Civil registration and vital statistics: key to better data on maternal mortality

Today, the UN Maternal Mortality Estimation Inter-Agency Group (MMEIG)^* released Trends in Maternal Mortality: 1990 to 2015.  It reports that, worldwide, maternal mortality ratio (MMR) declined by almost 44% between 1990 and 2015, from 385 maternal deaths per 100,000 live births to 216. 

While this progress is a testament to dedicated global and country efforts in the last decade to improve maternal health, it falls short of the MDG 5A target to reduce the maternal mortality ratio by 75% between 1990 and 2015.

As shown in figure 1, there are huge disparities across income groups, with the MMR in low-income countries nearly 30 times higher than in middle-income countries. Nevertheless, of the nine countries  (Bhutan, Cambodia, Cabo Verde, Iran, Lao People’s Democratic Republic, Maldives, Mongolia, Rwanda and Timor-Leste) that were reported to have “achieved MDG 5A”,  two (Cambodia, and Rwanda) are low-income countries.
 
Interestingly, a few days ago I was on mission in a country not on the above list where a ministry of health official proudly pointed out that the country has achieved MDG 5A. There may be other countries that may make similar claims or dispute the MMEIG estimates; this merits a further look at the underlying data employed in generating these estimates.
 
Figure 1. Maternal mortality ratio (MMR, maternal deaths per 100 000 live births), 1990–2015, by income group



Measuring maternal mortality remains a challenge
 
Although today’s report  provides trend estimates from 1990 to 2015, of the 183 countries included in the analysis, 12 countries (11%) had no data on maternal mortality and 20% had only one or two data points available. Further, of those that had three or more data points, the majority did not come from complete and accurate civil registration and vital statistics (CRVS) systems, which are the most reliable sources of data for computing MMR.
 
Indeed, in sub-Saharan Africa and South Asia, most countries have low death registration coverage, so requisite data are not available for any meaningful estimation of MMR. As part of the quality assurance process for the report, after developing the initial estimates, the World Health Organization (WHO) undertook consultations to give countries the opportunity to review the estimates and provide any additional data. 



CRVS systems key to accurate measurement

Today’s report calls on governments to “establish well-functioning civil registration systems with accurate attribution of cause of death.” Previous UN reports, over the past couple of decades, have made similar recommendations, and yet more than 110 low- and middle-income countries still have deficient CRVS systems. The good news is that the tide seems to be changing; a number of countries have committed recently to strengthening their CRVS systems, and this issue is a key component of the recently launched Global Financing Facility.
 
Implementation of the three-pronged approach outlined in the Global CRVS Scaling Up Investment Plan 2015-2024 will go a long way in providing needed data for monitoring not only Sustainable Development Goal (SDG) target 3.1 (by 2030, reduce the global maternal mortality ratio to less than 70 per 100,000 live births) but also several other SDG targets. In addition, CRVS is the most reliable source of data for planning and monitoring of programs at lower administrative levels. 
 
The World Bank Group is working closely with development partners and countries to improve CRVS systems. As part of efforts to address data gaps in monitoring all the SDGs, the Bank has prioritized CRVS, household surveys and price statistics. We’ve also recently launched a multisectoral Identification for Development (ID4D) initiative, linking CRVS with identity management systems. Further, as part of the Global Financing Facility, the government of Canada has committed C$100 million – to improve CRVS in low-income countries.
 
In the post-2015 era, stronger, more reliable data will be essential to ending preventable maternal deaths.

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• Maternal Mortality Estimation Inter-Agency Group (MMEIG) comprises the World Health Organization (WHO), the United Nations Children’s Fund (UNICEF), the United Nations Population Fund (UNFPA), The World Bank Group, and the Population Division of the UN Department of Economic and Social Affairs (DESA) together with researchers from the University of Massachusetts Amherst, the National University of Singapore, and the University of California at Berkeley, to generate internationally comparable MMR estimates.