Author Archives: Network Coordinator

Nigeria | Updates on MPDSR in Katsina, Yobe and Zamfara

The Maternal Neonatal and Child health programme (MNCH2) is a five year country led programme which aims to reduce maternal and child mortality in northern Nigeria.  The programme works across six states: Jigawa, Kaduna, Kano, Katsina, Yobe and Zamfara.

Image_Map of Nigeria_MNCH2Since 2014, MNCH2 has been supporting maternal and perinatal death surveillance and response (MPDSR) across its six states.  At secondary level facilities (which often have a high number of deliveries), maternal death review (MDR) committees have been set up to review the causes of maternal death and take action to prevent similar deaths in the future.  MNCH2 also supports State MDR Committees to mentor and monitor facility-level committees.

MNCH2’s support to MPDSR across northern Nigeria has resulted in a number of achievements. Following the country update from March 2017, which featured updates from Kaduna, Kano and Jigawa States, here are some further examples from Katsina, Yobe and Zamfara States:

Katsina State

Discussions in the State MDR Committee led to the development of a training in the use of non-pneumatic anti-shock garments for nurses and midwives working at maternity units in ten secondary health centres. Medical Directors, Medical Officers and Maternity personnel in charge of 18 secondary health facilities contributed to this development.

Twenty nurses and midwives were trained in October 2016 on the application of anti-shock garments. Within a month, these training participants trained other maternity staff from the same secondary health facilities to use anti-shock garments. To ensure that the training is cascaded to all general hospitals, the State is mentoring facility-MDR committees on a monthly basis.

Yobe State

A MPDSR Scorecard was developed in collaboration with the State-MPDSR Committee and the Yobe State Accountability Mechanism for MNCH (YoSAMM) with support from the MNCH2 programme. Data from April to December 2016 was collected from ten government general hospitals with MNCH services. The findings are available in box 1.

MNCH2 update_Text box

The State organised a meeting in January 2017 to review the evidence from the MPDSR scorecard. The meeting was chaired by the Honourable Commissioner of Health, Dr Mohammed Bello Kawuwa and attended by the Chief Medical Directors of the ten general hospitals, and other members of the State MPDSR Steering Committee. The key issues discussed during the meeting were:

  • Facility MDR Committees irregularly meet to review maternal deaths and take actions.
    • Proposed recommendation: YoSAMM, with support from the Advocacy sub-committee, is to visit health facilities where reviews of maternal deaths are not regularly conducted as planned. Progress in this area will be discussed at the next YoSAMM quarterly meeting in June 2017.
  • Completion of MPDSR tools not meeting national standards.
    • Proposed recommendation: Health-care providers should receive a refresher training in the completion of MPDSR forms. A training was conducted in February 2017.
  • Pregnant women are reluctant to deliver at a facility.
    • Proposed recommendation: Local government health promotion officers should conduct community mobilisation activities on the importance of antenatal care (ANC) visits and delivery by a skilled birth attendant.

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Zamfara State

MDR findings from a secondary facility led to the identification of a number of medical equipment and infrastructure features that were lacking. In response to this, the facility MDR committee called on the local government to build an ultrasound centre and provide ultrasound machines. The facility received these provisions in June 2016. Community MPDSR findings led to further action from the local government in the provision of a renovated labour room, a newly built ANC waiting room with a capacity of 250, and ten beds for the maternity ward.

Acknowledgements: This update was prepared based on feedback from:

  • Mohammad Anka – Evidence and Advocacy coordinator, MNCH2 Zamfara state office
  • Garba Haruna Idris – Evidence and Advocacy coordinator,MNCH2 Katsina state office
  • Musa Mohammad- Evidence and Advocacy coordinator, MNCH2 Yobe state office.

Ebola, and maternal and newborn health and mortality

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It was an honour to have hosted a seminar co-organised by the Global MDSR Action Network and the London School of Hygiene and Tropical Medicine’s Centre for Maternal, Adolescent, Reproductive, and Child Health and Health in Humanitarian Crises Centre where three speakers shared their experiences working in maternal health during the Ebola outbreak in Sierra Leone: Dr Chris Lewis, a general practitioner by training and Health Advisor with Department for International Development during the outbreak; Laura Sochas, a Global Health Researcher with the London School of Economics  formerly with Options;  and Dr Benjamin Black, an obstetrician and gynaecologist with vast experience in crisis settings, who was working with Médecins Sans Frontières in Sierra Leone at the time of the crisis.

