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Willcox ML, Okello IA, Maidwell-Smith A, Tura AK, van den Akker T, Knight M, Dumont A, Muller I. Determinants of behaviors influencing implementation of maternal and perinatal death surveillance and response in low- and middle-income countries: A systematic review of qualitative studies. Int J Gynaecol Obstet 2024; 165:586-600. [PMID: 37727893 DOI: 10.1002/ijgo.15132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Revised: 08/29/2023] [Accepted: 08/29/2023] [Indexed: 09/21/2023]
Abstract
BACKGROUND Maternal and Perinatal Death Surveillance and Review (MPDSR) can reduce mortality but its implementation is often suboptimal, especially in low- and middle-income countries (LMICs). OBJECTIVES To understand the determinants of behaviors influencing implementation of MPDSR in LMICs (through a systematic review of qualitative studies), in order to plan an intervention to improve its implementation. SEARCH STRATEGY Terms for maternal or perinatal death reviews and qualitative studies. SELECTION CRITERIA Qualitative studies regarding implementation of MPDSR in LMICs. DATA COLLECTION AND ANALYSIS We coded the included studies using the Theoretical Domains Framework and COM-B model of behavior change (Capability, Opportunity, Motivation). We developed guiding principles for interventions to improve implementation of MPDSR. MAIN RESULTS Fifty-nine studies met our inclusion criteria. Capabilities required to conduct MPDSR (knowledge and technical/leadership skills) increase cumulatively from community to health facility and leadership levels. Physical and social opportunities depend on adequate data, human and financial resources, and a blame-free environment. All stakeholders were motivated to avoid negative consequences (blame, litigation, disciplinary action). CONCLUSIONS Implementation of MPDSR could be improved by (1) introducing structural changes to reduce negative consequences, (2) strengthening data collection tools and information systems, (3) mobilizing adequate resources, and (4) building capabilities of all stakeholders.
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Affiliation(s)
- Merlin L Willcox
- Primary Care Research Centre, School of Primary Care, Population Sciences and Medical Education, University of Southampton, Aldermoor Health Centre, Southampton, UK
| | - Immaculate A Okello
- Primary Care Research Centre, School of Primary Care, Population Sciences and Medical Education, University of Southampton, Aldermoor Health Centre, Southampton, UK
| | - Alice Maidwell-Smith
- Primary Care Research Centre, School of Primary Care, Population Sciences and Medical Education, University of Southampton, Aldermoor Health Centre, Southampton, UK
| | - Abera Kenay Tura
- School of Nursing and Midwifery, College of Health and Medical Sciences, Haramaya University, Harar, Ethiopia
| | - Thomas van den Akker
- Department of Obstetrics and Gynecology, Leiden University Medical Center, Leiden, the Netherlands
- Athena Institute, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Marian Knight
- National Perinatal Epidemiology Unit, University of Oxford, Oxford, UK
| | | | - Ingrid Muller
- Primary Care Research Centre, School of Primary Care, Population Sciences and Medical Education, University of Southampton, Aldermoor Health Centre, Southampton, UK
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Willcox ML, Okello IA, Maidwell-Smith A, Tura AK, van den Akker T, Knight M. Maternal and perinatal death surveillance and response: a systematic review of qualitative studies. Bull World Health Organ 2023; 101:62-75G. [PMID: 36593778 PMCID: PMC9795385 DOI: 10.2471/blt.22.288703] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Revised: 10/02/2022] [Accepted: 10/03/2022] [Indexed: 01/04/2023] Open
Abstract
Objective To understand the experiences and perceptions of people implementing maternal and/or perinatal death surveillance and response in low- and middle-income countries, and the mechanisms by which this process can achieve its intended outcomes. Methods In June 2022, we systematically searched seven databases for qualitative studies of stakeholders implementing maternal and/or perinatal death surveillance and response in low- and middle-income countries. Two reviewers independently screened articles and assessed their quality. We used thematic synthesis to derive descriptive themes and a realist approach to understand the context-mechanism-outcome configurations. Findings Fifty-nine studies met the inclusion criteria. Good outcomes (improved quality of care or reduced mortality) were underpinned by a functional action cycle. Mechanisms for effective death surveillance and response included learning, vigilance and implementation of recommendations which motivated further engagement. The key context to enable effective death surveillance and response was a blame-free learning environment with good leadership. Inadequate outcomes (lack of improvement in care and mortality and discontinuation of death surveillance and response) resulted from a vicious cycle of under-reporting, inaccurate data, and inadequate review and recommendations, which led to demotivation and disengagement. Some harmful outcomes were reported, such as inappropriate referrals and worsened staff shortages, which resulted from a fear of negative consequences, including blame, disciplinary action or litigation. Conclusion Conditions needed for effective maternal and/or perinatal death surveillance and response include: separation of the process from litigation and disciplinary procedures; comprehensive guidelines and training; adequate resources to implement recommendations; and supportive supervision to enable safe learning.
