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Bangladesh scales up MPDSR

To prevent mothers and babies from dying, Bangladesh has taken steps to scale up its maternal and perinatal death surveillance and response (MPDSR) system nationally. The country first piloted maternal and perinatal death review (MPDR) in 2010. By 2015, MPDR was rolled out to 12 districts. In 2015, the estimated maternal mortality ratio was 176 per 100,000 live births and in 2016, the estimated neonatal mortality rate was 20 per 1,000 live births. While Bangladesh has made important gains, more needs to be done to achieve the Sustainable Development Goal 3 targets for maternal and newborn mortality.Image from Bex_Options

Photo credit: Rebecca McKay-Smith/Options

In 2016, the Ministry of Health and Family Welfare (MoH&FW) acted to roll out MPDR throughout the country. In line with the World Health Organization (WHO) Maternal Death Surveillance and Response (MDSR) Technical Guidance, the MPDR system was updated to ensure an increased focus on surveillance and response.

Both the Health Economic Unit of the MoH&FW and the Bangladeshi government financially supported this transition. To ensure integration and adoption across the health system, changes were carried out in collaboration with: The Directorate General of Health Services and their Management Information system, Directorate General of Family Planning, developmental partners (for example, UNICEF, UNFPA, WHO), professional bodies (such as, the Obstetrical and Gynaecological Society of Bangladesh), implementing partners (for example, non-governmental organisations), public health experts and research organisations (such as, the Centre for Injury Prevention and Research).national MPDSR guideline workshop

Photo caption: Workshop on “Sharing MPDSR Guidelines, Training Module and Strategic Implementation Plan” for Universal Health Coverage, 2 October 2016. Photo credit: Dr Animesh Biswas.

Twenty-two districts are currently implementing the new maternal and perinatal death surveillance and response (MPDSR) system with UNICEF supporting 13 districts, UNFPA five and Save the Children four. Scale-up activities took place at the policy and implementation levels to support the expansion of the system, including:

  • The adoption of national MPDSR guidance based on existing MPDR guidelines. New national guidelines were approved by the MoH&FW in October 2016.
  • The development of a national Training of Trainer’s (ToT) manual on MPDSR to use at various levels (approved in December 2016 by the MoH&FW).
  • The creation of a pocket handbook on MPDSR for on-the-ground health workers.
  • The development of six additional tools, also approved in December 2016 by the MoH&FW: The community death notification slip, the community maternal death review form, the community neonatal death review form, the facility death notification slip, the facility-based maternal death review form and the facility-based neonatal death review form.
  • A cascade training approach comprising of a:
    • National level three-day ToT for 78 health professionals from the 22 districts.
    • Training of health and family planning staff on the ground, and volunteers, doctors and nurses at the district and upazila (sub-district) levels across the 22 districts.
  • The identification of MPDSR focal persons at the upazila, district and national levels.
  • Establishment of MPDSR sub-committees in facilities at upazila and district levels. Facility death findings will be periodically discussed in hospital-based MPDSR sub-committees and necessary steps taken to improve facility services.
  • The newly created national MPDSR committee will sit twice a year to discuss progress towards achieving targets for maternal and neonatal mortality, and improvements in the health system.
  • Capacity development on the national level assignment of causes of death from community maternal and neonatal verbal autopsy forms – based on the International Classification of Diseases 10 (ICD-10) – were conducted for clinicians, including gynaecologists, obstetricians, neonatologists and paediatricians, from seven tertiary medical college hospitals.

A key element of the revised system is to improve the quantity and quality of the collection of data. To ensure the notification and reporting of every community- and facility-based maternal and neonatal deaths and stillbirths, notification is now mandatory. The review of every maternal and neonatal death will be conducted at the facility level and a verbal autopsy will be carried out for all maternal and neonatal deaths at the community level. Moreover, for community sensitisation and awareness building, social autopsies for maternal and neonatal deaths will be conducted in communities.

Data is now viewable via a dashboard linked to the online management information system database, the District Health Information Software (DHIS-2). In addition to being shared and discussed at MDPSR sub-committee meetings, review findings will be fed into Quality Improvement Committee (QIC) meetings at the upazila and district levels. The QICs will be tasked with monitoring follow-up actions. Additional system improvements to support collection, management and review of data included:

  • Trainings to support health-care providers in community clinics to report community deaths to the DHIS-2, the smallest health system unit covering approximately 6,000 persons.
  • Trainings to upload causes of death from verbal autopsies to the DHIS-2 at the divisional level.
  • Meetings with MPDSR facility-level sub-committees to discuss findings from facility death reviews to improve the quality of maternal and newborn care.

