Approaches to improve and adapt maternal mortality estimations in low- and middle-income countries: A scoping review

Background: In the absence of robust vital registration systems, many low- and middle-income countries (LMICs) rely on national surveys or routine surveillance systems to estimate the maternal mortality ratio (MMR). Although the importance of MMR estimates in ending preventable maternal deaths is acknowledged, there is limited research on how different approaches are used and adapted, and how these adaptations function. Objectives: To assess methods for estimating maternal mortality in LMICs and the rationale for these modifications. Search Strategy: A literature search with the terms “maternal death”, “surveys” and “low- and middle-income countries” was performed in Medline, Embase, Web of Science, Scopus, CINAHL, APA PsycINFO, ERIC, and IBSS from January 2013 to March 17, 2023. Selection Criteria: Studies were eligible if their main focus was to compare, adapt, or assess methods to estimate maternal mortality in LMICs. Data Collection and Analysis: Titles and abstracts were screened using Rayyan. Relevant articles were independently reviewed by two reviewers against inclusion criteria. Data were extracted on mortality measurement methods, their context, and results. Main Results: Nineteen studies were included, focusing on data completeness, subnational estimates, and community involvement. Routinely generated MMR estimates are more complete when multiple data sources are triangulated, including data from public and private health facilities, the community, and local authorities (e.g. vital registration, police reports). For subnational estimates, existing (e.g. the sisterhood method and reproductive-age mortality surveys [RAMOS]) and adapted methods (e.g. RAMOS 4 + 2 and Pictorial Sisterhood Method) provided reliable confidence intervals. Community engagement in data collection increased community awareness of maternal deaths, provided local ownership, and was expected to reduce implementation costs. However, most studies did not include a cost-effectiveness analysis. Conclusion: Household surveys with community involvement and RAMOS can be used to increase data validity, improve local awareness of maternal mortality estimates, and reduce costs in LMICs.