In the late 1970s clinicians were reporting maternal deaths incidences which were not consistent with the official statistics. This lead to Jamaica’s first confidential enquiry into maternal deaths which confirmed that less than a third of maternal deaths were being reported in vital data. As efforts to institute voluntary reporting failed, in 1998 Jamaica began maternal mortality surveillance classifying maternal deaths a class 1 notifiable event. This meant that all maternal deaths were to be reported to the Ministry of Health. Reported deaths were investigated by surveillance officers who also actively reviewed deaths in women of reproductive age to identify maternal and late maternal deaths.
In 1990 the 43rd World Health recommended the addition of a pregnancy check box to medical certificates to remind certifiers to consider whether the death was due to complication of pregnancy with suggested questions. The Jamaican registrar was advised of these recommendations but condensed the three questions to one which said “pregnancy ended within 42 days of death” and added it to the certificate in 2006. The maternal mortality surveillance committee was concerned that the wording might exclude women who died undelivered, and describes 25-33% of deaths each year. The check box has not been evaluated since its introduction.
After the Nairobi conference the millennium project created an environment where developed and developing countries agreed to work toward improving the quality of life for citizens in the developing world, with one of the outcomes being reducing maternal mortality. The millennium goals included indicators to monitor progress and created a measurement ethos around which measurement experts converged. Where data didn’t exist, then a great deal of time and money was invested in developing methodologies aimed at developing estimates of the outcome of the interest from whatever available data existed.
These models use proxy measures of risk including TFR, GDP, HIV prevalence, neonatal mortality and female literacy. The problem however is that the estimates that these models produced for Jamaica were not consistent with our research data.
With this move toward use of vital data as the basis for estimating maternal mortality Jamaica’s efforts to modernize our vital registration system, we aimed to understand why only one in five maternal deaths were consistently showing up in vital data
Pregnancy related deathswere identified from registered deaths, police cases and cases identified by the maternal mortality surveillance process. Short listed cases were selected from women 10-49 years regardless of whether coded to an obstetric code if the reported condition had a high likelihood of being associated with pregnancy.
This is a typically completed Jamaican Medical certificate. ►The check box, in a very small font and is often ignored. ►Also frequently ignored is the section on the duration of illness.
The information on the MCCD is transcribed to a death registration form or DRF by the registrar along with demographic information provided by the informant. ►It is on this form the coders record the ICD10 codes for the listed conditions and then ►select the underlying cause of death. Then it goes to data entry. For this young lady, while they appropriately select O99.4 to represent the heart disease complicating pregnancy, the I05 (mitral stenosis) is selected as the underlying cause.
Cases passing through the Coroner’s courts are registered using a Form D. For the most part it carries the same demographic and clinical information as the medical certificate however it has not been updated to include information on duration of illness or include the pregnancy check box.
Cases were classified as direct, indirect, coincidental or late maternal and analysed using SPSS. We looked at demographic and clinical factors associated with non-registration and misclassification of deaths and measured the impact of data quality issues on the maternal mortality ratio.
Three of four deaths were registered within 3 months of death, the time period necessary to ensure that a death gets counted for statistical purposes. Timeliness of registration however varied by health region from 93% in the south east to only 18% in the western region.
Of the 44 registered deaths, we were able to inspect 32 medical certificates and 5 Form Ds, used to register Coroners cases. 7 supporting documents were not located.► the pregnancy check box, which only appears on the medical certificate, was only used in 8 instances, correctly for 7 while for the 8th case the doctor checked no to the question ‘pregnancy ended within 42 days of death’ for a woman who died undelivered.►Likewise, duration of illness was also only reported on one in four certificates.
Performance improves however, with the logical sequence appropriate for 64% of certificates, including the Form Ds. One however had the underlying cause on line A and in another 7, things were a bit jumbled.►When we compared the surveillance reports to the certificates, in 8 instances doctors omitted important information which would have contributed to the misclassification of the cause of death. For example, one woman had eclampsia and a stroke at one hospital and was transferred to a tertiary hospital where she died in the ICU. Only the stroke was listed on the medical certificate; the doctor inappropriately thought it was adequate to only note the condition for which she was being treated in the ICU. These omissions however more often occur for indirect than direct deaths.