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Affiliation(s)
- Merlin L Willcox
- School of Primary Care, Population Sciences and Medical Education, University of Southampton, Aldermoor Health Centre, Aldermoor Close, SouthamptonSO16 5SE, England
| | - Immaculate A Okello
- School of Primary Care, Population Sciences and Medical Education, University of Southampton, Aldermoor Health Centre, Aldermoor Close, SouthamptonSO16 5SE, England
| | - Alice Maidwell-Smith
- School of Primary Care, Population Sciences and Medical Education, University of Southampton, Aldermoor Health Centre, Aldermoor Close, SouthamptonSO16 5SE, England
| | - Abera K Tura
- School of Nursing and Midwifery, Haramaya University, Harar, Ethiopia
| | - Thomas van den Akker
- Department of Obstetrics and Gynaecology, Leiden University Medical Centre, Leiden, Netherlands
| | - Marian Knight
- National Perinatal Epidemiology Unit, University of Oxford, Oxford, England
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Abouchadi S, Godin I, Zhang WH, De Brouwere V. Eight-year experience of maternal death surveillance in Morocco: qualitative study of stakeholders’ views at a subnational level. BMC Public Health 2022; 22:2111. [DOI: 10.1186/s12889-022-14556-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2022] [Accepted: 11/05/2022] [Indexed: 11/19/2022] Open
Abstract
Abstract
Background
Since 2009, Morocco has been implementing the Maternal Death Surveillance System (MDSS). The results obtained indicate significant regional variations in terms of implementation stage, completeness of maternal death reporting, and information use for action. The objective of this research is to better understand the contextual factors involved in the implementation process and use of MDSS, with a focus on the facilitators and barriers, as experienced by stakeholders in health regions.
Methods
Evaluation research was conducted in 2017 based on a descriptive qualitative study using semi-structured in-depth interviews, in four out of the twelve health regions of Morocco. A total of thirty-one in-depth interviews were held with members of regional committees of maternal death reviews (RC-MDR) and other key informant staff. Interviews focused on participants’ views and their experiences with the MDSS since the introduction in 2009. We conducted thematic analysis relied on inductive and deductive approaches. Applying the Consolidated Framework for Implementation Research guided data analysis and reporting findings.
Findings
Engaging leadership at all health system levels, regular training of district and regional MDSS coordinators and supportive supervision at a national level were the most important MDSS implementation facilitators. Reported barriers were essentially related to the review system: Irregular review meetings, blame culture, high turn-over of RC-MDR members, lack of analytical capacity to inform the review process and formulate recommendations, finally limited accountability for recommendation follow-up. While financial incentives boosted MDSS adoption, they were nonetheless a substantial barrier to its sustainability.
Conclusions
The MDSS is a complex process that requires taking numerous steps, including the commitment of multiple stakeholders with varying roles as well as information sharing across health system levels. Contextual factors that influence MDSS implementation at the sub-national level are to be considered. Horizontal and vertical communication about MDSS goals and feedback is crucial to strengthen stakeholders’ commitment, hence improving quality and use of MDSS. Furthermore, health regions should place emphasis on making high-quality recommendations in partnerships between the regional management teams, RC-MDR members and external stakeholders.
