{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2025,5,14]],"date-time":"2025-05-14T04:13:51Z","timestamp":1747196031560,"version":"3.40.5"},"reference-count":63,"publisher":"Public Library of Science (PLoS)","issue":"6","license":[{"start":{"date-parts":[[2021,6,3]],"date-time":"2021-06-03T00:00:00Z","timestamp":1622678400000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"DOI":"10.13039\/100008548","name":"Harvard T.H. Chan School of Public Health","doi-asserted-by":"crossref","award":["OPP1169546"],"award-info":[{"award-number":["OPP1169546"]}],"id":[{"id":"10.13039\/100008548","id-type":"DOI","asserted-by":"crossref"}]},{"DOI":"10.13039\/100004423","name":"World Health Organization","doi-asserted-by":"crossref","id":[{"id":"10.13039\/100004423","id-type":"DOI","asserted-by":"crossref"}]},{"name":"Ministry of Health and Child Care, Zimbabwe"}],"content-domain":{"domain":["www.plosone.org"],"crossmark-restriction":false},"short-container-title":["PLoS ONE"],"abstract":"<jats:sec id=\"sec001\">\n<jats:title>Background<\/jats:title>\n<jats:p>Sub-Saharan Africa (SSA) carries the highest burden of maternal mortality, yet, the accurate maternal mortality ratios (MMR) are uncertain in most SSA countries. Measuring maternal mortality is challenging in this region, where civil registration and vital statistics (CRVS) systems are weak or non-existent. We describe a protocol designed to explore the use of CRVS to monitor maternal mortality in Zimbabwe\u2014an SSA country.<\/jats:p>\n<\/jats:sec>\n<jats:sec id=\"sec002\">\n<jats:title>Methods<\/jats:title>\n<jats:p>In this study, we will collect deliveries and maternal death data from CRVS (government death registration records) and health facilities for 2007\u20132008 and 2018\u20132019 to compare MMRs and causes of death. We will code the causes of death using classifications in the maternal mortality version of the 10<jats:sup>th<\/jats:sup> revision to the international classification of diseases. We will compare the proportions of maternal deaths attributed to different causes between the two study periods. We will also analyse missingness and misclassification of maternal deaths in CRVS to assess the validity of their use to measure maternal mortality in Zimbabwe.<\/jats:p>\n<\/jats:sec>\n<jats:sec id=\"sec003\">\n<jats:title>Discussion<\/jats:title>\n<jats:p>This study will determine changes in MMR and causes of maternal mortality in Zimbabwe over a decade. It will show whether HIV, which was at its peak in 2007\u20132008, remains a significant cause of maternal deaths in Zimbabwe. The study will recommend measures to improve the quality of CRVS data for future use to monitor maternal mortality in Zimbabwe and other SSA countries of similar characteristics.<\/jats:p>\n<\/jats:sec>","DOI":"10.1371\/journal.pone.0252106","type":"journal-article","created":{"date-parts":[[2021,6,3]],"date-time":"2021-06-03T17:56:47Z","timestamp":1622743007000},"page":"e0252106","update-policy":"https:\/\/doi.org\/10.1371\/journal.pone.corrections_policy","source":"Crossref","is-referenced-by-count":6,"title":["Protocol for analysing the epidemiology of maternal mortality in Zimbabwe: A civil registration and vital statistics trend study"],"prefix":"10.1371","volume":"16","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-0622-2195","authenticated-orcid":true,"given":"Reuben","family":"Musarandega","sequence":"first","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Rhoderick","family":"Machekano","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Robert","family":"Pattinson","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Stephen Peter","family":"Munjanja","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"name":"Zimbabwe Maternal and Perinatal Mortality Study (ZMPMS) group","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"340","published-online":{"date-parts":[[2021,6,3]]},"reference":[{"volume-title":"The WHO Application of ICD-10 to deaths during pregnancy, childbirth and the puerperium: ICD-MM","year":"2011","author":"WHO","key":"pone.0252106.ref001"},{"volume-title":"Department of Health Statistics","year":"2011","author":"WHO","key":"pone.0252106.ref002"},{"volume-title":"Trends