Tag Archives: Maternal mortality

Seminar 2: Applying maternal death surveillance and response in crisis settings

Watch the live recording of the seminar here!

Read our blog on the event, Using Data to Prevent Maternal Deaths in Crisis Settings.

Event information

Date and Time: Thursday 23rd March 2017, 5:30 pm – 7:00 pm, followed by refreshments

Location: John Snow Lecture Theatre, London School of Hygiene and Tropical Medicine (LSHTM), Keppel Street, London, WC1E 7HT, UK

LSHTM & MDSR AN Seminar 2_event advert_imageOverview:

Mothers and their babies face greater risks to their survival during humanitarian crises. However, there is a dearth of evidence about how best to apply reproductive health interventions effectively in crisis settings. Understanding why women and their babies die in these specific circumstances is pivotal to designing appropriate interventions to prevent deaths from similar causes.

This seminar will explore tools and approaches to maternal death surveillance and response (MDSR) in crisis settings with presentations on the following:

  • Value of MDSR data and systems in crisis settings, and in contributing to achieving  sexual and reproductive health rights
  • Approaches to measuring maternal mortality in refugee settings and responding to findings
  • Participatory ethnographic evaluation research (PEER) as a tool to triangulate MDSR findings in crisis settings

Speakers:

  • Rajat Khosla, Human Rights Adviser – Sexual and Reproductive Health and Rights, World Health Organization, Geneva
  • Nadine Cornier, Humanitarian Adviser – Reproductive Health & Head of Office, UNFPA, Turkey
  • Eleanor Brown, Technical Specialist – Options, London

Moderator: Sarah Moxon, Research Fellow, the March Centre for Maternal, Adolescent, Reproductive and Child Health, LSHTM

This event is a collaboration between the Health in Humanitarian Crises Centre, the Global MDSR Action Network and the MARCH Centre for Maternal, Adolescent, Reproductive and Child Health

Admission and registration: It is free to attend this seminar, but registration is required. Registration is now closed.

To learn more about the seminar series, Innovations in Maternal and Perinatal Health in Humanitarian Settings: Exploring Evidence and Innovations to Improve Maternal and Newborn Survival among Populations Affected by Humanitarian Crises, click here.

Email: mdsr@evidence4action.net

Twitter: @E4AMamaYeAfrica #MDSR

The live stream recording is available here.

Watch this space for additional recordings of the event and access to supplementary materials.


Read more about the seminar series here.

Find out more about the first seminar of the series: Innovations to improve maternal and newborn death surveillance to respond to future Ebola outbreaks here.

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.

Helping midwives in Ghana to reduce maternal mortality

This case study highlights the work of the Kybele humanitarian organisation in a referral hospital in Accra, Ghana.

A Kybele midwife team member worked alongside doctors and midwives to support them to review maternal deaths and design quality of care improvements through small group work, supportive and targeted teaching.

The case study notes that lack of observation and monitoring of sick women had previously contributed to maternal mortality and highlights the need for basic midwifery care to improve. Through the partnership model, the midwives at the hospital identified key areas of improvement, including better monitoring of women using partographs. The author emphasises that midwives’ autonomy, standards and scope of practice within an interdisciplinary team were vital to their provision of safe care.

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Learning from Ireland: establishing a confidential maternal death enquiry in a low maternal mortality context

Ireland has recorded a low maternal death rate for several years now, but it was still important for the country to introduce confidential maternal death enquiry.

Edel Manning – the MDE Ireland Co-ordinator, tells us why and how they recently introduced confidential enquiries. Edel outlines the inspiration, the challenges and the results that this new system achieved for Ireland’s mothers.

In recent decades, Ireland has been credited with a low maternal death rate: 4 per 100,000 live births. This was based on data derived from the Irish civil death registration system. However, in acknowledging national and international evidence, it was considered that in the absence of active case ascertainment, under-reporting and misclassification of maternal deaths occur, even in countries with advanced civil registration systems.

The aim of establishing a confidential enquiry into maternal deaths in Ireland was not just to ascertain numbers, but principally to promote safer pregnancy by learning how such tragedies could be avoided in the future. This could make a major contribution to informing and improving standards of care in maternity services.