The DHIS-2 presents data on maternal and neonatal mortality by time period and geographic location. Improvements in data availability, accessibility and quality are supporting improved decision making by health managers, planners and policy makers at various levels of the health system. Another notable achievement has been the integration of MPDSR into the fourth Health Population Nutrition Sector Development Plan (2017-2021). The MoH&FW plans to achieve countrywide scale up of the MPDSR system by 2021.

This country update was written by Dr Animesh Biswas, PhD, Senior Scientist and Associate Director, Reproductive and Child Health Department at the Centre for Injury Prevention and Research (CIPRB) in Dhaka, Bangladesh.

To read some publications by Dr Biswas, please click the titles below:

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MDSR in Ethiopia: three years on

E4A has been providing technical assistance for the introduction, implementation and scale-up of Ethiopia’s national Maternal Death Surveillance & Response (MDSR) system since 2012.

At national level, this has involved contributing to the development of the MDSR Guidance, data collection tools and database, and training curriculum, participating as active members of the MDSR task force, and representing the programme internationally.

The Ethiopia E4A team is based in the MNCH department of the WHO Ethiopia country office. In addition to a Programme Director, E4A is supported by five regional Technical Advisors who have been supporting the four large agrarian regions (Amhara, Oromiya, SNNPR and Tigray) as well as Harari, Dire Dawa and Addis Ababa, and a Data Manager working in the EPHI Public Health Emergency Management (PHEM) directorate. The University of Aberdeen’s Immpact programme and Options serve as the E4A Technical Support Unit, providing strategic guidance and 2 advisors based in Ethiopia.

Read our two page summary of our experiences here>

Read our training materials and guidelines here>

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The 2012 MDSR Resource Room

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:

Email: l.hulton@evidence4action.net

Visit: www.mdsr-action.net

 

Ethiopia MPDSR training package and guidelines

The Ethiopian National Maternal and Perinatal Death Surveillance and Response (MPDSR) Training Package was developed by the multi-sectoral national MPDSR Task Force, with technical support from Evidence for Action (E4A) and the World Health Organization (WHO).

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In Ethiopia, an MDSR system was launched in May 2013, and a national level Train-the-Trainers workshop was conducted at that time by a multi-sectoral team drawn from the Task Force membership, the Ethiopian Society of Obstetricians and Gynaecologists (ESOG), WHO and the E4A technical assistance team. Following the national training workshop, a “training cascade” was introduced. Each Regional Health Bureau has been responsible for rolling-out the MDSR training to relevant participants in their regions.

Initially, Maternal and Child Health staff were trained using the MDSR Technical Guideline. In 2014, the MDSR system was integrated into the Public Health Emergency Management (PHEM) directorate in the Ethiopian Public Health Institute (EPHI). The PHEM Implementation Manual for MDSR was developed to help orientate surveillance officers around the country on collecting maternal death data.

In 2017, perinatal death surveillance and response started to be added to the existing MDSR platform. The MPDSR Technical Guidance document was produced and a new integrated training package developed (see below). Two Training of Trainers (ToT) sessions were held by the end of 2017. Training roll-out will begin in 2018.

The MPDSR and MDSR training packages are available to download below.

The MPDSR training package

Original MDSR training package

The MPDSR training package has been designed to be interactive. The emphasis throughout the training should be on the use of MPDSR as a basis for action. The importance of multi-professional team collaboration is also emphasised throughout the training, as this has been shown to benefit the MDSR system by strengthening communication between disciplinary groups (clinicians, midwives, data managers, community representatives, etc). Where possible, training at each level should be delivered by a multi-disciplinary training team.

FIGO LOGIC MDSR guidelines and training curriculum

These guidelines and training curriculum were developed by FIGO LOGIC to guide health professionals in their efforts to assess quality of care in their own service, and to help health staff conduct reviews of maternal death cases occurring in their health facility.

The FIGO LOGIC (Leadership in Obstetrics and Gynaecology for Impact and ChangeMaternal Death Review Guidelines and Maternal Death Review Training Curriculum were published in early September 2013. The practical guidelines aim to  support clinicians, health systems and facility administrators, MNCH programme managers, NGOs and policy makers in assessing quality of care in their own settings, and build their capacity to conduct maternal death reviews at facility-level. The training curriculum is designed to accompany these guidelines and support their implementation in practice.

Together, they are key tools to support local stakeholders to move forward with MDSR implementation in their own contexts. The tools were field tested in Cameroon with the support of the Society of Obstetricians and Gynaecologists of Cameroon.

To download the FIGO MDR guidelines, click here.

To download the FIGO MDR training curriculum for free, click here.