Tag Archives: MDR

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.

Improving obstetric care in low-resource settings: implementation of facility-based maternal death reviews in five pilot hospitals in Senegal

This mixed-methods study conducted in five hospitals in Senegal found that the implementation of maternal death reviews were hampered by issues such as the non-participation of the head of department at audit meetings and the lack of feedback about the audit meetings to staff who did not attend.

Factors which supported the MDRs included the involvement of the head of the maternity unit who acted as a moderator during audit meetings and the participation of managers in the audit meeting to plan appropriate and achievable actions to prevent future maternal deaths.

The authors conclude that leadership is vital to secure MDR success.

Expert opinions from around the world: The role of the multi-disciplinary team in MDSR

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.

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Mother and infant

A Maternal Survival Action Network for Sierra Leone

This case study outlines how Sierra Leone introduced a Maternal Survival Action Network to support the implementation of Maternal Death Reviews across the country. This is an updated version of a case study originally published in our April 2013 issue of the MDSR Action Network newsletter.

In Sierra Leone, implementation of Maternal Death Surveillance and Response (MDSR) has been revitalised since the onset of the Ebola outbreak.

Sierra Leone’s national MDSR framework previously focussed on facility-based MDRs. There is widespread agreement by experts and activists that the use of findings from MDRs for service delivery improvements in the current model of implementing MDRs could be significantly strengthened and efforts to re-establish facility-based MDRs on a regular basis is being re-established. A review of processes and challenges identified opportunities to strengthen MDRs and make better use findings at facility level. The intention is to strengthen the system by identifying context-specific barriers and enablers to the use of MDR findings for quality of care improvements. Continue reading

Maternal death reviews at Bugando hospital north-western Tanzania: a 2008–2012 retrospective analysis

This article by Moke Magoma and colleagues, published by BMC Pregnancy and Childbirth in December 2015, presents the findings of a statistical analysis of data from maternal death reviews (MDR) in Bugando Medical Centre, north-western Tanzania between 2008 and 2012. The study presents the findings from the analysis, as well as describing the challenges of the analysis and how it provided a greater understanding of maternal deaths. The authors found that routine MDRs in this setting were not complete, with key documentation missing, such as actions to address weaknesses in the system.  The authors conclude that the roll-out of new national guidelines in Tanzania may help to build capacity for tertiary institutions to carry-out training of health professionals in maternal and perinatal death reviews.

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.

Nigeria: Implementing a community component and using evidence for action

At national level, the Federal Ministry of Health carried-out a meeting in February with key stakeholders (UNICEF, E4A, National Primary Healthcare Development Agency, WHO, UNFPA, National Population Commission, and the Centre for Disease Control)  on their Maternal and Perinatal Death Surveillance and Response (MPDSR) system. The purpose of the meeting was to share updates on progress in implementing MPDSR and discuss moving MPDSR forward. Reported progress in implementing MPDSR to date from the federal-level includes: 

  • Development of MPDSR national guidelines
  • Nation-wide orientation on MPDSR held at zonal level
  • Establishment of National and State Steering Committees
  • Development of national and state implementation plan

The central discussion of the meeting focussed on how to leverage existing structures to implement a community component of MPDSR.

At sub-national level, E4A-MamaYe has supported the training of Maternal Death Review (MDR) committees in all Secondary Health Facilities in the following States: Bauchi, Jigawa, Kano, and Ondo. These facilities are now conducting MDRs. MDR data is collected quarterly and used to develop scorecards that provide evidence for the Advocacy Sub-Committees of the State-Led Accountability Mechanisms. Please see examples of MDR scorecards from Bauchi, Kano, and Ondo.

MDR evidence is influencing policy, service delivery and community action in Nigeria. For example, as a result of MDR evidence, Kano State Government included three key activities in the 2016-2018 State Medium Term Sector Strategy (MTSS). These include:

  1. Conduct of MDRs in facilities and quarterly MDR review meetings at the State level
  2. Provision and maintenance of functional blood banks in all State hospitals
  3. Integrated demand creation activities to improve uptake of ANC and maternal survival.

In response to the finding that post-partum haemorrhage is a leading cause of maternal deaths in Gumel General Hospital of Jigawa State, the hospital management mobilised community members (around the catchment areas of the facility) to form blood donation groups who are now donating their blood voluntarily, and blood is now available in the facility.

Update from Oko Igado, National Technical Advisor for E4A-MamaYe, Nigeria

Sierra Leone’s MDSR guidelines

Sierra Leone has one of the highest levels of maternal mortality in the world, with an estimated 2,400 women dying during pregnancy or childbirth every year. In order to prevent maternal deaths and improve quality of care, the Government of Sierra Leone has adopted the Maternal Death Surveillance and Response (MDSR) system and released these guidelines.

These guidelines provide guidance on the implementation of MDSR in Sierra Leone, building on the Maternal Death Review system and “piggybacking” onto the Integrated Disease Surveillance and Response (IDSR) system.  Maternal deaths have now been integrated into the notifiable reporting system of the IDSR. The guidelines focus on the following implementation steps:

  1. Identification and notification of maternal deaths
  2. Maternal death review
  3. Analysis – data aggregation and interpretation
  4. Response to maternal deaths
  5. Dissemination of results, recommendations and responses
  6. Monitoring and Evaluation for MDSR system
  7. MDSR implementation plan

Download Sierra Leone’s MDSR guidelines here.

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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/

Nigeria

At national level, the Federal Ministry of Health (FMOH) is planning to institutionalise Maternal and Perinatal Death Surveillance and Response (MPDSR) in Nigeria. As part of this, the FMOH carried out four zonal orientation meetings of representatives of the 36 State Steering Committees and the FCT, on MPDSR in Lagos, Port Harcourt, Jos and Kaduna in early November, which covered in-country experiences of implementing MPDSR at the facility and community level.  The meetings were attended by a variety of stakeholders, including representatives from the FMOH, the World Health Organization, Save the Children, Evidence for Action (E4A), UNICEF and the Society of Gynaecology and Obstetrics of Nigeria.

As a result of these four zonal orientation meetings, the FMOH established a virtual MDSR network on MPDSR titled ‘Maternal and Perinatal Death Surveillance and Response in Nigeria and is hosted on Facebook.

At sub-national level, in Ondo State, the first zonal facility MDR training has taken place for MDR agents, who included Chief Medical Directors, heads of the Obstetrics and Gynaecology departments, and the nurse/midwife or matron in charge of the hospital labour ward. In Kano, a two-day MDR review meeting has taken place for the State and Facility MDR Committees, which resulted in the development of a workplan for August 2015 to February 2016. In Bauchi State, the Technical Working Group on MDRs successfully trained 131 Facility MDR Committee members from 25 out of the 26 General Hospitals in the State. The committees have drawn up workplans to begin reviews in their facilities.

Update from Dr Tunde Segun, County Director E4A-Nigeria