These policy briefs are the outcome of national review of MDSR data from January 2014 to December 2015 covering 539 maternal deaths.
At the National MDSR Task Force’s inaugural meeting members conducted an analysis of national MDSR data in relation to the objectives of the Health Sector Transformation Plan 2015/2016 – 2019/2020. This analysis was distilled into four policy briefs published in July 2016.
- Recommendations on Quality of Care in MNH Services
- Recommendations on Community Participation and Engagement
- Recommendations on Appropriate Use of Blood and Blood Products
- Strengthening Response in the Maternal Death Surveillance and Response System
The briefs were designed by Evidence for Action and copies were distributed to regional health bureaus at the National RMNCH Meeting 2016.
These policy briefs comprise the first national level response to MDSR data in Ethiopia and as such mark an important milestone.
In July 2016, the Maternal and Newborn Health Improvements (MANI) project in Kenya’s Bungoma County funded by the UK Department for International Development, published a Human Interest Story in the MANI Learning Series. The MANI project supports six sub-counties in Bungoma to implement maternal and perinatal death surveillance and response (MPDSR).
MANI has been assisting Webuye Hospital to introduce and conduct maternal and perinatal death reviews (MPDRs). This Story presents a few ways MPDRs helped Webuye Hospital to improve maternal and newborn health. Various challenges were overcome by developing an on-call rota system, connecting a generator to the maternity ward and newborn unit, training staff in neonatal resuscitation, improving communication channels between all stakeholders and conducting a blood drive. A new operating theatre is due to open soon and the newborn unit is to be redesigned.
MANI Learning Series: Human Interest Story July 2016
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.
Pattinson et al (2009), published by the International Journal of Gynaecology and Obstetrics, conducted a systematic review and meta-analysis of perinatal mortality audit at the facility level in low- and middle-income countries. The results showed a reduction in perinatal mortality by 30% with the establishment of a perinatal audit system.
The findings suggest that an audit system may be helpful in reducing perinatal deaths in facilities and improving the quality of care. Pattinson and colleagues also reviewed information about community audits and verbal/social autopsy drawing on examples from Africa (Guinea and Uganda) and Asia (Uttar Pradesh, India). Furthermore, two country case studies were presented on scaling up perinatal audit in South Africa and Bangladesh.
The authors identify areas that merit further research and conclude that successful implementation of perinatal audit to improve the quality of care relies on closing the audit cycle.
This paper by Dr Paily and colleagues, describes the processes and findings from the Confidential Review of Maternal Deaths (CRMD) in Kerala, India.
The paper describes how actions and recommendations were developed based on the findings, and how the response and monitoring has conducted a pilot phase to support continuous improvements in the delivery of quality of care.
One of the key lessons learnt relates to the importance of raising awareness among administrators as a key group who can support the process of CRMDs as members of the multi-disciplinary team.
This article by Kate Kerber and colleagues in BMC Pregnancy & Childbirth presents the findings of a review and assessment of evidence for facility-based perinatal mortality audit in low- and middle- income countries, including their policy and implementation status on maternal and perinatal mortality audits.
The authors found that only 17 countries have a policy on reporting and reviewing stillbirths and neonatal deaths despite evidence suggesting that birth outcomes can be improved if the audit cycle is completed. Key challenges in completing the audit cycle and where improvements are needed were identified in the health system building blocks of “leadership” and “health information systems”. Evidence based solutions and experiences from high-income countries are provided to help address these challenges.
The authors conclude that the system needs data mechanisms (e.g. standardised classification for cause of death and best practice guidelines to track performance) as well as leaders to champion the process (e.g. bring about a no-blame culture) and access decision-makers at other levels to address ongoing challenges.
This article by Animesh Biswas and colleagues in PLoS ONE presents findings of a qualitative study with healthcare providers involved in Facility Maternal and Newborn Death Reviews (FDRs) in two districts in Bangladesh: Thakurgaon and Jamalpur. The study aimed to explore healthcare providers’ experiences, acceptance, and effects of carrying out FDRs.
The study found that there was a high level of acceptance of FDRs by healthcare providers and there were examples of FDRs leading to improvements in quality of care at facilities, such as the use of FDR findings in Thakurgaon district hospital which ensured that adequate blood supplies were available, which saved the life of a mother who had severe post-partum bleeding. The article also identified gaps and challenges in carrying-out FDRs to consider for future efforts, including ensuring incomplete patient records and inadequately skilled human resources to carry out FDRs.
