Maternal and Reproductive Health

Multiple Indicator Cluster Surveys Data Interpretation, Further Analysis and

Dissemination Workshop

Maternal and Reproductive Health

2

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)

3





(3 tables)

4

Fertility

Urban Rural Total

Age 15-191

20-24 25-29 30-34 35-39 40-44 45-49

TFRa

GFRb

CBRc

Table RH.1: Fertility ratesAdolescent birth rate, age-specif ic and total fertility rates, the general fertility rate, and the crude birth rate for the one-year / three-year period preceding the survey, by area, Country, Year

1 MICS indicator 5.1; MDG indicator 5.4 - Adolescent birth ratea TFR: Total fertility rate expressed per w oman age 15-49b GFR: General fertility rate expressed per 1,000 w omen age 15-49c CBR: Crude birth rate expressed per 1,000 population

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

5

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

Table RH.1: Fertility ratesAdolescent birth rate, age-specific and total fertility rates, the general fertility rate, and the crude birth rate for the one-year / three-year period preceding the survey, by area, Country, Year

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(3 tables)

7

Childbearing among adolescents

Adolescent birth rate1

(Age-specif ic fertility rate for w omen age 15-19) Total fertility rate

Total

RegionRegion 1Region 2Region 3Region 4Region 5

EducationNonePrimarySecondaryHigher

Table RH.2: Adolescent birth rate and total fertility rateAdolescent birth rates and total fertility rates for the one-year / three-year period preceding the survey, Country, Year

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

8


Have had a live birth

Are pregnant w ith f irst child

Have begun childbearing

Have had a live birth before age 15

Total

RegionRegion 1Region 2

Table RH.3: Early childbearing

Percentage of women age 15-19 who:

Percentage of w omen age 15-19 years w ho have had a live birth, are pregnant w ith the f irst child, have begun childbearing, and w ho have had a live birth before age 15, and percentage of w omen age 20-24 years w ho have had a live birth before age 18, Country, Year

Number of w omen age

15-19

Number of w omen age

20-24

Percentage of w omen age 20-24 w ho have had a live birth before age 181

Sum of first two columns

9


Percentage of w omen w ith a live

birth before age 15

Number of w omen age 15-49 years


birth before age 18



birth before age 15



birth before age 18



birth before age 15



birth before age 18


Total

Age 15-19 na na na na na na 20-24 25-29 30-34 35-39 40-44 45-49

Table RH.4: Trends in early childbearing

Urban Rural All

Percentage of w omen w ho have had a live birth, by age 15 and 18, by area and age group, Country,Year

na: not applicable

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

10

Adolescent childbearing – comparison of indicators

Indicator Value Adolescent birth rate (per 1000 women 15-19) 59

Example from MICS4

11


Indicator Value Adolescent birth rate (per 1000 women 15-19) 59 15-19 year old women who have had a live birth 8.5%

Example from MICS4

12


Indicator Value Adolescent birth rate (per 1000 women 15-19) 59 15-19 year old women who have had a live birth 8.5% Live birth before age 18 (among 20-24 year olds) 15.3%

Example from MICS4

13





(3 tables)

14

ContraceptionTable RH.5: Use of contraceptionPercentage of w omen age 15-49 years currently married or in union w ho are using (or w hose partner is using) a contraceptive method, Country, Year

Percent of women currently married or in union who are using (or whose partner is using):

No method

Female sterili-zation

Male sterili-zation IUD Injectables Implants Pill

Male condom

Female condom

Diaphragm/Foam/Jelly LAM

Total

Modern Percentage of w omen age 15-49 years currently married or in union w ho are using (or w hose partner is using) a contraceptive method, Country, Year

Periodic abstinence Withdraw al Other

Any modern method

Any tradi-tional

methodAny

method1

Total


currently married or in union

Traditional MDG Indicator

Should have been customized in-country

e.g. LAM

15

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

16

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

17

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

18

Unmet need

For spacing For limiting Total For spacing For limiting Total1

Total

Met need for contraception

Table RH.6: Unmet need for contraceptionPercentage of w omen age 15-49 years currently married or in union w ith an unmet need for family planning and percentage of demand for contraception satisf ied, Country, Year

