Measuring maternal mortality using a Reproductive Age Mortality Study (RAMOS).
BACKGROUND
Assessing the feasibility of conducting a prospective Reproductive Age Mortality Survey (RAMOS) study in the low-income setting of Mangochi District, Malawi to obtain cotemporaneous estimates of the number, cause of and conditions associated with maternal deaths (MD) in all women of reproductive age (WRA) (n = 207 688).


METHODS
MD among all deaths of WRA were identified using the ICD-10 definition. Cause of death and contributing conditions identified by a panel of experts using the classification system for deaths during pregnancy, childbirth and puerperium (ICD-MM).


RESULTS
Out of 424 deaths of WRA, 151 were MD giving a Maternal Mortality Ratio (MMR) of 363 per 100,000 live births (95 % CI: 307-425). Only 86 MD had been reported via existing reporting mechanisms representing an underreporting of 43 %. The majority of MD (62.3 %) occurred in a health facility and were the result of direct obstetric causes (74.8 %) with obstetric haemorrhage as the leading cause (35.8 %), followed by pregnancy-related infections (19.4 %), hypertensive disorders (16.8 %) and pregnancy with abortive outcome (13.2 %). Malaria was the most frequently identified indirect cause (9.9 %). Contributing conditions were more frequently identified when both verbal autopsy and facility-based death review had taken place and included obstructed labour (28.5 %), anaemia (12.6 %) and positive HIV status (4.0 %).


CONCLUSIONS
The high number of MD that occur at health facility level, cause of death and contributing conditions reflect deficiencies in the quality of care at health facility level. A RAMOS is feasible in low- and middle-income settings and provides contemporaneous estimates of MMR.
Centre for Maternal and Newborn Health, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, L3 5QA, UK. Florence.Mgawadere@lstmed.ac.uk.
Florence
F
Mgawadere
Centre for Maternal and Newborn Health, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, L3 5QA, UK.
Regine
R
Unkels
Centre for Maternal and Newborn Health, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, L3 5QA, UK.
Adetoro
A
Adegoke
Centre for Maternal and Newborn Health, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, L3 5QA, UK.
Nynke
N
van den Broek
Cause of death; Maternal mortality ratio; Quality of care; RAMOS
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