Monthly Archives: November 2017

Kenya | MPDSR committees across all levels jointly tackle referral systems challenges

In 2016, nearly half of maternal deaths (48%)1 and almost a third of perinatal deaths (31%)2 occurring in health facilities in Bungoma County were referred from another facility. The facility level maternal and perinatal death reviews in the County, supported by the Maternal and Newborn Initiative (MANI) project highlighted multiple problems with the referral system, including:

  • Delays in the decision to refer clients
  • Inappropriate treatment prior to referral or lack of efforts to try to stabilise clients before transit (e.g. Administering magnesium sulphate to clients experiencing pre-eclampsia)
  • Referring facilities not calling ahead to enable referral facilities to prepare for receiving emergency cases
  • Referring facilities not sending completed referral slips or client history
  • Lack of (or delays in organising) ambulances, drivers, and/or fuel, especially at night
  • Lack of a nurse or clinician to accompany clients in ambulance
  • Emergency clients being dropped off alone at facility entrances.

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Bangladesh scales up MPDSR

To prevent mothers and babies from dying, Bangladesh has taken steps to scale up its maternal and perinatal death surveillance and response (MPDSR) system nationally. The country first piloted maternal and perinatal death review (MPDR) in 2010. By 2015, MPDR was rolled out to 12 districts. In 2015, the estimated maternal mortality ratio was 176 per 100,000 live births and in 2016, the neonatal mortality rate was 20 per 1,000 live births. While Bangladesh has made important gains, more needs to be done to achieve the Sustainable Development Goal 3 targets for maternal and newborn mortality.

In 2016, the Ministry of Health and Family Welfare (MoH&FW) took action to roll out MPDR throughout the country. In line with the World Health Organization (WHO) Maternal Death Surveillance and Response (MDSR) Technical Guidance, the MPDR system was updated to ensure an increased focus on surveillance and response.national MPDSR guideline workshop

Photo caption: Workshop on “Sharing MPDSR Guidelines, Training Module and Strategic Implementation Plan” for Universal Health Coverage, 2 October 2016. Photo credit: Dr Animesh Biswas.

Both the Health Economic Unit of the MoH&FW and the Bangladeshi government financially supported this transition. To ensure integration and adoption across the health system, changes were carried out in collaboration with: The Directorate General of Health Services and their Management Information system, Directorate General of Family Planning, developmental partners (for example, UNICEF, UNFPA, WHO), professional bodies (such as, the Obstetrical and Gynaecological Society of Bangladesh), implementing partners (for example, non-governmental organisations), public health experts and research organisations (such as, the Centre for Injury Prevention and Research).

Twenty-two districts are currently implementing the new maternal and perinatal death surveillance and response (MPDSR) system with UNICEF supporting 13 districts, UNFPA five and Save the Children four. Scale-up activities took place at the policy and implementation levels to support the expansion of the system, including:

  • The adoption of national MPDSR guidance based on existing MPDR guidelines. New national guidelines were approved by the MoH&FW in October 2016.
  • The development of a national Training of Trainer’s (ToT) manual on MPDSR to use at various levels (approved in December 2016 by the MoH&FW).
  • The creation of a pocket handbook on MPDSR for on-the-ground health workers.
  • The development of six additional tools, also approved in December 2016 by the MoH&FW: The community death notification slip, the community maternal death review form, the community neonatal death review form, the facility death notification slip, the facility-based maternal death review form and the facility-based neonatal death review form.
  • A cascade training approach comprising of a:
    • National level three-day ToT for 78 health professionals from the 22 districts.
    • Training of health and family planning staff on the ground, and volunteers, doctors and nurses at the district and upazila (sub-district) levels across the 22 districts.
  • The identification of MPDSR focal persons at the upazila, district and national levels.
  • Establishment of MPDSR sub-committees in facilities at upazila and district levels. Facility death findings will be periodically discussed in hospital-based MPDSR sub-committees and necessary steps taken to improve facility services.
  • The newly created national MPDSR committee will sit twice a year to discuss progress towards achieving targets for maternal and neonatal mortality, and improvements in the health system.
  • Capacity development on the national level assignment of causes of death from community maternal and neonatal verbal autopsy forms – based on the International Classification of Diseases 10 (ICD-10) – were conducted for clinicians, including gynaecologists, obstetricians, neonatologists and paediatricians, from seven tertiary medical college hospitals.

A key element of the revised system is to improve the quantity and quality of the collection of data. To ensure the notification and reporting of every community- and facility-based maternal and neonatal deaths and stillbirths, notification is now mandatory. The review of every maternal and neonatal death will be conducted at the facility level and a verbal autopsy will be carried out for all maternal and neonatal deaths at the community level. Moreover, for community sensitisation and awareness building, social autopsies for maternal and neonatal deaths will be conducted in communities.

Data is now viewable via a dashboard linked to the online management information system database, the District Health Information Software (DHIS-2). In addition to being shared and discussed at MDPSR sub-committee meetings, review findings will be fed into Quality Improvement Committee (QIC) meetings at the upazila and district levels. The QICs will be tasked with monitoring follow-up actions. Additional system improvements to support collection, management and review of data included:

  • Trainings to support health-care providers in community clinics to report community deaths to the DHIS-2, the smallest health system unit covering approximately 6,000 persons.
  • Trainings to upload causes of death from verbal autopsies to the DHIS-2 at the divisional level.
  • Meetings with MPDSR facility-level sub-committees to discuss findings from facility death reviews to improve the quality of maternal and newborn care.

The DHIS-2 presents data on maternal and neonatal mortality by time period and geographic location. Improvements in data availability, accessibility and quality are supporting improved decision making by health managers, planners and policy makers at various levels of the health system. Another notable achievement has been the integration of MPDSR into the fourth Health Population Nutrition Sector Development Plan (2017-2021). The MoH&FW plans to achieve countrywide scale up of the MPDSR system by 2021.

This country update was written by Dr Animesh Biswas, PhD, Senior Scientist and Associate Director, Reproductive and Child Health Department at the Centre for Injury Prevention and Research (CIPRB) in Dhaka, Bangladesh.

To read some publications by Dr Biswas, please click the titles below: