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Gausman J, Kenu E, Adanu R, Bandoh DAB, Berrueta M, Chakraborty S, Khan N, Langer A, Nigri C, Odikro MA, Pingray V, Ramesh S, Saggurti N, Vázquez P, Williams CR, Jolivet RR. Validating the indicator "maternal death review coverage" to improve maternal mortality data: A retrospective analysis of district, facility, and individual medical record data. PLoS One 2024; 19:e0303028. [PMID: 38768186 PMCID: PMC11104582 DOI: 10.1371/journal.pone.0303028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Accepted: 04/17/2024] [Indexed: 05/22/2024] Open
Abstract
BACKGROUND Understanding causes and contributors to maternal mortality is critical from a quality improvement perspective to inform decision making and monitor progress toward ending preventable maternal mortality. The indicator "maternal death review coverage" is defined as the percentage of maternal deaths occurring in a facility that are audited. Both the numerator and denominator of this indicator are subject to misclassification errors, underreporting, and bias. This study assessed the validity of the indicator by examining both its numerator-the number and quality of death reviews-and denominator-the number of facility-based maternal deaths and comparing estimates of the indicator obtained from facility- versus district-level data. METHODS AND FINDINGS We collected data on the number of maternal deaths and content of death reviews from all health facilities serving as birthing sites in 12 districts in three countries: Argentina, Ghana, and India. Additional data were extracted from health management information systems on the number and dates of maternal deaths and maternal death reviews reported from health facilities to the district-level. We tabulated the percentage of facility deaths with evidence of a review, the percentage of reviews that met the World Health Organization defined standard for maternal and perinatal death surveillance and response. Results were stratified by sociodemographic characteristics of women and facility location and type. We compared these estimates to that obtained using district-level data. and looked at evidence of the review at the district/provincial level. Study teams reviewed facility records at 34 facilities in Argentina, 51 facilities in Ghana, and 282 facilities in India. In total, we found 17 deaths in Argentina, 14 deaths in Ghana, and 58 deaths in India evidenced at facilities. Overall, >80% of deaths had evidence of a review at facilities. In India, a much lower percentage of deaths occurring at secondary-level facilities (61.1%) had evidence of a review compared to deaths in tertiary-level facilities (92.1%). In all three countries, only about half of deaths in each country had complete reviews: 58.8% (n = 10) in Argentina, 57.2% (n = 8) in Ghana, and 41.1% (n = 24) in India. Dramatic reductions in indicator value were seen in several subnational geographic areas, including Gonda and Meerut in India and Sunyani in Ghana. For example, in Gonda only three of the 18 reviews conducted at facilities met the definitional standard (16.7%), which caused the value of the indicator to decrease from 81.8% to 13.6%. Stratification by women's sociodemographic factors suggested systematic differences in completeness of reviews by women's age, place of residence, and timing of death. CONCLUSIONS Our study assessed the validity of an important indicator for ending preventable deaths: the coverage of reviews of maternal deaths occurring in facilities in three study settings. We found discrepancies in deaths recorded at facilities and those reported to districts from facilities. Further, few maternal death reviews met global quality standards for completeness. The value of the calculated indicator masked inaccuracies in counts of both deaths and reviews and gave no indication of completeness, thus undermining the ultimate utility of the measure in achieving an accurate measure of coverage.
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Affiliation(s)
- Jewel Gausman
- Women and Health Initiative, Department of Global Health and Population, Harvard University T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
- Maternal and Child Nursing Department, School of Nursing, University of Jordan, Amman, Jordan
| | - Ernest Kenu
- Department of Epidemiology and Disease Control, University of Ghana School of Public Health, Accra, Ghana
| | - Richard Adanu
- Department of Population, Family, and Reproductive Health, University of Ghana School of Public Health, Accra, Ghana
| | - Delia A. B. Bandoh
- Department of Epidemiology and Disease Control, University of Ghana School of Public Health, Accra, Ghana
| | - Mabel Berrueta
- Institute for Clinical Effectiveness and Health Policy (Instituto de Efectividad Clínica y Sanitaria (IECS)), Buenos Aires, Argentina
| | | | | | - Ana Langer
- Women and Health Initiative, Department of Global Health and Population, Harvard University T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
| | - Carolina Nigri
- Institute for Clinical Effectiveness and Health Policy (Instituto de Efectividad Clínica y Sanitaria (IECS)), Buenos Aires, Argentina
| | - Magdalene A. Odikro
- Department of Epidemiology and Disease Control, University of Ghana School of Public Health, Accra, Ghana
| | - Verónica Pingray
- Institute for Clinical Effectiveness and Health Policy (Instituto de Efectividad Clínica y Sanitaria (IECS)), Buenos Aires, Argentina
| | | | | | - Paula Vázquez
- Institute for Clinical Effectiveness and Health Policy (Instituto de Efectividad Clínica y Sanitaria (IECS)), Buenos Aires, Argentina
- Department of Health Science, Kinesiology, and Rehabilitation, Universidad Nacional de La Matanza, Buenos Aires, Argentina
| | - Caitlin R. Williams
- Institute for Clinical Effectiveness and Health Policy (Instituto de Efectividad Clínica y Sanitaria (IECS)), Buenos Aires, Argentina
- Department of Maternal & and Child Health, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | - R. Rima Jolivet
- Women and Health Initiative, Department of Global Health and Population, Harvard University T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
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Kashililika C, Millanzi WC, Moshi FV. Predictors of health workers' knowledge of maternal and perinatal deaths surveillance and response system in Morogoro region, Tanzania: An analytical cross-sectional study. Medicine (Baltimore) 2024; 103:e37764. [PMID: 38608061 PMCID: PMC11018231 DOI: 10.1097/md.0000000000037764] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Accepted: 03/08/2024] [Indexed: 04/14/2024] Open
Abstract
This study aimed at assessing the predictors of knowledge about the Maternal and Perinatal Deaths Surveillance and Response (MPDSR) system among health workers in the Morogoro region. It was an analytical cross-sectional study, conducted from April 27 to May 29, 2020. A multistage sampling technique was used to recruit 360 health workers. A semi-structured questionnaire was used to collect the data. Statistical Package for Social Science (SPSS v.20) software was used for data entry and analysis. Bivariate and multivariate logistic regression analyses were used to assess factors associated with knowledge of MPDSR. A total of 105 (29.2%) health workers in the Morogoro region had adequate knowledge of the MPDSR system. After controlling for confounders, predictors of knowledge on the MPDSR system were the level of health facility a health worker was working (n [hospital [adjusted odds ratio [AOR] = 2.668 at 95% confidence intervals [CI] = 1.497-4.753, P = .001]), level of education of a health worker (diploma [AOR = 0.146 at 95% CI = 0.038-0.561, P = .005]), and status of training on MPDSR (trained [AOR = 7.253 at 95% CI = 3.862-13.621, P ≤ .001]). The proportion of health workers with adequate knowledge about the MPDSR system in the Morogoro region is unacceptably low. Factors associated with adequate knowledge were those working in hospitals with higher levels of professional training and those who had ever had training in MPDSR. A cost-effective strategy to improve the level of knowledge regarding MPDSR in this region is highly recommended.
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Affiliation(s)
- Christina Kashililika
- Department of Clinical Nursing, School of Nursing and Public Health of the University of Dodoma, Dodoma, Tanzania
| | - Walter C. Millanzi
- Department of Nursing Management and Education, School of Nursing and Public Health of the University of Dodoma, Dodoma, Tanzania
| | - Fabiola Vincent Moshi
- Department of Clinical Nursing, School of Nursing and Public Health of the University of Dodoma, Dodoma, Tanzania
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Rumbeli NM, August F, Silvestri V, Sirili N. Factors influencing maternal death surveillance and review implementation in Dodoma City, Tanzania. A qualitative case study. Learn Health Syst 2024; 8:e10390. [PMID: 38633026 PMCID: PMC11019372 DOI: 10.1002/lrh2.10390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Revised: 07/13/2023] [Accepted: 08/13/2023] [Indexed: 04/19/2024] Open
Abstract
Background With 295 000 maternal deaths in 2017, 94% in low- and middle-income countries, maternal death is a matter of global public health concern. To address it, Maternal Death Surveillance and Response (MDSR) strategy was introduced in 2013 by the World Health Organization. With a reported maternal mortality ratio of 556:100000 per live births, Tanzania adopted the strategy in 2015. Studies are needed to understand factors influencing the implementation of MDSR in this specific setting. Aims and Objectives The study aimed to assess the processes influencing MDSR implementation in Dodoma city council. Methods A qualitative case study was conceptualized according to the Consolidated Framework for Implementation Research, focusing on implementation process domain. Members of MDSR committees were enrolled by purposeful sampling in the five health centres in Dodoma where the strategy was fully implemented and functional. In-depth interviews were conducted with key informants concerning the implementation processes influencing MDSR. Saturation was reached with the 15th respondent. Qualitative inductive content analysis was used to analyse data. Results The inclusiveness in participatory planning process, stakeholders' readiness and accountability and collective learning were acknowledged as factors positively influencing the implementation of MDSR strategy by respondents. The interaction and alignment of influential factors were essential for successful implementation. Conclusions MDSR implementation is positively influenced by factors that interact and converge in the building of a learning health system, to increase knowledge through practice and improve practice through knowledge. Further studies are needed to analyse the influence of additional factors at different levels of implementation to fully understand and empower the MDSR implementation network, and to better target the goal of closing the knowledge to practice loop.
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Affiliation(s)
- Nelson M. Rumbeli
- Department of Epidemiology and Biostatistics MuhimbiliUniversity of Health and Allied SciencesDar es SalaamTanzania
| | - Furaha August
- Department of Obstetrics and GynecologyMuhimbili University of Health and Allied SciencesDar es SalaamTanzania
| | - Valeria Silvestri
- Department of Parasitology and Medical EntomologyMuhimbili University of Health and Applied Science MUHASDar es SalaamTanzania
| | - Nathanael Sirili
- Department of Development Studies, School of Public Health and Social SciencesMuhimbili University of Health and Allied SciencesDar es SalaamTanzania
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Whiting-Collins L, Serbanescu F, Moller AB, Binzen S, Monet JP, Cresswell JA, Brun M. Maternal death surveillance and response system reports from 32 low-middle income countries, 2011-2020: What can we learn from the reports? PLOS GLOBAL PUBLIC HEALTH 2024; 4:e0002153. [PMID: 38442110 PMCID: PMC10914274 DOI: 10.1371/journal.pgph.0002153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Accepted: 12/20/2023] [Indexed: 03/07/2024]
Abstract
Maternal Death Surveillance and Response (MDSR) systems generate information that may aid efforts to end preventable maternal deaths. Many countries report MDSR data, but comparability over time and across settings has not been studied. We reviewed MDSR reports from low-and-middle income countries (LMICs) to examine core content and identify how surveillance data and data dissemination could be improved to guide recommendations and actions. We conducted deductive content analysis of 56 MDSR reports from 32 LMICs. A codebook was developed assessing how reports captured: 1) MDSR system implementation, 2) monitoring of maternal death notifications and reviews, and 3) response formulation and implementation. Reports published before 2014 focused on maternal death reviews only. In September 2013, the World Health Organization and partners published the global MDSR guidance, which advised that country reports should also include identification, notification and response activities. Of the 56 reports, 33 (59%) described their data as incomplete, meaning that not all maternal deaths were captured. While 45 (80%) reports presented the total number of maternal deaths that had been notified (officially reported), only 16 (29%) calculated notification rates. Deaths were reported at both community and facility levels in 31 (55%) reports, but 25 (45%) reported facility deaths only. The number of maternal deaths reviewed was reported in 33 (59%) reports, and 17 (30%) calculated review completion rates. While 48 (86%) reports provided recommendations for improving MDSR, evidence of actions based on prior recommendations was absent from 40 (71%) of subsequent reports. MDSR reports currently vary in content and in how response efforts are documented. Comprehensive reports could improve accountability and effectiveness of the system by providing feedback to MDSR stakeholders and information for action. A standard reporting template may improve the quality and comparability of MDSR data and their use for preventing future maternal deaths.
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Affiliation(s)
- Lillian Whiting-Collins
- Division of Reproductive Health, Centers for Disease Control and Prevention, Atlanta Georgia, United States of America
| | - Florina Serbanescu
- Division of Reproductive Health, Centers for Disease Control and Prevention, Atlanta Georgia, United States of America
| | - Ann-Beth Moller
- Department of Sexual and Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | - Susanna Binzen
- Division of Reproductive Health, Centers for Disease Control and Prevention, Atlanta Georgia, United States of America
| | - Jean-Pierre Monet
- Technical Division, United Nations Population Fund, New York, New York, United States of America
| | - Jenny A. Cresswell
- Department of Sexual and Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | - Michel Brun
- Technical Division, United Nations Population Fund, New York, New York, United States of America
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Shafiq Y, Caviglia M, Juheh Bah Z, Tognon F, Orsi M, K Kamara A, Claudia C, Moses F, Manenti F, Barone-Adesi F, Sessay T. Causes of maternal deaths in Sierra Leone from 2016 to 2019: analysis of districts' maternal death surveillance and response data. BMJ Open 2024; 14:e076256. [PMID: 38216175 PMCID: PMC10806740 DOI: 10.1136/bmjopen-2023-076256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Accepted: 12/18/2023] [Indexed: 01/14/2024] Open
Abstract
INTRODUCTION Sierra Leone is among the top countries with the highest maternal mortality rates. Although progress has been made in reducing maternal mortality, challenges remain, including limited access to skilled care and regional disparities in accessing quality care. This paper presents the first comprehensive analysis of the burden of different causes of maternal deaths reported in the Maternal Death Surveillance and Response (MDSR) system at the district level from 2016 to 2019. METHODS The MDSR data are accessed from the Ministry of Health and Sanitation, and the secondary data analysis was done to determine the causes of maternal death in Sierra Leone. The proportions of each leading cause of maternal deaths were estimated by districts. A subgroup analysis of the selected causes of death was also performed. RESULTS Overall, obstetric haemorrhage was the leading cause of maternal death (39.4%), followed by hypertensive disorders (15.8%) and pregnancy-related infections (10.1%). Within obstetric haemorrhage, postpartum haemorrhage was the leading cause in each district. The burden of death due to obstetric haemorrhage slightly increased over the study period, while hypertensive disorders showed a slightly decreasing trend. Disparities were found among districts for all causes of maternal death, but no clear geographical pattern emerged. Non-obstetric complications were reported in 11.5% of cases. CONCLUSION The MDSR database provides an opportunity for shared learning and can be used to improve the quality of maternal health services. To improve the accuracy and availability of data, under-reporting must be addressed, and frontline community staff must be trained to accurately capture and report death events.
