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.
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.
This mixed-methods study conducted in five hospitals in Senegal found that the implementation of maternal death reviews were hampered by issues such as the non-participation of the head of department at audit meetings and the lack of feedback about the audit meetings to staff who did not attend.
Factors which supported the MDRs included the involvement of the head of the maternity unit who acted as a moderator during audit meetings and the participation of managers in the audit meeting to plan appropriate and achievable actions to prevent future maternal deaths.
The authors conclude that leadership is vital to secure MDR success.
This case study outlines how Sierra Leone introduced a Maternal Survival Action Network to support the implementation of Maternal Death Reviews across the country. This is an updated version of a case study originally published in our April 2013 issue of the MDSR Action Network newsletter.
In Sierra Leone, implementation of Maternal Death Surveillance and Response (MDSR) has been revitalised since the onset of the Ebola outbreak.
Sierra Leone’s national MDSR framework previously focussed on facility-based MDRs. There is widespread agreement by experts and activists that the use of findings from MDRs for service delivery improvements in the current model of implementing MDRs could be significantly strengthened and efforts to re-establish facility-based MDRs on a regular basis is being re-established. A review of processes and challenges identified opportunities to strengthen MDRs and make better use findings at facility level. The intention is to strengthen the system by identifying context-specific barriers and enablers to the use of MDR findings for quality of care improvements. Continue reading
In March 2015 we shared the news that the Evidence for Action programme in Ghana was piloting the use of Maternal Death Audit Monitoring Forms. This case study presents some of the key findings from this pilot, key challenges and lessons learned.
Ghana is faced with high maternal mortality. In 2015, the maternal mortality ratio was an estimated 319 deaths per 100,000 live births . Facility-based maternal death audits have been used in Ghana as an important strategy to improve maternal health care since 2000. These audits are a qualitative improvement process that seeks to improve pregnancy care and outcomes through the systematic review of the care received. The ultimate purpose of maternal death audits is to identify factors contributing to the deaths and to take remedial action . Continue reading
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
This article by Felix Sayinzoga and colleagues, published by BMJ Open in January 2016, presents the findings of a review of all health facility-based maternal death audits in Rwanda between January 2009 and December 2013. Based on this review, the authors found that the facility-based maternal death audit approach has helped facility teams to identity causes of death and contributing factors, as well as make recommendations for action to prevent future deaths. They recommend that Rwanda better inform corrective actions by complementing these audits with other strategies, such as confidential enquiries and near-miss audits
At national level, the Federal Ministry of Health (FMOH) is planning to institutionalise Maternal and Perinatal Death Surveillance and Response (MPDSR) in Nigeria. As part of this, the FMOH carried out four zonal orientation meetings of representatives of the 36 State Steering Committees and the FCT, on MPDSR in Lagos, Port Harcourt, Jos and Kaduna in early November, which covered in-country experiences of implementing MPDSR at the facility and community level. The meetings were attended by a variety of stakeholders, including representatives from the FMOH, the World Health Organization, Save the Children, Evidence for Action (E4A), UNICEF and the Society of Gynaecology and Obstetrics of Nigeria.
As a result of these four zonal orientation meetings, the FMOH established a virtual MDSR network on MPDSR titled ‘Maternal and Perinatal Death Surveillance and Response in Nigeria’ and is hosted on Facebook.
At sub-national level, in Ondo State, the first zonal facility MDR training has taken place for MDR agents, who included Chief Medical Directors, heads of the Obstetrics and Gynaecology departments, and the nurse/midwife or matron in charge of the hospital labour ward. In Kano, a two-day MDR review meeting has taken place for the State and Facility MDR Committees, which resulted in the development of a workplan for August 2015 to February 2016. In Bauchi State, the Technical Working Group on MDRs successfully trained 131 Facility MDR Committee members from 25 out of the 26 General Hospitals in the State. The committees have drawn up workplans to begin reviews in their facilities.
Update from Dr Tunde Segun, County Director E4A-Nigeria
This article by Kate Kerber and colleagues in BMC Pregnancy & Childbirth presents the findings of a review and assessment of evidence for facility-based perinatal mortality audit in low- and middle- income countries, including their policy and implementation status on maternal and perinatal mortality audits.
The authors found that only 17 countries have a policy on reporting and reviewing stillbirths and neonatal deaths despite evidence suggesting that birth outcomes can be improved if the audit cycle is completed. Key challenges in completing the audit cycle and where improvements are needed were identified in the health system building blocks of “leadership” and “health information systems”. Evidence based solutions and experiences from high-income countries are provided to help address these challenges.
The authors conclude that the system needs data mechanisms (e.g. standardised classification for cause of death and best practice guidelines to track performance) as well as leaders to champion the process (e.g. bring about a no-blame culture) and access decision-makers at other levels to address ongoing challenges.
Read more about the Maternal and Perinatal Death Review system in Bangladesh highlighted in this case study:
1) Biswas, A., Rahman, F., Halim, A., Eriksson, C. and Dalal, K. (2014) Maternal and Neonatal Death Review (MNDR): A Useful Approach to Identifying Appropriate and Effective Maternal and Neonatal Health Initiatives in Bangladesh. Health, 6, 1669-1679.
2) Biswas, A., Rahman, F., Eriksson, C., & Dalal, K. (2014). Community Notification of Maternal, Neonatal Deaths and Still Births in Maternal and Neonatal Death Review (MNDR) System: Experiences in Bangladesh. Health, 6(16), 2218.