Unmet need for contraceptionNumber of

w omen currently married or in

union

Percentage of demand for

contraception satisf ied

Number of w omen currently married or in union w ith need for contraception

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

19

Country example

Met need

for contra-

ception –

For spacing

Met Need for

contra-ception –

For limiting

Met need

for contra-

ception -

Total

Unmet need for

contra-ception –

For spacing

Unmet need

for contra-

ception –

For limiting

Unmet need

for contra-

ception –

Total

Number of women


Percentage of

demand for

contra-ception satisfied

Number of women


with need for

contra-ception

19.1 58.2 77.3 2.4 2.1 4.5 2,653 94.4 2,171

20

Country example

Met need

for contra-

ception –

For spacing

Met Need for

contra-ception –

For limiting

Met need

for contra-

ception -

Total

Unmet need for

contra-ception –

For spacing

Unmet need

for contra-

ception –

For limiting

Unmet need

for contra-

ception –

Total

Number of women


Percentage of

demand for

contra-ception satisfied

Number of women


with need for

contra-ception

19.1 58.2 77.3 2.4 2.1 4.5 2,653 94.4 2,171

Any method 77.2Any modern method 58.8Any traditional method 18.5

Use of contraception

Note that met need for contraception includes both traditional and modern methods

21





(3 tables)

22

Antenatal care

Medical doctor

Nurse/ Midw ife

Auxiliary midw ife

Traditional birth

attendant

Community health w orker Other

Total 100.0

Table RH.7: Antenatal care coveragePercent distribution of w omen age 15-49 years w ith a live birth in the last tw o years by antenatal care provider during the pregnancy for the last birth, Country, Year

Provider of antenatal careaNumber of

w omen w ith a live birth in the last tw o years

No antenatal

care Any skilled provider1Total

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

23

Table RH.8: Number of antenatal care visits and timing of first visitPercent distribution of w omen age 15-49 years w ith a live birth in the last tw o years by number of antenatal care visits by any provider and by the timing of f irst antenatal care visits, Country, Year

No antenetal care visits One visit Tw o visits Three visits

4 or more visits1

Total 100.0

Percent distribution of women who had:

Total

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

Antenatal care

MDG indicator

24

Table RH.8: Number of antenatal care visits and timing of first visitPercent distribution of w omen age 15-49 years w ith a live birth in the last tw o years by number of antenatal care visits by any provider and by the timing of f irst antenatal care visits, Country, Year

No antenatal care visits

First trimester 4-5 months 6-7 months 8+ months DK/Missing

Total 100.0

Number of w omen w ith a live birth in the last tw o years w ho had at least

one ANC visit

Percent distribution of women by number of months pregnant at the time of first antenatal care visit

Total

Number of w omen w ith a live birth in the last tw o years

Median months

pregnant at f irst ANC

visit

Antenatal care

Second part of table on timing of antenatal care visits

Important information on timing of antenatal visits

25

Antenatal care

Blood pressure measured

Urine sample taken

Blood sample taken

Blood pressure measured, urine and blood sample taken1

Total

Table RH.9: Content of antenatal carePercentage of w omen age 15-49 years w ith a live birth in the last tw o years w ho, at least once, had their blood pressure measured, urine sample taken, and blood sample taken as part of antenatal care, during the pregnancy for the last birth, Country, Year

Number of w omen w ith a live birth in the last tw o

years

Percentage of women who, during the pregnancy of their last birth, had:

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(3 tables)

27

Table RH.10: Assistance during delivery and caesarian sectionPercent distribution of w omen age 15-49 years w ith a live birth in the last tw o years by person providing assistance at delivery, and percentage of births delivered by C-section, Country, Year

Medical doctor

Nurse/ Midw ife

Auxiliary midw ife

Traditional birth

attendant

Community health w orker

Relative/Friend Other

Total 100.0

TotalNo

attendant

Person assisting at delivery Delivery assisted by any skilled attendant1

MICS5 standard -- Normally, skilled attendant

includes doctors, nurses and midwives. Auxiliary midwife may or may not be considered skilled personnel.

Delivery Care

MDG indicator

28

Table RH.10: Assistance during delivery and caesarian sectionPercent distribution of w omen age 15-49 years w ith a live birth in the last tw o years by person providing assistance at delivery, and percentage of births delivered by C-section, Country, Year

Decided before onset of labour

pains

Decided after onset of labour

pains Total2

Total

Percent delivered by C-section Number of w omen w ho had a live birth in the last tw o years

C-section should be within 5%-15%

Delivery Care

This is new in MICS – to establish emergency ceasarians

29

Public sector

Private sector

Total 100.0

Table RH.11: Place of deliveryPercent distribution of w omen age 15-49 years w ith a live birth in the last tw o years by place of delivery of their last birth, Country, Year

Number of w omen w ith a live birth in the last tw o years

Place of delivery

Total

Delivered in health facility1

Health facility

Home Other

Delivery Care

Place of delivery categories should have been modified in country

Possible to present additional categories.