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Sierra Leone is estimated to be one of the riskiest places in the world to be pregnant and deliver a baby, where a woman has a 1 in 17 lifetime risk of dying from a pregnancy-related cause.  My experience in Sierra Leone working on mother and newborn health programmes since 2012 highlighted some of the challenges in being able to count the real number of maternal and newborn deaths. Through research, I heard health workers explain how the deaths of women occurring outside of health facilities may be undocumented and how the lack of even minimal budgets to hold meetings hampered their ability to conduct reviews of maternal deaths. Interviews with communities revealed how during the Ebola outbreak, women in labour were turned away from or did not attend facilities because they were worried about contracting Ebola.

A key theme in the seminar was data and how the lack of available, open and quality data has implications in responding to the causes of Blog_LSHTM January seminar_Image_BBmaternal and newborn death. This becomes exacerbated in a crisis. In September 2014, Options started to look at the use of health services – such as antenatal care, facility delivery and postnatal care – and found evidence of a decline in usage. Building on this work, Laura Sochas discussed how she was then able to project the number of maternal deaths. In one year of the epidemic, Laura estimated the number of indirect maternal deaths during the Ebola outbreak was around 4,000 due to reduced uptake of services. This is roughly the same number as those who died directly from maternal deaths before Ebola.

It’s important to pause on this statistic and what it means for women and their families in Sierra Leone. And just as important was the reality – as Dr Benjamin Black explained – that pregnant women during the Ebola outbreak were often dying from the same things women die from in any context.

However, there are opBlog_LSHTM January seminar_Image_LSportunities. As Dr Chris Lewis explained we need to be proactive in the disclosure of information, especially as the secondary consequences of a crisis are so important. Data can help build resilience, help us to understand a problem, and justify and plan a response. It’s also important that we look closely at communities’ understanding and their barriers to action. Dr Benjamin Black emphasised in his talk the impact of the lack of trust between the community and health workers before, during and after the crisis and why the causes of this lack of trust need to be addressed to have an adequate response to maternal deaths.

Involving the community is a key aspect of maternal and perinatal death surveillance and response. The ability of communities to contribute to improving maternal and newborn health is immense – we must strive to build maternal and perinatal surveillance and response systems where communities are truly involved. Shocks and crises will happen but what makes a system resilient is being prepared with tools, data, knowledge and information to roll-out an integrated response.

To find out more, click on the links below to read about:

  • A presentation by Dr Chris Lewis about the UK Government’s response to Ebola in Sierra Leone and what opportunities there are to strengthen resilience of the health system, available to download here.
  • A method to estimate maternal and newborn mortality during a crisis, as presented by Laura Sochas. Click here to download.
  • A presentation by Dr Benjamin Black on how MSF’s maternal health programme adapted to respond to Ebola and his reflections on MDSRs, available to download here.

Acknowledgements: This blog was written by Sara Nam, Seminar Moderator, Technical Specialist at Options and Manager of the MDSR Action Network.

Midwives: Unique contributors to MDSR

Midwives are vital to ensuring women and their babies not only survive pregnancy and childbirth, but live healthy lives.

We know from the Lancet Midwifery series that:

What do we know about the role of midwives in maternal death surveillance and response (MDSR) systems?

Midwifery blog_N.Cornier_Image 1In 2016, we asked six experts in MDSR or similar models for their opinion. Experts agreed that midwives can make a unique contribution to MDSR being familiar with the medical and sociocultural factors relevant to each case. Their unique insights are meaningful in the investigation of and response to a maternal death. However, midwives are not always involved in the review of a maternal death and in some cases may have a low status within a health system.

In this blog, written for International Day of the Midwife on 5th May 2017, we turn our gaze to northern Syria where midwives are being trained in maternal and newborn care. We look at the challenges, benefits and opportunities in involving midwives in maternal care, in particular MDSR.

In March 2017, Nadine Cornier, a trained midwife and reproductive health Humanitarian Advisor at UNFPA in Turkey, gave a presentation at a seminar we co-organised at the London School of Hygiene and Tropical Medicine. She discussed her research and experience in measuring maternal mortality in humanitarian settings and responding to findings. Watch the live recording.

Her current work in Northern Syria involves re-training midwives in “life-saving capacities and competencies” as set out in the International Confederation of Midwives (ICM) Essential Competencies for Basic Midwifery Practice to raise their skill sets from an assistant midwife to a qualified midwife.

