Monthly Archives: October 2016

Three new tools from the World Health Organization

On 16 August, 2016 the World Health Organization (WHO) launched three new tools to count and review stillbirths, and maternal and neonatal deaths!

Browse the standardised system to capture and classify stillbirths and neonatal deaths in the WHO Application of the International Classification of Disease-10 to deaths during the perinatal period (ICD-PM).

Read the guide and toolkit, Making every baby count: audit and review of stillbirths and neonatal deaths. This publication assists countries to conduct audits and reviews to recommend and put into action solutions to prevent future stillbirths and neonatal deaths.

Explore Time to respond: a report on the global implementation of maternal death surveillance and response to review the findings of the WHO & UNFPA global survey of national MDSR systems in 2015.

Also…

Browse the press release and WHO website to learn more about these three tools, including related papers by the BJOG.

Read this Lancet commentary about all three publications.

Explore this photo story to learn more about MDSR implementation in ten countries around the world.

View this infographic about improving data to learn about what the WHO is doing to help countries save mothers’ and babies’ lives.

Do you know how many women each day experience a stillbirth worldwide? Browse this infographic on the tragedy of stillbirths to find out how many, and more!

Maternal and perinatal death reviews to reduce mortality: spotlight on Webuye Hospital, Kenya

In July 2016, the Maternal and Newborn Health Improvements (MANI) project in Kenya’s Bungoma County funded by the UK Department for International Development, published a Human Interest Story in the MANI Learning Series. The MANI project supports six sub-counties in Bungoma to implement maternal and perinatal death surveillance and response (MPDSR).

MANI has been assisting Webuye Hospital to introduce and conduct maternal and perinatal death reviews (MPDRs). This Story presents a few ways MPDRs helped Webuye Hospital to improve maternal and newborn health. Various challenges were overcome by developing an on-call rota system, connecting a generator to the maternity ward and newborn unit, training staff in neonatal resuscitation, improving communication channels between all stakeholders and conducting a blood drive. A new operating theatre is due to open soon and the newborn unit is to be redesigned.

MANI Learning Series: Human Interest Story July 2016

News updates: Global Financing Facility

Global Financing Facility (GFF): the Country Powered Investments report supporting Every Woman, Every Child, was launched 20 September. Four new countries – Guatemala, Guinea, Myanmar and Sierra Leone – have also recently become eligible to access GFF funding. For more information about the GFF, visit the website here.

 

 

The Lancet Maternal Health Series

On 18 September, The Lancet launched the 2016 maternal health series in New York City on the opening day of the United Nations’ General Assembly, following a decade since the maternal survival Series was published. The new Series comprises of six papers discussing the diversity and divergence of poor maternal health, the extremes of maternal care (too little, too late and too soon, too much), childbirth care, women centred care in high-income countries, future external factors and health-system innovations, and a call to action to presenting five key targets to ensure that the Sustainable Development Goals are met.

Tanzania | Scaling up MPDSR implementation with new guidelines

Maternal and perinatal death surveillance and response is recognised by the Tanzanian government as a process for improving quality of maternal and newborn care in health facilities. With a stepwise approach and the decision to initially focus on facility-based maternal and perinatal deaths before scaling up to include deaths occurring at the community level, new guidelines were developed and are being rolled out to all 26 regions in mainland Tanzania. The process is supported by the WHO country office and involves the training of trainers in each region so that implementation is tailored to the local settings rather than a centralised initiative led by the Ministry of Health (MoH).

Support from the WHO has complemented previous efforts by health stakeholders to roll out of the new national guidelines in four regions in the Lake and Southern zones. Funding from the WHO helped quicken the roll-out process across the country, especially in regions previously not supported.

Led by the MoH, national experts were invited to participate in drafting the timeframe of the countrywide roll-out. Three teams of at least three experts each helped disseminate the new guidelines and trained at least 20 trainers in each region to take over the dissemination and training in districts and health facilities.

