Author Archives: Network Coordinator

Seminar presentations: Maternal and perinatal survival in crisis settings

We invite you to watch the presentations below from the seminar series “Innovations in maternal and perinatal health in humanitarian settings: Exploring evidence and innovations to improve maternal and newborn survival among populations affected by humanitarian crises”.


Seminar 2: Applying maternal death surveillance and response in crisis settings

Nadine Cornier with UNFPA, Turkey, describes approaches to measure and respond to maternal mortality in humanitarian settings.

Rajat Khosla with the World Health Organization, discusses the value of maternal death surveillance and response (MDSR) to improve data and systems in crisis settings.

Eleanor Brown with Options, presents the value of participatory ethnographic evaluation research (PEER) as a tool to triangulate maternal death surveillance and response (MDSR) findings in conflict-affected settings.


Seminar 1: Innovations to improve maternal and newborn death surveillance to respond to future Ebola outbreaks

Dr Benjamin Black, Obstetrician and Gynaecologist at Médecins Sans Frontières, talks about the provision of maternal and newborn care during the Ebola.

Laura Sochas, Mphil/PhD candidate, Department of Social Policy at the London School of Economics, discusses a method to estimate the number of indirect maternal and newborn deaths during a humanitarian crisis.

Legal and policy frameworks that support MDSR: Series

According to the World Health Organization (WHO):

“Taking a human-rights based approach to health, making maternal death a notifiable event in law, and supporting this with policies for maternal death review, analysis and follow-up action, creates the preconditions necessary for successful implementation [of maternal death surveillance and response (MDSR)]”¹ (p.31).

While death review systems may draw from international guidance and be standardised to an extent across countries, legal regulations can vary and can support or hinder access to information, the conduct of an audit and the response to findings². Fear of litigation, can prevent the objective review of maternal deaths³, so having legal protection in place and ensuring an anonymous environment can encourage the sharing of information and involvement of health care workers in the MDSR system³. Similar principles can also support the investigation of stillbirths and neonatal deaths².

To gain a better understanding of how legal and policy frameworks support the successful implementation of MDSR, we developed a three-part series, publishing:

References

¹ World Health Organization. (2016). Time to respond: a report on the global implementation of maternal death surveillance and response. Geneva: WHO.

² World Health Organization. (2016). Making every baby count: audit and review of stillbirths and neonatal deaths. Geneva: WHO

³ World Health Organization. (2013). Maternal death surveillance and response: technical guidance. Information for action to prevent maternal death. Geneva: WHO.

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 estimated 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.Image from Bex_Options

Photo credit: Rebecca McKay-Smith/Options

In 2016, the Ministry of Health and Family Welfare (MoH&FW) acted 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.

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).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.

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:

Sierra Leone MDSR Report: 2016

Background

The national Maternal Death Surveillance and Response (MDSR) system was established in Sierra Leone in 2015. The objective of the MDSR system is to count and review maternal deaths, in order to identify causes and contributing factors, and to inform interventions to prevent future deaths.

This first national MDSR report highlights progress towards institutionalisation of MDSR; presents an overview of maternal deaths from January to December 2016; and includes recommendations for improving MDSR implementation and to address the main causes of maternal deaths. Continue reading

Using data to prevent maternal deaths in crisis settings

Triggers and chain of events leading to maternal deaths vary greatly according to contexts in humanitarian settings. We really need to dig up the issues. A systematic review of individual events is essential to take appropriate, life-saving corrective measures. You just need a few reports to understand what is happening, and you can do a lot to change the situation” – Nadine Cornier.
Seminar 2 blog_image 1

Every maternal death has a story to tell and should be counted, so that appropriate responses can be developed to prevent similar deaths. But how do we do so effectively and in a timely manner in settings where health systems are disrupted and populations are displaced? Continue reading

New MDSR reports galvanise action to improve quality of care in Malawi Northern Zone

As part of its efforts to improve accountability for women and children’s health, Malawi classified maternal death as a notifiable event in 2003, and the National Committee on Confidential Enquiry into Maternal Deaths (NCCEMD) was established in 2009. Like many other countries, from 2013, Malawi moved from maternal death reviews (MDRs) to the more robust system of maternal death surveillance and response (MDSR), which entails not only that maternal deaths are notifiable, but also places greater emphasis on response, and on the monitoring and evaluation of MDSR itself. Continue reading

Is scaling-up community maternal verbal autopsies a viable approach to inform action to reduce maternal mortality?

Key messages

  • Community verbal autopsies are recommended in maternal death surveillance and response systems. Potentially they can inform action to prevent further deaths by improving our understanding of: The circumstances surrounding deaths occurring in the community; individual and community-level factors contributing to delays for those deaths occurring at facilities; and family perspectives of treatment received at facilities. However, undertaking verbal autopsies at scale may not always be feasible.
  • Maternal deaths are rare events and, particularly in settings that are experiencing rapid increases in institutional delivery rates, are increasingly occurring in facilities.
  • Community verbal autopsies entail a high training cost, with large numbers of community health workers each covering relatively small geographical areas. Their low skill, high turnover and infrequency of conducting verbal autopsies generate poor quality information and limited new insights. The collection of data with limited use at a sensitive time also raises ethical concerns.
  • In low resource settings, other strategies could be considered to achieve the primary purposes of maternal death surveillance and response, for example strengthening community based vital registration systems for better notification of deaths; strengthening facility-based maternal death reviews with a focus on the community delays contributing to facility-based deaths; and intermittent qualitative research by skilled researchers.

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Local knowledge to reduce under-five mortality: Initiating participatory action research in rural South Africa

We asked Dr Lucia D’Ambruoso, Deputy Director of the Centre for Global Development, University of Aberdeen and co-author of this recent publication, to tell us about using participatory approaches to strengthen mortality surveillance and reporting systems. The process addresses deaths of children under five years of age, which includes newborn deaths. The approaches can be applied to surveillance of perinatal mortality. Continue reading

Mortality surveillance report in South Africa: Focus on neonatal population

The fifth Rapid Mortality Surveillance Report, 2015 by the Burden of Disease Research Unit of the South African Medical Research Council was published in December, 2016. This report provides a national picture of the trends and causes of death of the newborn population.

RMS Report 2015 Summary_image 1

This summary, written by Dr Natasha R Rhoda, Senior Neonatal Consultant at Groote Schuur Hospital in Cape Town and the chairperson of the National Perinatal Mortality and Morbidity Committee in South Africa, concentrates on data for the period 2012 to 2015 and presents the key findings of the Rapid Mortality Surveillance (RMS) report 2015 in relation to perinatal and neonatal mortality. For further reading, browse the report Perinatal Deaths in South Africa, 2015, which was published in July 2017. Continue reading