Maternal and Child Health Journal

, Volume 22, Issue 12, pp 1743–1750 | Cite as

Completeness of a Maternal and Perinatal Mortality Enhanced Surveillance System in Pakistan: Evidence from Capture–Recapture Methods

  • Jasim AnwarEmail author
  • Siranda Torvaldsen
  • Mohamud Sheikh
  • Richard Taylor


Objectives An enhanced surveillance system that integrated health information systems and extended surveillance to previously uncovered areas to capture all births, perinatal and maternal deaths in a rural district of Pakistan was established in 2015, and this study uses capture–recapture methodology to assess completeness. Methods Births and deaths collected by the survey were matched with the data captured by the enhanced surveillance system. Capture–recapture methodology was used to estimate the total number of births and deaths, measure the degree of underestimation, and adjust mortality rates. Results Of all births, 99% were captured by the enhanced surveillance system. Ninety percent of neonatal deaths and 86% of early neonatal deaths were recorded. The recorded neonatal mortality rate was 40 per 1000 live births (95% CI 35–44), and after adjustment for under-enumeration was 42 per 1000 live births (95% CI 37–46). Recorded rates underestimated neonatal mortality by 5% and perinatal mortality by 7%. Five stillbirths were recorded by the survey and all were matched to recorded stillbirths. The one maternal death recorded by the survey was matched with the maternal death captured by the enhanced surveillance system. The maternal mortality ratio prior to adjustment for under-enumeration was 247 per 100,000 live births (95% CI 147–391), whereas after adjustment it was 246 per 100,000 live births (95% CI 146–389). Conclusion Application of capture–recapture methods to the enhanced surveillance system indicated a high completeness of birth and death recording by the surveillance system.


Maternal mortality Perinatal mortality Capture–recapture methods Surveillance system Pakistan 



We acknowledge the financial support in term of tuition fee and stipend provided to JA by the University of New South Wales, Sydney.

Compliance with Ethical Standards

Conflict of interest

The authors declare that they have no conflict of interest.

Ethics Approval

Ethics approval was obtained from the Pakistan Medical Research Council (ref. no. 4-87/15/NBC-186/RDC411), and the University of New South Wales, Sydney (ref. no. HC14338).

Informed Consent

Written informed consent was obtained from all study participants.


