Tag Archives: Facility Death Review

Facility death review of maternal and neonatal deaths in Bangladesh

This article by Animesh Biswas and colleagues in PLoS ONE presents findings of a qualitative study with healthcare providers involved in Facility Maternal and Newborn Death Reviews (FDRs) in two districts in Bangladesh: Thakurgaon and Jamalpur. The study aimed to explore healthcare providers’ experiences, acceptance, and effects of carrying out FDRs.

The study found that there was a high level of acceptance of FDRs by healthcare providers and there were examples of FDRs leading to improvements in quality of care at facilities, such as the use of FDR findings in Thakurgaon district hospital which ensured that adequate blood supplies were available, which saved the life of a mother who had severe post-partum bleeding. The article also identified gaps and challenges in carrying-out FDRs to consider for future efforts, including ensuring incomplete patient records and inadequately skilled human resources to carry out FDRs.

The authors conclude that FDRs are a simple and non-blaming mechanism to improving outcomes for mothers and newborns in health facilities.

To read more about maternal and newborn death reviews in Bangladesh, take a look at several case studies: two from the MDSR Action Network website: “Mapping for Action” and “eHealth to support  MPDRs”; and another in the WHO’s global MDSR report here.

Experiences with facility-based maternal death reviews in northern Nigeria

The journal article Experiences with facility-based maternal death reviews in northern Nigeria presents the findings of a study evaluating the effectiveness of the use of facility-based MDRs by the Partnership for Reviving Routine Immunization in Northern Nigeria – Maternal Newborn and Child Health (PRRINN-MNCH).

The evaluation uncovers a number of findings, including:

  • Only 93 (12.1%) of the total maternal deaths reported in HMIS for the same facilities had been recorded on the MDR forms and only 52 of these maternal deaths had been reviewed; a mere 6.7%.
  • Despite the minimal number of MDRs taking place in these facilities, the MDRs that were conducted did result in improved quality of care, such as the better management of patients and the mobilisation of resources.
  • The process of using MDRs stopped for some time in the 11 hospitals visited for the study. Reasons included the transfer of key MDR committee members, inadequate supportive supervision and shortage of staff. Most did, however, restart with revitalisation of the MDR process by PRRINN-MNCH staff.
  • Challenges reported included fear of blame felt by health workers, shortage of staff to undertake committee meetings, inadequate supportive supervision and low quality record keeping.

The authors conclude by highlighting successful features of the MDR process, including teamwork, commitment, champions at the health facility level to lead the process, and guidance, coordination and support from the national and state Ministries of Health.

Full reference: Hofman, J.J., & Mohammed, H. (2014). Experiences with facility-based maternal death reviews in northern Nigeria. International Journal of Gynecology and Obstetrics, 126 (2): 111–114.