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Lesson Learnt from the Estimate of

Maternal Death in Thailand

Kanjana Tisayaticom Sudarat Tantivivat Phusit Prakongsai

International Health Policy Program (IHPP), Thailand

The 3rd Global Forum on Gender Statistics11-13 October 2010Manila, Philippines

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Outline

• Introduction– MDG achievements and maternal death in

Thailand• Details about different approaches on the

estimate of maternal death – Vital statistics - Bureau of Policy and Strategy,

MOPH– Multiple sources of data - Thailand Development

Research Institute (TDRI) – Reproductive age mortality surveys (RAMOS) and

verbal autopsy (VA) – Bureau of Health Promotion, MOPH

• Strengths and weaknesses of each approach• Conclusions and policy recommendations

Thailand: Country BackgroundPopulation in million (2008) 66.3 (~64)

Administrative areas (provinces) 76

Per Capita Income ($ in 2008) $4,125

% Growth GDP (2008) 2.6

% Population in urban area 31.6

Life expectancy at birth in years (2008)

70.5 yr male75.3 yr female

%Total health exp. of GDP in 2007

3.7

% public financing on health (2007)

73

Per capita total health expense (2007)

$144

Human Development Index (2007)

0.783

Infant Mortality Rate per 1000 live birth (2008)

18.23

Thailand achieved almost all MDGs in advance of 2015.

From the baseline data in 1990, significant achievements in:- poverty reduction,- gender equality in education,- HIV/AIDS and malaria infection, - access to safe drinking water and sanitation.

However, achieving reduction in MMR seems to be problematic.

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Maternal death in Thailand

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MMR 1960-2006: six sources of references

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1960 1962 1964 1966 1968 1970 1972 1974 1976 1978 1980 1982 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004 2006 2008

Year

MM

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BPS

BHP

RAMOS

TDRI

Lancet 2010

WHO

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Objectives of the study

• To describe differences in maternal death in Thailand using different types of data sources and data collection approaches,

• To explore strengths and weaknesses of three different approaches in estimation of maternal deaths in Thailand– Using vital registration by BPS, MOPH– Using multiple sources of data by TDRI,– RAMOS technique and verbal autopsy (VA) by

BHP.

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1.

Bureau of Policy and Strategy (BPS)

,MOPH

• Vital registration – Death registration (coverage 95.2% in 2006: SPC 2005-2006) – Birth registration (coverage 96.7% in 2006: SPC 2005-2006)

• Coding cause of death using ICD 10 by BPS staff • Pregnancy, childbirth and the puerperium O00-O99

• O00-O08 Pregnancy with abortive outcome• O10-O16 Oedema, proteinuria and hypertensive

disorders in pregnancy, childbirth and the puerperium• O20-O29 Other maternal disorders

predominantly related to pregnancy• O30-O48 Maternal care related to the fetus and

amniotic cavity and possible delivery problems• O60-O75 Complications of labour and delivery• O80-O84 Delivery• O85-O92 Complications predominantly related to

the puerperium• O94-O99 Other obstetric conditions, not

elsewhere classified 7

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Rates of Maternal Deaths per 100,000 Live births by Cause Grouping According to ICD

8source : Health Information Unit, Bureau of Health Policy and Strategy

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Skilled birth attendance in Thailand, 1996-2009

Profile birth attendants, Thailand 1996-2009Source: Civil Registration

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25%

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75%

100%19

96

1997

1998

1999

2000

2001

2002

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2004

2005

2006

2007

2008

2009

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others

midwife

TBA

nurse

No assistant

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2. Using Multiple sources of data for calculating the MMR in Thailand by TDRI

• Data sources– Vital registration

• Birth registration• Death registration

– Inpatient data set • Civil Servant beneficiaries scheme• Universal coverage scheme

• Methods– Method 1: Mothers Who Died after Giving a

Live Birth– Method 2: Women Ending Pregnancy with

Stillbirth or Neonatal Death

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Method 1: Mothers Who Died after Giving a Live Birth

