scholarly journals Mismatched ambition, execution and outcomes: implementing maternal death surveillance and response system in Mtwara region, Tanzania

2021 ◽  
Vol 6 (5) ◽  
pp. e005040
Author(s):  
Ali Said ◽  
Nathanael Sirili ◽  
Siriel Massawe ◽  
Andrea B Pembe ◽  
Claudia Hanson ◽  
...  
Keyword(s):  
Maternal Death ◽  
Health Providers ◽  
Quality Improvements ◽  
Group Discussions ◽  
Maternal Deaths ◽  
Surveillance And Response ◽  
Key Informant ◽  
Analyse Data ◽  
Inductive Thematic Analysis

BackgroundSince 2015, Tanzania has been implementing the Maternal Death Surveillance and Response (MDSR) system. The system employs interactions of health providers and managers to identify, notify and review maternal deaths and recommend strategies for preventing further deaths. We aimed to analyse perceptions and experiences of health providers and managers in implementing the MDSR system.MethodsAn exploratory qualitative study was carried out with 30 purposively selected health providers and 30 health managers in four councils from the Mtwara region between June and July 2020. Key informant interviews and focus group discussions were used to collect data. Inductive thematic analysis was used to analyse data.ResultsTwo main themes emerged from this study: ‘Accomplishing by ambitions’ and ‘A flawed system’. The themes suggest that health providers and managers have a strong desire to make the MDSR system work by making deliberate efforts to implement it. They reported working hard to timely notify, review death and implement action plans from meetings. Health providers and managers reported that MDSR has produced changes in care provision such as behavioural changes towards maternal care, increased accountability and policy changes. The system was however flawed by lack of training, organisational problems, poor coordination with other reporting and quality improvements systems, assigning blame and lack of motivation.ConclusionThe implementation of the MDSR system in Tanzania faces systemic, contextual and individual challenges. However, our results indicate that health providers and managers are willing and committed to improve service delivery to avoid maternal deaths. Empowering health providers and managers by training and addressing the flaws will improve the system and quality of care.

scholarly journals The reliability of maternal audit instruments to assign cause of death in maternal deaths review process: a systematic review and meta-analysis

2021 ◽  
Vol 21 (1) ◽  
Author(s):  
Ratnasari D. Cahyanti ◽  
Widyawati Widyawati ◽  
Mohammad Hakimi
Keyword(s):  
Systematic Review ◽  
Maternal Death ◽  
Meta Analysis ◽  
Diagnostic Reliability ◽  
Maternal Deaths ◽  
Measurement Tools ◽  
Study Population ◽  
Underlying Causes ◽  
Meta Regression Analysis

Abstract Background Maternal Death Reviews (MDR) can assist in formulating prevention strategies to reduce maternal mortality. To support MDR, an adequate MDR instrument is required to accurately identify the underlying causes of maternal deaths. We conducted a systematic review and meta-analysis to determine the reliability of maternal death instruments for conducting the MDR process. Method Three databases: PubMed, ProQuest and EBSCO were systematically searched to identify related research articles published between January 2004 and July 2019. The review and meta-analysis involved identification of measurement tools to conduct MDR in all or part of maternal audit. Eligibiliy and quality of studies were evaluated using the Modified Quality Appraisal of Diagnostic Reliability (QAREL) Checklist: Reliability Studies. Results Overall, 242 articles were identified. Six articles examining the instrument used for MDR in 4 countries (4 articles on verbal autopsy (VA) and 2 articles on facility-based MDR) were included. None of studies identified reliability in evaluation instruments assessing maternal audit cycle as a comprehensive approach. The pooled kappa for the MDR instruments was 0.72 (95%CI:0.43–0.99; p < 0.001) with considerable heterogeneity (I2 = 96.19%; p < 0.001). Subgroup analysis of MDR instruments showed pooled kappa in VA of 0.89 (95%CI:0.52–1.25) and facility-based MDR of 0.48 (95%CI:0.15–0.82). Meta-regression analysis tended to show the high heterogeneity was likely associated with sample sizes, regions, and year of publications. Conclusions The MDR instruments appear feasible. Variation of the instruments suggest the need for judicious selection of MDR instruments by considering the study population and assessment during the target periods.

