Lessons learned and  strategies for improvement November 2, 2010 Rafael Lozano Professor of Global Health
Outline <ul><li>Lessons Learned </li></ul><ul><li>Increase Vital Registration Completeness </li></ul><ul><li>Reduce Miscla...
Gaining Ground <ul><li>Global maternal deaths down to 342,900 in 2008 </li></ul><ul><li>Global trend is a 1.4% decline per...
Progress Undocumented But Not Unexpected <ul><li>Global total fertility rate has dropped from 3.70 in 1980 to 2.56 in 2008...
Adverse Impact of HIV <ul><li>Progress on reducing maternal mortality would have been much greater in the absence of HIV, ...
Analyze All the Evidence <ul><li>Making sense of levels of maternal mortality should begin with a careful consideration of...
Outline <ul><li>Lessons Learned </li></ul><ul><li>Increase Vital Registration Completeness </li></ul><ul><li>Reduce Miscla...
Incomplete Vital Registration Systems <ul><li>In the long-run, the most effective strategy for measuring maternal mortalit...
Outline <ul><li>Lessons Learned </li></ul><ul><li>Increase Vital Registration Completeness </li></ul><ul><li>Reduce Miscla...
Correcting Misclassification and underreporting <ul><li>Some experiences </li></ul><ul><ul><li>Mexico </li></ul></ul><ul><...
Systematic search of maternal deaths <ul><li>In 2002 the Mexican MoH started a  passive identification of maternal 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 <ul><li>Studies such as undertaken in Mexico can then lead both to improved ascerta...
Outline <ul><li>Lessons Learned </li></ul><ul><li>Increase Vital Registration Completeness </li></ul><ul><li>Reduce Miscla...
Wider Use of Sibling Histories in Household Surveys <ul><li>Sibling histories in the Demographic and Health Surveys and th...
Inclusion of Simple Pregnancy Related Death Questions in Censuses <ul><li>Another opportunity for measuring the pregnancy-...
Outline <ul><li>Lessons Learned </li></ul><ul><li>Increase Vital Registration Completeness </li></ul><ul><li>Reduce Miscla...
Verbal Autopsy <ul><li>In settings where medical certification of death for nearly all deaths is not feasible, verbal auto...
VA Data Collection Strategies <ul><li>Verbal autopsy for a representative sample of deaths can be obtained through three s...
Low-Cost High Validity VA <ul><li>Feasibility of implementing verbal autopsy can be dramatically improved if a standardize...
Global Congress on VA <ul><li>February 2011 the Global Congress on Verbal Autopsy will be held in Bali, Indonesia. </li></...
Outline <ul><li>Lessons Learned </li></ul><ul><li>Increase Vital Registration Completeness </li></ul><ul><li>Reduce Miscla...
Delays in Translating Data to Information <ul><li>Health measurement suffers in many settings from major delays.  </li></u...
Process Engineering Measurement <ul><li>Timely measurement is essential for having health information inform policy choice...
Outline <ul><li>Lessons Learned </li></ul><ul><li>Increase Vital Registration Completeness </li></ul><ul><li>Reduce Miscla...
Improved Maternal Mortality Measurement <ul><li>National assessment of maternal mortality will improve: </li></ul><ul><li>...
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maternal mortality sri lanka strategies for improving maternal mortality estimates in asia_lozano_110210_ihme

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

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