scholarly journals Community Perceptions and Experiences on the Events Leading to Facility Maternal Death; A Verbal Autopsy Qualitative Study

Author(s):  
Ali Said ◽  
Mats Malqvist ◽  
Siriel Massawe ◽  
Claudia Hanson ◽  
Andrea B Pembe

Abstract BackgroundTanzania Maternal Death Surveillance and Response (MDSR) system introduced in 2015 emphasizes review of facility maternal deaths with little community involvement. Involving the community in deaths enquiry can help to make better strategies to prevent future deaths. We aimed to explore family members (caregivers) perceptions and experiences on the events leading to facility maternal deaths to inform future community involvement in MDSRMethodsNarrative interviews were conducted with 20 caregivers who cared for women who died in childbirth to investigate into delays and health care seeking experience. The unstructured questions on perceptions and experiences of events leading to death were administered together with standard verbal autopsy questionnaire. Two regions, Lindi and Mtwara of Southern Tanzania were selected for the study in 2018. Narrative thematic analysis was used for data analysis.ResultsThree main themes evolved: ‘Prepared for birth but not ready for complications’, ‘Disconnect between caregivers and providers’ and ‘The bitter impact of maternal deaths’. Caregivers made efforts to prepare for birth but their preparation were severely inadequate when complications that necessitated referral occurred. Decision to seek care was made jointly between the pregnant woman, husband and other family members. Caregivers tried with little success in communicating with heath providers regarding their admitted patients. They also experienced emotions of grief such as denial, anger, depression, bargaining and acceptance once maternal deaths occurred. Caregivers (mostly old women) were left with the burden of caring for the newborns and other children left by the deceased mother. ConclusionCaregivers` perceptions and experiences of maternal deaths events provide valuable information for community interventions on birth preparedness, decision making, communication and providers` accountability. Maternal deaths bring far reaching mental, social and economic consequences to the family and society

2020 ◽  
Author(s):  
Lachmi R. Kodan ◽  
Kim J.C. Verschueren ◽  
Geertje E. Boerstra ◽  
Inder Gajadien ◽  
Robert S. Mohamed ◽  
...  

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.


2020 ◽  
Author(s):  
Ali Said ◽  
Andrea B. Pembe ◽  
Siriel Massawe ◽  
Claudia Hanson ◽  
Mats Malqvist

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.


2020 ◽  
Author(s):  
Ali Said ◽  
Andrea B. Pembe ◽  
Siriel Massawe ◽  
Claudia Hanson ◽  
Mats Malqvist

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.


2020 ◽  
Author(s):  
Ali Said ◽  
Mats Malqvist ◽  
Andrea B. Pembe ◽  
Siriel Massawe ◽  
Claudia Hanson

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.


2021 ◽  
Vol 6 (5) ◽  
pp. e005040
Author(s):  
Ali Said ◽  
Nathanael Sirili ◽  
Siriel Massawe ◽  
Andrea B Pembe ◽  
Claudia Hanson ◽  
...  

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.


2016 ◽  
Vol 18 (2) ◽  
pp. 364 ◽  
Author(s):  
Leidy Lozano-Avendaño ◽  
Alix Zoraida Bohórquez-Ortiz ◽  
Gloria Esperanza Zambrano-Plata