Critical cases of maternal mortality - a severe obstetrical complication, reflecting the quality of medical services provided

2017 ◽  
pp. 27-30
Author(s):  
Yu.V. Dondyuk ◽  
Keyword(s):  
Maternal Death ◽  
Maternal Morbidity ◽  
Obstetric Care ◽  
Near Miss ◽  
Maternal Near Miss ◽  
Maternal Deaths ◽  
Republic Of Moldova ◽  
Mortality Index ◽  
The Republic

Maternal near miss and maternal death audit has become an esssential process in the context of obstetric care in both developed and developing countries. The objective: of the present study was to assess the quality of medical services provided within the multilevel regionalized Perinatal Health System in the Republic of Moldova, by identifying the inconsistencies with existing standards of medical care, in cases of severe obstetric complications and maternal deaths. Materials and methods. All cases of maternal near miss cases and maternal deaths recorded in the Secondary and Tertiary Perinatal Centers of the Republic of Moldova during the period 2009–2014 were analyzed retrospectively. To assess the quality of obstetric care, the following indices have been calculated: maternal near miss/ maternal deaths ratio; the mortality index for each obstetric condition/ complication. Results. During a period of 6 years, in 11 Secondary and Tertiary Perinatal Centers of the Republic of Moldova there were registered 154 651 births, 2881 cases of maternal near miss and 21 maternal deaths. The General Mortality index was 0.72%, and the Mortality Index by direct obstetric morbidity was 0.48%. 92.86% of maternal deaths through direct obstetric causes were avoidable, and the proportion of near miss cases with substandard care was 81.85%. The most frequent gaps (82.48%) were caused by human factors, such as insufficient team work, communication deficiency, lack of knowledge and clinical skills necessary to properly recognize and treat critical obstetric patients, delay and errors in diagnosis and treatment, non-compliance with clinical protocols. Conclusions. The excessively high proportion of avoidable factors highlighted in the study is alarming and implies the need for more extensive activities and the development of strategies focused on ensuring the presence of qualified medical workers in medical institutions, which will allow the provision of qualitative care and safety for patients in the Republic of Moldova, reducing maternal morbidity and mortality. Key words: severe maternal morbidity, maternal near miss, maternal death, maternal mortality.

scholarly journals From Passive Surveillance to Response: Suriname's Steady Efforts to Implement Maternal Death Surveillance and Response (MDSR)

2020 ◽  
Author(s):  
Lachmi R. Kodan ◽  
Kim J.C. Verschueren ◽  
Geertje E. Boerstra ◽  
Inder Gajadien ◽  
Robert S. Mohamed ◽  
...  
Keyword(s):  
Health Care Providers ◽  
Maternal Death ◽  
Maternal Mortality Ratio ◽  
Lessons Learned ◽  
Local Health ◽  
Care Providers ◽  
Maternal Deaths ◽  
Surveillance And Response ◽  
Shame Culture ◽  
Maternal Death Review

Abstract Background Maternal death surveillance and response (MDSR) is essential in preventing avoidable maternal deaths. The cycle starts by accurately capturing maternal deaths with a surveillance system, followed by an audit to give insight into the underlying causes and "lessons learned." Subsequently, recommendations are formulated and targeted multisectoral responses such as quality of care improvement strategies, including clinical guidelines update, health promotion interventions, research to fulfill knowledge gaps, enabling policies and legislation and interventions addressing social determinants. Finally, continuous evaluation and monitoring close the MDSR cycle. We aim to describe the MDSR implementation process in Suriname to share valuable lessons with other countries.Methods We provide an overview of the evolvement from improved maternal death surveillance, toward review, response, and monitoring to fulfill the MDSR cycle in Suriname. Findings Middle-income country Suriname called for many years for improved surveillance and review, and in 2000 the first action was commenced by extension of maternal death case capturing from death certificates to active hospital surveillance. Consequently, the maternal mortality ratio increased in the following years. However, not the full MDSR cycle was completed in 2015, and local health care providers initiated the next step of the MDSR cycle with the installation of a national maternal death review committee (MaMS). Since then, the committee reviews each maternal death applying the "no blame, no shame" culture, formulates, and disseminates recommendations. Collaboration with the Ministry of Health (MOH), Bureau of Public Health (BOG), and the Pan American Health Organization (PAHO) should ensure progress to the sustainable implementation of MDSR. Committee MaMS demonstrates that maternal death review and recommended high impact interventions can only be effectively implemented and sustained, through strong professional and government commitment and practical, solution-oriented responses. Conclusions Crucial elements for a successful MDSR implementation are Commitment, "no blame, no shame" Culture, Coordination, Collaboration, and Communication (5 C's).We hope that describing this process toward successful nationwide MDSR implementation, with its facilitators and barriers, is helpful for other countries with similar ambitions.