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Match same PID from the date of birth plus 42 days

Birth Registration Obtain PID of mother

Match PID with death certificate Obtain the recorded cause of death

Incidental cause of deathMaternal death

Death Registration Obtain PID

Method 2: Women Ending Pregnancy with Stillbirth or Neonatal death

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Match same PID of those who have in

patient records nine month before the date

of death

Death registration Obtain PID of reproductive-aged women

Match PID with death certificate Obtain the recorded cause of death

Incidental cause of deathMaternal death

In patient record from CSMBS obtain

PID &ICD 10

In patient record from UC Obtain PID & ICD10

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Maternal mortality ratio using TDRI approach

were more than 3 times higher than the estimate from BPS of MOPH

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3. The Reproductive Age Mortality Survey (RAMOS)

Method• Primarily quantitative• Qualitative for verbal autopsies ApproachIdentifies and investigates all deaths of

womenof reproductive age (15-49 years) usingmultiple data sources.Phase 1: Death IdentificationPhase 2: Death Review

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The 1st Phase: Death Identification

Identify all deaths in the community throughone or more sources as listed below:

• Routine death registrations• Medical records in health facilities• Census• Multiples sources of information

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The 2nd Phase: Death Review

Investigate deaths of women reproductive age todetermine the cause of death and relatedness topregnancy through various sources as list below:

• Medical records and coroners’ reports• Interview of health care providers• Interview of family members (Verbal Autopsy)

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RAMOS and other methods

1990 1995

1997

2000

2002 2004 2005 2006

BPS – MOPH 25.0 10.7

9.7 13.2

14.7 13.3 12.2 11.7

TDRI 44.5 37.4 41.6

RAMOS* & verbal autopsy

44.3

36.5

WHO & UNICEF

50.0 52.0

63.0

51.0Source: Bureau of Health Promotion 2006 & WHONote: BPS = Bureau of Policy and StrategyMOPH = Ministry of Public HealthTDRI = Thailand Development Research Institute* The reproductive age mortality studies (RAMOS) technique identifies and investigates all deaths of women of reproductive age (15-49 years) using multiple data sources. This method includes interviewing household members and health care providers.

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Strengths and WeaknessesApproaches Strengths Weaknesses

BPS, MOPH • Availability of routine data • Coverage of birth and death registration over 95%

• High proportion of ill-defined cause of death (COD)• Require skillful of coding• Require good collaboration between MOPH and Bureau of Registration Administration (BORA)

TDRI • Higher accuracy in delivery related maternal death • Include medically certified COD (IP data)

• High investment in data warehouse and IT infrastructures• Missing data of non hospitalize patient• Ethical violation : invasion of privacy

Reproductive Age Mortality Surveys (RAMOS)

• Can address the mortality of women of reproductive age• Can identify the underlying cause groups of maternal deaths

• Complex, Costly and time-consuming• Requires complete death report and multiple sources 18

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Conclusions and policy recommendations

• Big gaps between the estimate of MMR from vital registration (VR) and other approaches,

• Improve accuracy of estimate MMR in any approaches inevitably need completeness and accuracy of birth and death registration,

• In developing countries, it is unlikely to conduct RAMOS either annually or biennially due to limited resources and time consuming problem,

• Though Thailand has achieved high coverage of birth and death registration, high proportion of ill-defined cause of death (COD) is the major challenge.

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The way forward

• Improving accuracy in cause of death (COD) data from death registration,

• Attempt using multiple sources of data for validating MMR estimated by using vital registration only,

• Conduct verbal autopsy every five years,

• Request WHO and international development agencies to support development of simpler tools for investigating COD rather than using verbal autopsy.

Child mortality in Thailand from various sources of surveys

Source: Hill et al. Int J Epidemiol 2007 (with updates)

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SPC 1985 - direct SPC 1985 - indirect SPC 1995 - direct SPC 1995 - indirect

SPC 2005 - indirect SPC 2005 - direct Predicted