ResumenIntroducción: La mortalidad materna es considerada un indicador sensible al desarrollo social, porque muchas de estas muertes ocurren por razones evitables, vinculadas a condiciones de pobreza. Hay datos estadísticos sobre el número de muertes maternas a nivel internacional y local, que resaltan la magnitud del problema, así como el conocimiento científico de las causas de estos fallecimientos; pero escasa información publicada sobre el impacto familiar y el desequilibrio que se produce cuando ocurre una muerte materna, situación que trae consigo desconocimiento sobre la real situación de los hijos huérfanos y la familia. Objetivo: Conocer las implicaciones familiares y sociales de la muerte materna a través de la revisión sistemática de la literatura científica publicada. Materiales y métodos: Se realizó una búsqueda en las bases de datos incluidas en los servicios LILACS, ProQuest, MEDLINE y en la biblioteca virtual de salud SciELO. La muestra final fue de 20 artículos. Resultados: Los estudios mostraron que la pérdida inesperada de la madre genera consecuencias emocionales, económicas y de salud en todos los miembros del hogar. Conclusiones: Los hallazgos indican que esta problemática debe ser abordada de manera integral con el fin de mitigar el impacto que genera la muerte materna. AbstractIntroduction: Maternal mortality is considered a sensitive indicator of social development, as many of these deaths occur for preventable reasons, linked to poverty. There is statistical data on the number of internationally and locally maternal deaths, which highlights the magnitude of the problem as well as the scientific knowledge of the causes of these deaths; but there is limited published information on the family impact and imbalance that occurs when a maternal death occurs, which leads to lack of knowledge about the real situation of orphaned children and family. Objective: To know the family and social implications of maternal death through a systematic review of the published scientific literature. Materials and methods: A search in the databases including LILACS, PROQUEST, MEDLINE services and virtual health library SCIELO was conducted. The final sample consisted of 20 articles. Results: The studies showed that the unexpected loss of the mother generates emotional, economic and health consequences for all household members. Conclusions: The findings indicate that this problem must be addressed comprehensively in order to mitigate the impact generated by maternal death. 


2020 ◽  
Author(s):  
Ali Said ◽  
Andrea B. Pembe ◽  
Siriel Massawe ◽  
Claudia Hanson ◽  
Mats Malqvist

Abstract Background Maternal deaths reviews are proposed as one strategy to address high maternal mortality in low and middle-income countries, including Tanzania. Review of maternal deaths relies on comprehensive documentation of medical records that can reveal the 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. Using a prepared checklist from Tanzania 2015 MDSR guideline, we assessed comprehensiveness by presence or absence of items in four domains, each with several attributes. 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 were good/comprehensive. Action plans were assessed by application of SMART criteria and according to the place of planned implementation (community, facility or higher level of health system).Results Almost half of narrative summaries (49%) scored poor, and only1% 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 were mostly about service delivery, 120(42%). Only 42% (32/76) of the action points were deemed to be SMART.Conclusions Abstraction of information to prepare narrative summaries used in the MDSR system is inadequately done. Most recommendations were unspecific with a focus on improving quality of care in health facilities


2020 ◽  
Author(s):  
Ali Said ◽  
Mats Malqvist ◽  
Andrea B. Pembe ◽  
Siriel Massawe ◽  
Claudia Hanson

Abstract Background To reduce high maternal mortality Tanzania introduced Maternal Death Surveillance and Response (MDSR) system in 2015 as recommended by World Health Organization. All health facilities are supposed to identify, notify and review all maternal deaths inorder to recommend quality improvement actions to prevent 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 cause of deaths and care delays with those assigned by an obstetrician expert panel with additional information from Verbal Autopsy (VA). Methods Our cross-sectional study included 109 reported and reviewed maternal deaths from two regions in Tanzania for the year 2018. We abstracted the recorded underlying medical cause of death and reported delays of care from MDSR system records. We interviewed bereaved families using the standard World Health Organization VA questionnaire. The obstetrician expert panel assigned underlying medical cause of deaths 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 and proportional differences to compare causes of deaths and delays in care categorization. Results Ten deaths were excluded in analysis of underlying medical causes and 25 for delays. Expert panel and MDSR system assigned same underlying medical cause for 64.6% of deaths, K statistic 0.60. The agreement increased (80.8%) when causes were assigned by ICD-MM groups, K statistic 0.76. The obstetrician expert panel identified phase one delays in 67.9%, phase two in 22.0% and phase three delays in 100% of the deaths while MDSR system identified delays in 50.0%, 11.9% and 92.9% respectively. The expert panel found human errors in management in 93.1% while MDSR system reported in 67.9% of deaths. Conclusion The MDSR committees performed reasonably well in assigning the underlying cause of deaths. The obstetrician expert panel found more delays to care than what was reported in MDSR system indicating difficulties within MDSR teams to critically review.


