Watch this video interview with our Network Founder, Louise Hulton, about the MDSR Action Network.
On 18 September, The Lancet launched the 2016 maternal health series in New York City on the opening day of the United Nations’ General Assembly, following a decade since the maternal survival Series was published. The new Series comprises of six papers discussing the diversity and divergence of poor maternal health, the extremes of maternal care (too little, too late and too soon, too much), childbirth care, women centred care in high-income countries, future external factors and health-system innovations, and a call to action to presenting five key targets to ensure that the Sustainable Development Goals are met.
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
|Maternal mortality ratio (per 100,000 live births)||660||–||–||258|
|Neonatal mortality rate (per 1,000 live births)||47.7||–||–||22.2|
|Perinatal mortality rate (per 1,000 births)||–||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.
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.
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.
 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.
 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
 Ministry of Health and Population, New ERA and ICF International. (2012) Nepal: Demographic Health Survey 2011. Kathmandu: Government of Nepal.
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.
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.
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.
This case study was informed by feedback from Dr Tunde Segun, Country Director for Evidence for Action in Nigeria.
The MDSR system in Malaysia is often referred to as a model upon which other countries can learn about how success can be achieved with limited resources. To support other countries in taking forward MDSRs, the Government and Ministry of Health of Malaysia are actively supporting implementation in Lao PDR, Vietnam and Nepal with regular visits conducted by Dr Ravichandran Jeganathan, the National Head of Obstetrics and Gynaecological Services at the Ministry of Health in Malaysia. Dr Jeganathan summarised the focus of his advocacy during the Lao PDR meeting as a call for ensuring adequate skilled birth attendance for each community at village level by ensuring that each village to have at least one midwife.
During these visits, local teams are guided in how to adapt and develop tools to conduct the investigation process, and have been trained how to conduct maternal death reviews. Specific attention is given to clarify the concept of a non-punitive approach and how the response mechanism can be implemented and achieved with ease, even with minimal resources. Dr Jeganathan is a keen advocate for including medical and nursing students on the training to ensure their exposure to the concept of MDSRs early on in their career.
In Malaysia, the sixth edition of the Report on the Confidential Enquiries into Maternal Deaths in Malaysia 2009 – 2011 that was in progress during the last newsletter is now available upon request.
In addition, a near miss registry is being finalised; parameters have been identified and tools drafted. This near miss approach will be piloted in one district hospital in September 2016 to ascertain its validity.
This country update was informed by feedback from Dr Ravichandran Jeganathan, the National Head of Obstetrics and Gynaecological Services at the Ministry of Health in Malaysia.
Evidence for Action (E4A) has been supporting the Federal Ministry of Health to strengthen the maternal death surveillance and response (MDSR) system in Ethiopia over the last five years. In the last quarter, the MDSR system has seen significant scale up, with technical assistance at national level and in Oromia, Amhara and Southern Nations, Nationalities and People’s region to support the extension of coverage of MDSR across Ethiopia.
In Amhara, MDSR training at zonal and woreda level have been held in all zones. Four weeks ago, a round of training was conducted in the region aimed at strengthening hospital facilities to use MDSR, with evidence from the two most functional zonal MDSR systems used to demonstrate the potential impact.
Training on integrating MDSR into the health system has also been conducted in 11 zones in Oromia since the end of February 2015, with over 380 participants attending from previously untrained zones. Three training sessions have been held in the Maji, Mizan and Yirgalem centres in the region to support MDSR integration, attended by a total of 181 participants from five zones.
In addition, the MDSR engagement by stakeholders at all levels of the health system has increased. For example, earlier this year, a special meeting of East Harege Zone representatives together with CEOs and Medical Directors from all five referral hospitals in Dire Dawa and Harar was coordinated and hosted by Ato Ali, Head of East Harege Zone, to discuss the fact that many of the women who die at hospitals in Dire Dawa and Harar are from East Harege Zone. This cross-regional, cross-zonal collaboration established valuable channels for communication about improving the referral process, the early transfer of critical patients, prioritising maternity patients and orientating ambulance drivers on the needs of maternity patients.
Supportive materials have been developed to help promote MDSR, such as a manual for National Public Health Emergency Management / MDSR and a promotional video targeted at leaders and decision-makers has been produced to give an overview of the workings of the MDSR system in Ethiopia. The video encourages institutionalising a ‘no blame’ approach, and uses real life examples to outline the process and purpose of MDSR as well as the importance of engaging staff from all tiers of the health system.
