Subnational estimates of maternal mortality in Nigeria: Secondary Data Analysis of female siblings' survivorship histories.

High Maternal Mortality (MM) in Nigeria is complicated by the absence of reliable estimates at subnational levels. Obtaining accurate data at the state and geopolitical region levels is crucial for effective policy-making and targeted interventions. This study employs novel small area estimation techniques to derive plausible estimates of Maternal Mortality rates and ratios for Nigerian states and geopolitical regions. Data from 293,769 female siblings, provided by 114,154 women in the Nigeria Demographic and Health Surveys of 2008, 2013, and 2018, are used. Empirical Bayesian technique and the James-Stein estimator are applied to estimate MM Rates and Ratios, respectively. Maternal Mortality Ratio is highest in rural areas, Northern Nigeria states, and regions. While the South West exhibits lower MMRatio, the Northern regions, particularly the North-East, show consistently higher ratios. Mortality trends have decreased in the North West and South East regions but increased in the South West from 2008 to 2018. Addressing these disparities is essential for achieving sustainable development goals and improving maternal health in Nigeria.

La mortalité maternelle (MM) élevée au Nigeria est compliquée par l'absence d'estimations fiables aux niveaux infranationaux. L'obtention de données précises au niveau des États et des régions géopolitiques est cruciale pour une élaboration de politiques efficaces et des interventions ciblées. Cette étude utilise de nouvelles techniques d'estimation sur petites zones pour dériver des estimations plausibles des taux et ratios de mortalité maternelle pour les États et les régions géopolitiques du Nigeria. Les données de 293 769 frères et soeurs, fournies par 114 154 femmes dans les enquêtes démographiques et sanitaires du Nigeria de 2008, 2013 et 2018, sont utilisées. La technique bayésienne empirique et l'estimateur de James-Stein sont appliqués pour estimer respectivement les taux et les ratios MM. Le taux de mortalité maternelle est le plus élevé dans les zones rurales, dans les États et les régions du nord du Nigéria. Alors que le Sud-Ouest présente un ratio MMR plus faible, les régions du Nord, en particulier le Nord-Est, affichent des ratios systématiquement plus élevés. Les tendances de la mortalité ont diminué dans les régions du Nord- Ouest et du Sud-Est, mais ont augmenté dans le Sud-Ouest de 2008 à 2018. Il est essentiel de remédier à ces disparités pour atteindre les objectifs de développement durable et améliorer la santé maternelle au Nigéria.

Gender, Police Culture, and Structured Ambivalence: Navigating 'Fit' with the Brotherhood, Boys' Club, and Sisterhood.

Women are increasingly represented in policing; however, inclusion alone will not eradicate existing structural and cultural barriers to meaningful change. Insights from interviews with ninety-one Canadian women police of varied rank and tenure, demonstrate women's experiences of structured ambivalence as they strategically deploy and resist gendered policing narratives of the Brotherhood, Boys' Club, and Sisterhood to negotiate their own 'fit.' In this way, they both challenge and reinforce gendered boundaries that create barriers to meaningful transformation. These findings demonstrate the need for change initiatives to address the complex and ever-shifting role of gender in policing organizations.

A Sisterhood of Hope: How China's Transgender Sex Workers Cope with Intimate Partner Violence.

Transgender sex workers (TSWs/TSW) face considerable challenges that affect their mental health and make their situations more vulnerable and precarious. TSWs often experience violence from clients, police, and others, but it is estimated that 50% of these acts of violence are at the hands of their intimate partners. The marginalization of TSWs is fueled by abuse through isolation and shaming which prevents them from seeking help through formal channels like police or counselling services. There is limited research on intimate partner violence (IPV) involving transgender sex workers (biologically male at birth who transition to women) and their partners who are typically heterosexual/bisexual men. In China, stigmatization, homophobia, heterosexism, and transphobia structurally disadvantage TSWs and this power structure tacitly supports violence and abuse against them. To survive, TSWs rely on informal networks with their 'sisters' for advice and emotional support which is more effective at combatting IPV than criminal justice or social policy efforts. Ethnographic data from in-depth interviews with 25 TSWs provide insight about IPV and how informal social support is a protective factor that helps them cope with routine acts of violence. The findings identify the importance of the 'sisterhood' and how it protects and helps TSWs manage their physical and mental health.

