Revised 1990 estimates of maternal mortalitywhqlibdoc.who.int/hq/1996/WHO_FRH_MSM_96.11.pdf · iii...

World HealthOrganization

UNICEF

Revised 1990 estimatesof maternal mortality

a new approachby WHO and UNICEF

April 1996

WHO/FRH/MSM/96.11UNICEF/PLN/96.1

DISTR.: General

ii

Revised 1990 estimates of maternal mortality: a new approach by WHO and UNICEF

© World Health Organization 1996

This is not a formal publication of the World Health Organization (WHO),and all rights are reserved by the Organization. The document may, how-ever, be freely reviewed, abstracted, reproduced or translated, in part orin whole, but not for sale or for use in conjunction with commercialpurposes.

The views expressed in documents by named authors are solely theresponsibility of those authors.

iii


Table of Contents

Executive summary 1

Introduction 2

New estimates of maternal mortality 2

Why is it important to measure maternal mortality? 2

Why is maternal mortality difficult to measure? 2

How can maternal mortality be measured? 4

How were these new estimates derived? 5

How do these revised estimates differ fromprevious estimates of maternal mortality? 5

What can the new estimates be used for? 7

What should these estimates NOT be used for? 7

What other methods are available for monitoring trends? 7

Inter-agency collaboration 8

What are the next steps? 8

References 8

Tables

Table 1: Revised estimates of maternal mortality by United Nations regions (1990) ......... 3

Table 2: New regional estimates compared with previous estimates ................................... 6

Table 3: Country estimates of maternal mortality, lifetime risk and numbersof maternal deaths (1990) ................................................................................ 9–15

Table 4: Estimates of maternal mortality by WHO regions (1990) .................................... 16

Table 5: Estimates of maternal mortality by UNICEF regions (1990) ................................ 16

iv


1

Revised 1990 estimatesof maternal mortality:

a new approachby WHO and UNICEF

Executive summaryReduction of maternal mortality is one of the WHO/UNICEF common goalsfor the health of women and children and one of the major goals of severalrecent international conferences. However, because measuring maternalmortality is difficult and complex, reliable estimates of the dimensions ofthe problem are not generally available and assessing progress towards thegoal is difficult.

In order to address the information gap, WHO and UNICEF have developednew estimates using a dual strategy. This involves using available datawherever possible, adjusted to account for the common problems ofunder-reporting and misclassification of maternal deaths, and developinga simple model to predict values for countries with no reliable nationaldata.

The estimates derived from this approach are considered to be more reli-able than those based on earlier strategies. Moreover, the new approachpermits the calculation of individual country data as well as regional andglobal totals.

The new approach has been used to recalculate maternal mortality for 1990and thus provide a baseline estimate against which it will be possible toassess progress by the year 2000.

The results of the WHO/UNICEF study indicate that globally some 585,000women died from pregnancy-related causes in 1990, 80,000 more than ear-lier estimates had suggested. Maternal mortality ratios are particularly highin sub-Saharan Africa.

2


IntroductionDuring the past decade, a number of international conferences have established goals relatedto the environment, population and development and health. The reduction of maternal mor-tality by half the 1990 levels by the year 2000 was a goal common to several such conferencesincluding, in particular, the Nairobi Safe Motherhood Conference in 1987, the World Summitfor Children (WSC) in 1990, the International Conference on Population and Development(ICPD) in 1994, and the Fourth World Conference on Women (FWCW) in 1995. Ascertainingprogress towards the goal is, however, extremely difficult for two reasons: maternal mortalityis difficult to measure; and the information available at country level does not generally per-mit the establishment of good baseline data.

In order to address these problems WHO and UNICEF have worked with Cynthia Stanton andKenneth Hill of Johns Hopkins University to develop a new approach to estimating levels ofmaternal mortality in developing countries. The new approach has the dual objective of gen-erating improved estimates for countries with inadequate or no national data on maternalmortality, while at the same time providing better estimates of maternal mortality in 1990 as abaseline against which to measure progress.

New estimates of maternal mortalityThe results of the new approach indicate that globally, there are some 585,000 maternal deaths,99% of them in developing countries. This is around 80,000 deaths more than earlier esti-mates have suggested and indicates a substantial underestimation of maternal mortality in thepast.

In developing countries as a whole, maternal mortality ratios range from 190 per 100,000 livebirths in Latin America and the Caribbean to 870 per 100,000 in Africa. Extremely high ratiosof over 1000 per 100,000 live births are found in Eastern and Western Africa (Table 1).

