Vital registration maternal mortality. Case of Jamaica
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Transcript of Vital registration maternal mortality. Case of Jamaica
WHY VITAL DATA UNDER-COUNT MATERNAL DEATHS IN DEVELOPING COUNTRIES -- CASE STUDY, JAMAICA: 2008
AFFETTE MCCAW-BINNSReproductive Health EpidemiologistUniversity of the West Indies, Mona, JamaicaYVETTE HOLDER International Biostatistics and Information Services, St LuciaJASNETH MULLINGSUniversity 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
Investigate reported deaths (community, hospital) Review deaths in women 10-50 years to identify
maternal and late maternal deaths
DEATH CERTIFICATION: MATERNAL DEATHS 43RD 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 & AIM
Change in Approach: Estimating Maternal Mortality: vital data vs. RAMOS data
WHO/UNICEF, World Bank, 2005 and 2008 Hogan, et al; 2008 and 2011
Jamaica’s efforts to modernize vital registration system
Aim 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)
DEATHREGISTRATIONFORM (DRF)
1. Cause of death transcribed from MCCD by registrar
2. Include demographic data
3. Code4. Select
underlying cause
5. Data entry
12
3
4
FORM D – CORONER’S CASES
Form D:Replaces MCCD
Same demographic and clinical information as MCCD but….
Not updated to include:a. Duration of illnessb. Pregnancy check
box
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 DDRFdatabase)
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).
FINDINGS
FLOW CHART – SHORT LISTED CASES
31 incorrectly coded
18 correctly coded
65 registered
44 WHO-defined
maternal deaths
19 non-pregnancy related
19 registered
1 ‘C’ coded ‘O’
10 WHO-defined
maternal deaths
81 pregnancy-related
16 not registered
100 Possible maternal deaths
4 late maternal & 2 coincidental
deaths
13 coded O00-95
2 coded O00-95
16 late maternal &
5 other deaths
0coded ‘O’
19 correctly coded
TIMELINESS OF MATERNAL DEATH REGISTRATION,BY REGION OF DEATH: 2008
JAMAICA South east North east South West0
102030405060708090
100
71.7
92.6
75 72.7
18.224.5
6.4
25 27.3 27.3
<3 months 3-11 months1-2 years Not registered (>2 years)
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, BY CATEGORY OF MATERNAL DEATH: JAMAICA, 2008
ALL DEATHS
Direct Indirect0
10
20
30
40
50
60
18.2
6.7
42.9
No mention of pregnancy/birthPregnancy check box only usedExplicit* reference to pregnancyImplicit** ref-erence
*EXPLICIT – use of terms such as pregnancy, abortion, childbirth on MCCD
** IMPLICIT -- implied in COD such as eclampsia, PPH, puerperal cardiomyopathy
ACME/SUPERMICAR: RGD, JAMAICA!
RGD code: A41.9 (sepsis)UWI/MMS code: O13ACME (Ja): I51.9 (heart dis)
SOURCES OF INFORMATION LOSS, MATERNAL MORTALITY RATIO: JAMAICA - 2008
Total 0
20
40
60
80
100
120
140 127.5
103.9
89.7
75.5
18.9 23.7
ALL DEATHSRegistered‡Maternal mortality surveillance‡Registered <3 monthsPregnancy men-tionedPregnancy men-tioned & registered <3 monthsPregnancy check box usedICD10 O code assignedICD10 O code & reg-istered <3 months
‡Not the same cases
CAUSE OF WHO MATERNAL DEATHS, BY SOURCE OF INFORMATIONCause of death All sources Maternal mortality
surveillanceFact of pregnancy on
MCCD/Form DRegistered <3 mo. & coded as maternal
Number Number % missed Number % missed Number % missedTOTAL 54 44 17.0 36 33.3 10 81.1DIRECT DEATHSHypertension 16 15 6.3 13 18.8 5 68.8Haemorrhage 8 7 12.5 7 12.5 2 75.0First trimester events 7 2 71.4 4 37.5 0 100Other direct deaths 6 5 16.7 4 0 2 66.7Subtotal – direct 37 29 21.6 28 24.3 9 75.0INDIRECT DEATHSCardiovascular 6 6 0 4 33.3 1 83.3Neoplasm 4 3 25.0 1 75.0 0 100Sickle cell disease 3 3 0 3 0 0 100Other indirect 4 4 0 0 100 0 100Subtotal – indirect 17 16 5.9 8 52.9 1 94.1MMR /100 000 127.2 106.0 84.9 23.6
DISCUSSION
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 FOR IDENTIFYING 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 terms
Registrars and coders should be required to:i. Have basic course in human biology/anatomyii. Understand medical terminologyiii. 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 MATERNAL DEATHS, 1981-83; 1998; 2008
Mat
erna
l dea
ths
Registe
red
Preg
nanc
y m
entio
ned
Coded
as m
ater
nal
0
20
40
60
64
3625 19
49
36
13
5444
36
13
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: JAMAICA1981-2009 (RATIO/100 000 LIVE BIRTHS)
Total Direct Indirect Coincidental Late0
20
40
60
80
100
120118.6
98.7
16.7
1.6
86.3
46.936.4
5.2
20.8
1981-3 1986-7 1993-5 1998-0 2001-3 2004-6 2007-9
SUMMARY OF CERTIFICATION & REGISTRATION EFFECTS ON MMR – 2008, JAMAICA
RGD O code, 24
RGD misclassi-fied, 64
Not regis-tered; 24
Poorly certified; 16Maternal Mortality Ratio
/100 000 live births Missed cases
CRUDE BIRTH RATE AND MARITAL STATUS: 1948 – PRESENT: JAMAICA
0
10
20
30
40
50
60
70
80
90
Crude birth rate Out of wedlock(%)
Father registered(%)
16.5
83.6
52.4
1948195319581963196819731978198319881993199820032005
Rate/ 1000population
Source: Demographic Statistics
TREND – NUMBER OF BIRTHS, BY MATERNAL AGE: JAMAICA: 1999-2007
<20 20-24 25-29 30-34 35-39 40+0
2000
4000
6000
8000
10000
12000
14000
199920002001200220032004200520062007
ACKNOWLEDGEMENTS
INTER-AMERICAN DEVELOPMENT BANKPLANNING INSTITUTE OF JAMAICADELAWARE GRUPO (ESP)
REGISTRAR GENERAL’S DEPARTMENTMINISTRY OF HEALTH/REGIONAL HEALTH AUTHORITIESMINISTRY OF NATIONAL SECURITY/JAMAICA CONSTABULARYMINISTRY OF JUSTICE/CORONER’S COURTSDATA COLLECTION TEAM