Tag Archives: verbal autopsy

Bangladesh | the roll out of MPDSR

Maternal and perinatal death surveillance and response in Bangladesh was initiated by the Ministry of Health and Family Welfare (MOH&FW) to monitor the overall improvement of maternal and neonatal health. Since its inception, the MoH&FW has been implementing MPDSR in 17 districts across Bangladesh following the pilot programme in Thakurgaon district in 2010. The approval of the national MPDSR guideline has paved the way to scale up MPDSR. From July to September 2016, a number of initiatives have taken place to further MPDSR implementation across the country.

RECENT ACTIVITIES

  • The national guidelines for MPDSR have been approved by the MOH&FW. Printing is underway and the dissemination workshop will take place in October 2016.
  • Plans to scale up MPDSR countrywide by 2021 have been drafted in the results framework of the Health, Population and Nutrition Sector Development Program 2011-2016
  • The MPDSR Training of Trainers manual is under development and will be implemented to train sub-national level facilitators who in-turn will train healthcare providers from multiple disciplines at the district and upazila levels. The upazila team will then train the field-level health care providers on death notification, verbal autopsy (VA), social autopsy and facility death review. Participants will also be trained in data collection and analysis
  • A booklet on MDPSR for health and family planning workers in the field is also being developed in the local Bengali language. A draft will be complete by September 2016. The booklet is expected to be distributed to field-level health workers (health assistants, family welfare assistants, health inspectors, assistant health inspectors, family planning inspectors and sanitary inspectors) by November 2016
  • Simplified tools of MPDSR to help facilitate death notification, VA and facility death reviews, to name a few, are being prepared for dissemination to all 17 districts. Selected variables of VA have been incorporated in the District Health Information System-2 (DHIS-2)
  • A national-level meeting – led by the Director, Primary Health Care and Line Director of Maternal, Neonatal, Child and Adolescent Health of the Directorate General of Health Services – was planned in September 2016 to share experiences in maternal and perinatal death review across 14 districts
  • The national MPDSR guidelines will be shared at six divisional workshops once finalised (expected date: December 2016).
  • The UNICEF South Asian Regional Office has organised a South-to-South exchange visit for the MOH&FW Obstetric and Gynaecological Society of Bangladesh to travel to China in November 2016 to share experiences about auditing maternal near misses

To learn more about Bangladesh’s implementation of MPDSR or components of it, please read the country update from July 2016.

Browse this case study to read about how social autopsy is used as an intervention tool to prevent maternal and neonatal deaths in communities in Bangladesh. The WHO has also published a case study about social autopsy in Bangladesh.

Acknowledgements: This country update was prepared and reviewed by Dr Riad Mahmud, Health Specialist (Maternal and Neonatal Health), Health Section, UNICEF Bangladesh and Dr Animesh Biswas, National Consultant (MPDSR), Health Section, UNICEF, Bangladesh.

An innovative approach to measuring maternal mortality at community level in low-resource settings using mid-level providers: a feasibility study in Tigray, Ethiopia

This paper proposes a community-based approach to measuring maternal mortality based on a feasibility study conducted in 2010-2011 in Tigray, Ethiopia, based on the concept of ‘task shifting’.

Priests, traditional birth attendants and community-based reproductive health agents were given responsibility for locating and reporting all births and deaths, and they assisted mid-level providers to locate key informants for verbal autopsy.

From there, nurses and nurse-midwives were trained to administer verbal autopsies and assign cause of death according to WHO ICD-10 classifications.

The study highlights the feasibility of using existing community and health structures to implement MDR.

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Social autopsy as an intervention tool in the community to prevent maternal and neonatal deaths: experiences from Bangladesh

Social autopsy in maternal and neonatal health

Social autopsy (SA) is an innovative strategy whereby a trained member leads a group within a community through a structured, standardised analysis of the root causes of a death or serious, non-fatal health event. Continue reading

Community-based surveillance of maternal deaths in rural Ghana

This article by Joseph Adomako and colleagues, published by the Bulletin of the World Health Organization in February 2016, presents the findings of a study examining the feasibility and effectiveness of community-based surveillance of maternal deaths in rural Ghana. Using a modified reproductive age mortality survey (RAMOS 4+2) and verbal autopsies in Bosomtwe district, the study found that community-based surveillance of deaths of women of reproductive age is feasible and can help to identify maternal deaths in rural communities where they can go unreported.

Verbal autopsy in Bangladesh

This case study by Helen Smith and colleagues, published by the World Health Organization in October 2015, describes the process in introducing verbal autopsy in four regions in Bangladesh in 2010. The authors describe the verbal autopsy model implemented, key findings from an analysis of verbal autopsies carried-out over two years,  and key implementation lessons.

