Tag Archives: Community

National MDSR Annual Report 2008 EFY (2015-16)

This is the second national report on maternal death surveillance and response (MDSR) data from Ethiopia. It presents data reported to the national MDSR database in the Ethiopian Financial Year (EFY) 2008 (2015-16). In 2008 EFY, 633 maternal deaths were reported; this is 6% of the expected maternal deaths and an increase from 387 deaths between 2006 and 2007 EFY (2013-15).
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The MDSR system has now been rolled-out to all regions in the country and includes data on deaths in the community and in facilities. In 2008 EFY the number of hospitals in Ethiopia grew significantly. Health-facility deaths now make up nearly 40% of investigated cases, which has contributed to an increase of reported events for 2008.

This expansion of the system leading to a larger number of community and facility data in 2008 makes it too early to compare the data from both reporting periods. This report should, therefore, be considered on its own. However, for future reports it is expected that the data will be used to determine patterns and trends in maternal mortality over time.

The feature of this report is a new response section with examples of actions from community level to national level in response to the review of maternal deaths and the data contained in the 2008 EFY MDSR Report.

Haemorrhage continues to be the leading cause of death with 42% of maternal deaths due to obstetric haemorrhage. The provision of trained staff and appropriate equipment is necessary to manage obstetric haemorrhage. All women should also be encouraged to use antenatal care services and be offered iron during their pregnancy to help prevent haemorrhage.

National MDSR Annual Report 2008 EFY_Box 1

Click here to download the report (PDF).

The power of communities: strengthening maternal death reporting…and much more!

  • Doubling the number of maternal deaths identified.
  • Accurate and cost-efficient method of measuring the maternal mortality ratio.
  • Strengthened relationships and trust between health facilities and communities they serve.
  • Community actions to prevent future deaths: establishing mobile antenatal care clinics, arranging community meetings to explore traditional beliefs and mobilising funds for bicycle ambulances.

9931220574_d3c293d629_cThese are some of the key results from a community-linked maternal death review (CLMDR) pilot that ran from 2011-2012 in Mchinji district, Malawi.  Presented by Dr Tim Colbourn, Lecturer in Global Health Epidemiology and Evaluation at the University College London (UCL) Institute for Global Heath, the results of the study show the importance of involving communities in the process of identifying maternal death and acting on the recommendations of maternal death review and surveillance (MDSR) systems. Continue reading

Community-linked maternal death review (CLMDR) to measure and prevent maternal mortality: a pilot study in rural Malawi

At a MDSR Action Network event at Options, Dr Tim Colbourn from the University College London (UCL) Institute for Global Health presented the findings of his co-authored paper: Community-linked maternal death review (CLMDR) to measure and prevent maternal mortality: a pilot study in rural Malawi. Continue reading

Policy Briefs

These policy briefs are the outcome of national review of MDSR data from January 2014 to December 2015 covering 539 maternal deaths.

Image_Policy Brief IV_PostAt the National MDSR Task Force’s inaugural meeting members conducted an analysis of national MDSR data in relation to the objectives of the Health Sector Transformation Plan 2015/2016 – 2019/2020. This analysis was distilled into four policy briefs published in July 2016.

  1. Recommendations on Quality of Care in MNH Services
  2. Recommendations on Community Participation and Engagement
  3. Recommendations on Appropriate Use of Blood and Blood Products
  4. Strengthening Response in the Maternal Death Surveillance and Response System

The briefs were designed by Evidence for Action and copies were distributed to regional health bureaus at the National RMNCH Meeting 2016.

These policy briefs comprise the first national level response to MDSR data in Ethiopia and as such mark an important milestone.

Tanzania | Scaling up MPDSR implementation with new guidelines

Maternal and perinatal death surveillance and response is recognised by the Tanzanian government as a process for improving quality of maternal and newborn care in health facilities. With a stepwise approach and the decision to initially focus on facility-based maternal and perinatal deaths before scaling up to include deaths occurring at the community level, new guidelines were developed and are being rolled out to all 26 regions in mainland Tanzania. The process is supported by the WHO country office and involves the training of trainers in each region so that implementation is tailored to the local settings rather than a centralised initiative led by the Ministry of Health (MoH).

Support from the WHO has complemented previous efforts by health stakeholders to roll out of the new national guidelines in four regions in the Lake and Southern zones. Funding from the WHO helped quicken the roll-out process across the country, especially in regions previously not supported.

Led by the MoH, national experts were invited to participate in drafting the timeframe of the countrywide roll-out. Three teams of at least three experts each helped disseminate the new guidelines and trained at least 20 trainers in each region to take over the dissemination and training in districts and health facilities.

