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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 crises 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.

For this year’s International Day of the Midwife, the world celebrated: “Midwives, Mothers and Families: Partners for Life!” Bearing this in mind, 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.

In 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 Crises 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

The 5th of May 2017 is International Day of the Midwife. This blog 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.

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

Feedback from Evidence for Action about ESOG and AFOG conferences

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Evidence for Action (E4A) Ethiopia were honoured to take part in the Second Annual Conference of the African Federation of Obstetrics and Gynaecology (AFOG), and 25th Annual Conference and Silver Jubilee Celebration of the Ethiopian Society of Obstetricians and Gynaecologists (ESOG) on 2-4 February, 2017 in Addis Ababa, Ethiopia.

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They were joined by Dr Tunde Segun, the E4A Country Director in Nigeria. Collectively, the E4A team provided support to a satellite session, gave five presentations and hosted a booth on behalf of the MDSR Action network. We share some reflections on the event here.

The conference was attended by around 400 participants from across Africa and included representatives from Ministries of Health, United Nations partners and non-governmental organisations. Continue reading

The power of communities: strengthening maternal death reporting…and much more!

  • Doubling the number of maternal deaths identified.
  • Accurate and cost-efficient method of measuring the maternal mortality ratio.
  • Strengthened relationships and trust between health facilities and communities they serve.
  • Community actions to prevent future deaths: establishing mobile antenatal care clinics, arranging community meetings to explore traditional beliefs and mobilising funds for bicycle ambulances.

9931220574_d3c293d629_cThese are some of the key results from a community-linked maternal death review (CLMDR) pilot that ran from 2011-2012 in Mchinji district, Malawi.  Presented by Dr Tim Colbourn, Lecturer in Global Health Epidemiology and Evaluation at the University College London (UCL) Institute for Global Heath, the results of the study show the importance of involving communities in the process of identifying maternal death and acting on the recommendations of maternal death review and surveillance (MDSR) systems. Continue reading