In contrast to the 2006-2015 maternal and perinatal death review guidelines, the MPDSR guidelines focus on strengthening skills in maternal and perinatal death audits at the facility level – including the use of information to improve service delivery – and improving capacities to oversee and support implementation at the district, regional and national levels. The MPDSR guidelines define the differences between audit committees at the facility level and technical teams at the district, regional and national levels. They also clarify the use of generated data to inform service delivery and MPDSR implementation at all levels. Reporting from facility to national levels and developing feedback loops are also highlighted in the guidelines to ensure a common understanding. Additionally, the use of information and communications technology, such as WhatsApp groups, to link MPDSR trainers to health facilities in each district and region is also encouraged and are already used to share progress in developing skills that are impactful at all levels.

The MPDSR guidelines are expected to be disseminated to all regions by September 2016 as the scale up of MPDSR in Tanzania progresses.

  • To read the country update for Tanzania from July 2016, please click here.
  • To learn more about MPDSR implementation in Tanzania, read this case study published by the World Health Organization.
  • Read this paper, published by the Tropical Medicine and International Health journal in 2014, to learn about the strengths and weaknesses in implementing MPDRs in Tanzania.

 Acknowledgements: This update was written by Dr Moke Magoma, Team Leader QI, TGPSH (Tanzanian German Programme to Support Health).

Nigeria | the development of a MPDSR system

Nigeria has been working towards developing a national MPDSR system and several activities have taken place at the national and State level over the past few months.

In April and May 2016, a maternal and perinatal death surveillance and response training was held in Lagos to build the capacity of key personnel of the state healthcare system (including gynaecologists, obstetricians, representatives from private hospitals and local government surveillance officers) to further efforts to institutionalise MPDSR in the state, building on existing Maternal Death Review structures. This was the first State-level training in country that incorporated perinatal, surveillance and response components. Read the July 2016 Nigeria update to learn more about the training.

After the training, the Chief Medical Directors of the participating secondary facilities were tasked with establishing maternal and perinatal death review committees at their facilities. To date, committees have been set up in 21 general hospitals that offer maternal, newborn and child health services. These committees have started reviewing maternal and perinatal deaths at the facility level and are sharing MPDSR findings with the State.

Also, participants from each facility developed work plans for MPDSR implementation. Progress towards implementing the facility work plans will be presented in a scorecard based on MPDSR data from July to September 2016. The Lagos State Ministry of Health, with support from the MamaYe-E4A, has collected and analysed the data, and will disseminate the scorecard to MPDSR stakeholders in October 2016.

In Bauchi State, the Bauchi State Maternal and Perinatal Death Surveillance and Response Committee provides mentorship to facility-MDR committees and recently supported the collection of data on maternal and perinatal deaths from 25 secondary facilities in the last quarter with support from MamaYe-E4A. A draft MPDSR scorecard has been prepared, and will be reviewed and validated at a stakeholder meeting at the end of September 2016 before printing.

As a follow up to the country update shared in the July 2016 newsletter, a workshop was conducted at the end of June to develop the national MPDSR training (for trainers) manual. This workshop took place over five days and was led by the FMOH with members of the national MPDSR Steering Committee.

Participants went through the MPDSR national guidelines and tools, and agreed on a modular format for the training manual. During the workshop, participants successfully developed some training sessions. Two consultants have since been tasked with completing the remaining sessions using the agreed format. They have submitted a completed draft of the training manual, which will be reviewed and finalised at a stakeholder meeting in October 2016. A National MPDSR Training of Trainers will then take place in November 2016.

Acknowledgements: This country update was developed based on feedback from Dr Tunde Segun, Country Director for MamaYe-E4A Nigeria; Mr Oko Igado, National Technical Advisor for MamaYe-E4A Nigeria; and content from the Report on the Training of Lagos State Health Care Providers on Maternal and Perinatal Death Surveillance and Response (MPDSR): April 28-29 and May 3-4, 2016, and MamaYe-E4A Quarterly and Country reports.