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Affiliation(s)
- Yasir Shafiq
- Department of Translational Medicine and Center for Research and Training in Disaster Medicine, Humanitarian Aid and Global Health, Università degli Studi del Piemonte Orientale Amedeo Avogadro Scuola di Medicina, Novara, Piemonte, Italy
- Center of Excellence for Trauma and Emergencies, The Aga Khan University, Karachi, Pakistan
| | - Marta Caviglia
- Università degli Studi del Piemonte Orientale Amedeo Avogadro Scuola di Medicina, Novara, Italy
| | - Zainab Juheh Bah
- Government of Sierra Leone Ministry of Health and Sanitation, Freetown, Western Area, Sierra Leone
| | | | - Michele Orsi
- Doctors with Africa CUAMM, Padova, Veneto, Italy
| | - Abibatu K Kamara
- Government of Sierra Leone Ministry of Health and Sanitation, Freetown, Western Area, Sierra Leone
| | | | - Francis Moses
- Reproductive Health and Family Planning Programme, Government of Sierra Leone Ministry of Health and Sanitation, Freetown, Western Area, Sierra Leone
| | | | - Francesco Barone-Adesi
- CRIMEDIM - Research Center in Emergency and Disaster Medicine, Università degli Studi del Piemonte Orientale Amedeo Avogadro Scuola di Medicina, Novara, Piemonte, Italy
| | - Tom Sessay
- Bombali District Ebola Response - Surveillance Team, Sierra Leone Ministry of Health and Sanitation, Bombali District, Makeni, Bombali, Sierra Leone
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Heemelaar S, Callard B, Shikwambi H, Ellmies J, Kafitha W, Stekelenburg J, van den Akker T, Mackenzie S. Confidential Enquiry into Maternal Deaths in Namibia, 2018-2019: A Local Approach to Strengthen the Review Process and a Description of Review Findings and Recommendations. Matern Child Health J 2023; 27:2165-2174. [PMID: 37777707 PMCID: PMC10618300 DOI: 10.1007/s10995-023-03771-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/01/2023] [Indexed: 10/02/2023]
Abstract
OBJECTIVES First objective was to strengthen the national maternal death review, by addressing local challenges with each step of the review cycle. Second objective was to describe review findings and compare these with available findings of previous reviews. METHODS Confidential Enquiry into Maternal Deaths methodology was used to review maternal deaths. To improve reporting, the national committee focussed on addressing fear of blame among healthcare providers. Second focus was on dissemination of findings and acting on recommendations forthcoming the review. Reviewed were reported maternal deaths, that occurred between 1 April 2018 and 31 March 2019. RESULTS Seventy maternal deaths were reported; for 69 (98.6%) medical records were available, compared to 80/119 (67.2%) in 2012-2015. Reported maternal mortality ratio increased with 48% (92/100,000 live births compared to 62/100,000 in 2012-2015). Obstetric haemorrhage was leading cause of death in the past three reviews. The "no name, no blame" policy, aiming to identify health system failures, rather than mistakes of individuals, was repeatedly explained to healthcare providers during facility visits. Recommendations based on findings of the review, such as retaining experienced staff, continuous in-service training and guidance, were shared with decision makers at regional and national levels. Healthcare providers received training based on review findings, which resulted in improved management of similar cases. CONCLUSIONS FOR PRACTICE Enhanced implementation of Confidential Enquiry into Maternal Deaths was possible after addressing local challenges. Focussing on obtaining trust of healthcare providers and feeding back findings, resulted in better reporting and prevention of potential maternal deaths.
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Affiliation(s)
- Steffie Heemelaar
- National Maternal Death, Stillbirth and Neonatal Death Review Committee, Division of Quality Assurance, Ministry of Health and Social Services, Windhoek, Namibia.
- Department of Obstetrics and Gynaecology, Leiden University Medical Center, Leiden, The Netherlands.
| | - Beatrix Callard
- National Maternal Death, Stillbirth and Neonatal Death Review Committee, Division of Quality Assurance, Ministry of Health and Social Services, Windhoek, Namibia
| | - Hilma Shikwambi
- National Maternal Death, Stillbirth and Neonatal Death Review Committee, Division of Quality Assurance, Ministry of Health and Social Services, Windhoek, Namibia
- Department of Nursing and Midwifery, International University of Management, Windhoek, Namibia
| | - Jana Ellmies
- National Maternal Death, Stillbirth and Neonatal Death Review Committee, Division of Quality Assurance, Ministry of Health and Social Services, Windhoek, Namibia
- Independent Midwives Association of Namibia, Windhoek, Namibia
| | - Wilhelmina Kafitha
- Division of Quality Assurance, Ministry of Health and Social Services, Windhoek, Namibia
| | - Jelle Stekelenburg
- Department of Health Science, Global Health, University Medical Center Groningen, Groningen, The Netherlands
- Department of Obstetrics and Gynaecology, Medical Center Leeuwarden, Leeuwarden, The Netherlands
| | - Thomas van den Akker
- Department of Obstetrics and Gynaecology, Leiden University Medical Center, Leiden, The Netherlands
- Athena Institute, VU University, Amsterdam, The Netherlands
| | - Shonag Mackenzie
- National Maternal Death, Stillbirth and Neonatal Death Review Committee, Division of Quality Assurance, Ministry of Health and Social Services, Windhoek, Namibia
- Department of Obstetrics and Gynaecology, University of Namibia, Windhoek, Namibia
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Zhao Y, Mbuthia D, Gathara D, Nzinga J, Tweheyo R, English M. 'We were treated like we are nobody': a mixed-methods study of medical doctors' internship experiences in Kenya and Uganda. BMJ Glob Health 2023; 8:e013398. [PMID: 37940204 PMCID: PMC10632815 DOI: 10.1136/bmjgh-2023-013398] [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: 07/12/2023] [Accepted: 10/21/2023] [Indexed: 11/10/2023] Open
Abstract
OBJECTIVE Medical interns are an important workforce providing first-line healthcare services in hospitals. The internship year is important for doctors as they transition from theoretical learning with minimal hands-on work under supervision to clinical practice roles with considerable responsibility. However, this transition is considered stressful and commonly leads to burn-out due to challenging working conditions and an ongoing need for learning and assessment, which is worse in countries with resource constraints. In this study, we provide an overview of medical doctors' internship experiences in Kenya and Uganda. METHODS Using a convergent mixed-methods approach, we collected data from a survey of 854 medical interns and junior doctors and semistructured interviews with 54 junior doctors and 14 consultants. Data collection and analysis were guided by major themes identified from a previous global scoping review (well-being, educational environment and working environment and condition), using descriptive analysis and thematic analysis respectively for quantitative and qualitative data. FINDINGS Most medical interns are satisfied with their job but many reported suffering from stress, depression and burn-out, and working unreasonable hours due to staff shortages. They are also being affected by the challenging working environment characterised by a lack of adequate resources and a poor safety climate. Although the survey data suggested that most interns were satisfied with the supervision received, interviews revealed nuances where many interns faced challenging scenarios, for example, poor supervision, insufficient support due to consultants not being available or being 'treated like we are nobody'. CONCLUSION We highlight challenges experienced by Kenyan and Ugandan medical interns spanning from burn-out, stress, challenging working environment, inadequate support and poor quality of supervision. We recommend that regulators, educators and hospital administrators should improve the resource availability and capacity of internship hospitals, prioritise individual doctors' well-being and provide standardised supervision, support systems and conducive learning environments.
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Affiliation(s)
- Yingxi Zhao
- NDM Centre for Global Health Research, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | | | - David Gathara
- KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
- MARCH Centre, London School of Hygiene and Tropical Medicine, London, UK
| | | | - Raymond Tweheyo
- Department of Health Policy Planning and Management, Makerere University School of Public Health, Kampala, Uganda
- Centre for Health Systems Research and Development (CHSRD), The University of Free State, Bloemfontein, South Africa
| | - Mike English
- NDM Centre for Global Health Research, Nuffield Department of Medicine, University of Oxford, Oxford, UK
- KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
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Namagembe I, Beyeza-Kashesya J, Rujumba J, K.Kaye D, Mukuru M, Kiwanuka N, Moffett A, Nakimuli A, Byamugisha J. Barriers and facilitators to maternal death surveillance and response at a busy urban National Referral Hospital in Uganda. OPEN RESEARCH AFRICA 2023; 5:31. [PMID: 37346758 PMCID: PMC10280031 DOI: 10.12688/openresafrica.13438.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 03/21/2023] [Indexed: 06/23/2023]
Abstract
Background: Preventable maternal and newborn deaths remain a global concern, particularly in low- and- middle-income countries (LMICs) Timely maternal death surveillance and response (MDSR) is a recommended strategy to account for such deaths through identifying contextual factors that contributed to the deaths to inform recommendations to implement in order to reduce future deaths. Implementation of MDSR is still suboptimal due to barriers such as inadequate skills and leadership to support MDSR. With the leadership of WHO and UNFPA, there is momentum to roll out MDSR, however, the barriers and enablers for implementation have received limited attention. These have implications for successful implementation. The aim of this study was: To assess barriers and facilitators to implementation of MDSR at a busy urban National Referral Hospital as perceived by health workers, administrators, and other partners in Reproductive Health. Methods: Qualitative study using in-depth interviews (24), 4 focus-group discussions with health workers, 15 key-informant interviews with health sector managers and implementing partners in Reproductive-Health. We conducted thematic analysis drawing on the Theory of Planned Behaviour (TPB). Results: The major barriers to implementation of MDSR were: inadequate knowledge and skills; fear of blame / litigation; failure to implement recommendations; burn out because of workload and inadequate leadership- to support health workers. Major facilitators were involving all health workers in the MDSR process, eliminate blame, strengthen leadership, implement recommendations from MDSR and functionalize lower health facilities (especially Health Centre -IVs). Conclusions: The barriers of MDSR include knowledge and skills gaps, fear of blame and litigation, and other health system factors such as erratic emergency supplies, and leadership/governance challenges. Recommendation: Efforts to strengthen MDSR for impact should use health system responsiveness approach to address the barriers identified, constructive participation of health workers to harness the facilitators and addressing the required legal framework.
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Affiliation(s)
- Imelda Namagembe
- Department of Obstetrics and Gynaecology, School of Medicine, Makerere University College of Health Sciences, Uganda, P.O Box 7072, Kampala, Uganda, Makerere University and Mulago Specialized Women Neonatal Hospital, Kampala, Uganda, +256, Uganda, Makerere University and MSWNH, Kampala, Uganda, +256, Uganda
| | - Jolly Beyeza-Kashesya
- Department of Obstetrics and Gynaecology, School of Medicine, Makerere University College of Health Sciences, Uganda, P.O Box 7072, Kampala, Uganda, Makerere University and Mulago Specialized Women Neonatal Hospital, Kampala, Uganda, +256, Uganda, Makerere University /MSWNH, Kampala, Uganda, +256, Uganda
| | - Joseph Rujumba
- Department of Paediatrics and Child Health, School of Medicine, Makerere University College of Health Sciences, Uganda, P.O Box 7072, Kampala, Uganda, Makerere University, Kampala, Uganda, +256, Uganda
| | - Dan K.Kaye
- Department of Obstetrics and Gynaecology, School of Medicine, Makerere University College of Health Sciences, Uganda, P.O Box 7072, Kampala, Uganda, Makerere University, Kampala, Uganda, +256, Uganda
| | - Moses Mukuru
- Department of Health Policy Planning and Management, School of Public Health, Makerere University College of Health Sciences, Uganda, P.O Box 7072, Kampala, Uganda, MakCHS, Kampala, Uganda, +256, Uganda
| | - Noah Kiwanuka
- Department of Epidemiology and Biostatistics, School of Public Health, Makerere University College of Health Sciences, Uganda, P.O Box 7072, Kampala, Uganda, MakCHS, Kampala, Uganda, +256, Uganda
| | - Ashley Moffett
- Department of Pathology and Centre for Trophoblast Research, University of Cambridge, Cambridge, United Kingdom, University of Cambridge, Cambridge, United Kingdom, +44, UK
| | - Annettee Nakimuli
- Department of Obstetrics and Gynaecology, School of Medicine, Makerere University College of Health Sciences, Uganda, P.O Box 7072, Kampala, Uganda, MakCHS, Kampala, Uganda, +256, Uganda
| | - Josaphat Byamugisha
- Department of Obstetrics and Gynaecology, School of Medicine, Makerere University College of Health Sciences, Uganda, P.O Box 7072, Kampala, Uganda, Mak- CHS, Kampala, Uganda, +256, Uganda
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Creanga AA, Dohlsten MA, Stierman EK, Moran AC, Mary M, Katwan E, Maliqi B. Maternal health policy environment and the relationship with service utilization in low- and middle-income countries. J Glob Health 2023; 13:04025. [PMID: 36892948 PMCID: PMC9997690 DOI: 10.7189/jogh.13.04025] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/10/2023] Open
Abstract
Background The extent to which a favorable policy environment influences health care utilization and outcomes for pregnant and postpartum women is largely unknown. In this study, we aimed to describe the maternal health policy environment and examines its relationship with maternal health service utilization in low- and middle-income countries (LMICs). Methods We used data from World Health Organization's 2018-2019 sexual, reproductive, maternal, newborn, child, and adolescent health (SRMNCAH) policy survey linked with key contextual variables from global databases, as well as UNICEF data on antenatal care (ANC), institutional delivery, and postnatal care (PNC) utilization in 113 LIMCs. We grouped maternal health policy indicators into four categories - national supportive structures and standards, service access, clinical guidelines, and reporting and review systems. For each category and overall, we calculated summative scores accounting for available policy indicators in each country. We explored variations of policy indicators by World Bank income group using χ2 tests and fitted logistic regression models for ≥85% coverage for each of four or more antenatal care visits (ANC4+), institutional delivery, PNC for the mothers, and for all ANC4+, institutional delivery, and PNC for mothers, adjusting for policy scores and contextual variables. Results The average scores for the four policy categories were as follows: 3 for national supportive structures and standards (score range = 0-4), 5.5 for service access (score range = 0-7), 6. for clinical guidelines (score range = 0-10), and 5.7 for reporting and review systems (score range = 0-7), for an average total policy score of 21.1 (score range = 0-28) across LMICs. After adjusting for country context variables, for each unit increase in the maternal health policy score, the odds of ANC4+>85% increased by 37% (95% confidence interval (CI) = 1.13-1.64) and the odds of all ANC4+, institutional deliveries and PNC>85% by 31% (95% CI = 1.07-1.60). Conclusions Despite the availability of supportive structures and free maternity service access policies, there is a dire need for stronger policy support for clinical guidelines and practice regulations, as well as national reporting and review systems for maternal health. A more favorable policy environment for maternal health can improve adoption of evidence-based interventions and increase utilization of maternal health services in LMICs.
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Affiliation(s)
- Andreea A Creanga
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA.,International Center for Maternal and Newborn Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA.,Department of Gynecology and Obstetrics, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Martin Aj Dohlsten
- Department of Maternal, Newborn, Child, Adolescent Health and Ageing, World Health Organization, Geneva, Switzerland
| | - Elizabeth K Stierman
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA.,International Center for Maternal and Newborn Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Allisyn C Moran
- Department of Maternal, Newborn, Child, Adolescent Health and Ageing, World Health Organization, Geneva, Switzerland
| | - Meighan Mary
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA.,International Center for Maternal and Newborn Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Elizabeth Katwan
- Department of Maternal, Newborn, Child, Adolescent Health and Ageing, World Health Organization, Geneva, Switzerland
| | - Blerta Maliqi
- Department of Maternal, Newborn, Child, Adolescent Health and Ageing, World Health Organization, Geneva, Switzerland
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10
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Chirwa MD, Nyasulu J, Modiba L, Limando MG. Challenges faced by midwives in the implementation of facility-based maternal death reviews in Malawi. BMC Pregnancy Childbirth 2023; 23:282. [PMID: 37095456 PMCID: PMC10124038 DOI: 10.1186/s12884-023-05536-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Accepted: 10/14/2022] [Indexed: 04/26/2023] Open
Abstract
BACKGROUND Maternal death reviews provide an in-depth understanding of the causes of maternal deaths. Midwives are well positioned to contribute to these reviews. Despite midwives' participation as members of the facility-based maternal death review team, maternal mortality continues to occur, therefore, this study aimed to explore the challenges faced by midwives as they participate in maternal death reviews in the context of the healthcare system in Malawi. METHODS This was a qualitative exploratory study design. Focus group discussions and individual face-to-face interviews were used to collect data in the study. A total of 40 midwives, who met the inclusion criteria, participated in the study. Data was analyzed manually using a thematic content procedure. RESULTS Challenges identified were: knowledge and skill gaps; lack of leadership and accountability; lack of institutional political will and inconsistency in conducting FBMDR, impeding midwives' effective contribution to the implementation of maternal death review. The possible solutions and recommendations that emerged were need-based knowledge and skills updates, supportive leadership, effective and efficient interdisciplinary work ethics, and sustained availability of material and human resources. CONCLUSION Midwives have the highest potential to contribute to the reduction of maternal deaths. Practice development strategies are required to improve their practice in all the areas they are challenged with.
