We asked six experts from Malaysia, Ireland, Ethiopia and India about the importance of multi-disciplinary teams in maternal death surveillance and response (MDSR) systems. Here are the insights they shared with us.
Our contributors have all worked closely with MDSR (or maternal death review also known as MDR, which is a component of MDSR) in various guises, contexts and parts of the world. We have drawn together common themes from their insights to draw out lessons learned for the successful implementation of multi-disciplinary health actor involvement in MDSR.
Several of our expert contributors who interviewed for this piece emphasised the need to involve broad civil society, community or religious stakeholders in the process of the review of maternal deaths, because, as Fiona Hanrahan, a senior midwife and midwifery reviewer of maternal deaths in Ireland, noted: “Not all maternal deaths are as a result of medical conditions or obstetric complications”.
As discussed in our March issue, involving a wide range of stakeholders such as communities and civil society in the MDSR process is essential to learning about the individual, familial, socio-cultural, economic and environmental factors that might have contributed to a maternal death. A multi-stakeholder approach involving all of these groups as well as health system actors is ideal.
In this issue, we are focusing on the teamwork required between clinical and non-clinical actors in the health system when working in MDSR systems. What do our experts say about how these multi-disciplinary teams can most effectively contribute to reviewing maternal deaths worldwide?
The importance of multi-disciplinary teams in MDSR
Our expert contributors agreed that successful MDSR systems always require the involvement of a range of clinical and non-clinical staff within the health system. “MDSR is team work,” explained Dr V P Paily, state coordinator of the Confidential Review of Maternal Deaths in Kerala, “It can be successful only as a team.”
Edel Manning, a midwife and ultrasonographer, and coordinator of the Maternal Death Enquiry Ireland, emphasised that a multi-disciplinary approach in the review process is essential “in order to make a complete assessment of factors impacting on the maternal death” to identify any system failures or training needs within the team.
Neglecting a multi-disciplinary approach can result in “a vital piece of the ‘jigsaw puzzle’ being missed” when investigating maternal deaths, explained Fiona Hanrahan, Assistant Director of Midwifery and Nursing and midwifery reviewer of maternal deaths in Ireland. She highlighted that the circumstances surrounding many maternal deaths are often complex and require multiple specialties other than midwifery and obstetrics: “As a midwife, I am aware of my limitations particularly in very complex cases. … It is crucial that the reviews follow the path that the patients take and [do] not look at any ‘event’ in isolation.” In Ireland, Ms Hanrahan explained, the maternal death review meetings involve contributors with different areas of clinical expertise, for example pathologists to interpret the post-mortem report; psychiatrists to comment on the mental health of the patient; or midwives to provide insight into the antenatal or postnatal care received. These specialist insights can shed light on, and offer alternative perspectives on the circumstances surrounding maternal deaths.
This approach is mirrored in India, where Dr Paily explained that the involvement of multiple disciplines is vital because “more and more maternal deaths are due to non-obstetric causes like cardiac disease and psychiatric illness.”
The involvement of such specialists can support development of learning packages, as occurs in Malaysia. Dr Ravichandran Jeganathan, obstetrician and gynaecologist, and Chairman of Confidential Enquiries for Maternal Deaths in Malaysia, highlighted how being open to engaging with different members of the multidisciplinary team can enable improvements in quality of care and better guidance for health professionals. He explained how findings from reviews of maternal deaths revealed that a large proportion of recent cases to be among women with cardiac disease. In response, cardiologists were engaged in the discussions about improving care for these women. This has resulted in the development of national guidelines for the management of heart disease in pregnancy, which has just been launched.
In addition to health professionals, non-clinical health system actors such as health inspectors, administrators, particularly administrative heads, and politicians are also essential in the process. A paper by Dr Paily and colleagues describes the importance of targeting administrators as a key group who benefit from awareness training about the advantages of MDSRs. While clinical actors can lead the surveillance and review processes, the engagement of non-clinical health system actors is vital to enable the ‘response’ aspect of the MDSR cycle in terms of identifying and ensuring funding, resource allocation, and policy changes to allow recommendations and actions to be implemented.
The role of midwives within multi-disciplinary teams
Midwives play different roles in different health systems and MDSR models, but in many contexts midwives are the primary providers of antenatal, intrapartum and postnatal care.