scholarly journals Maternal Death Surveillance and Response in Tanzania: Comprehensiveness of Maternal Deaths Narrative Summaries and Action Points from Death Reviews

2020 ◽  
Author(s):  
Ali Said ◽  
Andrea B. Pembe ◽  
Siriel Massawe ◽  
Claudia Hanson ◽  
Mats Malqvist
Keyword(s):  
Maternal Death ◽  
Medical Records ◽  
Causes Of Death ◽  
Demographic Characteristics ◽  
Standards Of Care ◽  
Action Plans ◽  
Maternal Deaths ◽  
Sequence Of Events ◽  
Surveillance And Response ◽  
Community Facility

Abstract BackgroundReview of maternal deaths relies on comprehensive documentation of medical records that can reveal sequence of events that led to death. Maternal Death and Surveillance (MDSR) system recommends the use of narrative summaries during maternal death reviews to discuss the case and categorize medical causes of death, identify gaps in care and recommend action plans to prevent deaths. Suggested action plans are recommended to be Specific, Measurable, Attainable, Relevant and Time bound (SMART). To identify gaps in documenting information and planning recommendations, comprehensiveness of written narrative summaries and adequacy of action plans according the MDSR guideline were assessed. MethodsA total of 76 facility maternal deaths that occurred in two regions in Southern Tanzania in 2018 were included for analysis. We assessed the comprehensiveness of narrative summaries and action plans using a prepared checklist from MDSR guideline of 2015. Presence or absence of items in four domains each with several attributes was recorded on the checklist. The domains were socio-demographic characteristics, antenatal care, referral information and events that occurred after admission. Less than 75% completeness of attributes in all domains was considered poor while >94% was good/comprehensive. Action plans were assessed by application of SMART criteria and according to place of planned implementation (community, facility or higher level of health system). Results Two-thirds of summaries (66%) scored poor, and none were scored as good/comprehensive. Summaries missed key information such as demographic characteristics, information of events that occurred in community (16%), time between diagnosis of complication and commencing treatment (65%), investigation results (47%), summary of case evolution (51%) and referral information (47%). A total of 285 action plans were analysed. Most action plans 242(85%) were allocated to health facilities for implementation and they were mostly 42(42%) on service delivery. Only 42% (32/76) of the action plans were deemed to be SMART.ConclusionsAbstraction of information to prepare narrative summaries used in MDSR system is inadequately done. Action plans and recommendations in MDSR system are mostly for facility sub standards of care and are not specific on the issues to be addressed.

scholarly journals Maternal Death Surveillance and Response in Tanzania: Comprehensiveness of narrative summaries and action points from maternal death reviews

2020 ◽  
Author(s):  
Ali Said ◽  
Andrea B. Pembe ◽  
Siriel Massawe ◽  
Claudia Hanson ◽  
Mats Malqvist
Keyword(s):  
Maternal Death ◽  
Demographic Characteristics ◽  
Health Facilities ◽  
World Health ◽  
Action Plans ◽  
Maternal Deaths ◽  
Middle Income ◽  
Middle Income Countries ◽  
Sequence Of Events ◽  
Surveillance And Response

Abstract Background Maternal deaths in Tanzania and other low and middle income countries occur both in and outside health facilities. Review of maternal deaths relies on comprehensive documentation of medical records that can reveal sequence of events leading to death. The World Health Organization’s and the Tanzanian Maternal Death and Surveillance (MDSR) system propose the use of narrative summaries during maternal death reviews for discussing the case to categorize causes of death, identify gaps in care and recommend action plans to prevent deaths. Suggested action plans are recommended to be Specific, Measurable, Attainable, Relevant and Time bound (SMART). To identify gaps in documenting information and developing recommendations, comprehensiveness of written narrative summaries and action plans were assessed. Methods A total of 76 facility maternal deaths that occurred in two regions in Southern Tanzania in 2018 were included for analysis. We assessed the comprehensiveness of summaries and action plans using a prepared checklist from Tanzania MDSR guideline of 2015. Presence or absence of items in four domains each with several attributes was recorded. These were socio-demographic characteristics, antenatal care, referral information and events that occurred after admission. Less than 75% completeness of attributes in all domains was considered poor while 95% and above was good/comprehensive. Action plans were assessed by application of SMART criteria and according to place of planned implementation (community, facility or higher level of health system).Results Almost half of narrative summaries (49%) scored poor, and only 1% scored good/comprehensive. Summaries missed key information such as demographic characteristics, time between diagnosis of complication and commencing treatment (65%), investigation results (47%), summary of case evolution (51%) and referral information (47%). A total of 285 action points were analysed. Most action points 242(85%) recommended strategies to be implemented at health facilities and they were mostly 42(42%) on service delivery. Only 42% (32/76) of the action points were deemed to be SMART.Conclusions Abstraction of information to prepare narrative summaries used in MDSR system is inadequately done. Action plans in MDSR system are mostly recommended to sub standard care in health facilities but are not specific on the issues to be addressed.

