Read about ‘strengthening research capacity for effective implementation of maternal and perinatal death reviews in Tanzania’ in this poster presented at the GLOW 2015 conference by Corinne Armstrong, Carine Ronsmans, and Moke Magoma.
Read more about the Maternal and Perinatal Death Review system in Bangladesh highlighted in this case study:
1) Biswas, A., Rahman, F., Halim, A., Eriksson, C. and Dalal, K. (2014) Maternal and Neonatal Death Review (MNDR): A Useful Approach to Identifying Appropriate and Effective Maternal and Neonatal Health Initiatives in Bangladesh. Health, 6, 1669-1679.
2) Biswas, A., Rahman, F., Eriksson, C., & Dalal, K. (2014). Community Notification of Maternal, Neonatal Deaths and Still Births in Maternal and Neonatal Death Review (MNDR) System: Experiences in Bangladesh. Health, 6(16), 2218.
The article ‘The cultural environment behind successful maternal death and morbidity reviews’ by G. Lewis in BJOG: An International Journal of Obstetrics and Gynaecology identifies common cultural factors for successful maternal mortality and near-miss reviews on the basis of experiences from health facilities around the world. The article identified three interrelated factors:
- Individual responsibility and ownership: health professionals who are supportive of the review process are essential
- A healthy institutional culture
- A supportive policy environment
Developing these cultural factors will require a change in mind-set by policymakers, administrators and health professionals. Experience from within and outside maternity care has demonstrated that, once developed, the cultural environment developed will result in improved access to and quality of healthcare.
A recent article ‘Easier said than done!: methodological challenges with conducting maternal death review research in Malawi’, by V.C. Thorsen, J, Sundby,& T, Meguid. in the BMC Medical Research Methodology, highlights challenges faced during a facility-based MDR study in Malawi. Key points include:
- The researchers recommend using Rapid Ascertainment Process of Institutional Deaths to identify unreported deaths. It involves the identification of all possible wards where women of reproductive age might receive care, reviewing the death records of these women, and finally assessing their pregnancy status.
- A number of challenges around data collection were identified and the researchers recommend using local authorities to help locate community and family members and triangulate data using several perspectives and sources.
- Challenges surrounding data analysis included difficulties in determining the causes of death due to varied accuracy and detail of health professional observations. The researchers recommend using at least two physicians to independently review and classify cause of death or establish a team of experts to review the death together and arrive at a consensus.
The journal article Experiences with facility-based maternal death reviews in northern Nigeria presents the findings of a study evaluating the effectiveness of the use of facility-based MDRs by the Partnership for Reviving Routine Immunization in Northern Nigeria – Maternal Newborn and Child Health (PRRINN-MNCH).
The evaluation uncovers a number of findings, including:
- Only 93 (12.1%) of the total maternal deaths reported in HMIS for the same facilities had been recorded on the MDR forms and only 52 of these maternal deaths had been reviewed; a mere 6.7%.
- Despite the minimal number of MDRs taking place in these facilities, the MDRs that were conducted did result in improved quality of care, such as the better management of patients and the mobilisation of resources.
- The process of using MDRs stopped for some time in the 11 hospitals visited for the study. Reasons included the transfer of key MDR committee members, inadequate supportive supervision and shortage of staff. Most did, however, restart with revitalisation of the MDR process by PRRINN-MNCH staff.
- Challenges reported included fear of blame felt by health workers, shortage of staff to undertake committee meetings, inadequate supportive supervision and low quality record keeping.
The authors conclude by highlighting successful features of the MDR process, including teamwork, commitment, champions at the health facility level to lead the process, and guidance, coordination and support from the national and state Ministries of Health.
Full reference: Hofman, J.J., & Mohammed, H. (2014). Experiences with facility-based maternal death reviews in northern Nigeria. International Journal of Gynecology and Obstetrics, 126 (2): 111–114.
In the journal article Audit-identified avoidable factors in maternal and perinatal deaths in low resource settings: a systematic review, Hasan Merali and colleagues present the findings of a systematic review of all published audits in low and low-middle income countries in order to identify the most common avoidable factors of maternal and perinatal deaths worldwide.
