As part of its efforts to improve accountability for women and children’s health, Malawi classified maternal death as a notifiable event in 2003, and the National Committee on Confidential Enquiry into Maternal Deaths (NCCEMD) was established in 2009. Like many other countries, from 2013, Malawi moved from maternal death reviews (MDRs) to the more robust system of maternal death surveillance and response (MDSR), which entails not only that maternal deaths are notifiable, but also places greater emphasis on response, and on the monitoring and evaluation of MDSR itself. Continue reading
The Maternal Neonatal and Child health programme (MNCH2) is a five year country led programme which aims to reduce maternal and child mortality in northern Nigeria. The programme works across six states: Jigawa, Kaduna, Kano, Katsina, Yobe and Zamfara.
Since 2014, MNCH2 has been supporting maternal and perinatal death surveillance and response (MPDSR) across its six states. At secondary level facilities (which often have a high number of deliveries), maternal death review (MDR) committees have been set up to review the causes of maternal death and take action to prevent similar deaths in the future. MNCH2 also supports State MDR Committees to mentor and monitor facility-level committees.
MNCH2’s support to MPDSR across northern Nigeria has resulted in a number of achievements. Following the country update from March 2017, which featured updates from Kaduna, Kano and Jigawa States, here are some further examples from Katsina, Yobe and Zamfara States:
Discussions in the State MDR Committee led to the development of a training in the use of non-pneumatic anti-shock garments for nurses and midwives working at maternity units in ten secondary health centres. Medical Directors, Medical Officers and Maternity personnel in charge of 18 secondary health facilities contributed to this development.
Twenty nurses and midwives were trained in October 2016 on the application of anti-shock garments. Within a month, these training participants trained other maternity staff from the same secondary health facilities to use anti-shock garments. To ensure that the training is cascaded to all general hospitals, the State is mentoring facility-MDR committees on a monthly basis.
A MPDSR Scorecard was developed in collaboration with the State-MPDSR Committee and the Yobe State Accountability Mechanism for MNCH (YoSAMM) with support from the MNCH2 programme. Data from April to December 2016 was collected from ten government general hospitals with MNCH services. The findings are available in box 1.
The State organised a meeting in January 2017 to review the evidence from the MPDSR scorecard. The meeting was chaired by the Honourable Commissioner of Health, Dr Mohammed Bello Kawuwa and attended by the Chief Medical Directors of the ten general hospitals, and other members of the State MPDSR Steering Committee. The key issues discussed during the meeting were:
- Facility MDR Committees irregularly meet to review maternal deaths and take actions.
- Proposed recommendation: YoSAMM, with support from the Advocacy sub-committee, is to visit health facilities where reviews of maternal deaths are not regularly conducted as planned. Progress in this area will be discussed at the next YoSAMM quarterly meeting in June 2017.
- Completion of MPDSR tools not meeting national standards.
- Proposed recommendation: Health-care providers should receive a refresher training in the completion of MPDSR forms. A training was conducted in February 2017.
- Pregnant women are reluctant to deliver at a facility.
- Proposed recommendation: Local government health promotion officers should conduct community mobilisation activities on the importance of antenatal care (ANC) visits and delivery by a skilled birth attendant.
MDR findings from a secondary facility led to the identification of a number of medical equipment and infrastructure features that were lacking. In response to this, the facility MDR committee called on the local government to build an ultrasound centre and provide ultrasound machines. The facility received these provisions in June 2016. Community MPDSR findings led to further action from the local government in the provision of a renovated labour room, a newly built ANC waiting room with a capacity of 250, and ten beds for the maternity ward.
Acknowledgements: This update was prepared based on feedback from:
- Mohammad Anka – Evidence and Advocacy coordinator, MNCH2 Zamfara state office
- Garba Haruna Idris – Evidence and Advocacy coordinator,MNCH2 Katsina state office
- Musa Mohammad- Evidence and Advocacy coordinator, MNCH2 Yobe state office.
- Doubling the number of maternal deaths identified.
- Accurate and cost-efficient method of measuring the maternal mortality ratio.
- Strengthened relationships and trust between health facilities and communities they serve.
- Community actions to prevent future deaths: establishing mobile antenatal care clinics, arranging community meetings to explore traditional beliefs and mobilising funds for bicycle ambulances.
