Monthly Archives: April 2014

Maternal mortality in Zimbabwe: evidence, costs and implications

This issue paper published in 2013 by the United Nations in Zimbabwe provides an overview of the country’s situation with regard to maternal mortality, as well as highlighting the need for better tracking, monitoring and reporting of maternal deaths as a key strategy.

The paper shows that Zimbabwe has an unacceptably high maternal mortality ratio (MMR) which has worsened by 28% from 1990 to 2010. Recent data shows that the MMR now stands at 960 deaths per 100,000 live births according to the Demographic Health Survey 2010-11. According to WHO 2004 estimates, about 2,593 disability-adjusted life years per 100,000 females are lost per year in Zimbabwe due to maternal causes.

The Ministry of Health and Child Welfare (MoHCW), implemented a national Maternal Death Notification System (complementing the national Health Management Information System) aimed at strengthening tracking, monitoring and reporting of maternal mortality in the country, but the system is reported to be inadequate. The system reports deaths at facilities but not those in the community and not attended to by professional health care staff. Continue reading

Easier said than done: methodological challenges with conducting maternal death review research in Malawi

This 2014 paper critically reflects on a facility-based maternal death review study in Lilongwe, Malawi, using the five step mortality surveillance cycle framework that was used for the study, and highlights the methodological challenges faced while doing such reviews.

Although studies using maternal death audit methodologies are widely available, few discuss the challenges in their implementation. This study was conducted at comprehensive emergency obstetric care units of a secondary hospital and a tertiary hospital. It found that there were gaps in identifying and reporting on maternal deaths that may have happened in units/wards other than the maternity unit, which may have led to under-reporting.

Data was also found to be as being poorly maintained, missing or incomplete in many cases, as there was no system in place for health information collection and storage in cases of maternal mortality. Whilst language barriers and cultural norms were thought to have potentially influenced data from the communities, busy schedules and fear of blame were some of the issues faced at the facility level. Continue reading

Implementing a maternal mortality surveillance system in Morocco – challenges and opportunities

The 2013 paper describes the development of the maternal death surveillance system (MDSS) in Morocco and discusses initial results.

When DHS surveys highlighted a high MMR in Morocco in 1997 and 2003 (227 and 228 per 100 000 respectively), the Ministry of Health established the National Commission on Maternal and Neonatal Mortality Reduction, in 2007 to strategise how the high levels of mortality can be reduced. One key aspect of the strategy was the systematic reporting and analysis of maternal deaths, by documenting the location, the cause and circumstances of each maternal death.

Although a routine reporting system for maternal deaths covering all public health facilities already existed it did not cover private facilities or all home deaths. The MDSS was designed to bridge this gap and the data collection includes:

  • mandatory reporting by local authorities (rural moqadems and the urban Municipal Hygiene Bureaus) of all home deaths of women aged 15 – 49 to local health services
  • reviews of discharge registers at all hospitals to record all hospital deaths of women of reproductive age in a special register

Maternal deaths are then identified and reviewed through confidential audit and verbal autopsy. Quarterly reports are submitted to the MDSS central team. After the first year of implementing the MDSS which relies on a Reproductive Age Mortality Study (RAMOS) approach covering the whole country, one of the weaknesses appeared to be the incompleteness of data. This helped to consider the shortcomings in the processes of reporting, particularly in the rural areas. However, over all, the system allowed for the identification of 12.3% more pregnancy-related deaths in health facilities than the routine information system. It enabled a better understanding of the causes and circumstances of maternal deaths, it also provided a basis for action.

Abouchadi, S., Belghiti Alaoui, A., Meski, F.Z., & De Brouwere, V. (2013). Implementing a maternal mortality surveillance system in Morocco – challenges and opportunitiesTropical Medicine and International Health, 18 (3) (open access)

The regional disparities in provincial maternal mortality surveillance system and maternal mortality in China

This recent systematic review aimed to identify and analyse studies reporting on provincial maternal mortality in China and to explore possible regional differences.

The authors searched for studies published between 1988 and January 2013 that reported on provincial maternal mortality in China. Although the country had provincial maternal mortality surveillance systems which are reported to cover a much larger population than national maternal and child mortality surveillance (NMCMS) system, little was known about them outside of China.

The review found there were regional disparities in maternal mortality surveillance systems within China. Although maternal deaths were registered in nearly all provinces in coast regions, stratified random sampling surveillance had been adopted in remote areas. The MMR across the country declined between 1996 and 2009.