Why is it important to measure maternal mortality?The incorporation of maternal mortality reduction into the goals of the international commu-nity reflect its importance as a measure of human and social development. Maternal mortalityis a particularly sensitive indicator of inequity. Of all the indicators commonly used to com-pare levels of development between countries and regions, levels of maternal mortality showthe widest disparities. Maternal mortality offers a litmus test of the status of women, theiraccess to health care and the adequacy of the health care system in responding to their needs.Information about the levels and trends of maternal mortality is needed, therefore, not onlyfor what it tells us about the risks of pregnancy and childbirth, but also for what it impliesabout women’s health in general and, by extension, their social and economic status.

Why is maternal mortality difficult to measure?It is extremely difficult to assess levels of maternal mortality at the national level. Doing sorequires knowledge about deaths of women of reproductive age (15-49 years), the cause ofdeath and also whether or not the woman was pregnant at the time of death or had recentlybeen so. Yet few countries count births and deaths; even fewer register the cause of death; and

3


Table 1: Revised estimates of maternal mortality by United Nations regions (1990)

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*snoigerdepolevederoM 72 0004 0081

snoigerdepolevedsseL 084 000285 84

acirfA 078 000532 61

acirfAnretsaE 0601 00079 21

acirfAelddiM 059 00013 41

acirfAnrehtroN 043 00061 55

acirfAnrehtuoS 062 0063 57

acirfAnretseW 0201 00078 21

*aisA 093 000323 56

aisAnretsaE 59 00042 014

aisAlartnec-htuoS 065 000722 53

aisAnretsae-htuoS 044 00065 55

aisAnretseW 023 00061 55

eporuE 63 0023 0041

eporuEnretsaE 26 0052 037

eporuEnrehtroN 11 041 0004

eporuEnrehtuoS 41 022 0004

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fewer still systematically note pregnancy status on the death form. Broadly speaking, coun-tries fall into one of three categories:-

1. Countries with no reliable system of vital registration where maternal deaths - like othervital events - go unrecorded;

4


2. Countries with relatively complete vital registration in terms of numbers of births anddeaths but where cause of death is not adequately classified; cause of death is routinelyreported for only 78 countries or areas, covering approximately 35% of the world’s popu-lation.1

3. Countries with complete vital registration and good cause of death attribution - thougheven here, misclassification of maternal deaths can arise for a variety of reasons.

Where vital registration systems are absent or inadequate it is possible to estimate maternalmortality using survey techniques but these have a number of disadvantages including cost(see below). In general, high maternal mortality countries have neither adequate systems ofvital registration nor the resources to rely on surveys instead.

How can maternal mortality be measured?A variety of innovative methodologies has been devised to overcome the absence of data incountries with poor or non-existent vital registration. For example, maternal mortality can bemeasured by incorporating questions on pregnancy and deaths into large-scale householdsurveys. The disadvantage of such approaches is that they require large sample sizes and areextremely expensive and time consuming.2

A more cost-effective approach is the Sisterhood Method. This method adds on to existinghousehold surveys a few simple questions about whether or not the sisters of the respondentare still alive. The advantage is that much smaller sample sizes are needed because each re-spondent can provide information on a number of sisters. The disadvantage is that the methoddoes not provide a current estimate, but gives an idea of the level of maternal mortality roughlyten years earlier. Furthermore, the methodology was developed for use where there werestrong cultural ties between siblings (usually sisters) and where siblings could be expected tobe fully aware of the vital events in each other’s lives. Where such cultural ties are less strong,the method is likely to be less effective and may underestimate pregnancy-related mortality.Indeed, evidence is emerging that the Sisterhood Method may miss a sizeable proportion ofmaternal deaths.3

The best way of measuring maternal mortality in the absence of vital registration is to identifyand investigate the causes of all deaths of women of reproductive age – the Reproductive AgeMortality Survey (RAMOS). This method has been applied in countries with good vital regis-tration systems to calculate the extent of misclassification,4 and in countries without vitalregistration of deaths, such as Jamaica and Guinea. Multiple sources of information – civilregisters, health facility records, community leaders, religious authorities, undertakers, cem-etery officials, schoolchildren – are used to identify all deaths.5 Subsequently, interviewswith household members and health care providers and facility record reviews are used toclassify deaths as maternal or otherwise (verbal autopsy).

