In March 2015 we shared the news that the Evidence for Action programme in Ghana was piloting the use of Maternal Death Audit Monitoring Forms. This case study presents some of the key findings from this pilot, key challenges and lessons learned.
Ghana is faced with high maternal mortality. In 2015, the maternal mortality ratio was an estimated 319 deaths per 100,000 live births . Facility-based maternal death audits have been used in Ghana as an important strategy to improve maternal health care since 2000. These audits are a qualitative improvement process that seeks to improve pregnancy care and outcomes through the systematic review of the care received. The ultimate purpose of maternal death audits is to identify factors contributing to the deaths and to take remedial action .
In order to strengthen the maternal death audit strategy, the 2012 Millennium Development Goal Acceleration Framework (MAF) programme supported the development of a new 2012 Maternal Death Audit policy and guidelines. The new 2012 guidelines sought to enhance facility-based audits and link them to a Confidential Enquiry System .
To support and maximize the impact of the new tools and guidelines, the Evidence for Action (E4A) programme in Ghana piloted a simple tool to follow up and monitor redress actions based on the facility-based audits. This simple form is called the Maternal Death Audit Monitoring Tool .
The Maternal Death Audit Monitoring Tool:
The Maternal Death Audit Monitoring Tool is focussed on the “action arm” of the audit process. It is a simple tool that supports health facilities in linking practical actions to service delivery gaps highlighted through the audit process. On the form a solution is attributed to each identified gap with a timeline and a responsible person to resolve the issue at the health facility [4, 5].
Click here for an example of the form. An example of a completed monitoring form. Photo credit: Sylvia Deganus
E4A-Ghana designed and piloted the Maternal Death Audit Monitoring Tool between January 2014 and January 2015 in Ashanti, Greater Accra, Volta, and Upper West regions. The pilot aimed to monitor and evaluate outcomes of facility based maternal death audits using the monitoring tool .
A total of 112 representatives from facility-based audit teams from 40 health facilities in the four regions were trained in the use of the tool and tasked to complete the form during each audit meeting activity. The training focussed on the procedures and steps during the audit meetings, and how to use the monitoring tool during these meeting [3, 6-8].
E4A-Ghana monitored the adoption of these forms and whether they were found to be useful through phone-based interviews with 21 representatives of health facilities . An independent policy study led by University College London, which reviewed E4A-Ghana’s activities, also collected data on the influence of this pilot .
The short implementation period for the pilot means that there is insufficient data to showcase whether the monitoring form had an influence on remedial action at facility death. Key findings on the adoption of the monitoring tool from the phone-based interviews include :
- The monitoring tools were more likely to be adopted and used in large referral hospitals. This could be due to the fact that large referral facilities experience more maternal deaths and, therefore, audit teams had the staff capacity and motivation to carry out facility-based audits to change the situation. However, health facilities with infrequent deaths often were unable to maintain their auditing skills, motivation, and use of the form.
- Phone-based interviews carried-out at the large referral hospitals revealed that users found the monitoring forms to be:
- Easy to use
- Useful in documenting meeting outputs and decisions
- Useful in monitoring the implementation of audit redress actions
The policy study revealed positive outcomes from the overall maternal death audit training :
- Participant’s felt that the training provided during the pilot w improved their understanding of the audit process, of who should attend review meetings, of questions on the audit form and of the purpose of the audits.
- Examples of tangible changes noted at Ridge Hospital in Accra after the training included:
- Improvements to meetings and record keeping: meetings take place at regular fixed-times and records of minutes and recommendations are more accurate and timely, as well as revisited at each meeting to assess progress. The minutes, clinical recommendations and policy recommendations are sent to the Regional Health Management Team after every review meeting.
- The entire process of a death is reviewed, from the point at which the woman first arrived at a facility to the time of her death. As a consequence, staff from referring facilities are also invited to the review meetings, so that recommendations are made for action at facilities and referral centres where the woman died. This process has shown positive outcomes. For example, previously, a lack of proper documentation by referring facilities made it difficult for the hospital to treat women appropriately. This changed due to recommendations being shared with facility staff and better communications between facilities and hospitals.
- New clinical protocols produced as a direct result of maternal death audits were linked to several outcomes, such as improved management of preeclampsia and hypertensive conditions due to changes in drug and fluid regimes and the number of emergency cases from referral centres has reduced.
Challenges and lessons learned:
- At first, the E4A monitoring forms were perceived as a potential threat to completion of the newly introduced national maternal death audit forms by some stakeholders, as it would mean an additional task to be completed. This challenge was addressed by including from the start the GHS in the training on the monitoring tool, to ensure full support of the government during this pilot .
- Sustained adoption of the monitoring tool was challenged by high staff turnover and poor knowledge / skill transfer on use of the monitoring tool at the facility level. This challenge could be addressed by providing mentorship and support in using the tool via the telephone; encouraging those trained in using the tool to train other team members; and institutionalizing the use of the tool as an official record of audit meetings .
- Demanding audit teams to provide summary reports on their audit activities and progress in the implementation of recommended actions will encourage use of the monitoring forms and promote increasing accountability from audit committees .
The Ghana Health Service has shown great interest in scaling up the use of the monitoring forms in the framework of maternal death audits, as well as for confidential enquiries .
This case study was developed by Dr Sylvia Deganus, Maternal and Newborn Health Advisor for E4A-Ghana, with support from Victoria le May, Technical Assistant for E4A.
 WHO, UNICEF, UNFPA, 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.
 Deganus, S. (2014). Catalysing monitoring & evaluation of facility based maternal death audits: an e4a intervention plan. Accra: Evidence for Action.
 Evidence for Action. (2014). Evidence for Action-Ghana Country Director Report: April-June 2014. Accra: Evidence for Action.
 Evidence for Action. (2016). Evidence for Action Annual Report 2015. London: Evidence for Action.
 Blake, C. (2015). Ghana introduces Maternal Death Audit Outcome Forms. Retrieved March 8, 2016, from http://mdsr-action.net/updates/ghana-introduces-maternal-death-audit-outcome-forms/
 Deganus, S. (2014). Strengthening Facility Based Maternal Death Review in E4A Regions: Report on Volta Regional Training, 18th-19th February 2014. Accra: Evidence for Action.
 Deganus, S. (2014). Strengthening Facility Based Maternal Death Review in E4A Regions: Report on Ashanti Region Training, 21st February 2014. Accra: Evidence for Action.
 Deganus, S. (2014). Strengthening Facility Based Maternal Death Review in E4A Regions: Report on Upper West Region Training, 27th February 2014. Accra: Evidence for Action.
 Deganus, S. (2015). Maternal Death Review Program Report: 1st July 2015. Accra: Evidence for Action.
 Clark, S. (2015). Sub-National Policy Study Bi-annual Report: Ghana content, March 2015. London: University College London.
 Deganus, S. (2016). Evidence for Action-Ghana MDR programme. Accra: Evidence for Action.