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Affiliation(s)
- Mercy Dokiso Chirwa
- Department of Health Studies, University of South Africa, Preller Street, Po Box 392, Pretoria, 0003, South Africa.
| | - Juliet Nyasulu
- Division of Health Systems and Public Health, Department of Global Health, Stellenbosch. University, Cape Town, South Africa
| | - Lebitsi Modiba
- Department of Health Studies, University of South Africa, Preller Street, Po Box 392, Pretoria, 0003, South Africa
| | - Makombo Ganga- Limando
- Department of Health Studies, University of South Africa, Preller Street, Po Box 392, Pretoria, 0003, South Africa
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11
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Serbanescu F, Monet JP, Whiting-Collins L, Moran AC, Hsia J, Brun M. Maternal death surveillance efforts: notification and review coverage rates in 30 low-income and middle-income countries, 2015-2019. BMJ Open 2023; 13:e066990. [PMID: 36806138 PMCID: PMC9944275 DOI: 10.1136/bmjopen-2022-066990] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/22/2023] Open
Abstract
OBJECTIVE Performance of maternal death surveillance and response (MDSR) relies on the system's ability to identify and notify all maternal deaths and its ability to review all maternal deaths by a committee. Unified definitions for indicators to assess these functions are lacking. We aim to estimate notification and review coverage rates in 30 countries between 2015 and 2019 using standardised definitions. DESIGN Repeat cross-sectional surveys provided the numerators for the coverage indicators; United Nations (UN)-modelled expected country maternal deaths provided the denominators. SETTING 30 low-income and middle-income countries responding to the Maternal Health Thematic Fund annual surveys conducted by the UN Population Fund between 2015 and 2019. OUTCOME MEASURES Notification coverage rate ([Formula: see text]) was calculated as the proportion of expected maternal deaths that were notified at the national level annually; review coverage rate ([Formula: see text]) was calculated as the proportion of expected maternal deaths that were reviewed annually. RESULTS The average annual [Formula: see text] for all countries increased from 17% in 2015 to 28% in 2019; the average annual [Formula: see text] increased from 8% to 13%. Between 2015 and 2019, 22 countries (73%) reported increases in the [Formula: see text]-with an average increase of 20 (SD 18) percentage points-and 24 countries (80%) reported increases in [Formula: see text] by 7 (SD 11) percentage points. Low values of [Formula: see text] contrasts with country-published review rates, ranging from 46% to 51%. CONCLUSION MDSR systems that count and review all maternal deaths can deliver real-time information that could prompt immediate actions and may improve maternal health. Consistent and systematic documentation of MDSR efforts may improve national and global monitoring. Assessing the notification and review functions using coverage indicators is feasible, not affected by fluctuations in data completeness and reporting, and can objectively capture progress.
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Affiliation(s)
- Florina Serbanescu
- Division of Reproductive Health, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Jean-Pierre Monet
- Technical Division, United Nations Population Fund, New York, New York, USA
| | - Lillian Whiting-Collins
- Division of Reproductive Health, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - A C Moran
- Department of Maternal, Newborn, Child and Adolescent Health, World Health Organization, Geneva, Switzerland
| | - Jason Hsia
- Division of Population Health, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Michel Brun
- Technical Division, United Nations Population Fund, New York, New York, USA
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12
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van Boekholt TA, Moturi E, Hölscher H, Schulte-Hillen C, Tappis H, Burton A. Review of maternal death audits in refugee camps in UNHCR East and Horn of Africa and Great Lakes Region, 2017-2019. Int J Gynaecol Obstet 2023; 160:483-491. [PMID: 36217727 PMCID: PMC10092615 DOI: 10.1002/ijgo.14504] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2022] [Revised: 09/25/2022] [Accepted: 10/02/2022] [Indexed: 01/20/2023]
Abstract
OBJECTIVES To review the quality of maternal death audits and identify factors contributing to refugee maternal deaths in the East and Horn of Africa. METHODS Maternal death audits submitted to The UN Refugee Agency (UNHCR) from 2017 to 2019 in 43 refugee camps in eight countries were analyzed for completeness, obstetric history, cause of death, and contributing factors. RESULTS A total of 191 refugee maternal death audits were retrieved. The mean age of the deceased was 28 years (range, 15-45 years), and 13% were adolescents and 17% were of advanced maternal age. Most patients (55%) were grand multigravida (≥5 pregnancies). The majority (86%) attended antenatal care visits, with 51% attending four or more visits. Among women who delivered (n = 140), 91% were facility-based deliveries. Most (68%) deaths occurred postpartum. Obstetric hemorrhage (49%) was the leading direct cause of death (with 77 cases of postpartum hemorrhage), followed by hypertensive disorder (19%) and infection (15%). Delays in care were identified in 185 (97%) cases. Delays in receiving care were more prevalent (81%) than in seeking (61%) and reaching (26%) care. CONCLUSION Factors contributing to delays in receiving care highlight the capacity gaps in provision of emergency obstetric care, including management of postpartum hemorrhage, requiring urgent additional investments. Audit findings also show the need for attention and action towards family planning, contraception, and adolescent sexual and reproductive health services.
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Affiliation(s)
- Tessa A van Boekholt
- UNHCR Regional Bureau of East and Horn of Africa and Great Lakes, Nairobi, Kenya
| | - Edna Moturi
- UNHCR Regional Bureau of East and Horn of Africa and Great Lakes, Nairobi, Kenya
| | | | | | - Hannah Tappis
- John Hopkins Center for Humanitarian Health, Johns Hopkins University, Baltimore, Maryland, USA
| | - Ann Burton
- UNHCR Public Health Section, Geneva, Switzerland
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13
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Swarray-Deen A, Attah DA, Sefogah PE, Oduro NE, Nuamah HG, Nuamah MA, Adzadi C, Oppong SA. Perinatal autopsy in Ghana: Healthcare workers knowledge and attitude. Front Glob Womens Health 2022; 3:1021474. [PMID: 36589149 PMCID: PMC9794746 DOI: 10.3389/fgwh.2022.1021474] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Accepted: 11/25/2022] [Indexed: 12/15/2022] Open
Abstract
Background Perinatal mortality refers to stillbirths and early neonatal deaths. Stillbirth, the death of a foetus from 28 weeks or with a birth weight below 1,000 g, and early neonatal deaths, the death of a new-born within 24 h of delivery, are among the most distressing global health problems, with approximately 2 million stillbirths occurring annually. Although a post-mortem examination of the stillborn baby is essential for understanding and learning the cause of stillbirth, many couples decline the procedure. Sub-Saharan Africa has one of the highest stillbirth rates in the world, yet there is a dearth of studies on post-mortem uptake from the region. Aim To explore healthcare professionals' views and perceptions of perinatal autopsy in Ghana. Methods Mixed-method approach consisted of semi-structured interviews and an electronic cross-sectional survey to evaluate the views and perceptions of healthcare professionals at Korle-Bu Teaching Hospital on autopsy for stillbirths and early neonatal deaths. Descriptive quantitative data were summarised in frequencies and percentages, and statistical results and descriptions were tabulated and coded in terms of types of barriers. For the qualitative aspect, the audio-taped interviews were transcribed, themes generated, and direct quotes and descriptions were coded for all knowledge, beliefs, attitudes and practices concerning the barriers and facilitators for post-mortem. Results Ninety-nine healthcare professionals participated. No participant had formal training regarding counselling for perinatal autopsy and 40% had " no idea " who is responsible for counselling and obtaining consent for a perinatal autopsy. Forty-four percent (44%) of the participants knew of only the "Conventional/ Full" autopsy and <4% were aware of less invasive methods of performing an autopsy. Qualitative data showed healthcare worker influence, religious and financial considerations impede the implementation of perinatal autopsies. Despite the low uptake of perinatal autopsies, interviews from healthcare workers suggest acceptance rates would improve if parents knew about different options, especially less invasive procedures. Conclusion At Ghana's largest referral centre, perinatal autopsy counselling and uptake are at extremely low levels. Most healthcare professionals have little knowledge, skills, and capacity to advise parents regarding perinatal autopsies. Training is needed to update the workforce on recommended perinatal autopsy practices.
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Affiliation(s)
- Alim Swarray-Deen
- Department of Obstetrics & Gynaecology, University of Ghana Medical School, Accra, Ghana
| | - Dzifa A. Attah
- Department of Psychiatry, University of Ghana Medical School, Accra, Ghana
| | - Promise E. Sefogah
- Department of Obstetrics & Gynaecology, University of Ghana Medical School, Accra, Ghana,Correspondence: Promise E. Sefogah
| | - Nana E. Oduro
- Department of Obstetrics & Gynaecology, Korle Bu Teaching Hospital, Accra, Ghana
| | - Hanson G. Nuamah
- Department of Epidemiology & Disease Control, School of Public Health, University of Ghana, Accra, Ghana
| | - Mercy A. Nuamah
- Department of Obstetrics & Gynaecology, University of Ghana Medical School, Accra, Ghana
| | - Catherine Adzadi
- Department of Psychiatry, University of Ghana Medical School, Accra, Ghana
| | - Samuel A. Oppong
- Department of Obstetrics & Gynaecology, University of Ghana Medical School, Accra, Ghana
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Quality Improvement Models and Methods for Maternal Health in Lower-Resource Settings. Obstet Gynecol Clin North Am 2022; 49:823-839. [DOI: 10.1016/j.ogc.2022.08.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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15
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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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Onambele L, Ortega-Leon W, Guillen-Aguinaga S, Forjaz MJ, Yoseph A, Guillen-Aguinaga L, Alas-Brun R, Arnedo-Pena A, Aguinaga-Ontoso I, Guillen-Grima F. Maternal Mortality in Africa: Regional Trends (2000-2017). INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph192013146. [PMID: 36293727 PMCID: PMC9602585 DOI: 10.3390/ijerph192013146] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Revised: 10/03/2022] [Accepted: 10/09/2022] [Indexed: 05/27/2023]
Abstract
BACKGROUND United Nations Sustainable Development Goals state that by 2030, the global maternal mortality rate (MMR) should be lower than 70 per 100,000 live births. MMR is still one of Africa's leading causes of death among women. The leading causes of maternal mortality in Africa are hemorrhage and eclampsia. This research aims to study regional trends in maternal mortality (MM) in Africa. METHODS We extracted data for maternal mortality rates per 100,000 births from the United Nations Children's Fund (UNICEF) databank from 2000 to 2017, 2017 being the last date available. Joinpoint regression was used to study the trends and estimate the annual percent change (APC). RESULTS Maternal mortality has decreased in Africa over the study period by an average APC of -3.0% (95% CI -2.9; -3,2%). All regions showed significant downward trends, with the greatest decreases in the South. Only the North African region is close to the United Nations' sustainable development goals for Maternal mortality. The remaining Sub-Saharan African regions are still far from achieving the goals. CONCLUSIONS Maternal mortality has decreased in Africa, especially in the South African region. The only region close to the United Nations' target is the North African region. The remaining Sub-Saharan African regions are still far from achieving the goals. The West African region needs more extraordinary efforts to achieve the goals of the United Nations. Policies should ensure that all pregnant women have antenatal visits and give birth in a health facility staffed by specialized personnel.
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Affiliation(s)
- Luc Onambele
- School of Health Sciences, Catholic University of Central Africa, Yaoundé 1110, Cameroon
| | - Wilfrido Ortega-Leon
- Epidemiology and Public Health Program, Department of Surgery, Medical and Social Sciences, University of Alcala de Henares, 28801 Madrid, Spain
| | - Sara Guillen-Aguinaga
- Department of Health Sciences, Public University of Navarra, 31008 Pamplona, Spain
- San Juan Health Center, Primary Health Care, Navarra Health Service, 31006 Pamplona, Spain
| | - Maria João Forjaz
- National Epidemiology Centre, Carlos III Health Institute, 28029 Madrid, Spain
- REDISSEC and REDIAPP, 28029 Madrid, Spain
| | - Amanuel Yoseph
- Department of Health Sciences, Public University of Navarra, 31008 Pamplona, Spain
- School of Public Health, College of Medicine and Health Sciences, Hawassa University, Hawassa P.O. Box 5, Ethiopia
| | | | - Rosa Alas-Brun
- Department of Health Sciences, Public University of Navarra, 31008 Pamplona, Spain
| | - Alberto Arnedo-Pena
- Department of Health Sciences, Public University of Navarra, 31008 Pamplona, Spain
- Epidemiology Division, Public Health Center, 12003 Castelló de la Plana, Spain
- Public Health and Epidemiology (CIBERESP), Instituto de Salud Carlos III, 28029 Madrid, Spain
| | - Ines Aguinaga-Ontoso
- Department of Health Sciences, Public University of Navarra, 31008 Pamplona, Spain
- Department of Preventive Medicine, Clínica Universidad de Navarra, 31008 Pamplona, Spain
- Facultad de Ciencias de la Salud, Universidad Pública de Navarra (UPNA), Avda. de Baranain sn, 31008 Pamplona, Spain
| | - Francisco Guillen-Grima
- Department of Health Sciences, Public University of Navarra, 31008 Pamplona, Spain
- Department of Preventive Medicine, Clínica Universidad de Navarra, 31008 Pamplona, Spain
- Instituto de Investigación Sanitaria de Navarra (IdiSNA), 31008 Pamplona, Spain
- Center for Biomedical Research Network, Physiopathology of Obesity and CIBER-OBN, Instituto de Salud Carlos III, 28029 Madrid, Spain
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Banke-Thomas A. The potential utility of an augmented data collection approach in understanding the journey to care of pregnant women for maternal and perinatal death surveillance and response. F1000Res 2022; 11:739. [PMID: 36128551 PMCID: PMC9475203 DOI: 10.12688/f1000research.123210.3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/16/2022] [Indexed: 01/13/2023] Open
Abstract
Background: The Maternal and Perinatal Death Surveillance and Response (MPDSR) proposed by the World Health Organization recognises the importance for health systems to understand the reasons underpinning the death of a pregnant woman or her newborn as an essential first step in preventing future similar deaths. Data for the surveillance component of the MPDSR process are typically collected from health facility sources and post-mortem interviews with affected families, though it may be traumatising to them. This brief report aimed to assess the potential utility of an augmented data collection method for mapping journeys of maternal and perinatal deaths, which does not require sourcing additional information from grieving family members. Methods: A descriptive analysis of maternal and perinatal deaths that occurred across 24 public hospitals in Lagos State, Nigeria, between 1 st November 2018 and 30 th October 2019 was conducted. Data on their demographic, obstetric history and complication at presentation, travel to the hospital, and mode of birth were extracted from their hospital records. The extracted travel data was exported to Google Maps, where driving distance and travel time to the hospital for the period of the day of travel were also extracted. Results: Of the 182 maternal deaths, most presented during the week (80.8%), travelled 5-10 km (30.6%) and 10-29 minutes (46.9%), and travelled to the nearest hospital to their places of residence (70.9%). Of the 442 pregnant women who had perinatal deaths, most presented during the week (78.5%), travelled <5 km (26.9%) and 10-29 minutes (38.0%). For both, the least reported travel data was the mode of travel used to care (>90.0%) and the period of the day they travelled (approximately 30.0%). Conclusion: An augmented data collection approach that includes accurate and complete travel data and closer-to-reality estimates of travel time and distance can be beneficial for MPDSR purposes.