in maternal mortality 2000 to 2017: estimates by WHO, UNICEF, UNFPA, World Bank Group and the United Nations Population Division","year":"2019","author":"WHO, UNICEF, UNFPA, World Bank Group and the United Nations Population Division","key":"pone.0252106.ref003"},{"issue":"10017","key":"pone.0252106.ref004","doi-asserted-by":"crossref","first-page":"462","DOI":"10.1016\/S0140-6736(15)00838-7","article-title":"Global, regional, and national levels and trends in maternal mortality between 1990 and 2015, with scenario-based projections to 2030: a systematic analysis by the UN Maternal Mortality Estimation Inter-Agency Group","volume":"387","author":"L Alkema","year":"2016","journal-title":"Lancet (London, England)"},{"issue":"10053","key":"pone.0252106.ref005","doi-asserted-by":"crossref","first-page":"1603","DOI":"10.1016\/S0140-6736(16)31460-X","article-title":"Global, regional, and national disability-adjusted life-years (DALYs) for 315 diseases and injuries and healthy life expectancy (HALE), 1990\u20132015: a systematic analysis for the Global Burden of Disease Study 2015","volume":"388","author":"NJ Kassebaum","year":"2016","journal-title":"The Lancet"},{"volume-title":"Sustainable Development Goal 3: Health","year":"2020","author":"WHO","key":"pone.0252106.ref006"},{"volume-title":"The Sustainable Development Goals and Maternal Mortality","year":"2020","author":"Maternal Health Task Force","key":"pone.0252106.ref007"},{"volume-title":"Zimbabwe Multiple Indicator Cluster Survey 2014: Final Report","year":"2015","author":"ZimStat and UNICEF","key":"pone.0252106.ref008"},{"volume-title":"Zimbabwe Demographic and Health Survey 2015: Final Report","year":"2016","author":"ZimStat and ICF International","key":"pone.0252106.ref009"},{"volume-title":"Zimbabwe Multiple Indicator Cluster Survey 2017: Final Report","year":"2019","author":"ZimStat and UNICEF","key":"pone.0252106.ref010"},{"issue":"7","key":"pone.0252106.ref011","doi-asserted-by":"crossref","first-page":"e002697","DOI":"10.1136\/bmjgh-2020-002697","article-title":"Measurement and accountability for maternal, newborn and child health: fit for 2030?","volume":"5","author":"T Marchant","year":"2020","journal-title":"BMJ Global Health"},{"issue":"10003","key":"pone.0252106.ref012","doi-asserted-by":"crossref","first-page":"1511","DOI":"10.1016\/S0140-6736(15)00517-6","article-title":"Maternal, newborn, and child health and the Sustainable Development Goals: a call for sustained and improved measurement","volume":"386","author":"J Grove","year":"2015","journal-title":"The Lancet"},{"key":"pone.0252106.ref013","doi-asserted-by":"crossref","first-page":"12","DOI":"10.1186\/1741-7015-6-12","article-title":"Measuring maternal mortality: an overview of opportunities and options for developing countries","volume":"6","author":"WJ Graham","year":"2008","journal-title":"BMC Med"},{"issue":"1","key":"pone.0252106.ref014","doi-asserted-by":"crossref","first-page":"121","DOI":"10.1093\/bmb\/ldw056","article-title":"Measuring maternal mortality: a systematic review of methods used to obtain estimates of the maternal mortality ratio (MMR) in low- and middle-income countries","volume":"121","author":"F Mgawadere","year":"2017","journal-title":"Br Med Bull"},{"issue":"Suppl 1","key":"pone.0252106.ref015","doi-asserted-by":"crossref","first-page":"7","DOI":"10.1111\/j.1471-0528.2009.02337.x","article-title":"Joining the dots: a plea for precise estimates of the maternal mortality ratio in sub-Saharan Africa","volume":"116 Suppl 1","author":"SP Munjanja","year":"2009","journal-title":"BJOG"},{"issue":"3","key":"pone.0252106.ref016","first-page":"1245","article-title":"A Bayesian approach to the global estimation of maternal mortality","volume":"11","author":"L Alkema","year":"2017","journal-title":"Appl Stat"},{"issue":"10053","key":"pone.0252106.ref017","doi-asserted-by":"crossref","first-page":"1775","DOI":"10.1016\/S0140-6736(16)31470-2","article-title":"Global, regional, and national levels of maternal mortality, 1990\u20132015: a systematic analysis for the Global Burden of Disease Study 2015","volume":"388","author":"NJ Kassebaum","year":"2016","journal-title":"The