Case fatality rate (CFR) - all complications

The proportion of women with major obstetric compli­cations who die in a facility within a reference period.

This indicator is calculated as:

# of deaths from specified obstetric complications in a facility x 100
________________________________________________________
# of women with specified obstetric complications attended in the facility

Where deaths from the following complications are in­cluded:

  • Hemorrhage: antepartum, intrapartum or post­partum;
  • Prolonged/obstructed labor;
  • Postpartum sepsis;
  • Complications of abortion;
  • Pre-eclampsia/eclampsia;
  • Ectopic pregnancy; and
  • Ruptured uterus.

All cases in the numerator also appear in the denomina­tor.  All complications specified in the list above ap­pear in both the numerator and denominator. By defini­tion, a CFR is cause-specific, but in this case, a single facility may only see a small number of women with any one complication.


The number of deaths from the specified complications in the facility during the specified time period; the num­ber of women diagnosed with one or more of these com­plications attended at the emergency obstetric care (EmOC) facility during the speci­fied time period.


Facility records


This indicator measures facility performance, in par­ticular, quality and promptness of care. It is most useful when comparisons are made over time for the same fa­cility.

The CFR has an extremely strong causal link to mater­nal mortality at the facility level. Its relationship to ma­ternal mortality in the general population depends on the proportion of women with obstetric complications who are managed in facilities. The higher the number of these women managed in facilities is, the closer the relationship between CFRs and the level of maternal mortality in the general population (Bertrand and Tsui, 1995).

If the facility treats obstetric complications and collects data on obstetric complications and maternal deaths, this indicator is easy to calculate. Case fatality rate should respond to changes within a fairly short period of time (e.g., 6-12 months).


This indicator is not useful for comparisons across facilities of different types because of variations in the charac­teristics of the client populations and in the services provided by the facilities. Women with more severe complications are more likely to present at referral hos­pitals, whereas women with less severe complications may access district hospitals or health centers (MotherCare, 2000a). Even comparisons among —same level“ or —like“ facilities may be difficult to interpret, as the population profile can vary dramatically because of socio-cultural factors or other circumstances outside the control of the health sector, such as transportation and road systems.

Whether a woman dies in the hospital will depend not only on the quality and readiness of the hospital‘s re­sponse to a woman with an obstetric emergency, but also on her condition on admission to the hospital. Thus, the hospital could function well and still have a high CFR because women in need of EmOC arrive in such poor condition. Where a facility‘s CFR is low, the qual­ity of care is not necessarily high; instead, few women with obstetric complications may use services. For these reasons, one should have other indicators of quality of care (e.g., the time interval between admission and treat­ment for women with complications) or more in-depth information on the woman‘s status at admission (e.g., pulse, blood pressure, and temperature).

This indicator is helpful with the other four to five —program-level“ indicators that UNICEF/WHO/ UNFPA recommend. For example, if the percentage of all births in EmOC facilities or met need is low, the CFR may be relatively meaningless.

UNICEF/WHO/UNFPA recommend a maximum ac­ceptable value for the indicator of less than 1 percent. However, a study of US hospitals showed a CFR of 0.03 percent in 1978 (Petitti et al., 1982). Certainly, coun­tries meeting even a level of 1 percent should strive to reduce the rate.

Where the number of maternal deaths or complicated cases is small, the CFR will not be sufficiently robust to be meaningful. However, where the number of cases is large, evaluators can calculate CFRs for individual complications.


access, safe motherhood (SM), postabortion care, obstetric fistula (OF)

Maine, McCarthy, and Ward, 1992 and UNICEF, WHO and UNFPA, 1997.

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