The 3 principal sources of data providers are surveys, censuses and official data. Regarding the lack and poor quality of existent data on maternal mortality in Burkina Faso, this study used one data in each category (household survey, census and health facility data) from the period 2006-2010. The first reason for the poor quality of information related to maternal mortality in general is the incapacity of the target population (the deaths) to provide information themselves. During household surveys, information about maternal deaths is generally collected from family members or relatives of the death. Sometimes, respondents are not able to give accurate answers about the cause, condition or circumstances of death.
They are either reluctant, unwilling to provide information or genuinely lack accurate information. This may be one of the reasons why there is little information on maternal deaths. Hence, this challenge has often limited the possibilities of further analyses. Therefore, all the three sources of data are analysed in this study starting from the census 2006 to DHS survey and EMOC survey data.
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3.1.1 DHS 2010
Demographic and Health Surveys (DHS 1) are the principal sources of information related to health and demographic issues in Burkina Faso. They have advantages to be representative at country and regional levels and contain a large amount of information. DHS has also the advantage of providing data regularly every five years using the same methodology.
Among the four DHS (1993, 1998, 2003, 2010) so far completed in Burkina Faso, only the DHS 1998 and the DHS 2010 incorporated questions related to maternal mortality. Indeed, the DHS 1998 and 2010 considered the issue of maternal mortality via direct and indirect sisterhood methods. All the 4 DHS data can be used to understand maternal health in general but only the DHS 1998 and 2010 can distinguish maternal deaths to maternal survivals. This is why, this study only considered the DHS 2010.
The DHS 2010 is used because it is the most recent data in Burkina (published in October 2012). In addition, among the DHS which collected information on maternal mortality (1998 and 2010); it is the only one after the establishment of the current administrative subdivisions of the country in 13 regions.
The DHS 2010 was combined with the multiple indicators cluster survey (MICS).
The data collection of the DHS 2010 follows three main phases. The first phase consists of the car-tography and enumeration of the households from August to October 2009, while the second phase constitutes the pre-survey held in January 2010. Finally the third phase and principal step covered the period from 20 May 2010 to January 2011.
The DHS 2010 used an updated sampling list of the census 2006. This list contains 13 989 enumeration areas called ”ZD2” including 2820 in urban and 11169 in rural areas. The average size of the enumera-tion area (ZD) is 192 households in urban and 154 in rural areas. The sample of the DHS 2010 is random and stratified with 2 levels. The primary unit of sampling is the enumeration area (ZD) as defined by the census 2006. Each urban and rural area of each region constitutes a stratum. Therefore, a total of 26 stratum composed of the 13 regions divided into urban and rural are considered. At the first level of sampling, 574 ZD are selected independently in each stratum with proportional probability to the size of the enumeration area (number of households in the ZD). The second level of sampling consisted of a systematic selection with equal probability of 26 households per enumeration area obtained from the first level of sampling. The sampling amounted to a total of 574 enumeration areas including 176 ZD in urban and 398 in rural areas. The sample is composed of 14 924 households with 4 576 in urban and
1called ”Enquˆete d´emographique et de sant´e / enquˆete `a indicateurs multiples - EDS/MICS”
2meaning ”zone de d´enombrement” in french
10 348 in rural areas.
Finally, 14 424 households were interviewed with 17 363 women aged 15-49 years identified eligible and among them 17 087 were interviewed successfully. The response rate of the interviews with women questionnaire is 98 %. Concerning the males, 7 506 males aged 15-59 years were identified eligible and 7 307 were interviewed successfully with a response rate of 97 %.
Data was collected through direct interviews using questionnaires. The DHS 2010 used a questionnaire specific households, females and males. The first questionnaire concerns all members of households in the sample. The questionnaire specific to females and males include a sub-population composed of eligible people based on selected criteria.
All females aged 15-49 years, usual member of a selected household in the sample or present in the household during the night before the interview were eligible for female questionnaire. A male question-naire was directed to all males aged 15-59 years, member of a household or present in the household during the night before the passage of the interviewer. Eligible males to this questionnaire were selected from a sub-sampling of one household for every 2 households concerned by female questionnaires. It is also important to mention the specific case of questions related to domestic violence which targeted only one woman aged 15-49 years per household in the sample.
This data is mainly used in this study to identify the determinants of maternal mortality at national and regional scales according to the age of women and socio-demographical characteristics their sisters who provided the information (the respondents). Concerning maternal mortality, the DHS data 2010 opted for sisterhood methods. In other words, questions were posed to female respondent aged 15-49 years old about their sisters’ from the same biological mother whether they are still alive, dead or living elsewhere.
In order to determine the level of maternal mortality, 4 questions were posed to female respondents aged 15-49 years about their siblings deceased at age 12 years old or more.
was (name) pregnant when she died? For negative answer to this question or unknown, ask the following question.
did (name) die during delivery? For negative answer to this question, ask the next question.
did (name) die during the 2 months after delivery or after the end of the pregnancy?
If the death occurred during pregnancy or two months after the end of the pregnancy, the following additional question was asked:
Was the deaths due to the pregnancy?
This additional question ensured that question about causes of maternal death were more precise. In other words, it is useful in selecting the deaths related to maternal causes among the deaths appearing during pregnancy or two months after the end of the pregnancy. To be able to make international comparisons and to determine the time period reference of the maternal deaths, the following questions have been added:
Year of death?
Number of years of death?
Age at death?
The DHS data is confronted with a range of limitations for the kind of analysis undertaken in this study.