In contrast to the 2006-2015 maternal and perinatal death review guidelines, the MPDSR guidelines focus on strengthening skills in maternal and perinatal death audits at the facility level – including the use of information to improve service delivery – and improving capacities to oversee and support implementation at the district, regional and national levels. The MPDSR guidelines define the differences between audit committees at the facility level and technical teams at the district, regional and national levels. They also clarify the use of generated data to inform service delivery and MPDSR implementation at all levels. Reporting from facility to national levels and developing feedback loops are also highlighted in the guidelines to ensure a common understanding. Additionally, the use of information and communications technology, such as WhatsApp groups, to link MPDSR trainers to health facilities in each district and region is also encouraged and are already used to share progress in developing skills that are impactful at all levels.

The MPDSR guidelines are expected to be disseminated to all regions by September 2016 as the scale up of MPDSR in Tanzania progresses.

  • To read the country update for Tanzania from July 2016, please click here.
  • To learn more about MPDSR implementation in Tanzania, read this case study published by the World Health Organization.
  • Read this paper, published by the Tropical Medicine and International Health journal in 2014, to learn about the strengths and weaknesses in implementing MPDRs in Tanzania.

 Acknowledgements: This update was written by Dr Moke Magoma, Team Leader QI, TGPSH (Tanzanian German Programme to Support Health).

Nepal | building on MPDRs to implement MPDSR

Nepal has shown significant progress in reducing maternal and perinatal mortality over the past two decades (see Table 1). Despite progress, maternal mortality in Nepal continues to be one of the main causes of death among women of reproductive age and a major public health problem. In 2015, it was estimated that about 1500 women died in Nepal during pregnancy, delivery and the puerperium period (WHO 2015).  While it is clearly important to monitor this, the maternal mortality ratio only illustrates part of the story. There is a real need to better understand the story behind the maternal mortality change over the past 10 years and to put in place the necessary steps to prevent maternal deaths in the future. Thus, Nepal has been undertaking a number of initiatives to identify programmatically useful information to inform investment and interventions in maternal health.

Table 1: Estimates on the maternal mortality ratio, neonatal mortality rate and perinatal mortality rate

Years 1995 2006 2011 2015
Maternal mortality ratio (per 100,000 live births)[1] 660 258
Neonatal mortality rate (per 1,000 live births)[2] 47.7 22.2
Perinatal mortality rate (per 1,000 births)[3] 45 37

Note: the next Demographic Health Survey for Nepal will report data from 2016.

In 1990, a maternal death review process was first introduced in Paropakar Maternity and Women’s Hospital in Kathmandu, the only maternity hospital in the country. The hospital began implementing perinatal death review in 2003. By 2006, maternal and perinatal death reviews were being conducted in six hospitals increasing to 44 referral hospitals by 2014. Furthermore, maternal mortality and morbidity studies were undertaken in three districts in 1998 increasing to eight districts in 2008-9.

In line with the recommendations of the Commission on Information and Accountability / World Health Organization (CoIA/WHO), the Government of Nepal (GoN) initiated a maternal and perinatal death surveillance and response system in 2014. The system builds on experiences from MPDR implementation and the maternal mortality and morbidity study.

While facility-based reviews of maternal and perinatal deaths continue in 44 referral hospitals, the GoN, with support from the WHO and other partners has been implementing MPDSR in five districts, namely Banke, Dhading, Kailali, Kaski and Solukhumbu since 2016. In these districts, MPDSR is implemented at two levels: health facility and community. At the facility level, both maternal and perinatal deaths are reviewed and appropriate actions are taken. In the community, verbal autopsies are conducted for maternal deaths only.

Diagram 1 (see link below) presents the role of different stakeholders/actors in MDSR at the community level and MPDSR at the facility level.

diagram-1_mdsr-mpdsr-process-in-nepal

The Ministry of Health of Nepal, with support from the WHO, UNICEF, Nepal Health Sector Support Programme / Department for International Development and other partners, has taken the lead and made a commitment to gradually scale up maternal and perinatal death surveillance and response to all hospitals across the country by 2020 and ultimately expand to include community-based maternal death surveillance and response. A series of planning meetings are taking place with  experts to finalise the training modules, review processes, and develop implementation guidelines, to name a few.

REFERENCES

World Health Organization (WHO), UNICEF, UNFPA, the World Bank Group & the United Nations Population Division. (2015). Trends in Maternal Mortality: 1990 – 2015. Estimates by WHO, UNICEF, UNFPA, World Bank Group and the United Nations Population Division. Geneva: WHO.

Acknowledgements: This country update was prepared and reviewed by Dr Sharad Kumar Sharma, Senior Demographer, Family Health Division, DoHS, MoH; Dr Pooja Pradhan, WHO Country Office, Nepal; and Mr Pradeep Poudel, NHSSP/DFID/MoH, Nepal.

[1] World Health Organization (WHO), UNICEF, UNFPA, the World Bank Group & the United Nations Population Division. (2015). Trends in Maternal Mortality: 1990 – 2015. Estimates by WHO, UNICEF, UNFPA, World Bank Group and the United Nations Population Division. Geneva: WHO.

[2] UNICEF, WHO, World Bank, UN DESA Population Division. (2015). Child mortality estimates: UN Inter-agency Group for Child Mortality Estimation. Retrieved September 22, 2016, from: http://www.childmortality.org

[3] Ministry of Health and Population, New ERA and ICF International. (2012) Nepal: Demographic Health Survey 2011. Kathmandu: Government of Nepal.

