As part of its efforts to improve accountability for women and children’s health, Malawi classified maternal death as a notifiable event in 2003, and the National Committee on Confidential Enquiry into Maternal Deaths (NCCEMD) was established in 2009. Like many other countries, from 2013, Malawi moved from maternal death reviews (MDRs) to the more robust system of maternal death surveillance and response (MDSR), which entails not only that maternal deaths are notifiable, but also places greater emphasis on response, and on the monitoring and evaluation of MDSR itself. Continue reading
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.
Since 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:
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.
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.
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.
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 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:
- Educated, licensed and supported midwives can greatly contribute to the continuum of maternal and newborn care
- Scaling up midwifery interventions that provide care for mothers and babies including family planning, would avert 80% of all maternal and newborn deaths, and stillbirths
- There is a need for improvements in education and regulation to scale up midwifery care, as well as a need for stronger partnerships between healthcare workers and communities
What do we know about the role of midwives in maternal death surveillance and response (MDSR) systems? Continue reading
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.
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.