Nepal | building on MPDRs to implement MPDSR

Nepal has shown significant progress in reducing maternal and perinatal mortality over the past two decades (see Table 1). Despite progress, maternal mortality in Nepal continues to be one of the main causes of death among women of reproductive age and a major public health problem. In 2015, it was estimated that about 1500 women died in Nepal during pregnancy, delivery and the puerperium period (WHO 2015).  While it is clearly important to monitor this, the maternal mortality ratio only illustrates part of the story. There is a real need to better understand the story behind the maternal mortality change over the past 10 years and to put in place the necessary steps to prevent maternal deaths in the future. Thus, Nepal has been undertaking a number of initiatives to identify programmatically useful information to inform investment and interventions in maternal health.

Table 1: Estimates on the maternal mortality ratio, neonatal mortality rate and perinatal mortality rate

Years 1995 2006 2011 2015
Maternal mortality ratio (per 100,000 live births)[1] 660 258
Neonatal mortality rate (per 1,000 live births)[2] 47.7 22.2
Perinatal mortality rate (per 1,000 births)[3] 45 37

Note: the next Demographic Health Survey for Nepal will report data from 2016.

In 1990, a maternal death review process was first introduced in Paropakar Maternity and Women’s Hospital in Kathmandu, the only maternity hospital in the country. The hospital began implementing perinatal death review in 2003. By 2006, maternal and perinatal death reviews were being conducted in six hospitals increasing to 44 referral hospitals by 2014. Furthermore, maternal mortality and morbidity studies were undertaken in three districts in 1998 increasing to eight districts in 2008-9.

In line with the recommendations of the Commission on Information and Accountability / World Health Organization (CoIA/WHO), the Government of Nepal (GoN) initiated a maternal and perinatal death surveillance and response system in 2014. The system builds on experiences from MPDR implementation and the maternal mortality and morbidity study.

While facility-based reviews of maternal and perinatal deaths continue in 44 referral hospitals, the GoN, with support from the WHO and other partners has been implementing MPDSR in five districts, namely Banke, Dhading, Kailali, Kaski and Solukhumbu since 2016. In these districts, MPDSR is implemented at two levels: health facility and community. At the facility level, both maternal and perinatal deaths are reviewed and appropriate actions are taken. In the community, verbal autopsies are conducted for maternal deaths only.

Diagram 1 (see link below) presents the role of different stakeholders/actors in MDSR at the community level and MPDSR at the facility level.

diagram-1_mdsr-mpdsr-process-in-nepal

The Ministry of Health of Nepal, with support from the WHO, UNICEF, Nepal Health Sector Support Programme / Department for International Development and other partners, has taken the lead and made a commitment to gradually scale up maternal and perinatal death surveillance and response to all hospitals across the country by 2020 and ultimately expand to include community-based maternal death surveillance and response. A series of planning meetings are taking place with  experts to finalise the training modules, review processes, and develop implementation guidelines, to name a few.

REFERENCES

World Health Organization (WHO), UNICEF, UNFPA, the World Bank Group & the United Nations Population Division. (2015). Trends in Maternal Mortality: 1990 – 2015. Estimates by WHO, UNICEF, UNFPA, World Bank Group and the United Nations Population Division. Geneva: WHO.

Acknowledgements: This country update was prepared and reviewed by Dr Sharad Kumar Sharma, Senior Demographer, Family Health Division, DoHS, MoH; Dr Pooja Pradhan, WHO Country Office, Nepal; and Mr Pradeep Poudel, NHSSP/DFID/MoH, Nepal.

[1] World Health Organization (WHO), UNICEF, UNFPA, the World Bank Group & the United Nations Population Division. (2015). Trends in Maternal Mortality: 1990 – 2015. Estimates by WHO, UNICEF, UNFPA, World Bank Group and the United Nations Population Division. Geneva: WHO.

