Tag Archives: Maternal and perinatal death reviews

Maternal and perinatal death reviews to reduce mortality: spotlight on Webuye Hospital, Kenya

In July 2016, the Maternal and Newborn Health Improvements (MANI) project in Kenya’s Bungoma County funded by the UK Department for International Development, published a Human Interest Story in the MANI Learning Series. The MANI project supports six sub-counties in Bungoma to implement maternal and perinatal death surveillance and response (MPDSR).

MANI has been assisting Webuye Hospital to introduce and conduct maternal and perinatal death reviews (MPDRs). This Story presents a few ways MPDRs helped Webuye Hospital to improve maternal and newborn health. Various challenges were overcome by developing an on-call rota system, connecting a generator to the maternity ward and newborn unit, training staff in neonatal resuscitation, improving communication channels between all stakeholders and conducting a blood drive. A new operating theatre is due to open soon and the newborn unit is to be redesigned.

MANI Learning Series: Human Interest Story July 2016

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.

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.

Perinatal death surveillance and response to improve survival of babies

The mortality audit (or review) process is an established tool to assess the events around a death. Applying an audit cycle can highlight breakdowns from local to national levels and ultimately improve civil registration and vital statistic (CRVS) systems and quality of care. Maternal death surveillance and response (MDSR) is a form of this strategy that has been used by many countries[1].

Less information, however, has been captured and assessed on stillbirths and neonatal deaths[2]. In 2014, 51 priority countries reported having a policy on maternal death notification, and only 17 countries had a policy for reporting and reviewing stillbirths and neonatal deaths[3].

Continue reading

Nigeria | Ensuring the sustainability of MPDSR

With the support of the MamaYe-E4A programme over the last five years, Nigeria has worked to embed the MDSR process at state level in the country –and is the only setting that we knew of with a sub-national level maternal death review (MDR) scorecard at the time of dissemination in October 2015.

In the last few quarters in Ondo State, two MDR scorecards have been developed by the Evidence Sub-Committee of Ondo State Accountability Mechanism for Maternal and Newborn, Health supported by E4A-MamaYe. These scorecards were based on the MDR data from all secondary-level facilities and two Mother and Child Hospitals in the state and aim to challenge the previous lack of reporting and review of maternal deaths. The scorecards were disseminated at a stakeholder meeting in Ondo and one of the key findings (that sepsis had overtaken haemorrhage to become the highest cause of maternal death) sparked lively debate.

The attendees explored the issues from both the woman’s and the facility’s point of view, and suggested strategies on both fronts for example, educating women on personal hygiene during antenatal care whilst also encouraging prompt referral of cases of premature rupture of the membranes at facilities.

One of the key issues discussed was while Ondo State Mother and Child Hospital provides most maternal, newborn and child health (MNCH) services for free, the most effective antibiotics, cephalosporins, are not exempted from costs. This means that staff may be forced to prescribe women cheaper antibiotics because they cannot afford cephalosporins. This was also leaving women open to the risk of being sold fake drugs by pharmacies, which would be ineffective against sepsis. The Ondo meeting attendees discussed strategies to counter this issue, for example, advocating at state level to get cephalosporins included in the free MNCH services, and using TruScan, a device which can detect fake drugs, to ensure women are being given genuine drugs.

While MamaYe-E4A’s presence in Ondo State ended in March 2016, key components of the programme are being integrated into the DfID-funded MNCH2 programme in Jigawa, Kano, Katsina, Zamfara, Yobe and Kaduna States including MDR scorecards and advocacy. In addition, under a new contract from the Gates Foundation, MamaYe-E4A is working to replicate this success in other States, including setting up similar systems in Lagos State.

Recent successes in Bauchi State include the review of MDR reports from 2015 by the Bauchi State MDSR Steering Committee, which enabled them and the Bauchi State Accountability Mechanism for MNCH to convene a stakeholder meeting to discuss and identify causes of maternal death and create action plans. At this meeting it was revealed that the highest cause of maternal death was anaemia, and possible factors causing this were identified to include the high prevalence of worm infestation and poor nutrition among women, as well as supply-side issues such as inadequate access to health services and lack of blood supplies. Discussions then focused on how to tackle these issues: how to ensure women are de-wormed regularly, provide nutrition education on diet using local foods, and how to make sure facilities have functional blood banks.

In Lagos State, the recent inauguration of the maternal and perinatal death surveillance and response system included launching a committee at state-level and supporting the training of 135 health care providers across secondary facilities and one tertiary facility. Training was conducted in four batches and was the first MamaYe-E4A had conducted under the updated national MPDSR guidelines which aimed to integrate perinatal death review into MDR systems.

This national level focus on perinatal death is being consolidated. In June, the National MPDR Steering Committee meeting members discussed building on the experience of MamaYe-E4A and MNCH2 in training health care providers on the updated MPDSR guidelines. A workshop was planned for the end of June where MamaYe-E4A and MNCH2 could share their training methodology, slides and materials to support the national MPDR Steering Committee in developing a training manual on MPDSR.