The fact of pregnancy should be noted on the medical certificate to prevent misclassification. This may include the explicit use of terms such as pregnancy, abortion or childbirth either in part 1 or 2 of the certificate. Pregnancy may also be implied from direct causes of death such as eclampsia, post partum haemorrhage or puerperal sepsis.Fact of pregnancy was omitted from 16% of certificates, particularly indirect deaths where more than 1 in 3 certificates failed to note this information. In a few indirect deaths, only the check box was used but this information was not transcribed to the death registration form which is coded.
This case represents how ACME/SuperMICAR, the NCHS coding software, functions in a developing world setting. This doctor used the ►check box and attempted to note duration of illness. ►Septicaemia was noted only in part II as a contributing cause, however the case appeared in the database as A41.9, sepsis of undetermined origin. When we enquired why the case was coded this way, the coder ran it through the ►ACME/superMICAR software and we were surprised when it spat back I51.9 for the cardiac disease listed on line b,► instead of the superimposed pre-eclampsia listed on line c.
This graph summarizes how Jamaican maternal deaths disappear. The universe of events consisted of 54 cases with a MMR of 128. 83% were registered, which is similar to the number picked up by the Ministry of Health’s maternal mortality surveillance system, they however were not the same cases. The 37 or 73% which had pregnancy explicitly mentioned or implied would have yielded an MMR of 87/100,000. The pregnancy check box was not very useful by itself. The greatest challenge however was that only 13 cases were coded by the RGD to an ICD-10 obstetric or O code, but only 10 were registered early enough to get counted for statistical purposes with the 2008. That rate was 23.7/100,000 compared to the 127.5 we started with.
So how do these registration and misclassification problems affect cause specific mortality? ►The first column shows the universe of deaths, the second cases identified by surveillance, the third the registered deaths with fact of pregnancy noted on the relevant certificates and the final column, those registered on time and coded to maternal causes.►Surveillance was missing 3 of 4 first trimester events, mainly community deaths from ruptured ectopic pregnancies. ►Both the surveillance and certification process were missing one in 4 direct deaths. When coding deficiencies were added, 3 of 4 direct deaths were being missed. ► Surveillance was more effective in identifying most of the indirect deaths, however certifiers were failing to record fact of pregnancy of half of the certificates, with only one indirect death correctly coded. ► In the end, the actual ratio of 127 end up as 24 per 100,000 in the official statistics, with 4 of 5 maternal deaths missed.While surveillance was picking up most indirect deaths, doctors were failing to note the fact of pregnancy on the certificates leading to 1 in 2 indirect deaths being lost at this stage. Poor coding practices however mean that more than 9 of every 10 indirect deaths were being missed.
Guidelines are need which distinguish between what are routine post mortems needed to clarify cause of death and Coroners cases. The former would be investigated by hospital pathologists who would advise the attending physician of their findings, who would then issue the medical certificate. Coroners cases would be referred to the forensic pathologist and restricted to cases of accidental deaths, violence and other sudden deaths outside of a medical facility.
The check box was only used on one in 8 certificates. It is probably being ignored because the font is too small. The wording was also misinterpreted by at least one person regarding one woman who died during labour; many certifiers are not completing the duration of illness part of the certificate and even when they do it is ingnored. Because the duration between delivery and death is not clearly noted some late deaths were misclassified. The revised certificate should include specific questions which clearly identify maternal deaths.
To get around the problems associated with deciphering poor penmanship, registrars and coders should have a basic understanding of human biology, anatomy and medical terminology. Coders in particular need to understand some of the common pathways from underlying to immediate cause so that they can qualitatively judge when certificates need to be returned for clarification. Electronic certification is now being field tested for births and should be included over the medium term for death registration.
Was 2008 typical? Well yes and now. Under-reporting is clearly a long standing problem, however more maternal deaths are registered, with better certification, more certificates bear evidence of the fact of pregnancy, however the coding practices at the RGD is letting us down.
As indirect deaths grow in increasing prevalence relative to all maternal deaths; misclassifications errors, if they persist, will increasingly under-estimate our maternal mortality ratio.
In summary, the 10 deaths registered on time and coded correctly by the RGD, give a MMR of 24/100,000. Another 64 deaths/100,000 could be added if the existing MCCDs were coded correctly, however 40/100,000 however would still be missed due to non-registration and poor certification. So, now we know why only one in 5 are officially reported in Jamaica. Is this problem unique to Jamaica or can be repeated in other developing countries where health information systems have been neglected for decades as countries faced with economic challenges and repeated IMF interventions to cut non-essential services have ignored these systems. Will the millennium project lead to revitalization of these systems or investment in more estimation?
Vital registration maternal mortality. Case of Jamaica
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