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Indirect Sisterhood Method

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Indirect Sisterhood Method: BACKGROUND

The original (indirect) sisterhood method was developed in the late 1980s as an efficient means of measuring maternal mortality through population-based surveys, generating a variety of indicators: the proportion of maternal deaths among female deaths (PMDF), the maternal mortality ratio (MMR), the maternal mortality rate (MMRate), the lifetime risk of maternal death (LTR), and the adult female death rate.

Adult respondents are asked four questions about the survival of all their adult sisters born to the same mother (see below).The method reduces the need for large sample sizes because there may be more than one respondent per household, more than one sister per respondent, and because the time period of death is not restricted.

Identification of death:

Adult respondent reports deaths of his/her adult sisters retrospectively to interviewer by responding to questions 1-3 of the 4 questions.

Ascertainment of maternal/pregnancy related status:

Adult responds to the 4th (pregnancy-related) question

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

Advantages:

Limitations:

Measurement requirements:

Questions are used to derive proportions of adult sisters dying during pregnancy, childbirth or puerperium. Standard adjustment factors convert these proportions into LTR. LTR can be converted to MMR and MMRate given assumptions about the Total Fertility Rate (TFR). The TFR is needed.

Sisterhood questions:

Four questions are asked in addition to the age of the respondent:

  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?
  2. How many of these sisters reaching age 15 are alive now?
  3. How many of these sisters are dead?
  4. How many of these dead sisters died during pregnancy or during childbirth, or during the six weeks after the end of the pregnancy?

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


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.

Oxford Journals - International Journal of Epidemiology Danel, I. Graham, W. Stupp, P. and Castillo, P. Applying the sisterhood method for estimating maternal mortality to a health facility-based sample: A comparison with results from a household-based sample. International Journal of Epidemiology, 1996, 25 (5): 1017-1022.

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).

Macro International Inc Rutenberg N, Sullivan JM (1991) Direct and indirect estimates of maternal mortality from the sisterhood method. Washington DC: IRD/Macro International Inc.

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.

Studies in Family Planning Trussell J, Rodriguez G (1990) A note on the sisterhood estimator of maternal mortality. Studies in Family Planning, 21(6): 344-6.

World Health Organisation WHO/UNICEF. The Sisterhood method to estimate maternal mortality. Report of a technical meeting, 5-6 December 1996.

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Immpact SSS Tool: Calculator for number of survey respondents required

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