Tag Archives: Quality of Care

Nigeria | Updates on MPDSR in Katsina, Yobe and Zamfara

The Maternal Neonatal and Child health programme (MNCH2) is a five year country led programme which aims to reduce maternal and child mortality in northern Nigeria.  The programme works across six states: Jigawa, Kaduna, Kano, Katsina, Yobe and Zamfara.

Image_Map of Nigeria_MNCH2Since 2014, MNCH2 has been supporting maternal and perinatal death surveillance and response (MPDSR) across its six states.  At secondary level facilities (which often have a high number of deliveries), maternal death review (MDR) committees have been set up to review the causes of maternal death and take action to prevent similar deaths in the future.  MNCH2 also supports State MDR Committees to mentor and monitor facility-level committees.

MNCH2’s support to MPDSR across northern Nigeria has resulted in a number of achievements. Following the country update from March 2017, which featured updates from Kaduna, Kano and Jigawa States, here are some further examples from Katsina, Yobe and Zamfara States:

Katsina State

Discussions in the State MDR Committee led to the development of a training in the use of non-pneumatic anti-shock garments for nurses and midwives working at maternity units in ten secondary health centres. Medical Directors, Medical Officers and Maternity personnel in charge of 18 secondary health facilities contributed to this development.

Twenty nurses and midwives were trained in October 2016 on the application of anti-shock garments. Within a month, these training participants trained other maternity staff from the same secondary health facilities to use anti-shock garments. To ensure that the training is cascaded to all general hospitals, the State is mentoring facility-MDR committees on a monthly basis.

Yobe State

A MPDSR Scorecard was developed in collaboration with the State-MPDSR Committee and the Yobe State Accountability Mechanism for MNCH (YoSAMM) with support from the MNCH2 programme. Data from April to December 2016 was collected from ten government general hospitals with MNCH services. The findings are available in box 1.

MNCH2 update_Text box

The State organised a meeting in January 2017 to review the evidence from the MPDSR scorecard. The meeting was chaired by the Honourable Commissioner of Health, Dr Mohammed Bello Kawuwa and attended by the Chief Medical Directors of the ten general hospitals, and other members of the State MPDSR Steering Committee. The key issues discussed during the meeting were:

  • Facility MDR Committees irregularly meet to review maternal deaths and take actions.
    • Proposed recommendation: YoSAMM, with support from the Advocacy sub-committee, is to visit health facilities where reviews of maternal deaths are not regularly conducted as planned. Progress in this area will be discussed at the next YoSAMM quarterly meeting in June 2017.
  • Completion of MPDSR tools not meeting national standards.
    • Proposed recommendation: Health-care providers should receive a refresher training in the completion of MPDSR forms. A training was conducted in February 2017.
  • Pregnant women are reluctant to deliver at a facility.
    • Proposed recommendation: Local government health promotion officers should conduct community mobilisation activities on the importance of antenatal care (ANC) visits and delivery by a skilled birth attendant.

MNCH2_May MDSR newsletter_image 1

Zamfara State

MDR findings from a secondary facility led to the identification of a number of medical equipment and infrastructure features that were lacking. In response to this, the facility MDR committee called on the local government to build an ultrasound centre and provide ultrasound machines. The facility received these provisions in June 2016. Community MPDSR findings led to further action from the local government in the provision of a renovated labour room, a newly built ANC waiting room with a capacity of 250, and ten beds for the maternity ward.

Acknowledgements: This update was prepared based on feedback from:

  • Mohammad Anka – Evidence and Advocacy coordinator, MNCH2 Zamfara state office
  • Garba Haruna Idris – Evidence and Advocacy coordinator,MNCH2 Katsina state office
  • Musa Mohammad- Evidence and Advocacy coordinator, MNCH2 Yobe state office.

Midwives: Unique contributors to MDSR

Midwives are vital to ensuring women and their babies not only survive pregnancy and childbirth, but live healthy lives.

We know from the Lancet Midwifery series that:

What do we know about the role of midwives in maternal death surveillance and response (MDSR) systems?