Malawi | Pioneering MDSR in new districts

In Malawi, the Reproductive Health Directorate, National Committee for Confidential Enquiries into Maternal Death (NCCEMD) and UNFPA are taking a lead in the establishment of MDSR in three new districts (Mzimba, Nkhata Bay and Rumphi) in the northern zone. Over the last few years, MamaYe-E4A has worked in the central and southern regions to introduce components of MDSR into several districts, and this expertise is now being called upon in the expansion of the system to the new districts.

With support from MamaYe-E4A in Balaka, district stakeholders have established MDSRs where there had not been any maternal deaths investigated for a substantial period of time. MamaYe-E4A worked with district authorities to use Health Management Information System and MDSR data to compile a district data dashboard: a user-friendly visual display of graphs in an Excel spreadsheet allowing decision-makers to easily use data to inform their decisions. Based on the analysis of these data, annual MDSR reports were developed, and submitted by the Maternal Health Coordinator to the Director of Health for Balaka to the District Council. The reports highlighted issues with lack of blood and equipment, and the information prompted the District Commissioner for Health to work in collaboration with representatives of civil society and representatives of the community to start fundraising for resources for the health sector.

This type of support is now being extended through MamaYe-E4A to selected districts in the northern region (Rumphi, Nkhata Bay and Mzimba) through funding through the Gates Foundation, in collaboration with the RHD, NCCEMD and UNFPA through the process of establishing the MDSR systems. Through a series of intensive meetings in June, representatives of MamaYe-E4A have supported these organisations to take the lead on MDSR through:

  1. Developing an MDSR monitoring tool for national level monitoring of the districts’ work on MDSR
  2. Adapting a maternal death audit form to be used by the districts themselves to monitor their own progress
  3. Putting together a 2016 workplan, including a commitment to support districts to produce their own quarterly reports according to the guidelines in order for district level decision-makers to be able to take action without having to wait for feedback from the national level monitoring. The plan also includes a proposed meeting between the NCCEMD committee and the National Minister for Health in July to share the progress report on the status for MDSR in the country
  4. Developing terms of reference for MamaYe-E4A’ssupport of MDSR-focused supportive supervision visits in the three districts.

In addition, MamaYe-E4A has been asked by the CCEMD to finalise the MDSR reports from 2014 and 2015, where these reports have experienced delays related to missing or un-submitted data.

In the last quarter, priorities in the new districts include establishing quarterly supervision of the community-MDSR (cMDSR) committees by district teams and training new cMDSR committees in verbal autopsy. Where there are periods of an absence of maternal deaths at this level, the momentum of the cMDSR committees is being maintained through a broader involvement in the MamaYe campaign. Committee members are engaging in work as MamaYe activists and also as activists mobilising their communities to give blood during the National Blood Transfusion Services’ blood donation drives to help prevent maternal deaths from haemorrhage.

District health authorities in the northern districts have also been supported to replicate the district data dashboard model used in Balaka. Based on evidence arising from the dashboards and MDSR data, e evidence-based advocacy materials have been developed, which call upon different groups to act in support of improving the lives of mothers and babies. For example, in Nkhata Bay, the district data dashboard has revealed that 22 women died from pregnancy or childbirth-related causes between 2013 and 2015, and posters and leaflets were developed to call on healthcare workers, district leaders and traditional authorities to address this issue.

Finally, Malawi is also in the process of establishing nationwide best practice guides. The training of health workers in MDSR has so far been based on the national guidelines, but the Ministry of Health is in the process of standardising the training through establishing a training manual. A database is also being established to list all the health workers already trained in MDSR so that they can be called upon to help scale up the system.

Dashboard1

Illustration of dashboard data from a district in Malawi

To view the posters and leaflets developed in Nkhata Bay to call for stakeholder action, please click here and read more about how this evidence on maternal health is used to drive accountability from this link.

Acknowledgements: This country update was developed based on feedback from Project Manager for MamaYe-E4A, Lumbani Banda, and Evidence Advisor for MamaYe-E4A, Hajj Daitoni, as well as updates from the programme reports.

An innovative approach to measuring maternal mortality at community level in low-resource settings using mid-level providers: a feasibility study in Tigray, Ethiopia

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.

Lao-PDR

Social autopsy as an intervention tool in the community to prevent maternal and neonatal deaths: experiences from Bangladesh

Social autopsy in maternal and neonatal health

Social autopsy (SA) is an innovative strategy whereby a trained member leads a group within a community through a structured, standardised analysis of the root causes of a death or serious, non-fatal health event. Continue reading

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Global experience with Maternal Death Surveillance and Response: building for the long-term

This briefing note written by Evidence for Action Ethiopia provides a review of the global experience of MDSR at April 2016. It covers the history and current state of national MDSR systems and provides six lessons learnt from countries’ experiences.

To read the briefing, click here.