Lancet"},{"volume-title":"Maternal and Perinatal Death Surveillance and Response: 2019 Annual Report","year":"2020","author":"Zimbabwe Ministry of Health and Child Care","key":"pone.0252106.ref018"},{"volume-title":"Zimbabwe Maternal and Perinatal Mortality Study 2007\u20132008: Short Report","year":"2008","author":"SP Munjanja","key":"pone.0252106.ref019"},{"issue":"4","key":"pone.0252106.ref020","first-page":"206","article-title":"Epidemiology of Maternal Mortality in Malawi","volume":"18","author":"E Geubbels","year":"2006","journal-title":"Malawi Med J"},{"key":"pone.0252106.ref021","first-page":"1","article-title":"Measuring maternal mortality using a Reproductive Age Mortality Study (RAMOS)","volume":"16","author":"A Adegoke","year":"2016","journal-title":"BMC Pregnancy and Childbirth"},{"key":"pone.0252106.ref022","volume-title":"Survey research methods","author":"FJ Fowler","year":"2009","edition":"4"},{"key":"pone.0252106.ref023","doi-asserted-by":"crossref","first-page":"582","DOI":"10.4103\/0301-4738.103809","article-title":"Sample size calculation","volume":"60","author":"K Rajeev","year":"2012","journal-title":"indian journal of ophthalmology"},{"issue":"5","key":"pone.0252106.ref024","doi-asserted-by":"crossref","first-page":"485","DOI":"10.1016\/j.aller.2013.03.008","article-title":"Sample size calculation","volume":"42","author":"M Rodr\u00edguez Del \u00c1guila","year":"2014","journal-title":"Allergol Immunopathol (Madr)"},{"issue":"Supplement 2","key":"pone.0252106.ref025","doi-asserted-by":"crossref","first-page":"S278","DOI":"10.1016\/S0020-7292(09)61019-5","article-title":"The maternal mortality ratio of Zimbabwe in 2007","volume":"107","author":"S Munjanja","year":"2009","journal-title":"International Journal of Gynecology and Obstetrics"},{"issue":"3","key":"pone.0252106.ref026","doi-asserted-by":"crossref","first-page":"204","DOI":"10.1370\/afm.141","article-title":"What is an intracluster correlation coefficient? Crucial concepts for primary care researchers","volume":"2","author":"S Killip","year":"2004","journal-title":"Annals of family medicine"},{"issue":"5","key":"pone.0252106.ref027","doi-asserted-by":"crossref","first-page":"2142","DOI":"10.4269\/ajtmh.20-0623","article-title":"Epidemiology, Outcomes, and Risk Factors for Mortality in Critically Ill Women Admitted to an Obstetric High-Dependency Unit in Sierra Leone","volume":"103","author":"C Marotta","year":"2020","journal-title":"Am J Trop Med Hyg"},{"key":"pone.0252106.ref028","first-page":"1","article-title":"WHO systematic review of maternal mortality and morbidity: methodological issues and challenges","volume":"4","author":"J Villar","year":"2004","journal-title":"BMC Medical Research Methodology"},{"key":"pone.0252106.ref029","doi-asserted-by":"crossref","DOI":"10.1201\/9781420075779","volume-title":"Logistic Regression Models","author":"JM H Hilbe","year":"2009","edition":"1"},{"key":"pone.0252106.ref030","volume-title":"Regression Methods in Biostatistics: Linear, Logistic, Survival, and Repeated Measures Models","author":"E GD Vittinghoff","year":"2005","edition":"2"},{"key":"pone.0252106.ref031","volume-title":"Using Stata for quantitative analysis","author":"KC Longest","year":"2015","edition":"2"},{"key":"pone.0252106.ref032","volume-title":"A handbook of statistical analyses using Stata","author":"S Rabe-Hesketh","year":"2007","edition":"4"},{"issue":"2","key":"pone.0252106.ref033","first-page":"38","article-title":"Maternal mortality ratio\u2014trends in the vital registration data: original article","volume":"18","author":"D Bradshaw","year":"2012","journal-title":"South African Journal of Obstetrics and Gynaecology"},{"issue":"3","key":"pone.0252106.ref034","first-page":"30","article-title":"Facility-based delivery and maternal and early neonatal mortality in sub-Saharan Africa: a regional review of the literature: review article","volume":"17","author":"P Dako-Gyeke","year":"2013","journal-title":"African Journal of Reproductive Health"},{"key":"pone.0252106.ref035","doi-asserted-by":"crossref","DOI":"10.1017\/CBO9780511575884","volume-title":"Statistical Modeling for Biomedical Researchers: a Simple Introduction to the Analysis