Armed conflict and maternal mortality: A micro-level analysis of sub-Saharan Africa, 1989-2013.

There is existing country-level evidence that countries with more severe armed conflict tend to have higher Maternal Mortality Rates (MMR). However, during armed conflict, the actual fighting is usually confined to a limited area within a country, affecting a subset of the population. Hence, studying the link between country-level armed conflict and MMR may involve ecological fallacies. We provide a more direct, nuanced test of whether local exposure to armed conflict impacts maternal mortality, building on the so-called "sisterhood method". We combine geo-coded data on different types of violent events from the Uppsala Conflict Data Program with geo-referenced survey data from the Demographic and Health Surveys (DHS) on respondents' reports on sisters dying during pregnancy, childbirth, or the puerperium. Our sample covers 1,335,161 adult sisters aged 12-45 by 539,764 female respondents in 30 countries in sub-Saharan Africa. Rather than aggregating the deaths of sisters to generate a maternal mortality ratio, we analyze the sisters' deaths at the individual level. We use a sister fixed-effects analysis to estimate the impact of recent organized violence events within a radius of 50 km of the home of each respondent on the likelihood that her sister dies during pregnancy, childbirth, or the puerperium. Our results show that local exposure to armed conflict events indeed increases the risk of maternal deaths. Exploring potential moderators, we find larger differences in rural areas but also in richer and more educated areas.

Estimating Maternal Mortality in Remote Rural Regions: an Application of the Sisterhood Method in Tajikistan.

INTRODUCTION: The sisterhood method of maternal mortality data collection and analysis provides a validated framework for estimating maternal mortality ratios in situations of limited infrastructure. The aim of this study is to assess sub-national maternal mortality in the Badakhshan region of Tajikistan using the sisterhood method as part of a larger ethnographic study on maternal risk. METHODS: In 2006-2007, 1004 married women of reproductive age in Gorno-Badakhshan Autonomous Oblast, Tajikistan were surveyed using the sisterhood method. Respondents were asked eleven questions about the sex, age and survivorship of all children born to the respondent's mother. RESULTS: Using a national total fertility rate (TFR) estimate of 4.88, the maternal mortality ratio (MMR) in Tajik Badakhshan was 141 maternal deaths per 100,000 live births (95% CI 49-235). The lifetime risk of maternal death was 1 in 141 (95% CI 34-103). CONCLUSION: Given the inherent time-lag of the sisterhood method, precise estimates of maternal mortality are dependent on accurate TFRs, which may vary based upon regional experiences of demographic transitions. Socio-political instability and the dismantling of Soviet welfare programs and civil war following Tajikistan's independence from the Soviet Union in 1991 likely impacted TFR in Tajik Badakhshan. Socio-political trends influencing TFR in rural regions compared to urban, and the investigation of factors associated with maternal mortality, require additional investigation.

Maternal mortality ratio in selected rural communities in Kebbi State, Northwest Nigeria.

BACKGROUND: Maternal mortality remains a topical issue in Nigeria. Dearth of data on vital events posed a huge challenge to policy formulation and design of interventions to address the scourge. This study estimated the lifetime risk (LTR) of maternal death and maternal mortality ratio (MMR) in rural areas of Kebbi State, northwest Nigeria, using the sisterhood method. METHODS: Using the sisterhood method, data was collected from 2917 women aged 15-49 years from randomly selected rural communities in 6 randomly selected local government area of Kebbi State. Retrospective cohort of their female siblings who had reached the childbearing age of 15 years was constructed. Using the most recent total fertility rate for Kebbi State, the lifetime risk and associated MMR were estimated. RESULT: A total of 2917 women reported 8233 female siblings of whom 409 had died and of whom 204 (49.8%) were maternal deaths. This corresponds to an LTR of 6% (referring to 11 years before the study) and an estimated MMR of 890 deaths/100,000 live births (95% CI, 504-1281). CONCLUSION: The findings provide baseline information on the MMR in rural areas of the State. It underscores the need to urgently address the bane of high maternity mortality, if Kebbi State and Nigeria in general, will achieve the health for all by year 2030 as stated in the Sustainable Development Goals (SDGs).