Although RAMOS studies are considered to be the “gold standard” for estimating maternalmortality they are also time consuming and complex to undertake, particularly on a largescale. Because of the difficulties and costs involved, only ten developing countries have car-ried out RAMOS or household studies to estimate maternal morality at the national level. Asa result, other methods have to be devised to provide broad estimates of the extent ofthe problem.

5


How were these new estimates derived?The new estimates were developed using a dual strategy: existing national maternal mortalityestimates were adjusted to account for underreporting and misclassification; and a simplemodel was developed to predict values for countries with no data. The model uses two widelyavailable independent variables – general fertility rates and proportion of births that are as-sisted by a trained person – to predict maternal mortality. The definition of ‘trained person’used comprises doctors (specialized or not specialized) and persons with formally recognizedmidwifery skills, but excludes traditional birth attendants (TBAs), whether trained or not.The rationale is that TBAs generally cannot manage obstetric complications or perform lifesavingprocedures needed to reduce maternal mortality.

Maternal mortality estimates for individual countries fall into five groups:

A Developed countries with complete vital registration systems and relatively goodattribution of cause of death – For these countries the maternal mortality ratio is thereported number adjusted by a factor of 1.5 to account for the well-known problem ofmisclassification of maternal deaths.6

B Developing countries with good death registration but poor or non-existent attri-bution of cause of death – The model is used to predict the proportion of deaths ofwomen of reproductive age that are maternal. This proportion is then applied to the deathsof women of reproductive age actually registered to obtain the number of maternal deathsand the maternal mortality ratio.

C Countries with RAMOS type estimates of maternal mortality – The maternal mortal-ity ratio derived from the RAMOS study is used directly without any adjustments.

D Countries with Sisterhood estimates of maternal mortality – Several recent studieshave found that the Sisterhood Method under-estimates total female adult mortality, andpresumably, maternal mortality as well.7 However, the sisterhood method, in addition toproviding an estimate of maternal mortality, also provides estimates of the proportion ofall deaths of women of reproductive age that are maternal.8 Therefore, for these countries,this observed proportion was applied to the total number of deaths of women of repro-ductive age generated by the United Nations Population Division’s population projections(1994 Revision) for the year 1990 since these are believed to be better estimates of femaleadult mortality.

E Countries with no estimates of maternal mortality – For countries without accurateinformation on numbers of deaths and without direct or indirect estimates of maternalmortality, the model is used to predict the proportion maternal of all deaths of women ofreproductive age and this proportion is applied to the 1990 United Nations projections ofadult female deaths to derive the maternal mortality ratio.

How do these revised estimates differ from previous estimatesof maternal mortality?

The maternal mortality ratios derived from this new approach differ from earlier estimates,both in terms of global numbers of maternal deaths, and in terms of the regional breakdowns.In particular, estimates for Africa are generally much higher whereas those for Asia and LatinAmerica as a whole are broadly comparable with the earlier figures (Table 2).

6


The earlier global and regional estimates of maternal mortality were developed by WHOusing a much cruder model based on female life expectancy. Although they were generallywell accepted and used by the international health community they suffered from a majorweakness. Because the model was greatly simplified and not very robust, WHO was unable toissue the individual country estimates from which the regional and global totals were calcu-lated. Thus the model could not be used to provide an approximation of the level of maternalmortality in an individual country.9

These new estimates differ – in some cases considerably - from official figures or from figuresderived from other sources such as Sisterhood studies. For example, the figures quoted for

Table 2: New regional estimates compared with previous estimates

noigeRNU

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SETAMITSEWEN

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SETAMITSEDLO

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SETAMITSEWEN

latotdlroW 073 034 905 585

*snoigerdepolevederoM 62 72 4 4

snoigerdepolevedsseL 024 084 505 285

acirfA 036 078 961 532

acirfAnretsaE 086 0601 06 79

acirfAelddiM 017 059 12 13

acirfAnrehtroN 063 043 71 61

acirfAnrehtuoS 072 062 4 6.3

acirfAnretseW 067 0201 66 78

*aisA 083 093 013 323

aisAnretsaE 021 59 03 42

aisAlartnec-htuoS )075( . *** 065 )422( . *** 722

aisAnretsae-htuoS 043 044 24 65

aisAnretseW 082 023 21 61

eporuE )32( . *** 63 )1( . *** 2.3

naebbiraCeht&aciremAnitaL 002 091 52 32

naebbiraC 062 004 2 2.3

aciremAlartneC 061 041 6 7.4

aciremAhtuoS 022 002 71 51

aciremAhtroN 21 11 1 5.0

**ainaecO 006 086 1 4.1

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7


developed countries are based on official figures inflated by a factor of 1.5 to account formisclassification of maternal deaths. As already noted, this new approach results in systemati-cally higher estimates of maternal mortality than Sisterhood studies due to the fact that theSisterhood estimates appear to underestimate adult female mortality and have been adjustedaccordingly.