In fact, households’ surveys data in general are confronted with the problem of sample size required to directly capture a representative number of maternal deaths. Indeed, as rare phenomenon (measure out of 100 000 live births), a very large sample size is required to collect representative information about maternal mortality particularly to satisfy a regional representativeness. In order to avoid this problem, the sisterhood method is usually adopted in surveys to collect maternal mortality data. However, the use of sisterhood method did not totally solve the problem since the number of maternal deaths in surveys’ data is still small particularly at sub-national levels. Furthermore, the sisterhood methods as an indirect method also present itself with a number of limitations. Finally, in the specific case of the DHS 2010, apart from questions related to the household and the respondents, the only information directly related to the deceased women are their age at death and number of children before the death.
3.1.2 RGPH-BF 2006
This study used the last general census of population and housing3 2006 data. The last census of 2006 was the fourth census of the country after those of 1996, 1987 and 1975. Only this census integrated the specific matter of maternal mortality and thus constitutes one of the most important sources of data related to this phenomenon in the country. The census has the advantage of providing exhaustive data disaggregated to all geographical levels. Another reason for using the census comes from its direct
3called ”Recensement G´en´eral de la population et de l’habitat - RGPH-BF”
method of recording maternal deaths. Unfortunately, it is very limited in terms of variables (questions) needed to conduct very thorough analysis in maternal mortality. However, in this study we tried, in addition to the few questions directly related to the death, to associate the determinants of maternal mortality with the characteristics of the head of the household (HoH).
The census 2006 was established by the governmental decree2005/394/PRES/PM/MEDEV/MFB/MATD/MD/MS/MEBA
of July 19th, 2005. This decree was a strong institutional act of approval for the census implementation.
After that, the census was carried on through many other steps. Firstly, the cartography took place from March to October 2006 and mainly entailed dividing the country into ZD. From 19 May to 4 June 2006, the pilot census were undertaken to test the questionnaire and all the procedure and tools of the data collection. The data was finally collected from 9th to 23rd December 2006 in all the country without any exception, involving all the people living in the territory at that time. Information were gathered through a face to face interview using a questionnaire (figure A.1 in annex). The operation of data collection has been followed by the post enumeration survey which aimed to check for errors, omissions and double counting.
The census 2006 provided the number of 14 017 262 inhabitants in the country. Among 6 768 739 are males and 7 248 523 are females, 3 181 967 people were living in urban areas and 10 835 295 people in rural areas. The size of the women population in reproductive ages (15-49 years old) was 3 302 636 people. The census 2006 covers an important range of topics such as age and sex structure of the population, education, migration, fertility, and mortality among others.
The Census 2006 of Burkina Faso also took into consideration the issue of maternal mortality through tree main questions. In each household of the country, information is collected about all female deaths aged 10 years or more. This is followed by questions about the period of death: during pregnancy, during delivery or after delivery. When the death occurred after delivery, a question was asked about the number of days after delivery. Additional information collected about the maternal deaths are the year of death, age at death, year of birth as well as information about the characteristics of the household and the head of the household. DHS data and census are both household data. They are the widely used data of maternal moratality estimate in the country. Nevertheless, they both present the limitation about the identification of the causes of death. However, Information are also collected in all the health facilities regarding patients coming for deliveries or prenatal visits or treatment related to complications during pregnancy, delivery or post-partum periods. Health facilities data are also very important. The EMOC survey is based on the collection of these data.
3.1.3 EMOC Survey 2010
The dysfunction of health systems is a reality in most developing countries, particularly visible in the delay of data from health services and the insufficiency of data provided. In fact, sanitary data are generally not sent on time at the central level and data are not taken seriously by some health workers.
In addition to this problem, more than an average of women give birth at home and the poor do not have access to health services Marie Th´er`ese Arcens-Som´e and Brouwere (2005). Health facilities data are also generally not used because of the weak and unequal representation of health services and the low hospital attendance in the country. Another weakness of this data is the few number of information treated computationally and the selective character of individuals included in the data compared to the entire population of the country. Nevertheless, health facilities sources of data are the best to inform the medical causes (real causes) of deaths. It is also the source of data capable to provide information on maternal mortality on weekly basis, even daily if well maintained. The availability of these data for different geographical areas is undoubtedly another asset that is used in this study. The ministry of Health in Burkina Faso publishes every year, the number of maternal mortality recorded in all the hospitals of the country. They provide also the numbers of maternal deaths by clinical causes of deaths.
Information published are very limited when we know that for every maternal deaths occurring in a health service, information is recorded Zougrana and Par´e (1999) about the Date and place of death, age, number of children, ethnic, size, cause of the death and profession of the death and her husband.
Unfortunately, all these information are not recorded numerically and made available for a researcher.
It is against this backdrop that the survey EMOC (Emergency Obstetric and Neonatal Care) has been initiated.
This study used EMOC data in its analyses. EMOC data contains a lot of information about maternal mortality collected from all health facilities (private and public) in Burkina Faso. This survey which was held in 2010 covered all the health facilities in the country. Based on the examination of each HC records, maternal deaths which occurred during the last 12 months (including 2010) were identified.
For every single case of maternal death identified, the medical dossier and all useful information were collected from health professionals point of view to a resource person. Data was also recorded from witness cases identified in the same service. A witness case is a female alive who has the same age and presents the same complications as the death identified. Witnesses are the control cases of the study and those aged more or less 2 years than the maternal death case have been accepted. This survey considered as maternal deaths, females who deceased from obstetrical causes during pregnancy, delivery
or 42 days after the end of pregnancy. The questionnaire of this survey is available in Annex A.2.
Finally, the data of the EMOC survey is used for in-depth analysis of the problem. This important mass of information put together with census and surveys data provide a comprehensive understanding of maternal mortality at national and regional scale.