On 16 August, 2016 the World Health Organization (WHO) launched three new tools to count and review stillbirths, and maternal and neonatal deaths!
Browse the standardised system to capture and classify stillbirths and neonatal deaths in the WHO Application of the International Classification of Disease-10 to deaths during the perinatal period (ICD-PM).
Read the guide and toolkit, Making every baby count: audit and review of stillbirths and neonatal deaths. This publication assists countries to conduct audits and reviews to recommend and put into action solutions to prevent future stillbirths and neonatal deaths.
Explore Time to respond: a report on the global implementation of maternal death surveillance and response to review the findings of the WHO & UNFPA global survey of national MDSR systems in 2015.
Browse the press release and WHO website to learn more about these three tools, including related papers by the BJOG.
Read this Lancet commentary about all three publications.
Explore this photo story to learn more about MDSR implementation in ten countries around the world.
View this infographic about improving data to learn about what the WHO is doing to help countries save mothers’ and babies’ lives.
Do you know how many women each day experience a stillbirth worldwide? Browse this infographic on the tragedy of stillbirths to find out how many, and more!
This paper by Nakibuuka et al (2012), published in the African Health Sciences journal, reports a retrospective descriptive study conducted from March to November 2008 to determine what effect an integrated perinatal death audit system in routine care would have on perinatal mortality at Nsambya Hospital. Modifiable factors that cause stillbirths and early neonatal deaths were: Low capacity of neonatal resuscitation, incorrect use of partographs and delays in administering caesarean sections. Interventions to offset these factors include training sessions in neonatal resuscitation and refresher courses on partograph use. Nakibuuka and colleagues conclude that perinatal audits are feasible and can reduce perinatal mortality at the facility level.
This commentary paper, published in the International Journal of Gynaecology and Obstetrics in 2014, gives an overview of the effect of perinatal death audit in low- and middle-income settings. It describes the function of an outcomes audit for perinatal deaths. Buchmann postulates that where perinatal mortality is less frequent (in some middle-income countries) then reviewing near misses may be a more appropriate audit outcome.
The author discusses the two frameworks that are regularly used to assess the preventable factors for each death – the ‘three delays’ and the ‘patient-administrative-healthcare provider’ models. The latter is typically applied to middle-income settings while the former is best suited for low-income areas. Buchmann goes on to describe the criterion-based clinical audit, a popular method used to assess recurrent adverse events commonly identified in an outcomes audit. Finally, the author reviews past studies to determine the effect of change by implementing perinatal audit and to identify where there are gaps in research.
Maternal death surveillance and response (MDSR) is a continuous cycle of notification, review, analysis and response. It builds on the concept of maternal death reviews (MDRs) by focusing on the response and follow-up to ensure recommendations are acted on.
MDSR is a relatively new concept and there is limited systematic data on its implementation. Therefore, in 2015, the World Health Organization (WHO), in collaboration with the United Nations Population Fund (UNFPA) conducted a global survey of national MDSR systems to provide baseline data on the status of implementation.
This report presents the findings of this survey, including additional information from the WHO-MNCAH policy indicator database. It details key aspects of the MDSR system, and discusses the importance of MDSR and its role in reducing preventable maternal death by 2030.
- A 46 question survey questionnaire was developed based on the indicators of MDSR implementation
- The questionnaire was circulated through WHO and UNFPA regional offices in April 2015 and responses were received between May-September 2015
- 67 countries responded, 64 of which were low- and middle-income countries (LMIC)
- Information from the WHO-MNCAH policy indicator database was used to supplement survey responses and build of picture of the current status of MDSR implementation in LMICs
- There has been widespread adoption of the important elements of the MDSR system globally, yet, there remains a gap between policy and practice and there is a lack of progress towards full implementation in many countries
- Most countries have national policies to notify all maternal deaths (86%) and review all maternal deaths (85%)
- Only a small proportion of countries have a national MDR committee that meets at least biannually (46%)
- Only 60% of countries have both a national and subnational MDR committee
- Frequent review meetings at all levels are important for successful surveillance and response. Therefore the functioning of the MDSR system may be sub-optimal in countries whose committees meet less than biannually
Case study insights
Member states were also invited to share case studies describing successful implementation. 18 countries contributed at least one case-study, describing how barriers were overcome and highlighting innovative approaches. Some of the challenges and barriers to implementation include:
- Limited political buy-in and long-term vision
- Under reporting of suspected maternal deaths due to inefficient/incomplete notification systems
- Blame culture
- Incomplete/inadequate legal frameworks
- Inadequate staff, resources, and budget
- Cultural norms and practices that limit MDSR operation
- Problems of geography and infrastructure that inhibit MDSR operation
Conclusions and next steps
- There is a gap between MDSR policy and practice in many countries, with the “response” component lagging the furthest behind
- Countries should be supported to focus on improving levels of maternal death notification and on strengthening mechanisms for response at all levels
- To support countries in their implementation effort, the MDSR Working Group will work with partners to develop flexible MDSR training packages that can be adapted to countries priorities
- The next global MDSR implementation survey is scheduled for 2017 and will be repeated every two years thereafter
To download the report for free, click here.
To read the WHO’s MDSR technical guidance, which describes the measures required to establish an effective MDSR system, click here.
Reference: World Health Organization. (2016). Time to respond: a report on the global implementation of maternal death surveillance and response. Geneva: WHO.
In this article, published in 2011 by the BMC Health Services Research, Belizan and colleagues set out to examine the implementation and management of the Perinatal Problem Identification Programme (PPIP) in South Africa. The authors conducted two workshop sessions to draw on the experiences of clinical care providers. An analytical framework was applied, divided into three phases: ‘pre-implementation’, ‘implementation’ and ‘institutionalisation’. Each phase has two stages of change.
The authors identified four themes that are key to sustaining the implementation of an audit system across the stages of change. These include:
- Drivers of change and teamwork
- Outreach visits and supervisory meetings
- The review of perinatal deaths and feedback meetings
- Communicating and networking
The six stages that correspond to the three phases – before implementation, during implementation and the institutionalisation of the audit programme – include:
- Building awareness
- Committing to audit implementation
- Preparing for audit implementation
- Implementing the audit programme
- Making audit routine practice
- Sustaining the programme
These findings may be applied to other low- and middle-income settings that have high neonatal mortality and are planning on adapting a perinatal audit system. The authors also provide a comprehensive tool to reflect on the implementation and management of a perinatal audit system.
This article, published by the International Journal of Obstetrics and Gynecology in 2014, discusses the development of the Perinatal Problem Identification Programme (PPIP) in South Africa, which was first implemented in a few hospitals in 1990 as a facility audit tool to improve the quality of maternal and newborn care. By 2012, PPIP became a requirement for all public health facilities delivering newborns and was introduced to all districts across the country.
The article describes the various functions of PPIP, including the audit cycle, data entry, verification and analysis, and training. Rhoda and colleagues detail the experiences of two facilities – Western Cape and Mpumalanga – that have been implementing PPIP the longest and offer two differing experiences that may be helpful to other facilities interested in using perinatal death audit. Finally, the authors draw on the strengths, challenges and opportunities of PPIP, concluding that with adequate support, training and guidance, PPIP can help mothers and their newborns survive in South Africa.
Bangladesh has introduced maternal and perinatal death reviews, which triggers action at both the health system and community level. As part of the 2010 pilot, multi-coloured maps were used to plot the number of deaths in the district.