Tag Archives: Health facilities

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).

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.

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.

Perinatal death audits in a peri-urban hospital in Kampala, Uganda

This paper by Nakibuuka et al (2012), published in the African Health Sciences journal, reports a retrospective descriptive study conducted from March to November 2008 to determine what effect an integrated perinatal death audit system in routine care would have on perinatal mortality at Nsambya Hospital. Modifiable factors that cause stillbirths and early neonatal deaths were: Low capacity of neonatal resuscitation, incorrect use of partographs and delays in administering caesarean sections. Interventions to offset these factors include training sessions in neonatal resuscitation and refresher courses on partograph use. Nakibuuka and colleagues conclude that perinatal audits are feasible and can reduce perinatal mortality at the facility level.

The conduct of maternal and perinatal death reviews in Oyam District, Uganda: a descriptive cross-sectional study

In this paper, published in the BMC Women’s Health in 2016, Agaro and colleagues critically look at the implementation of maternal and perinatal deaths reviews at health facilities in Oyam District, Uganda. They conducted a cross-sectional study reporting both quantitative data and qualitative findings.

Accordingly, the factors that affect the conduct of MPDR are the ‘functionality of maternal and perinatal review committees’, ‘service delivery’ and ‘health workforce’. The authors describe the challenges, lessons learnt and solutions to these factors. They conclude that for the successful implementation and sustainability of MPDRs it is necessary to have the following:

  • A functioning MPDR committee
  • Trained MPDR members
  • Senior staff and administrators attending meetings
  • Feedback and supportive supervision
  • An understanding of accountability
  • Staff motivation
  • An extension to communities

Perinatal mortality audit: counting, accountability, and overcoming challenges in scaling up in low- and middle-income countries

Pattinson et al (2009), published by the International Journal of Gynaecology and Obstetrics, conducted a systematic review and meta-analysis of perinatal mortality audit at the facility level in low- and middle-income countries. The results showed a reduction in perinatal mortality by 30% with the establishment of a perinatal audit system.

The findings suggest that an audit system may be helpful in reducing perinatal deaths in facilities and improving the quality of care. Pattinson and colleagues also reviewed information about community audits and verbal/social autopsy drawing on examples from Africa (Guinea and Uganda) and Asia (Uttar Pradesh, India). Furthermore, two country case studies were presented on scaling up perinatal audit in South Africa and Bangladesh.

The authors identify areas that merit further research and conclude that successful implementation of perinatal audit to improve the quality of care relies on closing the audit cycle.

The role of midwives in the implementation of maternal death review (MDR) in health facilities in Ashanti region, Ghana

This qualitative Master’s thesis from the University of the Western Cape, South Africa, highlights findings from the Ashanti region in Ghana, where midwives are actively involved in all stages of the implementation of facility-based maternal death review, including:

  • reporting and certifying maternal deaths
  • collecting and documenting evidence in order to notify the public health units
  • processing and preparing evidence for the audit meetings
  • participating in the audit meetings
  • helping to formulate recommendations as part of the audit team,
  • disseminating, implementing and monitoring the recommendations of the audit report.

The author found that midwives play a vital role, especially in facilities where there were no other clinical cadres of staff. The author recommends:

  • Junior midwives be included in MDR meetings to build their confidence and involvement in MDR
  • Continuous in-service training on issues related to MDR for nurses and midwives
  •  Inclusion of MDR in the Nurses and Midwifery Council of Ghana curriculum
  • Specific training for midwives on their particular role within the MDR process

Experiences with facility-based maternal death reviews in northern Nigeria

This mixed-methods study emphasised the value of teamwork, commitment and champions at health facility level to facility-based MDR in Nigeria.

The authors found that where key members of MDR committees transferred, where facilities were understaffed or there was a lack of supportive supervision, these problems significantly undermined the sustainability of the MDR process.

They recommend MDR be institutionalised in the Ministry of Health to provide adequate support to staff.

Preventable maternal mortality in Morocco, the role of hospitals

This analysis of the findings of the national confidential enquiry around maternal deaths conducted the Ministry of Health in Morocco shows that 54.3% of the deaths analysed in 2009 could have been avoided if appropriate action had been taken at health facilities.

This contradicted previous beliefs that the main causes of maternal death were due to women delaying seeking care. Lack of competence or motivation of staff were linked to the majority of cases of substandard care these women received.

The authors recommend that the managers of local health systems and practitioners themselves received the information and means to support them to implement the recommendations of the audits.

This study highlights the importance of involving hospitals and health providers in the audit process and particularly in supporting them to respond to findings.