2019 ◽  
pp. 71-85
Author(s):  
Doris Rodriguez Leal ◽  
Betty Sánchez de Parada ◽  
Patricia Elena Dueñas Granados

Objetivo: Conocer y analizar la muerte materna, a partir de una aproximación a la realidad familiar, al indagar la experiencia vivida por los familiares de la mujer fallecida y valorar los cambios en los roles y la dinámica familiar. Materiales y Métodos: La investigación se realizó mediante metodología cualitativa, a través del estudio de casos; éstos fueron diez familias que tuvieron una muerte materna en los últimos cinco años, atendidas en hospitales y clínicas del departamento del Tolima-Colombia. Resultados: Ante una muerte materna, las familias y cada uno de sus miembros se tornan vulnerables. Cuando se cuenta con el apoyo de otros familiares, amigos o vecinos, el jefe de familia tiene un trabajo, o la familia pertenece a un grupo religioso o red de apoyo social, la situación se hace menos traumática. Las relaciones familiares en algunos casos se fortalecen, en otros empeoran, particularmente entre suegras y yernos. Con respecto a los cuidados maternales, normalmente las abuelas son las que continúan desempeñando el rol de cuidadoras o madres sustitutas. Conclusiones: Este tipo de muertes, pueden generar sentimientos contradictorios, por un lado se vive el dolor por la ausencia del familiar fallecido y por otro, la alegría de un nuevo miembro. La familia vive una situación de duelo ante la muerte de alguien que trae y cuida la vida, considerada como una muerte trágica, prematura y evitable, por lo que la espera de recibir a un nuevo miembro es sustituida por una pérdida. Palabras clave: Mortalidad materna, familia, relaciones familiares, Colombia.   Family experience of maternal death Abstract Objective: Understanding and analyzing maternal death, approaching to the family reality by examining the experience of the family members of the deceased, and evaluating the change of roles and family dynamic. Materials and Methods: The research was made through study cases, using qualitative methodology; these were ten families that experienced maternal death in the last 5 years, and were attended in clinics and hospitals in de department of Tolima-Colombia. Results: Facing maternal death, families and each of their members become vulnerable. Having support from other family members, friends or neighbors, having a job, or belonging to a religious group or social support network, makes the situation less traumatic. Family relations in some cases are strengthened or worsened, particularly between the mother-in-law and son-in-law.  Regarding maternal care, grandmothers normally take the role of caretakers or substitute mothers. Conclusions: These types of deaths cause contradictory feelings, on one hand there is the pain for the absence of a dead family member and on the other, the joy of a new one. The family goes through a situation of facing the death of someone who brings life and cares for it. It is considered a tragic, premature, and avoidable death, consequently the longing of receiving a new family member is substituted by a loss. Keywords: Maternal mortality, family, family relationships, Colombia.   Experiência dos parentes diante da morte materna Resumo Objetivo: Conhecer e analisar a morte materna, a partir de uma aproximação à realidade da família, ao indagar a experiencia vivida pelos parentes da mulher falecida e valorar as mudanças nos papéis e na dinâmica da família. Materiais e Métodos: A pesquisa se realizou utilizando a metodologia qualitativa, através do estudo de casos; estes foram dez famílias que tiveram uma morte materna nos últimos cinco anos, atendidas em hospitais e clínicas do estado de Tolima, na Colômbia. Resultados: Diante uma morte materna, as famílias e cada um de seus membros se tornam vulneráveis. Quando se conta com o apoio de outros parentes, amigos ou vizinhos, o chefe de família tem um trabalho, ou a família pertence a um grupo religioso ou rede de apoio social, a situação se faz menos traumática. Os relacionamentos da família em alguns casos se fortalecem, em outros pioram, particularmente entre sogras e genros. Com respeito aos cuidados maternais, normalmente as avós são as que continuam desempenhando o papel de cuidadoras ou mães substitutas. Conclusões: Este tipo de mortes, podem gerar sentimentos contraditórios, por um lado se vive a dor pela ausência do parente falecido e por outro, a alegria de um novo membro da família. A família vive uma situação de luto diante da morte de alguém que traz e cuida da vida, considerada como uma morte trágica, prematura e evitável, pelo que a espera de receber a um novo membro na família é substituída por uma perda. Palavras-chave: Mortalidade materna, família, relações familiares, Colômbia.


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