Indicators of Target 6

16. Maternal Mortality Ratio

17. Proportion of Births Attended by Skilled Health Care Personnel

Status and Trends

Maternal mortality is defined as the death of a woman caused by complications during pregnancy, delivery, or the post-partum periods. Deaths arising from accidents or other causes are not included in the scope of maternal mortality in the figures.

The frequency of maternal mortality is not only used in measuring women's access to, and utilization of, health care services during pregnancy, delivery and the post-partum period, but is also applied to measuring women's general health and nourishment conditions, their access to reproductive health care services, their access to resources, and their educational, social, and economic status. The frequency of maternal mortality in its simplest form is the most preliminary and striking indicator of women's status in society.

The purpose of the maternal mortality rate is to observe mortality during delivery and the post-partum period. Considering the difficulties encountered in measuring maternal mortality, the "proportion of births attended by skilled health care staff," which is frequently used as a procedural indicator of maternal mortality, has also been included in Goal 5.

Target 6: Reduce by Three-Quarters, between 1990 and 2015, the Maternal Mortality Rate During Pregnancy, Delivery and the Post-Partum Period

Indicator 16: Maternal Mortality Rate

Complications during pregnancy, delivery and the post-partum period are the most common causes of death and disability among women of reproductive age in developing countries. Factors affecting maternal mortality also affect the chances of survival of the fetus and the newborn.

The maternal mortality rate is characteristically difficult to measure and keep track of. Even in countries where vital records of nearly perfect accuracy are kept, because of problems in the classification of the causes of mortality, the maternal mortality rate is thought to be higher than reported (WHO, 2001).

Information on maternal mortalities in Turkey is insufficient. As maternal mortality cannot be determined from vital records, efforts were made to determine maternal deaths initially through the Turkish Population Survey in 1974-1975. In this survey, the maternal mortality rate was found to be 208 for every 100,000 live births. Later, in the Turkish Population Survey conducted in 1989, the maternal mortality rate was predicted using the Indirect Sisterhood Method. This study produced a result of 132 deaths for every 100,000 live births for the year 1981 (SIS, 1993). There is no other estimate based on research data across Turkey.

In 1997, in a study entitled "Maternal Mortalities and their Causes," taken across 615 hospitals, the maternal mortality rate was determined to be 49 in 100,000. It is believed that this finding cannot be generalized to Turkey methodologically, and that its estimated ratio of maternal mortality is quite low (the Government of the Turkish Republic Government and UNICEF, 1999; UNFPA, 2003).

In the modeling study carried out by the World Health Organization (WHO) and UNICEF, it is estimated that the maternal mortality rate for Turkey in 1995 was 55 out of 100,000 live births, and that the life-long maternal mortality risk for women is one out of 570 (WHO, 2001). However, it should be noted that the maternal mortality rate estimated in this study includes an extremely high margin of error.

The majority of maternal deaths in Turkey occur during delivery, accounting for approximately half of all maternal deaths, one-quarter during pregnancy and the remaining one-quarter during the post-partum period. According to the 1997 Maternal Mortality Survey, the primary causes of death at delivery are through bleeding, infection and toxemia (Turkish Government and UNICEF, 1999). Among the factors that intensify the medical conditions related to maternal mortality in Turkey are high fertility, insufficient antenatal care and nourishment, under-use of health services and the low status of women.

Indicator 17: Proportion of Births Attended by Skilled Health Staff

It is important to have a skilled health care professional in attendance during delivery to intervene with the correct medical procedures in a timely manner in case of possible complications in either the mother or the newborn. Births assisted by skilled health care staff decreases the mortality and morbidity risks to both the mother and her infant.

The proportion of births attended by skilled health care staff is defined as the proportion of live births attended by skilled health care professionals in the total number of live births. The place of birth is not included in the definition of the indicator; for this reason, births attended by health care staff at home are also taken into account.

This indicator is addressed under Goal 5 because of its close connection with maternal mortality. International studies show a correlation between maternal mortality and having skilled health care staff attend births, and it is known that fewer mortalities occur when births are attended by doctors (WHO 1996).

The proportion of births attended by skilled health care staff is used as a measurement of observation related to the accessibility and quality of obstetric care.

According to the Turkey Demographic and Health Surveys, 46.7% of all live births during 1998-2003 were attended by doctors, and 45.1% by midwives and nurses (HUIPS, 2003-Hacettepe University Institute of Population Studies; Turkey Demographic and Health Surveys). The ratio of births attended by skilled health care staff had reached 83% by 1998. In other words, in the time period between the two surveys (1998 and 2003), the ratio of births attended by skilled health care staff increased from 80.6% to 83%.

