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Multiple Indicator Cluster Surveys Data Interpretation, Further Analysis and
Dissemination Workshop
Maternal and Reproductive Health
2
Overview of presentation
Fertility (1 table) Childbearing among
adolescents (3 tables) Contraception (2 tables) Antenatal care (3 tables) Delivery care (2 tables) Post-natal health care (6
tables) Adult and maternal mortality
(3 tables)
3
Overview of presentation
Fertility (1 table) Childbearing among
adolescents (3 tables) Contraception (2 tables) Antenatal care (3 tables) Delivery care (2 tables) Post-natal health care (6
tables) Adult and maternal mortality
(3 tables)
4
Fertility
Urban Rural Total
Age 15-191
20-24 25-29 30-34 35-39 40-44 45-49
TFRa
GFRb
CBRc
Table RH.1: Fertility ratesAdolescent birth rate, age-specif ic and total fertility rates, the general fertility rate, and the crude birth rate for the one-year / three-year period preceding the survey, by area, Country, Year
1 MICS indicator 5.1; MDG indicator 5.4 - Adolescent birth ratea TFR: Total fertility rate expressed per w oman age 15-49b GFR: General fertility rate expressed per 1,000 w omen age 15-49c CBR: Crude birth rate expressed per 1,000 population
Table may be produced if using either:
Fertility module (WITH Birth History)Fertility module (WITHOUT Birth History)
Age-specific fertility rate:Number of live births per 1,000 women in a specific age for a specific point in time (e.g. three years)
15-19 - Adolescent birth rate
Total Fertility Rate (TFR):
Average number of children to which a woman will have given birth by the end of her reproductive years (by age 50) if current fertility rates prevailed
The total fertility rate (TFR) is calculated by summing the age-specific fertility rates calculated for each of the 5-year age groups of women, from age 15 through to age 49.
General Fertility Rate (GFR):Number of births per 1,000 women of reproductive ages
Crude Birth Rate (CBR):Number of live births per 1,000 population
5
Fertility
If the Fertility module (which excludes the Birth History) is used: Date of last birth (CM12) is used for calculations Rates are based on the one-year period (1-12 months)
preceding the survey. Numerators and denominators should be carefully checked
for the total and urban-rural samples to ensure that they are based on sufficient numbers of cases.
Use of a one-year estimation period may result in very small denominators
Table RH.1: Fertility ratesAdolescent birth rate, age-specific and total fertility rates, the general fertility rate, and the crude birth rate for the one-year / three-year period preceding the survey, by area, Country, Year
6
Overview of presentation
Fertility (1 table) Childbearing among
adolescents (3 tables) Contraception (2 tables) Antenatal care (3 tables) Delivery care (2 tables) Post-natal health care (6
tables) Adult and maternal mortality
(3 tables)
7
Childbearing among adolescents
Adolescent birth rate1
(Age-specif ic fertility rate for w omen age 15-19) Total fertility rate
Total
RegionRegion 1Region 2Region 3Region 4Region 5
EducationNonePrimarySecondaryHigher
Table RH.2: Adolescent birth rate and total fertility rateAdolescent birth rates and total fertility rates for the one-year / three-year period preceding the survey, Country, Year
Calculations based on data from the child mortality module (Brass questions) or birth history
Pay attention to sample sizes, especially for breakdowns by background variables
8
Childbearing among adolescents
Have had a live birth
Are pregnant w ith f irst child
Have begun childbearing
Have had a live birth before age 15
Total
RegionRegion 1Region 2
Table RH.3: Early childbearing
Percentage of women age 15-19 who:
Percentage of w omen age 15-19 years w ho have had a live birth, are pregnant w ith the f irst child, have begun childbearing, and w ho have had a live birth before age 15, and percentage of w omen age 20-24 years w ho have had a live birth before age 18, Country, Year
Number of w omen age
15-19
Number of w omen age
20-24
Percentage of w omen age 20-24 w ho have had a live birth before age 181
