Tag Archives: Committees

State-level updates in northern Nigeria

The Maternal Neonatal and Child health programme (MNCH2) is a five year country led programme which aims to reduce maternal and child mortality in northern Nigeria.  The programme works across six states: Jigawa, Kaduna, Kano, Katsina, Yobe and Zamfara.

Image_Map of Nigeria_MNCH2Since 2014, MNCH2 has been supporting maternal and perinatal death surveillance and response (MPDSR) across its six states.  At secondary level facilities (which often have a high number of deliveries), MDR committees have been set up to review the causes of maternal death and take action to prevent similar deaths in the future.  MNCH2 also supports State MDR Committees to mentor and monitor facility-level committees.  MNCH2’s support to MPDSR across northern Nigeria has resulted in a number of achievements. Here are some examples: Continue reading

Nigeria | the development of a MPDSR system

Nigeria has been working towards developing a national MPDSR system and several activities have taken place at the national and State level over the past few months.

In April and May 2016, a maternal and perinatal death surveillance and response training was held in Lagos to build the capacity of key personnel of the state healthcare system (including gynaecologists, obstetricians, representatives from private hospitals and local government surveillance officers) to further efforts to institutionalise MPDSR in the state, building on existing Maternal Death Review structures. This was the first State-level training in country that incorporated perinatal, surveillance and response components. Read the July 2016 Nigeria update to learn more about the training.

After the training, the Chief Medical Directors of the participating secondary facilities were tasked with establishing maternal and perinatal death review committees at their facilities. To date, committees have been set up in 21 general hospitals that offer maternal, newborn and child health services. These committees have started reviewing maternal and perinatal deaths at the facility level and are sharing MPDSR findings with the State.

Also, participants from each facility developed work plans for MPDSR implementation. Progress towards implementing the facility work plans will be presented in a scorecard based on MPDSR data from July to September 2016. The Lagos State Ministry of Health, with support from the MamaYe-E4A, has collected and analysed the data, and will disseminate the scorecard to MPDSR stakeholders in October 2016.

In Bauchi State, the Bauchi State Maternal and Perinatal Death Surveillance and Response Committee provides mentorship to facility-MDR committees and recently supported the collection of data on maternal and perinatal deaths from 25 secondary facilities in the last quarter with support from MamaYe-E4A. A draft MPDSR scorecard has been prepared, and will be reviewed and validated at a stakeholder meeting at the end of September 2016 before printing.

As a follow up to the country update shared in the July 2016 newsletter, a workshop was conducted at the end of June to develop the national MPDSR training (for trainers) manual. This workshop took place over five days and was led by the FMOH with members of the national MPDSR Steering Committee.

Participants went through the MPDSR national guidelines and tools, and agreed on a modular format for the training manual. During the workshop, participants successfully developed some training sessions. Two consultants have since been tasked with completing the remaining sessions using the agreed format. They have submitted a completed draft of the training manual, which will be reviewed and finalised at a stakeholder meeting in October 2016. A National MPDSR Training of Trainers will then take place in November 2016.

Acknowledgements: This country update was developed based on feedback from Dr Tunde Segun, Country Director for MamaYe-E4A Nigeria; Mr Oko Igado, National Technical Advisor for MamaYe-E4A Nigeria; and content from the Report on the Training of Lagos State Health Care Providers on Maternal and Perinatal Death Surveillance and Response (MPDSR): April 28-29 and May 3-4, 2016, and MamaYe-E4A Quarterly and Country reports.

Kenya | A phased approach to MPDSR implementation and county focus

In order to eliminate preventable maternal and perinatal mortality, several measures have been taken by the Kenyan Government through the Ministry of Health. They include:

  • scaling up training of Emergency Obstetrics and Newborn Care countrywide
  • eliminating user fees for maternity services through the Free Maternity Services Initiative led by The President of Kenya, H.E. Uhuru Kenyatta
  • instituting maternal and perinatal death surveillance and response mechanisms

Kenya recently developed comprehensive national MPDSR guidelines. MPDSR, however, is not new to the Kenyan health system. In 2004, maternal deaths were declared a notifiable event which led to the implementation of maternal death reviews at health facilities. Maternal death reviews are the foundation to MPDSR while perinatal death reviews are less developed.