scholarly journals Causes of maternal deaths and delays in care: Comparison between routine Maternal Death Surveillance and Response system and an obstetrician expert panel in Tanzania

2020 ◽  
Author(s):  
Ali Said ◽  
Mats Malqvist ◽  
Andrea B. Pembe ◽  
Siriel Massawe ◽  
Claudia Hanson
Keyword(s):  
Maternal Death ◽  
Causes Of Death ◽  
Expert Panel ◽  
World Health ◽  
Cross Sectional ◽  
Maternal Deaths ◽  
Surveillance And Response ◽  
Independent Expert ◽  
Underlying Causes ◽  
Three Phases

Abstract Background To reduce maternal mortality Tanzania introduced Maternal Death Surveillance and Response (MDSR) system in 2015 as recommended by World Health Organization (WHO). All health facilities are to notify and review all maternal deaths inorder to recommend quality improvement actions to reduce deaths in future. The system relies on consistent and correct categorization of causes of maternal deaths and three phases of delays. To assess its adequacy we compared the routine MDSR categorization of causes of death and three phases of delays to those assigned by an independent expert panel with additional information from Verbal Autopsy (VA). Methods Our cross-sectional study included 109 reviewed maternal deaths from two regions in Tanzania for the year 2018. We abstracted the underlying medical causes of death and the three phases of delays from MDSR system records. We interviewed bereaved families using the standard WHO VA questionnaire. The obstetrician expert panel assigned underlying causes of death based on information from medical files and VA according to International Classification of Disease to Death in Pregnancy Childbirth and Puerperium (ICD-MM).They assigned causes to nine ICD-MM groups and identified the three phases of delays. We used Cohen`s K statistic to compare causes of deaths and delays categorization.Results Comparison of underlying causes was done for 99 deaths. While 109 and 84 deaths for expert panel and MDSR respectively were analyzed for delays because of missing data in MDSR system. Expert panel and MDSR system assigned the same underlying causes in 64(64.6%) deaths (K statistic 0.60). Agreement increased in 80(80.8%) when causes were assigned by ICD-MM groups (K statistic 0.76). The obstetrician expert panel identified phase one delays in 74(67.9%), phase two in 24(22.0%) and phase three delays in all 101(100%) deaths that were assessed for this delay while MDSR system identified delays in 42(50.0%), 10(11.9%) and 78(92.9%).The expert panel found human errors in management in 94(93.1%) while MDSR system reported in 53(67.9%) deaths.Conclusions MDSR committees performed reasonably well in assigning underlying causes of death. The obstetrician expert panel found more delays than reported in MDSR system indicating difficulties within MDSR teams to critically review deaths.

scholarly journals AN INSIGHT INTO MATERNAL DEATH CAUSED BY POSTPARTUM HEMORRHAGE IN WESTERN TIMOR, INDONESIA

2019 ◽  
Vol 22 (1) ◽  
pp. 1-10
Author(s):  
Kristiani Desimina Tauho ◽  
Ferry Fredy Karwur
Keyword(s):  
Maternal Death ◽  
Postpartum Hemorrhage ◽  
Health Workers ◽  
Health Providers ◽  
Maternal Deaths ◽  
Birth Attendants ◽  
Third Stage Of Labor ◽  
Third Stage ◽  
Communication Devices ◽  
Research Findings