Emergency referral transport for maternal complication: lessons from the community based maternal death audits in Unnao district, Uttar Pradesh, India

This article by Sunil Saksena Raj and colleagues, published by the International Journal of Health Policy and Management in January 2015, presents the findings of verbal autopsies carried out in Unnao District between 2009 and 2010. The findings point to the need to improve the inter-facility referral system.

Maternal and Perinatal Death Inquiry and Response (MAPEDIR): Empowering communities to avert maternal deaths in India

This document, produced by UNICEF in 2008, describes the Maternal and Perinatal Death Inquiry and Response (MAPEDIR) initiative implemented in 16 districts in India. The MAPEDIR tool is a detailed autopsy questionnaire, which aims to capture, from relatives or those close to the deceased woman, individual, familial, socio-cultural, economic and environmental factors missing from medical records. The document describes the development, implementation, key findings, obstacles and opportunities of the MAPEDIR initiative in India. The initiative found that the generation of data by the community highlighted areas where several deaths had occurred and stimulated responses by the community and health providers.

Scaling-up Maternal and Perinatal Death Reviews in Bangladesh

The Maternal and Perinatal Death Review (MPDR) system is now being scaled-up in Bangladesh since it was piloted in Thakurgaon district in 2010. Read this case study about the pilot.  Recent developments include:

  • To date, MPDR is being implemented in 14 out of Bangladesh’s 64 districts.
  • In the later part of 2015, the Ministry of Health & Family Welfare revised the existing MPDR guidelines to reflect a countrywide scale-up, which was also highlighted in the Government’s fourth Health Sector Development Programme (2016-2021). As part of these revisions, a simpler version of community verbal autopsy and facility death review tools on maternal and newborn deaths were developed from existing MPDR tools.
  • The MPDR death notification system has been incorporated into the online District Health Information System (DHIS-2) by the Directorate General of Health Services (DGHS). As a consequence, the health system is gradually notifying each maternal and neonatal death from the community into the DHIS-2 database routinely. Read this case study about the transfer to DHIS-2.
  • In 2015, professional experts at the periphery medical college hospitals, including consultants of obstetricians/gynaecologists, paediatricians, and neonatologists,   undertook training to improve the analysis of causes of deaths taken during verbal autopsies at the district and sub-district level.

Update from Dr Animesh Biswas, PhD, Senior Scientist, Reproductive and Child health Unit at Centre for Injury Prevention and Research, Bangladesh (CIPRB), Dhaka, Bangladesh.

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Using mobile technology to support vital registration and verbal autopsy in the community: Bonsaaso Millennium Villages Project, Ghana

Prior to the inception of the Ghana Bonsaaso Millennium Villages Project in 2006,  maternal mortality was as high as 345 deaths per 100,000 live births, child mortality was 110 deaths per 1000 live births, and the institutional delivery rate was as low as 32%. The challenge of accessing healthcare was identified as the main cause of poor health indicators in the area at that time.

The Millennium Villages Project (MVP) in Ghana initiated vital registration and verbal autopsy (VRVA) in 2008 to support the improvement of maternal and child health services, and, in turn, to reduce infant, child and maternal deaths. Vital registration ensured that all community members were properly identified and included in the denominator of measures being tracked by MVP. In 2011, verbal autopsy was strengthened to ensure that any death in the village was recorded and analysed for medical and social causes so that future deaths could be prevented.

The vital registration and verbal autopsy system

At the community level, community health workers (CHWs) registered household members within their community, making sure to include pregnant women and children under five. They also collected data on the following vital statistics: birth registration (indicating date and place of birth), pregnancy outcomes, and all deaths.

Prior to 2008, a paper-based system was used to collect this data. Multiple challenges were experienced from the paper-based system, including a large volume of information being gathered making it difficult to manage and data analysis very time-consuming.

In late 2009, mobile communications were established throughout the area and, in 2010, the mobile-phone based system called ChildCount+ (CC+) was introduced by the project to address the problems of the paper-based system. The open-source system, CC+, enabled CHWs to send data via SMS text messages to a central server, collecting data in real-time. This system was later migrated to a smartphone-based system called CommCare for general home visits.

A verbal autopsy specialist assists CHWs in conducting in-depth verbal investigations into the causes of each death in the community.  This investigation gathers information from the household and the health facilities of the catchment area where the death occurred to understand the circumstances behind the death.

This more extensive data collection by the verbal autopsy specialists required the use of a complementary electronic system known as Open Data Kit (ODK), where verbal autopsy data is inputted into smartphones using mobile forms.  Specialists visit homes, record the data on the phones and later return to an area with good coverage to send data to a central electronic medical record system – OpenMRS. The OpenMRS system then automatically uses this verbal autopsy data to generate reports on the social and medical causes of each death, which were reported back to local and remote teams. The mobile phone-based system integrated with Open MRS was also eventually migrated to run on the CommCare system in 2014.