of Complex Data","author":"WD Dupont","year":"2009"},{"volume-title":"Essentials of multivariate data analysis","year":"2014","author":"NH Spencer","key":"pone.0252106.ref036"},{"issue":"4","key":"pone.0252106.ref037","doi-asserted-by":"crossref","first-page":"220","DOI":"10.2307\/2137955","article-title":"Confidence Intervals and Sample-size Calculations for the Sisterhood Method of Estimating Maternal Mortality","volume":"27","author":"JA Hanley","year":"1996","journal-title":"Stud Fam Plann"},{"issue":"4","key":"pone.0252106.ref038","doi-asserted-by":"crossref","first-page":"541","DOI":"10.2307\/2530374","article-title":"The analysis of failure times in the presence of competing risks","volume":"34","author":"RL Prentice","year":"1978","journal-title":"Biometrics"},{"key":"pone.0252106.ref039","first-page":"1","article-title":"National estimates for maternal mortality: an analysis based on the WHO systematic review of maternal mortality and morbidity","volume":"5","author":"S Posner","year":"2005","journal-title":"BMC Public Health"},{"key":"pone.0252106.ref040","doi-asserted-by":"crossref","first-page":"958262","DOI":"10.1155\/2012\/958262","article-title":"Understanding methods for estimating HIV-associated maternal mortality","volume":"2012","author":"JE Rosen","year":"2012","journal-title":"J Pregnancy"},{"volume-title":"Methods for statistical data analysis of multivariate observations","year":"1977","author":"R Gnanadesikan","key":"pone.0252106.ref041"},{"key":"pone.0252106.ref042","doi-asserted-by":"crossref","DOI":"10.4135\/9781412986113","volume-title":"Tests of significance","author":"RE Henkel","year":"1976"},{"key":"pone.0252106.ref043","volume-title":"An introduction to statistical methods and data analysis","author":"L Ott","year":"2001","edition":"5"},{"key":"pone.0252106.ref044","doi-asserted-by":"crossref","DOI":"10.1002\/9780470374597","volume-title":"Sampling of populations: methods and applications","author":"PS Levy","year":"2008","edition":"4"},{"volume-title":"Statistical data analysis handbook","year":"1986","author":"FJ Wall","key":"pone.0252106.ref045"},{"key":"pone.0252106.ref046","article-title":"Methods used to measure maternal mortality in Sub-Saharan Africa from 1980 to 2020: A systematic literature review","author":"R Musarandega","year":"2021","journal-title":"Int J Gynaecol Obstet"},{"key":"pone.0252106.ref047","article-title":"Adetoro Adegoke & Nynke van den Broek. Measuring maternal mortality using a Reproductive Age Mortality Study (RAMOS)","author":"RU Mgawadere Florence","year":"2016","journal-title":"BMC Pregnancy and Childbirth"},{"issue":"2","key":"pone.0252106.ref048","doi-asserted-by":"crossref","first-page":"86","DOI":"10.2471\/BLT.15.154849","article-title":"Community-based surveillance of maternal deaths in rural Ghana","volume":"94","author":"J Adomako","year":"2016","journal-title":"Bull World Health Organ"},{"key":"pone.0252106.ref049","doi-asserted-by":"crossref","first-page":"102","DOI":"10.1186\/1471-2393-11-102","article-title":"Maternal mortality in Kassala State\u2014Eastern Sudan: community-based study using reproductive age mortality survey (RAMOS)","volume":"11","author":"AA Mohammed","year":"2011","journal-title":"BMC pregnancy and childbirth"},{"issue":"1","key":"pone.0252106.ref050","doi-asserted-by":"crossref","first-page":"29","DOI":"10.1016\/j.ijgo.2011.01.011","article-title":"Improving maternal mortality reporting at the community level with a 4-question modified reproductive age mortality survey (RAMOS)","volume":"114","author":"J Geynisman","year":"2011","journal-title":"International Journal of Gynecology & Obstetrics"},{"key":"pone.0252106.ref051","doi-asserted-by":"crossref","first-page":"7","DOI":"10.1186\/1742-4755-6-7","article-title":"Reproductive age mortality survey (RAMOS) in Accra, Ghana","volume":"6","author":"AY Zakariah","year":"2009","journal-title":"Reproductive health"},{"issue":"5","key":"pone.0252106.ref052","first-page":"603","article-title":"Maternal mortality in rural Gambia: levels, causes and contributing factors","volume":"78","author":"G Walraven","year":"2000","journal-title":"Bull World Health