Midwifery blog_N.Cornier_Image 1In 2016, we asked six experts in MDSR or similar models for their opinion. Experts agreed that midwives can make a unique contribution to MDSR being familiar with the medical and sociocultural factors relevant to each case. Their unique insights are meaningful in the investigation of and response to a maternal death. However, midwives are not always involved in the review of a maternal death and in some cases may have a low status within a health system.

In this blog, written for International Day of the Midwife on 5th May 2017, we turn our gaze to northern Syria where midwives are being trained in maternal and newborn care. We look at the challenges, benefits and opportunities in involving midwives in maternal care, in particular MDSR.

In March 2017, Nadine Cornier, a trained midwife and reproductive health Humanitarian Advisor at UNFPA in Turkey, gave a presentation at a seminar we co-organised at the London School of Hygiene and Tropical Medicine. She discussed her research and experience in measuring maternal mortality in humanitarian settings and responding to findings. Watch the live recording.

Her current work in Northern Syria involves re-training midwives in “life-saving capacities and competencies” as set out in the International Confederation of Midwives (ICM) Essential Competencies for Basic Midwifery Practice to raise their skill sets from an assistant midwife to a qualified midwife.

While Nadine Cornier describes this as a large task, maximising the competencies of midwives is invaluable in a setting where hundreds of health workers have been killed and numerous have fled the country. It is also important to note that accordingly assessments of maternal deaths have not been carried out in this area because of the security risks to health workers and health facilities.

For the panel discussion, Nadine Cornier was joined by Rajat Khosla, Human Rights Adviser in sexual and reproductive health and rights at the World Health Organization, and Eleanor Brown, Technical Specialist at Options.

When asked about the role of professional associations, especially professional midwifery associations, Eleanor Brown shared her work experience in Nigeria. She tells us that the Society for Obstetricians and Gynaecologists of Nigeria is integral to the maternal death review process and in instilling a culture of no blame. Eleanor Brown further states:

“The professional association for midwives plays quite an important role in other [Options] maternal health programmes as champions, particularly for getting people to have the political will to address maternal mortality”.

N.Cornier_presentation slideImage caption: Slide from Nadine Cornier’s seminar presentation

Let us celebrate the work of midwives as champions in maternal and newborn care around the world. Let us also reaffirm that midwives can play an important part in MDSR as they can uniquely contribute to making effective decisions to improve the quality of maternal and newborn care.

To watch the live stream of the seminar at LSHTM, Applying Maternal Death Surveillance and Response in Crisis Settings, click here.

To download Nadine Cornier’s presentation, click here.

This seminar is part of a series. To read about the seminar series including the first seminar which took place in January 2017, click here.

Read this blog by UNFPA to learn more about Nadine Cornier’s work with midwives in northern Syria.

Acknowledgements: This blog was written by Jenna de St. Jorre, Evidence for Action-MamaYe Technical Assistant at Options.

[1] Rounded from 83%

Policy Briefs

These policy briefs are the outcome of national review of MDSR data from January 2014 to December 2015 covering 539 maternal deaths.

Image_Policy Brief IV_PostAt 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.

  1. Recommendations on Quality of Care in MNH Services
  2. Recommendations on Community Participation and Engagement
  3. Recommendations on Appropriate Use of Blood and Blood Products
  4. 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.

Maternal and perinatal death reviews to reduce mortality: spotlight on Webuye Hospital, Kenya

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

The Lancet Maternal Health Series

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.

Perinatal mortality audit: counting, accountability, and overcoming challenges in scaling up in low- and middle-income countries

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.

Confidential review of maternal deaths in Kerala: a case study

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.

Counting every stillbirth and neonatal death through mortality audit to improve quality of care for every pregnant woman and her baby

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.

Facility death review of maternal and neonatal deaths in Bangladesh

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.

UNICEF Ethiopia_2010_Tuschman

Ethiopia puts ‘R’ in MDSR

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.

Acknowledgements:

Case study written by Evidence for Action in Ethiopia.

Photo credit: UNICEF Ethiopia/2010/Tuschman