Lessons learned and strategies for improvement

November 2, 2010

Rafael Lozano

Professor of Global Health

OutlineLessons Learned

Increase Vital Registration Completeness

Reduce Misclassification

Increase Opportunities for Multiple Measurements

Introduce Nation-Wide Verbal Autopsy

Shorten Analysis Time

Conclusions

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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%

o Includes Egypt, Albania, Tunisia, El Salvador, Romania

• Other countries are achieving substantial progress

o Including China, Bolivia, Ecuador, Peru, Rwanda

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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

o 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

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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

o 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

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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.

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OutlineLessons Learned

Increase Vital Registration Completeness

Reduce Misclassification

Increase Opportunities for Multiple Measurements

Introduce Nation-Wide Verbal Autopsy

Shorten Analysis Time

Conclusions

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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.

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OutlineLessons Learned

Increase Vital Registration Completeness

Reduce Misclassification

Increase Opportunities for Multiple Measurements

Introduce Nation-Wide Verbal Autopsy

Shorten Analysis Time

Conclusions

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Correcting Misclassification and underreporting• Some experiences

o Mexico

o Developed countries (UK, USA, etc.)

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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 deathso 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.

o Corroborate one by one with INEGI database and Incorporating those which qualify as new registries into the “official” mortality database (INEGI)

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1,320 Mat. deaths added = 13.2% in 8 years %Deaths

Correction of Misclassification of Maternal Deaths, Mexico 2007-2008

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All4digit 4digit 3 digit 2 digit

Correct 54.0 42.6 65.7 78.2Direct obstetric misplaced (000-095) 28.0 44.6 21.5 9.0Direct obstetric misplaced and should be Indirect 1.6 - - -Indirect obstetric misplaced and should be Direct 4.4 4.5 4.5 4.5Indirect obstetric misplaced 1.5 - - -Early maternal deaths tha shoul be late maternal 0.8 - - -Maternal Missclasiffi ed 9.8 8.2 8.2 8.2Total 2,324 160 160 160

Abortion

Cause

Maternal deaths

Correct

(4th digit) %

Direct misscoded

Indirect misscoded

Out of chapter

Abortion 157 42.6 44.6 4.5 8.3Hypertensive dis. Pregnacy 561 43.1 49.6 4.1 3.2Haemorrhage pregnancy, labor or pueperium 551 63.7 29.0 4.0 3.3Other complications during pregnancy and labor 292 41.4 38.4 10.6 9.6Sepsis and other complications of puerperium 176 57.4 15.9 9.7 17.0Indirect Obstetrics 507 66.7 7.3 6.9 19.1Late maternal 71 42.3 21.1 5.6 31.0Total 2,324 54.0 30.2 6.0 9.8

Type of Misclassification

Abortions out of Maternal Chapter, Mexico 2007-2008

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Before Correction After CorrectionICD 10th Name ICD 10th Name

A419 Septicaemia, unspecified O021 Missed abortion

A419 Septicaemia, unspecified O060 Unspecified Ab., Incomplete, complicated by genital tract and pelvic infection

A419 Septicaemia, unspecified O063 Unspecified Ab., Incomplete, with other and unspecified complications

D65X Disseminated intravascular coagulation [defibrination syndrome] O041 Medical, Incomplete, complicated by delayed or excessive haemorrhage

D65X Disseminated intravascular coagulation [defibrination syndrome] O061 Unspecified Ab.,Incomplete, complicated by delayed or excessive haemorrhage

D849 Immunodeficiency, unspecified O061 Unspecified Ab.,Incomplete, complicated by delayed or excessive haemorrhage

J189 Pneumonia, unspecified O055 Other Ab., Complete or unspecified, complicated by genital tract and pelvic infection

N180 End-stage renal disease O060 Unspecified Ab., Incomplete, complicated by genital tract and pelvic infection

N710 Acute inflammatory disease of uterus O055 Other Ab., Complete or unspecified, complicated by genital tract and pelvic infection

N719 Inflammatory disease of uterus, unspecified O065 Unspecified Ab., Complete or unspecified, complicated by genital tract and pelvic infection

N735 Female pelvic peritonitis, unspecified O060 Unspecified Ab.,Incomplete, complicated by genital tract and pelvic infection

N939 Abnormal uterine and vaginal bleeding, unspecified O061 Unspecified Ab., Incomplete, complicated by delayed or excessive haemorrhage

R688 Other specified general symptoms and signs O051 Other Ab., Incomplete, complicated by delayed or excessive haemorrhage

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.

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OutlineLessons Learned

Increase Vital Registration Completeness

Reduce Misclassification

Increase Opportunities for Multiple Measurements

Introduce Nation-Wide Verbal Autopsy

Shorten Analysis Time

Conclusions

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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.

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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.

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OutlineLessons Learned

Increase Vital Registration Completeness

Reduce Misclassification

Increase Opportunities for Multiple Measurements

Introduce Nation-Wide Verbal Autopsy

Shorten Analysis Time

Conclusions

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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.

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VA Data Collection Strategies

• Verbal autopsy for a representative sample of deaths can be obtained through three strategies:

1)Using verbal autopsy in a sample of communities where there is active surveillance of deaths e.g. SRS in India

2)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

3)Using verbal autopsy in household surveys. Verbal autopsy can be included for sibling deaths and deaths in the household

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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.

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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.

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OutlineLessons Learned

Increase Vital Registration Completeness

Reduce Misclassification

Increase Opportunities for Multiple Measurements

Introduce Nation-Wide Verbal Autopsy

Shorten Analysis Time

Conclusions

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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.

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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.

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OutlineLessons Learned

Increase Vital Registration Completeness

Reduce Misclassification

Increase Opportunities for Multiple Measurements

Introduce Nation-Wide Verbal Autopsy

Shorten Analysis Time

Conclusions

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Improved Maternal Mortality Measurement• National assessment of maternal mortality will improve:

1) with the accumulation of more measurements,

2)creation of enhanced national capacity to understand and analyze data sources,

3)data sharing so that different analysts can interpret all the available data and

4)a community of analysts who can share lessons learned across countries within a region and between regions.

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