Monthly Archives: July 2016

Malawi | Pioneering MDSR in new districts

In Malawi, the Reproductive Health Directorate, National Committee for Confidential Enquiries into Maternal Death (NCCEMD) and UNFPA are taking a lead in the establishment of MDSR in three new districts (Mzimba, Nkhata Bay and Rumphi) in the northern zone. Over the last few years, MamaYe-E4A has worked in the central and southern regions to introduce components of MDSR into several districts, and this expertise is now being called upon in the expansion of the system to the new districts.

With support from MamaYe-E4A in Balaka, district stakeholders have established MDSRs where there had not been any maternal deaths investigated for a substantial period of time. MamaYe-E4A worked with district authorities to use Health Management Information System and MDSR data to compile a district data dashboard: a user-friendly visual display of graphs in an Excel spreadsheet allowing decision-makers to easily use data to inform their decisions. Based on the analysis of these data, annual MDSR reports were developed, and submitted by the Maternal Health Coordinator to the Director of Health for Balaka to the District Council. The reports highlighted issues with lack of blood and equipment, and the information prompted the District Commissioner for Health to work in collaboration with representatives of civil society and representatives of the community to start fundraising for resources for the health sector.

This type of support is now being extended through MamaYe-E4A to selected districts in the northern region (Rumphi, Nkhata Bay and Mzimba) through funding through the Gates Foundation, in collaboration with the RHD, NCCEMD and UNFPA through the process of establishing the MDSR systems. Through a series of intensive meetings in June, representatives of MamaYe-E4A have supported these organisations to take the lead on MDSR through:

  1. Developing an MDSR monitoring tool for national level monitoring of the districts’ work on MDSR
  2. Adapting a maternal death audit form to be used by the districts themselves to monitor their own progress
  3. Putting together a 2016 workplan, including a commitment to support districts to produce their own quarterly reports according to the guidelines in order for district level decision-makers to be able to take action without having to wait for feedback from the national level monitoring. The plan also includes a proposed meeting between the NCCEMD committee and the National Minister for Health in July to share the progress report on the status for MDSR in the country
  4. Developing terms of reference for MamaYe-E4A’ssupport of MDSR-focused supportive supervision visits in the three districts.

In addition, MamaYe-E4A has been asked by the CCEMD to finalise the MDSR reports from 2014 and 2015, where these reports have experienced delays related to missing or un-submitted data.

In the last quarter, priorities in the new districts include establishing quarterly supervision of the community-MDSR (cMDSR) committees by district teams and training new cMDSR committees in verbal autopsy. Where there are periods of an absence of maternal deaths at this level, the momentum of the cMDSR committees is being maintained through a broader involvement in the MamaYe campaign. Committee members are engaging in work as MamaYe activists and also as activists mobilising their communities to give blood during the National Blood Transfusion Services’ blood donation drives to help prevent maternal deaths from haemorrhage.

District health authorities in the northern districts have also been supported to replicate the district data dashboard model used in Balaka. Based on evidence arising from the dashboards and MDSR data, e evidence-based advocacy materials have been developed, which call upon different groups to act in support of improving the lives of mothers and babies. For example, in Nkhata Bay, the district data dashboard has revealed that 22 women died from pregnancy or childbirth-related causes between 2013 and 2015, and posters and leaflets were developed to call on healthcare workers, district leaders and traditional authorities to address this issue.

Finally, Malawi is also in the process of establishing nationwide best practice guides. The training of health workers in MDSR has so far been based on the national guidelines, but the Ministry of Health is in the process of standardising the training through establishing a training manual. A database is also being established to list all the health workers already trained in MDSR so that they can be called upon to help scale up the system.

Dashboard1

Illustration of dashboard data from a district in Malawi

To view the posters and leaflets developed in Nkhata Bay to call for stakeholder action, please click here and read more about how this evidence on maternal health is used to drive accountability from this link.

Acknowledgements: This country update was developed based on feedback from Project Manager for MamaYe-E4A, Lumbani Banda, and Evidence Advisor for MamaYe-E4A, Hajj Daitoni, as well as updates from the programme reports.

Sierra Leone | Investing in MDSR

In Sierra Leone, significant investments have been made to move MDSR-related work forward over the last quarter. The National MDSR Committee held a meeting in June 2016, chaired by the Director of Reproductive and Child Health, with representatives from UNICEF, UNFPA, WHO as well as a representative of other health NGOs including Options, to assess progress and propose strategies for the next quarter. The meeting highlighted to following achievements and activities:

  • MDR committees at district level which had operated before the Ebola outbreak have been restructured and adapted to MDSR committees and inaugural meetings have been completed in all districts except Western Area.
  • In some districts, the process of actively reviewing deaths has begun.
  • Social media platforms are being used to support the multi-professional communication needed to sustain and grow the MDSR system through WhatsApp groups for District Medical Officers, Midwife Investigators, M&E Officers, Disease Surveillance Officers and other stakeholders. The World Health Organization has supported the development of an MDSR database using EpiData and training material including presentations on MDSR to support collection, inputting and analysis have been developed.
  • UNFPA is supporting a pilot regional blood collection campaign in response to findings from reviews of maternal deaths from haemorrhage between June and July 2016, as well as providing desktop computers to all districts for MDSR activities and supporting educational discussion programmes on maternal and child health on radio and television.

