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
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
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.
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
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).
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.
Click here to download the report (PDF).
A recent event at University College London (UCL) will be of interest to those working on maternal death surveillance and response. The seminar, Improving Data, Improving Health: Verbal Autopsy for Health Systems Strengthening, was organised by the University of Aberdeen’s Centre for Global Development and UCL’s Institute for Global Health. The half-day event in October 2016 featured six speakers from the World Health Organization, Umeå University, UCL, Malaria Consortium, University of Aberdeen and the Africa Health Research Institute. Continue reading
This is the first national report on data from Ethiopia’s Maternal Death Surveillance and Response (MDSR) system. The report includes data from 387 maternal deaths between 2006 and 2007 Ethiopian Financial Year (2013-15). It is intended to be used to guide Ethiopia’s efforts to reduce maternal mortality.
The national Maternal Death Surveillance and Response (MDSR) system was established in 2006 Ethiopian Financial Year (EFY) (2013-14) and formally integrated into the Public Health Emergency Management (PHEM) data collection systems in 2007 EFY (2014-15). The objective of the MDSR system is to document, count and review maternal deaths in order to identify causes and contributing factors, and to put in place interventions to prevent future deaths.
In the Ethiopian MDSR system, community-based and facility-based maternal deaths are noted in weekly reports. Community-based deaths are then investigated further through a Verbal Autopsy (an interview with someone close to the woman to establish the circumstances and symptoms leading up to her death) and reviewed at health centre level by a committee. Maternal deaths in facilities are also investigated then reviewed by a team. During each review, a case-based Maternal Death Reporting Form is completed, summarising key information from the Verbal Autopsy or facility review and noting the woman’s cause of death.
This report represents the first time MDSR data has been compiled at national level. It covers 387 anonymised deaths occurring during a 20 month period across 2006 and 2007 EFY (2013-15). The data come from five regions (Amhara, Oromiya, Tigray, SNNP and Harari) and two city administrations (Addis Ababa and Dire Dawa). It presents a summary of progress in implementing the MDSR system, the results of the data analysis, and recommendations for preventing future maternal deaths.
- The integration of the MDSR into the PHEM system is a good example of collaboration within the health system
- Early lessons from the MDSR experience in Ethiopia show that the information gained from the MDSR system gives communities and health workers real information about maternal death and encourages focused change to improve maternity services
- Over half of the reviewed deaths occurred in health facilities (54%) while 25% died at home and 19% on the way to a facility. This reflects both the fact that data collection on maternal deaths is easier in facilities, and also the fact that women are more likely to be taken to a facility after becoming critically ill at home
- 69% of deaths occurred to women with no education
- 60% of deaths occurred after labour/delivery, while 20% occurred prior to labour/delivery and 15% occurred during labour/delivery period.
- 83% of deaths were caused by direct obstetric causes, 15% were indirect causes and 2% were unknown
- Haemorrhage (excessive bleeding) was the major cause of death (accounting for 58% of the causes listed), accounting for about half of maternal deaths, followed by other causes such as hypertension (high blood pressure) , sepsis (from infections), obstructed labour (when the baby’s head gets stuck during delivery) and anaemia (low levels of iron in the blood, putting women at risk of haemorrhage)
- Delay 1 (deciding to seek care) was reported for 66% of maternal deaths, delay 2 (accessing care) was reported for 38% of deaths and delay 3 (receiving care at a facility) was reported for 36% of cases. In around half of cases the death had multiple delays.
- Haemorrhage was more common in women who had more than four children – women with more than for children accounted for 46% of haemorrhage deaths
- Delays in making the decision to seek care were linked to the majority of haemorrhage deaths
For the MDSR system:
- The strengthening and scale up of the MDSR system is needed
- The MDSR system needs to be embedded in the PHEM to further improve communication
- MDSR support should be integrated with the supportive supervision system for health workers at all levels
- Regular performance monitoring of the MDSR system at regional and zonal is required
- A regional annual meeting to feedback to communities and facilities and showcase good practice should be planned
- MDSR data should be used to inform the community, health workers and decision makers to improve the health status of the population of Ethiopia.
- All health facilities should be active participants in the system by setting up an MDSR committee
To address obstetric haemorrhage:
- All health facilities should have trained staff and equipment to deal with obstetric haemorrhage
- All women should be encouraged to access antenatal care and should be offered iron in pregnancy
- Women with more than four children should be offered family planning, particularly long-acting reversible methods (like the implant or intrauterine device) or a permanent method (sterilisation)
Whilst the deaths included in this report represent the tip of the iceberg, it is hoped that the lessons learnt from the loss of these 387 women can help guide Ethiopia’s efforts to reduce maternal mortality.
Click here to download the report (PDF).
In July 2016, the Maternal and Newborn Health Improvements (MANI) project in Kenya’s Bungoma County funded by the UK Department for International Development, published a Human Interest Story in the MANI Learning Series. The MANI project supports six sub-counties in Bungoma to implement maternal and perinatal death surveillance and response (MPDSR).
MANI has been assisting Webuye Hospital to introduce and conduct maternal and perinatal death reviews (MPDRs). This Story presents a few ways MPDRs helped Webuye Hospital to improve maternal and newborn health. Various challenges were overcome by developing an on-call rota system, connecting a generator to the maternity ward and newborn unit, training staff in neonatal resuscitation, improving communication channels between all stakeholders and conducting a blood drive. A new operating theatre is due to open soon and the newborn unit is to be redesigned.
MANI Learning Series: Human Interest Story July 2016
This paper by Nakibuuka et al (2012), published in the African Health Sciences journal, reports a retrospective descriptive study conducted from March to November 2008 to determine what effect an integrated perinatal death audit system in routine care would have on perinatal mortality at Nsambya Hospital. Modifiable factors that cause stillbirths and early neonatal deaths were: Low capacity of neonatal resuscitation, incorrect use of partographs and delays in administering caesarean sections. Interventions to offset these factors include training sessions in neonatal resuscitation and refresher courses on partograph use. Nakibuuka and colleagues conclude that perinatal audits are feasible and can reduce perinatal mortality at the facility level.
This commentary paper, published in the International Journal of Gynaecology and Obstetrics in 2014, gives an overview of the effect of perinatal death audit in low- and middle-income settings. It describes the function of an outcomes audit for perinatal deaths. Buchmann postulates that where perinatal mortality is less frequent (in some middle-income countries) then reviewing near misses may be a more appropriate audit outcome.
The author discusses the two frameworks that are regularly used to assess the preventable factors for each death – the ‘three delays’ and the ‘patient-administrative-healthcare provider’ models. The latter is typically applied to middle-income settings while the former is best suited for low-income areas. Buchmann goes on to describe the criterion-based clinical audit, a popular method used to assess recurrent adverse events commonly identified in an outcomes audit. Finally, the author reviews past studies to determine the effect of change by implementing perinatal audit and to identify where there are gaps in research.
In this paper, published in the BMC Women’s Health in 2016, Agaro and colleagues critically look at the implementation of maternal and perinatal deaths reviews at health facilities in Oyam District, Uganda. They conducted a cross-sectional study reporting both quantitative data and qualitative findings.
Accordingly, the factors that affect the conduct of MPDR are the ‘functionality of maternal and perinatal review committees’, ‘service delivery’ and ‘health workforce’. The authors describe the challenges, lessons learnt and solutions to these factors. They conclude that for the successful implementation and sustainability of MPDRs it is necessary to have the following:
- A functioning MPDR committee
- Trained MPDR members
- Senior staff and administrators attending meetings
- Feedback and supportive supervision
- An understanding of accountability
- Staff motivation
- An extension to communities