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. 2018 Apr 2;18(1):428.
doi: 10.1186/s12889-018-5363-3.

Under-estimation of maternal and perinatal mortality revealed by an enhanced surveillance system: enumerating all births and deaths in Pakistan

Jasim Anwar  1   2 , Siranda Torvaldsen  3   4 , Mohamud Sheikh  3 , Richard Taylor  3
Affiliations

Under-estimation of maternal and perinatal mortality revealed by an enhanced surveillance system: enumerating all births and deaths in Pakistan

Jasim Anwar et al. BMC Public Health. .

Abstract

Background: Reliable and timely data on maternal and neonatal mortality is required to implement health interventions, monitor progress, and evaluate health programs at national and sub-national levels. In most South Asian countries, including Pakistan, vital civil registration and health information systems are inadequate. The aim of this study is to determine accurate maternal and perinatal mortality through enhanced surveillance of births and deaths, compared with prior routinely collected data.

Methods: An enhanced surveillance system was established that measured maternal, perinatal and neonatal mortality rates through more complete enumeration of births and deaths in a rural district of Pakistan. Data were collected over a period of 1 year (2015/16) from augmentation of the existing health information system covering public healthcare facilities (n = 19), and the community through 273 existing Lady Health Workers; and with the addition of private healthcare facilities (n = 10), and 73 additional Community Health Workers to cover a total study population of 368,454 consisting of 51,690 eligible women aged 18 to 49 years with 7580 pregnancies and 7273 live births over 1 year. Maternal, neonatal, perinatal and stillbirth rates and ratios were calculated, with comparisons to routine reporting from the previous period (2014-15).

Results: Higher maternal mortality, perinatal mortality and neonatal mortality rates were observed through enhanced surveillance compared to mortality rates in the previous 1.5 years from the routine monitoring system from increased completeness and coverage. Maternal mortality was 247 compared to 180 per 100, 000 live births (p = 0.36), neonatal mortality 40 compared to 20 per 1, 000 live births (p < 0.001), and perinatal mortality 60 compared to 47 per 1000 live births (p < 0.001). All the mortality rates were higher than provincial and national estimates proffered by international agencies based on successive Pakistan Demographic and Health Surveys and projections.

Conclusion: Extension of coverage and improvement in completeness through reconciliation of data from health information systems is possible and required to obtain accurate maternal, perinatal and neonatal mortality for assessment of health service interventions at a local level.

Keywords: Health information system; Health system strengthening; Maternal mortality; Mortality surveillance; Neonatal mortality; Pakistan; Perinatal mortality; Stillbirths.

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Conflict of interest statement

Authors’ information

JA is a medical doctor and public health specialist having a decade of experience working with World Health Organization. JA was awarded AusAID scholarship to obtain Master degree in applied science from the University of Sydney. JA is currently enrolled in a PhD program at the University of New South Wales and was awarded international scholarship for his PhD studies.

Ethics approval and consent to participate

Ethics approval was obtained from the Pakistan Medical Research Council (ref. no. 4–87/15/NBC-186/RDC411), and the University of New South Wales, Sydney (ref. no. HC14338). Administrative approvals and use of health resources including LHWs, District health staff and health information system data were obtained from the Director General Health Services of the province and concerned programs. Written informed consent was obtained from all study participants including women who become pregnant during the study period and the respondents of the verbal autopsy interviews.

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interests.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Figures

Fig. 1
Fig. 1
Map of study area, Tehsil Havelian, District Abbottabad, Pakistan. aExtended coverage through Community Health Workers to previously uncovered areas. bCommunity Health Workers were allocated to these areas, but did not stay for the entire duration of the study because of the arduous nature of the work in such remote locations. Uncovered areas comprise only 4% of the population of Tehsil Havelian
Fig. 2
Fig. 2
Birth and death reporting in Tehsil Havelian, District Abbottabad: existing routine reporting and the enhanced surveillance system. Abbreviations: LHW, Lady Health Worker; DHIS, District Health Information System; MIS, Management Information System
Fig. 3
Fig. 3
Maternal and neonatal mortality in the study area, Tehsil Havelian, Abbottabad, compared to Pakistan provincial and national estimates. aWHO, UNICEF, UNFPA and World Bank modeled estimates maternal and neonatal mortality for 1990, 1995, 2000, 2005, 2010 and 2015; bDemographic Health Survey national data for maternal mortality for 1991 and 2006 and for neonatal mortality for 1991, 2006 and 2012; cDemographic Health Survey provincial data for maternal mortality for 2006 (data point offset to 2005 due to overlapping points) and for neonatal mortality for 1991, 2006 and 2012; dRoutine Lady Health Workers data for maternal and neonatal mortality for 2013, 2014 and 2015; eEnhanced surveillance system data for maternal and neonatal mortality for 2015/2016. Abbreviations: MMR, Maternal Mortality Ratio; NMR, Neonatal Mortality Rate
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