UNIVERSITY OF WASHINGTON

Maternal Mortality in Mexico:lessons learned from improvingthe data quality

Prof. Rafael Lozano, IHME and former General Director of Health Information at the Ministry of Health in Mexico

Measuring the Progress on Maternal and Child Mortality:Data, alternative methods, and findings

Washington, D.C. May 24th, 2010

La democratización de la salud en México

Hacia un sistema universal de salud

Programa Nacional de Salud 2001-2006

National Health Program 2001-2006 Annual Report of Accountability

How do we measure and report progress?

•Benchmark by state

•Selected health indicators

1)Health Outcomes2)Health System Performance

o Qualityo Fair Financeo Health Resourceso Health expenditure

•The best performance for specific health interventions

Annual Report of AccountabilityMexico-Salud (2001)

Under-five mortality rate

MMR was not included in first Annual Report of Accountability !!!• There was evidence that maternal deaths were under registered

in Mexico

o WHO (2000) used a correction factor of 1.4

o National Survey of Demographic Dynamic (ENADID 1997) showed 38% under registry

• Evidence was national only; not sufficient at subnational level

• In 2001, evidence gathered showed misclassification of causes of death as a major component of the problem (study in 9 states)

• After deliberation, Minister supported decision not to publish MMR

…We need an instrument that at the same time can improve the quality of the measurement and include all the actors in the exercise .....

Implications of the decision

• Skepticism of the program managers of Reproductive Health

• Disbelief of many … we were giving more importance to the use of healthy information, even for a very sensitive indicator…

o Presidential Goal; NHP Goal; MDG 5

• Opportunity for NGOs to give input

The challenge of counting maternal deaths

Objective: To produce timely and reliable indicator (MMR) by state and involve all relevant participants

•Designed a passive identification of maternal deaths in women of reproductive age using death certificate records and a special list of potential causes of maternal- or pregnancy-related deaths

•Participants

o State Health Systems (MOH); other health providers (social security, private, etc.); other statistics agencies (INEGI, RENAPO, etc.)

o Information areas, epidemiological surveillance, reproductive health, at federal and state level

The challenge of counting maternal deaths

• Process

o Collect all information available of each “potential maternal death”: Medical records, Verbal Autopsy, Death Certificate, Maternal Mortality Committee Report, Critical Links of maternal deaths, etc.

o Verify one by one with INEGI database

o Incorporate those which qualify as new registries into the “official” mortality database (INEGI)

o Include the reliable numbers by state in the Annual Report of Accountability (August). These numbers should match with the consolidated statistics of causes of death in the official INEGI release (November)

Passive identification of maternal deaths from VR

Confirmed maternal deaths in

2002

38 597 5 849 1 330

Possible maternal deaths

Deaths of women 10-

54 years

Short-term effects of the publication 2002• Following a long debate about the limitations of the method

selected, we received the support of the authorities of the States Health Systems and other health providers

• Special attention to NGOs, without total success

o Small correction of underreporting, because deaths from indigenous areas still not included in the statistics

• Newspapers treated the publication harshly

o Rates seemed to be getting worse instead of improving

Mid-term effects of the publication (2002-2008)

• Empowerment of neglected areas in the state health systems, such as: information and evaluation (more training)

• More attention to keeping the data healthy and the process transparent

• More credibility from NGOs

• Better culture of information1,221 maternal deaths addeddeaths %

Maternal Mortality Ratio Crude and Predicted

Mexico, 2000-2015

Source: Lozano R 2008 MMR per 100,000 lb

0.0 30.0 60.0 90.0 120.0 150.0 180.0

Low

Medium

High

Very High

Very Low

0.0

10.0

20.0

30.0

40.0

50.0

60.0

70.0

80.0

90.0

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015

RMM

x 1

00,0

00 lb

Predicted UNICEF,OMSCrude after passive identification

Maternal deaths in Mexico, 1980-2008

Sources: MoH/INEGI. crude or “official”Hogan, et al. 2010: Low, Media, High

Maternal deaths in Mexico, 1980-2008

25-29 years 30-34 years

Lessons learned

• The health of the data and the health of the program = the health of women

• Annual accountability reports have improved the quality of the numbers of maternal deaths in Mexico and created better culture of information

• Even in times of scandal and controversy, it is better to provide reliable numbers

• When you do not know the correct level of maternal deaths in the past, it is very difficult to know where you are now

• New methods and tools can help countries better measure the progress