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maternal mortality sri lanka strategies for improving maternal mortality estimates in asia_lozano_110210_ihme maternal mortality sri lanka strategies for improving maternal mortality estimates in asia_lozano_110210_ihme Presentation Transcript

  • Lessons learned and strategies for improvement November 2, 2010 Rafael Lozano Professor of Global Health
  • Outline
    • Lessons Learned
    • Increase Vital Registration Completeness
    • Reduce Misclassification
    • Increase Opportunities for Multiple Measurements
    • Introduce Nation-Wide Verbal Autopsy
    • Shorten Analysis Time
    • Conclusions
  • Gaining Ground
    • Global maternal deaths down to 342,900 in 2008
    • Global trend is a 1.4% decline per year since 1990
    • 23 countries are on track to meet MDG 5, achieving an annual rate of decline of 5.5%
      • Includes Egypt, Albania, Tunisia, El Salvador, Romania
    • Other countries are achieving substantial progress
      • Including China, Bolivia, Ecuador, Peru, Rwanda
  • Progress Undocumented But Not Unexpected
    • Global total fertility rate has dropped from 3.70 in 1980 to 2.56 in 2008
    • Income per capita has been rising over the period, particularly in Asia and Latin America
    • Maternal education has been increasing as well
      • In sub-Saharan Africa, the average years of schooling for women aged 25-44 rose from 1.5 years in 1980 to 4.4 years in 2008
    • The steady, slow rise in skilled birth attendance coverage may also have contributed
  • Adverse Impact of HIV
    • Progress on reducing maternal mortality would have been much greater in the absence of HIV, especially in sub-Saharan Africa
    • Important implications for intervention policy
      • Interventions for treating pregnant women with HIV would include antiretrovirals, not part of the set of interventions targeting HIV-negative women
    • Critical to track HIV-related maternal mortality, but challenging in settings without vital registration
  • Analyze All the Evidence
    • Making sense of levels of maternal mortality should begin with a careful consideration of all sources of data that pertain to mortality of reproductive aged women.
    • It is easier to make sense of available data when it is in the context of all sources overtime.
  • Outline
    • Lessons Learned
    • Increase Vital Registration Completeness
    • Reduce Misclassification
    • Increase Opportunities for Multiple Measurements
    • Introduce Nation-Wide Verbal Autopsy
    • Shorten Analysis Time
    • Conclusions
  • Incomplete Vital Registration Systems
    • In the long-run, the most effective strategy for measuring maternal mortality that will yield timely results is a complete vital registration system with good medical certification.
    • Invigorated efforts to improve completeness should be a core strategy for countries with incomplete vital registration.
    • New technology can facilitate aggregation and monitoring of vital events recording.
  • Outline
    • Lessons Learned
    • Increase Vital Registration Completeness
    • Reduce Misclassification
    • Increase Opportunities for Multiple Measurements
    • Introduce Nation-Wide Verbal Autopsy
    • Shorten Analysis Time
    • Conclusions
  • Correcting Misclassification and underreporting
    • Some experiences
      • Mexico
      • Developed countries (UK, USA, etc.)
  • Systematic search of maternal deaths
    • In 2002 the Mexican MoH started a passive identification of maternal deaths in women of reproductive age using death certificates recorded and a special list of potential causes of maternal or pregnancy related deaths
      • Collecting all information available of each “potential maternal death”: Medical records, Verbal Autopsy, Death Certificate, Maternal Mortality Committee Report, Critical Links of maternal deaths, etc.
      • Corroborate one by one with INEGI database and Incorporating those which qualify as new registries into the “official” mortality database (INEGI)
    1,320 Mat. deaths added = 13.2% in 8 years % Deaths
  • Correction of Misclassification of Maternal Deaths, Mexico 2007-2008 Type of Misclassification
  • Abortions out of Maternal Chapter, Mexico 2007-2008
  • Maternal Death Misclassification Study
    • Studies such as undertaken in Mexico can then lead both to improved ascertainment through training of those involved in certification and provide a basis for improved garbage code reassignment algorithms.