[2] UNICEF, WHO, World Bank, UN DESA Population Division. (2015). Child mortality estimates: UN Inter-agency Group for Child Mortality Estimation. Retrieved September 22, 2016, from: http://www.childmortality.org

[3] Ministry of Health and Population, New ERA and ICF International. (2012) Nepal: Demographic Health Survey 2011. Kathmandu: Government of Nepal.

Kenya | A phased approach to MPDSR implementation and county focus

In order to eliminate preventable maternal and perinatal mortality, several measures have been taken by the Kenyan Government through the Ministry of Health. They include:

  • scaling up training of Emergency Obstetrics and Newborn Care countrywide
  • eliminating user fees for maternity services through the Free Maternity Services Initiative led by The President of Kenya, H.E. Uhuru Kenyatta
  • instituting maternal and perinatal death surveillance and response mechanisms

Kenya recently developed comprehensive national MPDSR guidelines. MPDSR, however, is not new to the Kenyan health system. In 2004, maternal deaths were declared a notifiable event which led to the implementation of maternal death reviews at health facilities. Maternal death reviews are the foundation to MPDSR while perinatal death reviews are less developed.

With the launch of the National MPDSR guidelines – 2016, Kenya is taking a phased approach in implementing the “P” in MPDSR. The implementation has recently begun in facilities with a low burden of maternal morbidity and mortality. It is noted that in health facilities with low maternal death occurrence, perinatal deaths remain quite high.

Murang’a County Referral Hospital is one such facility, with a low burden of maternal mortality but a persistently high perinatal mortality rate. At Murang’a County Referral Hospital, the (facility-level) MPDSR committee holds monthly meetings to discuss each case of perinatal mortality. The case files are usually accompanied by a review of the maternal file. The team reviews each case individually discussing the clinical care and health system factors that contributed to the death. The recommendations are well documented and followed up in the next meeting.

The Ministry of Health is working with the facility, sub-county and county teams to monitor the response to the recommendations made during perinatal death reviews.

COUNTY FOCUS: BUNGOMA COUNTY

The Maternal and Newborn Improvement (MANI) project supports six sub-counties in the roll out of MPDSR within and across 42 facilities in Bungoma County. The national maternal death review (MDR) and perinatal death review (PDR) tools are regularly used at these facilities. Narrative qualitative analyses describing the events of each maternal and perinatal case were introduced in September 2015 and are reviewed on a monthly basis.

The 42 facilities have received ongoing support through trainings, mentorship and supportive-supervisory visits to identify maternal and perinatal deaths, conduct reviews and analyse probable causes of death.

The MPDSR committees in six sub-counties meet quarterly to discuss feasible and immediate interventions that are within the capacity of the sub-county or facility levels to apply remedial solutions to each cause of death.

“…The MPDSR reviews have improved our teamwork, both amongst ourselves and even interdepartmental collaboration. Everyone involved in the care of mothers and newborns are involved in the MPDSR committee deliberation…” (Webuye staff about MPDSR meetings)

From September to December 2015 and April to June 2016, there were reported increases in the number of facilities with functional MPDSR committees from 20 to 42. From the committees that met, 33 facilities made necessary changes to service provision and/or management practices based on MPDR findings between April and June 2016; an increase from two facilities between September and December 2015.

While the percentage of maternal deaths that were reviewed and uploaded to the District Health Information System (DHIS) stayed constant at 100% from September 2015 to June 2016, perinatal deaths reviewed and uploaded to the DHIS increased from 54% to 67%, over the respective quarterly periods.

SUB-FOCUS: WEBUYE HOSPITAL

Webuye hospital has the second highest number of maternal and perinatal deaths in Bungoma County. With the roll out of the new 2015 Kenya National Maternal and Perinatal Death Surveillance and Response Guidelines, there has been substantial progress to review perinatal causes of death to inform the quality of care.

The facility-MPDSR committee at Webuye hospital was established in October 2015 with the support of the MANI project and Bungoma County Health Management Team (CHMT). Prior to this, maternal and perinatal deaths were seldom reviewed, collaboration between maternal and newborn health departments was particularly low and record keeping was poor. As such, perinatal deaths were infrequently accounted for and the true causes of death rarely known.