Finally, as E4A Ethiopia DfID funding ended in March and an extended contract supported by the Gates Foundation was implemented from April, a technical symposium has been organised to take stock of lessons learned on MDSR so far and discuss future implications for strengthening the MDSR system to become nationally embedded in Ethiopia.
To read more about the MDSR work in Ethiopia, see the Ethiopia February 2016 newsletter, or look out for the upcoming June 2016 version, here.
This country update was developed based on feedback from Dr Ruth Lawley, Technical Support Unit Coordinator for E4A in Ethiopia, as well as information from the E4A quarterly report and the February 2016 Ethiopian newsletter.
In the lead up to the 2016 Women Deliver Conference in Copenhagen, the UNFPA, the World Health Organization and the International Confederation of Midwives held a satellite Midwifery Symposium titled ‘Young Midwives in the Lead’.
- Support young midwives with leadership potential to become powerful strategic leaders and advocates, who can engage in national policy dialogues with a stronger evidence-based voice.
- Emphasise the vital role that midwives can play in achieving the new Sustainable Development Goals (SDGs) and equip them with increased knowledge about global commitments, latest research findings and evidence base, and knowledge of global midwifery programmes to fulfil this role.
- Create a global network of YMLs to serve as a platform for exchanging good practices and innovations for improving quality of midwifery care and enabling the young midwives to have a wider impact across the entire health and social care system.
- Showcase how global investments in YML can help improve quality of midwifery practice and emphasising the importance of investment in research, advocacy, mentorship and leadership skills of young midwife leaders.
The organisers of the Symposium invited the Coordinator for the Maternal Death Surveillance and Response Action Network, Dr Louise Hulton, to participate as a technical resource and an advocate to raise awareness of the MDSR network.
In a session titled ‘Harnessing the Evidence’, Dr Hulton worked with a group of Young Midwife Leaders to familiarise them with the process of MDSR and to support them to take the lead in advocating for the MDSR model in their home countries. She was joined by Louise Silverton from the Royal College of Midwives who supported the exercise.
The session was the perfect opportunity to engage YMLs in a discussion about the importance of their role in every aspect of the cycle of MDSRs, from the identification and notification of maternal deaths, through the review and analysis process, to the creation, implementation and monitoring of recommendations to improve quality of care.
It was emphasised that the fundamental principles of the MDSR model protect and support health workers through the process, with Confidentiality, Anonymity and a ‘No name, no blame’ culture essential to the success of the model.
Dr Hulton explained the role that midwives and other healthcare actors can play in establishing these principles:
- Confidentiality: local data collectors and involved health care workers should be the only staff to see the names of the deceased and keep that knowledge contained within the review committees. All individuals with access to identifying information should sign a non-disclosure confidentiality agreement.
- Anonymity: all paperwork involved in the reviews should have identifying names obscured or absent to protect the patient, family, friends, and staff members involved.
- ‘No name, no blame’ culture: there needs to be acknowledgements throughout the health system that mistakes do happen, and a constructive approach taken when they do. Learning from mistakes allows preventive measures to be taken in the future. ‘No blame’ should never mean ‘no accountability’, but support and training are better solutions to preventing future deaths than encouraging healthcare workers to shoulder blame. The establishment of a multi-professional committee to oversee MDSR can go a long way towards building a sense of solidarity and understanding of the crucial role that each cadre of worker, including midwives, plays in the process. This sort of committee can also bring in new perspectives on the process and draw a fuller picture.
Finally, the YMLs were engaged in a short role play where they were asked to make the case to Clinical Officer (played by International Confederation of Midwives’ Senior Midwifery Advisor, Nester Moyo) for introducing MDSR to measure maternal and newborn deaths and identify evidence-based actions needed to improve quality of care.
The YMLs stepped up to the challenge and delivered a compelling case to the Clinical Officer for establishing MDSR in order to create an evidence-based culture of accountability and action for women and babies.
The training and advocacy opportunity for these YMLs during the ‘Harnessing the Evidence’ session directly delivered on the objectives of the Symposium by providing YMLs with the practical tools to be able to draw on evidence, strategically advocate for improvements, and in so doing, take the lead on MDSR.
To read more about the Midwifery Symposium and to hear the voices of the YMLs, please visit the ICM website here.
This case study was informed by feedback from Dr Louise Hulton and materials drafted for the ‘Harnessing the Evidence’ session.
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.