Can studying the pattern and circumstances of women’s deaths over a period of time really create sustainable change? In my country, Georgia, it has happened.
Over the last seven years, USAID and JSI supported two reproductive age mortality studies (RAMOS) in Georgia. Reproductive age mortality studies are important because they identify and investigate the causes of all deaths of women of reproductive age (WRA) and determine the burden of disease among women of reproductive age. Properly conducted, the RAMOS approach is considered to provide the most complete estimation of maternal mortality (WHO 2004).
When Georgia conducted its first RAMOS in 2008, a team from the U.S. Centers for Disease Control (CDC) came to train experts from Georgia’s National Center for Disease Control (NCDC) in how to conduct the study.
The results from that first RAMOS, which used 2006 data, were groundbreaking. Among other things, Georgia learned that breast cancer was the leading cause of death among reproductive age women. Georgia also learned that its national system for registering maternal and other deaths of reproductive age women was seriously flawed and needed to be fixed.
When an opportunity arose to conduct a second RAMOS in 2014, using 2012 data, the Georgian NCDC jumped at the chance. Except this time, they conducted the entire study on their own, without any outside technical assistance. With this, the NCDC has proven it has the internal capacity to conduct successfully large, population-based studies that can inform policy decisions.
The results from the second RAMOS were again astounding. Maternal mortality declined by 40% between 2006 and 2012, which is a huge accomplishment for Georgia.
The second RAMOS also found that nearly all deaths (98%) among women of reproductive age were registered in Georgia’s vital registration system. This is a significant improvement over the death registration results from RAMOS 2008, which found that only (84%) of all deaths among women of reproductive age (WRA) were registered.
Between the first and second RAMOS, the Georgian government initiated several successful initiatives to improve the registration of deaths. First, the country’s widely recognized civil registration reform introduced legislative and administrative regulations and interventions (e.g. a monetary penalty was imposed on all responsible bodies for failing to report death events, Georgia instituted electronic medical death certificates [as opposed to paper]), which resulted in improved death registration coverage.
Second, the State Statistics Office began to match maternal death records against birth and fetal death records. And the NCDC began active surveillance of maternal mortality by incorporating WRA deaths into an already existing, integrated electronic disease surveillance system and implementing a verbal autopsy methodology and medical records audits. These sustainable initiatives have had profound implications for correctly identifying maternal deaths.
As the recent Lancet series “Counting Births and Deaths” points out, “civil registries and vital statistics systems not only contribute to better health outcomes in the long term, but are also a necessary component of sustainable development.”
Yet to make birth and death registration data even more useful for public health decision making, Georgia needs to make further improvements in the quality of reported cause-of-death statistics and decrease the number of poorly defined causes of death. Indeed, the second RAMOS found that discrepancies with official statistics in determining and coding underlying causes of death are still large (46.6%).
Turning back to maternal health issues, infection (21.7%) and obstetric hemorrhage (17.4%) were the leading causes of direct maternal deaths. Sub-standard care by health care providers and poor organization of health services remain the most important avoidable factor in maternal deaths.
JSI is currently working intensively with Georgia’s Ministry of Health to introduce sustainable measures to prevent avoidable maternal deaths including: 1) ensuring pregnant women at risk receive care in facilities that are able to provide the required level of specialized care (i.e., implement a perinatal care regionalization policy); 2) improving coordination of maternal care throughout the continuum of antenatal, intrapartum, and postpartum care; and 3) establishing nationwide comprehensive quality measures and increasing accountability for the quality of services.
In addition to producing extremely useful data for decision- and policy-making, RAMOS has also spurred the adoption of several far-reaching and sustainable initiatives that, together, will save women’s lives and help strengthen the entire Georgian health system.