  1. Anwar, J., Torvaldsen, S., Sheikh, M., & Taylor, R. (2018). Under-estimation of maternal and perinatal mortality revealed by an enhanced surveillance system: enumerating all births and deaths in Pakistan. BMC Public Health, 18(1), 428. Scholar
  2. Azofeifa, A., Yeung, L. F., Duke, C. W., Gilboa, S. M., & Correa, A. (2012). Evaluation of an active surveillance system for stillbirths in metropolitan Atlanta. Journal of Registry Management, 39(1), 13–18 (quiz 36).PubMedPubMedCentralGoogle Scholar
  3. Barnett, S., Nair, N., Tripathy, P., Borghi, J., Rath, S., & Costello, A. (2008). A prospective key informant surveillance system to measure maternal mortality: Findings from indigenous populations in Jharkhand and Orissa, India. BMC Pregnancy and Childbirth, 8, 6.CrossRefGoogle Scholar
  4. Cesare, M. D., Bhatti, Z., Soofi, S. B., Fortunato, L., Ezzati, M., & Bhutta, Z. A. (2015). Geographical and socioeconomic inequalities in women and children’s nutritional status in Pakistan in 2011: An analysis of data from a nationally representative survey. The Lancet: Global Health, 3(4), e229–e239. Scholar
  5. Chao, A., Pan, H. Y., & Chiang, S.-C. (2008). The Petersen–Lincoln estimator and its extension to estimate the size of a shared population. Biometrical Journal, 50(6), 957–970. Scholar
  6. Ding, Y., & Fienberg, S. E. (1996). Multiple sample estimation of population and census undercount in the presence of matching errors. Survey Methodology, 22, 55–64.Google Scholar
  7. Duque-Portugal, F., Martin, A. J., Taylor, R., & Ross, M. W. (1994). Mark-recapture estimates of injecting drug users in Sydney. Australian and New Zealand Journal of Public Health, 18(2), 201–204.CrossRefGoogle Scholar
  8. Eisele, T. P., Lindblade, K. A., Rosen, D. H., Odhiambo, F., Vulule, J. M., & Slutsker, L. (2003). Evaluating the completeness of demographic surveillance of children less than five years old in western Kenya: A capture-recapture approach. The American Journal of Tropical Medicine and Hygiene, 69(1), 92–97.CrossRefGoogle Scholar
  9. Fatima, R., Harris, R. J., Enarson, D. A., Hinderaker, S. G., Qadeer, E., Ali, K., & Bassilli, A. (2014). Estimating tuberculosis burden and case detection in Pakistan. The International Journal of Tuberculosis and Lung Disease, 18(1), 55–60.CrossRefGoogle Scholar
  10. German, R. R., Lee, L., Horan, J., Milstein, R., Pertowski, C., & Waller, M. (2001). Updated guidelines for evaluating public health surveillance systems. MMWR Recommendations and Reports, 50, 1–35.PubMedGoogle Scholar
  11. Godefay, H., Abrha, A., Kinsman, J., Myleus, A., & Byass, P. (2014). Undertaking cause-specific mortality measurement in an unregistered population: An example from Tigray Region, Ethiopia. Global Health Action. Scholar
  12. Himes, C. L., & Clogg, C. C. (1992). An overview of demographic analysis as a method for evaluating census coverage in the United States. Population Index, 58(4), 587–607.CrossRefGoogle Scholar
  13. International Working Group for Disease Monitoring and Forecasting. (1995). Capture-recapture and multiple-record systems estimation II: Applications in human diseases. American Journal of Epidemiology, 142(10), 1059–1068. Scholar
  14. Joubert, J., Rao, C., Bradshaw, D., Dorrington, R. E., Vos, T., & Lopez, A. D. (2012). Characteristics, availability and uses of vital registration and other mortality data sources in post-democracy South Africa. Global Health Action. Scholar
  15. Lambo, J. A., Khahro, Z. H., Memon, M. I., & Lashari, M. I. (2011). Completeness of reporting and case ascertainment for neonatal tetanus in rural Pakistan. International Journal of Infectious Diseases, 15(8), e564–e568.CrossRefGoogle Scholar
  16. Lateef, M. U. (2010). Estimation of fatalities due to road traffic crashes in Karachi, Pakistan, using capture-recapture method. Asia Pacific Journal of Public Health, 22(3), 332–341.CrossRefGoogle Scholar
  17. Mahapatra, P., Shibuya, K., Lopez, A. D., Coullare, F., Notzon, F. C., Rao, C., & Szreter, S. (2007). Civil registration systems and vital statistics: Successes and missed opportunities. The Lancet, 370(9599), 1653–1663. Scholar
  18. Mahmood, A., & Naz, S. S. (2012). Assessment of management information system (MIS) of National Program for Family Planning and Primary Health Care [LHW Program]. Population Council.Google Scholar
  19. Mir, A. M., Shaikh, M. S., Qomariyah, S. N., Rashida, G., Khan, M., & Masood, I. (2015). Using community informants to estimate maternal mortality in a rural district in Pakistan: A feasibility study. Journal of Pregnancy. Scholar
  20. Mony, P. K., Varghese, B., & Thomas, T. (2015). Estimation of perinatal mortality rate for institutional births in Rajasthan state, India, using capture–recapture technique. British Medical Journal Open, 5(3), e005966. Scholar
  21. National Institute of Population Studies. (2008). Pakistan Demographic and Health Survey 2006-07. Retrieved from Islamabad, Pakistan,
  22. National Institute of Population Studies (Pakistan) and ICF International. (2013). Pakistan Demographic and Health Survey 2012-13. Retrieved from Islamabad, Pakistan, and Calverton, MA,
  23. Razzak, J. A., & Luby, S. P. (1998). Estimating deaths and injuries due to road traffic accidents in Karachi, Pakistan, through the capture-recapture method. International Journal of Epidemiology, 27(5), 866–870.CrossRefGoogle Scholar
  24. Sekar, C. C., & Deming, W. E. (1949). On a method of estimating birth and death rates and the extent of registration. Journal of the American Statistical Association, 44(245), 101–115. Scholar
  25. UNDP. (2011). Khyber Pakhtunkhwa Millenium Development Goal Report 2011. Retrieved from Islamabad,
  26. World Health Organization. (2016). Time to respond: A report on the global implementation of maternal death surveillance and response (MDSR). Retrieved from Switzerland,

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2018

Authors and Affiliations

  1. 1.School of Public Health and Community Medicine, Faculty of MedicineThe University of New South WalesSydneyAustralia
  2. 2.Department of Community MedicineWomen Medical and Dental CollegeAbbottabadPakistan
  3. 3.Clinical and Population Perinatal Health Research, Kolling Institute, Sydney Medical School NorthernThe University of SydneySydneyAustralia

Personalised recommendations