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WHY VITAL DATA UNDER-COUNTMATERNAL DEATHS IN DEVELOPINGCOUNTRIES -- CASE STUDY, JAMAICA: 2008 AFFETTE MCCAW-BINNS Reproductive Health Epidemiologist University of the West Indies, Mona, Jamaica YVETTE HOLDER International Biostatistics and Information Services, St Lucia JASNETH MULLINGS University of the West Indies, Mona, Jamaica
MATERNAL MORTALITY SURVEILLANCE:JAMAICA - HISTORY 1981-83: First confidential enquiry Only 31% of maternal deaths reflected in vital data Registrar General‟s Department (RGD) 1986-95: Voluntary MM reporting failed 1998: Maternal mortality surveillance initiated Maternal deaths classified as a Class I event Active surveillance by public health team Investigatereported deaths (community, hospital) Review deaths in women 10-50 years to identify maternal and late maternal deaths
DEATH CERTIFICATION: MATERNAL DEATHS43RD WORLD HEALTH ASSEMBLY (1990): RESOLUTION WHA 43.24 ICD-10 recommends countries include on death certificates: Questions about pregnancy within one year preceding death Shown to reduce under-reporting of maternal deaths Reminds the certifier to consider whether the death was due to a complication of pregnancy. Suggested questions for inclusion on MCCD. If female, was the woman: [ ] pregnant at the time of death [ ] not pregnant at the time of death, but pregnant within 42 days [ ] pregnant within the past year 2006: pregnancy check box added to Jamaican MCCD “pregnancy ended within 42 days of death [ ] yes [ ] no” ?? exclusion of women who died undelivered
MILLENNIUM PROJECT: MDGs Contract between developed and developing countries to work to improve quality of life in developing world 8 goals; 3 health related (MDG4, 5, 6) MDG 5: reduce maternal mortality ratio by 75% Indicators and monitoring framework Created measurement ethos No data? Estimate it!
GLOBAL MATERNAL MORTALITY ESTIMATES(WHO ET AL, 2005 & 08; IHME, 2008 & 11) Modeled estimates used proxy measures of risk: Total fertility rate GDP HIV seroprevalence Neonatal mortality Female literacy Produce maternal mortality estimates for Jamaica inconsistent with our surveillance data, e.g. IHME (2008) – 34 vs 89/100,000 WHO (2005) – 170 vs 94/100,000 Where vital data available: Information used without regard for its validity or reliability.
JUSTIFICATION & AIMChange in Approach:Estimating Maternal Mortality: vital data vs. RAMOSdata WHO/UNICEF, World Bank, 2005 and 2008 Hogan, et al; 2008 and 2011 Jamaica‟s efforts to modernize vital registration systemAim Understand why only one in five maternal deaths show up in vital data
OBJECTIVES:PREGNANCY RELATED DEATHS 2008… Identify the universe of maternal, coincidental and late maternal deaths for 2008 Determine whether they are accurately certified, registered and correctly coded Examine factors associated with delays in registration of maternal deaths
METHODOLOGYCASE IDENTIFICATION AND DATA COLLECTION Deaths in women 10-49 years reviewed from: Registered deaths – RGD MVAs, violence, suicide – police Maternal mortality surveillance – MOH Preliminary list given to data collectors who visited – Hospitals (public and private) Forensic pathologists (community deaths) Existing cases updated with any new information Missed cases added to the database
CERTIFICATION:JAMAICAN MEDICAL CERTIFICATE (MCCD)
DEATH REGISTRATION FORM (DRF)1. Cause of death 4 transcribed from 1 2 MCCD by registrar 32. Include demographic data3. Code4. Select underlying cause5. Data entry
Form D:Replaces MCCD Same demographic and clinical information as MCCD but….Not updated toinclude:a. Duration of illnessb. Pregnancy check boxFORM D –CORONER’S CASES
QUALITY REVIEW: CERTIFICATION AND CODING Inspected MCCDs/Form Ds at RGD to determine if: Pregnancy check box was utilized (MCCD only) MCCD /Form D accurately reflected cause of death information in maternal mortality surveillance reports Inadequate/incomplete certification Logical sequence of events Duration of illness noted ICD10 codes accurately reflect UCOD on MCCD Coding/misclassification errors RGD database consistent with the MCCD Transcription/data entry errors (MCCD/Form D DRF database)
DATA ANALYSIS Deaths classified as: Direct obstetric Indirect obstetric Coincidental Late maternal Data analysed (SPSS 16.0) to: Determine factors associated with non-registration and misclassification Demographic: Age, region of residence, place of death Clinical: Duration from delivery to death, cause of death Measure impact of delayed registration and misclassification on the maternal mortality ratio (MMR).
