Direct obstetric case fatality rate
The percent of women admitted to a hospital or an emergency obstetric care (EmOC) facility with major direct obstetric complications, or who develop such complications after admission, and die before discharge. The seven main direct causes of maternal death are: hemorrhage, hypertensive diseases, abortion, sepsis or infections, obstructed labor, ectopic pregnancy, embolism, and anesthesia-related death (WHO et al., 2010).
Other categories of maternal death, such as accidental or incidental deaths, generally are not included in the calculation of maternal death rates or ratios, and they are excluded from the numerator for this indicator. For further details on this indicator and on classification of direct and indirect causes of maternal deaths, see WHO et al. (2010).
Ideally, the direct obstetric case fatality rate should be calculated for all facilities rather than just for EmOC facilities, such as for district hospitals.
This indicator is calculated as:
(Number of maternal deaths due to direct causes in hospitals and EmOC facilities / Total number of maternal deaths in the same facilities during the same period) x 100
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.
National health information system; death records/certificates in the vital registration system; health facility records.
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).
The maximum acceptable level for the value of this indicator is less than 1 percent. Studies in low-income countries have shown direct obstetric case fatality rates ranging from approximately 2 to 10 percent, whereas an analysis applying EmOC indicators to data from the United States showed a direct obstetric case fatality rate of 0.06 percent (Lobis et.al, 2005). Given this range and results from evaluations of safe motherhood interventions demonstrating that it is possible to reduce a high rate to below 1 percent, the 1 percent cut-off appears to be a reasonable maximum acceptable level for low-income countries (WHO et al., 2010). Through comparing aggregate and cause-specific direct case fatality rates over time, evaluators can identify where progress has been made in preventing and treating the various complications associated with major direct obstetric complications.
When a direct obstetric case fatality rate is high or fails to decrease, a review should be conducted. Maternal deaths can be reviewed in health facilities and at district and national levels to identify gaps in management or clinical service delivery. An alternative approach to improve quality is to study the care given to women with life threatening obstetric complications who are saved by the health facility (‘near misses’). One benefit of this method is that near misses occur more frequently than maternal deaths and provide more opportunities for studying the quality of care. More detailed information can be found on reviewing maternal deaths (WHO, 2004) and near misses (WHO, 2011).
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.
access, obstetric fistula (OF), postabortion care, safe motherhood (SM)
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.
WHO, 2004, Beyond the numbers: Reviewing maternal deaths and complications to make pregnancy safer. Geneva: WHO. http://whqlibdoc.who.int/publications/2004/9241591838.pdf
WHO, UNFPA, UNICEF, AMDD, 2010, Monitoring Emergency Obstetric Care: A handbook, Geneva: WHO. http://whqlibdoc.who.int/publications/2009/9789241547734_eng.pdf
WHO, 2011, Evaluating the Quality of Care for Severe Pregnancy Complications: The WHO near-miss approach for maternal health, Geneva: WHO. http://whqlibdoc.who.int/publications/2011/9789241502221_eng.pdf
WHO, 1992, International Statistical Classification of Diseases and Related Health Problems. Tenth Revision (ICD-10). Geneva: WHO. http://apps.who.int/classifications/icd10/browse/2010/en