Establishing MDE Ireland had many challenges. First, engaging and establishing support at governance level with stakeholders in the Irish maternity service including: the national health authority, maternity service providers, multidisciplinary health professionals and academics proved more protracted than expected.

This process was driven by a dedicated Maternal Mortality in Ireland Working Group, a joint Institute of Obstetricians and Gynaecologists in Ireland/Health Service Executive initiative which helped to garner the required support. Inviting multidisciplinary representatives from relevant stakeholders to join the Working Group, in the development stage, was considered key to establishing commitment for the project.  Although support for the ethos of the project was widely considered as laudable, issues of concern related to data protection, potential adverse litigation and anticipated review of cases by agencies out with MDE Ireland.

Jeyheich, Flickr (Creative Commons license)

Jeyheich, Flickr (Creative Commons license)

The confidential Maternal Death Enquiry (MDE) Ireland was officially established in 2009, with the stated objective of linking with the UK Confidential Enquiry into Maternal Deaths (CEMD). Given the relatively small number of maternities in Ireland (70,709 in 2012) there was much to be gained from pooling Irish data with data from the UK.  Joining a larger cohort of maternal death case reviews would help to preserve confidentiality and allow for more meaningful analysis and recommendations.  The UK, our nearest neighbour, has a similar maternity service and a respected and validated methodology in the 60 year old CEMD, which could easily be adapted to the Irish context.

The UK CEMD is part of the national Maternal, Newborn and Infant Clinical Outcomes Review Programme, which was previously conducted by the Centre for Maternal and Child Enquiries (CMACE), and was transferred to Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries (MBRRACE-UK) in 2012. MBRRACE-UK has revised and streamlined the process of data collection and analysis on maternal deaths, which will result in reports being published annually.

The first MBRRACE-UK report including data on maternal deaths occurring in Ireland was published in December 2015: ‘Saving Lives, Improving Mother’s Care: Lessons learned to inform future maternity care from the UK and Ireland Confidential Enquiries into Maternal Death and Morbidity 2009 – 2012’ 1.  Surveillance data on maternal deaths occurring in Ireland is not included in the MBRRACE-UK report.  Irish maternal mortality rates (MMR) are published independently in annual data briefs and in more detailed triennial MDE Ireland reports (available on the MDE Ireland website).

Since the inception of MDE Ireland in 2009, there have been many challenges in implementing the enquiry process nationally. It was clear to us that confidence and ‘buy-in’ for the confidential enquiry process was paramount at service level as it was a ‘top down’ approach.  We attempted to build this by:

  • Raising awareness and support for the MDE through presentations at the service level, articles in multidisciplinary journals and a national workshop;
  • Establishing a national reporting network to the MDE at service level and collaboration with coroners.
  • Promoting awareness that the MDE process is independent of clinical incident reporting and local review of serious adverse incidents;
  • Alleviating concerns regarding potential litigation.  Confidentiality is assured through a process of anonymisation of data submitted prior to multidisciplinary assessment of cases. There is no disclosure of information to any outside agency.

Similar to experience in the UK and other European countries, a key learning point was that a proactive approach to case ascertainment identified maternal deaths that were not captured by the civil death registration system.  However, achieving this has been labour intensive and, despite support letters from governing bodies, was challenging.  Participation in the Enquiry is policy but not statutory for publicly funded health care providers.  Further, the dedicated time of a national co-ordinator and the support and guidance of the Maternal Mortality in Ireland Working Group has been essential to implementing the enquiry process in Ireland.

A fundamental component of the UK CEMD process is dissemination of recommendations from enquiry reports.  Since its inception, MDE Ireland has promoted this element of the audit cycle through a series of organised educational events.

MDE Ireland’s most recent report was published in February 20152.  To improve the power of analysis and to facilitate direct comparisons with the UK, Irish MMR is presented over a rolling three year period.  Although the overall MMR identified by MDE Ireland (outlined in Table 1), compares favourably with the UK (MMR = 10.1 per 100,000 maternities for the years 2010-2012) and other developed countries, it is important to avoid complacency.  The ongoing enquiry process and collaboration with the UK CEMD will provide learning points for health professionals in advancing quality and safety within the Irish maternity services. As in the UK, our findings were that maternal deaths in Ireland during the years 2010-2012 were predominately due to indirect causes (70%) with the remainder (30%) due to direct obstetric causes.