Sum of first two columns
9
Childbearing among adolescents
Percentage of w omen w ith a live
birth before age 15
Number of w omen age 15-49 years
Percentage of w omen w ith a live
birth before age 18
Number of w omen age 20-49 years
Percentage of w omen w ith a live
birth before age 15
Number of w omen age 15-49 years
Percentage of w omen w ith a live
birth before age 18
Number of w omen age 20-49 years
Percentage of w omen w ith a live
birth before age 15
Number of w omen age 15-49 years
Percentage of w omen w ith a live
birth before age 18
Number of w omen age 20-49 years
Total
Age 15-19 na na na na na na 20-24 25-29 30-34 35-39 40-44 45-49
Table RH.4: Trends in early childbearing
Urban Rural All
Percentage of w omen w ho have had a live birth, by age 15 and 18, by area and age group, Country,Year
na: not applicable
Two indicators - Note that each indicator has a different denominator Data from different cohorts provides trends
10
Adolescent childbearing – comparison of indicators
Indicator Value Adolescent birth rate (per 1000 women 15-19) 59
Example from MICS4
11
Adolescent childbearing – comparison of indicators
Indicator Value Adolescent birth rate (per 1000 women 15-19) 59 15-19 year old women who have had a live birth 8.5%
Example from MICS4
12
Adolescent childbearing – comparison of indicators
Indicator Value Adolescent birth rate (per 1000 women 15-19) 59 15-19 year old women who have had a live birth 8.5% Live birth before age 18 (among 20-24 year olds) 15.3%
Example from MICS4
13
Overview of presentation
Fertility (1 table) Childbearing among
adolescents (3 tables) Contraception (2 tables) Antenatal care (3 tables) Delivery care (2 tables) Post-natal health care (6
tables) Adult and maternal mortality
(3 tables)
14
ContraceptionTable RH.5: Use of contraceptionPercentage of w omen age 15-49 years currently married or in union w ho are using (or w hose partner is using) a contraceptive method, Country, Year
Percent of women currently married or in union who are using (or whose partner is using):
No method
Female sterili-zation
Male sterili-zation IUD Injectables Implants Pill
Male condom
Female condom
Diaphragm/Foam/Jelly LAM
Total
Modern Percentage of w omen age 15-49 years currently married or in union w ho are using (or w hose partner is using) a contraceptive method, Country, Year
Periodic abstinence Withdraw al Other
Any modern method
Any tradi-tional
methodAny
method1
Total
Number of w omen age 15-49 years
currently married or in union
Traditional MDG Indicator
Should have been customized in-country
e.g. LAM
15
Defining unmet need………
Women with an unmet need for family planning are women who: are married or in union are fecund report not wanting any more children or
wanting to delay the birth of their next child for at least two years
not using any method of contraception
16
Defining unmet need………
The following are also considered to have unmet need:
Women* who are pregnant, but whose current pregnancy unwanted or mistimed
Postpartum amenorrheic women* (not using contraception) whose last birth was unwanted or mistimed
*Married/in union
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Key indicator elements
Marital status Fecundity Desire for future births Current use of contraception (any method) Pregnant or amenorrheic Desire for last birth
Large amount of data needed to estimate unmet need, with a complex algorithm
18
Unmet need
For spacing For limiting Total For spacing For limiting Total1
Total
Met need for contraception
Table RH.6: Unmet need for contraceptionPercentage of w omen age 15-49 years currently married or in union w ith an unmet need for family planning and percentage of demand for contraception satisf ied, Country, Year
Unmet need for contraceptionNumber of
w omen currently married or in
union
Percentage of demand for
contraception satisf ied
Number of w omen currently married or in union w ith need for contraception
Women married or in a union who are fecund but are not using any
method of contraception, and report not wanting any more children
(limiting) or wanting to delay the next child (spacing).