This proximity to the delivery of care positions midwives to provide a unique contribution to successful MDSR systems: “They have crucial information to contribute,” argued Dr Ruth Lawley, a British obstetrician and gynaecologist who is currently working with the E4A programme in supporting the Ministry of Health to roll out the MDSR system in Ethiopia. “They will be familiar with the case, they’ll understand more from the woman’s perspective, they’ll know the context in terms of what drugs or equipment were available … they’ll know why the woman presented at a health facility late, or what her family dynamics are”.
These unique insights that midwives can bring to the review of maternal deaths and more widely in MDSR allows committees to make the most relevant decisions. The involvement of midwives is important at all stages of the review, from ascertaining cases, through the review process, to implementing the actions recommended by the review. As Dr Jeganathan stated: “if we exclude them, then the MDSR system is very weak”.
Unfortunately, in some settings, midwives are not as involved in the review of maternal deaths or more widely in MDSR systems as they could be. However, our experts assert that this needs to change. As Dr Paily noted: “In our own state of Kerala at present, the role played by midwives is secondary, but this has to change. It is mostly an obstetrician-centred [model of] care, but actual observation and conduct of labour are [conducted] by midwives in most of the hospitals. There is [a] need to bring them up to share more responsibility.”
“In many low-income countries, midwives often occupy quite a low status [within the health systems],” explained Dr Lawley, “However that does not mean that they can’t and shouldn’t play a role in MDSR. I think there is generally an increasing recognition that midwives have a vital role to play in MDSR.”
Supporting effective teams
Our expert contributors suggested various ways to support multi-disciplinary teams to more effectively play their roles.
Notably, the importance of good leadership and coordination was highlighted. Ms Manning emphasised the essential role of the overarching review coordinator: a role which often requires dedicated funding in order to effectively manage the process and overcome the time and schedule constraints of the contributors. Dr Lawley highlighted the importance of a strong chair of the review meetings, who is able to call equally upon all members to contribute.
The “buy-in” of strong leaders who are committed to MDSR processes is essential for the system to function effectively: “If you haven’t got the buy-in of the senior obstetrician or gynaecologist in a facility setting or if you haven’t got the buy-in of the health managers, the CEO, the medical directors, etc., your system is not going to be successful” said Dr Lawley.
A notable challenge is finding professionals with the suitable competencies and time to commit to the process, as noted by Ms Hanrahan, especially as the review of cases requires notable time commitments and may require challenges to one’s own professional opinions. She explained that the selection of experts must not be compromised despite this challenge, and highlighted the importance of ensuring that health professionals involved should be those who demonstrate “a real interest in the work as reviewing cases is a commitment of time… [and should]… have an open mind to the opinion of other disciplines.”
Our experts believe that communication and respect across disciplines and professions is essential to the review process, but not always forthcoming. Bringing together different disciplines with different ideas and approaches may, on occasion, lead to major differences of opinion or be complicated by poor communication.
Unequal power relations between clinical and non-clinical health actors may also pose a challenge, warned Renu Khanna, co-coordinator of the ‘Dead Women Talking’ civil society initiative into maternal deaths in India. This challenge, however, may be overcome through creating an environment for respectful teamwork throughout the MDSR process, where all contributors of different cadres and disciplines can contribute to the discussions equally. There is a sense that the importance of this factor had started to become more widely acknowledged, for example in Ethiopia Dr Lawley described that there is “more recognition that teamwork is needed, and training across professional groups is now becoming more common.”
In Kerala, Dr Paily described how such an environment has been achieved in committees by ensuring all contributors are volunteers to their positions and roles in MDSR, and explained that uniting them behind the common goal of preventing avoidable maternal deaths is important.
In Ireland, Edel Manning explained the strong preference for face-to-face multi-disciplinary team discussion of cases, as opposed to individual members of the team reviewing the cases remotely, as this was felt to be most educational and supportive. Importantly, being able to share findings in light of the insights of other reviewers enabled a more transparent and comprehensive picture of the circumstances surrounding cases that would otherwise be missed when cases are reviewed in isolation from other reviewers.
