1. International Health Policy Program -Thailand Lesson Learnt from the Estimate of Maternal Death in Thailand Kanjana Tisayaticom Sudarat Tantivivat Phusit Prakongsai International Health Policy Program (IHPP), Thailand The 3 rd Global Forum on Gender Statistics 11-13 October 2010 Manila, Philippines

2. International Health Policy Program -Thailand Panel 2 B Gender disparities in refugee context Maternal Mortality in Maldives MMR Thailand US Pregnancy Mortality Maternal Mortality in Ghana CountryDataMMR (2006) MaldivesMinistry of Health69 ThailandVital registration11.7 USVital statistics system15.3 GhanaMinistry of Health187

3. International Health Policy Program -Thailand Maternal death Deffinitions Maternal mortality ratio :number of maternal deaths in a period per number live births during same period. MMR = (M/B) * 100,000 Maternal mortality rate : number of maternal deaths in a period per number of women of reproductive age during same period. Mmrate = (M/W 15-49)*100,000 Maternal Death: The death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and the site of pregnancy, from any cause related to or aggravated by the pregnancy or its management but not from accidental or incidental causes.

4. International Health Policy Program -Thailand Maternal mortality ratio (MMR) and Pregnancy-related mortality ratio (PMR): United States, 1979-2006 Deaths per 100,000 live births

5. International Health Policy Program -Thailand Conclusions No single system identifies all deaths due to pregnancy. Combining data from two systems provides a more precise measurement of maternal mortality. Use of a standard format checkbox increases ascertainment of pregnancy deaths. Mortality ratios increased significantly between 2002 and 2005 in states using a standard format checkbox in 2005 No significant increase in states without a checkbox in 2005

6. International Health Policy Program -Thailand 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

7. Thailand: Country Background Population 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 area31.6 Life expectancy at birth in years (2008) 70.5 yr male 75.3 yr female %Total health exp. of GDP in 20073.7 % 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

8. 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.

9. International Health Policy Program -Thailand Maternal death in Thailand 9

10. International Health Policy Program -Thailand 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.

11. International Health Policy Program -Thailand 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-O08Pregnancy with abortive outcome O10-O16Oedema, proteinuria and hypertensive disorders in pregnancy, childbirth and the puerperium O20-O29Other maternal disorders predominantly related to pregnancy O30-O48Maternal care related to the fetus and amniotic cavity and possible delivery problems O60-O75Complications of labour and delivery O80-O84Delivery O85-O92Complications predominantly related to the puerperium O94-O99Other obstetric conditions, not elsewhere classified 11

12. International Health Policy Program -Thailand Rates of Maternal Deaths per 100,000 Live births by Cause Grouping According to ICD 12 source : Health Information Unit, Bureau of Health Policy and Strategy

13. International Health Policy Program -Thailand Skilled birth attendance in Thailand, 1996-2009

14. International Health Policy Program -Thailand 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 14

15. International Health Policy Program -Thailand Method 1: Mothers Who Died after Giving a Live Birth 15 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 death Maternal death Death Registration Obtain PID

16. Method 2: Women Ending Pregnancy with Stillbirth or Neonatal death 16 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 death Maternal death In patient record from CSMBS obtain PID &ICD 10 In patient record from UC Obtain PID & ICD10

17. International Health Policy Program -Thailand Maternal mortality ratio using TDRI approach were more than 3 times higher than the estimate from BPS of MOPH 17

18. International Health Policy Program -Thailand 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

19. International Health Policy Program -Thailand The 1 st 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

20. International Health Policy Program -Thailand The 2 nd 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) 20

21. RAMOS and other methods 19901995199720002002200420052006 BPS – MOPH25.010.79.713.214.713.312.211.7 TDRI44.537.441.6 RAMOS * & verbal autopsy 44.336.5 WHO & UNICEF50.052.063.051.0 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.

22. International Health Policy Program -Thailand Strengths and Weaknesses ApproachesStrengthsWeaknesses 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 22

23. International Health Policy Program -Thailand 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. 23

24. International Health Policy Program -Thailand 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.

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