This paper by Dr Paily and colleagues, describes the processes and findings from the Confidential Review of Maternal Deaths (CRMD) in Kerala, India.
The paper describes how actions and recommendations were developed based on the findings, and how the response and monitoring has conducted a pilot phase to support continuous improvements in the delivery of quality of care.
One of the key lessons learnt relates to the importance of raising awareness among administrators as a key group who can support the process of CRMDs as members of the multi-disciplinary team.
We asked six experts from Malaysia, Ireland, Ethiopia and India about the importance of multi-disciplinary teams in maternal death surveillance and response (MDSR) systems. Here are the insights they shared with us.
Our contributors have all worked closely with MDSR (or maternal death review also known as MDR, which is a component of MDSR) in various guises, contexts and parts of the world. We have drawn together common themes from their insights to draw out lessons learned for the successful implementation of multi-disciplinary health actor involvement in MDSR.
This article by Sunil Saksena Raj and colleagues, published by the International Journal of Health Policy and Management in January 2015, presents the findings of verbal autopsies carried out in Unnao District between 2009 and 2010. The findings point to the need to improve the inter-facility referral system.
This document, produced by UNICEF in 2008, describes the Maternal and Perinatal Death Inquiry and Response (MAPEDIR) initiative implemented in 16 districts in India. The MAPEDIR tool is a detailed autopsy questionnaire, which aims to capture, from relatives or those close to the deceased woman, individual, familial, socio-cultural, economic and environmental factors missing from medical records. The document describes the development, implementation, key findings, obstacles and opportunities of the MAPEDIR initiative in India. The initiative found that the generation of data by the community highlighted areas where several deaths had occurred and stimulated responses by the community and health providers.
Kerala has been successful in establishing a Confidential Enquiry into Maternal Deaths (CEMD), learning from the system in the United Kingdom. You can read here more about the main causes of maternal deaths in Kerala, the challenges in establishing the CEMD system, and ways forward to make it more efficient.
This articleby Chittaranjan Purandare and colleagues in the International Journal of Gynecology and Obstetrics describes the process that led to the development of an electronic Maternal Death Review (MDR) system in India. Users were positive about the software, finding it simple to use, secure, and useful to generate reports for planning. Key lessons learned include:
Ensure alignment of the country’s objectives and strategies into software development plans
Have a clear implementation road map and project management system to ensure that timelines are followed
Have an action plan for both intended and unintended problems that arise
Involve programme “champions” who will see implementation to its end
Establish public-private partnerships for guidance and support from key stakeholders
Share regular updates on progress to ensure help is provided when needed and that team-members are motivated to provide high-quality work
Civil Society Report on Maternal Deaths in India describes the findings of an analysis of 124 maternal deaths identified and documented over two years between January 2012 and December 2013. The analysis is a part of the Dead Women Talking initiative, established by several civil society organisations in response to the high maternal mortality in the country.
The 124 maternal deaths were first identified by community members and civil society. Following a home visit to verify if the death was a maternal death, families of the deceased are invited to participate in a social autopsy.
The findings of the social autopsy were analysed and recommendations developed using a framework developed to identify gaps that contributed to the deaths across four domains: technical factors, health system factors, social factors, and human rights.
Number of training sessions: One training session on social autopsies was not sufficient to train civil society organisation staff.
Incomplete information from families: Information from families needed to be triangulated as they did not always want or were unable to provide a complete story behind the death.
Deaths under certain conditions missed: Late maternal deaths and deaths due to unsafe abortions and home deliveries were likely missed. As a result, greater efforts, such as training community-based organisations, were needed to ensure deaths under these conditions were recognised.
Difficulty in getting the health system perspective: In almost all districts any attempt to link with the government conducting verbal autopsies was not successful. There was also resistance from the health system to cooperate in CSO-led social autopsies, questioning the expertise of the team conducting the social autopsies and thus not engaging with the findings.
Blame culture: There was a culture of blaming those at the lowest of the hierarchy for the death, such as peripheral health workers. This meant that health workers were reluctant to speak about the deaths.
Involve multiple stakeholders in the MDR process, such as CSOs, community-based organisations, and local governance structures such as Village Health and Sanitation Committees.
Ensure that Action Taken Reports are on the agenda for the MDR committee meetings and are made public. Feedback loops should be established in order for lessons learnt from preventable maternal deaths to be used by the health system and for community action.
This paper published in 2013 reports on the findings from the reviews of a total of 470 maternal deaths which occurred in 2006-2007 in Jharkhand, India.
These verbal autopsies collected data at the household level and found that maternal deaths were related to a range of inter-related medical and non-medical (socio-demographic, economic and cultural) factors. In addition, this study confirmed that maternal mortality disproportionately affects poor, less educated women, showing existing disparities.
Three packages of recommendations stem from these findings: strengthening the quality of antenatal, emergency obstetric and post-abortion care; strengthening the broader health system as well as building the capacity of the health workforce; implementing behaviour change interventions and mobilising the community to increase maternal and obstetric care usage.
This 2013 paper presents key findings from the analysis of 23 maternal deaths which occurred between April 2011 and March 2012 in two blocks of the Godda district of Jharkhand (India).
The qualitative study on which this paper is based aimed at recording maternal deaths at the local level as well as identifying the non-medical factors that contributed to these deaths. Improper and multiple referrals, absence of easily accessible and quality emergency obstetric care, lack of transport facilities and high out-of-pocket expenditure were key factors contributing to delays at multiple levels – delays in seeking care, reaching the health facility and receiving adequate care.
This study thus shows how reviewing maternal deaths can highlight a range of non-medical factors which all contribute towards preventable maternal mortality, and need to be addressed in policy and practice.
This 2013 paper introduces an approach to verbal autopsies that engages with the Rashomon phenomenon: the presence of multiple, and often conflicting, narratives about the same death due to differing interests, uneven knowledge, and power asymmetries among stakeholders.
This approach evolved from the Gender and Health Equity Project in Koppal, India and differs from other verbal autopsies in its approach to data collection and its framework of analysis. Data collection entails working with and triangulating multiple narratives, and minimising power inequalities in the investigation process. The framework of analysis focuses on the missed opportunities for death prevention as an alternative to (or deepening of) the Three Delays Model.