While Nadine Cornier describes this as a large task, maximising the competencies of midwives is invaluable in a setting where hundreds of health workers have been killed and numerous have fled the country. It is also important to note that accordingly assessments of maternal deaths have not been carried out in this area because of the security risks to health workers and health facilities.

For the panel discussion, Nadine Cornier was joined by Rajat Khosla, Human Rights Adviser in sexual and reproductive health and rights at the World Health Organization, and Eleanor Brown, Technical Specialist at Options.

When asked about the role of professional associations, especially professional midwifery associations, Eleanor Brown shared her work experience in Nigeria. She tells us that the Society for Obstetricians and Gynaecologists of Nigeria is integral to the maternal death review process and in instilling a culture of no blame. Eleanor Brown further states:

“The professional association for midwives plays quite an important role in other [Options] maternal health programmes as champions, particularly for getting people to have the political will to address maternal mortality”.

N.Cornier_presentation slideImage caption: Slide from Nadine Cornier’s seminar presentation

Let us celebrate the work of midwives as champions in maternal and newborn care around the world. Let us also reaffirm that midwives can play an important part in MDSR as they can uniquely contribute to making effective decisions to improve the quality of maternal and newborn care.

To watch the live stream of the seminar at LSHTM, Applying Maternal Death Surveillance and Response in Crisis Settings, click here.

To download Nadine Cornier’s presentation, click here.

This seminar is part of a series. To read about the seminar series including the first seminar which took place in January 2017, click here.

Read this blog by UNFPA to learn more about Nadine Cornier’s work with midwives in northern Syria.

Acknowledgements: This blog was written by Jenna de St. Jorre, Evidence for Action-MamaYe Technical Assistant at Options.

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MPDSR: a supportive process for midwives to boost morale

This blog, written for International Day of the Midwife on 5th May 2017, illustrates how the maternal and perinatal death surveillance and response (MPDSR) process in Kenya helped to lift the morale of midwives working in extremely challenging conditions.

The Maternal and Newborn Health Improvement (MANI) project has trained eight midwives from Lugulu hospital since September 2015 in MPDSR. Since then the facility has regularly conducted maternal and perinatal death reviews (M/PDRs). The primary objective of MPDSR is to identify areas where quality and access to emergency obstetric and newborn health care services can be improved to help prevent future deaths. However, in Lugulu hospital, the midwives found that MPDSR equipped them with strategies to cope during an exceptionally difficult period.

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Like many faith-based facilities across Kenya, health providers in Lugulu Hospital in Bungoma County felt unable to turn maternity clients away during the four-month strike by Government doctors. During the strike, from November 2016 to February 2017, Lugulu Hospital experienced:

  • An increase in maternity in-referrals from an average of two per month to over 100, including many cases from facilities in neighbouring counties
  • A sudden six-fold increase in the number of deliveries and a seven-fold increase in the number of caesarean sections

Ordinarily, these additional clients would have used the free government maternity services, and lacked the resources to pay Lugulu’s standard fees. With clients unable to pay, Lugulu struggled to cover the additional demands on staffing, drugs and supplies, leaving the facility in a compromising situation. Midwives experienced a huge increase in their workload, typically working over 12-hour days, often for seven-consecutive days, leaving them both “physically and mentally drained” (Matron in-charge). Postnatal wards were grossly overcrowded. Emergency clients had to queue for caesarean sections in the hospital’s only operating theatre, with staff having to make difficult decisions regarding which emergency case was most critical. For some emergency patients arriving from elsewhere, delays in the weak referral system proved to be fatal.

The increased caseload and detrimental impact on quality of care resulted in midwives witnessing over 20 perinatal deaths a month at its peak, compared to an average of one per month before the strike. No maternal deaths had occurred at the facility between January and November 2017, but five occurred during the strike, leaving staff to feel “upset and demotivated seeing so many lives lost just because of money” (Maternity-in-charge).

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Despite the excessive strain already placed on their workload by the doctor’s strike, midwives and other health personnel at Lugulu continued to meet to review all of the maternal and perinatal deaths that occurred during the course of the strike, and found that this was “a positive experience at a time when morale was low” (Matron-in-charge). The Maternity-in-charge went on to explain:

“Midwives see MPDSR as a learning experience and an important process for identifying and addressing preventable factors contributing to deaths. The review process helps us to see our weakness. We identify gaps in the management of difficult cases. We then take action, such as internal continuous medical education and training in emergency obstetric and newborn care.”

