Tag Archives: Accountability

National Report EFY 2006-7 (2013-15)

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.

Background

Image_National Report_PostThe 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.

Methods

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.

Key findings

  • 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

Recommendations

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).

Nigeria | Ensuring the sustainability of MPDSR

With the support of the MamaYe-E4A programme over the last five years, Nigeria has worked to embed the MDSR process at state level in the country –and is the only setting that we knew of with a sub-national level maternal death review (MDR) scorecard at the time of dissemination in October 2015.

In the last few quarters in Ondo State, two MDR scorecards have been developed by the Evidence Sub-Committee of Ondo State Accountability Mechanism for Maternal and Newborn, Health supported by E4A-MamaYe. These scorecards were based on the MDR data from all secondary-level facilities and two Mother and Child Hospitals in the state and aim to challenge the previous lack of reporting and review of maternal deaths. The scorecards were disseminated at a stakeholder meeting in Ondo and one of the key findings (that sepsis had overtaken haemorrhage to become the highest cause of maternal death) sparked lively debate.

The attendees explored the issues from both the woman’s and the facility’s point of view, and suggested strategies on both fronts for example, educating women on personal hygiene during antenatal care whilst also encouraging prompt referral of cases of premature rupture of the membranes at facilities.

One of the key issues discussed was while Ondo State Mother and Child Hospital provides most maternal, newborn and child health (MNCH) services for free, the most effective antibiotics, cephalosporins, are not exempted from costs. This means that staff may be forced to prescribe women cheaper antibiotics because they cannot afford cephalosporins. This was also leaving women open to the risk of being sold fake drugs by pharmacies, which would be ineffective against sepsis. The Ondo meeting attendees discussed strategies to counter this issue, for example, advocating at state level to get cephalosporins included in the free MNCH services, and using TruScan, a device which can detect fake drugs, to ensure women are being given genuine drugs.

While MamaYe-E4A’s presence in Ondo State ended in March 2016, key components of the programme are being integrated into the DfID-funded MNCH2 programme in Jigawa, Kano, Katsina, Zamfara, Yobe and Kaduna States including MDR scorecards and advocacy. In addition, under a new contract from the Gates Foundation, MamaYe-E4A is working to replicate this success in other States, including setting up similar systems in Lagos State.

Recent successes in Bauchi State include the review of MDR reports from 2015 by the Bauchi State MDSR Steering Committee, which enabled them and the Bauchi State Accountability Mechanism for MNCH to convene a stakeholder meeting to discuss and identify causes of maternal death and create action plans. At this meeting it was revealed that the highest cause of maternal death was anaemia, and possible factors causing this were identified to include the high prevalence of worm infestation and poor nutrition among women, as well as supply-side issues such as inadequate access to health services and lack of blood supplies. Discussions then focused on how to tackle these issues: how to ensure women are de-wormed regularly, provide nutrition education on diet using local foods, and how to make sure facilities have functional blood banks.

In Lagos State, the recent inauguration of the maternal and perinatal death surveillance and response system included launching a committee at state-level and supporting the training of 135 health care providers across secondary facilities and one tertiary facility. Training was conducted in four batches and was the first MamaYe-E4A had conducted under the updated national MPDSR guidelines which aimed to integrate perinatal death review into MDR systems.

This national level focus on perinatal death is being consolidated. In June, the National MPDR Steering Committee meeting members discussed building on the experience of MamaYe-E4A and MNCH2 in training health care providers on the updated MPDSR guidelines. A workshop was planned for the end of June where MamaYe-E4A and MNCH2 could share their training methodology, slides and materials to support the national MPDR Steering Committee in developing a training manual on MPDSR.

This focus on perinatal death is also filtering down to state level: the last MDR scorecards from Ondo State (January to March 2016) highlighted perinatal death review data in line with the national shift towards a commitment to perinatal survival.

To view the MDR scorecard for Ondo State (January to March 2016), please click here.

Acknowledgements: This country update was compiled from feedback from Dr Tunde Segun, Country Director for E4A-MamaYe Nigeria, and content from E4A quarterly reports.

Making the case for MDSR at Women Deliver

The MDSR Action Network was represented at the Women Deliver conference through an Options evening side event on ‘Accountability for Health Results’.

The event included talks and booths about Options’ work in Nigeria, Nepal, Tanzania and Malawi as well as Options’ regional network and platforms: MamaYe, Africa Health Budget Network, The Girl Generation, African Health Stats and the MDSR Action Network.

Photo credit: E4A

The MDSR booth at the event exhibited materials highlighting Options’ MDSR work worldwide, including copies of the MDSR Action Network newsletter and the MDSR scorecards from Sierra Leone and Nigeria. It provided a great opportunity to share resources and experiences of how different countries are using MDSR to strengthen accountability to improve the care of mothers and babies.