Note that met need for contraception includes both traditional and modern methods
19
Country example
Met need
for contra-
ception –
For spacing
Met Need for
contra-ception –
For limiting
Met need
for contra-
ception -
Total
Unmet need for
contra-ception –
For spacing
Unmet need
for contra-
ception –
For limiting
Unmet need
for contra-
ception –
Total
Number of women
currently married or in union
Percentage of
demand for
contra-ception satisfied
Number of women
currently married or in union
with need for
contra-ception
19.1 58.2 77.3 2.4 2.1 4.5 2,653 94.4 2,171
20
Country example
Met need
for contra-
ception –
For spacing
Met Need for
contra-ception –
For limiting
Met need
for contra-
ception -
Total
Unmet need for
contra-ception –
For spacing
Unmet need
for contra-
ception –
For limiting
Unmet need
for contra-
ception –
Total
Number of women
currently married or in union
Percentage of
demand for
contra-ception satisfied
Number of women
currently married or in union
with need for
contra-ception
19.1 58.2 77.3 2.4 2.1 4.5 2,653 94.4 2,171
Any method 77.2Any modern method 58.8Any traditional method 18.5
Use of contraception
Note that met need for contraception includes both traditional and modern methods
21
Overview of presentation
Fertility (1 table) Childbearing among
adolescents (3 tables) Contraception (2 tables) Antenatal care (3 tables) Delivery care (2 tables) Post-natal health care (6
tables) Adult and maternal mortality
(3 tables)
22
Antenatal care
Medical doctor
Nurse/ Midw ife
Auxiliary midw ife
Traditional birth
attendant
Community health w orker Other
Total 100.0
Table RH.7: Antenatal care coveragePercent distribution of w omen age 15-49 years w ith a live birth in the last tw o years by antenatal care provider during the pregnancy for the last birth, Country, Year
Provider of antenatal careaNumber of
w omen w ith a live birth in the last tw o years
No antenatal
care Any skilled provider1Total
Only the most qualified provider is considered in cases where more than one
provider was reported
Key indicator: At least one ANC visit (MDG)
MICS5 standard -- Normally, skilled providers includes doctors, nurses and midwives. Auxilliary midwife may or may not be considered skilled personnel.
Provider categories: Should have been modified in country
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Table RH.8: Number of antenatal care visits and timing of first visitPercent distribution of w omen age 15-49 years w ith a live birth in the last tw o years by number of antenatal care visits by any provider and by the timing of f irst antenatal care visits, Country, Year
No antenetal care visits One visit Tw o visits Three visits
4 or more visits1
Total 100.0
Percent distribution of women who had:
Total
Watch out for:• Indicator definition (any provider)• “don’t knows”
Antenatal care
MDG indicator
24
Table RH.8: Number of antenatal care visits and timing of first visitPercent distribution of w omen age 15-49 years w ith a live birth in the last tw o years by number of antenatal care visits by any provider and by the timing of f irst antenatal care visits, Country, Year
No antenatal care visits
First trimester 4-5 months 6-7 months 8+ months DK/Missing
Total 100.0
Number of w omen w ith a live birth in the last tw o years w ho had at least
one ANC visit
Percent distribution of women by number of months pregnant at the time of first antenatal care visit
Total
Number of w omen w ith a live birth in the last tw o years
Median months
pregnant at f irst ANC
visit
Antenatal care
Second part of table on timing of antenatal care visits
Important information on timing of antenatal visits
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Antenatal care
Blood pressure measured
Urine sample taken
Blood sample taken
Blood pressure measured, urine and blood sample taken1
Total
Table RH.9: Content of antenatal carePercentage of w omen age 15-49 years w ith a live birth in the last tw o years w ho, at least once, had their blood pressure measured, urine sample taken, and blood sample taken as part of antenatal care, during the pregnancy for the last birth, Country, Year
Number of w omen w ith a live birth in the last tw o
years
Percentage of women who, during the pregnancy of their last birth, had:
26
Overview of presentation
Fertility (1 table) Childbearing among
adolescents (3 tables) Contraception (2 tables) Antenatal care (3 tables) Delivery care (2 tables) Post-natal health care (6
tables) Adult and maternal mortality
(3 tables)
27
Table RH.10: Assistance during delivery and caesarian sectionPercent distribution of w omen age 15-49 years w ith a live birth in the last tw o years by person providing assistance at delivery, and percentage of births delivered by C-section, Country, Year
Medical doctor
Nurse/ Midw ife
Auxiliary midw ife
Traditional birth
attendant
Community health w orker
Relative/Friend Other
Total 100.0
TotalNo
attendant
Person assisting at delivery Delivery assisted by any skilled attendant1
MICS5 standard -- Normally, skilled attendant
includes doctors, nurses and midwives. Auxiliary midwife may or may not be considered skilled personnel.
