practices. They also highlight the need to increase antenatal care and other medical services. In all of these areas, the NFHS results indicate wide variation among India's regions and states. Furthermore, a general lack of AIDS awareness suggests that the government's AIDS awareness campaign, relying primarily upon electronic media, has not yet reached the majority of India's population.     

Data on survival of recent births as a source of child mortality estimates in the developing world: An assessment of census data

In many less developed countries, household surveys collect full and summary birth histories to provide estimates of child mortality. However, full birth histories are expensive to collect and cannot provide precise estimates for small areas, and summary birth histories only provide past child mortality trends. A simple method that provides estimates for the most recent past uses questions about the survival of recent births in censuses or large household surveys. This study examines such data collected by 45 censuses and shows that on average they tend to underestimate under-5 mortality in comparison with alternative estimates, albeit with wide variations. In addition, the high non-sampling uncertainty in this approach precludes its use in providing robust estimates of child mortality at the country level. Given these findings, we suggest that questions about the survival of recent births to collect data on child mortality not be included in census questionnaires.     

The effect of female migration on infant and child survival in Uganda

This article uses data from the 1996 Uganda Demographic and Health Survey to examine whether migration of women improves the survival chances of their children to age five. We expand on prior research by testing not only the hypothesized positive effect of rural-urban migration, but also the effects of other migration stream behaviours on child survival. Results show that up to 10% of children die before age five and within-group differences in mortality exist among urban and rural children depending on their mother's migration status. Only urban-urban migration was significantly related to child survival, compared to rural non-migrants, after controlling for other factors, although other streams of migration (rural-urban, urban-rural, rural-rural) were positively related to child survival. Generally, migration explains a small component of the variance in child survival. Several other factors, including parents' education, household size, household headship, mother's age at birth, duration of breastfeeding, and place of delivery have a significant predictive power on child survival.     

Sample registration in gujarat,india

Since October, 1965, births and deaths in rural Gujarat State, India, have been recorded under two independent systems in a random sample of units. First, a part-time local "registrar" is appointed in each sample unit (village or segment thereof) who: prepares a house list; conducts a baseline survey showing the individuals in each household; and maintains a list of the vital events reported by informants whom he contacts fortnightly. Second, a staff member at the rural health centre is assigned part-time supervisory and survey duties: to check the initial listings of the registrar; thereafter, to inspect the registrar's records at least quarterly; and to conduct a household survey each six months, updating the household register and recording births and deaths independently. The registrar's list is sent to the district office immediately before the survey, where it is matched with the survey list forwarded by the local supervisor. A list of unmatched events is returned to the supervisor who with the registrar revisits households to resolve the discrepancies. Under-registration is estimated to be 13 to 20 percent by the registrar method, 8 to 17 percent by the survey method. The birth rate is estimated to be about 44 and the death rate about 19.     

The unintended effects of cash transfers on fertility: evidence from the Safe Motherhood Scheme in India

India launched the Safe Motherhood Scheme (Janani Suraksha Yojana or JSY) in 2005 in response to persistently high maternal and child mortality rates. JSY provides a cash incentive to socioeconomically disadvantaged women for childbirth at health facilities. This study explores some unintended consequences of JSY. Using data from two large household surveys, we examine a policy variation that exploits the differential incentive structure under JSY across states and population subgroups. We find that JSY may have resulted in a 2.5–3.5 percentage point rise in the probability of childbirth or pregnancy over a 3-year period in states already experiencing high population growth.     

"Struggling to Keep the Wolf from the Door"? Analysis of Rural Poverty Using a Consumption-Based Approach in West Belesa District,Ethiopia

Ethiopia has one of the highest poverty rates in the world where 24% of the population lives in extreme poverty. While urban poverty reduced from 26% in 2011 to 15% in 2016, rural poverty reduced only from 30 to 26% in the same periods. Improper identification of the rural poor and ill-understanding of the extent of rural poverty is among the challenges in designing appropriate poverty reduction interventions in rural areas. Thus, this study analyzes the extent of rural poverty employing a consumption-based approach and identifies the determinants of rural poverty at a household level. A household survey was conducted and data were randomly collected from 194 households from four representative villages in the west Belesa district of Ethiopia. The food and non-food consumption measurement calculated by the cost of basic need approach were 2949.40 ETB (ETB is Ethiopian Birr, which is the Ethiopian currency. 1 ETB is equivalent to 0.025 US$) and 1485.78 ETB per year per Adult Equivalent (AE), respectively. The rural poverty indices (i.e. headcount index, poverty gap, and squared poverty gap) calculated based on the consumption-based poverty line were 38.1, 8.84, and 3.1%, respectively. The binary logit analysis shows that having a bigger family had a significant and positive relationship with rural poverty. Conversely, larger landholding, plowing oxen, and livestock ownership as well as a higher amount of non/off-farm income have a significant and negative relationship with the poverty status of households. The study found that rural poverty is deep and complex in the study area calling for the design of location-specific and holistic poverty reduction strategies.

     

Mother’s,Household, and Community U.S. Migration Experience and Infant Mortality in Rural and Urban Mexico

This study explores rural and urban differences in the relationship between U.S. migration experience measured at the individual, household, and community levels and individual-level infant mortality outcomes in a national sample of recent births in Mexico. Using 2000 Mexican Census data and multi-level regression models, we find that women’s own U.S. migration experience is associated with lower odds of infant mortality in both rural and urban Mexico, possibly reflecting a process of healthy migrant selectivity. Household migration has mixed blessings for infant health in rural places: remittances are beneficial for infant survival, but recent out-migration is disruptive. Recent community-level migration experience is not significantly associated with infant mortality overall, although in rural places, there is some evidence that higher levels of community migration are associated with lower infant mortality. Household- and community-level migration have no relationship with infant mortality in urban places. Thus, international migration is associated with infant outcomes in Mexico in fairly complex ways, and the relationships are expressed most profoundly in rural areas of Mexico.

