MATERNAL DEATH AUDIT & REVIEW – A CHALLENGE

Dr. S. S. Datta

Dist. MCH Officer, Nadia

KEY FACTS OF MATERNAL DEATHS – W.H.O, MAY, 2012 Every day, approximately 800 women die from

preventable causes related to pregnancy and childbirth. 99% of all maternal deaths occur in developing countries. Maternal mortality is higher in women living in rural areas

and among poorer communities. Young adolescents face a higher risk of

complications and death as a result of pregnancy than older women.

Skilled care before, during and after childbirth can save the lives of women to achieve MDG 5 (to reduce maternal mortality by three quarters between 1990 and 2015 – for India=109)

The major complications that account for 80% of all maternal deaths are: Severe bleeding (mostly bleeding after childbirth) Infections (usually after childbirth) High blood pressure during pregnancy (pre-eclampsia and

eclampsia) Unsafe abortion.

MMR – INDIA & WEST BENGAL

1997-98 1991-01 2001-03 2004-06 2007-09

398

327301

254

212

303

218194

141 145

India West Bengal

PREVENT MATERNAL DEATHS – CONCEPT OF “DELAYS”

1. Delay in Seeking Care Unawareness of danger signs Illiteracy & Ignorance Delay in decision making No birth preparedness Beliefs and customs Non availability of health care professional Any other/specify

2. Delay in reaching first level health facility Delay in getting transport Delay in mobilizing funds Not reaching appropriate facility in time Difficult terrain Any other/specify

3. Delay in receiving adequate care in facility Delay in initiating treatment Substandard care in hospital Lack of blood, equipment & drugs Lack of adequate funds Any other/specify

WHY MATERNAL DEATH REVIEW

Maternal Death Review lies in the fact that it provides detailed information on various factors at facility, district, community, regional and national level that are needed to be addressed to reduce maternal deaths. Analysis of these deaths can identify the delays that contribute to maternal deaths at various levels and the information used to adopt measures to fill the gaps in service.

The process of MDR should not be utilized for taking punitive action against service providers.

GUIDELINE

The objectives of the guidelines are: To establish operational mechanisms/modalities

for undertaking MDR at selected institutions and in community level

To disseminate information on data collection tools, data/information flow, analysis

To develop systems for review and remedial follow up actions

METHODS FOR INVESTIGATING MATERNAL DEATHS:

Community based maternal death reviews The main purpose of the CBMDR is to identify the maternal

deaths would be the first step in the process, the second step would be the investigation of the factors/causes which led to the maternal death – whether medical, social, systemic, and the third step would be to take appropriate and corrective measures on these.

Facility based maternal death reviews Identifying maternal deaths would be the first step in the process

of review, the second step would be the investigation of the causes which led to the maternal death mainly clinical and systemic and the third step would be to take appropriate and corrective measures.

INVESTIGATING OFFICER/HEALTH PERSONNEL

For Facility Based Maternal Death Investigation:

1. MCH: G&O faculty to be nominated by HOD G&O Deptt. (G&O specialist looking after the deceased will not be entitled to investigate)

2. Health Facilities at Districts: Sub-Divisional ACMOHs

For Community Based Maternal Death Investigation:

1. Community: BPHN/PHN

MDR COMMITTEES AT DISTRICT LEVELDistrict Maternal Death Review Committee under the chairpersonship of District CMOH: Every district will have a committee for maternal death review. DMCHO will be the nodal

person for this committee. The District MDR Committee will review all the maternal deaths in the district once every month on a pre-fixed date.

District MDR Committee should have following members- CMOH as the chairman. DMCHO as Nodal Officer Sub divisional ACMOHs as nodal officer for FBMDR Medical officer of Gynaecology & Obstetrics Anaesthetist / Physician Officer in charge of blood bank/blood storage centre Senior nurse nominated by the CMOHH Invited members from the facilities where maternal death has taken place. One representative from district administration (ADM), to be nominated by DM.