With the launch of the National MPDSR guidelines – 2016, Kenya is taking a phased approach in implementing the “P” in MPDSR. The implementation has recently begun in facilities with a low burden of maternal morbidity and mortality. It is noted that in health facilities with low maternal death occurrence, perinatal deaths remain quite high.

Murang’a County Referral Hospital is one such facility, with a low burden of maternal mortality but a persistently high perinatal mortality rate. At Murang’a County Referral Hospital, the (facility-level) MPDSR committee holds monthly meetings to discuss each case of perinatal mortality. The case files are usually accompanied by a review of the maternal file. The team reviews each case individually discussing the clinical care and health system factors that contributed to the death. The recommendations are well documented and followed up in the next meeting.

The Ministry of Health is working with the facility, sub-county and county teams to monitor the response to the recommendations made during perinatal death reviews.

COUNTY FOCUS: BUNGOMA COUNTY

The Maternal and Newborn Improvement (MANI) project supports six sub-counties in the roll out of MPDSR within and across 42 facilities in Bungoma County. The national maternal death review (MDR) and perinatal death review (PDR) tools are regularly used at these facilities. Narrative qualitative analyses describing the events of each maternal and perinatal case were introduced in September 2015 and are reviewed on a monthly basis.

The 42 facilities have received ongoing support through trainings, mentorship and supportive-supervisory visits to identify maternal and perinatal deaths, conduct reviews and analyse probable causes of death.

The MPDSR committees in six sub-counties meet quarterly to discuss feasible and immediate interventions that are within the capacity of the sub-county or facility levels to apply remedial solutions to each cause of death.

“…The MPDSR reviews have improved our teamwork, both amongst ourselves and even interdepartmental collaboration. Everyone involved in the care of mothers and newborns are involved in the MPDSR committee deliberation…” (Webuye staff about MPDSR meetings)

From September to December 2015 and April to June 2016, there were reported increases in the number of facilities with functional MPDSR committees from 20 to 42. From the committees that met, 33 facilities made necessary changes to service provision and/or management practices based on MPDR findings between April and June 2016; an increase from two facilities between September and December 2015.

While the percentage of maternal deaths that were reviewed and uploaded to the District Health Information System (DHIS) stayed constant at 100% from September 2015 to June 2016, perinatal deaths reviewed and uploaded to the DHIS increased from 54% to 67%, over the respective quarterly periods.

SUB-FOCUS: WEBUYE HOSPITAL

Webuye hospital has the second highest number of maternal and perinatal deaths in Bungoma County. With the roll out of the new 2015 Kenya National Maternal and Perinatal Death Surveillance and Response Guidelines, there has been substantial progress to review perinatal causes of death to inform the quality of care.

The facility-MPDSR committee at Webuye hospital was established in October 2015 with the support of the MANI project and Bungoma County Health Management Team (CHMT). Prior to this, maternal and perinatal deaths were seldom reviewed, collaboration between maternal and newborn health departments was particularly low and record keeping was poor. As such, perinatal deaths were infrequently accounted for and the true causes of death rarely known.

The MPDSR committee at Webuye holds monthly review meetings. During the initial stages of these meetings, discrepancies were identified between the Ministry of Health PDR forms and the DHIS, preventing PDR data from being uploaded to the DHIS system. As a result, the Webuye team supported the standardisation of the PDR tools in January 2016. The PDR form has since been updated and pretested. The review and upload of PDR findings have increased since the new PDR tool was introduced. For each quarterly period from September 2015 to June 2016, there were marked increases from 44% to 100%, respectively.