  • Outline
    • Lessons Learned
    • Increase Vital Registration Completeness
    • Reduce Misclassification
    • Increase Opportunities for Multiple Measurements
    • Introduce Nation-Wide Verbal Autopsy
    • Shorten Analysis Time
    • Conclusions
  • Wider Use of Sibling Histories in Household Surveys
    • Sibling histories in the Demographic and Health Surveys and their analogue have been extremely useful for measuring reproductive aged female mortality and the fraction of deaths from maternal causes.
    • Sibling histories can be improved by asking them of both male and female respondents – this increases sample size and thus statistical power.
  • Inclusion of Simple Pregnancy Related Death Questions in Censuses
    • Another opportunity for measuring the pregnancy-related cause fraction is the inclusion in censuses of items on whether household deaths are pregnancy-related.
    • Many countries have included these items in the 2010 census round.
  • Outline
    • Lessons Learned
    • Increase Vital Registration Completeness
    • Reduce Misclassification
    • Increase Opportunities for Multiple Measurements
    • Introduce Nation-Wide Verbal Autopsy
    • Shorten Analysis Time
    • Conclusions
  • Verbal Autopsy
    • In settings where medical certification of death for nearly all deaths is not feasible, verbal autopsy can be an effective tool.
    • Verbal autopsy is the assignment of cause of death on the basis of a household interview after death.
    • Extensive research using verbal autopsy instruments has meant that verbal autopsy methods have become more standardized and have improved performance.
    • Multiple options for introducing verbal autopsy systems are available.
    • A well-designed verbal autopsy system can yield not only maternal mortality estimates but critical information on a wide range of causes.
  • VA Data Collection Strategies
    • Verbal autopsy for a representative sample of deaths can be obtained through three strategies:
    • Using verbal autopsy in a sample of communities where there is active surveillance of deaths e.g. SRS in India
    • Using verbal autopsy as a follow-up to a national census that included questions on deaths in the recent time period. Deaths in the recent time period will be an undercount but the cause-specific mortality fractions should be useful if the recall of death is not related to the cause of death
    • Using verbal autopsy in household surveys. Verbal autopsy can be included for sibling deaths and deaths in the household
  • Low-Cost High Validity VA
    • Feasibility of implementing verbal autopsy can be dramatically improved if a standardized instrument is used and automated systems for assigning cause of death are implemented.
    • Physician reading of open-ended VA instruments is costly and slow to implement.
    • WHO standardized VA instrument provides a standard reference tool.
    • New analytical methods (Symptom Pattern Method, Machine Learning, Tariff Methods, InterVA) provide options for analyzing VA data without requiring physician review.
    • Validation studies have been completed that show some standardized methods do as well as or better than physician reading.
  • Global Congress on VA
    • February 2011 the Global Congress on Verbal Autopsy will be held in Bali, Indonesia.
    • Opportunity for the VA research community to present the latest developments in VA instruments, analytical methods and integration of VA into national health information systems.
  • Outline
    • Lessons Learned
    • Increase Vital Registration Completeness
    • Reduce Misclassification
    • Increase Opportunities for Multiple Measurements
    • Introduce Nation-Wide Verbal Autopsy
    • Shorten Analysis Time
    • Conclusions
  • Delays in Translating Data to Information
    • Health measurement suffers in many settings from major delays.
    • This week, Lancet publishes SRS results on child deaths in India based on verbal autopsy for 2001-2003: an 8-year delay in information.
    • The typical delay in a sibling history analysis for maternal mortality is 3-4 years from publication time to the reference period.
    • Delays are due to the time take to process data and the nature of the methods.
  • Process Engineering Measurement
    • Timely measurement is essential for having health information inform policy choice.
    • Some of the delays can be eliminated or reduced by having each new data point immediately analyzed in the context of all previously collected information.
    • Some delays can be eliminated through use of better and automated tools such that the time from data collection to analysis is days not years.
  • Outline
    • Lessons Learned
    • Increase Vital Registration Completeness
    • Reduce Misclassification
    • Increase Opportunities for Multiple Measurements
    • Introduce Nation-Wide Verbal Autopsy
    • Shorten Analysis Time
    • Conclusions
  • Improved Maternal Mortality Measurement
    • National assessment of maternal mortality will improve:
    • with the accumulation of more measurements,
    • creation of enhanced national capacity to understand and analyze data sources,
    • data sharing so that different analysts can interpret all the available data and
    • a community of analysts who can share lessons learned across countries within a region and between regions.