Measuring and estimating maternal mortality in the era of HIV / AIDS.

In this 21st century safe motherhood remains an elusive goal for many developing countries. The obstacles to progress in reducing the burden of avoidable maternal mortality and severe morbidity include both old and new challenges and emphasise the reality of no “quick fix” nor “magic bullet”. Among the older challenges are some familiar barriers to public health such as dysfunctional health systems poverty and the low status of women. As regards the new challenges foremost among these is HIV/AIDS. Global recognition of the magnitude and implications of this modern-day plague broadly coincided with raised awareness of the neglected tragedy of maternal mortality in developing countries (Mahler 1987; Quinn and others 1986). Looking back over the lapsed time since then reveals several similarities in the evolution of these two major challenges to global health. The concentration of the burden in developing countries is similar experiencing annually an estimated 99% of all maternal deaths (WHO/UNICEF/UNFPA 2001) and a similar proportion of AIDS deaths (1999) (UNAIDS 2003). The serious difficulties of measuring the burden especially on a population basis are comparable for maternal mortality and HIV/AIDS. In terms of reliable evidence of progress in reducing mortality in developing countries from either condition there is little to celebrate particularly in sub-Saharan Africa (AbouZahr and Wardlaw 2001; Buve Bishikwabo-Nsarhaza and Mutangagura 2002). What is perhaps most surprising however in this evolution is the comparatively limited attention given to the relationship between maternal mortality and HIV/AIDS (Graham and Newell 1999). This has many manifestations. A search of Medline for example reveals just 43 papers in the last 10 years with “maternal mortality” and “HIV/AIDS” as key words compared with over 6200 identified using “child mortality” and “HIV/AIDS”. There are a host of scientific practical and ethical reasons for acknowledging the relationship between maternal mortality and HIV/AIDS (Berer 1999). The focus of this paper is specifically on the challenge of measuring maternal mortality in the context of HIV/AIDS. Although there is little empirical evidence on the scale or stage of the HIV/AIDS epidemic at which effects on maternal mortality are significant “context” here is assumed to be populations with adult prevalence rates (15-49 year olds living with HIV/AIDS) in excess of 1% and thus relates predominantly to sub-Saharan Africa with an estimated prevalence of 8.8% in late 2000 (Morrison 2001). The first section of the paper explores possible biological or behavioural synergies. The remainder focuses on the implications of the presence of HIV/AIDS for the classification quality sources and interpretation of data on maternal mortality. Finally a brief descriptive profile of global and regional patterns in maternal mortality is given along with recommendations on priorities for research and development. There are two sides or facets to exploring the relationship – the effects of HIV/AIDS on the measurement of maternal mortality and the effects of HIV/AIDS on the risk of maternal mortality. In practice these effects are totally conflated and thus hard to differentiate – the analogy being two sides to the same coin or currency as represented in Figure 1. The latter shows that the level of maternal mortality may increase or decrease in the context of HIV/AIDS owing to changes in the numerator of deaths and/or denominator of women or births. These changes in turn can be due to real alterations in the risk of maternal death or of exposure. Alternatively they can be measurement artefacts in other words the consequences or knock-on effects of HIV/AIDS. (authors)