Please visit here to read the country update for Kenya from March 2016.

Acknowledgements: The national update was prepared and reviewed Dr Wangui Muthigani, Program Manager- Maternal and Newborn Health at Ministry of Health in Kenya. The update for Bungoma county was developed based on feedback from Mr Peter Ken Kaimenyi, Maternal and Newborn Health Technical Advisor at MANI Project funded by UK Aid; two MANI Project abstracts accepted for presentation at the Kenya Midwives Annual Scientific Conference 2016; and the MANI Project power-point presentation for the Kenya Midwives Annual Scientific Conference 2016.

Sierra Leone | Investing in MDSR

In Sierra Leone, significant investments have been made to move MDSR-related work forward over the last quarter. The National MDSR Committee held a meeting in June 2016, chaired by the Director of Reproductive and Child Health, with representatives from UNICEF, UNFPA, WHO as well as a representative of other health NGOs including Options, to assess progress and propose strategies for the next quarter. The meeting highlighted to following achievements and activities:

  • MDR committees at district level which had operated before the Ebola outbreak have been restructured and adapted to MDSR committees and inaugural meetings have been completed in all districts except Western Area.
  • In some districts, the process of actively reviewing deaths has begun.
  • Social media platforms are being used to support the multi-professional communication needed to sustain and grow the MDSR system through WhatsApp groups for District Medical Officers, Midwife Investigators, M&E Officers, Disease Surveillance Officers and other stakeholders. The World Health Organization has supported the development of an MDSR database using EpiData and training material including presentations on MDSR to support collection, inputting and analysis have been developed.
  • UNFPA is supporting a pilot regional blood collection campaign in response to findings from reviews of maternal deaths from haemorrhage between June and July 2016, as well as providing desktop computers to all districts for MDSR activities and supporting educational discussion programmes on maternal and child health on radio and television.

The meeting provided a good opportunity to plan further consultative meetings, for example, with Paramount chiefs in June and religious and women’s groups at later dates, to ensure wide stakeholder buy-in to the system and maximum impact for MDSR data in the future.

Acknowledgements: This country update was informed and approved by Bockarie Sesay, M&E Advisor for Options-PMEL, in Freetown, Sierra Leone.

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.

The difficulties of conducting maternal death reviews in Malawi

This article uses a strengths, weaknesses, opportunities and threats (SWOT) analysis to assess the difficulties faced in conducting MDR in Malawi.

It highlights the importance of the multi-disciplinary team in promoting collaboration and in ensuring issues relating to different disciplines are addressed.

Good leadership, an emphasis on building staff capacity and ensuring the motivation of different members of the MDR committees are vital for sustainability and success.

Report on the Confidential Enquiry into Maternal Deaths in Malawi (2008-2012)

In 2009, the Government of Malawi established the National Committee on Confidential Enquiry into Maternal Deaths. The Committee are tasked with producing national reports on maternal deaths in a given time period in order to guide actions and responses to prevent future maternal deaths. The first report produced by the Committee investigates maternal deaths that took place between 2008 and 2012.

The retrospective review of records from 27/28 districts included 1433 maternal deaths that took place in facilities or en route to a facility between 2008-2012 (inc.). In total, 57% were due to direct causes including haemorrhage (14% of all maternal deaths), pre-eclampsia (14%), sepsis (10%), and abortion (10%). Key indirect causes of deaths included: anaemia (19%), malaria  (15%), and HIV/AIDS  (8%).

The report, made public in May 2015, explains the methods of the enquiry, presents the findings, and provides recommendations for action.

To read the report, click here.

Mother and baby_Malawi_MamaYe

Malawi builds trust and accountability with a community MDSR system

This case study is an excerpt from a collection of 22 case studies by the Evidence for Action-MamaYe! programme based on their experiences. These case studies bring to light new learning about the specific ways in which evidence, advocacy and accountability must work together to bring about change.

