Tag Archives: Malawi

Malawi | Pioneering MDSR in new districts

In Malawi, the Reproductive Health Directorate, National Committee for Confidential Enquiries into Maternal Death (NCCEMD) and UNFPA are taking a lead in the establishment of MDSR in three new districts (Mzimba, Nkhata Bay and Rumphi) in the northern zone. Over the last few years, MamaYe-E4A has worked in the central and southern regions to introduce components of MDSR into several districts, and this expertise is now being called upon in the expansion of the system to the new districts.

With support from MamaYe-E4A in Balaka, district stakeholders have established MDSRs where there had not been any maternal deaths investigated for a substantial period of time. MamaYe-E4A worked with district authorities to use Health Management Information System and MDSR data to compile a district data dashboard: a user-friendly visual display of graphs in an Excel spreadsheet allowing decision-makers to easily use data to inform their decisions. Based on the analysis of these data, annual MDSR reports were developed, and submitted by the Maternal Health Coordinator to the Director of Health for Balaka to the District Council. The reports highlighted issues with lack of blood and equipment, and the information prompted the District Commissioner for Health to work in collaboration with representatives of civil society and representatives of the community to start fundraising for resources for the health sector.

This type of support is now being extended through MamaYe-E4A to selected districts in the northern region (Rumphi, Nkhata Bay and Mzimba) through funding through the Gates Foundation, in collaboration with the RHD, NCCEMD and UNFPA through the process of establishing the MDSR systems. Through a series of intensive meetings in June, representatives of MamaYe-E4A have supported these organisations to take the lead on MDSR through:

  1. Developing an MDSR monitoring tool for national level monitoring of the districts’ work on MDSR
  2. Adapting a maternal death audit form to be used by the districts themselves to monitor their own progress
  3. Putting together a 2016 workplan, including a commitment to support districts to produce their own quarterly reports according to the guidelines in order for district level decision-makers to be able to take action without having to wait for feedback from the national level monitoring. The plan also includes a proposed meeting between the NCCEMD committee and the National Minister for Health in July to share the progress report on the status for MDSR in the country
  4. Developing terms of reference for MamaYe-E4A’ssupport of MDSR-focused supportive supervision visits in the three districts.

In addition, MamaYe-E4A has been asked by the CCEMD to finalise the MDSR reports from 2014 and 2015, where these reports have experienced delays related to missing or un-submitted data.

In the last quarter, priorities in the new districts include establishing quarterly supervision of the community-MDSR (cMDSR) committees by district teams and training new cMDSR committees in verbal autopsy. Where there are periods of an absence of maternal deaths at this level, the momentum of the cMDSR committees is being maintained through a broader involvement in the MamaYe campaign. Committee members are engaging in work as MamaYe activists and also as activists mobilising their communities to give blood during the National Blood Transfusion Services’ blood donation drives to help prevent maternal deaths from haemorrhage.

District health authorities in the northern districts have also been supported to replicate the district data dashboard model used in Balaka. Based on evidence arising from the dashboards and MDSR data, e evidence-based advocacy materials have been developed, which call upon different groups to act in support of improving the lives of mothers and babies. For example, in Nkhata Bay, the district data dashboard has revealed that 22 women died from pregnancy or childbirth-related causes between 2013 and 2015, and posters and leaflets were developed to call on healthcare workers, district leaders and traditional authorities to address this issue.

Finally, Malawi is also in the process of establishing nationwide best practice guides. The training of health workers in MDSR has so far been based on the national guidelines, but the Ministry of Health is in the process of standardising the training through establishing a training manual. A database is also being established to list all the health workers already trained in MDSR so that they can be called upon to help scale up the system.

Dashboard1

Illustration of dashboard data from a district in Malawi

To view the posters and leaflets developed in Nkhata Bay to call for stakeholder action, please click here and read more about how this evidence on maternal health is used to drive accountability from this link.

Acknowledgements: This country update was developed based on feedback from Project Manager for MamaYe-E4A, Lumbani Banda, and Evidence Advisor for MamaYe-E4A, Hajj Daitoni, as well as updates from the programme reports.

Making the case for MDSR at Women Deliver

The MDSR Action Network was represented at the Women Deliver conference through an Options evening side event on ‘Accountability for Health Results’.

The event included talks and booths about Options’ work in Nigeria, Nepal, Tanzania and Malawi as well as Options’ regional network and platforms: MamaYe, Africa Health Budget Network, The Girl Generation, African Health Stats and the MDSR Action Network.

Photo credit: E4A

The MDSR booth at the event exhibited materials highlighting Options’ MDSR work worldwide, including copies of the MDSR Action Network newsletter and the MDSR scorecards from Sierra Leone and Nigeria. It provided a great opportunity to share resources and experiences of how different countries are using MDSR to strengthen accountability to improve the care of mothers and babies.

Dr Tunde Segun, Country Director of MamaYe-E4A Nigeria, manned the booth and engaged with a steady stream of visitors, talking them through the materials, answering questions, and inviting them to sign up for the MDSR Action Network newsletter. Almost all of those approaching the booth readily agreed to sign up to be kept in the loop on this important issue.

Dr Segun spoke to a crowded room about how the MamaYe-E4A programme in Nigeria has supported MDSR. For example, four states have now established MDSR scorecards, which measure the strength of the MDSR system and can act as powerful catalysts of action to improve quality of care. In Jigawa State, the MDSR data showed clearly that more maternal deaths were occurring at night, and action was taken to modify staff rotas to ensure senior midwives were on duty during the night shifts.

