Over 5 million perinatal deaths are estimated to occur annually in low-income and middle-income countries. Most of these deaths are not registered, reported or investigated by the health systems in these countries.
The 10th revision of the International Statistical Classification of Diseases and Related Health Problems (ICD-10) is a document that contains different codes for diseases, signs and symptoms. It is used globally by doctors and systems recording deaths to give a standardised code to different causes of adult and child deaths. In 2012, the WHO wrote ICD-MM: guidance on how to apply ICD-10 to deaths of women during pregnancy, childbirth and the puerperium (the period after delivery). However there was no single globally-recognised guidance on how to code the causes of the deaths of stillbirths and neonatal deaths, meaning that countries could not compare their estimates.
The World Health Organization has launched two important documents to address this problem: the WHO Application of ICD-10 to deaths during the perinatal period (ICD-PM) and the Making Every Baby Count: Audit and Review of Stillbirths and Neonatal Deaths. Continue reading
While many countries have been implementing maternal death surveillance and response (a mortality audit cycle to address the contributing factors of maternal deaths from local to national levels and ultimately improve quality of care), less attention has been given to stillbirths and neonatal deaths despite babies sharing the same periods of risk as their mothers. This publication by the World Health Organizatio (WHO) gives guidance on conducting a mortality audit system to investigate the modifiable factors in perinatal deaths and prevent similar causes of events. Continue reading
Maternal death surveillance and response (MDSR) is a continuous cycle of notification, review, analysis and response. It builds on the concept of maternal death reviews (MDRs) by focusing on the response and follow-up to ensure recommendations are acted on.
MDSR is a relatively new concept and there is limited systematic data on its implementation. Therefore, in 2015, the World Health Organization (WHO), in collaboration with the United Nations Population Fund (UNFPA) conducted a global survey of national MDSR systems to provide baseline data on the status of implementation.
This report presents the findings of this survey, including additional information from the WHO-MNCAH policy indicator database. It details key aspects of the MDSR system, and discusses the importance of MDSR and its role in reducing preventable maternal death by 2030.
- A 46 question survey questionnaire was developed based on the indicators of MDSR implementation
- The questionnaire was circulated through WHO and UNFPA regional offices in April 2015 and responses were received between May-September 2015
- 67 countries responded, 64 of which were low- and middle-income countries (LMIC)
- Information from the WHO-MNCAH policy indicator database was used to supplement survey responses and build of picture of the current status of MDSR implementation in LMICs
- There has been widespread adoption of the important elements of the MDSR system globally, yet, there remains a gap between policy and practice and there is a lack of progress towards full implementation in many countries
- Most countries have national policies to notify all maternal deaths (86%) and review all maternal deaths (85%)
- Only a small proportion of countries have a national MDR committee that meets at least biannually (46%)
- Only 60% of countries have both a national and subnational MDR committee
- Frequent review meetings at all levels are important for successful surveillance and response. Therefore the functioning of the MDSR system may be sub-optimal in countries whose committees meet less than biannually
Case study insights
Member states were also invited to share case studies describing successful implementation. 18 countries contributed at least one case-study, describing how barriers were overcome and highlighting innovative approaches. Some of the challenges and barriers to implementation include:
- Limited political buy-in and long-term vision
- Under reporting of suspected maternal deaths due to inefficient/incomplete notification systems
- Blame culture
- Incomplete/inadequate legal frameworks
- Inadequate staff, resources, and budget
- Cultural norms and practices that limit MDSR operation
- Problems of geography and infrastructure that inhibit MDSR operation
Conclusions and next steps
- There is a gap between MDSR policy and practice in many countries, with the “response” component lagging the furthest behind
- Countries should be supported to focus on improving levels of maternal death notification and on strengthening mechanisms for response at all levels
- To support countries in their implementation effort, the MDSR Working Group will work with partners to develop flexible MDSR training packages that can be adapted to countries priorities
- The next global MDSR implementation survey is scheduled for 2017 and will be repeated every two years thereafter
To download the report for free, click here.
To read the WHO’s MDSR technical guidance, which describes the measures required to establish an effective MDSR system, click here.
Reference: World Health Organization. (2016). Time to respond: a report on the global implementation of maternal death surveillance and response. Geneva: WHO.
This report was published in May 2016 and is based on information collected of perinatal deaths in the UK for births from January to December 2014. The document focuses on deaths reported through the secure online reporting system, which include all late foetal losses (22nd to 23rd weeks of gestational age), stillbirths (a baby delivered at or after 24 weeks of gestational age with no signs of life) and neonatal deaths (a liveborn baby delivered at 20 weeks of gestational age or later, or weighing 400g or more when gestation is unavailable) who died within 28 days of being born. The findings are displayed in mortality rates for stillbirths, neonatal deaths and extended perinatal deaths (both stillbirths and neonatal deaths). The report offers key findings and recommendations, as well as describing causes of death and factors that influence rates of perinatal death.