30

Continuum of reproductive and maternal health interventions

0

20

40

60

80

100 94 97

7185

7156 51

97 96

Pre-preg

Pregnancy (Antenatal Care)

Delivery Care

31

Continuum of reproductive and maternal health interventions

0102030405060708090

100 94 97

7185

7156 51

97 96

Pre-preg

Pregnancy (Antenatal Care)

Delivery Care

Gap!Gap!

32





(3 tables)

33

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

34

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

35

Post-natal health – indicators, definitions

Institutional Deliveries Non-institutional deliveries

With Attendant Without attendant

While in facility or at home following birth

Duration of post-partum stay in facility

Health check in facility after birth, before discharge

Health check from attendant before leaving mother & child

after birth

Post-natal care visit (with info on timing, location, provider)

Health check after discharge

Health check after attendant leaves home after birth Any health check

Post-natal health check (Global Indicator)

Health check in facility and/or

Health check after discharge (PNC visit within 2 days of

delivery)

Health check from attendant and/or

Health check after attendant leaves home (PNC visit within

two days of delivery)

Health check (PNC visit within two

days of delivery)

36

PNC Data from Ghana MICS 2011

Newborns

Health checks after delivery

(%)

PNC Visits (%)

Post-natal Health

Check (%)Within 2 days 2-6 days

After the first

week

No PNC Visit

Ghana total 81 13 7 21 59 83Facility birth 97 10 7 27 56 97

Home birth 47 20 7 9 64 55

37

PNC Data from Ghana MICS 2011

Newborns

Health checks after delivery

(%)

PNC Visits (%)

Post-natal Health

Check (%)Within 2 days 2-6 days

After the first

week

No PNC Visit

Ghana total 81 13 7 21 59 83Facility birth 97 10 7 27 56 97

Home birth 47 20 7 9 64 55

More PNC visits for newborns than mothers – both for home and facility deliveries

38

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

39





(3 tables)

40

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.

41

Adult and maternal mortality

Three tables are generated On adult mortality rates On adult mortality probabilities On maternal mortality

42

Adult mortality rates

Number of Deaths

Exposure years

Mortality ratesa

Number of Deaths

Exposure years

Mortality ratesa

Total 15-49 b b

Age15-1920-2425-2930-3435-3940-4445-49

Table RH.18: Adult mortality ratesDirect estimates of female and male mortality rates for the seven years preceding the survey, by five-year age groups, Country, Year

Female Male

Mortality rates for males and females, for ages 15 to 49,

during the last 7 years

43

Adult mortality probabilities

Women 35q15 a

Men 35q15 a

Country, Year

Table RH.19: Adult mortality probabilitiesThe probability of dying betw een the ages of 15 and 50 for w omen and men for the seven years preceding the survey, Country, Year

a The probability of dying betw een exact ages 15 and 50, expressed per 1,000 person-years of exposure

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

44

Maternal mortality

Percentage of female deaths that are

maternalMaternal Deaths

Exposure (Years) Maternal mortality ratesa

Total 15-49 b

Age15-1920-2425-2930-3435-3940-4445-49

General fertility ratec b

Maternal mortality ratio1, d

Lifetime risk of maternal deathe

Table RH.20: Maternal mortalityDirect estimates of maternal mortality rates for the 7 years preceding the survey, by five-year age groups, Country, Year

1 MICS indicator 5.13; MDG indicator 5.1 - Maternal mortality ratioa Expressed per 1,000 w oman-years of exposureb Age-adusted ratec Expressed per 1,000 w omen age 15-49d Calculated as the maternal mortality rate divided by the general fertility rate, expressed per 100,000 live birthse Calculated as 1-(1-MMR)TFR w here MMR is the maternal mortality ratio, and TFR represents the total fertility rate for the seven years preceding the survey

Additional questions on when female deaths occurred (pregnancy, delivery or post-partum periods) make it possible

to calculate maternal mortality rates and ratios

Deaths during pregnancy or childbirth or deaths within 2 months after the termination of a pregnancy or childbirth

GFR and TFR should be estimated from the survey results, or from external sources - should refer to the 7-year period preceding the survey

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

MMRate: Expressed per 1,000 woman-years of exposure

45

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

46

Trend Estimation with 95% Confidence Intervals (Namibia)

0

100

200

300

400

500

600

Pre

gnan

cy-R

elat

ed M

orta

lity

Rat

io

1985 1990 1995 2000 2005Year

1992 DHS 2000 DHS2007 DHS

Source: Ken Hill – UN maternal mort workshop,Nairobi December 2010

Estimates are averages over long periods (here 7 or 9 years) and 95% confidence intervals are large

47

Further use of the data

48

Coverage of interventions varies across the continuum of care

Source: Countdown to 2015: The 2012 report

49Tracking Progress on Child and Maternal Nutrition

50

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)

51

Thank You

Documents

Maternal and Reproductive Health