These are some of the key results from a community-linked maternal death review (CLMDR) pilot that ran from 2011-2012 in Mchinji district, Malawi. Presented by Dr Tim Colbourn, Lecturer in Global Health Epidemiology and Evaluation at the University College London (UCL) Institute for Global Heath, the results of the study show the importance of involving communities in the process of identifying maternal death and acting on the recommendations of maternal death review and surveillance (MDSR) systems. Continue reading
At a MDSR Action Network event at Options, Dr Tim Colbourn from the University College London (UCL) Institute for Global Health presented the findings of his co-authored paper: Community-linked maternal death review (CLMDR) to measure and prevent maternal mortality: a pilot study in rural Malawi. Continue reading
In order to eliminate preventable maternal and perinatal mortality, several measures have been taken by the Kenyan Government through the Ministry of Health. They include:
- scaling up training of Emergency Obstetrics and Newborn Care countrywide
- eliminating user fees for maternity services through the Free Maternity Services Initiative led by The President of Kenya, H.E. Uhuru Kenyatta
- instituting maternal and perinatal death surveillance and response mechanisms
Kenya recently developed comprehensive national MPDSR guidelines. MPDSR, however, is not new to the Kenyan health system. In 2004, maternal deaths were declared a notifiable event which led to the implementation of maternal death reviews at health facilities. Maternal death reviews are the foundation to MPDSR while perinatal death reviews are less developed.
With the launch of the National MPDSR guidelines – 2016, Kenya is taking a phased approach in implementing the “P” in MPDSR. The implementation has recently begun in facilities with a low burden of maternal morbidity and mortality. It is noted that in health facilities with low maternal death occurrence, perinatal deaths remain quite high.
Murang’a County Referral Hospital is one such facility, with a low burden of maternal mortality but a persistently high perinatal mortality rate. At Murang’a County Referral Hospital, the (facility-level) MPDSR committee holds monthly meetings to discuss each case of perinatal mortality. The case files are usually accompanied by a review of the maternal file. The team reviews each case individually discussing the clinical care and health system factors that contributed to the death. The recommendations are well documented and followed up in the next meeting.
The Ministry of Health is working with the facility, sub-county and county teams to monitor the response to the recommendations made during perinatal death reviews.
COUNTY FOCUS: BUNGOMA COUNTY
The Maternal and Newborn Improvement (MANI) project supports six sub-counties in the roll out of MPDSR within and across 42 facilities in Bungoma County. The national maternal death review (MDR) and perinatal death review (PDR) tools are regularly used at these facilities. Narrative qualitative analyses describing the events of each maternal and perinatal case were introduced in September 2015 and are reviewed on a monthly basis.
The 42 facilities have received ongoing support through trainings, mentorship and supportive-supervisory visits to identify maternal and perinatal deaths, conduct reviews and analyse probable causes of death.
The MPDSR committees in six sub-counties meet quarterly to discuss feasible and immediate interventions that are within the capacity of the sub-county or facility levels to apply remedial solutions to each cause of death.
|“…The MPDSR reviews have improved our teamwork, both amongst ourselves and even interdepartmental collaboration. Everyone involved in the care of mothers and newborns are involved in the MPDSR committee deliberation…” (Webuye staff about MPDSR meetings)|
From September to December 2015 and April to June 2016, there were reported increases in the number of facilities with functional MPDSR committees from 20 to 42. From the committees that met, 33 facilities made necessary changes to service provision and/or management practices based on MPDR findings between April and June 2016; an increase from two facilities between September and December 2015.
While the percentage of maternal deaths that were reviewed and uploaded to the District Health Information System (DHIS) stayed constant at 100% from September 2015 to June 2016, perinatal deaths reviewed and uploaded to the DHIS increased from 54% to 67%, over the respective quarterly periods.
SUB-FOCUS: WEBUYE HOSPITAL
Webuye hospital has the second highest number of maternal and perinatal deaths in Bungoma County. With the roll out of the new 2015 Kenya National Maternal and Perinatal Death Surveillance and Response Guidelines, there has been substantial progress to review perinatal causes of death to inform the quality of care.