Facility Based MDR Committee: At DH/SGH/SDH/RH/BPHC: Every facility will have a committee for maternal death review

in the facility. Sub Divisional ACMOHs will be the Nodal Officer for FB-MDR. Following are the members of this committee: Supdtt./MO-I/C, G & O specialist, Physician,

Anesthetist, Nursing Personnel, MO-Blood Bank and any other relevant departments. The Nodal officer will be the member secretary of this committee. The FB MDR Committee will review all the maternal deaths in the facility once every month on a pre-fixed date.

FLOW OF CBMDR PROCESSReporting of Maternal deaths

ANM reports the maternal death (Maternal Death Information reporting Format - Annexure-6) to BMOH/BPHN. But telephonic intimation should be made immediately within 24hrs after the occurrence of any maternal death to BMOH/BPHN.BMOH will immediately send information of this death by telephone within 24 hours to the ACMOH, DMCHO & CMOH.

Investigate the maternal deaths

BMOH deploys BPHN/PHN visit the deceased woman’s house and conduct a Verbal Autopsy within 2 to 3 weeks of death using the Verbal Autopsy Questionnaire.( Verbal Autopsy Format – Annexure-2)

Summary of each case is drawn

BMOH will draw a Case summary sheet (Case Summary Sheet Format – Annexure-3) for every maternal death investigated sent to the District CMO as soon as possible.

Review the cause of death at block Level

Confirmed death recorded at Block level -All the confirmed maternal deaths have to be recorded serially in a register at block level (Block level register format at Annexure – 4)

Monthly Maternal Death review at CMOH Level

The District MDR Committee will review all the maternal deaths in the district once every month on a pre-fixed date.

Quarterly Review at DM level

All the Maternal Death Reports compiled by the District MDR Committee will be put up to the District Magistrate, in the form of Case Summaries. The DM will review in detail of these deaths in the quarterly meeting. DMCHO will assist the DM in these quarterly reviews.

Reporting of deaths of women

For DH/SDH/SGH/RH and below level: The Superintendent/ MO- I/C reports to the ACMOH, DMCHO, and CMOH by telephone within 24hrs after the occurrence of any maternal death in the facility.

Formation of Facility based MDR Committee

For DH/SDH/SGH/RH and below level: Sub Divisional ACMOHs will be the Nodal Officer for FB-MDR. Following are the members of this committee: Supdtt./BMOH/MO-I/C, specialists from Gynecology & Obstetrics, Anesthesia, Medicine, N.S/ D.N.S., M.O.-Blood Bank and any other relevant departments.

Investigate the maternal deaths

For DH/SDH/SGH/RH and below level: For each case of maternal death, the form for facility based MDR at Annexure 1 is to be filled up and signed by ACMOH in consultation with on duty /Medical Officer I/C ward/emergency within 24 hours .

Review the cause of death at Facility

Monthly Review of all Maternal Deaths at the facility by the FB- MDR Committee at Facility level. The committee will have the responsibility of reviewing all the MDR forms filled and collected during the month. All deaths should be entered in Annexure 4

Summary of each case is drawn

For DH/SDH/SGH/RH and below level: ACMOH will submit the filled up FBMDR Questionnaire including Case summary sheet (Annexure 3) to the CMOH on a monthly basis.

Monthly review at CMOH Level

The District MDR Committee will review all the maternal deaths in the district once every month on a pre-fixed date.

Quarterly Review at DM level

The DM will review in detail of these deaths in the quarterly meeting. DMCHO will assist the DM in these quarterly reviews.