What can the new estimates be used for?This new approach is primarily intended to be of use in countries with no estimates ofmaternal mortality or where there is concern about the adequacy of officially reportedestimates. The intention was to draw attention to the existence and likely dimensionsof the problem of maternal mortality. The estimates should be taken as indicating ordersof magnitude rather than precise estimates and are not necessarily what governments con-sider most appropriate. The results for each country should serve as a stimulus to action andto help mobilize national and external resources to this end. The nature of such action will bedetermined in large measure by the social and economic conditions of the country but mustinclude increasing access to high quality care during pregnancy and childbirth for all women.

What should these estimates NOT be used for?The standard errors associated with the predicted maternal mortality ratios are very large.They cannot, therefore, be used to monitor trends on a year to year basis, but may be used tomonitor changes over the decade. The figures pertain to the year 1990 and should be seen asa recalculation of the earlier 1991 revision rather than as indicative of trends since then.

What other methods are available for monitoring trends?Where current vital registration systems underestimate maternal mortality due tomisclassification of maternal deaths, there is room for improvement through the establish-ment of a system of confidential inquiries which not only result in better estimation of thedimensions of the problem but also, insofar as they identify the causes of misclassification andanalyse the management of each case, lead directly to improvements in case management andreductions in “substandard care”.10

For monitoring progress towards the year 2000 goals, UNICEF and WHO propose processindicators which describe the causal pathways leading to maternal deaths and examine thecoverage and quality of services for the management of obstetric complications.11 Processindicators can help to identify the most appropriate mix of interventions and to assess progresstowards improved coverage and quality of care.

UNICEF and WHO are currently developing guidelines on the use of such process indicatorsat country level. The use of process indicators does not imply the abandonment of efforts tomeasure impact - that is maternal mortality ratios. However, it is unrealistic to expect that allcountries will be able to establish the kind of ongoing monitoring systems needed for a regu-lar appraisal of maternal mortality. Nor would it be appropriate to direct scarce resources tosuch an undertaking at the expense of programmes to deal with the problem at its source.

8


Inter-agency collaborationThese new maternal mortality figures will be used by all the agencies of the United Nationssystem in their work, including the United Nations Population Fund (UNFPA), the UnitedNations Development Programme (UNDP), the United Nations Population Division and Statis-tical Division, and The World Bank. The new approach was developed by Cynthia Stantonand Kenneth Hill of Johns Hopkins University. A detailed description of the methodologywill be issued separately.12 The work was guided throughout by an informal advisory groupcomprising these UN agencies as well as non-governmental organizations working to reducematernal mortality, notably the Population Council, Family Health International, MotherCare,Columbia University School of Public Health, the London School of Hygiene and TropicalMedicine, and the Dugald Baird Centre for Women’s Health. WHO and UNICEF wish to ex-press their gratitude to all the individuals whose time and commitment contributed greatly tothe process.

What are the next steps?Despite its limitations in terms of monitoring, this approach represents a substantial improve-ment on earlier efforts to estimate maternal mortality at regional and global levels, but moreparticularly at national level. At regular intervals, WHO and UNICEF will update and expandthe data set and re-estimate maternal mortality.

The use of such strategies to estimate maternal mortality is a short-term solution to the prob-lem of measurement. In the long term, accurate information about maternal mortality is de-pendent on improvements in vital registration systems and their incorporation into all nationalhealth information systems. This must be the ultimate objective of all national authorities andof multilateral and bilateral development agencies.

References1 World Health Organization. Cause of death statistics and vital rates, civil registration systems and alternative

sources of information. World Health Statistics Annual 1993.