Delivery Care
MDG indicator
28
Table RH.10: Assistance during delivery and caesarian sectionPercent distribution of w omen age 15-49 years w ith a live birth in the last tw o years by person providing assistance at delivery, and percentage of births delivered by C-section, Country, Year
Decided before onset of labour
pains
Decided after onset of labour
pains Total2
Total
Percent delivered by C-section Number of w omen w ho had a live birth in the last tw o years
C-section should be within 5%-15%
Delivery Care
This is new in MICS – to establish emergency ceasarians
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Public sector
Private sector
Total 100.0
Table RH.11: Place of deliveryPercent distribution of w omen age 15-49 years w ith a live birth in the last tw o years by place of delivery of their last birth, Country, Year
Number of w omen w ith a live birth in the last tw o years
Place of delivery
Total
Delivered in health facility1
Health facility
Home Other
Delivery Care
Place of delivery categories should have been modified in country
Possible to present additional categories.
30
Continuum of reproductive and maternal health interventions
0
20
40
60
80
100 94 97
7185
7156 51
97 96
Pre-preg
Pregnancy (Antenatal Care)
Delivery Care
31
Continuum of reproductive and maternal health interventions
0102030405060708090
100 94 97
7185
7156 51
97 96
Pre-preg
Pregnancy (Antenatal Care)
Delivery Care
Gap!Gap!
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Overview of presentation
Fertility (1 table) Childbearing among
adolescents (3 tables) Contraception (2 tables) Antenatal care (3 tables) Delivery care (2 tables) Post-natal health care (6
tables) Adult and maternal mortality
(3 tables)
33
Post-natal health
6 tables covering post-natal health checks for both mother and child Post-partum stay in health facility Post-natal health checks for newborns Post-natal care (PNC) visits for newborns Post-natal health checks for mothers Post-natal care (PNC) visits for mothers Post-natal health checks for mothers and
newborns
34
Post-natal health terminology
MICS developed the module to capture information on: Health checks after delivery
• While in health facility after delivery or before the birth attendant leaves the mother and baby
Post-natal visits• Contact of providers with mothers and babies after
discharge from health facility, or after the attendant leaves the mother and baby
Post-natal health checks• Encompassing both – the global indicator
35
Post-natal health – indicators, definitions
Institutional Deliveries Non-institutional deliveries
With Attendant Without attendant
While in facility or at home following birth
Duration of post-partum stay in facility
Health check in facility after birth, before discharge
Health check from attendant before leaving mother & child
after birth
Post-natal care visit (with info on timing, location, provider)
Health check after discharge
Health check after attendant leaves home after birth Any health check
Post-natal health check (Global Indicator)
Health check in facility and/or
Health check after discharge (PNC visit within 2 days of
delivery)
Health check from attendant and/or
Health check after attendant leaves home (PNC visit within
two days of delivery)
Health check (PNC visit within two
days of delivery)
36
PNC Data from Ghana MICS 2011
Newborns
Health checks after delivery
(%)
PNC Visits (%)
Post-natal Health
Check (%)Within 2 days 2-6 days
After the first
week
No PNC Visit
Ghana total 81 13 7 21 59 83Facility birth 97 10 7 27 56 97
Home birth 47 20 7 9 64 55
37
PNC Data from Ghana MICS 2011
Newborns
Health checks after delivery
(%)
PNC Visits (%)
Post-natal Health
Check (%)Within 2 days 2-6 days
After the first
week
No PNC Visit
Ghana total 81 13 7 21 59 83Facility birth 97 10 7 27 56 97
Home birth 47 20 7 9 64 55
More PNC visits for newborns than mothers – both for home and facility deliveries
38
To conclude
Substantial increase in PNC data availability due to inclusion in MICS 18 surveys in 2009-2012 Many more in MICS5
Large amount of data now to perform secondary analysis
39
Overview of presentation
Fertility (1 table) Childbearing among
adolescents (3 tables) Contraception (2 tables) Antenatal care (3 tables) Delivery care (2 tables) Post-natal health care (6
tables) Adult and maternal mortality
(3 tables)
40
Adult and maternal mortality Standard MICS questionnaires include the maternal
mortality module that collect data for the direct sisterhood method (survivorship of all siblings)
Data is collected on survivorship of all siblings of interviewed women, including ages at death and since death (MM8) of the respondents' brothers and sisters and this information is used to re-construct cohorts in the recent past and calculate mortality rates.