In Ondo State during the last quarter of 2015 and first quarter of 2016, the MDSR scorecard showed that sepsis had overtaken haemorrhage as the primary cause of maternal death. Health care providers, policy makers and stakeholders discussed these findings, looking at gains made in addressing haemorrhage by improving the functionality of blood banks in Ondo, but also in terms of the practical actions the state could take to confront sepsis. Actions such as lobbying to get the most effective antibiotics available under the state’s free maternity services are being considered.

Finally, Dr Segun celebrated Nigeria’s pioneering spirit on MDSR by sharing the fact that during the FIGO World Congress in Vancouver 2015, the World Health Organization had revealed that Nigeria was the only country at that time to have produced an MDSR scorecard at the sub-national level.

Acknowledgements:

This case study was informed by feedback from Dr Tunde Segun, Country Director for Evidence for Action in Nigeria.

The difficulties of conducting maternal death reviews in Malawi

This article uses a strengths, weaknesses, opportunities and threats (SWOT) analysis to assess the difficulties faced in conducting MDR in Malawi.

It highlights the importance of the multi-disciplinary team in promoting collaboration and in ensuring issues relating to different disciplines are addressed.

Good leadership, an emphasis on building staff capacity and ensuring the motivation of different members of the MDR committees are vital for sustainability and success.

Report on the Confidential Enquiry into Maternal Deaths in Malawi (2008-2012)

In 2009, the Government of Malawi established the National Committee on Confidential Enquiry into Maternal Deaths. The Committee are tasked with producing national reports on maternal deaths in a given time period in order to guide actions and responses to prevent future maternal deaths. The first report produced by the Committee investigates maternal deaths that took place between 2008 and 2012.

The retrospective review of records from 27/28 districts included 1433 maternal deaths that took place in facilities or en route to a facility between 2008-2012 (inc.). In total, 57% were due to direct causes including haemorrhage (14% of all maternal deaths), pre-eclampsia (14%), sepsis (10%), and abortion (10%). Key indirect causes of deaths included: anaemia (19%), malaria  (15%), and HIV/AIDS  (8%).

The report, made public in May 2015, explains the methods of the enquiry, presents the findings, and provides recommendations for action.

To read the report, click here.

Mother and baby_Malawi_MamaYe

Malawi builds trust and accountability with a community MDSR system

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

Malawi’s MDSR guidelines

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.

Community-linked maternal death review (CLMDR) to measure and prevent maternal mortality: a pilot study in rural Malawi

This article by Olivia Bayley and colleagues, published by BMJ Open in April 2015, describes a pilot study in rural Malawi which assesses the value of involving communities in investigating and responding to local maternal deaths. The pilot developed and implemented a community-led maternal death review (CLMDR) system over a 1-year period in the Mchinji District of Malawi. The study found that engaging and empowering communities through the CLMDR system can help ensure effective review of maternal deaths, and can facilitate targeted response planning and accountability.

Malawi

At national level, the National Committee for Confidential Enquiries into Maternal Deaths (NCCEMD) quarterly update meeting took place at the end of August. The meeting focussed on revising the Terms of Reference of the NCCEMD members and how they should be reporting. MDSR tools have also been reviewed in Malawi in order to integrate duplications in data collection and lessen the burden on those reporting. Now the MDSR form in the DHIS II system will not be filled in, but instead all MDSR variables have been integrated into the Maternal and Newborn Health form in DHIS II. Another form has also been created to track recommendations at district level.

At sub-national level, in Kasunga, four more community MDSR (cMDSR) committees were trained in the area of Senior Chief Kaomba. The senior chief dedicated his time as one of the participants for the three day training.

Update from Lumbani Banda, Project Manager for Evidence for Action-Malawi

The National Committee for Confidential Enquiries into Maternal Deaths (NCCEMD) meets in Malawi

The Reproductive Health Directorate organised an update meeting for the National Committee for Confidential Enquiries into Maternal Deaths (NCCEMD), which was attended by members of the NCCEMD, the focal person for Integrated Disease Surveillance and Response.

At this meeting it was made known that the National MDR report had been approved by the senior management team at the Ministry of Health and additional recommendations had been put forward. These recommendations have been communicated and streamlined across the health system and a reporting template for the health zones’ quarterly updates to the NCCEMD has been developed.

 

Easier said than done: methodological challenges with conducting maternal death review research in Malawi

This 2014 paper critically reflects on a facility-based maternal death review study in Lilongwe, Malawi, using the five step mortality surveillance cycle framework that was used for the study, and highlights the methodological challenges faced while doing such reviews.

Although studies using maternal death audit methodologies are widely available, few discuss the challenges in their implementation. This study was conducted at comprehensive emergency obstetric care units of a secondary hospital and a tertiary hospital. It found that there were gaps in identifying and reporting on maternal deaths that may have happened in units/wards other than the maternity unit, which may have led to under-reporting.

Data was also found to be as being poorly maintained, missing or incomplete in many cases, as there was no system in place for health information collection and storage in cases of maternal mortality. Whilst language barriers and cultural norms were thought to have potentially influenced data from the communities, busy schedules and fear of blame were some of the issues faced at the facility level. Continue reading