Professor Affette McCaw-Binns, a Reproductive Health Epidemiologist at the University of the West Indies (Mona) and Dr Simone Spence, Director of Family Health Services at the Ministry of Health in Jamaica explain how legislation and policy strengthened the reporting of maternal deaths in Jamaica. This case study describes how the policy framework was amended to improve the reporting of maternal deaths and how other interventions implemented simultaneously together strengthen the maternal death surveillance and response (MDSR) system. Continue reading
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 World Health Organization (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 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).
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.
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.
Maternal and perinatal death surveillance and response in Bangladesh was initiated by the Ministry of Health and Family Welfare (MOH&FW) to monitor the overall improvement of maternal and neonatal health. Since its inception, the MoH&FW has been implementing MPDSR in 17 districts across Bangladesh following the pilot programme in Thakurgaon district in 2010. The approval of the national MPDSR guideline has paved the way to scale up MPDSR. From July to September 2016, a number of initiatives have taken place to further MPDSR implementation across the country.
- The national guidelines for MPDSR have been approved by the MOH&FW. Printing is underway and the dissemination workshop will take place in October 2016.
- Plans to scale up MPDSR countrywide by 2021 have been drafted in the results framework of the Health, Population and Nutrition Sector Development Program 2011-2016
- The MPDSR Training of Trainers manual is under development and will be implemented to train sub-national level facilitators who in-turn will train healthcare providers from multiple disciplines at the district and upazila levels. The upazila team will then train the field-level health care providers on death notification, verbal autopsy (VA), social autopsy and facility death review. Participants will also be trained in data collection and analysis
- A booklet on MDPSR for health and family planning workers in the field is also being developed in the local Bengali language. A draft will be complete by September 2016. The booklet is expected to be distributed to field-level health workers (health assistants, family welfare assistants, health inspectors, assistant health inspectors, family planning inspectors and sanitary inspectors) by November 2016
- Simplified tools of MPDSR to help facilitate death notification, VA and facility death reviews, to name a few, are being prepared for dissemination to all 17 districts. Selected variables of VA have been incorporated in the District Health Information System-2 (DHIS-2)
- A national-level meeting – led by the Director, Primary Health Care and Line Director of Maternal, Neonatal, Child and Adolescent Health of the Directorate General of Health Services – was planned in September 2016 to share experiences in maternal and perinatal death review across 14 districts
- The national MPDSR guidelines will be shared at six divisional workshops once finalised (expected date: December 2016).
- The UNICEF South Asian Regional Office has organised a South-to-South exchange visit for the MOH&FW Obstetric and Gynaecological Society of Bangladesh to travel to China in November 2016 to share experiences about auditing maternal near misses
To learn more about Bangladesh’s implementation of MPDSR or components of it, please read the country update from July 2016.
Browse this case study to read about how social autopsy is used as an intervention tool to prevent maternal and neonatal deaths in communities in Bangladesh. The WHO has also published a case study about social autopsy in Bangladesh.
Acknowledgements: This country update was prepared and reviewed by Dr Riad Mahmud, Health Specialist (Maternal and Neonatal Health), Health Section, UNICEF Bangladesh and Dr Animesh Biswas, National Consultant (MPDSR), Health Section, UNICEF, Bangladesh.
A maternal and perinatal death reviews (MPDR) system has been embedded in Mara Region in Tanzania with support from the Mama Ye-E4A programme. This programme worked with the Ministry of Health to establish accountability mechanisms at and council levels in line with the national MPDR guidelines which ensures timely reviews of the implementation progress. The evidence-based National MPDR Guidelines have been replaced by MPDSR guidelines.
Mara was chosen by the Ministry of Health to act as an initial roll-out region for the new MPDSR guidelines in Tanzania. A subsequent assessment suggests that health care providers and managers have the required skills to implement the national guidelines effectively across all levels of service delivery and administration. This brings optimism that for the first time in the national implementation of maternal and perinatal death audits, progress will be monitored and evaluated to inform subsequent responses in maternal and perinatal survival and well-being for transformative gains across the health sector and beyond.
In embedding a functioning action and response cycle through the MPDSR process, Mama Ye-E4A ensured that decision-makers have been supported to continue to deliver against their responsibilities and commitments such that a functioning action and response cycle is embedded and sustainable in Mara region. The last quarter saw the end of the Mama Ye-E4A programme in Tanzania, but the important progress and championing of the establishment and subsequent roll-out of MPDSR looks set to continue under the remit of the GIZ-supported Tanzania German Health Support Programme.
The MPDSR system has been rolled out by the Ministry of Health to two more regions of Kagera and Lindi. Already, training has been conducted for key personnel in all hospitals in the two regions, regional and council health management team members and to stakeholders’ staffs supporting the two regions in RMNCAH namely Jhpiego and GIZ respectively. MPDSRs are recognised as key accountability and quality of care improvement mechanisms and referred to in the National Health Sector Strategic Plan 2016-2020- an important health sector guiding document beyond RMNCAH to ensure they remain a priority in the years to come. They have also been incorporated in the final drafts of the One Plan II (National RMNCAH Strategy for 2016-2020).
At the national level, the WHO country office has released funds for rolling out MPDSR across all regions in the country using the same platform that was used to roll-out the Sharpened National Accelerated Plan for Reduction of Maternal, Newborn and Child Deaths. Thus, significant activities are expected countrywide with a focus to impact appropriate skills in MPDSR implementation across all regions.
This update was informed by feedback from Moke Magoma, former Evidence Advisor on Mama Ye-E4A Tanzania; a March 2016 policy study conducted by Dr Sarah Clark (University College London), Dr Stephanie Smith (University of New Mexico), and Dr Moritz Hunsmann (French National Centre for Scientific Research); country director reports; and Mama Ye-E4A quarterly reports.
E4A has been providing technical assistance for the introduction, implementation and scale-up of Ethiopia’s national Maternal Death Surveillance & Response (MDSR) system since 2012.
At national level, this has involved contributing to the development of the MDSR Guidance, data collection tools and database, and training curriculum, participating as active members of the MDSR task force, and representing the programme internationally.
The Ethiopia E4A team is based in the MNCH department of the WHO Ethiopia country office. In addition to a Programme Director, E4A is supported by five regional Technical Advisors who have been supporting the four large agrarian regions (Amhara, Oromiya, SNNPR and Tigray) as well as Harari, Dire Dawa and Addis Ababa, and a Data Manager working in the EPHI Public Health Emergency Management (PHEM) directorate. The University of Aberdeen’s Immpact programme and Options serve as the E4A Technical Support Unit, providing strategic guidance and 2 advisors based in Ethiopia.
Read our two page summary of our experiences here>
Read our training materials and guidelines here>
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
The Ministry of Health in Malawi released Maternal Death Surveillance and Response (MDSR) guidelines for health professionals in 2014. These guidelines aim to inform capacity building and implementation of a functional MDSR system in Malawi, incorporating it within the current Integrated Disease Surveillance and Response (IDSR) system.
Download Malawi’s MDSR guidelines here.
This article by Moke Magoma and colleagues, published by BMC Pregnancy and Childbirth in December 2015, presents the findings of a statistical analysis of data from maternal death reviews (MDR) in Bugando Medical Centre, north-western Tanzania between 2008 and 2012. The study presents the findings from the analysis, as well as describing the challenges of the analysis and how it provided a greater understanding of maternal deaths. The authors found that routine MDRs in this setting were not complete, with key documentation missing, such as actions to address weaknesses in the system. The authors conclude that the roll-out of new national guidelines in Tanzania may help to build capacity for tertiary institutions to carry-out training of health professionals in maternal and perinatal death reviews.