Methodological Considerations in Implementing the WHO Global Survey for Monitoring Maternal and Perinatal Health/Considerations Methodologiques Dans L'application De l'Enquete Mondiale De l'OMS Sur la Surveillance De la Sante Maternelle et perinatale/Consideraciones Metodologicas a Raiz De la Encuesta Mundial OMS De Vigilancia De la Salud Materna Y Perinatal

Introduction The WHO Global Survey on Maternal and Perinatal Health aims to develop a network of health institutions worldwide that collects up-to-date information on services provided and on how evidence-based recommendations are implemented in maternal and perinatal health care. Information is collected through a technologically simple online data entry and management system for large data sets. h is expected that use of this information will help to identify gaps at the facility and sub-national levels and to assist in effective planning, implementation and monitoring. The survey was first implemented in the WHO regions of Africa and the Americas between September 2004 and March 2005 to study the relationship between intra-partum care and maternal and perinatal health outcomes. Preliminary results on increasing rates of caesarean section in Latin America were published. (1) This paper describes methodological issues related to the establishment and implementation of the survey, and sets the foundation for reports to be published from this project. Methods The survey eventually will be implemented in 54 countries, four from each of the 14 WHO defined subregions. WHO subregions, classified by the levels of under-five child and adult mortality rates (2) were used as a proxy for the burden of maternal and perinatal mortality. A stratified multistage cluster sampling design was used to obtain a sample of countries and health institutions worldwide. Selection of countries, provinces and health facilities From each subregion, four countries were selected with probability proportional to population size (Table 1). When there were less than four countries in a subregion, all countries within that subregion were included. This process resulted in 12 subregions having four countries each, and two subregions having three countries each (Table 1). It was decided that no replacement would be made for a country that did not participate. In each country, the capital city was always included in the sample. In addition, two provinces were randomly selected from the other administrative areas. The third-stage sampling unit was obtained by drawing a random sample of up to seven health institutions, each of which reported at least 1000 deliveries in the year before the implementation of the survey. If there were fewer than seven eligible health institutions in the capital city or other provinces, then all available health institutions were selected. In each country, an up-to-date census of health institutions in the selected areas was obtained. In the absence of a recent census, a list of health institutions was prepared by the country coordinators, in collaboration with WHO country offices and ministries of health. All women who were delivered in the participating sites during the specified period comprised the study population. Those delivered elsewhere were not included. Data were collected over a two- or three-month period depending on the annual number of deliveries in each health institution. For those health facilities with less than 6000 deliveries, data were collected for three months; for those with over 6000 deliveries, data were collected for a two-month period. As a one-time event, an institutional level data collection form (available at: http://www.who.int/making_pregnancy_safer/health_systems/ global_survey/en/index.html) was completed by institution's medical director. Data were collected on services influencing maternal and perinatal care and outcomes such as laboratory tests, anaesthesiology resources, intrapartum care including emergency obstetric care, and human resources for maternal and perinatal health. Individual level data were abstracted directly from medical records onto a two-page data collection form (available at: http://www.who.int/making_pregnancy_safer/health_systems/ global_survey/en/index.html) by trained data collectors. …