2 For example, a sample of nearly 10,000 pregnancies in Addis Ababa, Ethiopia, yielded 45 deaths and anestimated maternal mortality ratio of 480. At the 95% level of significance this gives a sampling error ofaround 30%, that is, the ratio could lie between 370 and 660. (Source: Kwast BE et al. Epidemiology ofmaternal mortality in Addis Ababa: a community-based study. Ethiopian Medical Journal, 1985, 23:7-16)

3 Shahidullah , M. (1995) The Sisterhood Method of estimating maternal mortality: the Matlab experience.Studies in Family Planning 26:2:101-106

Stanton, C. et al. (1996) Modelling maternal mortality in the developing world (forthcoming)

4 See for example, Bouvier-Colle et al. Reasons for the underreporting of maternal mortality in France, asindicated by a survey of all deaths of women of childbearing age. International Journal of Epidemiology 1991,20:717-721

5 See, for example, Walker, GJ et al Maternal mortality in Jamaica Lancet 1986, 1(8479):486-488

6 The 1.5 adjustment factor is based on evidence from several studies. See, for example, Bouvier-Colle et al.op.cit. and Atrash, HK et al. (1995) Maternal mortality in developed countries: Not just a concern of the past.Obstetrics and Gynecology 86:700-705

7 See Shahidullah, and Stanton, et al, op. cit

9


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:ni1foyrogetaC

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ainablA 56 05 034 A

aireglA 061 0021 021 E

alognA 0051 0027 8 E

*adubraB/augitnA

anitnegrA 001 096 092 B

ainemrA 05 04 046 A

ailartsuA 9 52 0094 A

airtsuA 01 01 0065 A

najiabrezA 22 04 0041 A

samahaB 001 5 004 E

niarhaB 06 01 063 E

hsedalgnaB 058 00033 12 E

sodabraB 34 5 0011 E

suraleB 73 05 0031 A

muigleB 01 01 0025 A

*ezileB

nineB 099 0032 21 E

natuhB 0061 089 9 E

aiviloB 056 0061 62 D

*anivogezreHdnaainsoB

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lizarB 022 0048 031 E

*sdnalsInigriVhsitirB

malassuraDienurB 06 5 034 B

airagluB 72 03 0081 A

osaFanikruB 039 0004 41 E

idnuruB 0031 0043 9 E

aidobmaC 009 0063 71 E

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Table 3: Country estimates of maternal mortality, lifetime risk and numbers of maternal deaths (1990)

10






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adanaC 6 52 0077 A

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anihC 59 00022 004 C

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soromoC 059 062 21 E

ognoC 098 098 51 E

*sdnalsIkooC

aciRatsoC 55 54 024 B

eriovI’detoC 018 0094 41 E

*aitaorC

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surpyC 5 5 0096 E

cilbupeRhcezC 51 02 0092 A

aeroKfo.peRs’elpoeP.meD 07 073 005 E

kramneD 9 5 0085 A

ituobijD 075 011 42 E

*acinimoD

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*romiTtsaE

rodaucE 051 064 051 E

tpygE 071 0013 021 C

rodavlaSlE 003 035 56 D

aeniuGlairotauqE 028 031 71 E

aertirE 0041 0091 01 E

ainotsE 14 01 0011 A

aipoihtE 0041 00033 9 E


11






foksiremitefiLhtaedlanretam ,

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aigroeG 33 03 0011 A

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anahG 047 0084 81 E

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aeniuG 0061 0074 7 D

uassiB-aeniuG 019 083 61 C

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sarudnoH 022 014 57 C

gnoKgnoH 7 5 0029 A

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)focilbupeRcimalsI(narI 021 0072 031 C

