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Accounts of christenings and burials in England and Wales started to be recorded in 1593. In 1665, Bills of Mortality were introduced to provide statistics on deaths caused by the plague, with data largely derived from parish registers. The Registration Act of 1836 enabled the creation of the General Register Office, which was set up a year later. The Act required the General Register Office to prepare an annual report for the Parliament. Under the Act, families had to report the death to the local registrar of births, deaths, and marriages. Death certification by a medical practitioner was not required. All that was required was minimum information on the deceased – date of death, name, age, sex, rank or profession, and cause of death. Three years later, in 1839, William Farr devised the first system of disease classification (nosology). From 1845, qualified medical practitioners were supposed to certify any death. Following the 1874 Registration Amendment Act, medical practitioners were formally required to issue death certificates, which were printed forms provided by Registrar-General (1-4).
In developed countries or the current high-income countries, until the mid 1930s, maternal mortality rates were high. The major determinants of the high levels of maternal mortality were the standard of care at delivery and puerperal fever. Between 1880 and 1980, the maternal mortality ratio for England and Wales was largely under 500 deaths per 100000 births, with a noticeable spike of above 500 deaths between 1890 and 1900 (5). The maternal mortality ratio for England and Wales considerably improved thirty years ago, reaching the value of 9 deaths per 100000 births (5).
Malawi’s maternal mortality is one of the highest in the world, ie, between 800 and 1200 maternal deaths per 100000 live births (6-8), which is unacceptable since maternal mortality ratios that exceed 100 maternal deaths per 100000 live births are already considered bad.
Comparing deaths, let alone maternal mortality, between jurisdictions is fraught with problems if enough attention is not paid to data collection methods. For instance, data on maternal mortality rates for the US before 1915 are largely considered unreliable and problematic for comparison with other settings. If we take into consideration only the data after 1915, the US have the highest rates of maternal mortality among developed countries (5). However, there are always some problems with such comparisons. First, there is the definition of the setting for which the data are recorded. In the case of the US, data until 1933 were based on the expanding death registration area, ie, a limited number of states only. Second, the criteria used to define a maternal death in the US differed from those used in the UK. Deaths that would have been excluded as indirect maternal deaths in the UK were included in the US data. In 1935, a survey by Tandy (9) showed that one-half of the number of deaths in the US exceeding the UK number was due to differences in the classification of deaths or to the methods of data collection, whereas about one-half was real.
There is coordinated vital statistics recording and reporting system in Malawi. Maternal mortality data from districts are collected at the respective district level and when a death occurs at home, it may not be reported. There is no requirement to report deaths in the community. Much of the data on maternal mortality come from interviews using the Sisterhood method (10,11).
While the overall maternal mortality ratio for Malawi may not have changed much over the years, two districts have not registered a maternal death for 3 consecutive years. These districts are Ntcheu and Mchinji in the central region of the country. What did these districts do? Certainly no randomized controlled trials, no case-control studies, or ecological studies. It is simple. They just banned home deliveries. Traditional leaders formulated a regulation that anyone who delivered or allowed a home delivery will be fined. No excuses; no maternal death has been registered so far.