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Direct Sisterhood Method

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Direct Sisterhood Method: BACKGROUND

The direct sisterhood method is a variant of the indirect Sisterhood Method, and is currently used by Demographic and Health Surveys (DHS). While it requires larger sample sizes than its predecessor, the advantage of the direct method is the targeting of a more limited reference period for sister deaths. Using a more detailed set of questions, in particular to ascertain deaths among all sibling and then those that are pregnancy-related as well as when the death occurred, point estimates for maternal mortality usually relate to 0-6 years and >6 years prior to the survey. A retrospective maternal mortality ratio (MMR) can be calculated for the reference period in question. The method is not recommended for duplication at short time intervals due to large confidence intervals.

Identification of death:

Adult respondent reports deaths (and sex and age at death) among all his/her brothers and sisters born to the same mother in response to sibling survivorship questions and direct sisterhood method questions.

Ascertainment of maternal/pregnancy related status:

Adult responds to pregnancy-related questions (see below).

It is not possible to obtain sub-causes of maternal death, as respondent may not know the signs and symptoms that preceded the death.


* Rutstein, SO; Rojas, G. (2006) Guide to DHS Statistics. Calverton: ORC Macro J. p134


Measurement requirements:

Involves conducting a sibling history, with dates of births and deaths, and for sisters dying of reproductive age the 4th question of the indirect sisterhood method is also asked. Data on births are also needed to derive the maternal mortality ratio.

Direct sisterhood questions:

  1. How many children did your mother give birth to?
  2. How many of these births did your mother have before you were born?
  3. What was the name given to your oldest (next oldest) brother or sister?
  4. Is (NAME) male or female?
  5. Is (NAME) still alive?
  6. How old is (NAME)?
  7. In what year did (NAME) die? OR
    How many years ago did (NAME) die?
  8. How old was (NAME) when she died?

  9. For dead sisters aged 15-49 only:

  10. Was (NAME) pregnant when she died?
  11. Did (NAME) die during childbirth?
  12. Did (NAME) die within two months after the end of pregnancy or childbirth?

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Direct Sisterhood Method: GUIDELINES

World Health Organisation WHO (1997) The sisterhood method for estimating maternal mortality: Guidance notes for potential users. Geneva: World Health Organization.

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Direct Sisterhood Method: REFERENCES

Studies in Family Planning
Graham W, Brass W, Snow RW (1989) Indirect estimation of maternal mortality: the sisterhood method. Studies in Family Planning, 20(3):125-35.

Studies in Family Planning Hanley JA, Hagen CA, Shiferaw T (1996) Confidence intervals and sample size calculations for the sisterhood method of estimating maternal mortality. Studies in Family Planning, July/August 27(4).

Studies in Family Planning Shahidullah M (1995) The Sisterhood method of estimating maternal mortality: The Matlab experience. Studies in Family Planning, March-April 26(2): 101-6.

Macro International Inc Stanton, C., Abderrahim, N. and Hill, K. DHS maternal mortality indicators: An assessment of data and implications for data use. Demographic and Health Surveys Analytical Report No 4, Macro International Inc. Calverton, Maryland USA September 1997

Studies in Family Planning Stanton, C; Abderrahim, N; Hill, K (2000) An assessment of DHS maternal mortality indicators. Studies in Family Planning; 31(2): 111-23.


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