Professor Glen Mola Head of Reproductive Health, Obstetrics and Gyneology School of Medicine and Health Sciences, UPNG

Professor Glen Mola Head of Reproductive Health, Obstetrics and Gyneology School of Medicine and Health Sciences, UPNG

The PNG maternal mortality ratio is one of the worst in the world The MMR is the best indicator of the total functionality of a health system and the logistics that are needed to help people access it. Many people think that it is a good indicator of how maternity care is performing: IT IS NOT. Many people want to use it to make decisions about resource allocation in maternal health care: this is INAPPROPRIATE The main function of the MMR is to allow comparison between countries and to elicit LONG TERM health trends.

Maternal Mortality Ratio and Health System Performance. The MMR is the most sensitive indicator of total functionality of a health care system 10000 1000 MMR (deaths per 100 000 live births) [log scale] 100 10 1 0.0 0.2 0.4 0.6 0.8 1.0 WHO Overall Health Systems Performance Index

Types of data Surveys, - Demographic Health Surveys (1996 and 2006) - Census, 1960,1970, 1980, 1990, 2000, 2011 - Research surveys Health Information System of National Dept of Health Individual facility data; some very good (PMGH) and some not (many facilities) Health Metrics (IHME, UNMMEIG): data from mathematical models

30 25 The Population of PNG, Known and Projected If start planning now 20 If no action milions 15 10 If only 2 kids each now 5 0

900 800 700 IHME data trendline IHME data trendline Maternal mortality data 733 600 585 MMR 500 400 300 200 UNMMEIG trendline 476 390372 371 330 310 312 270289 230 100 0 PNG DHS data trendline Years 7

Supervised birth in a facility Family Planning

2000 Maternal deaths per 100000 live births 1800 1600 1400 1200 1000 800 600 400 200 0 % skilled attendant at delivery

Relationship among MMR, TFR and Life-time Risk of maternal death in selected countries or areas of WPR (1998) 4.11 1.71 1 in 14229 Singapore 3.50 2.04 1 in 14006 New Zealand 7.30 1.15 1 in 11912 Hong Kong 6.90 1.42 1 in 10206 Japan 9.40 1.80 1 in 5910 Australia 13.00 1.74 1 in 4421 Republic of Korea 19.00 3.30 1 in 1595 Malaysia 20.00 3.50 1 in 1429 Cook Is 31.00 2.90 1 in 1112 Fiji 42.00 2.60 1 in 916 New Caledonia 63.07 2.20 1 in 721 China 50.00 4.50 1 in 444 American Samoa 68.00 4.50 1 in 327 Vanuatu 120.00 2.78 1 in 300 Viet Nam 70.00 4.80 1 in 298 Samoa 144.00 2.40 1 in 289 Mongolia 160.00 4.10 1 in 152 Tonga 179.00 3.80 1 in 147 Philippines 170.00 4.83 1 in 122 Tokelau 225.00 3.80 1 in 117 Kiribati 473.00 3.70 1 in 57 Cambodia 561.00 4.40 1 in 41 Micronesia 549.00 5.40 1 in 34 Solomon Islands 745.00 5.60 1 in 24 Lao PDR 930.00 MMR TFR 4.70 Life-Time Risk of Maternal death 1 in 23 Papua New Guinea

UN MMEIG (They use mathematical models ie they don t actually count anything) - total fertility rate (TFR), gross national income (GNI) per capita, neonatal mortality rate, HIV seroprevalence, skilled birth attendance rate and age-specific female education (with five-year stratification) for the reproductive ages 15 45 years. IHME (Seattle, USA) - GDP per capita, general fertility rate and skilled birth attendance rate PNG Demographic Health Surveys (Uses the indirect sisterhood method for MMR: this gives you a number that reflects the situation about 10-12 years in the past.) Cluster sample population from the whole country is determined, and then people are interviewed intensively by a survey instrument. Indirect sisterhood method, means that women are asked if any of their sisters have died related to pregnancy conditions. National Health Information System data. Health facilities send in data collection sheets to Health HQ on a monthly basis. Not consistent, no data management/cleansing

MMR for health facilities in Simbu, 200-300/100,000 MMR for unsupervised village births in Simbu, 700-1000/100,000 Overall MMR for the province for the period, 530/100,000 Comparable with the 1996 DHS MMR figure (that is centred on 1984) of 625/100,00 for the Highlands region. While it is not possible to extrapolate data from one Highlands province to the rest of the country, the fact that this independent data is in line with the 1996 DHS is quite validating. Mola GDL 1989: Maternal Mortality in Papua New Guinea. 1984-1987, PNG Med J 32:27-33.

= 587

But by taking all the available data into account By triangulation of data sets and, By cross checking and cross referencing data, and By sensible analysis and synthesisation of data taking circumstances and source into account We can make an educated estimation of what the MMR is likely to be with more accuracy than that predicted by the mathematical models of the international agencies PNG best estimate of MMR for 2005-2013 = 545 But standard errors with MMR estimation are very wide (no matter what methodology one uses), - and for these reasons it is not possible to use MMR as a health sector monitoring indicator. For national monitoring purposes, we need to monitor process indicators.