Total number of years lived by all surviving and deceased brothers and sisters (that is, exposure years) during the 7 years preceding the survey are calculated to form the denominators.
41
Adult and maternal mortality
Three tables are generated On adult mortality rates On adult mortality probabilities On maternal mortality
42
Adult mortality rates
Number of Deaths
Exposure years
Mortality ratesa
Number of Deaths
Exposure years
Mortality ratesa
Total 15-49 b b
Age15-1920-2425-2930-3435-3940-4445-49
Table RH.18: Adult mortality ratesDirect estimates of female and male mortality rates for the seven years preceding the survey, by five-year age groups, Country, Year
Female Male
Mortality rates for males and females, for ages 15 to 49,
during the last 7 years
43
Adult mortality probabilities
Women 35q15 a
Men 35q15 a
Country, Year
Table RH.19: Adult mortality probabilitiesThe probability of dying betw een the ages of 15 and 50 for w omen and men for the seven years preceding the survey, Country, Year
a The probability of dying betw een exact ages 15 and 50, expressed per 1,000 person-years of exposure
Age-specific mortality rates in the previous table are then converted to
probabilities of dying from age
15 to 50 – a summary
measure of the force of
mortality during adulthood, for
use in life tables
44
Maternal mortality
Percentage of female deaths that are
maternalMaternal Deaths
Exposure (Years) Maternal mortality ratesa
Total 15-49 b
Age15-1920-2425-2930-3435-3940-4445-49
General fertility ratec b
Maternal mortality ratio1, d
Lifetime risk of maternal deathe
Table RH.20: Maternal mortalityDirect estimates of maternal mortality rates for the 7 years preceding the survey, by five-year age groups, Country, Year
1 MICS indicator 5.13; MDG indicator 5.1 - Maternal mortality ratioa Expressed per 1,000 w oman-years of exposureb Age-adusted ratec Expressed per 1,000 w omen age 15-49d Calculated as the maternal mortality rate divided by the general fertility rate, expressed per 100,000 live birthse Calculated as 1-(1-MMR)TFR w here MMR is the maternal mortality ratio, and TFR represents the total fertility rate for the seven years preceding the survey
Additional questions on when female deaths occurred (pregnancy, delivery or post-partum periods) make it possible
to calculate maternal mortality rates and ratios
Deaths during pregnancy or childbirth or deaths within 2 months after the termination of a pregnancy or childbirth
GFR and TFR should be estimated from the survey results, or from external sources - should refer to the 7-year period preceding the survey
LTR: 1-(1-MMR)TFR where MMR is the maternal mortality ratio, and TFR represents the total fertility rate for the seven years preceding the survey
MMRate: Expressed per 1,000 woman-years of exposure
45
Limitations
Reference period usually 7 years or 10 years before the survey
Confidence intervals are very wide Studies indicate that both male and female mortality
underestimated
But know that maternal mortality is underestimated even in countries with good vital registration systems
46
Trend Estimation with 95% Confidence Intervals (Namibia)
0
100
200
300
400
500
600
Pre
gnan
cy-R
elat
ed M
orta
lity
Rat
io
1985 1990 1995 2000 2005Year
1992 DHS 2000 DHS2007 DHS
Source: Ken Hill – UN maternal mort workshop,Nairobi December 2010
Estimates are averages over long periods (here 7 or 9 years) and 95% confidence intervals are large
47
Further use of the data
48
Coverage of interventions varies across the continuum of care
Source: Countdown to 2015: The 2012 report
49Tracking Progress on Child and Maternal Nutrition
50
Brainstorming
Focus on adolescents – coverage of maternal health services
Maternal health…
Fertility desires by background characteristics
HIV and maternal care (knowledge, testing during ANC)
Malaria in pregnancy (provision of IPTp during ANC visits)
51
Thank You