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    The sisterhood method for estimating maternal


    Guidance notes for potential users



    World Health Organization, Department of Reproductive Health and Research

    Publication details

    Number of pages: 28

    Publication date: 1997

    Languages: English, French

    WHO reference number: WHO/RHT/97.28


    English [pdf 469kb] French

    Web only


    The sisterhood method is an indirect measurement technique of the kind

    frequently used for a variety of demographic parameters which has been
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    adapted to maternal mortality. It reduces sample size requirements because it

    obtains information by interviewing respondents about the survival of all their

    adult sisters. These guidance notes are intended for health policy-makers and

    planners who wish to estimate levels of maternal mortality, but who may not befamiliar with the different approaches available and the strengths and

    weaknesses of each. They are not intended to provide detailed technical

    guidance on how to carry out sisterhood studies.

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    Sisterhood methodFrom Wikipedia, the free encyclopedia
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    This article may be written likean advertisement. If so, please

    helprewrite this articlefrom aneutral point of view.(February 2011)

    Although maternal deaths are a major problem in developing countries,high quality data are rare. Yet, numbers are needed for planning in order to

    reduce the problem ofmaternal death. Several methods have been used

    to estimate maternal deaths. One household survey to estimate maternal

    deaths is theSisterhood Method, which includes only 4 simple questions.

    The Sisterhood Method is one method recommended by theWHO. It is

    useful, because it is quick, cheap, and reduces sample size




    1 Background

    2 Estimating maternal deaths

    3 Sisterhood Method

    4 How is the Sisterhood Method applied

    5 When should the Sisterhood Method not be used

    6 Variant of the original Sisterhood Method

    7 References


    The death of a woman during or shortly after a pregnancyis an

    important medical problem in developing countries. 99% of allmaternal

    deathsoccur indeveloping countries.[3]In the poorest countries in the

    world, e.g. Sierra Leone, the lifetime risk for a woman dying because of amaternal death is approx 1 in 6, whereas in developed countries, e.g.

    Sweden, the same lifetime risk is approx 1 in 30,000.[4]Half of all maternal

    deaths occur in six countries only: Afghanistan, Democratic Republic of

    Congo, Ethiopia, India, Nigeria, and Pakistan. Worldwide, maternal deaths

    decreased from approx 500,000 in 1980 to approx 350,000 in 2008. This

    decline in maternal deaths was associated mainly with better maternal

    education, maternal income, increased availability of trained birth

    attendants, and decreased pregnancy rates.

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    [edit]Estimating maternal deaths

    Although maternal deaths are a major problem in developing countries,

    seen globally, the numbers are not very large, and there is an absence of

    high quality data. Yet, numbers are needed for planning in order to reducematernal deaths. Several methods have been used to estimate maternal

    deaths. They include analysing census records and medical/death

    certificates[6], andReproductive Age Mortality

    Studies(RAMOS).[7]Also,household surveysare used. All of these

    methods are not totally precise, but they can provide some useful

    information to decrease maternal mortality.

    In contrast, fullsurveillance programmeswould be too costly and too

    unrealistic for many developing countries.[8]

    [edit]Sisterhood Method

    TheSisterhood Methodis the commonest household survey for

    estimating maternal deaths. It is quick, cheap, and reduces sample size

    requirements; in countries or areas with high levels of maternal deaths, i.e.

    over 500 maternal deaths per 100,000 live births, a sample size of only

    4000 households or less is acceptable for this method[9]. But the method

    still provides a useful means of assessing maternal mortality.

    This method includes only 4 simple questions about the sisters of the

    woman in question:

    Question 1:How many sisters have you ever had, born to the same

    mother, who ever reached the age 15 (or who were ever married), including

    those who are now dead?

    Question 2:How many of your sisters who reached the age of 15 are alive


    Question 3:How many of these sisters are dead?

    Question 4:How many of your sisters who are dead died during a

    pregnancy or during childbirth, or during the six weeks after the end of a


    [edit]How is the Sisterhood Method applied

    Deaths occurring over a large interval of time are documented. The overallestimate of maternal mortality is determined for 10-12 years before the
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    survey. The Sisterhood Method is useful because usually maternal

    mortality changes slowly. It provides some meaningful data in countries or

    areas where there are no alternative means of generating estimates.

    [edit]When should the Sisterhood Method not beused

    The Sisterhood Method is not appropriate in countries or areas where the

    total fertility rate is less than 4 children per family, in areas of significant

    migration, as well as during civil war, civil unrest or other significant social


    [edit]Variant of the original Sisterhood Method

    The original Sisterhood Method is an indirect method. The newerDirect

    Sisterhood Methodtargets a more limited reference period for sister

    deaths and uses more in depth questions (e.g., deaths among all siblings,

    all deaths that are pregnancy related, and when these deaths occurred).

    This variant relies on fewer assumptions than the original Sisterhood

    Method. However, it requires a larger sample size, data gathering and

    analysis are more complex, and has large confidence intervals. Despite

    these limitations, the Direct Sisterhood Method can result in greater

    specificity of information. A retrospective maternal mortality ratio (MMR)

    can be calculated. This variant is used byDemographic and Health




    1.^The sisterhood method for estimating maternal mortality: Guidance

    notes for potential users. WHO. Geneva, Switzerland. 1997.

    2.^Indirect estimation of maternal mortality: The sisterhood method.Graham W, Brass W, Snow RW. Stud Fam Planning. 1989:20(3):125-


    3.^Maternal mortality in 2000: Estimates developed by WHO, UNICEF

    and UNFPA. AbouZahar C, Wardlaw T (Eds). WHO. Geneva,

    Switzerland. 2003.