Dr Tunde Segun, Country Director of MamaYe-E4A Nigeria, manned the booth and engaged with a steady stream of visitors, talking them through the materials, answering questions, and inviting them to sign up for the MDSR Action Network newsletter. Almost all of those approaching the booth readily agreed to sign up to be kept in the loop on this important issue.

Dr Segun spoke to a crowded room about how the MamaYe-E4A programme in Nigeria has supported MDSR. For example, four states have now established MDSR scorecards, which measure the strength of the MDSR system and can act as powerful catalysts of action to improve quality of care. In Jigawa State, the MDSR data showed clearly that more maternal deaths were occurring at night, and action was taken to modify staff rotas to ensure senior midwives were on duty during the night shifts.

In Ondo State during the last quarter of 2015 and first quarter of 2016, the MDSR scorecard showed that sepsis had overtaken haemorrhage as the primary cause of maternal death. Health care providers, policy makers and stakeholders discussed these findings, looking at gains made in addressing haemorrhage by improving the functionality of blood banks in Ondo, but also in terms of the practical actions the state could take to confront sepsis. Actions such as lobbying to get the most effective antibiotics available under the state’s free maternity services are being considered.

Finally, Dr Segun celebrated Nigeria’s pioneering spirit on MDSR by sharing the fact that during the FIGO World Congress in Vancouver 2015, the World Health Organization had revealed that Nigeria was the only country at that time to have produced an MDSR scorecard at the sub-national level.

Acknowledgements:

This case study was informed by feedback from Dr Tunde Segun, Country Director for Evidence for Action in Nigeria.

Helping midwives in Ghana to reduce maternal mortality

This case study highlights the work of the Kybele humanitarian organisation in a referral hospital in Accra, Ghana.

A Kybele midwife team member worked alongside doctors and midwives to support them to review maternal deaths and design quality of care improvements through small group work, supportive and targeted teaching.

The case study notes that lack of observation and monitoring of sick women had previously contributed to maternal mortality and highlights the need for basic midwifery care to improve. Through the partnership model, the midwives at the hospital identified key areas of improvement, including better monitoring of women using partographs. The author emphasises that midwives’ autonomy, standards and scope of practice within an interdisciplinary team were vital to their provision of safe care.

Mother and infant

A Maternal Survival Action Network for Sierra Leone

This case study outlines how Sierra Leone introduced a Maternal Survival Action Network to support the implementation of Maternal Death Reviews across the country. This is an updated version of a case study originally published in our April 2013 issue of the MDSR Action Network newsletter.

In Sierra Leone, implementation of Maternal Death Surveillance and Response (MDSR) has been revitalised since the onset of the Ebola outbreak.

Sierra Leone’s national MDSR framework previously focussed on facility-based MDRs. There is widespread agreement by experts and activists that the use of findings from MDRs for service delivery improvements in the current model of implementing MDRs could be significantly strengthened and efforts to re-establish facility-based MDRs on a regular basis is being re-established. A review of processes and challenges identified opportunities to strengthen MDRs and make better use findings at facility level. The intention is to strengthen the system by identifying context-specific barriers and enablers to the use of MDR findings for quality of care improvements. Continue reading

Strengthening accountability to end preventable maternal deaths

This article by Matthews Matthai and colleagues in the International Journal of Gynecology and Obstetric’s October supplement World Report on Women’s Health 2015 describes the MDSR system, explaining its role as a mechanism for strengthening accountability and ending preventable maternal deaths.  The article also provides updates from around the world on how far the system is being implemented using findings from the WHO Global Maternal, Newborn, Child and Adolescent Health (MNCAH) policy survey 2013-2014. This information has since been updated with findings from the MDSR implementation monitoring survey (April-Sept 2015) presented in the WHO’s latest online report on the status of MDSR implementation globally.

The article highlights that around the world countries are adopting MDSR into policy. However, there is a gap between policy development and placing it into practice:

  • Findings from the MNCAH policy survey found that three-quarters of high-priority countries surveyed had a policy stating that all maternal deaths must be reviewed and yet less than a third had a national MDR committee that meets on a quarterly basis.
  • More recent findings from the MDSR implementation monitoring survey has found that 90 per cent of countries surveyed had a policy stating that all maternal deaths must be reviewed and yet 42 per cent had a national MDR committee that meets at least biannually.

The authors conclude that training more health workers, monitoring and evaluation, and building partnerships with technical experts are recommended to support greater up-take of MDSR.

ICT for improving information and accountability for women’s and children’s health

This report by the International Telecommunication Union provides practical information on the variety of information and communication technology (ICT) solutions available that could help support countries in improving information and accountability for maternal and child health, as advocated by the Commission on Information and Accountability (CoIA).  The report firstly provides an overview of the status of different ICT services available in CoIA focus countries before presenting examples of the role that ICTs can have in implementing CoIA’s 10 recommendations. The report also highlights key governance, policy, and human resources considerations for the successful implementation of ICT projects at national scale.