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Affiliation(s)
- Aduragbemi Banke-Thomas
- School of Human Sciences, University of Greenwich, London, SE10 9LS, UK,Maternal and Reproductive Health Research Collective, Lagos, Nigeria,
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18
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Witter S, Sheikh K, Schleiff M. Learning health systems in low-income and middle-income countries: exploring evidence and expert insights. BMJ Glob Health 2022; 7:bmjgh-2021-008115. [PMID: 36130793 PMCID: PMC9490579 DOI: 10.1136/bmjgh-2021-008115] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2021] [Accepted: 02/16/2022] [Indexed: 11/29/2022] Open
Abstract
Introduction Learning health systems (LHS) is a multifaceted subject. This paper reviewed current concepts as well as real-world experiences of LHS, drawing on published and unpublished knowledge in order to identify and describe important principles and practices that characterise LHS in low/middle-income country (LMIC) settings. Methods We adopted an exploratory approach to the literature review, recognising there are limited studies that focus specifically on system-wide learning in LMICs, but a vast set of connected bodies of literature. 116 studies were included, drawn from an electronic literature search of published and grey literature. In addition, 17 interviews were conducted with health policy and research experts to gain experiential knowledge. Results The findings were structured by eight domains on learning enablers. All of these interact with one another and influence actors from community to international levels. We found that learning comes from the connection between information, deliberation, and action. Moreover, these processes occur at different levels. It is therefore important to consider experiential knowledge from multiple levels and experiences. Creating spaces and providing resources for communities, staff and managers to deliberate on their challenges and find solutions has political implications, however, and is challenging, particularly when resources are constrained, funding and accountability are fragmented and the focus is short-term and narrow. Nevertheless, we can learn from countries that have managed to develop institutional mechanisms and human capacities which help health systems respond to changing environments with ‘best fit’ solutions. Conclusion Health systems are knowledge producers, but learning is not automatic. It needs to be valued and facilitated. Everyday governance of health systems can create spaces for reflective practice and learning within routine processes at different levels. This article highlights important enablers, but there remains much work to be done on developing this field of knowledge.
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Affiliation(s)
- Sophie Witter
- Institute for Global Health and Development & ReBUILD Consortium, Queen Margaret University Edinburgh, Edinburgh, UK
| | - Kabir Sheikh
- Alliance For Health Policy and System Research, Geneva, Switzerland
| | - Meike Schleiff
- Department of International Health, Johns Hopkins School of Public Health, Baltimore, Maryland, USA
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Ouedraogo CMR, Ouedraogo OMAA, Conombo Kafando SG, Roungou JB, Moluh S, Emah IY, Kouanda S. Implementation of maternal and neonatal death surveillance and response in Cameroon. Int J Gynaecol Obstet 2022; 158 Suppl 2:61-66. [PMID: 35795984 DOI: 10.1002/ijgo.14299] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
OBJECTIVE To analyze implementation of maternal and neonatal death surveillance and response (MNDSR) in Cameroon to determine to what extent monitoring objectives are being met and highlight the main obstacles and facilitating factors. METHODS Secondary analysis of a cross-sectional study using a qualitative method and routine data on maternal health. Semistructured interviews were conducted with participants involved in MNDSR at the central, regional, and district levels. RESULTS Notification of maternal deaths has been incorporated into the Integrated Disease Surveillance and Response (IDSR) system since January 2014. However, maternal deaths are underreported in most hospitals and neonatal and community deaths are not recorded. Comprehensive review of maternal deaths does not occur in all hospitals despite training of providers in 2013 on how to conduct reviews. CONCLUSION Implementation of MNDSR in Cameroon is insufficient. More commitment from the Ministry of Health is needed to develop an action plan and secure funding.
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Affiliation(s)
| | | | | | | | | | | | - Seni Kouanda
- Health Sciences Research Institute (IRSS), Ouagadougou, Burkina Faso.,African Institute of Public Health (IASP), Ouagadougou, Burkina Faso
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Ameh CA, Meka RJ, West F, Dickinson F, Allott H, Godia P. A synthesis of clinical and health system bottlenecks to implementing new WHO postpartum hemorrhage recommendations: Secondary data analysis of the Kenya Confidential Enquiry into Maternal Deaths 2014-2017. Int J Gynaecol Obstet 2022; 158 Suppl 1:14-22. [PMID: 35762810 PMCID: PMC9544179 DOI: 10.1002/ijgo.14270] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Objective To describe maternal deaths from postpartum hemorrhage (PPH) in Kenya by secondary analysis of the Kenya Confidential Enquiry into Maternal Deaths (CEMD) database and clinical audit of a sample of those deaths, and to identify the perceived challenges to implementing country‐specific PPH guidelines. Methods A retrospective descriptive study using the Kenyan CEMD database and anonymized maternal death records from 2014–2017. Eight standards from the Kenya National Guidelines for Quality Obstetric and Perinatal Care were selected to perform clinical audit. The process of supporting eight Sub‐Saharan African countries to develop country‐specific PPH guidelines was described and perceived challenges implementing these were identified. Results In total, 725 women died from PPH. Most women attended at least one antenatal care visit (67.2%) and most did not receive iron and folate supplementation (35.7%). Only 39.0% of women received prophylactic uterotonics in the third stage of labor. Factors significantly associated with receiving prophylactic uterotonics were place of delivery (χ2 = 43.666, df = 4; P < 0.001), being reviewed by a medical doctor (χ2 = 16.905, df = 1; P < 0.001), and being reviewed by a specialist (χ2 = 49.244, df = 1; P < 0.001). Only three of eight standards had a greater percentage of met cases in comparison to unmet cases. Key concerns about implementation of the new WHO PPH guidance included use of misoprostol by unskilled health personnel, availability of misoprostol and tranexamic acid (TXA) at primary healthcare level, lack of availability of heat‐stable carbetocin (HSC) due to cost, lack of awareness and education about HSC and TXA, and lack of systems to ensure quality oxytocin is available at point of care. Conclusion There is a need for improved quality of care for women to minimize the risk of mortality from PPH, by implementing updated clinical guidelines combined with focused health system interventions. Improving quality of care for women with postpartum hemorrhage requires use of up‐to‐date clinical guidelines combined with focused health system interventions.
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Affiliation(s)
- Charles A Ameh
- Emergency Obstetric Care and Quality of Care Unit, WHO collaborating Centre for Research and Training in Maternal and Newborn Health, International Public Health Department, Liverpool School of Tropical Medicine, Liverpool, UK.,Department of Obstetrics and Gynecology, Kenya
| | - Ramya Jyothi Meka
- Emergency Obstetric Care and Quality of Care Unit, WHO collaborating Centre for Research and Training in Maternal and Newborn Health, International Public Health Department, Liverpool School of Tropical Medicine, Liverpool, UK
| | | | - Fiona Dickinson
- Emergency Obstetric Care and Quality of Care Unit, WHO collaborating Centre for Research and Training in Maternal and Newborn Health, International Public Health Department, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Helen Allott
- Emergency Obstetric Care and Quality of Care Unit, WHO collaborating Centre for Research and Training in Maternal and Newborn Health, International Public Health Department, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Pamela Godia
- Emergency Obstetric Care and Quality of Care Unit, WHO collaborating Centre for Research and Training in Maternal and Newborn Health, International Public Health Department, Liverpool School of Tropical Medicine, Liverpool, UK.,School of Public Health, University of Nairobi, Nairobi, Kenya.,Liverpool School of Tropical Medicine, Nairobi, Kenya
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Congo B, Yaméogo WME, Millogo T, Compaoré R, Tougri H, Ouédraogo CMR, Kouanda S. Barriers to the implementation of quality maternal death reviews in health districts in Burkina Faso. Int J Gynaecol Obstet 2022; 158 Suppl 2:29-36. [PMID: 35616151 DOI: 10.1002/ijgo.14232] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVE To identify barriers to the implementation of maternal death reviews in health districts in Burkina Faso. METHODS We conducted a multiple case study in seven health facilities chosen by contrasted purposive sampling. Sampling criteria were based on intrahospital maternal mortality rates and the location of the health facility. Data collection was conducted from April 27 to May 30, 2015, using structured and semistructured interviews and data extraction from source documents. Data were analyzed using a thematic approach. RESULTS Barriers to quality maternal death reviews identified were primarily implementation conditions, including poor skills and motivation of healthcare personnel, low interest in quality of care, lack of suitable equipment, insufficient coordination and collaboration between health services, insufficient monitoring, and weakness in programming and conducting the reviews. CONCLUSION Barriers to achieving quality maternal death reviews remain numerous at the operational level of the health system. Taking steps to remove these barriers is key to improving the quality of maternal death reviews and childbirth outcomes in Burkina Faso.
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Affiliation(s)
- Boukaré Congo
- African Institute of Public Health (AIPH), Ouagadougou, Burkina Faso
| | - Wambi M E Yaméogo
- African Institute of Public Health (AIPH), Ouagadougou, Burkina Faso
| | - Tieba Millogo
- African Institute of Public Health (AIPH), Ouagadougou, Burkina Faso
| | | | - Halima Tougri
- Institute for Research and Health Sciences, Ouagadougou, Burkina Faso
| | | | - Seni Kouanda
- African Institute of Public Health (AIPH), Ouagadougou, Burkina Faso
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22
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Russell N, Tappis H, Mwanga JP, Black B, Thapa K, Handzel E, Scudder E, Amsalu R, Reddi J, Palestra F, Moran AC. Implementation of maternal and perinatal death surveillance and response (MPDSR) in humanitarian settings: insights and experiences of humanitarian health practitioners and global technical expert meeting attendees. Confl Health 2022; 16:23. [PMID: 35526012 PMCID: PMC9077967 DOI: 10.1186/s13031-022-00440-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Accepted: 02/03/2022] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Maternal and perinatal death surveillance and response (MPDSR) is a system of identifying, analysing and learning lessons from such deaths in order to respond and prevent future deaths, and has been recommended by WHO and implemented in many low-and-middle income settings in recent years. However, there is limited documentation of experience with MPDSR in humanitarian settings. A meeting on MPDSR in humanitarian settings was convened by WHO, UNICEF, CDC and Save the Children, UNFPA and UNHCR on 17th-18th October 2019, informed by semi-structured interviews with a range of professionals, including expert attendees. CONSULTATION FINDINGS Interviewees revealed significant obstacles to full implementation of the MPDSR process in humanitarian settings. Many obstacles were familiar to low resource settings in general but were amplified in the context of a humanitarian crisis, such as overburdened services, disincentives to reporting, accountability gaps, a blame approach, and politicisation of mortality. Factors more unique to humanitarian contexts included concerns about health worker security and moral distress. There are varying levels of institutionalisation and implementation capacity for MPDSR within humanitarian organisations. It is suggested that if poorly implemented, particularly with a punitive or blame approach, MPDSR may be counterproductive. Nevertheless, successes in MPDSR were described whereby the process led to concrete actions to prevent deaths, and where death reviews have led to improved understanding of complex and rectifiable contextual factors leading to deaths in humanitarian settings. CONCLUSIONS Despite the challenges, examples exist where the lessons learnt from MPDSR processes have led to improved access and quality of care in humanitarian contexts, including successful advocacy. An adapted approach is required to ensure feasibility, with varying implementation being possible in different phases of crises. There is a need for guidance on MPDSR in humanitarian contexts, and for greater documentation and learning from experiences.
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Affiliation(s)
| | - Hannah Tappis
- grid.21107.350000 0001 2171 9311Jhpiego, Baltimore, MD USA
| | - Jean Paul Mwanga
- Hôpital Générale de Mweso, Nord Kivu, Democratic Republic of the Congo
| | - Benjamin Black
- grid.452780.cMédecins Sans Frontières, Amsterdam, The Netherlands
| | - Kusum Thapa
- grid.21107.350000 0001 2171 9311Jhpiego, Baltimore, MD USA
| | - Endang Handzel
- grid.416738.f0000 0001 2163 0069Centre for Disease Control and Prevention, Atlanta, GA USA
| | - Elaine Scudder
- grid.420433.20000 0000 8728 7745International Rescue Committee, New York, NY USA
| | - Ribka Amsalu
- grid.266102.10000 0001 2297 6811University of California San Francisco, San Francisco, CA USA
| | - Jyoti Reddi
- grid.3575.40000000121633745World Health Organization, Geneva, Switzerland
| | - Francesca Palestra
- grid.3575.40000000121633745World Health Organization, Geneva, Switzerland
| | - Allisyn C. Moran
- grid.3575.40000000121633745World Health Organization, Geneva, Switzerland
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Compaoré R, Millogo T, Ouedraogo AM, Tougri H, Ouedraogo L, Tall F, Kouanda S. Maternal and neonatal death surveillance and response in Liberia: An assessment of the implementation process in five counties. Int J Gynaecol Obstet 2022; 158 Suppl 2:46-53. [PMID: 35434804 DOI: 10.1002/ijgo.14174] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To evaluate the implementation of the maternal and neonatal death surveillance and response (MNDSR) system at county level in Liberia. METHODS Secondary analysis of data from a cross-sectional study carried out in March 2016, using both quantitative and qualitative methods to collect data in five counties based on set criteria. Three health facilities were selected in each county through the Health Management Information System (HMIS) by random sampling. The evaluation was also carried out in one catchment community per health facility and at the county referral hospital. Primary data were collected through individual interviews and a review of MNDSR tools and structure. Data were analyzed using thematic analysis. RESULTS Implementation of the MNDSR system was very low in the five counties. Only two out of the five counties were currently conducting MNDSR. MNDSR guidelines and standard operating procedures were not available at the county level. Only 12 (23.5%) health facilities had a maternal and neonatal death review committee. Less than a quarter of the assessed community members could correctly give the definition of a maternal or neonatal death. CONCLUSION The MNDSR system is weak in Liberia, at county, health facility, and community levels. Strong national commitment is needed in collaboration with diverse partners for successful implementation of the system.
