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Excess female mortality within the reproductive age group in South Africa

PresentationTo

Global Forum on Gender Statistics11-13 October 2010Manila, Philippines

Statistics South Africa11 October 2010

ESA/STAT/AC.19/9

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Presentation outline

• Overview of the functioning of the civil registration system: deaths

• Objectives

• Methods

• Results

• Limitations of the study and overall challenges faced

• Conclusion

• Way forward

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Overview of the functioning of the death registration system

• Statistics South Africa has a mandate to publish vital statistics based on deaths reported at the Department of Home Affairs

• The registration of deaths is governed by the Births and Deaths Registration Act, 1992 (Act No. 51 of 1992)

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Overview of the functioning of the death registration system continued

• The Department of Home Affairs collects information on deaths for administrative purposes:

• To update the population register

• To issue death certificates

• The form used to report a death is the BI-1663 form: Notification / Register of Death / Stillbirth

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The BI-1663 form

It consists of two pages

The Department of Home Affairs (DHA) is responsible for the first page.

It includes socio-demographic details of the deceased and particulars of the informant and funeral undertaker.

The Department of Health (DoH) is responsible for the second page.

It includes information on the causes of death.

The second page from DoH is submitted to DHA where the two pages are matched.

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Page one of the death notification form

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Page two of the death notification form

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Processing of death notification forms

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ICD-10 coding

Classification of causes of death

International Classification of Diseases, 10th revision (ICD-10) coding used to classify causes of death

“Code what you see” Rule Code up to three characters

Coding staff

20 Trained and experienced coders Regular up-dates and re-fresher courses Trained in anatomy and physiology, medical terminology Attend ICD-10 Standards meetings and NHISSA meetings

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Derivation of the underlying cause

ACME (2000 version) is used to automatically derive the underlying cause of death

ACME usually fails to derive about 1% of the total of deaths in a particular year

Rejected cases derived manually by selected staff

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Objectives of the study

• To assess the potential for usability of death registration data for maternal mortality estimation

• To verify the suspicion that there is excess female mortality at the reproductive age group in the era of HIV/AIDS

• To establish causes of death associated with excess female mortality

• To establish patterns and trends of maternal deaths reflected in these data

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Methods

• The scope includes registered deaths from 1999-2005

• Indirect methods of estimating completeness are used

• Comparison of sex ratios between the periods 1999-2001 and 2002-2005

• Comparison of leading causes between the two study periods

• Maternal mortality ratios are also provided

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• Completeness was found to be at about 91%: applying GGB and SEG

• Total numbers of female deaths aged 12-50 in 1999-2005

Pregnancy status

Number

Pregnant 9932

Not pregnant 202709

Unknown 1249

Unspecified 560616

Total 774506

Source: South African death registration dataNote: Figures may have been updated over time

Results

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Causes of death grouped according to ICD-10 chapters % Deaths

Pregnancy, childbirth and puerperium (O00-O99) 31

Infectious diseases (A00-B99) 26

Respiratory diseases (J00-J99) 9

Disorders of the immune mechanism (D80-D89) 7

External causes (V01-Y98) 7

Other natural causes 20

N 9932

Source: South African death registration data

Percentages of female deaths who died while pregnant, aged 12-50: 1999-2005

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Comparison of sex ratios – female deaths per 100 male deaths

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The ten leading natural causes of death for females aged 20-29

  1999-2001 2002-2005

Causes of death based on the Tenth Revision of the ICD Rank Frequency % Rank Frequency %

Tuberculosis (A15-A19) 1 15249 22.2 1 34104 22.9

Influenza and pneumonia (J10-J18) 2 8177 11.9 2 20773 14.0

Certain disorders involving the immune mechanism (D80-D89) 3 5523 8.0 5 11837 7.9

Human immunodeficiency virus [HIV] disease (B20-B24) 4 5036 7.3 3 9317 6.3

Intestinal infectious diseases (A00-A09) 5 4431 6.4 4 7937 5.3

Other viral diseases (B25-B34) 6 1990 2.9 6 5100 3.4

Other forms of heart disease (I30-I52) 7 1955 2.8 8 4062 2.7

Inflammatory diseases of the central nervous system (G00-G09) 8 1320 1.9 7 3096 2.1

Noninfective enteritis and colitis (K50-K52) 9 888 1.3 … 2589 1.7

Chronic lower respiratory diseases (J40-J47) 10 881 1.3 9 2353 1.6

Protozoal diseases (B50-B64) 11 863 1.3 10 1867 1.3

Ill-defined and unknown causes of mortality (R95-R99) 9122 13.3   18910 12.7

Other natural causes 13269 19.3   26961 18.1

Total   68704 100.0   148906 100.0

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Adjusted numbers of maternal deaths: 1999-2005

0

100

200

300

400

500

600

700

15-19 20-24 25-29 30-34 35-39 40-44 45-49

num

ber o

f mate

rnal

death

s

age

1999 2000 2001 2002

2003 2004 2005

• Adjusted for completeness of death registration for each age group, Estimated completeness using Extinct Generation Method

• Adjusted for unspecified pregnancy status: Proportional allocation of missing information based on specified pregnancy status

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Comparison of maternal mortality ratios

0

100

200

300

400

500

600

700

1998 1999 2000 2001 2002 2003 2004 2005

year

mat

erna

l dea

ths

per

100

000

live

birt

hs

Death registration Census 2001 UN DHS 1998

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Limitations of the study

• Incompleteness of death notification forms

• The proportions of unspecified for pregnancy status at the time of death range from 68% in 1999 to 75% in 2005

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Challenges faced: recording of information

• Lack of adherence to the guidelines for completing the death notification form provided on the Department of Health website

• Inconsistent information among variables on the death notification form

• High proportions of non-response for some demographic variables

• Invalid responses recorded on some variables

• Under reporting of female deaths

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Methodological and administrative issues among stakeholder departments

• Lack of a checking point for content quality at the Department of Home Affairs

• There is no cut-off date for collection of death notification forms for a specific statistical release

• Some forms that are separated during data capturing at the DHA may not be reconciled during processing

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Conclusions

• Vital registration data provides expected age patterns and trends of maternal mortality, therefore, usability is confirmed

• However, maternal mortality ratios derived from these data are implausibly low compared to those derived from enumerated data

• Excess female mortality is linked to the age group 20-29 in 2002-2005

• Leading causes of death for females aged 20-29 seem to be HIV/AIDS-related, also, shifting of rankings and proportions of deaths due to selected diseases signify misclassification of causes of death

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Way forward Improvements required in civil registration:

o Department of Home Affairs – coverage; fully completed and accurate information collected

o Department of Health – accurate and detailed certification of causes of deatho Statistics South Africa – accurate and timely production of vital statistics

Prioritising civil registration and vital statistics nationally and internationally, e.g.o African Ministers responsible for civil registration took a resolution that African

statisticians must prioritise civil registration and vital statistics (recommended as the next theme of African Symposia for Statistical Development)

Statistics South Africa to take the lead through National Statistics System to address problems identified with civil registration by forming partnerships to improve civil registration.

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Thank you