The authors conclude that FDRs are a simple and non-blaming mechanism to improving outcomes for mothers and newborns in health facilities.
To read more about maternal and newborn death reviews in Bangladesh, take a look at several case studies: two from the MDSR Action Network website: “Mapping for Action” and “eHealth to support MPDRs”; and another in the WHO’s global MDSR report here.
In May 2013, the Federal Ministry of Health launched Ethiopia’s MDSR system. By the end of 2014, the system had been introduced in 17 zones and has been integrated into the existing surveillance system. This case study presents the findings of a preliminary audit of responses to maternal death. The “response” arm of MDSR is recognized to be the most challenging part of MDSR with few centres managing to respond in an organised constructive manner to maternal death.
A preliminary audit of responses to maternal death from health facilities at different levels of the health system demonstrated an average of 3 responses to each maternal death.
The audit captured 211 responses to 71 maternal deaths at 33 health facilities/ communities. Of the 211 responses 39% were aimed at improving care within the hospital or health centre demonstrating a constructive approach to the MDSR process. In other words, health facility staff did not simply pass blame to the community or referring health facility for the woman’s death and say “she came too late”.
Actions improved feedback and training to staff, improving services available at the health facility, improving access to essential drugs and equipment and redistribution of staff to improve effectiveness. A further 35% of responses targeted community awareness of the need to access health care in pregnancy. This was done through a variety of methods including regular women’s groups, community meetings and pregnant women’s conference.
MDSR information is a powerful tool of communication between health professionals and communities. Fifteen per cent of actions involved communication with referring health facilities thereby strengthening referral pathways, whilst the remaining 10% targeted the regional or zonal offices to improve transport systems and obtain essential drugs.
It is noted that the majority of the responses taken were not expensive in terms of cash but contributed to staff professional development and raising community awareness of maternal health issues.
To read more, take a look at Ethiopia’s MDSR Newsletter here and a case study in the World Health Organization’s global MDSR report here.
Case study written by Evidence for Action in Ethiopia.
Photo credit: UNICEF Ethiopia/2010/Tuschman
The Evidence for Action programme has developed a structured literature review of how information communication technology (ICT)/mobile technology have been used in low and middle income countries for monitoring and improving the quality of maternal and newborn healthcare in general, as well as in the context of vital event registration and/or maternal death reviews.
The review identified a total of 24 projects covering four thematic areas:
- data management including collection, transmission, and analysis of information
- point of care support by assisting decision-making and diagnosis
- training and disseminating knowledge to healthcare workers (e.g. latest research and guidelines)
- improving communication and networking between healthcare workers and health facilities, patients or other healthcare workers
The review found that these technologies could have greater potential in improving and monitoring quality of maternal and newborn care if the following factors are considered:
- ensuring the deployment of technology that can be installed and maintained locally
- deploying devices and infrastructure that is low cost and can be integrated within the health system
- ensure the buy-in and commitment of key stakeholders
The paper concludes that the future of ICT to contributing to quality of care improvements is promising; however it must be complemented by other inputs such as adequate infrastructure and human resources to maximize its potential.
In October 2012, Evidence for Action hosted a half day practical and interactive “resource room” on Maternal Death Surveillance and Response (MDSR) at the International Federation of Gynecology and Obstetrics (FIGO) 2012 World Congress.
The interactive resource session aimed to:
1) Provide delegates with access to resources and expertise on MDSR
2) Identify training and guidance needs
3) Identify the range of global expertise on MDSR
Key themes covered during the interactive session included:
1) Creating a conducive enabling environment. Resources developed for this theme include:
- Legal briefing leaflet focused on overcoming legal challenges and creating an enabling environment on MDSRs
- Poster on legal considerations related MDSRs.
2) Maternal death identification, notification and reporting. Resources developed for this theme include:
- Poster on maternal death identification, notification and reporting
- Poster on maternal death identification, notification and reporting flowchart
3) Use of findings at multiple levels, including data management, to improve quality of care, prevent further deaths and influence the health system more broadly. Resources developed for this theme include:
- Poster on analysis and response within MDSR
- Poster on improvements in quality of care
- Literature review on the impact of Maternal Death Reviews on quality of care compiled by the Evidence for Action team, September 2012.
4) Components of MDSR. Resources developed for this theme include:
- Poster on MDSR and verbal autopsy
5) Training and support. Resources developed for this theme include:
For more information on MDSR or to join the MDSR Action Network, please: