Setting a Target for M aternal Mortality

Setting a Target for Maternal Mortality

Marjorie Koblinsky, USAIDThomas Pullum, MEASURE DHS

Tessa Wardlaw, Danzhen You, UNICEFLale Say, Doris Chou (WHO)

Sam Whipple (KMS)

Sept 5, 2013Original presentation condensed

1

1. Setting a target for maternal mortality

Characteristics : ambitious but plausible; should accelerate progress

Four key components to target setting:

– End year: Focus here on 2035, but actual value is TBD (MDG 5: 1990-2015)

– Indicator: MMR or # maternal deaths, LTR, other? (MDG 5: MMR)

– Annual Rate of Reduction (ARR) does not have to be constant, but the average value should be feasible, aggressive

(MDG 5: ARR of 5.5%)

– End value: Determined by the choice of end year and ARR, with rounding (MDG 5: 25% of the start value, or a decline of 75%--a relative target—over 25 year period) 2

• Global MMR: 210 maternal deaths per 100,000 live births in 2010

• Global number of maternal deaths: 287,000 in 2010• 77 countries already reached an MMR of 50 or lower; among

them, 58 already reached an MMR of 30 or lower• 26 countries still had an MRR more than 400 deaths per

100,000 live births

Statistics & Monitoring Section/DPS

Table 1: Number of Countries with specific ranges of MMR in 2010 (n=189)

MMR≤30 30<MMR≤50

50<MMR≤100

100<MMR≤200

200<MMR≤500

MMR>400

Number of countries

58 19 35 16 35 26

1. Indicator: Present MMR

4

1990 1995 2000 2005 2010 2015 2020 2025 2030 20350

50

100

150

200

250

300

350

400

450

Mat

erna

l Mor

talit

y R

atio

(per

100

,000

live

birt

hs)

543,000 deaths annually

287,000 deaths annually

4.1% Annual Rate of MMR Reduc-

tion 2000-2010

5.6% Annual Rate of MMR

Reduction 2010-2035

Accelerated Trend

4.1% Annual Rate of MMR

Reduction 2010-2035

Current trend

Global MMR

OECD Upper Limit MMR

2015 MDGMMR=100

Source: UN Estimates for Trends in Maternal Mortality 1990-2010.World Health Organization, 2012.

74

50

2. Absolute Target: Historical trends and projections, MMR = 50 by 2035, worldwide

5

1990 1995 2000 2005 2010 2015 2020 2025 2030 20350

100

200

300

400

500

600

700

800

900

1000

Mat

erna

l Mor

talit

y Ra

tion

(per

100

,000

live

birt

hs)

Asia, excl. India and China

India

Sub-Saharan Africa

Global MMR

OECD Countries - Upper Limit

Asia: Afghanistan, Bhutan, Cambodia, Indonesia, Iran, Iraq, Kyrgyzstan, Lao, Morocco, Myanmar, Nepal, Pakistan, Papua New Guinea, Philippines, Solomon Islands, Tajikistan, Turkmenistan, Uzbekistan, VietNam, YemenAfrica: Angola, Benin, Botswana, Burkina Faso, Burundi, Cameroon, Central African Republic, Chad, Congo, Cote d'Ivoire, Democratic Republic of the Congo, Equatorial Guinea, Eritrea, Ethiopia, Gabon, Gambia, Ghana, Guinea, Guinea-Bissau, Kenya, Lesotho, Liberia, Madagascar, Malawi, Mali, Mauritania, Mozambique, Niger, Nigeria, Rwanda, Sao Tome and Principe, Senegal, Sierra Leone, Somalia, South Africa, Sudan, Swaziland, Togo, Uganda, Tanzania, Zambia, Zimbabwe

225

50

Current AAR 2000-2010

AAR to Reach MMR = 50

Sub-Saharan Africa -3.7% -8.9%India -6.5% -5.4%Asia, excluding India and China -4.8% -5.1%Global -4.1% -5.6%

2. Absolute Target: Historical trends and projections

MMR = 50 by 2035, regions

Statistics & Monitoring Section/DPS

ARR≤1 1<ARR≤2 2<ARR≤3 3<ARR≤4 4<ARR≤5 5<ARR≤6 ARR>6

Number of countries

20 36 40 32 23 10 20

Table 2: Number of Countries with specific ranges of ARR in 2000-2010

• Global ARR: 3.1% in 1990-2010; 4.1% in 2000-2010

• Only 20 countries had an ARR more than 6%; among them, only 5 countries had an ARR more than 8%

• Plausible ARR range: 5-7%

2. Absolute target: Annual rates of reduction (ARR)

8

50

1990 1995 2000 2005 2010 2015 2020 2025 2030 20350

200

400

600

800

1000

1200

1400

Mat

erna

l Mor

talit

y Ra

tio (p

er 1

00,0

00 li

ve b

irths

)

Current ARR ARR to Reach 2000-2010 MMR=50Afghanistan -7.5% -8.5%Bangladesh -5.0% -6.1%Nepal -7.2% -4.8%Pakistan -3.7% -6.4%

Afghanistan

Pakistan

Nepal

Bangladesh


2. Absolute target: Afghanistan, Bangladesh, Nepal, Pakistan

9

3. Relative Target: 2010 and 2035 MMR Estimates (85% Reduction; ARR=7.3%)

MMR<1515≤MMR<3030≤MMR<60MMR≥60

MMR<100100≤MMR<200200≤MMR<400

MMR≥400

2010 Estimate 2035 Target

10

Already achieved MMR≤500≤ARR<4%4%≤ARR<8%ARR≥8%

Required ARR to Reach MMR=50

2. Absolute target: Countries Require Different Annual Rates of Reduction to Achieve MMR=50 by

2035

• Afghanistan*: 46069• Angola: 45068• Bangladesh*: 24036• Burundi: 800120• Cameroon: 690104• Central African Republic: 890134• Chad: 1100165• Congo: 56084• DRC*: 54081• Ethiopia*: 35053• Ghana: 35053• Guinea: 61092• Guinea-Bissau: 790119• Haiti*: 35053• India*: 20030• Indonesia*: 22033• Ivory Coast*: 40060• Kenya*: 36054• Laos: 47071• Lesotho: 62093

11

3. Relative Target: MCH Priority Countries with 2035 Projection (85% Reduction, ARR=7.3%)

• Liberia*: 770116• Madagascar*: 24036• Malawi*: 46069• Mali*: 54081• Mauritania: 51077• Mozambique*: 49074• Nepal*: 17026• Niger: 59089• Nigeria*: 63095• Pakistan*: 26039• Rwanda*: 34051• Senegal*: 37056• Sierra Leone: 890134• Somalia: 1000150• Sudan*: 730110• Tanzania*: 46069• Uganda*: 31047• Yemen*: 20030• Zambia*: 44066• Zimbabwe*: 57086

Source: UN Estimates for Trends in Maternal Mortality 1990-2010.World Health Organization, 2012. * MCH Priority Country

4. Key points and questions

• Indicator: Should we continue with the MMR? • Absolute Target depends on current MMR, end year

– Does a GLOBAL indicator make sense? Absolute country targets make achieving goals difficult for high MMR countries, particularly sub-Saharan African countries.

– ARR trajectory: Depends on country’s current MMR• Should high MMR countries aim for higher MMR in 2035 (MMR=100)? • Should low MMR countries focus on equity (high MMR subpopulations)? • Should we set 5 year milestones?

• Plausible Relative Target will depend on the end year– 2035: 80% decline, global MMR target=50– 2030: 70% decline, global MMR target=60 – 2025: 60% decline, global MMR target=80 or 90

Setting a Target for Maternal Mortality

In LAC

Peg Marshall, USAID Kelsey Wright (KMS)

November 14, 2013

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Trends shown in these slides include:-Projections to 2035 using current ARR-Projections to 2035 using goal of MMR=50 by 2035-Projections to 2035 using goal of 50% reduction in MMR-Projections to 2035 using goal of 75% reduction in MMR

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• Current ARRs are based on 1990-2010 estimates

• Regional Averages are weighted by live births from 1990-2010

Weighted Regional Projections

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*Countries included in weighted analysis are: Bolivia, Brazil, Canada, Colombia, Costa Rica, Dominican Republic, Guatemala, Guyana, Haiti, Jamaica, Paraguay, United StatesSources: (1) MMR data from WHO (2012). Trends in Maternal Mortality: 1990 to 2010; (2) Live births data from U.S. Census Bureau International Data Base; (3) Census Bureau Table of Live Births 1909-2003 (http://www.cdc.gov/nchs/data/statab/natfinal2003.annvol1_01.pdf)

Weighted Average of Selected LAC Countries*

1990 1995 2000 2005 2010 2015 2020 2025 2030 20350

20

40

60

80

100

120

140

160

180

30

50

29.1695170031427

14.5847585015713

Mat

erna

l Mor

talit

y Ra

tio (p

er 1

00,0

00 li

ve b

irths

)

Weighted Average of Selected LAC Countries*

ARR 2035 MMRCurrent -2.6 30MMR=50 -0.6 5050% Reduction -2.7 2975% Reduction -5.4 15

Select LAC Countries where Current MMR ARR is Positive (MMR is increasing)

17

Positive MMR ARRs in the LAC Region

Source: Trends in maternal mortality: 1990 to 2010. WHO, UNICEF, UNFPA and The World Bank estimates. World Health Organization, 2012.

18

1990 1995 2000 2005 2010 2015 2020 2025 2030 20350

10

20

30

40

50

60

29

50

6

3

Mat

erna

l Mor

talit

y Ra

tio (p

er 1

00,0

00 li

ve

birt

hs)

Canada ARR 2035 MMRCurrent 3.5 29MMR=50 5.9 5050% Reduction -2.7 6 75% Reduction -5.4 3

1990 1995 2000 2005 2010 2015 2020 2025 2030 20350

100

200

300

400

500

600

486

50

14069.9999999999

999

Mat

erna

l Mor

talit

y Ra

tio (p

er 1

00,0

00 li

ve

birt

hs)

Guyana ARR 2035 MMRCurrent 2.2 486MMR=50 -6.7 5050% Reduction -2.7 14075% Reduction -5.4 70

1990 1995 2000 2005 2010 2015 2020 2025 2030 20350

10

20

30

40

50

60

43

50.0000000000001

20

9.99999999999999M

ater

nal M

orta

lity R

atio

(per

100

,000

live

bi

rths

)

Costa Rica

ARR 2035 MMRCurrent 0.3 43MMR=50 0.9 5050% Reduction -2.7 2075% Reduction -5.4 10

Positive MMR ARRs in the LAC Region

Source: Trends in maternal mortality: 1990 to 2010. WHO, UNICEF, UNFPA and The World Bank estimates. World Health Organization, 2012. 19

1990 1995 2000 2005 2010 2015 2020 2025 2030 20350

10

20

30

40

50

60

42

49.9999999999999

10.5

5.24999999999999M

ater

nal M

orta

lity

Ratio

(per

100

,000

live

bi

rths

)

United States of America ARR 2035 MMRCurrent 2.8 42MMR=50 3.5 5050% Reduction -2.7 1175% Reduction -5.4 5

1990 1995 2000 2005 2010 2015 2020 2025 2030 20350

50

100

150

200

250

300

240

5055

27.5Mat

erna

l Mor

talit

y Ra

tio (p

er 1

00,0

00 li

ve

birt

hs)

Jamaica ARR 2035 MMRCurrent -3.2 240MMR=50 -3.1 5050% Reduction -2.7 5575% Reduction -5.4 28

Canada MMR Projections


1990 1995 2000 2005 2010 2015 2020 2025 2030 20350

10

20

30

40

50

60

29

50

6

3

Mat

erna

l Mor

talit

y Ra

tio (p

er 1

00,0

00 li

ve b

irths

)

Canada

ARR 2035 MMRCurrent 3.5 29MMR=50 5.9 5050% Reduction -2.7 6 75% Reduction -5.4 3

Costa Rica MMR Projections


1990 1995 2000 2005 2010 2015 2020 2025 2030 20350

10

20

30

40

50

60

43

50.0000000000001

20

9.99999999999999

Mat

erna

l Mor

talit

y Ra

tio (p

er 1

00,0

00 li

ve b

irths

)

Costa Rica ARR 2035 MMRCurrent 0.3 43MMR=50 0.9 5050% Reduction -2.7 2075% Reduction -5.4 10

Guyana MMR Projections


1990 1995 2000 2005 2010 2015 2020 2025 2030 20350

100

200

300

400

500

600

486

50

140

69.9999999999999

Mat

erna

l Mor

talit

y Ra

tio (p

er 1

00,0

00 li

ve b

irths

)

Guyana ARR 2035 MMRCurrent 2.2 486MMR=50 -6.7 5050% Reduction -2.7 14075% Reduction -5.4 70

Jamaica MMR Projections


1990 1995 2000 2005 2010 2015 2020 2025 2030 20350

50

100

150

200

250

300

240

5055

27.5

Mat

erna

l Mor

talit

y Ra

tio (p

er 1

00,0

00 li

ve b

irths

)

Jamaica ARR 2035 MMRCurrent -3.2 240MMR=50 -3.1 5050% Reduction -2.7 5575% Reduction -5.4 28

U.S. MMR Projections


1990 1995 2000 2005 2010 2015 2020 2025 2030 20350

10

20

30

40

50

60

42

49.9999999999999

10.5

5.24999999999999

Mat

erna

l Mor

talit

y Ra

tio (p

er 1

00,0

00 li

ve b

irths

)

United States of America

ARR 2035 MMRCurrent 2.8 42MMR=50 3.5 5050% Reduction -2.7 1175% Reduction -5.4 5

Select LAC Countries where 50% Reduction by 2035 is equal to or below MMR=50

25

50% Reduction by 2035 is ≤MMR=50


1990 1995 2000 2005 2010 2015 2020 2025 2030 20350

20

40

60

80

100

120

140

22

50

28

14

Mat

erna

l Mor

talit

y Ra

tio (p

er 1

00,0

00 li

ve

birt

hs)

Brazil ARR 2035 MMRCurrent -3.8 22MMR=50 -4.5 5050% Reduction -2.7 28 75% Reduction -5.4 14

1990 1995 2000 2005 2010 2015 2020 2025 2030 20350

20

40

60

80

100

120

140

160

180

43

49.999999999999946

23Mat

erna

l Mor

talit

y Ra

tio (p

er 1

00,0

00

live

birt

hs)

Columbia ARR 2035 MMRCurrent -3.0 43MMR=50 -2.4 5050% Reduction -2.7 46 75% Reduction -5.4 23

1990 1995 2000 2005 2010 2015 2020 2025 2030 20350

20

40

60

80

100

120

140

78

50

49.5

24.75

Mat

erna

l Mor

talit

y Ra

tio (p

er 1

00,0

00 li

ve

birt

hs)

Paraguay


Brazil MMR Projections


1990 1995 2000 2005 2010 2015 2020 2025 2030 20350

20

40

60

80

100

120

140

22

50

28

14

Mat

erna

l Mor

talit

y Ra

tio (p

er 1

00,0

00 li

ve b

irths

)

Brazil ARR 2035 MMRCurrent -3.8 22MMR=50 -4.5 5050% Reduction -2.7 28 75% Reduction -5.4 14

Colombia MMR Projections


1990 1995 2000 2005 2010 2015 2020 2025 2030 20350

20

40

60

80

100

120

140

160

180

43

49.999999999999946

23

Mat

erna

l Mor

talit

y Ra

tio (p

er 1

00,0

00 li

ve b

irths

)

Columbia ARR 2035 MMRCurrent -3.0 43MMR=50 -2.4 5050% Reduction -2.7 46 75% Reduction -5.4 23

Paraguay MMR Projections


1990 1995 2000 2005 2010 2015 2020 2025 2030 20350

20

40

60

80

100

120

140

78

50

49.5

24.75Mat

erna

l Mor

talit

y Ra

tio (p

er 1

00,0

00 li

ve b

irths

)

Paraguay ARR 2035 MMRCurrent -1.0 78MMR=50 -2.7 5050% Reduction -2.7 5075% Reduction -5.4 25

30

Select LAC Countries where 75% Reduction by 2035 is equal to or below MMR=50

75% Reduction by 2035 is ≤MMR=50


1990 1995 2000 2005 2010 2015 2020 2025 2030 20350

50

100

150

200

250

300

350

400

450

500

6550

94.9999999999999

47.4999999999999

Mat

erna

l Mor

talit

y Ra

tio (p

er 1

00,0

00 li

ve

birt

hs)

Bolivia ARR 2035 MMRCurrent -4.2 65MMR=50 -5.2 5050% Reduction -2.7 95 75% Reduction -5.4 48

1990 1995 2000 2005 2010 2015 2020 2025 2030 20350

50

100

150

200

250

93

50

74.9999999999999

37.4999999999999M

ater

nal M

orta

lity

Ratio

(per

100

,000

live

bi

rths

)

Dominican Repub-lic ARR 2035 MMRCurrent -1.9 93MMR=50 -4.3 5050% Reduction -2.7 7575% Reduction -5.4 38

1990 1995 2000 2005 2010 2015 2020 2025 2030 20350

20

40

60

80

100

120

140

160

180

84

5060

30

Mat

erna

l Mor

talit

y Ra

tio (p

er 1

00,0

00

live

birt

hs)

Guatemala


Bolivia MMR Projections


1990 1995 2000 2005 2010 2015 2020 2025 2030 20350

50

100

150

200

250

300

350

400

450

500

65

50

94.9999999999999

47.4999999999999

Mat

erna

l Mor

talit

y Ra

tio (p

er 1

00,0

00 li

ve b

irths

)