Maternal deaths in Timor Island, East Nusa Tenggara Province, are one of the contributors to the overall maternal mortality rate (MMR) of Indonesia. The MMR of Western Timor Island was 150/100,000 live births in 2015. The aim of this qualitative study was to explore the perceived causes of maternal death due to postpartum hemorrhage. Data were obtained from family members, traditional birth attendants, and Posyandu cadres, as well as health providers. Using the retrospective method, this study traced six out of nine postpartum hemorrhage cases in the four sub-districts with the highest maternal death rate in 2010. The research findings showed that most childbirth processes were done at home without any help from health workers. Postpartum hemorrhage happened among women ranging from 24-42 years old; five among them had been pregnant more than four times. Medically, five cases were caused by a prolonged third stage of labor due to a retained placenta. Non-medical factors causing postpartum hemorrhage were poor accessibility, lack of communication devices, and lack of infrastructure.  Keywords: maternal death, postpartum hemorrhage, Western Timor Abstrak Pengetahuan Tentang Kematian Maternal Karena Perdarahan Postpartum di Timor Barat, Indonesia. Kematian maternal di Pulau Timor, Provinsi Nusa Tenggara Timur, merupakan salah satu penyumbang Angka Kematian Ibu (AKI) di Indonesia. Tahun 2015, AKI di Pulau Timor bagian barat adalah sebesar 150/100.000 kelahiran hidup. Tujuan dari studi kualitatif ini adalah untuk mengeksplorasi persepsi para pihak yang paling mengetahui mengenai penyebab kematian maternal karena perdarahan postpartum. Data diberikan oleh anggota keluarga, dukun bersalin, dan kader Posyandu, serta penyedia layanan. Menggunakan metode retrospektif, penelitian ini menyusur enam dari sembilan kasus perdarahan postpartum yang terjadi di empat kecamatan yang memiliki angka kematian maternal tertinggi pada tahun 2010. Hasil penelitian menunjukkan bahwa sebagian besar prosedur persalinan dilakukan di rumah tanpa bantuan dari tenaga kesehatan. Perdarahan postpartum terjadi di antara wanita dengan rentang umur 24–42 tahun; empat di antara mereka sudah pernah hamil sebanyak lebih dari empat kali. Secara medis, lima kasus disebabkan oleh perpanjangan kala tiga persalinan berhubungan dengan retensi plasenta. Faktor- faktor non medis yang menyebabkan perdarahan posrpartum adalah aksesibilitas yang buruk, ketiadaan piranti komunikasi, dan kurangnya infrastruktur. Kata kunci: kematian ibu, perdarahan postpartum, Timor Barat

scholarly journals Quality of Maternal Death Documentation in Afghanistan: A Retrospective Health Facility Record Review

2021 ◽  
Vol 2 ◽  
Author(s):  
Farzana Maruf ◽  
Hannah Tappis ◽  
Jelle Stekelenburg ◽  
Thomas van den Akker
Keyword(s):  
Health Facility ◽  
Cause Of Death ◽  
Maternal Death ◽  
Newborn Health ◽  
Maternal And Newborn Health ◽  
Maternal Deaths ◽  
Care Assessment ◽  
Death Cases ◽  
Maternal And Newborn

Objectives: To assess the quality of health facility documentation related to maternal deaths at health facilities in Afghanistan.Methods: Analysis of a subset of findings from the 2016 National Maternal and Newborn Health Quality of Care Assessment in Afghanistan. At each facility, maternity registers were reviewed to obtain data related to maternity caseload, and number and causes of maternal deaths in the year preceding the survey. Detailed chart reviews were conducted for up to three maternal deaths per facility. Analyses included completeness of charts, quality of documentation, and cause of death using WHO application of International Statistical Classification of Disease to deaths during pregnancy, childbirth and the puerperium.Key findings: Only 129/226 (57%) of facilities had mortality registers available for review on the day of assessment and 41/226 (18%) had charts documenting maternal deaths during the previous year. We reviewed 68 maternal death cases from the 41 facilities. Cause of death was not recorded in nearly half of maternal death cases reviewed. Information regarding mode of birth was missing in over half of the charts, and one third did not capture gestational age at time of death. Hypertensive disorders of pregnancy and obstetric hemorrhage were the most common direct causes of death, followed by maternal sepsis and unanticipated complications of clinical management including anesthesia-related complications. Documented indirect causes of maternal deaths were anemia, cardiac arrest, kidney and hepatic failure. Charts revealed at least eight maternal deaths from indirect causes that were not captured in register books, indicating omission or misclassification of registered deaths.Conclusion: Considerable gaps in quality of recordkeeping exist in Afghanistan, including underreporting, misclassification and incompleteness. This hampers efforts to improve quality of maternal and newborn health data and priority setting.

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