Tag Archives: Midwives

MPDSR: a supportive process for midwives to boost morale

This blog, written for International Day of the Midwife on 5th May 2017, illustrates how the maternal and perinatal death surveillance and response (MPDSR) process in Kenya helped to lift the morale of midwives working in extremely challenging conditions.

The Maternal and Newborn Health Improvement (MANI) project has trained eight midwives from Lugulu hospital since September 2015 in MPDSR. Since then the facility has regularly conducted maternal and perinatal death reviews (M/PDRs). The primary objective of MPDSR is to identify areas where quality and access to emergency obstetric and newborn health care services can be improved to help prevent future deaths. However, in Lugulu hospital, the midwives found that MPDSR equipped them with strategies to cope during an exceptionally difficult period.

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Like many faith-based facilities across Kenya, health providers in Lugulu Hospital in Bungoma County felt unable to turn maternity clients away during the four-month strike by Government doctors. During the strike, from November 2016 to February 2017, Lugulu Hospital experienced:

  • An increase in maternity in-referrals from an average of two per month to over 100, including many cases from facilities in neighbouring counties
  • A sudden six-fold increase in the number of deliveries and a seven-fold increase in the number of caesarean sections

Ordinarily, these additional clients would have used the free government maternity services, and lacked the resources to pay Lugulu’s standard fees. With clients unable to pay, Lugulu struggled to cover the additional demands on staffing, drugs and supplies, leaving the facility in a compromising situation. Midwives experienced a huge increase in their workload, typically working over 12-hour days, often for seven-consecutive days, leaving them both “physically and mentally drained” (Matron in-charge). Postnatal wards were grossly overcrowded. Emergency clients had to queue for caesarean sections in the hospital’s only operating theatre, with staff having to make difficult decisions regarding which emergency case was most critical. For some emergency patients arriving from elsewhere, delays in the weak referral system proved to be fatal.

The increased caseload and detrimental impact on quality of care resulted in midwives witnessing over 20 perinatal deaths a month at its peak, compared to an average of one per month before the strike. No maternal deaths had occurred at the facility between January and November 2017, but five occurred during the strike, leaving staff to feel “upset and demotivated seeing so many lives lost just because of money” (Maternity-in-charge).


Despite the excessive strain already placed on their workload by the doctor’s strike, midwives and other health personnel at Lugulu continued to meet to review all of the maternal and perinatal deaths that occurred during the course of the strike, and found that this was “a positive experience at a time when morale was low” (Matron-in-charge). The Maternity-in-charge went on to explain:

“Midwives see MPDSR as a learning experience and an important process for identifying and addressing preventable factors contributing to deaths. The review process helps us to see our weakness. We identify gaps in the management of difficult cases. We then take action, such as internal continuous medical education and training in emergency obstetric and newborn care.”

What was especially important during this crisis was that midwives found the meetings were an opportunity to “sit together as a team” (Matron-in-charge). During the doctors’ strike they felt determined to continue the M/PDR process as it helped them at a truly difficult time emotionally. Akin to a peer-support counselling session “some midwives even came to attend review meetings after working a night shift,” (Health Record Information Officer).

The MPDSR process was thus a pivotal mechanism enabling the midwives to cope in this difficult context. It confirmed MPDSR as a valuable process that strengthened their team work, reinforcing the need and appreciation of their collaborative efforts.

This blog was written by Sarah Barnett, Technical Specialist at Options.

Click here to read a Maternal Health Task Force blog, Saving Lives During Health Worker Strikes: Lessons From Kenya, written by Nicole Sijenyi Fulton, Team Leader at Options.

To learn more about the experiences of midwives conducting confidential enquiries in Ireland, including the importance of having a peer-support system within the process, read our expert opinion piece on the role of the multi-disciplinary team in MDSR or similar models.

The role of midwives in the implementation of maternal death review (MDR) in health facilities in Ashanti region, Ghana

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

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.

Feedback from the Midwifery Symposium: young midwives in the lead

Photo credit: Rosie Le Voir/ E4A

Coordinator of the MDSR Action Network, Dr Louise Hulton, worked with Young Midwife Leaders as part of the Midwifery Symposium to demonstrate the value of multi-disciplinary team involvement in MDSR

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’.

  1. 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.
  2. 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.
  3. 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.
  4. 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.

Photo credit: E4A

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.

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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