The facility-MPDSR committee at Webuye hospital was established in October 2015 with the support of the MANI project and Bungoma County Health Management Team (CHMT). Prior to this, maternal and perinatal deaths were seldom reviewed, collaboration between maternal and newborn health departments was particularly low and record keeping was poor. As such, perinatal deaths were infrequently accounted for and the true causes of death rarely known.
The MPDSR committee at Webuye holds monthly review meetings. During the initial stages of these meetings, discrepancies were identified between the Ministry of Health PDR forms and the DHIS, preventing PDR data from being uploaded to the DHIS system. As a result, the Webuye team supported the standardisation of the PDR tools in January 2016. The PDR form has since been updated and pretested. The review and upload of PDR findings have increased since the new PDR tool was introduced. For each quarterly period from September 2015 to June 2016, there were marked increases from 44% to 100%, respectively.
Please visit here to read the country update for Kenya from March 2016.
Acknowledgements: The national update was prepared and reviewed Dr Wangui Muthigani, Program Manager- Maternal and Newborn Health at Ministry of Health in Kenya. The update for Bungoma county was developed based on feedback from Mr Peter Ken Kaimenyi, Maternal and Newborn Health Technical Advisor at MANI Project funded by UK Aid; two MANI Project abstracts accepted for presentation at the Kenya Midwives Annual Scientific Conference 2016; and the MANI Project power-point presentation for the Kenya Midwives Annual Scientific Conference 2016.
In Sierra Leone, significant investments have been made to move MDSR-related work forward over the last quarter. The National MDSR Committee held a meeting in June 2016, chaired by the Director of Reproductive and Child Health, with representatives from UNICEF, UNFPA, WHO as well as a representative of other health NGOs including Options, to assess progress and propose strategies for the next quarter. The meeting highlighted to following achievements and activities:
- MDR committees at district level which had operated before the Ebola outbreak have been restructured and adapted to MDSR committees and inaugural meetings have been completed in all districts except Western Area.
- In some districts, the process of actively reviewing deaths has begun.
- Social media platforms are being used to support the multi-professional communication needed to sustain and grow the MDSR system through WhatsApp groups for District Medical Officers, Midwife Investigators, M&E Officers, Disease Surveillance Officers and other stakeholders. The World Health Organization has supported the development of an MDSR database using EpiData and training material including presentations on MDSR to support collection, inputting and analysis have been developed.
- UNFPA is supporting a pilot regional blood collection campaign in response to findings from reviews of maternal deaths from haemorrhage between June and July 2016, as well as providing desktop computers to all districts for MDSR activities and supporting educational discussion programmes on maternal and child health on radio and television.
The meeting provided a good opportunity to plan further consultative meetings, for example, with Paramount chiefs in June and religious and women’s groups at later dates, to ensure wide stakeholder buy-in to the system and maximum impact for MDSR data in the future.
Acknowledgements: This country update was informed and approved by Bockarie Sesay, M&E Advisor for Options-PMEL, in Freetown, Sierra Leone.
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.
This qualitative Master’s thesis from the University of the Western Cape, South Africa, highlights findings from the Ashanti region in Ghana, where midwives are actively involved in all stages of the implementation of facility-based maternal death review, including:
- reporting and certifying maternal deaths
- collecting and documenting evidence in order to notify the public health units
- processing and preparing evidence for the audit meetings
- participating in the audit meetings
- helping to formulate recommendations as part of the audit team,
- disseminating, implementing and monitoring the recommendations of the audit report.
The author found that midwives play a vital role, especially in facilities where there were no other clinical cadres of staff. The author recommends:
- Junior midwives be included in MDR meetings to build their confidence and involvement in MDR
- Continuous in-service training on issues related to MDR for nurses and midwives
- Inclusion of MDR in the Nurses and Midwifery Council of Ghana curriculum
- Specific training for midwives on their particular role within the MDR process
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 paper proposes a community-based approach to measuring maternal mortality based on a feasibility study conducted in 2010-2011 in Tigray, Ethiopia, based on the concept of ‘task shifting’.
Priests, traditional birth attendants and community-based reproductive health agents were given responsibility for locating and reporting all births and deaths, and they assisted mid-level providers to locate key informants for verbal autopsy.
From there, nurses and nurse-midwives were trained to administer verbal autopsies and assign cause of death according to WHO ICD-10 classifications.
The study highlights the feasibility of using existing community and health structures to implement MDR.