-Thailand
Program
Health Policy
International
-Thailand
Program
Policy
Health
International
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 Statistics
11-13 October 2010
Manila, Philippines
ESA/STAT/AC.219/36
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Outline
• Introduction
– MDG achievements and maternal death in Thailand
• Different approaches and statistics 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)
• Conclusions and policy recommendations
Maternal death in Thailand
450
400
MMR per 100,000 live births
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MMR 1960-2006: six sources of references
350
BPS
300
BHP
250
RAMOS
200
TDRI
Lancet 2010
150
WHO
100
50
0
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
3
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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 data by TDRI,
– RAMOS technique and verbal autopsy (VA).
Bureau of Policy and Strategy (BPS),MOPH
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• 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
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Rates of Maternal Deaths per 100,000 Live births by
Cause Grouping According to ICD
16
14
O95-O99
12
O85-O92
10
O80-O84
O60-O75
8
O30-O48
6
O20-O29
O10-O16
4
O00-O08
2
0
2002
2003
2004
2005
2006
2007
source : Health Information Unit, Bureau of Health Policy and Strategy
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Using Multiple Data for Calculating the Maternal
Mortality Ratio 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
Birth Registration Obtain
PID of mother
Death Registration Obtain
PID
Match same PID from the date of
birth plus 42 days
Match PID with death certificate
Obtain the recorded cause of death
Maternal death
Incidental cause of death
8
Method 2: Women Ending Pregnancy with Stillbirth or Neonatal
Death registration Obtain PID of
reproductive-aged women
Match same PID of
those who have in
patient records nine
month before the date
of death
In patient record
from CSMBS obtain
PID
&ICD 10
In patient record
from UC Obtain
PID & ICD10
Match PID with death certificate
Obtain the recorded cause of death
Maternal death
Incidental cause of death
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Maternal mortality ratio using TDRI approach
were more than 3 times higher than the estimate
from BPS of MOPH
10
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The Reproductive Age Mortality Survey (RAMOS)
Method
• Primarily quantitative
• Qualitative for verbal autopsies
Approach
Identifies and investigates all deaths of women
of reproductive age (15-49 years) using
multiple data sources.
Phase 1: Death Identification
Phase 2: Death Review
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The 1st Phase: Death Identification
Identify all deaths in the community through
one or more sources as listed below:
•
•
•
•
•
Routine death registrations
Medical records in health facilities
Interviews with health care providers
Census
Multiples sources of information
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The 2nd Phase: Death Review
Investigate deaths of women reproductive age to
determine the cause of death and relatedness to
pregnancy 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
BPS – MOPH
1990
1995 1997 2000 2002
2004
2005
2006
25.0
10.7
13.3
12.2
11.7
44.5
37.4
41.6
9.7
13.2
TDRI
RAMOS* &
verbal autopsy
WHO & UNICEF
14.7
44.3 36.5
50.0
52.0
63.0
51.0
Source: Bureau of Health Promotion 2006
Note:
BPS = Bureau of Policy and Strategy
MOPH = Ministry of Public Health
TDRI = 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.
Strengths and Weaknesses
Approaches
Weaknesses
BPS, MOPH
• Availability of routine data
• Coverage of birth and death
registration over 95%
• High proportion of illdefined 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
-Thailand
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Strengths
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Conclusions and policy recommendation
• High gaps between the estimate of MMR from vital
registration and other approaches,
• Improve accuracy of estimate MMR in any
approaches inevitably need completeness and
accuracy of vital registration,
• In developing countries, it is unlikely to conduct
RAMOS either annually or biennially due to limited
resources and time consuming,
• 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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Thank you for your attention