The reporting of maternal deaths and their causes varies widely and is associated with a country’s level of statistical development, although all countries tend to follow some version of the International Classification of Diseases (WHO, 1992). In countries with well-developed health and statistical reporting systems, the source of this information is the vital registration system. Separate cause-specific rates can be calculated for each of the major direct causes of maternal death. The number of maternal deaths in a given facility or aggregate of facilities may be too small (e.g., fewer than 20) to calculate a stable rate for each complication. Therefore, in most facilities, only an aggregate direct obstetric case fatality rate should be calculated. The data can be disaggregated by the type of facilities (e.g., basic versus comprehensive EmOC and/or public, private, non-governmental, community based) and by other relevant factors, such as district and urban/rural location.

Data Source(s):

National health information system; death records/certificates in the vital registration system; health facility records.

Purpose:

The direct obstetric case fatality rate is a relatively crude indicator of the quality of obstetric services and can be used to monitor national and local trends, as well as inform policies, programs and interventions. This indicator is related to achieving Millennium Development Goals #5. improve maternal health #4. reduce child mortality. Previously, this indicator was called the ‘case fatality rate.’  However, the indicator has been renamed to distinguish it from a new indicator that has been added for indirect obstetric complications (see the indicator ‘Percent of maternal deaths due to indirect causes at emergency obstetric care facilities’ in this technical area).

Issue(s):

Direct obstetric case fatality rates do not take into account deaths outside the health system and are not generalizable to the wider population. In settings where many women give birth at home or outside facilities, this indicator may be subject to bias because a disproportionate number of maternal deaths in a facility result from women who come for treatment of complications. In addition, the numbers of deaths and direct obstetric case fatality rates may increase when efforts are made to improve hospital services and more women come for treatment. On the other hand, the absence of maternal deaths might indicate that women with serious complications are not brought to facilities or are referred on. The absence of reported deaths can also suggest that deaths are not being reported. Moreover, misclassification of cause of death can lead to serious under-recording and problems of attribution of cause (WHO et al., 2010). Death certificates may never be filled out, may fail to indicate whether pregnancy was a recent occurrence, or may list multiple causes of death but an underlying cause is not registered. Similar to the recording of obstetric complications, training staff to comply with national standards of death certificate completion can result in more accurate and complete recording.

Lobis S, Fry D, Paxton A, 2005, ‘Program note: Applying the UN process indicators for emergency obstetric care to the United States’, International Journal of Gynecology and Obstetrics, 88(2):203-207.