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Affiliation(s)
- Rachidatou Compaoré
- Institut de Recherche en Sciences de la Santé (IRSS), Ouagadougou, Burkina Faso
| | - Tieba Millogo
- Institut Africain de Santé Publique (IASP), Ouagadougou, Burkina Faso
| | - Adja M Ouedraogo
- Institut de Recherche en Sciences de la Santé (IRSS), Ouagadougou, Burkina Faso
| | - Halima Tougri
- Institut de Recherche en Sciences de la Santé (IRSS), Ouagadougou, Burkina Faso
| | - Leopold Ouedraogo
- Reproductive, Maternal Health and Ageing, WHO Regional Office for Africa, Brazzaville, Congo
| | - Fatim Tall
- Reproductive, Maternal Health and Ageing, WHO IST Office for Central Africa, Libreville, Gabon
| | - Seni Kouanda
- Institut de Recherche en Sciences de la Santé (IRSS), Ouagadougou, Burkina Faso.,Institut Africain de Santé Publique (IASP), Ouagadougou, Burkina Faso
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Compaoré R, Kouanda S, Kuma-Aboagye P, Sagoe-Moses I, Brew G, Deganus S, Srofenyo E, Dansowaa Doe R, Nkurunziza T, Tall F. Transitioning to the maternal death surveillance and response system from maternal death review in Ghana: Challenges and lessons learned. Int J Gynaecol Obstet 2022; 158 Suppl 2:37-45. [PMID: 35315062 DOI: 10.1002/ijgo.14147] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To assess the current system of maternal death review (MDR) in Ghana and identify the achievements, challenges, and gaps that will assist in transitioning to the maternal death surveillance and response system (MDSR). METHODS A secondary analysis of data from a cross-sectional study on MDSR implementation was conducted between September and October 2018. The MDSR cycle served as an analytical framework to measure the country's performance in implementing MDSR. Common facilitating or hindering factors were also identified. RESULTS The MDR system is moderately strong at regional level with timely receipt of data and regular review meetings and reports in most regions. At district level the MDR system is less well implemented, although there is evidence of good communication with regional teams in providing timely data. Communication between districts and communities about maternal deaths seemed to be poor in general. There was no MDR committee at national level and the recommendations made were poorly implemented. CONCLUSION MDRs in Ghana were structurally sound, but recommendations were poorly implemented. Leadership at the national level needs to be developed to ensure that the current system could transition to an MDSR system.
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Affiliation(s)
- Rachidatou Compaoré
- Institut de Recherche en Sciences de la Santé (IRSS), Ouagadougou, Burkina Faso
| | - Seni Kouanda
- Institut de Recherche en Sciences de la Santé (IRSS), Ouagadougou, Burkina Faso.,Institut Africain de Santé Publique (IASP), Ouagadougou, Burkina Faso
| | | | | | - Gladys Brew
- Family Health Division, Ghana Health Service, Accra, Ghana
| | | | | | | | - Triphonie Nkurunziza
- Reproductive, Maternal Health and Ageing, WHO Regional Office for Africa, Brazzaville, Congo
| | - Fatim Tall
- Reproductive, Maternal Health and Ageing, WHO IST Office for Central Africa, Libreville, Gabon
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Ogola M, Njuguna EM, Aluvaala J, English M, Irimu G. Audit identified modifiable factors in Hospital Care of Newborns in low-middle income countries: a scoping review. BMC Pediatr 2022; 22:99. [PMID: 35180843 PMCID: PMC8855576 DOI: 10.1186/s12887-021-02965-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Accepted: 10/19/2021] [Indexed: 12/05/2022] Open
Abstract
BACKGROUND Audit of facility-based care provided to small and sick newborns is a quality improvement initiative that helps to identify the modifiable gaps in newborn care (BMC Pregnancy Childbirth 14: 280, 2014). The aim of this work was to identify literature on modifiable factors in the care of newborns in the newborn units in health facilities in low-middle-income countries (LMICs). We also set out to design a measure of the quality of the perinatal and newborn audit process. METHODS The scoping review was conducted using the methodology outlined by Arksey and O'Malley and refined by Levac et al, (Implement Sci 5:1-9, 2010). We reported our results using the PRISMA Extension for Scoping Reviews (PRISMA-ScR) guidelines. We identified seven factors to ensure a successful audit process based on World Health Organisation (WHO) recommendations which we subsequently used to develop a quality of audit process score. DATA SOURCES We conducted a structured search using PubMed, CINAHL, EMBASE, LILACS, POPLINE and African Index Medicus. STUDY SELECTION Studies published in English between 1965 and December 2019 focusing on the identification of modifiable factors through clinical or mortality audits in newborn care in health facilities from LMICs. DATA EXTRACTION We extracted data on the study characteristics, modifiable factors and quality of audit process indicators. RESULTS A total of six articles met the inclusion criteria. Of these, four were mortality audit studies and two were clinical audit studies that we used to assess the quality of the audit process. None of the studies were well conducted, two were moderately well conducted, and four were poorly conducted. The modifiable factors were divided into three time periods along the continuum of newborn care. The period of newborn unit care had the highest number of modifiable factors, and in each period, the health worker related modifiable factors were the most dominant. CONCLUSION Based on the significant number of modifiable factors in the newborn unit, a neonatal audit tool is essential to act as a structured guide for auditing newborn unit care in LMICs. The quality of audit process guide is a useful method of ensuring high quality audits in health facilities.
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Affiliation(s)
- Muthoni Ogola
- Health Services Unit, KEMRI-Wellcome Trust Research Programme, 197 Lenana Place, Lenana Road, P. O. Box 43640, Nairobi, 00100, Kenya.
- Paediatrics and Child Health, University of Nairobi, Nairobi, Kenya.
- Pumwani Maternity Hospital, Nairobi, Kenya.
| | | | - Jalemba Aluvaala
- Health Services Unit, KEMRI-Wellcome Trust Research Programme, 197 Lenana Place, Lenana Road, P. O. Box 43640, Nairobi, 00100, Kenya
- Paediatrics and Child Health, University of Nairobi, Nairobi, Kenya
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Mike English
- Health Services Unit, KEMRI-Wellcome Trust Research Programme, 197 Lenana Place, Lenana Road, P. O. Box 43640, Nairobi, 00100, Kenya
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Grace Irimu
- Health Services Unit, KEMRI-Wellcome Trust Research Programme, 197 Lenana Place, Lenana Road, P. O. Box 43640, Nairobi, 00100, Kenya
- Paediatrics and Child Health, University of Nairobi, Nairobi, Kenya
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Jepkosgei J, Nzinga J, Adam MB, English M. Exploring healthcare workers' perceptions on the use of morbidity and mortality audits as an avenue for learning and care improvement in Kenyan hospitals' newborn units. BMC Health Serv Res 2022; 22:172. [PMID: 35144594 PMCID: PMC8832787 DOI: 10.1186/s12913-022-07572-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2021] [Accepted: 02/01/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In many sub-Saharan African countries, including Kenya, the use of mortality and morbidity audits in maternal and perinatal/neonatal care as an avenue for learning and improving care delivery is sub-optimal due to structural, organizational, and human barriers. While attempts to address these barriers have been reported, lots of emphasis has been paid to addressing the role of tangible inputs (e.g., availing guidelines and training staff in the success of mortality and morbidity audits), while process-related factors (i.e., the role of the people, their experiences, relationships, and motivations) remain inadequately explored. We examined the processes of neonatal audits, their potential in promoting learning from gaps in care and improving care delivery, with a deliberate focus on process-related factors that generally influence mortality and morbidity (M&M) audits. METHODS This was an exploratory qualitative study, conducted in three hospitals, in Nairobi and Muranga counties. We employed a mix of in-depth interviews (17) and observation of 12 mortality and morbidity audit meetings. Our study participants included: nurses, doctors, trainee clinicians (i.e., junior doctors on internships), and nursing students involved in providing newborn care. These data were coded using NVivo12 employing a thematic content analysis approach. RESULTS Perceived shortcomings in the conduct of M&M audits such as unclear structure was reported to have contributed to its sub-optimal nature in promoting learning. These shortcomings, in addition to hierarchy and power dynamics, poor implementation of audit recommendations, and negative experiences, (e.g., blame) also demotivated health workers from attendance and participation in audits. Despite these, positive outcomes linked to audit recommendations, such as revision of care protocols, were reported. Overall, leadership and a blame-free culture enabled positive changes and promoted learning from audit-identified modifiable factors. CONCLUSION Our findings indicate that M&M audits provide a space for meaningful discussions, which may lead to learning and improvement in care delivery processes. However, a lack of participation, lack of observed positive outcomes, and negative experiences may reduce their usefulness. An enabling environment characterized by minimized effects of hierarchy and positive use of power and a blame-free culture may promote active participation, enhancing positive relationships and interactions thus promoting team learning.
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Affiliation(s)
- Joyline Jepkosgei
- Health Services Unit, KEMRI-Wellcome Trust Research Programme, P. O. Box 43640 - 00100, 197 Lenana Place, Lenana Road, Nairobi, Kenya.
| | - Jacinta Nzinga
- Health Services Unit, KEMRI-Wellcome Trust Research Programme, P. O. Box 43640 - 00100, 197 Lenana Place, Lenana Road, Nairobi, Kenya
| | | | - Mike English
- Health Services Unit, KEMRI-Wellcome Trust Research Programme, P. O. Box 43640 - 00100, 197 Lenana Place, Lenana Road, Nairobi, Kenya.,Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
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Boyi Hounsou C, Agossou MCU, Bello K, Delvaux T, Benova L, Vigan Guézodjè A, Hounkpatin H, Dossou JP. "So hard not to feel blamed!": Assessment of implementation of Benin's Maternal and Perinatal Death Surveillance and Response strategy from 2016-2018. Int J Gynaecol Obstet 2021; 158 Suppl 2:6-14. [PMID: 34961924 DOI: 10.1002/ijgo.14041] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
OBJECTIVE To assess the implementation of the Maternal and Perinatal Death Surveillance and Response (MPDSR) strategy institutionalized in Benin in 2013 to address the alarmingly high maternal and neonatal death rates. METHODS A retrospective, mixed-methods study was performed. We used all maternal and neonatal death notifications and reviews from 2016 to 2018, reviewed the reports of 63 MPDSR working groups, and held two online group discussions. Descriptive quantitative analysis was performed, and content analysis was applied to qualitative data. RESULTS Deaths were under-notified, with estimated notification rates at 46%-48% for maternal and 16%-21% for neonatal deaths over the 3 years. Review completion rates were low, corresponding to 50%-56% of maternal and 8%-17% of neonatal deaths. Causes of undernotification included very low notification of community-based and private health facility deaths, and fear of blame. Low review completion rates were due to heavy workload, staffing shortages, fear of blame, and weak leadership. Moreover, reviews were of poor quality and the response was weak. CONCLUSION Maternal and Perinatal Death Surveillance and Response is operational in Benin. However, this assessment highlights the need to strengthen the notification strategy, continuously build MPDSR committee members' capacities, engage decision-makers for an effective response, and create a better blame-free, accountable, and learning culture.
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Affiliation(s)
- Christelle Boyi Hounsou
- Centre de Recherche en Reproduction Humaine et en Démographie (CERRHUD), Cotonou, Bénin.,Institute of Tropical Medicine, Antwerp, Belgium
| | - Mahugnon C U Agossou
- Centre de Recherche en Reproduction Humaine et en Démographie (CERRHUD), Cotonou, Bénin
| | - Kéfilath Bello
- Centre de Recherche en Reproduction Humaine et en Démographie (CERRHUD), Cotonou, Bénin
| | | | - Lenka Benova
- Institute of Tropical Medicine, Antwerp, Belgium
| | | | - Hashim Hounkpatin
- Centre de Recherche en Reproduction Humaine et en Démographie (CERRHUD), Cotonou, Bénin
| | - Jean-Paul Dossou
- Centre de Recherche en Reproduction Humaine et en Démographie (CERRHUD), Cotonou, Bénin
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Maruf F, Tappis H, Stekelenburg J, van den Akker T. Quality of Maternal Death Documentation in Afghanistan: A Retrospective Health Facility Record Review. Front Glob Womens Health 2021; 2:610578. [PMID: 34816182 PMCID: PMC8593965 DOI: 10.3389/fgwh.2021.610578] [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: 09/26/2020] [Accepted: 02/17/2021] [Indexed: 11/26/2022] Open
Abstract
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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Affiliation(s)
- Farzana Maruf
- Global Financing Facility, World Bank Group, Kabul, Afghanistan.,Faculty of Science, Athena Institute, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | | | - Jelle Stekelenburg
- Global Health Unit, Department of Health Sciences, University Medical Centre Groningen/University of Groningen, Groningen, Netherlands.,Department of Obstetrics and Gynaecology, Leeuwarden Medical Centre, Leeuwarden, Netherlands
| | - Thomas van den Akker
- Faculty of Science, Athena Institute, Vrije Universiteit Amsterdam, Amsterdam, Netherlands.,Department of Obstetrics and Gynaecology, Leiden University Medical Centre, Leiden, Netherlands
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Cahyanti RD, Widyawati W, Hakimi M. "Sharp downward, blunt upward": district maternal death audits' challenges to formulate evidence-based recommendations in Indonesia - a qualitative study. BMC Pregnancy Childbirth 2021; 21:730. [PMID: 34706687 PMCID: PMC8554828 DOI: 10.1186/s12884-021-04212-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Accepted: 10/18/2021] [Indexed: 11/10/2022] Open
Abstract
Background Indonesia, the largest archipelago globally with a decentralized health system, faces a stagnant high maternal mortality ratio (MMR). The disparity factors among regions and inequities in access have deterred the local assessments in preventing similar maternal deaths. This study explored the challenges of district maternal death audit (MDA) committees to provide evidence-based recommendations for local adaptive practices in reducing maternal mortality. Methods A qualitative study was conducted with four focus-group discussions in Central Java, Indonesia, between July and October 2019. Purposive sampling was used to select 7–8 members of each district audit committee. Data were analyzed using the thematic analysis approach. Triangulation was done by member checking, peer debriefing, and reviewing audit documentation. Results The district audit committees had significant challenges to develop appropriate recommendations and action plans, involving: 1) non-informative audit tool provides unreliable data for review; 2) unstandardized clinical indicators and the practice of “sharp downward, blunt upward”; 3) unaccountable hospital support and lack of leadership commitment, and 4) blaming culture, minimal training, and insufficient MDA committee’ skills. The district audit committees tended to associated maternal death in lower and higher-level health facilities (hospitals) with mismanagement and unavoidable cause, respectively. These unfavorable cultures discourage transparency and prevent continuing improvement, leading to failure in addressing maternal death’s local avoidable factors. Conclusion A productive MDA is required to provide an evidence-based recommendation. A strong partnership between the key hospital decision-makers and district health officers is needed for quality evidence-based policymaking and adaptive practice to prevent maternal death.
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Affiliation(s)
- Ratnasari D Cahyanti
- Obstetrics and Gynecology Department, Faculty of Medicine, Diponegoro University, Semarang, Indonesia. .,Doctoral Program, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Yogyakarta, Indonesia.
| | - Widyawati Widyawati
- Pediatric and Maternity Nursing Department, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Yogyakarta, Indonesia
| | - Mohammad Hakimi
- Obstetrics and Gynecology Department, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Yogyakarta, Indonesia
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Melberg A, Teklemariam L, Moland KM, Aasen HS, Sisay MM. Juridification of maternal deaths in Ethiopia: a study of the Maternal and Perinatal Death Surveillance and Response (MPDSR) system. Health Policy Plan 2021; 35:900-905. [PMID: 32594165 PMCID: PMC7553756 DOI: 10.1093/heapol/czaa043] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/17/2020] [Indexed: 12/14/2022] Open
Abstract
Juridification of maternal health care is on the rise globally, but little is known about its manifestations in resource constrained settings in sub-Saharan Africa. The Maternal and Perinatal Death Surveillance and Response (MPDSR) system is implemented in Ethiopia to record and review all maternal and perinatal deaths, but underreporting of deaths remains a major implementation challenge. Fear of blame and malpractice litigation among health workers are important factors in underreporting, suggestive of an increased juridification of birth care. By taking MPDSR implementation as an entry point, this article aims to explore the manifestations of juridification of birth care in Ethiopia. Based on multi-sited fieldwork involving interviews, document analysis and observations at different levels of the Ethiopian health system, we explore responses to maternal deaths at various levels of the health system. We found an increasing public notion of maternal deaths being caused by malpractice, and a tendency to perceive the juridical system as the only channel to claim accountability for maternal deaths. Conflicts over legal responsibility for deaths influenced birth care provision. Both health workers and health bureaucrats strived to balance conflicting concerns related to the MPDSR system: reporting all deaths vs revealing failures in service provision. This dilemma encouraged the development of strategies to avoid personalized accountability for deaths. In this context, increased juridification impacted both care and reporting practices. Our study demonstrates the need to create a system that secures legal protection of health professionals reporting maternal deaths as prescribed and provides the public with mechanisms to claim accountability and high-quality birth care services.