The meeting provided a good opportunity to plan further consultative meetings, for example, with Paramount chiefs in June and religious and women’s groups at later dates, to ensure wide stakeholder buy-in to the system and maximum impact for MDSR data in the future.

Acknowledgements: This country update was informed and approved by Bockarie Sesay, M&E Advisor for Options-PMEL, in Freetown, Sierra Leone.

Nigeria | Ensuring the sustainability of MPDSR

With the support of the MamaYe-E4A programme over the last five years, Nigeria has worked to embed the MDSR process at state level in the country –and is the only setting that we knew of with a sub-national level maternal death review (MDR) scorecard at the time of dissemination in October 2015.

In the last few quarters in Ondo State, two MDR scorecards have been developed by the Evidence Sub-Committee of Ondo State Accountability Mechanism for Maternal and Newborn, Health supported by E4A-MamaYe. These scorecards were based on the MDR data from all secondary-level facilities and two Mother and Child Hospitals in the state and aim to challenge the previous lack of reporting and review of maternal deaths. The scorecards were disseminated at a stakeholder meeting in Ondo and one of the key findings (that sepsis had overtaken haemorrhage to become the highest cause of maternal death) sparked lively debate.

The attendees explored the issues from both the woman’s and the facility’s point of view, and suggested strategies on both fronts for example, educating women on personal hygiene during antenatal care whilst also encouraging prompt referral of cases of premature rupture of the membranes at facilities.

One of the key issues discussed was while Ondo State Mother and Child Hospital provides most maternal, newborn and child health (MNCH) services for free, the most effective antibiotics, cephalosporins, are not exempted from costs. This means that staff may be forced to prescribe women cheaper antibiotics because they cannot afford cephalosporins. This was also leaving women open to the risk of being sold fake drugs by pharmacies, which would be ineffective against sepsis. The Ondo meeting attendees discussed strategies to counter this issue, for example, advocating at state level to get cephalosporins included in the free MNCH services, and using TruScan, a device which can detect fake drugs, to ensure women are being given genuine drugs.

While MamaYe-E4A’s presence in Ondo State ended in March 2016, key components of the programme are being integrated into the DfID-funded MNCH2 programme in Jigawa, Kano, Katsina, Zamfara, Yobe and Kaduna States including MDR scorecards and advocacy. In addition, under a new contract from the Gates Foundation, MamaYe-E4A is working to replicate this success in other States, including setting up similar systems in Lagos State.

Recent successes in Bauchi State include the review of MDR reports from 2015 by the Bauchi State MDSR Steering Committee, which enabled them and the Bauchi State Accountability Mechanism for MNCH to convene a stakeholder meeting to discuss and identify causes of maternal death and create action plans. At this meeting it was revealed that the highest cause of maternal death was anaemia, and possible factors causing this were identified to include the high prevalence of worm infestation and poor nutrition among women, as well as supply-side issues such as inadequate access to health services and lack of blood supplies. Discussions then focused on how to tackle these issues: how to ensure women are de-wormed regularly, provide nutrition education on diet using local foods, and how to make sure facilities have functional blood banks.

In Lagos State, the recent inauguration of the maternal and perinatal death surveillance and response system included launching a committee at state-level and supporting the training of 135 health care providers across secondary facilities and one tertiary facility. Training was conducted in four batches and was the first MamaYe-E4A had conducted under the updated national MPDSR guidelines which aimed to integrate perinatal death review into MDR systems.

This national level focus on perinatal death is being consolidated. In June, the National MPDR Steering Committee meeting members discussed building on the experience of MamaYe-E4A and MNCH2 in training health care providers on the updated MPDSR guidelines. A workshop was planned for the end of June where MamaYe-E4A and MNCH2 could share their training methodology, slides and materials to support the national MPDR Steering Committee in developing a training manual on MPDSR.

This focus on perinatal death is also filtering down to state level: the last MDR scorecards from Ondo State (January to March 2016) highlighted perinatal death review data in line with the national shift towards a commitment to perinatal survival.

To view the MDR scorecard for Ondo State (January to March 2016), please click here.

Acknowledgements: This country update was compiled from feedback from Dr Tunde Segun, Country Director for E4A-MamaYe Nigeria, and content from E4A quarterly reports.