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12






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*itabiriK

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ainauhtiL 63 02 0021 A

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aisyalaM 08 044 072 B

*sevidlaM

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atlaM 0 0 0 A

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*euqinitraM

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ocixeM 011 0072 022 B

*setatSlaredeFaisenorciM

ailognoM 56 54 013 B

*tarrestnoM

occoroM 016 0054 33 D



13






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aibimaN 073 091 24 D

lapeN 0051 00011 01 E

sdnalrehteN 21 52 0034 A

*sellitnAsdnalrehteN

*ainodelaCweN

dnalaeZweN 52 51 0061 A

augaraciN 061 052 001 C

regiN 0021 0015 9 D

airegiN 0001 00044 31 E

yawroN 6 5 0037 A

namO 091 051 06 E

natsikaP 043 00081 83 E

*ualaP

amanaP 55 53 015 B

aeniuGweNaupaP 039 0021 71 E

yaugaraP 061 042 021 E

ureP 082 0071 58 E

senippilihP 082 0045 57 D

dnaloP 91 001 0022 A

lagutroP 51 02 0053 A

*ociRotreuP

*rataQ

aeroKfocilbupeR 031 009 083 B

avodloMfocilbupeR 06 05 085 A

*noinueR

ainamoR 031 014 043 A

noitaredeFnaissuR 57 0051 026 A

adnawR 0031 0004 9 E



14






:ni1foyrogetaC

etamitse

*siveN/sttiKtniaS

*aicuLtniaS

*senidanerG/tnecniVtniaS

aomaS 53 5 005 E

epicnirP/emoToaS D

aibarAiduaS 031 037 59 E

lageneS 0021 0093 11 D

*sellehcyeS

enoeLarreiS 0081 0063 7 E

eropagniS 01 5 0094 A

*aikavolS

ainevolS 31 5 0004 A

*sdnalsInomoloS

ailamoS 0061 0007 7 E

acirfAhtuoS 032 0072 58 E

niapS 7 03 0029 A

aknaLirS 041 025 032 B

naduS 066 0066 12 E

*emaniruS

dnalizawS 065 061 92 E

nedewS 7 01 0006 A

dnalreztiwS 6 5 0078 A

cilbupeRbarAnairyS 081 059 57 C

natsikijaT 031 072 021 A

*ainodecaMRYFT

dnaliahT 002 0032 081 E

ogoT 046 0001 02 E

*agnoT

ogaboTdnadadinirT 09 52 063 B

aisinuT 071 083 041 E



15






:ni1foyrogetaC

etamitse

yekruT 081 0092 031 C

natsinemkruT 55 07 053 A

*sdnalsIsociaC/skruT

*ulavuT

adnagU 0021 00011 01 E

eniarkU 05 023 039 A

setarimEbarAdetinU 62 01 037 E

modgniKdetinU 9 07 0015 A

ainaznaTfo.peRdetinU 077 0078 81 E

aciremAfosetatSdetinU 21 084 0053 A

yaugurU 58 54 014 B

natsikebzU 55 083 073 A

utaunaV 082 51 06 E

aleuzeneV 021 086 002 B

maNteiV 061 0033 031 E

nemeY 0041 0018 8 E

*aivalsoguY

eriaZ 078 00061 41 E

aibmaZ 049 0053 41 E

ewbabmiZ 075 0032 82 E



16


8 Insofar as the Sisterhood Method identifies all pregnancy-related deaths which may include some due tofortuitous or accidental causes, it may over-estimate maternal mortality. However, the method is likely to misssome early maternal deaths such as those related to abortion or ectopic pregnancy. It has been assumed thatthe two biases cancel out.

9 In 1992 the individual country estimates were inadvertently issued in the 1992 Human Development Reportbut were never officially used by any UN agency.

10United Kingdom, Department of Health. Report on confidential enquiries into maternal deaths in Englandand Wales 1982-1984. HMSO 1989.

11UNICEF and WHO (1996) Maternal mortality: Guidelines for monitoring progress. Second edition. (forthcom-ing)

12Stanton, C et al. (1996) Op. cit.

Table 5: Estimates of maternal mortality by UNICEF regions (1990)

Table 4: Estimates of maternal mortality by WHO regions (1990)


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)ORFA(acirfArofeciffOlanoigeR 049 000312

)ORMA(saciremAehtrofeciffOlanoigeR 041 00032

)ORME(naenarretideMnretsaEehtrofeciffOlanoigeR 044 00086

)ORUE(eporuErofeciffOlanoigeR 95 0007

)ORAES(aisAtsaE-htuoSrofeciffOlanoigeR 016 000532

)ORPW(cificaPnretseWehtrofeciffOlanoigeR 021 00093

LATOTDLROW 034 000585


)shtribevil000,001 shtaedlanretamforebmuN

)ORASE(acirfAnrehtuoSdnanretsaE 089 000801

)ORACW(acirfAlartneCdnanretseW 089 000111

)ANEM(acirfAhtroNdnatsaEelddiM 023 00023

)ASOR(aisAhtuoS 016 000422

)ORPAE(cificaPehtdnaaisAtsaE 012 00008

)ORCAT(naebbiraCehtdnaaciremAnitaL 091 00022

tnednepednIylweNehtdnaeporuEnretsaEdnalartneC)SIN-EEC(setatS 59 0007

seirtnuocdepoleveD 71 0002

LATOTDLROW 034 000585

.gnidnuorfoesuacebslatototddatonyamserugiF

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Revised 1990 estimates of maternal mortalitywhqlibdoc.who.int/hq/1996/WHO_FRH_MSM_96.11.pdf · iii...

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