Gang, X.L., Hao, C.L., Dong, X.J., Alexander, S., Dramaix, M., Hu, L.M., & Zhang, W.H. (2013). The regional disparities in provincial maternal mortality surveillance system and maternal mortality in China: an analytical review. European Journal of Public Health, 23(suppl 1) (open access)

Identifying factors associated with maternal deaths in Jharkhand, India: A verbal autopsy study

This paper published in 2013 reports on the findings from the reviews of a total of 470 maternal deaths which occurred in 2006-2007 in Jharkhand, India.

These verbal autopsies collected data at the household level and found that maternal deaths were related to a range of inter-related medical and non-medical (socio-demographic, economic and cultural) factors. In addition, this study confirmed that maternal mortality disproportionately affects poor, less educated women, showing existing disparities.

Three packages of recommendations stem from these findings: strengthening the quality of antenatal, emergency obstetric and post-abortion care; strengthening the broader health system as well as building the capacity of the health workforce; implementing behaviour change interventions and mobilising the community to increase maternal and obstetric care usage.

Khan, N., & Pradhan, M.R. (2013). Identifying factors associated with maternal deaths in Jharkhand, India: A verbal autopsy study. Journal of Health, Population and Nutrition, 31(2) (open access).

Ending preventable maternal deaths: the time is now

This comment published in Lancet Global Health in 2013 reaffirms the need to accelerate progress towards the elimination of all preventable maternal mortality, and highlights recent targets and tools designed in this respect.

Between 1990 and 2015, maternal mortality underwent a decline of nearly 50% globally, from 543 000 maternal deaths per year to 287 000. But efforts need to be sustained and strengthened, and current discussions on the post-2015 agenda offer a great opportunity for a global push to end all preventable maternal deaths.

This comment also describes new targets on maternal health set up by WHO, the US government and other stakeholders, as well as the tools they designed to track progress against these targets. Lastly, this paper argues that new strategies are needed to catalyse this progress, should address the multiple causes of death beyond their clinical causes, and should take into account context-specific challenges. MDSR systems are highlighted as a necessary and key first step in this respect, with improved information allowing for the development of strategies addressing the multiple, context-specific causes of maternal mortality.

Bustreo F., Say L., Koblinsky M., Pullum T.W., Temmerman M., Pablos-Méndez, A. (2013). Ending preventable maternal deaths: the time is now. The Lancet Global Health, 1(4), e176 – e177.

PMNCH briefing note on implementing maternal death surveillance and response

This PMNCH briefing note provides a short introduction to maternal death surveillance and response systems and will be useful to anyone looking for an overview of MDSR.

this briefing note was produced by the Partnership for Maternal Newborn and Child Health (PMNCH) and the Department of Maternal, Newborn, Child and Adolescent Health at the World Health Organization, and was used as a “note for discussion” at the Asia-Pacific Leadership and Policy Dialogue in Manila (November 2012).

In just two pages, this document provides a clear overview of why MDSR systems are important, what they are, how to implement one with an example from Malaysia, and a list of additional resources. The summary is helpful to anyone wanting a general understanding of MDSRs and their implementation, with an option to find out more by going to the list of resources.

The Partnership for Maternal, Newborn & Child Health, & World Health Organization. (2012). Implementing Maternal Death Surveillance and Response (MDSR). Geneva: WHO.

Dr Matthews Mathai (WHO) on maternal death surveillance and response

In this video put together by the Health & Education Advice & Resource Team (HEART),  Dr Matthews Mathai from the World Health Organization introduces maternal death surveillance and response. 

Dr Matthews Mathai is Coordinator, Epidemiology, Monitoring and Evaluation & Focal Point, Maternal and Perinatal Health at the Department of Maternal, Newborn, Child & Adolescent Health at the World Health Organization. Continue reading

Stairway to Death: Maternal Mortality beyond Numbers

This 2013 paper presents key findings from the analysis of 23 maternal deaths which occurred between April 2011 and March 2012 in two blocks of the Godda district of Jharkhand (India).

The qualitative study on which this paper is based aimed at recording maternal deaths at the local level as well as identifying the non-medical factors that contributed to these deaths. Improper and multiple referrals, absence of easily accessible and quality emergency obstetric care, lack of transport facilities and high out-of-pocket expenditure were key factors contributing to delays at multiple levels – delays in seeking care, reaching the health facility and receiving adequate care.

This study thus shows how reviewing maternal deaths can highlight a range of non-medical factors which all contribute towards preventable maternal mortality, and need to be addressed in policy and practice.

Banerjee, S., John, P., & Singh, S. (2013). Stairway to Death: Maternal Mortality beyond Numbers. Economic and Political Weekly, 48(31). (subscription of payment required)