What was especially important during this crisis was that midwives found the meetings were an opportunity to “sit together as a team” (Matron-in-charge). During the doctors’ strike they felt determined to continue the M/PDR process as it helped them at a truly difficult time emotionally. Akin to a peer-support counselling session “some midwives even came to attend review meetings after working a night shift,” (Health Record Information Officer).

The MPDSR process was thus a pivotal mechanism enabling the midwives to cope in this difficult context. It confirmed MPDSR as a valuable process that strengthened their team work, reinforcing the need and appreciation of their collaborative efforts.

Acknowledgements: This blog was written by Sarah Barnett, Technical Specialist at Options.

To learn more about the experiences of midwives conducting confidential enquiries in Ireland, including the importance of having a peer-support system within the process, read our expert opinion piece on the role of the multi-disciplinary team in MDSR or similar models.

National MDSR Annual Report 2008 EFY (2015-16)

This is the second national report on maternal death surveillance and response (MDSR) data from Ethiopia. It presents data reported to the national MDSR database in the Ethiopian Financial Year (EFY) 2008 (2015-16). In 2008 EFY, 633 maternal deaths were reported; this is 6% of the expected maternal deaths and an increase from 387 deaths between 2006 and 2007 EFY (2013-15).
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The MDSR system has now been rolled-out to all regions in the country and includes data on deaths in the community and in facilities. In 2008 EFY the number of hospitals in Ethiopia grew significantly. Health-facility deaths now make up nearly 40% of investigated cases, which has contributed to an increase of reported events for 2008.

This expansion of the system leading to a larger number of community and facility data in 2008 makes it too early to compare the data from both reporting periods. This report should, therefore, be considered on its own. However, for future reports it is expected that the data will be used to determine patterns and trends in maternal mortality over time.

The feature of this report is a new response section with examples of actions from community level to national level in response to the review of maternal deaths and the data contained in the 2008 EFY MDSR Report.

Haemorrhage continues to be the leading cause of death with 42% of maternal deaths due to obstetric haemorrhage. The provision of trained staff and appropriate equipment is necessary to manage obstetric haemorrhage. All women should also be encouraged to use antenatal care services and be offered iron during their pregnancy to help prevent haemorrhage.

National MDSR Annual Report 2008 EFY_Box 1

Click here to download the report (PDF).

Value of data: Sexual and reproductive health and rights in crisis settings

Summary_Rajat Khosla presentation_IDMHR_11.4.17The World Health Organization (WHO) says it is crucial for women to have access to quality health care throughout their pregnancy, childbirth and postpartum period and overall life course at any time and in any place, including humanitarian and crisis settings. Enabling environments that are rights-based, equitable and legally protective can help ensure quality health care is available to women and girls.

Last month, Rajat Khosla, a trained lawyer and Human Rights Adviser in Sexual and Reproductive Health and Rights (SRHR) at the WHO, gave a compelling presentation about sexual and reproductive health, and the value of maternal death surveillance and response (MDSR) data and systems in crisis settings, at a seminar we co-organised at the London School of Hygiene and Tropical Medicine (LSHTM). Watch the live recording here. Continue reading

Report on perinatal deaths in South Africa

In late 2016, two reports reflecting perinatal population statistics were released in South Africa: April newsletter_Evidence summary_image 1Perinatal Deaths in South Africa, 2014, which is
the second annual report by Statistics South Africa (the government department mandated to produce statistical information) and the fifth Rapid Mortality Surveillance Report, 2015 by the Burden of Disease Research Unit of the South African Medical Research Council. These reports provide the most recent national picture of the trends and causes of death of the perinatal population.

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 the most recent data for the period 2012 to 2014 and will summarise the findings of the Perinatal Deaths in South Africa, 2014 report. Continue reading

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

Event information

Date and Time: Tuesday 17 January 2017, 5:30 pm – 7:00 pm

Location: John Snow Lecture Theatre, LSHTM, Keppel Street, London, WC1E 7HT, UK

seminar-1-photoRecently, the Ebola outbreak in West Africa hit the poorest hardest. The three countries most affected by the crisis were amongst the top 11 countries in Africa with the highest maternal mortality (click here to see data).

In Sierra Leone, which holds the highest maternal mortality in the world, systems to count and investigate maternal deaths were hampered.