How the data is used

The data is discussed during weekly MVP health team meetings comprising selected senior doctors, nurses and heads of public health programmes in the district. During these weekly meetings, vital statistics and verbal autopsy data is reviewed and analysed in order to identify solutions to the circumstances that led to the death and/or morbidity, and to prevent future occurrences.

On a monthly basis, a meeting with a larger stakeholder group takes place where issues on all deaths and morbidity trends are discussed. During these larger stakeholder meetings the verbal autopsy specialist presents on all cases of deaths that have been investigated. Participants of this monthly meeting comprise the MVP health team and multiple representatives from where the death occurred, including from the district referral hospital, from local facilities, from communities, and CHWs.  The meeting discusses the issues presented, finds solutions, and sets timelines for their implementation.

Examples of solutions implemented as a result of the verbal autopsy data include community health information sharing sessions and staff in-service training. These would be based on recommendations from the larger, monthly stakeholder meeting.

Achievements

The transition towards using these electronic data collection systems saw a greater volume of data reporting (see tables 1 and 2), which was in real-time and more accurate. This data collection has become an important monitoring and managerial tool, providing vital information in real-time, so that resources and staff performance gaps can be quickly identified and action taken immediately.  The programme has seen improvements in health staff performance, logistics provision and management. This implies that an effective data collection system provides the edge to improve performance for better results.

Table 1 and table 2Challenges and lessons learned

MVP has been successful in using effective data systems to improve performance and health outcomes. However, this was not achieved without challenges. Key challenges and lessons learned include:

  • Although the paper-based system cost less compared to the CommCare system, it was not cost-effective due to the limitations faced in using it:  time consuming to collect, numerous errors, risk of data loss, large costs for data entry, and lack of real-time data collection limiting rapid decision-making. Key costs to consider for the CommCare system include the smartphone and data bundle.
  • While the CC+ mobile phone-based system introduced in 2010 reduced data bulkiness, there were a number of challenges in using it, including CHWs having to type a lot of information into basic-feature phones, which led to significant errors, and CC+ requiring mobile service at the point of sending SMS text messages. Transferring to the CommCare system using smart phones in 2012 helped to address these problems. CommCare enabled CHWs to enter data on the smart phone anytime, anywhere with or without a mobile network service since data can be synchronized as soon as the CHW enters a network zone.  Also, CommCare can be designed to limit the amount of typing, and therefore reducing errors, by using drop down selection boxes and multiple choice selection options.
  • Training on using the technology takes time. It takes about three days to train someone in the technology and one to two months to become skilful in using it. Allocating time for this is important.
  • There will always be the challenge of the equipment, namely the phones getting lost, broken, or faulty. To address this challenge, the programme provides supervisors with back-up phones ready to be used until a permanent replacement is found.
  • We have not experienced families being concerned about using the mobile phones to collect the verbal autopsy data. Nevertheless, it is important to be culturally sensitive on when you conduct the interview (e.g. in our case, conduct the interview one week after the death) and explain to the family how the data is to be collected before the interview and that it will not be used for any wrong motive.

Future plans and the way forward

The success of the system has meant that the Ministry of Health and the Ghana Health Service have expressed interest in scaling up. MVP is currently working with the Ghana Government to look for both domestic and foreign support to scale-up the interventions.

Acknowledgments

This case study was written by Eric Akosah and Seth Ohemeng Dapaah from Millennium Villages Project, Bonsaaso-Ghana and reviewed by Dr Andrew S. Kanter, Columbia University.

Further information

Read more about this mHealth solution in the article ‘Combining vital events registration, verbal autopsy and electronic medical records in rural Ghana for improved health services delivery’ published by Studies in health technology and informatics and written by contributors to this case study and their colleagues – S., Ohemeng-Dapaah,  P., Pronyk, Akosa, E., Nemser, B., & Kanter, A.

Photo Credit: Danielle Goldman

Early detection of maternal death in Senegal through household-based death notification integrating verbal and social autopsy: a community-level case study

The article by Mosa Moshabela and colleagues in the BMC Health Services Research presents a case study of community-level surveillance in Senegal as part of the Millennium Villages Project (MVP). The mobile technology based (mHealth) platform Childcare+ was used to identify pregnancies, births and deaths. Once this information is entered into the surveillance system, this then prompts a verbal and social autopsy to be conducted. Verbal Autopsy and Social Autopsy (VASA) data was collected using a standardised tool based on the WHO’s Verbal Autopsy questionnaire but with some modifications on questions related to social contributors to mortality (e.g. accessing transport). The VASA data was collected either by hand or using a mobile device and then uploaded to a central database where a pre-set algorithm was used to calculate the likely cause of death and any contributory social factors.

The case study highlights how the routine community-based surveillance system identified inefficiencies at a tertiary level of care as the main contributor to the five maternal deaths in the area. The study concludes that mHealth data collection tools are able to detect small changes in community-level mortality in real-time, can help facilitate rapid-cycle quality improvement interventions when linked with accountability structures such as mortality reviews.