Tied to this, there is consensus among our experts for a strong need to promote a ‘no blame’ culture: “we must encourage [committees to learn] how to work better together … not as a fault-finding machine, but as a fact-building one” said Dr Jeganathan. Dr Paily and Ms Hanrahan also highlighted the importance of maintaining confidentiality in all discussions to avoid “the blame game” when discussing maternal deaths.
To support implementation of effective MDRS processes, clear guidelines towards contextually-adapted standardised manuals and tools are necessary. In addition, promoting the roles of multi-disciplinary team members through information campaigns and workshops is important to raise awareness among stakeholders, as supported by Dr Paily and colleagues.
Supporting midwives within teams
Our experts offered recommendations for strengthening the role of midwives within MDSR systems in contexts where they had been traditionally excluded from the process.
Firstly, midwives must be embedded in the structure of the system for them to be valued and have a voice. The role of midwives should be advocated for at all levels of the health system, from national to facility level. Guidelines supporting their roles in MDSR can help build their acceptance in the committees and embed their involvement in the system, as has been done in Ethiopia. As Dr Lawley argued, the “long-term survival of the MDSR system […] depends on the buy-in of midwives. Midwives are often vital in terms of active risk management on a labour ward and they can play a prominent role in the reviews.”
“[Midwives] are the back bones of any maternal health service.”
Dr Jeganathan, National Head of Obstetrics and Gynaecological Services at the Ministry of Health in Malaysia
Secondly, training about the importance of MDSR and its components should be part of the pre-service curricula for midwifery in order for midwives to enable them to “to contribute more confidently and effectively to the MDSR system” said Dr Lawley. In Malaysia, Dr Jeganathan described how MDSR has been routinely integrated in the training manuals of midwives and nursing staff, which has helped to build their capacity and sensitise them to the process.
Beyond pre-service training, the importance of continuous, in-service training is necessary because, as Fiona Hanrahan explained, “most of the work of the reviewer is based on relevant experience grounded in [the] knowledge of current guidelines”. Thus, ensuring that reviewers and other contributors to MDSRs are aware of changes and developments is important. Further, guidelines for midwives in the local languages explaining the content, process and ethics of conducting reviews of maternal deaths is important as a way to ensure holistic and culturally relevant contributions are made by a wider set of contributors, as is the experience of Renu Khanna in India.
Fiona Hanrahan raised an additional and important point about supporting colleagues, particularly those newly involved in the review of maternal deaths, who should be mentored by a more experienced reviewer. As she explained, reviewing in detail the circumstances surrounding a death can be “mentally strenuous”. It is important to “develop personal strategies to separate yourself, emotionally, from the stark reality that each case you review involves a family losing a loved one and, often, young children and a new baby never knowing their mother”. Tapping into a professional network for support, such as fellow reviewers, could provide vital support, she suggested.
In conclusion, as part of the broad stakeholder involvement in MDSR systems and processes, it is important that clinical and non-clinical health actors are equally empowered across disciplines and professions to each contribute their unique and valuable voice to the process of learning and growing from every tragedy of a facility-based maternal death, free from blame and as part of a cohesive team with a shared commitment to improve the health of mothers and their babies .
This piece was written based on interviews and feedback from our six expert contributors: Dr Ruth Lawley, obstetrician and gynaecologist, and Technical Support Unit Coordinator for E4A in Ethiopia working with the Ministry of Health to establish MDSR; Ms Edel Manning, midwife, ultrasonographer and Coordinator of the Maternal Death Enquiry (MDE) Ireland; Ms Fiona Hanrahan, Assistant Director of Midwifery and Nursing at Dublin’s Rotunda Hospital and midwifery reviewer of maternal deaths with MBRRACE; Dr Ravichandran Jeganathan, National Head of Obstetrics and Gynaecological Services at the Ministry of Health in Malaysia, President of the Obstetrical and Gynaecological Society of Malaysia, and Chairman of Confidential Enquiries for Maternal Deaths; Ms Renu Khanna, social scientist and women’s health and rights activist in India, and co-coordinator of the ‘Dead Women Talking’ civil society initiative into maternal deaths; and Dr V P Paily, Senior Consultant and Head of Department at Rajagiri Hospital, Kerala, India and State Coordinator of the Confidential Review of Maternal Deaths in Kerala.