Bolivia ARR 2035 MMRCurrent -4.2 65MMR=50 -5.2 5050% Reduction -2.7 95 75% Reduction -5.4 48

Dominican Republic MMR Projections


1990 1995 2000 2005 2010 2015 2020 2025 2030 20350

50

100

150

200

250

93

50

74.9999999999999

37.4999999999999

Mat

erna

l Mor

talit

y Ra

tio (p

er 1

00,0

00 li

ve b

irths

)

Dominican Republic ARR 2035 MMRCurrent -1.9 93MMR=50 -4.3 5050% Reduction -2.7 7575% Reduction -5.4 38

Guatemala MMR Projections


1990 1995 2000 2005 2010 2015 2020 2025 2030 20350

20

40

60

80

100

120

140

160

180

84

50

60

30Mat

erna

l Mor

talit

y Ra

tio (p

er 1

00,0

00 li

ve b

irths

)

Guatemala ARR 2035 MMRCurrent -1.4 84MMR=50 -3.4 5050% Reduction -2.7 6075% Reduction -5.4 30

Select LAC countries where no projections for 2035 are below MMR=50

35

Haiti MMR Projections


1990 1995 2000 2005 2010 2015 2020 2025 2030 20350

100

200

300

400

500

600

700

171

50.0000000000001

175

87.4999999999999

Mat

erna

l Mor

talit

y Ra

tio (p

er 1

00,0

00 li

ve b

irths

)

Haiti ARR 2035 MMRCurrent -2.8 171MMR=50 -7.5 5050% Reduction -2.7 17575% Reduction -5.4 88

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2010 Maternal Mortality Ratio (MMR) in Selected LAC Countries


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2035 Projected Maternal Mortality Ratio (MMR) in Selected LAC Countries (Current ARR)


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2035 Projected Maternal Mortality Ratio (MMR) in Selected LAC Countries (ARR to reach 50% reduction in MMR)


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2035 Projected Maternal Mortality Ratio (MMR) in Selected LAC Countries (ARR to reach 75% reduction in MMR)


2010 MMR Estimates vs. 2035 MMR Projections in Selected LAC Countries

2010 MMR Estimates 2035 MMR Projections (Current ARR)


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2035 MMR Projections (ARR to reach 75% Reduction)

2035 MMR Projections (ARR to reach 50% Reduction)

2035 MMR Projections in Selected LAC Countries: 50% vs. 75% reduction


43

2010 ARR in Selected LAC Countries


• Our recommendations for future targets which include the diversity and special needs of the region are???

44

Thank you!

45

48

1990 1995 2000 2005 2010 2015 2020 2025 2030 2035-10

10

30

50

70

90

110

130

Mat

erna

l Mor

talit

y Ra

tio (p

er 1

00,0

00 li

ve b

irths

)

Current ARR ARR to Reach 2000-2010 MMR=50Sri Lanka -4.9% 1.4%Thailand -3.1% 0.2%Sri Lanka

Thailand50

10

22


2. Absolute target: Sri Lanka & Thailand

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3. Relative Target: 2010 and 2035 MMR Estimates (75% Reduction; ARR=5.5%)

MMR<100100≤MMR<200200≤MMR<400

MMR≥400

MMR<2525≤MMR<5050≤MMR<100MMR≥100

2010 Estimate 2035 Target

50Source: UN Estimates for Trends in Maternal Mortality 1990-2010.World Health Organization, 2012.

2010 2015 2020 2025 2030 20350

50

100

150

200

250

300

Mat

erna

l Mor

talit

y Ra

tio (p

er 1

00,0

00 li

ve b

irths

)

58

75% ReductionARR=5.5%

Bangladesh 2010 MMR=240, ARR=5.0%

36


41

Nepal 2010 MMR=170, ARR=7.2%

26

3. Relative target for MMR: Bangladesh & Nepal--75% and 85%

51Source: UN Estimates for Trends in Maternal Mortality 1990-2010.World Health Organization, 2012.

2010 2015 2020 2025 2030 20350

5

10

15

20

25

30

35

40

Mat

erna

l Mor

talit

y Ra

tio (p

er 1

00,0

00 li

ve b

irths

)

9

China 2010, MMR=37, ARR=4.9%

6

Sri Lanka 2010 MMR=35ARR=4.9%

5



3. Relative target for MMR: China & Sri Lanka --75% and 85%

Setting a Target for M aternal Mortality

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