This article by Kate Kerber and colleagues in BMC Pregnancy & Childbirth presents the findings of a review and assessment of evidence for facility-based perinatal mortality audit in low- and middle- income countries, including their policy and implementation status on maternal and perinatal mortality audits.
The authors found that only 17 countries have a policy on reporting and reviewing stillbirths and neonatal deaths despite evidence suggesting that birth outcomes can be improved if the audit cycle is completed. Key challenges in completing the audit cycle and where improvements are needed were identified in the health system building blocks of “leadership” and “health information systems”. Evidence based solutions and experiences from high-income countries are provided to help address these challenges.
The authors conclude that the system needs data mechanisms (e.g. standardised classification for cause of death and best practice guidelines to track performance) as well as leaders to champion the process (e.g. bring about a no-blame culture) and access decision-makers at other levels to address ongoing challenges.
In May 2013, the Federal Ministry of Health launched Ethiopia’s MDSR system. By the end of 2014, the system had been introduced in 17 zones and has been integrated into the existing surveillance system. This case study presents the findings of a preliminary audit of responses to maternal death. The “response” arm of MDSR is recognized to be the most challenging part of MDSR with few centres managing to respond in an organised constructive manner to maternal death.
A preliminary audit of responses to maternal death from health facilities at different levels of the health system demonstrated an average of 3 responses to each maternal death.
The audit captured 211 responses to 71 maternal deaths at 33 health facilities/ communities. Of the 211 responses 39% were aimed at improving care within the hospital or health centre demonstrating a constructive approach to the MDSR process. In other words, health facility staff did not simply pass blame to the community or referring health facility for the woman’s death and say “she came too late”.
Actions improved feedback and training to staff, improving services available at the health facility, improving access to essential drugs and equipment and redistribution of staff to improve effectiveness. A further 35% of responses targeted community awareness of the need to access health care in pregnancy. This was done through a variety of methods including regular women’s groups, community meetings and pregnant women’s conference.
MDSR information is a powerful tool of communication between health professionals and communities. Fifteen per cent of actions involved communication with referring health facilities thereby strengthening referral pathways, whilst the remaining 10% targeted the regional or zonal offices to improve transport systems and obtain essential drugs.
It is noted that the majority of the responses taken were not expensive in terms of cash but contributed to staff professional development and raising community awareness of maternal health issues.
To read more, take a look at Ethiopia’s MDSR Newsletter here and a case study in the World Health Organization’s global MDSR report here.
Case study written by Evidence for Action in Ethiopia.
Photo credit: UNICEF Ethiopia/2010/Tuschman
In the journal article Audit-identified avoidable factors in maternal and perinatal deaths in low resource settings: a systematic review, Hasan Merali and colleagues present the findings of a systematic review of all published audits in low and low-middle income countries in order to identify the most common avoidable factors of maternal and perinatal deaths worldwide.
Notably, the majority (two-thirds) of avoidable factors were accounted for within the category health worker-oriented factors, such as substandard practice of health workers and delay in receiving care on admission. The leading three factors of deaths were:
- substandard practice of health workers
- patient delay to seek care
- lack of capacity in blood transfusion
The review reiterates the valuable insight that audits provide in identifying systematic deficiencies in clinical care, which in turn can be used for targeting interventions to address these system failures. What’s more, the very fact that the causes of maternal and perinatal deaths are often similar in low-resource settings means that these avoidable factors could be used to inform a rational design of health systems.
Full reference: Merali, H., Lipsitz, S., Hevelone, N., Gawande, A., Lashoher, A., Agrawal, P., & Spector, J. (2014). Audit-identified avoidable factors in maternal and perinatal deaths in low resource settings: a systematic review. BMC Pregnancy and Childbirth, 14(1), 280.
Maternal Death Audit Outcome Forms have been introduced in Evidence for Action’s (E4A) focal districts. These are a simple tool that supports health facilities in linking practical actions to service delivery gaps highlighted by the Maternal Death Audits. On this form, a solution is attributed to each identified gap with a timeline and a responsible person to resolve the issue at the health facility. E4A Ghana is now focusing on collecting evidence on the use of these forms and how this tool has influenced change at the facility level. For more information, please contact Carolyn Blake from the Swiss Tropical and Public Health Institute: Carolyn.Blake@unibas.ch