FLOW OF FBMDR PROCESS

MATERNAL DEATH REVIEW

APRIL 2012-MARCH 2013

Nadia

STATUS OF MDR IN THE DISTRICT - REPORTING

Total live births: 72,817 No. of maternal deaths reported: 54 No. of facilities reported MDs (names & no.s): 13 (DH -

10, Chapra RH-1, Nabadwip SGH - 1, Tehatta SDH -1) No. of blocks reported MDs (names & no.s): 50

(Chapra – 8, Karimpur II – 7, Maheshganj , Nakashipara & Ranaghat II – 6, Santipur, Tehatta I, Krishnagar I & Krishnagar II -3, Hanskhali – 2, Haringhata, Kaliganj & Karimpur I-1)

Blocks not reported a single MD: Ranaghat-I, Tehatta-II, Nabadweep & Krishnaganj

STATUS OF MDR IN THE DISTRICTINVESTIGATION & REVIEW

No. of MDs investigated: 54By only FBMDR: 04By only CBMDR: 41Both : 9

No. of review meetings held:Chaired by CMOH: 7Chaired by DM: 1

MAJOR FINDINGS Place of death:

On road-09, Home–04, Private facility-2, Public facility-39(with in district – 21, outside district - 18)

Time of Death: Antepartum-17, Intrapartum-04, Postpartum-32

(L.B-23, S.B-9) Age of women at death: Mean age-25yrs.

Age ≤ 20yrs. - 13 Gravida: Primi-19, 2nd Gravida-16 Religion: Hindu = 34/ Muslim = 20 Risk factors identified: 08 (High BP-3, out of

which 1 died of eclampsia)

MAJOR FINDINGS – MORTALITY PROFILE

12; 22%

5; 9%

1; 2%

5; 9%

31; 57%

Haemorrhage Eclampsia Obst. Labour SepsisOthers

MAJOR FINDINGS – SERVICE PROVIDED

Comments on: Delays:

Delay in seeking treatment: 07 (Hge-2, Obst. Labor-1, Sepsis-1, Others-3)

Delay in transport: 01 Delay in treatment: 04 (Blood transfusion)

Care received: ≥ 4 ANC: 15 3 ANC: 17 2 ANC: 03 1 ANC: 03 No ANC: 04 (Ectopic-1, Sepsis-1, Hge.-1, Other-1) PNC: No PNC in 2 cases

KEY ISSUES IDENTIFIED Community Issues:

Early age of marriage & Childbirth Lack of planning of delivery & transport Lack of identification of danger sign Lack of quality of post natal care

Supply side Issues: Lack of quality ANC – birth planning,, transport

planning, risk factor identification 102 – Ambulance many a times found busy Poor functioning of B.B / BSU Poor quality intranatal care lack of adherence to labour room protocol.

KEY ACTION POINTS/RECOMMENDATIONS EMERGED FROM THE MATERNAL DEATH REVIEWS Action points for facility level: Monthly MDR meeting with

corrective measures to be taken to avoid delay 3, Strict adherence to L.R (partograph etc.) & JSSK protocol, Avoid indiscriminate use of ‘Misoprostol’ for induction of labour

Action points for community level: Fill up of case summery by BMOH, Provision of quality ANC by the ANM, BCC by ASHAs, Involvement of Social welfare, Education, PRI & Civil administration for prevention of early marriage

Action points for district level: Ensuring availability of ambulance service, drugs & investigations (JSSK) and Functioning of BSU/BB. District Level MDR training for both, facility and community level.

Action points for state level: HR crisis management for proper functioning of CEmOC center. Arrange requisite fund for District level training.

CHALLENGES Poor involvement of ACMOHs for conducting

regular FBMDR meetings FBMDR forms (Annexure 1) were not properly

filled up by the Superintendent / ACMOH Poor involvement of Specialists doctors in fill

up of BHT, cause of death (Direct, indirect & underlying)

Quality of CBMDR (Annexure 2) reporting is poor – all the points were not filled up & no case summery (Annexure 3) given by the BMOHs

Crisis of Human Resources at facility level Social factors for early age of marriage &

pregnancy

OPPORTUNITIES

Optimum use of: JSSKNischay-YanAdolescent / Annwesha counselor to

impart IEC for birth preparedness & avoid early marriage and early pregnancy

B.B & BSU – 24x7 functioningSC untied fund could be utilized for

patient ref. in absence of Nischay-Yan (provision is there in the order)