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Affiliation(s)
- Andrea Melberg
- Centre for International Health, University of Bergen, Årstadveien 21, N-5007 Bergen, Norway
| | - Lidiya Teklemariam
- O'Neill Institute for National and Global Health Law, Georgetown University Law Center, USA
| | - Karen Marie Moland
- Centre for International Health, University of Bergen, Årstadveien 21, N-5007 Bergen, Norway
| | | | - Mitike Molla Sisay
- School of Public Health, College of Health Sciences, Addis Ababa University, Ethiopia
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Kodan LR, Verschueren KJC, Boerstra G, Gajadien I, Mohamed RS, Olmtak LD, Mohan SR, Bloemenkamp KWM. From Passive Surveillance to Response: Suriname's Efforts to Implement Maternal Death Surveillance and Response. GLOBAL HEALTH, SCIENCE AND PRACTICE 2021; 9:379-389. [PMID: 34234026 PMCID: PMC8324199 DOI: 10.9745/ghsp-d-20-00594] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/03/2020] [Accepted: 04/27/2021] [Indexed: 11/21/2022]
Abstract
Implementation of maternal death surveillance and response (MDSR) is crucial to reduce maternal deaths. In Suriname, MDSR was not implemented until 2015. We describe the process of MDSR implementation in Suriname and share the "lessons learned," as experienced by the health care providers, national maternal death review committee members, and public health experts. Before 2015, maternal deaths were identified using death certificates and by active surveillance in the hospitals. Based on the recommendations from a 2010-2014 Reproductive Age Mortality Survey in Suriname, a maternal death review committee has improved the identification of maternal deaths and has audited every death since 2015. Although this review committee initiated several actions to implement MDSR together with health care providers, the involvement of the Ministry of Health (MOH) was crucial. Therefore, the Maternal Health Steering Committee was recently installed as a direct working arm of MOH to guide MDSR implementation. One of the main barriers to implementing MDSR in Suriname has been the lack of action following recommendations. Delineating roles and responsibilities for action, establishing accountability mechanisms, and influencing stakeholders in a position to act are critical to ensure a response to the recommendations. To implement MDSR, the 5 Cs-commitment, "no blame, no shame" culture, coordination, collaboration, and communication-are crucial.
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Affiliation(s)
- Lachmi R Kodan
- Academic Hospital Paramaribo, Paramaribo, Suriname.
- Department of Obstetrics, Division Women and Baby, Birth Centre Wilhelmina's Children Hospital, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Kim J C Verschueren
- Department of Obstetrics, Division Women and Baby, Birth Centre Wilhelmina's Children Hospital, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
| | | | | | | | | | | | - Kitty W M Bloemenkamp
- Department of Obstetrics, Division Women and Baby, Birth Centre Wilhelmina's Children Hospital, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
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Kinney MV, Walugembe DR, Wanduru P, Waiswa P, George A. Maternal and perinatal death surveillance and response in low- and middle-income countries: a scoping review of implementation factors. Health Policy Plan 2021; 36:955-973. [PMID: 33712840 PMCID: PMC8227470 DOI: 10.1093/heapol/czab011] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/26/2021] [Indexed: 11/13/2022] Open
Abstract
Maternal and perinatal death surveillance and response (MPDSR), or any form of maternal and/or perinatal death review or audit, aims to improve health services and pre-empt future maternal and perinatal deaths. With expansion of MPDSR across low- and middle-income countries (LMIC), we conducted a scoping review to identify and describe implementation factors and their interactions. The review adapted an implementation framework with four domains (intervention, individual, inner and outer settings) and three cross-cutting health systems lenses (service delivery, societal and systems). Literature was sourced from six electronic databases, online searches and key experts. Selection criteria included studies from LMIC published in English from 2004 to July 2018 detailing factors influencing implementation of MPDSR, or any related form of MPDSR. After a systematic screening process, data for identified records were extracted and analysed through content and thematic analysis. Of 1027 studies screened, the review focuses on 58 studies from 24 countries, primarily in Africa, that are mainly qualitative or mixed methods. The literature mostly examines implementation factors related to MPDSR as an intervention, and to its inner and outer setting, with less attention to the individuals involved. From a health systems perspective, almost half the literature focuses on the tangible inputs addressed by the service delivery lens, though these are often measured inadequately or through incomparable ways. Though less studied, the societal and health system factors show that people and their relationships, motivations, implementation climate and ability to communicate influence implementation processes; yet their subjective experiences and relationships are inadequately explored. MPDSR implementation contributes to accountability and benefits from a culture of learning, continuous improvement and accountability, but few have studied the complex interplay and change dynamics involved. Better understanding MPDSR will require more research using health policy and systems approaches, including the use of implementation frameworks.
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Affiliation(s)
- Mary V Kinney
- School of Public Health, University of the Western Cape, Bellville, South Africa
| | - David Roger Walugembe
- School of Health Studies and Faculty of Information and Media Studies, The University of Western Ontario, London, ON, Canada
| | - Phillip Wanduru
- School of Public Health, Makerere University College of Health Sciences, Kampala, Uganda
| | - Peter Waiswa
- Global Health Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden
| | - Asha George
- School of Public Health, University of the Western Cape, Bellville, South Africa
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Said A, Sirili N, Massawe S, Pembe AB, Hanson C, Malqvist M. Mismatched ambition, execution and outcomes: implementing maternal death surveillance and response system in Mtwara region, Tanzania. BMJ Glob Health 2021; 6:bmjgh-2021-005040. [PMID: 34020994 PMCID: PMC8144036 DOI: 10.1136/bmjgh-2021-005040] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Revised: 04/22/2021] [Accepted: 04/26/2021] [Indexed: 11/07/2022] Open
Abstract
Background Since 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. Methods An 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. Results Two 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. Conclusion The 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.
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Affiliation(s)
- Ali Said
- Department of Women and Children's Health, Uppsala University, Uppsala, Sweden .,Department of Obstetrics and Gynecology, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania, United Republic of
| | - Nathanael Sirili
- Department of Development Studies, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania, United Republic of
| | - Siriel Massawe
- Department of Obstetrics and Gynecology, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania, United Republic of
| | - Andrea B Pembe
- Department of Obstetrics and Gynecology, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania, United Republic of
| | - Claudia Hanson
- Department of Global Public Health, Karolinska Institute, Stockholm, Sweden.,Department of Disease Control, London School of Hygiene and Tropical Medicine, London, UK
| | - Mats Malqvist
- Department of Women and Children's Health, Uppsala University, Uppsala, Sweden
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Cahyanti RD, Widyawati W, Hakimi M. The reliability of maternal audit instruments to assign cause of death in maternal deaths review process: a systematic review and meta-analysis. BMC Pregnancy Childbirth 2021; 21:380. [PMID: 34001025 PMCID: PMC8127245 DOI: 10.1186/s12884-021-03840-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Accepted: 04/28/2021] [Indexed: 11/10/2022] Open
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.
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Affiliation(s)
- Ratnasari D Cahyanti
- Doctoral Program, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Yogyakarta, Indonesia.,Obstetrics and Gynecology Department, Faculty of Medicine, Diponegoro University, Semarang, Indonesia
| | - Widyawati Widyawati
- Pediatric and Maternity Nursing Department, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Yogyakarta, Indonesia.
| | - Mohammad Hakimi
- Obstetrics and Gynecology Department, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Yogyakarta, Indonesia
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Mukinda FK, George A, Van Belle S, Schneider H. Practice of death surveillance and response for maternal, newborn and child health: a framework and application to a South African health district. BMJ Open 2021; 11:e043783. [PMID: 33958337 PMCID: PMC8103944 DOI: 10.1136/bmjopen-2020-043783] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2020] [Revised: 04/07/2021] [Accepted: 04/11/2021] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVE To assess the functioning of maternal, perinatal, neonatal and child death surveillance and response (DSR) mechanisms at a health district level. DESIGN A framework of elements covering analysis of causes of death, and processes of review and response was developed and applied to the smallest unit of coordination (subdistrict) to evaluate DSR functioning. The evaluation design was a descriptive qualitative case study, based on observations of DSR practices and interviews. SETTING Rural South African health district (subdistricts and district office). PARTICIPANTS A purposive sample of 45 front-line health managers and providers involved with maternal, perinatal, neonatal and child DSR. The DSR mechanisms reviewed included a system of real-time death reporting (24 hours) and review (48 hours), a nationally mandated confidential enquiry into maternal death and regular facility and subdistrict mortality audit and response processes. PRIMARY OUTCOME MEASURES Functioning of maternal, perinatal, neonatal and child DSR. RESULTS While DSR mechanisms were integrated into the organisational routines of the district, their functioning varied across subdistricts and between forms of DSR. Some forms of DSR, notably those involving maternal deaths, with external reporting and accounting, were more likely to trigger reactive fault-finding and sanctioning than other forms, which were more proactive in supporting evidence-based actions to prevent future deaths. These actions occurred at provider and system level, and to a limited extent, in communities. CONCLUSIONS This study provides an empirical example of the everyday practice of DSR mechanisms at a district level. It assesses such practice based on a framework of elements and enabling organisational processes that may be of value in similar settings elsewhere.
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Affiliation(s)
- Fidele Kanyimbu Mukinda
- School of Public Health, University of the Western Cape, Faculty of Community and Health Sciences, Cape Town, South Africa
| | - Asha George
- School of Public Health, University of the Western Cape, Faculty of Community and Health Sciences, Cape Town, South Africa
| | - Sara Van Belle
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
| | - Helen Schneider
- School of Public Health, South African Medical Research Council (MRC)/Health Services and Systems Unit, Cape Town, South Africa
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Musarandega R, Machekano R, Munjanja SP, Pattinson R. Methods used to measure maternal mortality in Sub-Saharan Africa from 1980 to 2020: A systematic literature review. Int J Gynaecol Obstet 2021; 156:206-215. [PMID: 33811639 DOI: 10.1002/ijgo.13695] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2021] [Revised: 03/23/2021] [Accepted: 04/01/2021] [Indexed: 01/08/2023]
Abstract
BACKGROUND Gobally, Sub-Saharan Africa (SSA) has the largest maternal mortality burden, but the region lacks accurate data. OBJECTIVE To review methods historically used to measure maternal mortality in SSA to inform future study methods. SEARCH STRATEGY We searched databases: PubMed, Medline, WorldCat and CINHAL, using keywords "maternal mortality," "pregnancy-related death," "reproductive age mortality," "ratio," "rate," and "risk," using Boolean operators "OR" and "AND" to combine the search terms. SELECTION CRITERIA We searched for empirical and analytical studies that: (1) measured maternal mortality levels, (2) were in SSA, (3) reported original results, and (4) were not duplicate studies. We included studies published in English since 1980. DATA COLLECTION AND ANALYSIS We screened the studies using titles and abstracts, reading the full text of selected studies. We analyzed the estimates and strengths, and limitations of the methods. MAIN RESULTS We identified 96 studies that used nine methods: demographic surveillance (n = 4), health record reviews (n = 18), confidential enquiries and maternal death surveillance and response (n = 7), prospective cohort (n = 9), reproductive age mortality survey (RAMOS) (n = 6), sisterhood method (n = 35), mixed methods (n = 4), and mathematical modeling (n = 13). CONCLUSION Sisterhood method studies and RAMOS studies that combined institutional records and community data produced maternal mortality ratios more comparable with WHO estimates.
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Affiliation(s)
- Reuben Musarandega
- School of Health Systems and Public Health, Faculty of Health Sciences, University of Pretoria, Pretoria, South Africa
| | - Rhoderick Machekano
- Biostatistics and Epidemiology Department, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Stephen Peter Munjanja
- Obstetrics and Gynaecology Department, College of Health Sciences, University of Zimbabwe, Harare, Zimbabwe
| | - Robert Pattinson
- Maternal, Fetal, Newborn & Child Health Care Strategies Research Centre, University of Pretoria, Pretoria, South Africa
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Maternal death surveillance and response in Tanzania: comprehensiveness of narrative summaries and action points from maternal death reviews. BMC Health Serv Res 2021; 21:52. [PMID: 33430848 PMCID: PMC7802180 DOI: 10.1186/s12913-020-06036-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Accepted: 12/21/2020] [Indexed: 11/24/2022] Open
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.
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Yucel A, Tanacan A, Atalay F, Altinboga O, Koksal Z, Baydilli MB, Esen M, Karabacak Y, Ongun VD, Sahlar TE, Keskinkilic B, Kara F. Maternal deaths with epilepsy: A population-based study in Turkey. Eur J Obstet Gynecol Reprod Biol 2020; 258:33-37. [PMID: 33401066 DOI: 10.1016/j.ejogrb.2020.12.045] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Revised: 12/19/2020] [Accepted: 12/24/2020] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To evaluate the clinical characteristics of maternal deaths with epilepsy in Turkey. STUDY DESIGN This epidemiological population-based study was conducted on all consecutive early maternal deaths with epilepsy in Turkey from 2012 to 2019. Maternal deaths accompanied by epilepsy as a comorbidity (n = 13) were evaluated separately. Epilepsy related maternal deaths were divided into two groups: 1) status epilepticus (n = 19) and 2) Sudden unexpected death in epilepsy (n = 19). Two groups were compared in terms of demographic features and clinical characteristics. RESULTS Maternal deaths with epilepsy ranged between 2.5 % and 5.3 % among total maternal deaths. Pulmonary embolism (32 %), cerebrovascular event (23 %), and cerebral vein thrombosis (15.4 %) were the leading mortality reasons in maternal deaths accompanied by epilepsy. Epilepsy duration, the time interval between pregnancy and the last epileptic seizure, compatibility with medication, rates of preconceptional counseling, and regular antenatal follow-up were all significantly higher in the sudden unexpected death in epilepsy group. The perinatal complication rate was significantly higher in the status epilepticus group (p > 0.05). CONCLUSION Physicians who deal with pregnant women with epilepsy should be attentive for severe complications and the increased risk of maternal mortality in these cases should be kept in mind.
