Tool Name: Reproductive Age Mortality Survey (RAMOS)Origin / Source: Multiple. Technical area: Maternal Health. Basic Description: The Reproductive Age Mortality Survey (RAMOS) is a type of study where all deaths among women of reproductive age (WRA; females 15 years to 49 years of age, or whatever span is appropriate for the culture, depending on average age at marriage and age at first birth, etc.) are reviewed to identify the cause of each death and ways to prevent such deaths. Most often, RAMOS are conducted retrospectively but may also be done prospectively if a population of WRA is monitored and all deaths are reviewed as they occur. Country Applications: Cape Verde,i Egypt,ii Indonesia, iii Pakistan,iv, v and others. Language(s) Available: English. Investigators have also translated their questionnaires into the local language as required Purpose: Results from RAMOS are most useful for evaluating the magnitude of maternal mortality and other causes of death among WRA, assessing the importance or burden of maternal causes of deaths relative to other causes of death, and conducting a needs assessment for health care service quality improvement to prevent maternal deaths. Technical Scope/Purpose: The RAMOS method provides a rich source of data useful to inform the many stakeholders in maternal health, including women and their families, community planners, and health care providers. RAMOS may be customized to address the needs of the researchers and communities. Types of data that can be collected during a RAMOS study include the following:
RAMOS can also provide an evaluation of the routine death registration in the community. Design: Retrospective survey with two phases of data collection: Phase one: Death Identification: This step requires identifying all deaths in the community to identify deaths among WRA. Deaths among women may be identified through either one source, if of adequate data quality, or multiple sources as listed below:
Phase two: Death Review: This stage involves investigating or reviewing WRA deaths to determine the cause of each death and relatedness to pregnancy. Data may be obtained from several sources, such as:
Because maternal deaths are relatively rare events, RAMOS studies are generally conducted on a population level and in a circumscribed setting. In settings with very large populations and many deaths among WRA, however, it may be possible to select a random sample of the deaths for further investigation. Method: Primarily quantitative. If verbal autopsies are conducted, qualitative data may also be collected. Frequency of Administration: Usually once as this method can be time and resource intensive, repeated use for monitoring maternal mortality over time may not be feasible in some settings. However, periodic death review may be helpful to monitor trends in maternal mortality in settings where there is no routine death registration, and it may allow evaluation of the effectiveness of reproductive health care services over time. Key Users of the Information: Health care providers; programmers and policy-makers who provide services to pregnant women; and communities. Key Indicators:
Tool Design: Methods to identify pregnancy-related deaths are optional, depending on the local availability and feasibility in the local setting. The duration of the study depends on the number of deaths among WRA that need to be investigated. Death investigation is a relatively time-consuming activity. For example, identification of deaths by a census among Afghan refugees in Pakistan took several months and it took one month to train interviewers, conduct verbal autopsy interviews among families of 66 WRA who died, input and analyze data and present a report to the participating non-governmental organization (NGO). The goal should be to have a population or area-based study population. Essential partners include local health care providers, NGO's, and the Ministry of Health, etc. Implementation and Training: The local study coordinator and/or principal investigator (PI) must be familiar with general survey methodology, including questionnaire development or adaptation, data collection techniques such as interviews and interviewer training, and data input and analyses. Depending on the local research skills available, external epidemiological technical assistance may be required. Depending on how deaths are identified, staff who participate in the first phase of this study (death idenification) may require instruction on reading death registration forms or death certificates or on actively finding deaths by asking people in the community (such as health care providers; religious leaders; grave diggers; and community leaders) if deaths among WRA have occurred. When deaths are identified, these staff will need to record each decedent's identification, age, and gender and what the source thinks was the cause of death. If more than one person is identifying deaths in one site, lists should be compared to ensure that duplicative counting of deaths does not occur. In phase 2 of this study, death investigation, there should be consensus before study implementation on which causes of death are of primary concern. Further agreement on criteria for diagnoses of certain causes of death is required to collect the data necessary for cause of death diagnoses, either by including the relevant questions in the verbal autopsy questionnaire or on the data collection forms for medical record abstraction. Data collectors must also be directed to collect data as accurately, objectively, thoroughly, and legibly as possible while respecting the deceased's privacy and the family's confidentiality. (See the section on verbal autopsy for more specific information on training interviewers for verbal autopsy interviews.) Finally, for any translation into the local language that were made, researchers should ensure that back-translation of the survey questionnaire occurs by a different person than the one who did the initial translation to check on the accuracy. Depending on the skills and experience of the staff person responsible for data entry and analyses, courses in Epi-Info, Microsoft Excel or other simple software use may be necessary. Epi-Info software and user manuals are available free on the internet at http://www.cdc.gov/epiinfo/. Manuals and Guidelines: There are no comprehensive guidelines for RAMOS, but see Studying Maternal Mortality in Developing Countries: Rates and Causes. World Health Organization. WHO/FHE/87.7. Data Processing and Analysis: Data can be entered locally into any simple data system, including Epi Info. Analyses include calculating indicators (for which data on live births will be needed), proportional mortality of deaths related to pregnancy, and frequencies of risk factors for death, such as age, parity, socio-economic status, and distance to health care facility. If possible, one person should be responsible for data entry and analyses, ideally the principal investigator. Reporting and Dissemination of Results: It is essential to report back to the key people delivering programs in the region, health care providers, and general community. Preliminary analyses of data can often be conducted in the field such that results can be presented immediately to local stakeholders. After complete review of the data, recommendations for programs to prevent deaths can then be developed. A final written report should then be sent to the stakeholders. In some cases, results may be presented in public venues so families interviewed may attend. Cost: This study could be done at a local level if the research skills are available locally. If not, at least some donor funding would be required to access the appropriate technical support. Lessons from Experience: Although this study has two distinct phases and can be labor-intensive, the RAMOS method is very effective in providing a rich amount of data to determine the relative burden and risk factors for various causes of death among WRA, including pregnancy-related deaths. In addition, the researchers can customize the data collection to address issues of particular concern, such as barriers to health care access. Contact Person: L. Bartlett MD, MHSc. Medical Epidemiologist, For more information, contact: Silvia Alayon, Measure Evaluation Notes 1. Wessel H., Reitmaier P., Dupret A., Cnattungius S., Bergstrom S. Deaths among women of reproductive age in Cape Verde: causes and avoidability. Acta Obstetrica Gynecologica Scandinavica. 1999;78:225-232. 2. Grubb G., Fortney J., Saleh S., Gadalla S., El-Baz A., Feldblum P., Rogers S. A comparison of two cause-of-death classification systems for deaths among women of reproductive age in Menoufia, Egypt. International Journal of Epidemiology, 17 (2):385-391. 3. Fortney J., Susanti I., Gadalla S., Saleh S., Rogers S., Potts M. Reproductive mortality in two developing countries. American Journal of Public Health; 1986; 76(2): 134-138. 4. Bartlett L., Khan T., Sultana M., Jamieson M., Wilson H. Results of a reproductive age mortality survey (RAMOS) among Afghan refugee women in Pakistan, 1999-2000. Journal of Pediatric and Perinatal Epidemiology, in press. 5. Bartlett L., Khan T., Sultana M., Jamieson M., Wilson H. The burden of mortality due to reproductive health-related causes among Afghan refugees in Pakistan, 1999-2000 (abstract). In Conference 2000: Findings on Reproductive Health of Refugees and Displaced Persons: proceedings. Washington, D.C., December 5-6, 2000. Reproductive Health for Refugees Consortium, 2001, pg.18. |