Piloting PNDSR in Tigray region to inform national implementation – Part 1

This case study is the first of two. The second part will be published in 2017 and will report on progress toward scaling up perinatal and neonatal death surveillance and response (PNDSR) across the country.

BACKGROUND

In December 2015, Ethiopia began piloting a perinatal and neonatal death surveillance and response system in Tigray region in response to national commitments to improve newborn survival. The perinatal mortality rate in Ethiopia is high, estimated 46 per 1,000 births in 2011)[1]. The Tigray Regional Health Bureau (RHB) initiated the implementation of PNDSR after learning the importance of maternal death surveillance and response to generate evidence to save pregnant women’s lives following the scale up and national launch of maternal death surveillance and response (MDSR) in May 2013. The World Health Organization (WHO) has been supporting the region following its good performance during the initial phase of MDSR implementation.

PROCESS OF IMPLEMENTATION

  • The MDSR platform is used to implement PNDSR, which is incorporated in the Integrated Disease Surveillance and Response (IDSR) – Public Health Emergency Management (PHEM) system in the region. The methods used for MDSR guide the case definition, and method of surveillance (identification, investigation and review) and response used for PNDSR.
  • Maternal and child health (MCH) officers and surveillance focal persons implement MDSR at the facility level. These same officers have been oriented on case definition and tools of PNDSR. As the officers were already familiar with the methods of surveillance from MDSR implementation, the orientation was given at a reduced cost and therefore improved efficiency in conducting the training.  Overall, nearly 680 health professionals were oriented and trained in PNDSR in the region at the beginning of 2016.
  • A regional MPNDSR technical working group (TWG) has already been established, with the addition of paediatricians from hospitals and a university in the region as members to the existing members of the MDSR TWG. The terms of reference for the TWG have been revised and so far, the meetings have been held every two months.
  • The E4A programme is affiliated with the WHO country office and has been supporting the region on PNDSR implementation both technically and financially.
  • The WHO/E4A Technical Assistant supports regional PNDSR and MDSR activities, and also helps to scale up maternal, perinatal and neonatal death surveillance and response (MPNDSR) to the national level.

MPNDSR techical support at the labour ward in Mekele Hospital (Mr Solomon Hailu and two midwives). Photo credit: Dr Tamiru Wondie, E4A National Coordinator for PDSR.

GUIDELINES AND TOOLS

  • The regional MPNDSR guidelines combine PNDSR with MDSR. Five-hundred copies have been printed and distributed to all health facilities, Woreda/district health offices and universities across the region.
  • Tools for PNDSR are included in the regional guideline in both English and Tigrigna languages. These tools are distributed in both hard and soft copies to all health facilities in the region.

RESULTS

  • As of September 2016, almost all hospitals and some health centres have started to implement facility-based PNDSR in Tigray region. The ‘perinatal and neonatal death review form’ is used to collect relevant data for each case. Between June and August 2016, more than 200 perinatal deaths were identified, investigated and reviewed in the region. Based on this data it has become possible to determine the causes, contributing factors and preventability of perinatal deaths. This information was presented in the national reproductive, maternal, neonatal, child, adolescent and nutrition review meeting in August 2016.
  • All Ethiopian regions have planned to start implementing PNDSR in the coming fiscal year. The Ministry of Health (MoH) included a plan to develop a national MPNDSR guideline, training manuals, and standard tools in its Annual Plan. At the national level, the MDSR focal person at the MoH is tasked to manage the PNDSR programme and receives technical assistance from the WHO/E4A programme.
  • Applying the lessons learnt from Tigray implementation and consulting with national experts will help adapt the recently published the WHO guide – Making Every Baby Count: Audit and review of stillbirths and neonatal deaths – to the local context.
MPNDSR supportive supervision at Axume Health Centre (from left: Mr Solomon Hailu, Mr Fisha Gebrewhad and Dr Tamiru Wondie). Photo credit: Dr Tamiru Wondie, E4A National Coordinator for PDSR.

MPNDSR supportive supervision at Axume Health Centre (from left: Mr Solomon Hailu, Mr Fisha Gebrewhad and Dr Tamiru Wondie). Photo credit: Dr Tamiru Wondie, E4A National Coordinator for PDSR.

CHALLENGES, LESSONS LEARNT AND FUTURE PLANS

  • Currently, there are no national guidelines, standard tools or training materials for MPNDSR. Plans are under way to develop, print and distribute these.
  • PNDSR in Tigray region has yet to develop a community based surveillance system. Applying lessons learnt from community based MDSR implementation could be helpful when developing such a system.
  • Greater mobilisation of resources are required to tackle the high burden of perinatal mortality, conduct trainings and provide technical assistance at all levels of the health system. Future plans include conducting a national training of trainers and regional cascade of trainings on PNDSR.
  • Presently, there is no database available for PNDSR data. Plans are in progress to establish a PNDSR database nationally and regionally in a phased approach.
  • Although civil registration and vital statistics (CRVS) systems have been launched nationally, they have not yet been linked to MPNDSR. Linking CRVS and MPNDSR is needed to strengthen the notification of maternal, perinatal and neonatal deaths.
  • A legal framework for MPNDSR is not yet available on a global or national level. The development of a legal framework could help curb the fear of blame – which currently challenges MDSR implementation – in PNDSR.
  • Continued technical assistance support will help strengthen MPNDSR in Tigray region.
  • Plans to support the MoH and RHBs will help scale up MPNDSR implementation to all regions at the facility and community level.

Learn more about recent MDSR activities in Ethiopia by visiting the country update from July 2016.

To read more about Tigray region and measuring maternal mortality at the community level using mid-level providers, browse this feasibility study.

[1] Central Statistical Agency and ICF International. (2012). Ethiopia Demographic Health Survey, 2011. Addis Ababa: Government of Ethiopia.

Acknowledgements: This country update was prepared and reviewed by:

  • Dr Tamiru Wondie, paediatrician and National Coordinator for the Perinatal Death Surveillance and Response system at E4A Ethiopia based at Ethiopia WHO Country Office
  • Dr Azmach Hadush, the MCH and MPNDSR Program Coordinator at Ethiopia WHO Office
  • Mr Solomon Hailu, MPNDSR Officer at Tigray WHO Office
  • Dr Ruth Lawley, obstetrician and gynaecologist, and Technical Support Unit Coordinator for E4A Ethiopia working with the Ministry of Health to establish MDSR.

The content was also based on information from the E4A quarterly and country reports, and the following briefs/reports: Evidence for Action (E4A) in Ethiopia: Experiences from the first three years of the National MDSR Programme (April 2016); the MDSR Technical Guideline, Ethiopia: 2014.