High maternal mortality in Jigawa State, Northern Nigeria estimated using the sisterhood method.

BACKGROUND: Maternal mortality is extremely high in Nigeria. Accurate estimation of maternal mortality is challenging in low-income settings such as Nigeria where vital registration is incomplete. The objective of this study was to estimate the lifetime risk (LTR) of maternal death and the maternal mortality ratio (MMR) in Jigawa State, Northern Nigeria using the Sisterhood Method. METHODS: Interviews with 7,069 women aged 15-49 in 96 randomly selected clusters of communities in 24 Local Government Areas (LGAs) across Jigawa state were conducted. A retrospective cohort of their sisters of reproductive age was constructed to calculate the lifetime risk of maternal mortality. Using most recent estimates of total fertility for the state, the MMR was estimated. RESULTS: The 7,069 respondents reported 10,957 sisters who reached reproductive age. Of the 1,026 deaths in these sisters, 300 (29.2%) occurred during pregnancy, childbirth or within 42 days after delivery. This corresponds to a LTR of 6.6% and an estimated MMR for the study areas of 1,012 maternal deaths per 100,000 live births (95% CI: 898-1,126) with a time reference of 2001. CONCLUSIONS: Jigawa State has an extremely high maternal mortality ratio underscoring the urgent need for health systems improvement and interventions to accelerate reductions in MMR. TRIAL REGISTRATION: The trial is registered at clinicaltrials.gov ( NCT01487707 ). Initially registered on December 6, 2011.

Developing a Pictorial Sisterhood Method in collaboration with illiterate Maasai traditional birth attendants in northern Tanzania.

OBJECTIVE: To study whether data on maternal mortality can be gathered while maintaining local ownership of data in a pastoralist setting where a scarcity of data sources and a culture of silence around maternal death amplifies limited awareness of the magnitude of maternal mortality. METHODS: As part of a participatory action research project, investigators and illiterate traditional birth attendants (TBAs) collaboratively developed a quantitative participatory tool-the Pictorial Sisterhood Method-that was pilot-tested between March 12 and May 30, 2011, by researchers and TBAs in a cross-sectional study. RESULTS: Fourteen TBAs interviewed 496 women (sample), which led to 2241 sister units of risk and a maternal mortality ratio of 689 deaths per 100000 live births (95% confidence interval 419-959). Researchers interviewed 474 women (sample), leading to 1487 sister units of risk and a maternal mortality ratio of 484 (95% confidence interval 172-795). CONCLUSION: The Pictorial Sisterhood Method is an innovative application that might increase the participation of illiterate individuals in maternal health research and advocacy. It offers interesting opportunities to increase maternal mortality data ownership and awareness, and warrants further study and validation.

Comparability of sociodemographic and pregnancy characteristics of pregnancy-related deaths identified via the sisterhood method versus the household/verbal autopsy method.

OBJECTIVE: To compare sociodemographic and pregnancy characteristics of pregnancy-related deaths identified by the direct sisterhood and the verbal autopsy with household mortality (HHVA) methods. METHODS: Nationally representative data for 1997-2001 were obtained from the household, verbal autopsy, and women's questionnaires of the Bangladesh Maternal Health Services and Maternal Mortality Services Survey, 2001. Sociodemographic and pregnancy characteristics were compared for maternal deaths identified by the two methods. Characteristics of deceased women were reported directly with HHVA, but extrapolated in the direct sisterhood method using the reporting sister as proxy. RESULTS: Overall, 201 pregnancy-related deaths were identified via HHVA and 388 through DS reporting. There were no significant differences between reporting sister characteristics and deceased women's characteristics in educational attainment, working status, husband's educational attainment, and spouse educational parity. However, timing of death relative to pregnancy phase, number of previous live births, and years since death did differ (P<0.05). CONCLUSION: The sociodemographic characteristics of women with pregnancy-related deaths identified via the two methods were similar. However, some pregnancy characteristics differed significantly, suggesting that different policy interventions are required. Before considering using sister proxy characteristics to target services, issues responsible for these differences should be resolved, and generalizability of evaluated indicators must be considered.