Bangladesh | Rolling out MPDSR across the country

Following a successful pilot in Thakurgaon district in 2010 by UNICEF1,2,3, the Ministry of Health and Family Welfare (MoH & FW) of Bangladesh has taken the lead and made a commitment to gradually scale up maternal and perinatal death surveillance and response (MPDSR) across the entire country by 2021.

The national guideline for MPDSR has been approved and the Quality Improvement Secretariat of the Health Economics Unit at the MOH & FW is working with key stakeholders including Directorate General of Health Services, Directorate General of Family Planning, UNICEF, UNFPA, WHO, The Centre for Injury Prevention and Research, Bangladesh and other partners to plan for the roll out in a phase wise manner.

To date, MPDR/ MPDSR is being implemented in 17 out of Bangladesh’s 64 districts with support from UNICEF in 13 districts and, Save the Children in four districts, with implementation due to take place in   two more districts supported by UNFPA in 2016. A series of planning meetings are being conducted by the MoH & FW with the experts to finalise the roll out plan, determining training modalities, review processes, etc. UNICEF, Bangladesh has been providing technical and implementation support to the Ministry of Health and Family Welfare for rolling out MPDSR in collaboration with UNFPA and WHO.

Recent activities include:

  • A six-member team comprising representatives from the MOH & FW, professional societies, UNICEF and WHO attended the regional MPDSR Meeting organised by the WHO’s South East Asia Regional Office in February 2016, where progress on MPDSR in Bangladesh to date and plans for the country wide phase wide scale up by 2020.
  • National MPDSR tools (death notification, community verbal autopsies, facility death reviews) have been simplified by MOH & FW. Key variables incorporated in District Health Information System software of Management Information System of Directorate General of Family Planning which will enable real time data tracking
  • MPDSR national guideline sharing workshop was organized by the Health Economics Unit, MOH & FW in Chittagong division in May 2016 with support from UNICEF. Participants included health and family planning managers from division, district and upazila level, health officers of the City Corporation, obstetricians and neonatologists from the teaching hospitals and other related stakeholders. News of the workshop can be seen by clicking here.
  • A case study on social autopsy titled ‘Social autopsy triggered community responses for averting maternal and neonatal death in Bangladesh’ was published in WHO global website in April which was prepared jointly by UNICEF Bangladesh, MOH&FW and the Centre for Injury Prevention and Research2. Click here to read this.

Upcoming events: July – September 2016

  • A dissemination workshop on the newly developed national guideline on MPDSR will be organized by the Quality Improvement Secretariat, HEU, MOH&FW with support from UNICEF
  • An experience sharing meeting on MPDSR with 17 districts will be organised by Director General of Health Services, MOH&FW with support from UNICEF.
  • A dissemination workshop of the newly developed national guideline on MPDSR will soon be held by the Quality Improvement Secretariat of the ministry. Seven divisional sharing and orientation workshops are in the upcoming plans of the ministry.

Acknowledgements: This update was prepared by Dr Riad Mahmud, Health Specialist (MNH), UNICEF, Bangladesh, and reviewed by Dr. Md. Aminul Hasan, Deputy Director, Health Economics Unit, Ministry of Health & Family Welfare; Dr. Lianne Kuppens, Chief Health section, UNICEF Bangladesh; Dr. Abu Sadat Md. Sayem, Health Officer, UNICEF; Dr. Shayma Khorshed, Consultant, Health Economics Unit, Ministry of Health & Family Welfare and Dr Animesh Biswas, Senior Scientist, Reproductive and Child Health Unit of CIPRB, Bangladesh.

References

  1. Biswas A.; Rahman F.; Halim A.; Eriksson C;  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. Mahmud R.; Sohel HA.; Sharif M.; Kuppens L.; Rakhimdjanov S.; Sayem ASM.; Khan M.; & Biswas A. (2016). Social autopsy triggers community response for averting maternal and neonatal death in Bangladesh: Experience from ‘Maternal and Perinatal Death Review in 10 Districts’. World Health Organization. p.1-5. Available here>
  3. Biswas A. (2016). Maternal and perinatal death review (MPDR): experiences in Bangladesh. World Health Organization. Cited on 15 June 2015. Available here>

Making the case for MDSR at Women Deliver

The MDSR Action Network was represented at the Women Deliver conference through an Options evening side event on ‘Accountability for Health Results’.

The event included talks and booths about Options’ work in Nigeria, Nepal, Tanzania and Malawi as well as Options’ regional network and platforms: MamaYe, Africa Health Budget Network, The Girl Generation, African Health Stats and the MDSR Action Network.

Photo credit: E4A

The MDSR booth at the event exhibited materials highlighting Options’ MDSR work worldwide, including copies of the MDSR Action Network newsletter and the MDSR scorecards from Sierra Leone and Nigeria. It provided a great opportunity to share resources and experiences of how different countries are using MDSR to strengthen accountability to improve the care of mothers and babies.