This seminar will explore:

  • limited data availability affecting operations in maternal and newborn health through a donor lens;
  • an innovative method to quantify the indirect mortality effects of the crisis; and the
  • changing landscape of maternal health response, including implications for maternal death surveillance and response and how will we react in the future.

Speakers:

Moderator: Dr Sara L Nam, Global MDSR Action Network – Evidence for Action, Options

Admission and registration: It is free to attend this seminar, but registration is required. Registration is now closed.

To learn more about 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, click here.

Email: mdsr@evidence4action.net

Twitter: @E4AMamaYeAfrica #MDSR

The seminar will be filmed. The recording will be available on this page after the event.


Please watch this space for updates on Seminar 1.

Click here to read a blog on the seminar, click here.

Click on the links below to read and download:

  • A presentation by Dr Chris Lewis about the UK Government’s response to Ebola in Sierra Leone and what opportunities there are to strengthen resilience of the health system, available here.
  • A method to estimate maternal and newborn mortality during a crisis, as presented by Laura Sochas, click here.
  • A presentation by Dr Benjamin Black on how MSF’s maternal health programme adapted to respond to Ebola and his reflections on MDSRs, available here.

Read more about the seminar series here.

Find out more about the second seminar: Applying maternal death surveillance and response in crisis settings here.

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

Watch the live recording of the event here!

Event information

Date and Time: Thursday 23rd March 2017, 5:30 pm – 7:00 pm, followed by refreshments

Location: John Snow Lecture Theatre, London School of Hygiene and Tropical Medicine (LSHTM), Keppel Street, London, WC1E 7HT, UK

LSHTM & MDSR AN Seminar 2_event advert_imageOverview:

Mothers and their babies face greater risks to their survival during humanitarian crises. However, there is a dearth of evidence about how best to apply reproductive health interventions effectively in crisis settings. Understanding why women and their babies die in these specific circumstances is pivotal to designing appropriate interventions to prevent deaths from similar causes.

This seminar will explore tools and approaches to maternal death surveillance and response (MDSR) in crisis settings with presentations on the following:

  • Value of MDSR data and systems in crisis settings, and in contributing to achieving  sexual and reproductive health rights
  • Approaches to measuring maternal mortality in refugee settings and responding to findings
  • Participatory ethnographic evaluation research (PEER) as a tool to triangulate MDSR findings in crisis settings

Speakers:

  • Rajat Khosla, Human Rights Adviser – Sexual and Reproductive Health and Rights, World Health Organization, Geneva
  • Nadine Cornier, Humanitarian Adviser – Reproductive Health & Head of Office, UNFPA, Turkey
  • Eleanor Brown, Technical Specialist – Options, London

Moderator: Sarah Moxon, Research Fellow, the March Centre for Maternal, Adolescent, Reproductive and Child Health, LSHTM

This event is a collaboration between the Health in Humanitarian Crises Centre, the Global MDSR Action Network and the MARCH Centre for Maternal, Adolescent, Reproductive and Child Health

Admission and registration: It is free to attend this seminar, but registration is required. Registration is now closed.

To learn more about 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, click here.

Email: mdsr@evidence4action.net

Twitter: @E4AMamaYeAfrica #MDSR

The live stream recording is available here.

Watch this space for additional recordings of the event and access to supplementary materials.


Read more about the seminar series here.

Find out more about the first seminar of the series: Innovations to improve maternal and newborn death surveillance to respond to future Ebola outbreaks here.

How legal and policy frameworks support MDSR in Jamaica

Image_map of JamaicaProfessor Affette McCaw-Binns, a Reproductive Health Epidemiologist at the University of the West Indies (Mona) and Dr Simone Spence, Director of Family Health Services at the Ministry of Health in Jamaica explain how legislation and policy strengthened the reporting of maternal deaths in Jamaica. This case study describes how the policy framework was amended to improve the reporting of maternal deaths and how other interventions implemented simultaneously together strengthen the maternal death surveillance and response (MDSR) system.

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In the early 1980s1,2, maternal deaths in Jamaica were significantly under-reported in vital registration records by as much as 75%. With over 80% of all live births occurring in public hospitals2 it was suggested that establishing a surveillance system at public hospitals could capture needed information about the number of maternal deaths in the country. Given the findings3, the government agreed to implement an active (as opposed to the pre-existing passive) surveillance system to monitor maternal deaths.

This case study will describe the approaches that the government adopted, including how the legal framework was used in support of strengthening the MDSR system and reversing under-reporting.  Continue reading