Pattinson et al (2009), published by the International Journal of Gynaecology and Obstetrics, conducted a systematic review and meta-analysis of perinatal mortality audit at the facility level in low- and middle-income countries. The results showed a reduction in perinatal mortality by 30% with the establishment of a perinatal audit system.
The findings suggest that an audit system may be helpful in reducing perinatal deaths in facilities and improving the quality of care. Pattinson and colleagues also reviewed information about community audits and verbal/social autopsy drawing on examples from Africa (Guinea and Uganda) and Asia (Uttar Pradesh, India). Furthermore, two country case studies were presented on scaling up perinatal audit in South Africa and Bangladesh.
The authors identify areas that merit further research and conclude that successful implementation of perinatal audit to improve the quality of care relies on closing the audit cycle.
In this article, published in 2011 by the BMC Health Services Research, Belizan and colleagues set out to examine the implementation and management of the Perinatal Problem Identification Programme (PPIP) in South Africa. The authors conducted two workshop sessions to draw on the experiences of clinical care providers. An analytical framework was applied, divided into three phases: ‘pre-implementation’, ‘implementation’ and ‘institutionalisation’. Each phase has two stages of change.
The authors identified four themes that are key to sustaining the implementation of an audit system across the stages of change. These include:
- Drivers of change and teamwork
- Outreach visits and supervisory meetings
- The review of perinatal deaths and feedback meetings
- Communicating and networking
The six stages that correspond to the three phases – before implementation, during implementation and the institutionalisation of the audit programme – include:
- Building awareness
- Committing to audit implementation
- Preparing for audit implementation
- Implementing the audit programme
- Making audit routine practice
- Sustaining the programme
These findings may be applied to other low- and middle-income settings that have high neonatal mortality and are planning on adapting a perinatal audit system. The authors also provide a comprehensive tool to reflect on the implementation and management of a perinatal audit system.
This article, published by the International Journal of Obstetrics and Gynecology in 2014, discusses the development of the Perinatal Problem Identification Programme (PPIP) in South Africa, which was first implemented in a few hospitals in 1990 as a facility audit tool to improve the quality of maternal and newborn care. By 2012, PPIP became a requirement for all public health facilities delivering newborns and was introduced to all districts across the country.
The article describes the various functions of PPIP, including the audit cycle, data entry, verification and analysis, and training. Rhoda and colleagues detail the experiences of two facilities – Western Cape and Mpumalanga – that have been implementing PPIP the longest and offer two differing experiences that may be helpful to other facilities interested in using perinatal death audit. Finally, the authors draw on the strengths, challenges and opportunities of PPIP, concluding that with adequate support, training and guidance, PPIP can help mothers and their newborns survive in South Africa.
This qualitative Master’s thesis from the University of the Western Cape, South Africa, highlights findings from the Ashanti region in Ghana, where midwives are actively involved in all stages of the implementation of facility-based maternal death review, including:
- reporting and certifying maternal deaths
- collecting and documenting evidence in order to notify the public health units
- processing and preparing evidence for the audit meetings
- participating in the audit meetings
- helping to formulate recommendations as part of the audit team,
- disseminating, implementing and monitoring the recommendations of the audit report.
The author found that midwives play a vital role, especially in facilities where there were no other clinical cadres of staff. The author recommends:
- Junior midwives be included in MDR meetings to build their confidence and involvement in MDR
- Continuous in-service training on issues related to MDR for nurses and midwives
- Inclusion of MDR in the Nurses and Midwifery Council of Ghana curriculum
- Specific training for midwives on their particular role within the MDR process
This mixed-methods study emphasised the value of teamwork, commitment and champions at health facility level to facility-based MDR in Nigeria.
The authors found that where key members of MDR committees transferred, where facilities were understaffed or there was a lack of supportive supervision, these problems significantly undermined the sustainability of the MDR process.
They recommend MDR be institutionalised in the Ministry of Health to provide adequate support to staff.
This paper proposes a community-based approach to measuring maternal mortality based on a feasibility study conducted in 2010-2011 in Tigray, Ethiopia, based on the concept of ‘task shifting’.
Priests, traditional birth attendants and community-based reproductive health agents were given responsibility for locating and reporting all births and deaths, and they assisted mid-level providers to locate key informants for verbal autopsy.
From there, nurses and nurse-midwives were trained to administer verbal autopsies and assign cause of death according to WHO ICD-10 classifications.
The study highlights the feasibility of using existing community and health structures to implement MDR.