Organ"},{"issue":"6","key":"pone.0252106.ref053","doi-asserted-by":"crossref","first-page":"e323","DOI":"10.1016\/S2214-109X(14)70227-X","article-title":"Global causes of maternal death: a WHO systematic analysis","volume":"2","author":"L Say","year":"2014","journal-title":"The Lancet Global Health"},{"key":"pone.0252106.ref054","doi-asserted-by":"crossref","first-page":"e40","DOI":"10.1017\/S0950268820000370","article-title":"Maternal caesarean section infection (MACSI) in Sierra Leone: a case-control study","volume":"148","author":"F Di Gennaro","year":"2020","journal-title":"Epidemiol Infect"},{"issue":"1","key":"pone.0252106.ref055","doi-asserted-by":"crossref","first-page":"12","DOI":"10.1177\/0049475519884436","article-title":"Factors associated with maternal mortality from sepsis in a low-resource setting: a five-year review at Mpilo Central Hospital, Bulawayo, Zimbabwe","volume":"50","author":"S Ngwenya","year":"2020","journal-title":"Trop Doct"},{"issue":"2","key":"pone.0252106.ref056","first-page":"249","article-title":"The Cholera Epidemic in Zimbabwe, 2008\u20132009: A Review and Critique of the Evidence","volume":"19","author":"CN Cuneo","year":"2017","journal-title":"Health and human rights"},{"first-page":"2018","volume-title":"Zimbabwe National and Sub-national HIV Estimates Report 2017","author":"NAC","key":"pone.0252106.ref057"},{"volume-title":"Zimbabwe Population-based HIV Impact Assessment (ZIMPHIA) 2015\u20132016. ICAP Global Health Action","year":"2018","author":"ICAP","key":"pone.0252106.ref058"},{"issue":"1","key":"pone.0252106.ref059","doi-asserted-by":"crossref","DOI":"10.1186\/s12913-020-05900-4","article-title":"Using the critical path method to rollout and optimise new PMTCT guidelines to eliminate mother-to-child transmission of HIV in Zimbabwe: a descriptive analysis","volume":"20","author":"R Musarandega","year":"2020","journal-title":"BMC Health Services Research"},{"issue":"10","key":"pone.0252106.ref060","doi-asserted-by":"crossref","first-page":"e015898","DOI":"10.1136\/bmjopen-2017-015898","article-title":"Documenting and explaining the HIV decline in east Zimbabwe: the Manicaland General Population Cohort","volume":"7","author":"S Gregson","year":"2017","journal-title":"BMJ Open"},{"issue":"9947","key":"pone.0252106.ref061","doi-asserted-by":"crossref","first-page":"1005","DOI":"10.1016\/S0140-6736(14)60844-8","article-title":"Global, regional, and national incidence and mortality for HIV, tuberculosis, and malaria during 1990\u20132013: a systematic analysis for the Global Burden of Disease Study 2013","volume":"384","author":"CJ Murray","year":"2014","journal-title":"Lancet"},{"issue":"9","key":"pone.0252106.ref062","doi-asserted-by":"crossref","first-page":"1397","DOI":"10.1097\/QAD.0000000000002552","article-title":"Direct maternal deaths attributable to HIV in the era of antiretroviral therapy: evidence from three population-based HIV cohorts with verbal autopsy","volume":"34","author":"C Calvert","year":"2020","journal-title":"AIDS"},{"issue":"6","key":"pone.0252106.ref063","doi-asserted-by":"crossref","first-page":"e024516","DOI":"10.1136\/bmjopen-2018-024516","article-title":"Introducing a sector-wide pooled fund in a fragile context: mixed-methods evaluation of the health transition fund in Zimbabwe","volume":"9","author":"L D\u2019Aquino","year":"2019","journal-title":"BMJ Open"}],"container-title":["PLOS ONE"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/dx.plos.org\/10.1371\/journal.pone.0252106","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2021,6,3]],"date-time":"2021-06-03T17:58:00Z","timestamp":1622743080000},"score":1,"resource":{"primary":{"URL":"https:\/\/dx.plos.org\/10.1371\/journal.pone.0252106"}},"subtitle":[],"editor":[{"given":"Claudia","family":"Marotta","sequence":"first","affiliation":[],"role":[{"role":"editor","vocabulary":"crossref"}]}],"short-title":[],"issued":{"date-parts":[[2021,6,3]]},"references-count":63,"journal-issue":{"issue":"6","published-online":{"date-parts":[[2021,6,3]]}},"URL":"https:\/\/doi.org\/10.1371\/journal.pone.0252106","relation":{},"ISSN":["1932-6203"],"issn-type":[{"type":"electronic","value":"1932-6203"}],"subject":[],"published":{"date-parts":[[2021,6,3]]}}}