Intra-uterine Mortality and Maternal Nutritional Status in Rural Bangladesh

This paper is an investigation of the relationship of a maternal nutritional status with intra-uterine mortality in a population of chronically malnourished rural Bangladeshi women. First, life-table techniques are used to compare the level of intra-uterine mortality in this population with levels reported in other studies. Then the relationships of maternal nutritional status, age, parity, foetal loss and season of conception with intra-uterine mortality are examined in a multivariate analysis. The results indicate foetal mortality in rural Bangladesh to be markedly higher than in other populations where living conditions and health care are superior. Maternal nutritional status, maternal age and season of conception all appear to be related significantly to foetal mortality.     

Estimates of Survival of Diabetics from Repeated, Independent Sample Surveys

Little is known about death rates among diabetic populations. The few prior estimates have used two data systems, usually a registry or a survey to identify diabetics and death certificates to identify deaths. In this research, the diabetic population aged 18–94 in 1996–1998 and those surviving in 2001–2003 were estimated from repeated cross-sectional surveys, the Behavioral Risk Factor Surveillance System of the Centers for Disease Control and Prevention. Forward survival ratios were computed using a method developed for successive censuses and these were used to compute death rates. Nonlinear regression models for age-sex specific survival ratios were used to estimate parametric rates and thereby increase the accuracy of estimates. About 81.4 % (SE = 1.3 %) of diabetics survived 5 years, for an annual death rate of 41.1 per thousand (SE = 3.2). Among men survival was 84.7 % (SE = 2.1 %) with an annual death rate of 33.8 (SE = 4.9) per thousand; among women survival was 78.5 % (SE = 2.2 %) with an annual death rate of 48.1 (SE = 4.1) per thousand. Model estimates of mortality rates showed an odds ratio of 3.17 (95 % CI 2.64, 3.82) for each 10 year age interval and of 1.35 (95 % CI 1.02, 1.79) for women compared with men. Pooled annual samples, longer time intervals for survival, and parametric estimates of rates all help overcome the small numbers and large sampling variation of survey estimates of survival and mortality. Useful estimates of survival rates can be made from a single data system, a sample survey of the general population. This can be done for any condition where a respondent’s status at the earlier survey time is obtained at the later survey time. It could also be used to make estimates from periodic surveys for nations with limited information systems.     

Annual mortality rates and excess deaths of children under five in Iraq, 1991-98

Data from two parallel household surveys conducted in Iraq by UNICEF in 1999 show that under-5 mortality declined steadily from 1974 to 1990, reaching about 63 per 1,000 live births in the period 1986-90. It then rose dramatically to 118 per 1,000 in 1991, the year of the Gulf War. The number of 'excess' under-5 deaths (i.e., the number in excess of the number predicted from past trends) in Iraq between 1991 and 1998 was calculated assuming that, instead of the rates measured by the 1999 survey for this period, either (a) average mortality rates for the period 1986-90 had been maintained, or (b) mortality had continued to decline at the rate observed between 1974 and 1990. According to these calculations, the estimated number of excess deaths resulting from the Gulf War and its aftermath up to 1998 was between 400,000 (assumption a) and 500,000 (assumption b).     

Methods for combining ancillary data in stochastic compartment models of cancer mortality: Generalization of heterogeneity models∗

In analyzing mortality data there may be available information from survey and other sources that describe the marginal distribution of risk factors. We present a mortality model where nationally representative survey data on risk factor distributions are combined with data on cohort mortality rates to increase information, i.e., a fixed marginal risk factor distribution is combined with a cohort model representing unobserved individual risk heterogeneity. The model is applied to lung cancer mortality in nine U.S. white male cohorts aged 30 to 70 in 1950 and followed 38 years. Estimates of the cohort specific proportions of smokers were made from the National Health Interview Survey. Comparisons are made for models with different patterns of changes with age of individual heterogeneity.     

Sample registration in India

Abstract The Sample Registration Project in India is designed to obtain current estimates of birth and death rates for the whole country. It is being implemented quite rapidly. Rural and urban areas in all states and Union Territories in India will be covered before the close of 1969. Bigger states have 150 sample units in rural areas and 60 to 100 units in urban areas. Essential elements of the project for each unit are: (1) continuous enumeration of births and deaths in respect of usual resident population by a paid part-time local enumerator; (2) a six-month household survey to detect births and deaths which occurred to the usual resident population during the previous six months; and (3) manual matching of all event from enumeration and surveys and field re-check of unmatched events to obtain the 'best' count of real number of events. The results of a full-scale sample in four states and pilot sample in ten states indicate that the crude birth and death rates are around 40 and 18 per 1,000, respectively, for India's rural population. Most of the problems of implementation are operational or administrative rather than statistical. The main problem in the whole project is to maintain control of field operations well enough at each stage to ensure that prescribed instructions and methodology are being followed; particularly in the six-month survey. Experience in India indicates that sample registration techniques are capable of providing reliable birth and death rates in similar conditions in developing countries. However, there are still a number of methodological problems which must be tested as the sample registration evolves.