This focus on perinatal death is also filtering down to state level: the last MDR scorecards from Ondo State (January to March 2016) highlighted perinatal death review data in line with the national shift towards a commitment to perinatal survival.

To view the MDR scorecard for Ondo State (January to March 2016), please click here.

Acknowledgements: This country update was compiled from feedback from Dr Tunde Segun, Country Director for E4A-MamaYe Nigeria, and content from E4A quarterly reports.

Bangladesh | Rolling out MPDSR across the country

Following a successful pilot in Thakurgaon district in 2010 by UNICEF1,2,3, the Ministry of Health and Family Welfare (MoH & FW) of Bangladesh has taken the lead and made a commitment to gradually scale up maternal and perinatal death surveillance and response (MPDSR) across the entire country by 2021.

The national guideline for MPDSR has been approved and the Quality Improvement Secretariat of the Health Economics Unit at the MOH & FW is working with key stakeholders including Directorate General of Health Services, Directorate General of Family Planning, UNICEF, UNFPA, WHO, The Centre for Injury Prevention and Research, Bangladesh and other partners to plan for the roll out in a phase wise manner.

To date, MPDR/ MPDSR is being implemented in 17 out of Bangladesh’s 64 districts with support from UNICEF in 13 districts and, Save the Children in four districts, with implementation due to take place in   two more districts supported by UNFPA in 2016. A series of planning meetings are being conducted by the MoH & FW with the experts to finalise the roll out plan, determining training modalities, review processes, etc. UNICEF, Bangladesh has been providing technical and implementation support to the Ministry of Health and Family Welfare for rolling out MPDSR in collaboration with UNFPA and WHO.

Recent activities include:

  • A six-member team comprising representatives from the MOH & FW, professional societies, UNICEF and WHO attended the regional MPDSR Meeting organised by the WHO’s South East Asia Regional Office in February 2016, where progress on MPDSR in Bangladesh to date and plans for the country wide phase wide scale up by 2020.
  • National MPDSR tools (death notification, community verbal autopsies, facility death reviews) have been simplified by MOH & FW. Key variables incorporated in District Health Information System software of Management Information System of Directorate General of Family Planning which will enable real time data tracking
  • MPDSR national guideline sharing workshop was organized by the Health Economics Unit, MOH & FW in Chittagong division in May 2016 with support from UNICEF. Participants included health and family planning managers from division, district and upazila level, health officers of the City Corporation, obstetricians and neonatologists from the teaching hospitals and other related stakeholders. News of the workshop can be seen by clicking here.
  • A case study on social autopsy titled ‘Social autopsy triggered community responses for averting maternal and neonatal death in Bangladesh’ was published in WHO global website in April which was prepared jointly by UNICEF Bangladesh, MOH&FW and the Centre for Injury Prevention and Research2. Click here to read this.

Upcoming events: July – September 2016

  • A dissemination workshop on the newly developed national guideline on MPDSR will be organized by the Quality Improvement Secretariat, HEU, MOH&FW with support from UNICEF
  • An experience sharing meeting on MPDSR with 17 districts will be organised by Director General of Health Services, MOH&FW with support from UNICEF.
  • A dissemination workshop of the newly developed national guideline on MPDSR will soon be held by the Quality Improvement Secretariat of the ministry. Seven divisional sharing and orientation workshops are in the upcoming plans of the ministry.

Acknowledgements: This update was prepared by Dr Riad Mahmud, Health Specialist (MNH), UNICEF, Bangladesh, and reviewed by Dr. Md. Aminul Hasan, Deputy Director, Health Economics Unit, Ministry of Health & Family Welfare; Dr. Lianne Kuppens, Chief Health section, UNICEF Bangladesh; Dr. Abu Sadat Md. Sayem, Health Officer, UNICEF; Dr. Shayma Khorshed, Consultant, Health Economics Unit, Ministry of Health & Family Welfare and Dr Animesh Biswas, Senior Scientist, Reproductive and Child Health Unit of CIPRB, Bangladesh.

References

  1. Biswas A.; Rahman F.; Halim A.; Eriksson C;  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. Mahmud R.; Sohel HA.; Sharif M.; Kuppens L.; Rakhimdjanov S.; Sayem ASM.; Khan M.; & Biswas A. (2016). Social autopsy triggers community response for averting maternal and neonatal death in Bangladesh: Experience from ‘Maternal and Perinatal Death Review in 10 Districts’. World Health Organization. p.1-5. Available here>
  3. Biswas A. (2016). Maternal and perinatal death review (MPDR): experiences in Bangladesh. World Health Organization. Cited on 15 June 2015. Available here>
Lao-PDR

Social autopsy as an intervention tool in the community to prevent maternal and neonatal deaths: experiences from Bangladesh

Social autopsy in maternal and neonatal health

Social autopsy (SA) is an innovative strategy whereby a trained member leads a group within a community through a structured, standardised analysis of the root causes of a death or serious, non-fatal health event. Continue reading

Tanzania | Rolling out MPDR to new regions

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.