Evidence for Action-MamaYe! was established in 2011 through funding from the UK Department of International Development. The programme’s goal is to save maternal and newborn lives in Ethiopia, Ghana, Malawi, Nigeria, Sierra Leone and Tanzania, through better resource allocation and improved quality of care.

When the Evidence for Action-MamaYe (E4A) programme first started operations in Malawi, we observed that while some facilities and districts were carrying out maternal death reviews, committees met only rarely and did not communicate systematically with other levels. Rudimentary action plans were sometimes developed, but there were no follow-up meetings to track change. Furthermore, the maternal death review process did not include the community level. Consequently, community factors that might have contributed to facility deaths and maternal deaths occurring within communities were not recorded, no explanation was fed back to families or communities on the reasons for facility-based deaths, and no actions were taken in response. This led to distrust between community members and facility staff, who themselves often blamed the families for bringing the woman to the facility too late. Continue reading

Nigeria: Implementing a community component and using evidence for action

At national level, the Federal Ministry of Health carried-out a meeting in February with key stakeholders (UNICEF, E4A, National Primary Healthcare Development Agency, WHO, UNFPA, National Population Commission, and the Centre for Disease Control)  on their Maternal and Perinatal Death Surveillance and Response (MPDSR) system. The purpose of the meeting was to share updates on progress in implementing MPDSR and discuss moving MPDSR forward. Reported progress in implementing MPDSR to date from the federal-level includes: 

  • Development of MPDSR national guidelines
  • Nation-wide orientation on MPDSR held at zonal level
  • Establishment of National and State Steering Committees
  • Development of national and state implementation plan

The central discussion of the meeting focussed on how to leverage existing structures to implement a community component of MPDSR.

At sub-national level, E4A-MamaYe has supported the training of Maternal Death Review (MDR) committees in all Secondary Health Facilities in the following States: Bauchi, Jigawa, Kano, and Ondo. These facilities are now conducting MDRs. MDR data is collected quarterly and used to develop scorecards that provide evidence for the Advocacy Sub-Committees of the State-Led Accountability Mechanisms. Please see examples of MDR scorecards from Bauchi, Kano, and Ondo.

MDR evidence is influencing policy, service delivery and community action in Nigeria. For example, as a result of MDR evidence, Kano State Government included three key activities in the 2016-2018 State Medium Term Sector Strategy (MTSS). These include:

  1. Conduct of MDRs in facilities and quarterly MDR review meetings at the State level
  2. Provision and maintenance of functional blood banks in all State hospitals
  3. Integrated demand creation activities to improve uptake of ANC and maternal survival.

In response to the finding that post-partum haemorrhage is a leading cause of maternal deaths in Gumel General Hospital of Jigawa State, the hospital management mobilised community members (around the catchment areas of the facility) to form blood donation groups who are now donating their blood voluntarily, and blood is now available in the facility.

Update from Oko Igado, National Technical Advisor for E4A-MamaYe, Nigeria

Sierra Leone: Introducing Maternal Death Surveillance and Response

The Ministry of Health and Sanitation (MoHS) have developed national MDSR guidelines (see here) in partnership with UNFPA, the World Bank, and the WHO. The Directorate of Reproductive and Child Health are now leading on the national roll-out of these guidelines. Also, the MoHS, in partnership with UNFPA and other health development partners, has developed a three year costed plan to be implemented over the next three years.

In February 2016, the national MDSR committee was inaugurated and an orientation meeting took place in the same month.  This month, an orientation meeting is planned for all MDSR focal point persons, including midwife investigators and other key staff from the districts. All districts will shortly have inaugural meetings for their MDSR committees (building on existing MDR committees).

Update from Bockarie Sesay, Monitoring & Evaluation Advisor for the Partnership Management, Evaluation and Learning (PMEL) programme, and Rosanna le Voir, Technical Assistant for PMEL