Going ‘Beyond the Numbers’: Maternal Death Reviews in India

Hospital Paperworlds: Medical (Mis)Reporting and Maternal Health in Northern Pakistan

Global health metrics come into being in complex circumstances. Through ethnography that focuses closely on the forces driving uneven obstetric case reporting in a government hospital in northern Pakistan, this article challenges the integrity of the health care system documentation on which the state and non-state interventions and evaluations rely. Incomplete and skipped case records not only resulted from the time constraints posed by work on a busy maternity ward. They also helped vulnerable frontline providers disguise and avoid accountability for the aftermaths of the medical mismanagement and maltreatment made more likely by infrastructural scarcity and disarray. Yet the provider-side protections these tactics afforded came at patients' expense because they rendered error, wrongdoing, and iatrogenesis as invisible and unactionable. The sum of these reporting practices was "hospital paperworlds": defensively authored and aspirational datasets that conveyed desired rather than achieved outcomes, decontextualized risks and harms, and were too-rarely triangulated for their correlational significances or deficiencies. [hospital ethnography, obstetrics, case reporting, metrics, Pakistan].

The development of a new accountability measurement framework and tool for global health initiatives

The Global Strategy for Women’s Children’s and Adolescents’ Health emphasizes accountability as essential to ensure that decision-makers have the information required to meet the health needs of their populations and stresses the importance of tracking resources, results, and rights to see ‘what works, what needs improvement and what requires increased attention’. However, results from accountability initiatives are mixed and there is a lack of broadly applicable, validated tools for planning, monitoring and evaluating accountability interventions. This article documents an effort to transform accountability markers—including political will, leadership and the monitor–review–act cycle—into a measurement tool that can be used prospectively or retrospectively to plan, monitor and evaluate accountability initiatives. It describes the development process behind the tool including the literature review, framework development and subsequent building of the measurement tool itself. It also examines feedback on the tool from a panel of global experts and the results of a pilot test conducted in Bauchi and Gombe states in Nigeria. The results demonstrate that the tool is an effective aid for accountability initiatives to reflect on their own progress and provides a useful structure for future planning, monitoring and evaluation. The tool can be applied and adapted to other accountability mechanisms working in global health.

Systematic exploration of local reviews of the care of maternal deaths in the UK and Ireland between 2012 and 2014: a case note review study

OBJECTIVES

Local reviews of the care of women who die in pregnancy and post-birth should be undertaken. We investigated the quantity and quality of hospital reviews.

DESIGN

Anonymised case notes review.

PARTICIPANTS

All 233 women in the UK and Ireland who died during or up to 6 weeks after pregnancy from any cause related to or aggravated by pregnancy or its management in 2012-2014.

MAIN OUTCOME MEASURES

The number of local reviews undertaken. Quality was assessed by the composition of the review panel, whether root causes were systematically assessed and actions detailed.

RESULTS

The care of 177/233 (76%) women who died was reviewed locally. The care of women who died in early pregnancy and after 28 days post-birth was less likely to be reviewed as was the care of women who died outside maternity services and who died from mental health-related causes. 140 local reviews were available for assessment. Multidisciplinary review was undertaken for 65% (91/140). External involvement in review occurred in 12% (17/140) and of the family in 14% (19/140). The root causes of deaths were systematically assessed according to national guidance in 13% (18/140). In 88% (123/140) actions were recommended to improve future care, with a timeline and person responsible identified in 55% (77/140). Audit to monitor implementation of changes was recommended in 14% (19/140).

CONCLUSIONS

This systematic assessment of local reviews of care demonstrated that not all hospitals undertake a review of care of women who die during or after pregnancy and in the majority quality is lacking. The care of these women should be reviewed using a standardised robust process including root cause analysis to maximise learning and undertaken by an appropriate multidisciplinary team who are given training, support and adequate time.

New challenges for verbal autopsy: Considering the ethical and social implications of verbal autopsy methods in routine health information systems

Verbal autopsy (VA) methods are designed to collect cause-of-death information from populations where many deaths occur outside of health facilities and where death certification is weak or absent. A VA consists of an interview with a relative or carer of a recently deceased individual in order to gather information on the signs and symptoms the decedent presented with prior to death. These details are then used to determine and assign a likely cause-of-death. At a population level this information can be invaluable to help guide prioritisation and direct health policy and services. To date VAs have largely been restricted to research contexts but many countries are now venturing to incorporate VA methods into routine civil registration and vital statistics (CRVS) systems. Given the sensitive nature of death, however, there are a number of ethical, legal and social issues that should be considered when scaling-up VAs, particularly in the cross-cultural and socio-economically disadvantaged environments in which they are typically applied. Considering each step of the VA process this paper provides a narrative review of the social context of VA methods. Harnessing the experiences of applying and rolling out VAs as part of routine CRVS systems in a number of low and middle income countries, we identify potential issues that countries and implementing institutions need to consider when incorporating VAs into CRVS systems and point to areas that could benefit from further research and deliberation.