Lesson Learnt from the Estimate of Maternal Death in Thailand

1. 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

2. 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

3. Thailand: Country Background

4. 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.

5. Maternal death in Thailand 5

6. 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.

7. 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

8. Rates of Maternal Deaths per 100,000 Live births by Cause Grouping According to ICD source : Health Information Unit, Bureau of Health Policy and Strategy 8

9. Skilled birth attendance in Thailand, 1996-2009

10. 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

11. 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 11

12. Method 2: Women Ending Pregnancy with Stillbirth or Neonatal death 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 UC Obtain PID & ICD10 In patient record from CSMBS obtain PID &ICD 10 Match PID with death certificate Obtain the recorded cause of death Maternal death Incidental cause of death 12

13. Maternal mortality ratio using TDRI approachwere more than 3 times higher than the estimate from BPS of MOPH

14. 3. 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

15. 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 Census Multiples sources of information

16. 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)

17. RAMOS and other methods Source: Bureau of Health Promotion 2006 & WHO 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.

18. Strengths and Weaknesses

19. 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.

20. 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.

21. Child mortality in Thailand from various sources of surveys Source: Hill et al. Int J Epidemiol 2007 (with updates)