Methods used to measure maternal mortality in Sub-Saharan Africa from 1980 to 2020: A systematic literature review.

BACKGROUND Sub-Saharan Africa (SSA) has the biggest maternal mortality burden, but the region lacks accurate data. OBJECTIVE We reviewed methods historically used to measure maternal mortality in SSA to inform future study methods. SEARCH STRATEGY We searched databases: PubMed, Medline, WorldCat and CINHAL, using keywords "maternal mortality", "pregnancy-related death", "reproductive age mortality", "ratio", "rate" and "risk", using Boolean operators "OR" and "AND" to combine the search terms. SELECTION CRITERIA We searched for empirical and analytical studies that: 1) measured maternal mortality levels, 2) in SSA, 3) reporting original results, 4) de-duplicating the studies. We included studies published in English since 1980. DATA COLLECTION AND ANALYSIS We screened the studies using titles and abstracts, reading full articles of selected studies. We analysed the estimates and strengths, and limitations of the methods. MAIN RESULTS We identified 96 studies that used nine methods: demographic surveillance (n=4), health record reviews (n=18), confidential enquiries and maternal death surveillance and response (n=7), prospective cohort (n=9), reproductive age mortality survey (RAMOS) (n=6), sisterhood method (n=35), mixed methods (n=4), and mathematical modelling (n=13). CONCLUSION Sisterhood method studies and RAMOS studies that combined institutional records and community data produced MMRs more comparable with WHO estimates.