Incompleteness and misclassification of maternal deaths in Zimbabwe: data from two reproductive age mortality surveys, 2007-08 and 2018-19

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Introduction: Reducing maternal mortality is a high-priority global health goal, especially in sub-Saharan Africa, where the maternal mortality ratios (MMRs) of most of the countries is higher than the average global MMR. We implemented two cross-sectional reproductive age mortality surveys, in 2007-08 and 2018-19, to assess changes in the MMR and causes of death in Zimbabwe after a raft of interventions implemented to reduce maternal mortality. This paper analysed the missingness and misclassification of deaths in the surveys. Methods: We compared percentages of missed deaths in each survey using the Chi-square test. The risk ratios of missing deaths in different data sources in each survey were calculated using log-linear regression models. Proportions of misclassified deaths were compared using Fisher’s exact test and sensitivity and specificity of incompleteness and misclassification of deaths compared using the six-box method and the Chi-square test. Results: The proportion of missed pregnancy-related deaths decreased from 27% in 2007-08 to 18% in 2018-19 (p=0.044) and the proportion of missed maternal deaths decreased from 30% in 2007-08 to 19% in 2018-19. Misclassification of maternal deaths in health records was 17% in 2007-08 and 8.5% in 2018-19 (p=0.160). The proportion of pregnancy-related deaths identified through health records increased from 11% in 2007-08 to 60% in 2018-19 (p<0.001). Sensitivity of incompleteness and misclassification of deaths was 95% in 2007-08 and 77% in 2018-19, and specificity was 29% and 83% respectively. Conclusion: Incompleteness and misclassification of maternal deaths are still a challenge in Zimbabwe. Maternal death studies must triangulate data sources to improve the completeness of data and efforts to reduce misclassification of deaths should continue to improve maternal mortality estimates.