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