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Cetin K, Worku D, Demtse A, Melberg A, Miljeteig I. "Death audit is a fight" - provider perspectives on the ethics of the Maternal and Perinatal Death Surveillance and Response (MPDSR) system in Ethiopia. BMC Health Serv Res 2022; 22:1214. [PMID: 36175949 PMCID: PMC9524002 DOI: 10.1186/s12913-022-08568-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Accepted: 09/12/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Maternal and neonatal health are regarded as important indicators of health in most countries. Death auditing through, for example, the Maternal and Perinatal Death Surveillance and Response (MPDSR) is viewed as key to preventing maternal and newborn mortality. However, little is known about the implications of implementing perinatal auditing for healthcare professionals in low-income contexts. This study aimed to explore the ethical and practical consequences clinicians experience concerning MPDSR reporting practices in Ethiopia. METHODS: Qualitative semi-structured in-depth individual interviews were conducted with 16 healthcare workers across professions at selected facilities in Ethiopia. The interview questions were related to clinicians' experiences with, and perceptions of, death auditing. Their strategies for coping with newborn losses and the related reporting practices were also explored. The material was analyzed following systematic text condensation, and the NVivo11 software was used for organizing and coding the data material. RESULTS Participants experienced fear of punishment and blame in relation to the perinatal death auditing process. They found that auditing did not contribute to reducing perinatal deaths and that their motivation to stick to the obligation was negatively affected by this. Performing audits without available resources to provide optimal care or support in the current system was perceived as unfair. Some hid information or misreported information in order to avoid accusations of misconduct when they felt they were not to blame for the baby's death. Coping strategies such as engaging in exceedingly larger work efforts, overtreating patients, or avoiding complicated medical cases were described. CONCLUSIONS Experiencing perinatal death and death reporting constitutes a double burden for the involved healthcare workers. The preventability of perinatal death is perceived as context-dependent, and both clinicians and the healthcare system would benefit from a safe and blame-free reporting environment. To support these healthcare workers in a challenging clinical reality, guidelines and action plans that are specific to the Ethiopian context are needed.
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Affiliation(s)
- Kaya Cetin
- Bergen Center for Ethics and Priority Setting, University of Bergen, Bergen, Norway.
| | - Dawit Worku
- Addis Center for Ethics and Priority Setting, Addis Ababa University, Addis Ababa, Ethiopia
| | - Asrat Demtse
- Addis Center for Ethics and Priority Setting, Addis Ababa University, Addis Ababa, Ethiopia
| | - Andrea Melberg
- Bergen Center for Ethics and Priority Setting, University of Bergen, Bergen, Norway
| | - Ingrid Miljeteig
- Bergen Center for Ethics and Priority Setting, University of Bergen, Bergen, Norway
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Kinney M, Bergh AM, Rhoda N, Pattinson R, George A. Exploring the sustainability of perinatal audit in four district hospitals in the Western Cape, South Africa: a multiple case study approach. BMJ Glob Health 2022; 7:bmjgh-2022-009242. [PMID: 35738843 PMCID: PMC9226866 DOI: 10.1136/bmjgh-2022-009242] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Accepted: 05/29/2022] [Indexed: 11/24/2022] Open
Abstract
Introduction Maternal and perinatal death surveillance and response (MPDSR) is an intervention process that uses a continuous cycle of identification, notification and review of deaths to determine avoidable causes followed by actions to improve health services and prevent future deaths. This study set out to understand how and why a perinatal audit programme, a form of MPDSR, has sustained practice in South Africa from the perspectives of those engaged in implementation. Methods A multiple case study design was carried out in four rural subdistricts of the Western Cape with over 10 years of implementing the programme. Data were collected from October 2019 to March 2020 through non-participant observation of seven meetings and key informant interviews with 41 purposively selected health providers and managers. Thematic analysis was conducted inductively and deductively adapting the extended normalisation process theory to examine the capability, contribution, potential and capacity of the users to implement MPDSR. Results The perinatal audit programme has sustained practice due to integration of activities into routine tasks (capability), clear value-add (contribution), individual and collective commitment (potential), and an enabling environment to implement (capacity). The complex interplay of actors, their relationships and context revealed the underlying individual-level and organisational-level factors that support sustainability, such as trust, credibility, facilitation and hierarchies. Local adaption and the broad social and structural resources were required for sustainability. Conclusion This study applied theory to explore factors that promote sustained practice of perinatal audit from the perspectives of the users. Efforts to promote and sustain MPDSR will benefit from overall good health governance, specific skill development, embedded activities, and valuing social processes related to implementation. More research using health policy and system approaches, including use of implementation theory, will further advance our understanding on how to support sustained MPDSR practice in other settings.
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Affiliation(s)
- Mary Kinney
- School of Public Health, Faculty of Community and Health Sciences, University of the Western Cape, Bellville, South Africa
| | - Anne-Marie Bergh
- Maternal and Infant Health Care Strategies Research Unit, Medical Research Council of South Africa, Faculty of Health Sciences, University of Pretoria, Pretoria, South Africa
| | - Natasha Rhoda
- Department of Neonatology, Mowbray Maternity Hospital, Cape Town, South Africa.,Department of Paediatrics, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Robert Pattinson
- Maternal and Infant Health Care Strategies Research Unit, Medical Research Council of South Africa, Faculty of Health Sciences, University of Pretoria, Pretoria, South Africa
| | - Asha George
- School of Public Health, Faculty of Community and Health Sciences, University of the Western Cape, Bellville, South Africa
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