FLOW CHART – SHORT LISTED CASES 100 Possible maternal deaths 81 19 pregnancy-related non-pregnancy related 65 16 19 registered not registered registered 44 16 late maternal 10 4 late maternal WHO-defined & WHO-defined & 2 coincidental maternal deaths 5 other deaths maternal deaths deaths 13 31 2 19 0 1 18coded O00-95 incorrectly coded coded O00-95 correctly coded coded ‘O’ ‘C’ coded ‘O’ correctly coded
TIMELINESS OF MATERNAL DEATH REGISTRATION,BY REGION OF DEATH: 2008 <3 months 3-11 months 1-2 years Not registered (>2 years)100 92.6 90 80 71.7 75.0 72.7 70 60 50 40 25.0 27.3 27.3 30 24.5 18.2 20 6.4 10 0 JAMAICA South east North east South West
QUALITY OF CERTIFICATION BY PHYSICIANS44 registered deaths 32 MCCD, 5 Form D, 7 not locatedPregnancy Check Box (MCCD only) 7/32(22%) pregnancy check box used correctly 8th case: check box inappropriately used Doctor checked “no” to the question “pregnancy ended within 42 days of death” for a woman who had died undelivered.Duration of Illness (MCCD only) Reported on 8/32 certificates (25%) Less often completed for indirect (9%) than direct (32%) deaths (Fisher‟s p=.158)
QUALITY OF CERTIFICATION BY PHYSICIANS,continued…Logical sequence of events (MCCD/Form D) 64% of cases (28/44) sequence of events logical One: totally backwards,(UCOD before immediate) Seven: out of sequence (16%)Omission of important information Eight (18%): Omission misclassification Information available on MM surveillance reports e.g. Eclampsia (O15) and stroke (I61.9); MCCD-stroke listed More often for indirect (43%) than direct deaths (7%)
EVIDENCE OF PREGNANCY ON MCCD, BYCATEGORY OF MATERNAL DEATH: JAMAICA, 200860 No mention of pregnancy/birth50 Pregnancy check 42.9 box only used40 Explicit* reference to pregnancy30 Implicit** reference 18.2 *EXPLICIT – use of terms20 such as pregnancy, abortion, 6.7 childbirth on MCCD10 ** IMPLICIT -- implied in 0 COD such as eclampsia, PPH, ALL Direct Indirect puerperal cardiomyopathy DEATHS
DELAYED REGISTRATION Coroner‟s cases Possible unintended consequence of policy requiring autopsy (post mortem or PM) for all maternal deaths Distinguish between „routine‟ PMs & Coroners cases Routine PM – hospital pathologist Hospital death within 24 hours of admission Death within 72 hours of surgery Uncertain cause of death during admission Maternal deaths (in hospital) Coroner‟s case – forensic pathologist Accidental deaths Violence, including suicide Sudden unexpected death in previously healthy person Including maternal deaths in the community Death where no medical certificate forthcoming
MCCD: JAMAICA – NOT GOOD FORIDENTIFYING MATERNAL DEATHS Check box not being used: 1 in 8 certificates only Font size too small, ignored Duration of illness often missing Late deaths being misclassified Revised MCCD should ask “if female 10-50 years” 1. At the time of death was she pregnant (y/n) 2. Did she have a pregnancy which ended in past year (y/n) 3. If yes, date pregnancy ended: ___________ 4. Gestation: < 22 weeks ≥ 22 weeks or unknown
TRANSCRIPTION ERRORS Poor penmanship Inadequate understanding of medical termsRegistrars and coders should be required to: i. Have basic course in human biology/anatomy ii. Understand medical terminology iii. Understand common pathways from underlying to immediate cause of death Electronic certification Now being field tested for births Medium term plan for deaths
CODING MATERNAL DEATHS RGD coders Lack of training to manually code maternal deaths Limited experience coding difficult cases Over-reliance on ACME/MICAR coding software to perform functions not intended to perform 1 in 3 pregnancy related deaths=late deaths 096=late deaths O97=deaths from sequelae of pregnancy related conditions >1 year Deaths of clinical significance for programme planners despite lack of statistical importance WHO guidelines forthcoming (October 2012)
TRENDS: MISCLASSIFICATION OF MATERNALDEATHS, 1981-83; 1998; 2008 70 64 49 54 60 50 44 36 36 36 40 25 30 19 20 13 13 10 0 Maternal Registered Pregnancy Coded as deaths mentioned maternal Avg/yr 1981-83 1998 2008References:1981-83: Walker et al. Identifying maternal deaths in developing countries, IJE 1990 19: 599.1998: McCaw-Binns et al. Multi-source method for determining mortality in Jamaica: 1996 and 1998. Report to PAHO, 2002.
MATERNAL MORTALITY TRENDS: JAMAICA 1981-2009 (RATIO/100 000 LIVE BIRTHS) 1981-3 1986-7 1993-5 1998-0 2001-3 2004-6 2007-9 118.6120 98.7100 86.3 80 60 46.9 36.4 40 20.8 20 16.7 5.2 1.6 0 Total Direct Indirect Coincidental Late
SUMMARY OF CERTIFICATION & REGISTRATIONEFFECTS ON MMR – 2008, JAMAICA Maternal Mortality Ratio /100 000 live births Missed cases RGD Poorlymisclassified, 6 certified, 16 4 Other, 40 Not registered, 24 RGD O code, 24
CRUDE BIRTH RATE AND MARITAL STATUS:1948 – PRESENT: JAMAICA 90 83.6 1948 80 1953 Rate/ 1000 70 population 1958 60 1963 52.4 1968 50 1973 40 1978 30 1983 1988 20 16.5 1993 10 1998 0 2003 Crude birth rate Out of Father 2005 wedlock(%) registered(%) Source: Demographic Statistics
ACKNOWLEDGEMENTS REGISTRAR GENERAL‟S DEPARTMENT INTER-AMERICAN MINISTRY OF HEALTH/REGIONAL HEALTH AUTHORITIES DEVELOPMENT BANK MINISTRY OF NATIONAL SECURITY/JAMAICA PLANNING INSTITUTE OF JAMAICA CONSTABULARY DELAWARE GRUPO (ESP) MINISTRY OF JUSTICE/CORONER‟S COURTS DATA COLLECTION TEAM