#ConversandoSobreSIS #ZeroMaternalDeaths #EveryMaternalDeathMatters

Series of Webinars – Paraguay’s experience with implementing BIRMM


Tuesday - 16 October

Presenters: Dr. Gladys Ester Mora / Juan Edgar Tullo Gómez 


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Maternal mortality is included among the global targets that highlight the fragility of the most vulnerable populations. The now-completed Millennium Development Goals (MDGs) and the current Sustainable Development Goals (SDGs) both include maternal mortality as an indicator of the coverage and quality of the health services to which a population has access.

Paraguay was included among the 26 countries classified as having made no progress towards MDG 5, which involved reducing the estimated 1990 maternal mortality ratio by 75 percent; to ensure comparability, data were estimated uniformly by an interagency group comprising WHO, UNFPA, UNICEF, and the Inter-American Development Bank (2015, WHO).  

To improve the classification of information by correctly filling out death certificates and to reduce the underreporting of births and deaths, the Deliberate Search and Reclassification of Maternal Deaths (BIRMM) method has been implemented in Paraguay since 2015. 

This procedure includes research, documentation, analysis, and coding with the International Classification of Diseases (ICD-10) of the deaths of women of childbearing age—both in confirmed cases of maternal death and suspected concealed cases. This procedure has been shown to have a significant impact on the trends and distribution of causes of death, by including cases that had not been considered previously and correcting their misclassification (attributable in the first place to improperly filling in causes on the corresponding death certificate). 

BIRMM is based on the Reproductive Age Mortality Survey (RAMOS), a methodology that analyzes the entire population of women of childbearing age to determine maternal mortality figures, using different sources of information. 

Moreover, BIRMM is based mainly on information from death certificates and other sources that could provide information on the deaths of mothers who have given birth in the previous year: certificates of live birth, birth certificates, certificates of fetal death, information from the civil registry, hospital discharges, and immediate notification of maternal death. 

The BIRMM process begins with the classification of death certificates, dividing them into two categories: cases that are already recognized as maternal deaths with the proper ICD-10 code, and probable cases of maternal death. The cases are selected using an algorithm based on the information provided by the physician filling out the cause of death on the death certificate. Suspected concealed cases of maternal death are matched with a list that includes 61 causes. 

With this methodology, 6 maternal deaths were reclassified: 2 from 2015, and 4 from 2016. Another very important aspect of the results was that 20% of the deaths initially considered to be non-maternal were reclassified; this indicates that efforts should continue to achieve a higher level of quality in the data recorded by Paraguay’s Ministry of Public Health and Social Welfare. 


Dr. Gladys Ester Mora

Obstetrician-Gynecologist, specialized in Epidemiology, Administration of Hospital Resources, Public Health, and the Health System.

Technical Advisor to the Directorate-General of Health Programs of the Ministry of Public Health and Social Welfare, and Technical Coordinator of its Commission on Maternal, Fetal, and Neonatal Morbidity and Mortality.


Juan Edgar Tullo Gómez 

Undergraduate degree in Statistical Mathematics, specialized in Demographic Analysis.

Director-General of Strategic Health Information, Ministry of Public Health and Social Welfare.