Notably, the majority (two-thirds) of avoidable factors were accounted for within the category health worker-oriented factors, such as substandard practice of health workers and delay in receiving care on admission. The leading three factors of deaths were:
- substandard practice of health workers
- patient delay to seek care
- lack of capacity in blood transfusion
The review reiterates the valuable insight that audits provide in identifying systematic deficiencies in clinical care, which in turn can be used for targeting interventions to address these system failures. What’s more, the very fact that the causes of maternal and perinatal deaths are often similar in low-resource settings means that these avoidable factors could be used to inform a rational design of health systems.
Full reference: Merali, H., Lipsitz, S., Hevelone, N., Gawande, A., Lashoher, A., Agrawal, P., & Spector, J. (2014). Audit-identified avoidable factors in maternal and perinatal deaths in low resource settings: a systematic review. BMC Pregnancy and Childbirth, 14(1), 280.
An International Journal of Obstetrics and Gynaecology has published a special supplement International Reviews: Quality of Care, covering review articles, country studies, and commentaries on the provision and accurate assessment of quality of care for maternal and newborn health. In particular, the supplement highlights experiences in developing and implementing different types of audit to improve the quality of maternal and newborn health, including maternal and /or perinatal death reviews, confidential enquiries, near miss audits, and clinical audits.
The International Journal of Gynecology and Obstetrics has published a special supplement about the Leadership in Obstetrics and Gynecology for Impact and Change (LOGIC) initiative. This initiative was launched by the International Federation of Gynecology and Obstetrics (FIGO) to build capacity for their members in Burkina Faso, Cameroon, Ethiopia, India, Mozambique, Nepal, Nigeria, and Uganda.
This supplement documents the major achievements of the completed programme in a series of articles, including:
- Emerging lessons from the FIGO LOGIC initiative on maternal death and near-miss reviews by Gwyneth Lewis
- Guidelines and tools for organizing and conducting maternal death reviews by Vincent De Brouwere, Véronique Zinnen, Thérèse Delvaux, & Robert Leke
- Training health professionals in conducting maternal death reviews by Vincent De Brouwere, Véronique Zinnen, Thérèse Delvaux, Philip Njotang Nana,& Robert Leke
- Improving maternity care in Ethiopia through facility based review of maternal deaths and near misses by Yirgu Gebrehiwot & Birukkidus T. Tewolde
- Every death counts: Electronic tracking systems for maternal death review in India by Chittaranjan Purandare, Ajey Bhardwaj, Manisha Malhotra, Himanshu Bhushan, & Paramanand Keshavlal Shah
Civil Society Report on Maternal Deaths in India describes the findings of an analysis of 124 maternal deaths identified and documented over two years between January 2012 and December 2013. The analysis is a part of the Dead Women Talking initiative, established by several civil society organisations in response to the high maternal mortality in the country.
The 124 maternal deaths were first identified by community members and civil society. Following a home visit to verify if the death was a maternal death, families of the deceased are invited to participate in a social autopsy.
The findings of the social autopsy were analysed and recommendations developed using a framework developed to identify gaps that contributed to the deaths across four domains: technical factors, health system factors, social factors, and human rights.
- Number of training sessions: One training session on social autopsies was not sufficient to train civil society organisation staff.
- Incomplete information from families: Information from families needed to be triangulated as they did not always want or were unable to provide a complete story behind the death.
- Deaths under certain conditions missed: Late maternal deaths and deaths due to unsafe abortions and home deliveries were likely missed. As a result, greater efforts, such as training community-based organisations, were needed to ensure deaths under these conditions were recognised.
- Difficulty in getting the health system perspective: In almost all districts any attempt to link with the government conducting verbal autopsies was not successful. There was also resistance from the health system to cooperate in CSO-led social autopsies, questioning the expertise of the team conducting the social autopsies and thus not engaging with the findings.
- Blame culture: There was a culture of blaming those at the lowest of the hierarchy for the death, such as peripheral health workers. This meant that health workers were reluctant to speak about the deaths.
- Involve multiple stakeholders in the MDR process, such as CSOs, community-based organisations, and local governance structures such as Village Health and Sanitation Committees.
- Ensure that Action Taken Reports are on the agenda for the MDR committee meetings and are made public. Feedback loops should be established in order for lessons learnt from preventable maternal deaths to be used by the health system and for community action.
Full reference: Subha, Sri, B. & Khanna, R. (2014). Dead Women Talking: A civil society report on maternal deaths in India. CommonHealth and Jan Swasthya Abhiyan
Bangladesh has introduced maternal and perinatal death reviews, which triggers action at both the health system and community level. As part of the 2010 pilot, multi-coloured maps were used to plot the number of deaths in the district.