Dr Tunde Segun, Country Director of MamaYe-E4A Nigeria, manned the booth and engaged with a steady stream of visitors, talking them through the materials, answering questions, and inviting them to sign up for the MDSR Action Network newsletter. Almost all of those approaching the booth readily agreed to sign up to be kept in the loop on this important issue.

Dr Segun spoke to a crowded room about how the MamaYe-E4A programme in Nigeria has supported MDSR. For example, four states have now established MDSR scorecards, which measure the strength of the MDSR system and can act as powerful catalysts of action to improve quality of care. In Jigawa State, the MDSR data showed clearly that more maternal deaths were occurring at night, and action was taken to modify staff rotas to ensure senior midwives were on duty during the night shifts.

In Ondo State during the last quarter of 2015 and first quarter of 2016, the MDSR scorecard showed that sepsis had overtaken haemorrhage as the primary cause of maternal death. Health care providers, policy makers and stakeholders discussed these findings, looking at gains made in addressing haemorrhage by improving the functionality of blood banks in Ondo, but also in terms of the practical actions the state could take to confront sepsis. Actions such as lobbying to get the most effective antibiotics available under the state’s free maternity services are being considered.

Finally, Dr Segun celebrated Nigeria’s pioneering spirit on MDSR by sharing the fact that during the FIGO World Congress in Vancouver 2015, the World Health Organization had revealed that Nigeria was the only country at that time to have produced an MDSR scorecard at the sub-national level.

Acknowledgements:

This case study was informed by feedback from Dr Tunde Segun, Country Director for Evidence for Action in Nigeria.

The role of midwives in the implementation of maternal death review (MDR) in health facilities in Ashanti region, Ghana

This qualitative Master’s thesis from the University of the Western Cape, South Africa, highlights findings from the Ashanti region in Ghana, where midwives are actively involved in all stages of the implementation of facility-based maternal death review, including:

  • reporting and certifying maternal deaths
  • collecting and documenting evidence in order to notify the public health units
  • processing and preparing evidence for the audit meetings
  • participating in the audit meetings
  • helping to formulate recommendations as part of the audit team,
  • disseminating, implementing and monitoring the recommendations of the audit report.

The author found that midwives play a vital role, especially in facilities where there were no other clinical cadres of staff. The author recommends:

  • Junior midwives be included in MDR meetings to build their confidence and involvement in MDR
  • Continuous in-service training on issues related to MDR for nurses and midwives
  •  Inclusion of MDR in the Nurses and Midwifery Council of Ghana curriculum
  • Specific training for midwives on their particular role within the MDR process

Experiences with facility-based maternal death reviews in northern Nigeria

This mixed-methods study emphasised the value of teamwork, commitment and champions at health facility level to facility-based MDR in Nigeria.

The authors found that where key members of MDR committees transferred, where facilities were understaffed or there was a lack of supportive supervision, these problems significantly undermined the sustainability of the MDR process.

They recommend MDR be institutionalised in the Ministry of Health to provide adequate support to staff.

An innovative approach to measuring maternal mortality at community level in low-resource settings using mid-level providers: a feasibility study in Tigray, Ethiopia

This paper proposes a community-based approach to measuring maternal mortality based on a feasibility study conducted in 2010-2011 in Tigray, Ethiopia, based on the concept of ‘task shifting’.

Priests, traditional birth attendants and community-based reproductive health agents were given responsibility for locating and reporting all births and deaths, and they assisted mid-level providers to locate key informants for verbal autopsy.

From there, nurses and nurse-midwives were trained to administer verbal autopsies and assign cause of death according to WHO ICD-10 classifications.

The study highlights the feasibility of using existing community and health structures to implement MDR.

The difficulties of conducting maternal death reviews in Malawi

This article uses a strengths, weaknesses, opportunities and threats (SWOT) analysis to assess the difficulties faced in conducting MDR in Malawi.

It highlights the importance of the multi-disciplinary team in promoting collaboration and in ensuring issues relating to different disciplines are addressed.

Good leadership, an emphasis on building staff capacity and ensuring the motivation of different members of the MDR committees are vital for sustainability and success.

Preventable maternal mortality in Morocco, the role of hospitals

This analysis of the findings of the national confidential enquiry around maternal deaths conducted the Ministry of Health in Morocco shows that 54.3% of the deaths analysed in 2009 could have been avoided if appropriate action had been taken at health facilities.

This contradicted previous beliefs that the main causes of maternal death were due to women delaying seeking care. Lack of competence or motivation of staff were linked to the majority of cases of substandard care these women received.

The authors recommend that the managers of local health systems and practitioners themselves received the information and means to support them to implement the recommendations of the audits.

This study highlights the importance of involving hospitals and health providers in the audit process and particularly in supporting them to respond to findings.