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Affiliation(s)
- Aykan Yucel
- Turkish Public Health Agency, Preliminary Investigation Committee for Maternal Deaths, Turkish Ministry of Health, Ankara, Turkey; University of Health Sciences, Turkish Ministry of Health Ankara City Hospital, Ankara, Turkey
| | - Atakan Tanacan
- Turkish Public Health Agency, Preliminary Investigation Committee for Maternal Deaths, Turkish Ministry of Health, Ankara, Turkey.
| | - Funda Atalay
- Turkish Public Health Agency, Preliminary Investigation Committee for Maternal Deaths, Turkish Ministry of Health, Ankara, Turkey
| | - Orhan Altinboga
- Turkish Public Health Agency, Preliminary Investigation Committee for Maternal Deaths, Turkish Ministry of Health, Ankara, Turkey
| | - Zuhal Koksal
- Turkish Public Health Agency, Preliminary Investigation Committee for Maternal Deaths, Turkish Ministry of Health, Ankara, Turkey
| | - Meltem Buz Baydilli
- Turkish Public Health Agency, Preliminary Investigation Committee for Maternal Deaths, Turkish Ministry of Health, Ankara, Turkey
| | - Meral Esen
- Turkish Public Health Agency, Preliminary Investigation Committee for Maternal Deaths, Turkish Ministry of Health, Ankara, Turkey
| | - Yurdum Karabacak
- Turkish Public Health Agency, Preliminary Investigation Committee for Maternal Deaths, Turkish Ministry of Health, Ankara, Turkey
| | - Veli Dundar Ongun
- Turkish Public Health Agency, Preliminary Investigation Committee for Maternal Deaths, Turkish Ministry of Health, Ankara, Turkey
| | - Tuba Esra Sahlar
- Turkish Public Health Agency, Preliminary Investigation Committee for Maternal Deaths, Turkish Ministry of Health, Ankara, Turkey
| | - Bekir Keskinkilic
- Turkish Public Health Agency, Preliminary Investigation Committee for Maternal Deaths, Turkish Ministry of Health, Ankara, Turkey
| | - Fatih Kara
- Turkish Public Health Agency, Preliminary Investigation Committee for Maternal Deaths, Turkish Ministry of Health, Ankara, Turkey
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Kinney MV, Ajayi G, de Graft-Johnson J, Hill K, Khadka N, Om’Iniabohs A, Mukora-Mutseyekwa F, Tayebwa E, Shittu O, Lipingu C, Kerber K, Nyakina JD, Ibekwe PC, Sayinzoga F, Madzima B, George AS, Thapa K. "It might be a statistic to me, but every death matters.": An assessment of facility-level maternal and perinatal death surveillance and response systems in four sub-Saharan African countries. PLoS One 2020; 15:e0243722. [PMID: 33338039 PMCID: PMC7748147 DOI: 10.1371/journal.pone.0243722] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Accepted: 11/29/2020] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Maternal and perinatal death surveillance and response (MPDSR) systems aim to understand and address key contributors to maternal and perinatal deaths to prevent future deaths. From 2016-2017, the US Agency for International Development's Maternal and Child Survival Program conducted an assessment of MPDSR implementation in Nigeria, Rwanda, Tanzania, and Zimbabwe. METHODS A cross-sectional, mixed-methods research design was used to assess MPDSR implementation. The study included a desk review, policy mapping, semistructured interviews with 41 subnational stakeholders, observations, and interviews with key informants at 55 purposefully selected facilities. Using a standardised tool with progress markers defined for six stages of implementation, each facility was assigned a score from 0-30. Quantitative and qualitative data were analysed from the 47 facilities with a score above 10 ('evidence of MPDSR practice'). RESULTS The mean calculated MPDSR implementation progress score across 47 facilities was 18.98 out of 30 (range: 11.75-27.38). The team observed variation across the national MPDSR guidelines and tools, and inconsistent implementation of MPDSR at subnational and facility levels. Nearly all facilities had a designated MPDSR coordinator, but varied in their availability and use of standardised forms and the frequency of mortality audit meetings. Few facilities (9%) had mechanisms in place to promote a no-blame environment. Some facilities (44%) could demonstrate evidence that a change occurred due to MPDSR. Factors enabling implementation included clear support from leadership, commitment from staff, and regular occurrence of meetings. Barriers included lack of health worker capacity, limited staff time, and limited staff motivation. CONCLUSION This study was the first to apply a standardised scoring methodology to assess subnational- and facility-level MPDSR implementation progress. Structures and processes for implementing MPDSR existed in all four countries. Many implementation gaps were identified that can inform priorities and future research for strengthening MPDSR in low-capacity settings.
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Affiliation(s)
- Mary V. Kinney
- Save the Children US, Washington, DC, United States of America
- University of the Western Cape, Cape Town, South Africa
| | - Gbaike Ajayi
- US Agency for International Development (USAID)’s Maternal and Child Survival Program (MCSP), Washington, DC, United States of America
- Jhpiego, Baltimore, Maryland, United States of America
| | - Joseph de Graft-Johnson
- Save the Children US, Washington, DC, United States of America
- US Agency for International Development (USAID)’s Maternal and Child Survival Program (MCSP), Washington, DC, United States of America
| | - Kathleen Hill
- US Agency for International Development (USAID)’s Maternal and Child Survival Program (MCSP), Washington, DC, United States of America
- Jhpiego, Baltimore, Maryland, United States of America
| | - Neena Khadka
- Save the Children US, Washington, DC, United States of America
- US Agency for International Development (USAID)’s Maternal and Child Survival Program (MCSP), Washington, DC, United States of America
| | - Alyssa Om’Iniabohs
- Save the Children US, Washington, DC, United States of America
- US Agency for International Development (USAID)’s Maternal and Child Survival Program (MCSP), Washington, DC, United States of America
| | | | | | | | | | - Kate Kerber
- Save the Children US, Washington, DC, United States of America
| | | | - Perpetus Chudi Ibekwe
- Maternal and perinatal death surveillance and response, Abakaliki, Ebonyi State, Nigeria
| | - Felix Sayinzoga
- Maternal, Child, and Community Health Division, Rwanda Biomedical Center, Kigali, Rwanda
| | - Bernard Madzima
- Family Health Directorate, Ministry of Health and Child Care, Harare, Zimbabwe
| | | | - Kusum Thapa
- US Agency for International Development (USAID)’s Maternal and Child Survival Program (MCSP), Washington, DC, United States of America
- Jhpiego, Baltimore, Maryland, United States of America
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Beigi M, Jahanian Sadatmahaleh S, Changizi N, Mohammadi E, Kazemi A. Analysis of the Iranian maternal mortality surveillance system and providing system improvement strategies: study protocol for strategy formulation. Reprod Health 2020; 17:111. [PMID: 32703296 PMCID: PMC7376841 DOI: 10.1186/s12978-020-00963-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Accepted: 07/13/2020] [Indexed: 11/18/2022] Open
Abstract
Background The implementation of the maternal mortality surveillance system in Iran has significantly reduced the incidence of maternal mortality. However, the pattern of the causes of the mortalities, which has remained constant over the years, are still concerning. This study aimed to explain the experiences of the actors of the Iranian maternal mortality surveillance and provide strategies for improving this system. Methods This research is a qualitative study to develop strategies, that will be conducted in two phases. In the first phase, purposive sampling will be performed, and the data will be collected based on the experiences of the Iranian maternal mortality surveillance system actors in Iran’s Ministry of Health and the selected universities (Shiraz, Isfahan, Tehran, Zahedan, Alborz, Shahrekord) through semi-structured interviews. Moreover, during this phase, some part of the data will be collected through random participation of the researcher in some maternal mortality committees of the selected universities. In order to carry out the second phase, a panel of experts will be set up to discuss the best strategies for improving the Iranian maternal mortality surveillance by considering the above results. Discussion The analysis of maternal mortality surveillance system needs to evaluate the experiences of the actors who are the policymakers of this system and can be effective in identifying its challenges. This analysis and formulation of the subsequent strategies can lead to maternal health indicators remaining within the range of international standards or even beyond those standards in Iranian universities and countries with similar surveillance system.
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Affiliation(s)
- Marjan Beigi
- Department of Midwifery and Reproductive Health, Faculty of Medical Sciences, Tarbiat Modares University, Tehran, Iran
| | | | | | - Eesa Mohammadi
- Department of Nursing, Faculty of Medical Sciences, Tarbiat Modares University, Tehran, Iran
| | - Ashraf Kazemi
- Nursing and Midwifery Care Research Center, Department of Midwifery and Reproductive Health, Faculty of Nursing and Midwifery, Isfahan University of Medical Sciences, Isfahan, Iran
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Sen G, Iyer A, Chattopadhyay S, Khosla R. When accountability meets power: realizing sexual and reproductive health and rights. Int J Equity Health 2020; 19:111. [PMID: 32635915 PMCID: PMC7341588 DOI: 10.1186/s12939-020-01221-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Accepted: 06/15/2020] [Indexed: 11/17/2022] Open
Abstract
This paper addresses a critical concern in realizing sexual and reproductive health and rights through policies and programs - the relationship between power and accountability. We examine accountability strategies for sexual and reproductive health and rights through the lens of power so that we might better understand and assess their actual working. Power often derives from deep structural inequalities, but also seeps into norms and beliefs, into what we 'know' as truth, and what we believe about the world and about ourselves within it. Power legitimizes hierarchy and authority, and manufactures consent. Its capillary action causes it to spread into every corner and social extremity, but also sets up the possibility of challenge and contestation.Using illustrative examples, we show that in some contexts accountability strategies may confront and transform adverse power relationships. In other contexts, power relations may be more resistant to change, giving rise to contestation, accommodation, negotiation or even subversion of the goals of accountability strategies. This raises an important question about measurement. How is one to assess the achievements of accountability strategies, given the shifting sands on which they are implemented?We argue that power-focused realist evaluations are needed that address four sets of questions about: i) the dimensions and sources of power that an accountability strategy confronts; ii) how power is built into the artefacts of the strategy - its objectives, rules, procedures, financing methods inter alia; iii) what incentives, disincentives and norms for behavior are set up by the interplay of the above; and iv) their consequences for the outcomes of the accountability strategy. We illustrate this approach through examples of performance, social and legal accountability strategies.
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Affiliation(s)
- Gita Sen
- Distinguished Professor and Director, Ramalingaswami Centre on Equity and Social Determinants of Health, Public Health Foundation of India, Bangalore, India
| | - Aditi Iyer
- Senior Research Scientist, Ramalingaswami Centre on Equity and Social Determinants of Health, Public Health Foundation of India, Bangalore, India
| | | | - Rajat Khosla
- Human Rights Advisor for the Human Reproduction Programme at the World Health Organization, Geneva, Switzerland
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Heslop P, Baker-Glenn E, Fleming P, Knight M, Mason M, Turnbull P, Wade C. The impact of the national clinical outcome review programmes in England: a review of the evidence. Clin Med (Lond) 2020; 20:e52-e58. [DOI: 10.7861/clinmed.2019-0359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Jayakody H, Knight M. Implementation assessment in confidential enquiry programmes: A scoping review. Paediatr Perinat Epidemiol 2020; 34:399-407. [PMID: 31846103 PMCID: PMC7383863 DOI: 10.1111/ppe.12604] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2019] [Revised: 09/08/2019] [Accepted: 09/17/2019] [Indexed: 01/30/2023]
Abstract
BACKGROUND Response should be a key part of maternal death surveillance and response (MDSR) programmes, which include confidential enquiries into maternal deaths. The programmes investigate avoidable factors in maternal deaths and make recommendations for improving maternity care. There is a gap in information on how these recommendations are transformed into practice. OBJECTIVE To explore the methods used to assess the implementation status of recommendations made in confidential enquiries into maternal deaths and other health outcomes. DATA SOURCES We searched PubMed, Web of Science, CINAHL, and Google Scholar databases and general web for grey literature using the "Arksey and O'Malley framework" in all major scientific databases and search engines. STUDY SELECTION AND DATA EXTRACTION An initial screening was followed by extraction of information using a data chart. Variables in the chart were based on the response component of maternal death and surveillance systems. SYNTHESIS Information collected was summarised using content analysis method. RESULTS We reviewed 13 confidential enquiry systems into maternal deaths. Many confidential enquiries into maternal deaths published reports with their recommendations and dissemination often involved national-level scientific presentations. Only five reports provided strategies for implementing the recommendations. Follow-up of previous recommendations was routinely published in only two reports. However, impact assessment of recommendations on other health outcomes was found only in the UK. CONCLUSION There is a gap in monitoring the response generated by confidential enquiries into maternal deaths. Actions to develop this are therefore needed.
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Affiliation(s)
- Hemali Jayakody
- National Perinatal Epidemiology UnitUniversity of OxfordOxfordUK
| | - Marian Knight
- National Perinatal Epidemiology UnitUniversity of OxfordOxfordUK
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Tura AK, Fage SG, Ibrahim AM, Mohamed A, Ahmed R, Gure T, Zwart J, van den Akker T. Beyond No Blame: Practical Challenges of Conducting Maternal and Perinatal Death Reviews in Eastern Ethiopia. GLOBAL HEALTH, SCIENCE AND PRACTICE 2020; 8:150-154. [PMID: 32461200 PMCID: PMC7326520 DOI: 10.9745/ghsp-d-19-00366] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Accepted: 03/24/2020] [Indexed: 11/15/2022]
Abstract
Lack of a professional body to address patients’ complaints regarding quality of health care and absence of clear medicolegal guidance hamper maternal death reviews in Ethiopia.
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Affiliation(s)
- Abera Kenay Tura
- School of Nursing and Midwifery, College of Health and Medical Sciences, Haramaya University, Harar, Ethiopia.
- Department of Obstetrics and Gynaecology, University Medical Centre Groningen, University of Groningen, Groningen, Netherlands
| | - Sagni Girma Fage
- School of Nursing and Midwifery, College of Health and Medical Sciences, Haramaya University, Harar, Ethiopia
| | - Alexander Mohamed Ibrahim
- Department of Obstetrics and Gynaecology, Hiwot Fana Specialized University Hospital, Harar, Ethiopia
| | - Ahmed Mohamed
- Department of Paediatrics, Hiwot Fana Specialized University Hospital, Harar, Ethiopia
| | - Redwan Ahmed
- Department of Obstetrics and Gynaecology, Hiwot Fana Specialized University Hospital, Harar, Ethiopia
| | - Tadesse Gure
- Department of Obstetrics and Gynaecology, Hiwot Fana Specialized University Hospital, Harar, Ethiopia
| | - Joost Zwart
- Department of Obstetrics and Gynaecology, Deventer Ziekenhuis, Deventer, Netherlands
| | - Thomas van den Akker
- Department of Obstetrics and Gynaecology, Leiden University Medical Centre, Leiden University, Leiden, Netherlands
- Athena Institute, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
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Tayebwa E, Sayinzoga F, Umunyana J, Thapa K, Ajayi E, Kim YM, van Dillen J, Stekelenburg J. Assessing Implementation of Maternal and Perinatal Death Surveillance and Response in Rwanda. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17124376. [PMID: 32570817 PMCID: PMC7345772 DOI: 10.3390/ijerph17124376] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/17/2020] [Revised: 06/15/2020] [Accepted: 06/16/2020] [Indexed: 11/16/2022]
Abstract
Maternal deaths remain a major public health concern in low- and middle-income countries. Implementation of maternal and perinatal deaths surveillance and response (MPDSR) is vital to reduce preventable deaths. The study aimed to assess implementation of MPDSR in Rwanda. We applied mixed methods following the six-step audit cycle for MPDSR to determine the level of implementation at 10 hospitals and three health centers. Results showed various stages of implementation of MPDSR across facilities. Maternal death audits were conducted regularly, and facilities had action plans to address modifiable factors. However, perinatal death audits were not formally done. Implementation was challenged by lack of enough motivated staff, heavy workload, lack of community engagement, no linkages with existing quality improvement efforts, no guidelines for review of stillbirths, incomplete medical records, poor classification of cause of death, and no sharing of feedback among others. Implementation of MPDSR varied from facility to facility indicating varying capacity gaps. There is need to integrate perinatal death audits with maternal death audits and ensure the process is part of other quality improvement initiatives at the facility level. More efforts are needed to support health facilities to improve implementation of MPDSR and contribute to achieving sustainable development goal (SDG) 3.