The increasing number of pregnant women presenting in Ireland with co-morbidities has highlighted the ongoing need for appropriate assessment of women at the booking visit to a maternity unit, allocation of appropriate pathways of care and pre-conception counselling. Also, the disproportionately high representation of ethnic minorities in this cohort challenges us to address health seeking behaviours of immigrant pregnant women in a country which provides free maternity services for all pregnant women.

Table 1: Direct and Indirect Maternal Mortality rates per 100,000 maternities in Ireland: rolling three year average 2009 – 2012

Ireland_maternal death rates_tablesNB: The apparent increase in the MMR 2010 – 2012 is not statistically significant.

Acknowledgements:

This case study was written by Edel Manning – a trained midwife and currently the MDE Ireland Co-ordinator who is responsible for the co-ordination of the maternal death enquiry process and dissemination of MDE recommendations. This is an updated version of a case study originally published in our May 2014 issue of the MDSR Action Network newsletter.

For further information on MDE Ireland please visit their website – https://www.ucc.ie/en/mde/

References:

  1. Knight M, Kenyon S, Brocklehurst P, Neilson J, Shakespeare J, Kurinczuk JJ (Eds.) on behalf of MBRRACE-UK. Saving Lives, Improving Mothers’ Care – Lessons learned to inform future maternity care from the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2009–12. Oxford: National Perinatal Epidemiology Unit, University of Oxford 2014. Available at: https://www.npeu.ox.ac.uk/mbrrace-uk/reports
  2. O’Hare MF, Manning E, Greene RA on behalf of MDE Ireland. Confidential Maternal Death Enquiry in Ireland, Report for 2009 – 2012. Cork: National Perinatal Epidemiology Centre, February 2015. Available at: http://www.ucc.ie/en/mde/publications/

Resources on the International Classification of Diseases – Maternal Mortality

The Liverpool School of Tropical Medicine have published the following resources on the International Classification of Diseases – Maternal Mortality (ICD-MM):

Trends in Maternal Mortality: 1990 to 2013

The recent report on MMR estimates for 2013 that was released by the UN agencies – Trends in Maternal Mortality: 1990 to 2013 – shows a 45% decline in global maternal deaths between 1990 and 2013. The burden and risk of maternal death remains the highest in sub-Saharan Africa and South Asia with these regions accounting for 62% and 24% of the deaths, respectively. Whilst absolute numbers show that India and Nigeria account for one third of all global maternal deaths, country level MMR estimates show that Sierra Leone records the highest (1100), and Chad and Somalia have the highest lifetime risk of maternal death. Giving birth is becoming safer, but not yet at the rate at which it should to meet the MDG targets in several countries. Continue reading

Autopsy-certified maternal mortality at Ile-Ife, Nigeria

An article – Autopsy-certified maternal mortality at Ile-Ife, Nigeria, by Amatare Dinyain, G Olutoyin Omoniyi-Esan, Olaejirinde O Olaofe, et al, published in the International Journal of Women’s Health 2014:6 41–46, reports on findings based on a retrospective review of post-mortem autopsies of maternal deaths at a hospital in Nigeria over a 5-year period. Continue reading

Maternal mortality in Zimbabwe: evidence, costs and implications

This issue paper published in 2013 by the United Nations in Zimbabwe provides an overview of the country’s situation with regard to maternal mortality, as well as highlighting the need for better tracking, monitoring and reporting of maternal deaths as a key strategy.

The paper shows that Zimbabwe has an unacceptably high maternal mortality ratio (MMR) which has worsened by 28% from 1990 to 2010. Recent data shows that the MMR now stands at 960 deaths per 100,000 live births according to the Demographic Health Survey 2010-11. According to WHO 2004 estimates, about 2,593 disability-adjusted life years per 100,000 females are lost per year in Zimbabwe due to maternal causes.

The Ministry of Health and Child Welfare (MoHCW), implemented a national Maternal Death Notification System (complementing the national Health Management Information System) aimed at strengthening tracking, monitoring and reporting of maternal mortality in the country, but the system is reported to be inadequate. The system reports deaths at facilities but not those in the community and not attended to by professional health care staff. Continue reading