Demographic and Health Surveys Methodology - Measure DHS

Notes and ConsiderationsThe DHS maternal mortality module questionnaire collects information from respondents (female andmale) about the maternal status of the death of their sisters born to the same mother by asking if the sisterdied while pregnant, during delivery or within two months after the end of a pregnancy or a childbirth.Younger (and male) respondents may not know that their older sister was even pregnant if the sister wasseveral years older or died during pregnancy or from an induced abortion, thus biasing maternal mortalityrates downward. Women who intend to have an induced abortion may also not disclose their pregnancystatus to family members. On the other hand, deaths due to non-maternal causes, such as accidents andillnesses, will be included as maternal deaths if they occurred during pregnancy or within two monthsafter the end of the pregnancy or childbirth. Simulation models show that up to one-third of classified asmaternal may not be due to maternal causes, resulting in an upward bias. The final result of both thesebiases, which operate simultaneously, is unknown.Another important issue is location. The DHS does not collect information on the residence of neithersisters who died nor of the residence during the exposure period of both living and dead sisters. Theresidence at the time of interview of respondents is not necessarily the same as that of their sisters.Therefore, DHS usually does not publish maternal mortality rates and maternal mortality ratios by area.Maternal mortality rates and ratios are subject to high levels of relative sampling error due to theirrelatively rare occurrence. For example, a maternal mortality ratio of 500 maternal deaths per 100,000births has the same sampling error as an infant mortality rate of 5 infant deaths per 1000 births. For asample of about 15,000 respondents, the 95% confidence interval of the MMR would be about 406 to 594maternal deaths per 100,000 births.ReferencesRutenberg, N. and Sullivan, J.M. Direct and indirect estimates of maternal mortality from the sisterhoodmethod. IRD/Macro International Inc., Washington DC, 1991.Hanley, J.A., Hagen, C.A. and Shiferaw, T. Confidence intervals and sample size calculations for thesisterhood method of estimating maternal mortality. Studies in Family Planning 27(4) July/August 1996.WHO/UNICEF. The Sisterhood method to estimate maternal mortality. Report of a technical meeting,5-6 December 1996.Stanton, C., Abderrahim, N. and Hill, K. DHS maternal mortality indicators: An assessment of dataquality and implications for data use. Demographic and Health Surveys Analytical Report No 4, MacroInternational Inc. Calverton, Maryland, USA, September 1997.Guide to DHS Statistics 157 Updated September 2006