The MPDSR committee at Webuye holds monthly review meetings. During the initial stages of these meetings, discrepancies were identified between the Ministry of Health PDR forms and the DHIS, preventing PDR data from being uploaded to the DHIS system. As a result, the Webuye team supported the standardisation of the PDR tools in January 2016. The PDR form has since been updated and pretested. The review and upload of PDR findings have increased since the new PDR tool was introduced. For each quarterly period from September 2015 to June 2016, there were marked increases from 44% to 100%, respectively.

Please visit here to read the country update for Kenya from March 2016.

Acknowledgements: The national update was prepared and reviewed Dr Wangui Muthigani, Program Manager- Maternal and Newborn Health at Ministry of Health in Kenya. The update for Bungoma county was developed based on feedback from Mr Peter Ken Kaimenyi, Maternal and Newborn Health Technical Advisor at MANI Project funded by UK Aid; two MANI Project abstracts accepted for presentation at the Kenya Midwives Annual Scientific Conference 2016; and the MANI Project power-point presentation for the Kenya Midwives Annual Scientific Conference 2016.

Bangladesh | the roll out of MPDSR

Maternal and perinatal death surveillance and response in Bangladesh was initiated by the Ministry of Health and Family Welfare (MOH&FW) to monitor the overall improvement of maternal and neonatal health. Since its inception, the MoH&FW has been implementing MPDSR in 17 districts across Bangladesh following the pilot programme in Thakurgaon district in 2010. The approval of the national MPDSR guideline has paved the way to scale up MPDSR. From July to September 2016, a number of initiatives have taken place to further MPDSR implementation across the country.

RECENT ACTIVITIES

  • The national guidelines for MPDSR have been approved by the MOH&FW. Printing is underway and the dissemination workshop will take place in October 2016.
  • Plans to scale up MPDSR countrywide by 2021 have been drafted in the results framework of the Health, Population and Nutrition Sector Development Program 2011-2016
  • The MPDSR Training of Trainers manual is under development and will be implemented to train sub-national level facilitators who in-turn will train healthcare providers from multiple disciplines at the district and upazila levels. The upazila team will then train the field-level health care providers on death notification, verbal autopsy (VA), social autopsy and facility death review. Participants will also be trained in data collection and analysis
  • A booklet on MDPSR for health and family planning workers in the field is also being developed in the local Bengali language. A draft will be complete by September 2016. The booklet is expected to be distributed to field-level health workers (health assistants, family welfare assistants, health inspectors, assistant health inspectors, family planning inspectors and sanitary inspectors) by November 2016
  • Simplified tools of MPDSR to help facilitate death notification, VA and facility death reviews, to name a few, are being prepared for dissemination to all 17 districts. Selected variables of VA have been incorporated in the District Health Information System-2 (DHIS-2)
  • A national-level meeting – led by the Director, Primary Health Care and Line Director of Maternal, Neonatal, Child and Adolescent Health of the Directorate General of Health Services – was planned in September 2016 to share experiences in maternal and perinatal death review across 14 districts
  • The national MPDSR guidelines will be shared at six divisional workshops once finalised (expected date: December 2016).
  • The UNICEF South Asian Regional Office has organised a South-to-South exchange visit for the MOH&FW Obstetric and Gynaecological Society of Bangladesh to travel to China in November 2016 to share experiences about auditing maternal near misses

To learn more about Bangladesh’s implementation of MPDSR or components of it, please read the country update from July 2016.

Browse this case study to read about how social autopsy is used as an intervention tool to prevent maternal and neonatal deaths in communities in Bangladesh. The WHO has also published a case study about social autopsy in Bangladesh.

Acknowledgements: This country update was prepared and reviewed by Dr Riad Mahmud, Health Specialist (Maternal and Neonatal Health), Health Section, UNICEF Bangladesh and Dr Animesh Biswas, National Consultant (MPDSR), Health Section, UNICEF, Bangladesh.