Table 14: Proportion of Births Attended by Skilled Health Care Staff

Source: TDHS, HUIPS

It is known that there is a wide gap between the figures of birth attendance by health care professionals for eastern Turkey and the average rate across the country in having skilled health care professionals attend births. For example, if the births that occurred between 1998-2003 are compared it can be seen that skilled staff attended 59.7% of the births in Eastern Anatolia, whereas in Western Anatolia this figure was as high as 95.3%. Discrepancies related to the educational level of the mother are also striking: the indicator value for births to mothers with secondary or higher education goes up to 98.5%; that is, almost all births are attended by skilled staff. On the other hand, the indicator remains at 54.9% for births to uneducated women.

Relevant Policies

An indirect calculation of maternal deaths as defined above is possible in ideal circumstances where there is no problem in the scope of the vital records system. However, even in countries where this is the case, because of problems related to the classification of maternal mortalities during recording the number of maternal deaths is underestimated (WHO, 2001).

Obtaining maternal mortality statistics from hospital records is one of the methods occasionally used. However, since not all pregnancies are covered by the health system, and observations on the births and maternal deaths occurring in hospitals are of a subjective nature, there are methodological drawbacks in generalizing the estimates obtained from this source of data to the whole country.

WHO and UNICEF have developed a modeling study to estimate the maternal mortality rate based on procedural variables (WHO, 2001). According to this, the level of maternal mortality rate is estimated by considering a given country's general rate of fertility and the ratio of births attended by skilled heath care staff. In countries where there is no other information concerning maternal mortalities, this model is used to estimate the maternal mortality rate, and international institutions can base their evaluations of countries on these estimates.

Among skilled health care staff are doctors and/or other health care professionals such as midwives or nurses who have been trained to assist labor, who can detect and intervene in obstetric complications, or can refer such cases to the appropriate facilities. Even if they have received training in birth assistance, traditional midwives (traditional birth assistants) are not included in the indicator. As mentioned in the previous chapter, the Conditional Cash Transfer (CCT) Program now covers pregnant women.

Benchmarks and Monitoring Capabilities

As maternal mortalities are statistically rare incidences, measuring them indirectly by means of sampling research necessitates large samples, and this increases the cost of research, as well as the likelihood of quality problems that arise in working with large groups. However, techniques have also been developed to measure maternal mortality indirectly through research. Among these is the Sisterhood technique, which can project the maternal mortality rate under certain assumptions by compiling data from interviews with women who have lost a relative, friend or acquaintance as a result of maternity-related causes. Nonetheless, these techniques also necessitate large samples in circles where the level of fertility is low, and where, in addition to the indubitable statistical reliability intervals of the estimates, the reference dates can go back 10 to 12 years.

Sources of data on the causes of maternal mortalities are extremely limited in Turkey. Vital records fall under the responsibility of the General Directorate of Population and Citizenship Affairs of the Ministry of Internal Affairs. The recording system is not designed to enable the extraction of specific information on maternity-related deaths. Publications that provide information based on the vital records are limited in both number and content.

Since information from the register system is not used, maternal mortality is determined by means of two research methods. The first is the Turkish Population Survey, conducted by the State Institute of Statistics in 1974-1975. Even though this study, which was carried out using a dual register system, did not produce reliable results in general, the maternal mortality rate was calculated taking into consideration the number of live births and maternal deaths, and in situations where other sources of data are lacking, it has been widely used. In the Turkish Population Survey similarly conducted by the State Institute of Statistics in 1989, questions enabling the use of the Sisterhood technique to estimate the maternal mortality rate (SIS, 1993) were included.

In 1997 an effort was made to determine the maternal mortality rate with a survey entitled "Maternal Mortality and its Causes in Turkey," involving 615 hospitals. The results obtained from this survey based on hospital records cannot be generalized to Turkey, but the study produced important information on causes of maternal mortality.

Moreover, a "National Maternal Mortality Study" was begun in October 2004 by the Hacettepe University Institute of Population. This study is scheduled for completion in November 2006.

In addition to the above, the State Institute of Statistics compiles and publishes data on deaths occurring in city and town centers. However, this information cannot be used in monitoring maternal mortalities in Turkey because it lacks universal relevance to Turkey and has a limited content.

Monitoring Capability

Challenges

Information related to this indicator in Turkey is obtained from the Demographic and Health Surveys conducted every five years at the national and regional levels (HUIPS-TDHS, 2003). The Ministry of Health (MoH) cannot provide information related to births attended by health care staff across Turkey as births occurring in health care facilities that are not affiliated to the MoH cannot be tracked. The MoH can only produce information related to births taking place in health care facilities under its authority. Births attended by health care personnel at home and unattended births are insufficiently monitored.

Research results indicate that there are both supply and demand problems related to a significant portion of deliveries taking place in unhealthy conditions. While service-related problems such as inaccessibility persist, problems also exist with regard to demand for services, caused especially by educational levels and cultural characteristics. In order to increase the value of the indicator to the highest levels, health care services need to develop the full capacity to follow up all pregnancies, mothers need to be motivated to take advantage of routine pregnancy care, and obstacles such as cost and lack of health insurance need to be addressed.

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