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Affiliation(s)
- Edwin Tayebwa
- IntraHealth International, P.O. Box 6639 Kigali, Rwanda;
- University Medical Centre Groningen, Department of Health Sciences, Global Health, University of Groningen, 9700 RB Groningen, The Netherlands;
- Correspondence:
| | | | | | - Kusum Thapa
- Jhpiego, An Affiliate of Johns Hopkins University, Baltimore, MD 21231, USA; (K.T.); (E.A.); (Y.-M.K.)
| | - Efugbaike Ajayi
- Jhpiego, An Affiliate of Johns Hopkins University, Baltimore, MD 21231, USA; (K.T.); (E.A.); (Y.-M.K.)
- Maternal and Child Survival Program, Washington, DC 20036, USA
| | - Young-Mi Kim
- Jhpiego, An Affiliate of Johns Hopkins University, Baltimore, MD 21231, USA; (K.T.); (E.A.); (Y.-M.K.)
| | - Jeroen van Dillen
- Amalia Children’s Hospital, Radboudumc Nijmegen, 6500 HB Nijmegen, The Netherlands;
| | - Jelle Stekelenburg
- University Medical Centre Groningen, Department of Health Sciences, Global Health, University of Groningen, 9700 RB Groningen, The Netherlands;
- Department of Obstetrics and Gynaecology, Leeuwarden Medical Centre, 8934 AD Leeuwarden, The Netherlands
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Hadush A, Dagnaw F, Getachew T, Bailey PE, Lawley R, Ruano AL. Triangulating data sources for further learning from and about the MDSR in Ethiopia: a cross-sectional review of facility based maternal death data from EmONC assessment and MDSR system. BMC Pregnancy Childbirth 2020; 20:206. [PMID: 32272930 PMCID: PMC7147013 DOI: 10.1186/s12884-020-02899-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2019] [Accepted: 03/27/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Triangulating findings from MDSR with other sources can better inform maternal health programs. A national Emergency Obstetric and Newborn Care (EmONC) assessment and the Maternal Death Surveillance and Response (MDSR) system provided data to determine the coverage of MDSR implementation in health facilities, the leading causes and contributing factors to death, and the extent to which life-saving interventions were provided to deceased women. METHODS This paper is based on triangulation of findings from a descriptive analysis of secondary data extracted from the 2016 EmONC assessment and the MDSR system databases. EmONC assessment was conducted in 3804 health facilities. Data from interview of each facility leader on MDSR implementation, review of 1305 registered maternal deaths and 679 chart reviews of maternal deaths that happened form May 16, 2015 to December 15, 2016 were included from the EmONC assessment. Case summary reports of 601 reviewed maternal deaths were included from the MDSR system. RESULTS A maternal death review committee was established in 64% of health facilities. 5.5% of facilities had submitted at least one maternal death summary report to the national MDSR database. Postpartum hemorrhage (10-27%) and severe preeclampsia/eclampsia (10-24.1%) were the leading primary causes of maternal death. In MDSR, delay-1 factors contributed to 7-33% of maternal deaths. Delay-2, related to reaching a facility, contributed to 32% & 40% of maternal deaths in the EmONC assessment and MDSR, respectively. Similarly, delay-3 factor due to delayed transfer of mothers to appropriate level of care contributed for 29 and 22% of maternal deaths. From the EmONC data, 72% of the women who died due to severe pre-eclampsia or eclampsia were given anticonvulsants while 48% of those dying of postpartum haemorrhage received uterotonics. CONCLUSION The facility level implementation coverage of MDSR was sub-optimal. Obstetric hemorrhage and severe preeclampsia or eclampsia were the leading causes of maternal death. Delayed arrival to facility (Delay 2) was the predominant contributing factor to facility-based maternal deaths. The limited EmONC provision should be the focus of quality improvement in health facilities.
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Affiliation(s)
| | - Ftalew Dagnaw
- Ethiopian Public Health Institute, Addis Ababa, Ethiopia
| | | | - Patricia E Bailey
- Averting Maternal Death & Disability, Columbia University, New York, NY, USA
| | - Ruth Lawley
- Evidence for Action, Options Consultancy Service, Addis Ababa, Ethiopia
| | - Ana Lorena Ruano
- Centre for International Health, Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
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Geleto A, Chojenta C, Taddele T, Loxton D. Magnitude and determinants of obstetric case fatality rate among women with the direct causes of maternal deaths in Ethiopia: a national cross sectional study. BMC Pregnancy Childbirth 2020; 20:130. [PMID: 32106814 PMCID: PMC7045465 DOI: 10.1186/s12884-020-2830-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Accepted: 02/20/2020] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND In sub-Saharan Africa, maternal death due to direct obstetric complications remains an important health threat for women. A high direct obstetric case fatality rate indicates a poor quality of obstetric care. Therefore, this study was aimed at assessing the magnitude and determinants of the direct obstetric case fatality rate among women admitted to hospitals with direct maternal complications. METHODS In 2015, the Ethiopian Public Health Institute conducted a national survey about emergency obstetric and newborn care in which data about maternal and neonatal health indicators were collected. Maternal health data from these large national dataset were analysed to address the objective of this study. Descriptive statistics were used to present hospital specific characteristics and the magnitude of direct obstetric case fatality rate. Logistic regression analysis was performed to examine determinants of the magnitude of direct obstetric case fatality rate and the degree of association was measured using an adjusted odds ratio with 95% confidence interval at p < 0.05. RESULTS Overall, 335,054 deliveries were conducted at hospitals and 68,002 (20.3%) of these women experienced direct obstetric complications. Prolonged labour (23.4%) and hypertensive disorders (11.6%) were the two leading causes of obstetric complications. Among women who experienced direct obstetric complications, 435 died, resulting in the crude direct obstetric case fatality rate of 0.64% (95% CI: 0.58-0.70%). Hypertensive disorders (27.8%) and maternal haemorrhage (23.9%) were the two leading causes of maternal deaths. The direct obstetric case fatality rate varied considerably with the complications that occurred; highest in postpartum haemorrhage (2.88%) followed by ruptured uterus (2.71%). Considerable regional variations observed in the direct obstetric case fatality rate; ranged from 0.27% (95% CI: 0.20-0.37%) at Addis Ababa city to 3.82% (95% CI: 1.42-8.13%) at the Gambella region. Type of hospitals, managing authority and payment required for the service were significantly associated with the magnitude of direct obstetric case fatality rate. CONCLUSIONS The high direct obstetric case fatality rate is an indication for poor quality of obstetric care. Considerable regional differences occurred with regard to the direct obstetric case fatality rate. Interventions should focus on quality improvement initiatives and equitable resource distribution to tackle the regional disparities.
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Affiliation(s)
- Ayele Geleto
- School of Public Health, College of Health and Medical Sciences, Haramaya University, Harar, Ethiopia. .,Research Centre for Generational Health and Ageing, School of Medicine and Public Health, Faculty of Health and Medicine, the University of Newcastle, Newcastle, Australia.
| | - Catherine Chojenta
- Research Centre for Generational Health and Ageing, School of Medicine and Public Health, Faculty of Health and Medicine, the University of Newcastle, Newcastle, Australia
| | - Tefera Taddele
- Health System and Reproductive Health Directorate, the Ethiopian Public Health Institute, Addis Ababa, Ethiopia
| | - Deborah Loxton
- Research Centre for Generational Health and Ageing, School of Medicine and Public Health, Faculty of Health and Medicine, the University of Newcastle, Newcastle, Australia
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Melberg A, Mirkuzie AH, Sisay TA, Sisay MM, Moland KM. 'Maternal deaths should simply be 0': politicization of maternal death reporting and review processes in Ethiopia. Health Policy Plan 2020; 34:492-498. [PMID: 31365076 PMCID: PMC6788214 DOI: 10.1093/heapol/czz075] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/04/2019] [Indexed: 11/17/2022] Open
Abstract
The Maternal Death Surveillance and Response system (MDSR) was implemented in Ethiopia in 2013 to record and review maternal deaths. The overall aim of the system is to identify and address gaps in order to prevent future death but, to date, around 10% of the expected number of deaths are reported. This article examines practices and reasoning involved in maternal death reporting and review practices in Ethiopia, building on the concept of ‘practical norms’. The study is based on multi-sited fieldwork at different levels of the Ethiopian health system including interviews, document analysis and observations, and has documented the politicized nature of MDSR implementation. Death reporting and review are challenged by the fact that maternal mortality is a main indicator of health system performance. Health workers and bureaucrats strive to balance conflicting demands when implementing the MDSR system: to report all deaths; to deliver perceived success in maternal mortality reduction by reporting as few deaths as possible; and to avoid personalized accountability for deaths. Fear of personal and political accountability for maternal deaths strongly influences not only reporting practices but also the care given in the study sites. Health workers report maternal deaths in ways that minimize their number and deflect responsibility for adverse outcomes. They attribute deaths to community and infrastructural factors, which are often beyond their control. The practical norms of how health workers report deaths perpetuate a skewed way of seeing problems and solutions in maternal health. On the basis of our findings, we argue that closer attention to the broader political context is needed to understand the implementation of MDSR and other surveillance systems.
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Affiliation(s)
- Andrea Melberg
- Centre for International Health, University of Bergen, Årstadveien 21, N-5007 Bergen, Norway
| | - Alemnesh Hailemariam Mirkuzie
- National Data Management Center for Health, Ethiopian Public Health Institute, Gulelle Arbegnoch Street, Gulele Sub City, Addis Ababa, Ethiopia
| | - Tesfamichael Awoke Sisay
- School of Public Health, College of Health Sciences, Addis Ababa University, Algeria Street, Arada Sub City, Addis Ababa, Ethiopia
| | - Mitike Molla Sisay
- School of Public Health, College of Health Sciences, Addis Ababa University, Algeria Street, Arada Sub City, Addis Ababa, Ethiopia
| | - Karen Marie Moland
- Centre for International Health, University of Bergen, Årstadveien 21, N-5007 Bergen, Norway.,Centre for Intervention Science in Maternal and Child Health, University of Bergen, Årstadveien 21, N-5007 Bergen, Norway
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van den Broek N. Happy Mother's Day? Maternal and neonatal mortality and morbidity in low- and middle-income countries. Int Health 2019; 11:353-357. [PMID: 31529113 PMCID: PMC6748767 DOI: 10.1093/inthealth/ihz058] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Revised: 06/03/2019] [Accepted: 07/12/2019] [Indexed: 11/24/2022] Open
Abstract
At least 800 women die each day during pregnancy or birth and more than 15 000 babies each day are stillborn or die in the first month of life. Almost all of these deaths occur in low- and middle-income countries. Many more women and babies are known to suffer morbidity as a result of pregnancy and childbirth. However, reliable estimates of the burden of physical, psychological and social morbidity and comorbidity during and after pregnancy are not available. Although there is no single intervention or ‘magic bullet’ that would reduce mortality and improve health, there are evidence-based care packages which are defined and agreed internationally. A functioning health system with care available and accessible for everyone at all times is required to ensure women and babies survive and thrive.
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Affiliation(s)
- Nynke van den Broek
- Centre for Maternal and Newborn Health, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, L3 5QA, UK
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50
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Aikpitanyi J, Ohenhen V, Ugbodaga P, Ojemhen B, Omo-Omorodion BI, Ntoimo LFC, Imongan W, Balogun JA, Okonofua FE. Maternal death review and surveillance: The case of Central Hospital, Benin City, Nigeria. PLoS One 2019; 14:e0226075. [PMID: 31856173 PMCID: PMC6922332 DOI: 10.1371/journal.pone.0226075] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2019] [Accepted: 11/18/2019] [Indexed: 12/03/2022] Open
Abstract
Background Despite the adoption of Maternal and Perinatal Death Surveillance and Response (MPDSR) by Nigeria’s Federal Ministry of Health to track and rectify the causes of maternal mortality, very limited documentation exists on experiences with the method and its outcomes at institutional and policy levels. Objective The objective of this study was to identify through the MPDSR process, the medical causes and contributory factors of maternal mortality, and to elucidate the policy response that took place after the dissemination of the results. Methods The study was conducted at the Central Hospital, Benin between October 1, 2017, and May 31, 2019. We first developed a strategic plan with the objective to reduce maternal mortality by 50% in the hospital in two years. An MPDSR committee was established and the members and all staff of the Maternity Department of the hospital were trained to use the nationally approved protocol. All consecutive cases of maternal deaths in the hospital were then reviewed using the MPDSR protocol. The results were submitted to the hospital Management and its supporting agencies for administrative action to correct the identified deficiencies. Results There were 18 maternal deaths in the hospital during the period, and 4,557 deliveries giving a maternal mortality ratio (MMR) of 395/100,000 deliveries. This amounted to a seven-fold reduction in MMR in the hospital at the onset of the project. The main medical causes identified were obstetric hemorrhage (n = 10), pulmonary embolism (n = 2), ruptured uterus (n = 2), eclampsia (n = 1), anemic heart failure (n = 1) and post-partum sepsis (n = 2). Several facility-based and patient contributory factors were identified such as lack of blood in the hospital and late reporting with severe obstetric complication among others. Response to the recommendations from the committee include increased commitment of hospital managers to immediately rectify the attributable causes of deaths, the establishment of a couples health education program, mobilization and sensitization of staff to handle pregnant women with great sensitivity, promptness and care, the refurbishing of an intensive care unit, and the increased availability of blood for transfusion through the intensification of blood donation drive in the hospital. Conclusion We conclude that the results of MPDSR, when acted upon by hospital managers and policymakers can lead to an improvement in quality of care and a consequent decline in maternal mortality ratio in referral hospitals.
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Affiliation(s)
- Josephine Aikpitanyi
- The Women’s Health and Action Research Centre (WHARC), Benin City, Nigeria
- The Centre of Excellence in Reproductive Health Innovation (CERHI), University of Benin, Benin City, Nigeria
| | - Victor Ohenhen
- The Centre of Excellence in Reproductive Health Innovation (CERHI), University of Benin, Benin City, Nigeria
- The Central Hospital, Benin City, Nigeria
| | | | - Best Ojemhen
- The Women’s Health and Action Research Centre (WHARC), Benin City, Nigeria
- The Centre of Excellence in Reproductive Health Innovation (CERHI), University of Benin, Benin City, Nigeria
| | | | - Lorretta FC Ntoimo
- The Women’s Health and Action Research Centre (WHARC), Benin City, Nigeria
- The Federal University, Oye-Ekiti, Nigeria
| | - Wilson Imongan
- The Women’s Health and Action Research Centre (WHARC), Benin City, Nigeria
| | - Joseph A. Balogun
- The University of Medical Sciences, Ondo City, Ondo State, Nigeria
- Chicago State University, Chicago, United States of America
| | - Friday E. Okonofua
- The Women’s Health and Action Research Centre (WHARC), Benin City, Nigeria
- The Centre of Excellence in Reproductive Health Innovation (CERHI), University of Benin, Benin City, Nigeria
- The University of Medical Sciences, Ondo City, Ondo State, Nigeria
- * E-mail:
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