    4.^Maternal mortality: Who, when, where, and why. Ronsmans C,

    Graham WJ; Lancet Maternal Survival Series Steering Group. Lancet.

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    5.^Maternal mortality for 181 countries, 1980-2008: A systematic

    analysis of progress towards Millennium Development Goal 5. Hogan

    MC, Foreman KJ, Naghavi M, Ahn SY, Wang M, Makela SM, Lopez

    AD, Lozano R, Murray CJ. Lancet. 2010;375(9726):1609-23.

    6.^Underreporting of maternal deaths on death certificates and the

    magnitude of the problem of maternal mortality. Horon IL. Am J Public

    Health. 2005;95(3):478-82.

    7.^National maternal mortality study, 2005. Carried out by: Haceteppe

    University Medical School, Institute of Population Studies. For the

    Turkish Ministry of Health, the General Directorate of Mother and Child

    Health and Family Planning, and the Delegation of European

    Commission to Turkey. Ankara, Turkey. 2006.

    8.^Measuring maternal mortality: An overview of opportunities and

    options for developing countries. Graham WJ, Ahmed S, Stanton C,

    Abou-Zahr C, Campbell OM. BMC Med. 2008;6:12.



    10. ^Direct and indirect estimates of maternal mortality from the

    Sisterhood Method. Rutenberg N, Sullivan JM (Eds). Washington DC,

    USA. 1991.

    11. ^An assessment of DHS maternal mortality indicators. Stud Fam

    Planning. 2000:31(2):111-23.

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    Applying the Sisterhood Method forEstimating Maternal Mortality to aHealth Facility-Based Sample: AComparison with Results from a

    Household-Based Sample1. ISABELLA DANEL*,
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    +Author Affiliations1. *Centers for Disease Control and Prevention, Division of Reproductive

    Health MS K-35, 1600 Clifton Road, Atlanta, GA30333, USA.2. **Dugald Baird Centre for Research on Women's Health, Aberdeen

    University UK.

    3. Alejandro Davila Bolanos Hospital Esteli, Nicaragua. Revision received March 1, 1996.


    Danel I (Centers for Disease Control and Prevention, Division of

    Reproductive Health, MS K-35, 1600 Clifton Road, Atlanta, GA 30333,

    USA), Graham W, Stupp P and Castillo P. Applying the sisterhoodmethod for estimating maternal mortality to a health facility-basedsample: A comparison with results from a household-based sample.

    International Journal of Epidemiology 1996; 25: 10171022.BackgroundThe sisterhood method Is an Indirect technique used to

    estimate maternal mortality In developing countries, where maternal

    deaths are often poorly registered in official statistics. It has been usedsuccessfully in many community-based household surveys. Because such

    surveys can be costly, this study investigated the suitability of using data

    collected in outpatient hearth facilities.MethodsAdults visiting any one of 91 health centres or posts in a rural

    region of Nicaragua were randomly sampled and interviewed by health

    personnel A sample size, proportional to the population served, wasassigned to each facility and 9232 adults were interviewed.

    Characteristics of heath facility users were compared with the general

    population to identify factors that would allow generalization of results to

    other settings.Results Based on these data, the lifetime risk of maternal death was

    0.0144 (1 in 69). This estimate is essentially identical to that from a

    household-based survey in the same region 8 months earlier, whichobtained a lifetime nsk of 0.0145 (1 in 69). These findings correspond to

    a maternal mortality ratio of 241 and 243/100 000 livebirths, respectively.ConclusionsThis is the first report comparing results of the sisterhood

    method from household and health facility-based samples. The sisterhood

    method provided a robust estimate of the magnitude of maternal

    mortality. Results from the opportunistic health facility-based sample

    were virtually identical to results from the household-based study.

    Guidelines need to be developed for applying this low-cost and efficient

    aproach to estimating maternal mortality in suitable opportunistic settingsat subnational levels.
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    Key words

    maternal mortality

    sisterhood method

    health surveys


    International Epidemiological Association

    Articles citing this article Adult mortality: time for a reappraisalInt J Epidemiol (2004) 33(4): 710-717

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    Online ISSN 1464-3685 -

    Print ISSN 0300-5771

    Stud Fam Plann.1989 May-Jun;20(3):125-35.

    Estimating maternal mortality: the sisterhood method.

    Graham W,Brass W,Snow RW.


    Maternal and Child Epidemiology Unit, London School of Hygiene and TropicalMedicine, United Kingdom.

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    This paper describes a new indirect technique for deriving population-based

    estimates of maternal mortality. The technique, called the "sisterhood

    method," is relevant to developing countries where the alternative data

    sources and approaches to estimation are often inadequate and inappropriate.The sisterhood method uses the proportions of adult sisters dying during

    pregnancy, childbirth, or the puerperium reported by adults during a census or

    survey, to derive a variety of indicators of maternal mortality. The first field trial

    of the method was carried out in the North Bank Division of The Gambia, West

    Africa, in 1987. The results indicate a lifetime risk of maternal mortality of

    0.0584, or 1 in 17, approximating a maternal mortality ratio of 1,005 per

    100,000 live births, which is consistent with previous estimates for this region.



    [PubMed - indexed for MEDLINE]

    Publication Types, MeSH Terms

    Estimating Maternal Mortality: The Sisterhood MethodWendy Graham, William Brass and Robert W. SnowStudies in Family PlanningVol. 20, No. 3 (May - Jun., 1989), pp. 125-135(article consists of 11 pages)Published by:Population CouncilStable URL:
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    Studies in Family Planning 1989Population Council