maternal death review -surveillance and indicator analysis
TRANSCRIPT
“Women are not dying because of a disease we can not treat. They are dying because societies have yet to make the decision that their lives are worth saving”
---------Mamoud Fathalla
The death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of
the duration and site of the pregnancy, from any cause related to or aggravated by the pregnancy or
its management but not from accidental or incidental causes.
Maternal Death?
Goal Target Indicators Achievements
MDG-5: To improve Maternal health
NRHM/RCH II-Reduce to 100/1,00,000 Live-births
MMR
Proportion of births attended by SBA.
Institutional delivery.
MMR : 167 per 100,000 live births
52.6 %Safe Delivery47% Institutional Delivery
76%Safe Delivery72.9% Institutional Delivery(UNICEF Coverage Evaluation Survey 2009)
MDG goals, targets and indicators …MDG 5… NRHM /RCH goals in line
Maternal Deaths… unacceptable numbers
• 28 million pregnancies per year in India
• 26 million live births
• 15% of pregnancies likely to develop complications
• 67 000 maternal deaths in a year
Maternal Death Scenario
Maternal Mortality Ratio (MMR) India
India & Major States MMRINDIA 167Assam 300Bihar / Jharkhand 208Madhya Pradesh / Chhatisgarh 221Orissa 222Rajasthan 244Uttar Pradesh / Uttarakhand 285EAG AND ASSAM SUBTOTAL 246Andhra Pradesh 92Karnataka 133Kerala 61Tamil Nadu 79SOUTH SUBTOTAL 93Gujarat 112Haryana 127Maharashtra 68Punjab 141West Bengal 113Other states 126OTHER sub total 115
MULTI-PRONGED
APPROACH..
Maternal Health Strategies
Demand Promotion-
( Janani Suraksha Yojana)
Provision of services Public sector
1. Essential and Emergency Obstetric Care•Quality ANC, INC, Safe and Institutional delivery•Skilled birth attendance•Multi-skilling 2.Operationalize FRU s & 24*7 PHCs 3. Services for RTIs & STIs –convergence with the NACP4. Safe abortion services- New Guidelines5. Strengthen referral systems6. Village Health and Nutrition Day.. Mother-Child Protection Card
Provision of Services : Private sector
•Accreditation of Pvt. Health Facilities for RCH services and SBA training•Fixed package for outsourcing services
• Maternal Death Review• Pregnancy and Child Tracking –web based system• Prioritizing resources for identified “delivery points” or MCH Centres
New
MATERNAL DEATH REVIEWMDR
• 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
Objectives
Maternal deaths in the community (CBMDR)
Maternal deaths in facilities (FBMDR)
Confidential enquiries into maternal deaths
Learning from women who survived: “near miss” cases
Evidence-based clinical audit
Five approaches to help understand why women die ...
• Identify cases (maternal deaths)
• Review cases confidentially and no blame
• Look for avoidable factors
• Promote change in practices
• Review the outcome of these changes
• Refine and develop
All these approaches…….
• Reduce maternal mortality and morbidity• Improve quality of obstetric care• Understand determinants of maternal death • Provide stimulus for action at all levels• Take corrective action to fill the gaps in service provision
Prerequisite:
A commitment to act upon the findings Not for punitive action
Why conduct maternal death
Direct Deaths resulting from obstetric complications in pregnancy, labour and puerperium
Indirect Deaths resulting from previous existing disease or diseases that developed during
pregnancy and which was aggravated during pregnancyFortuitous
Deaths from other causes not related to or influenced by pregnancy
Only direct and indirect deaths are included in MMR calculation.
Classification Maternal Death Cause
Maternal Death Review (MDR)
Community Based Maternal Death Review (CBMDR)
Facility Based Maternal Death Review (FBMDR)
• It is a method of finding out the medical causes of death and ascertaining the personal, family or community factors that may have contributed to the deaths.
• Community based reviews must be taken up for all deaths that occurred in the specified geographical area, irrespective of the place of death, be it at home, facility or in transit.
• The BMO is overall responsible for the MD review process at the block and will act as a supervisor for the investigation team.
Community Based Maternal Death Review (CBMDR)
Investigation of the maternal deaths will be done using Verbal Autopsy Format within 3 weeks (21 days)of notification
BMO must report suspected maternal deaths to the State Nodal Officer by telephone within 24 hours.
The ASHA/AWW/ANM will fill up the format for primary informer and send the format to the BMO.
The ASHA/AWW/ANM will notify all women deaths in the age group of 15 to 49 years from her area by telephone to the BMO within 24 hour.
Steps of Community Based Maternal Death Review
• Appoint the ANM/LHV to visit the family of the deceased to verify whether or not it is a maternal or non- maternal death, after receiving primary informer format from the notifier.
• Report all suspected maternal deaths to the DNO based on the report from the primary informant by phone and by sending Format for Primary Informer.
• Report suspected maternal deaths to the State Nodal Officer by telephone within 24 hours
• Maintain registers of all women deaths (15-49 yrs) & maternal deaths.
• Assigns interview team to investigate and fills the first page of the Format for Verbal Autopsy. The cause of the death can be filled based on the findings after the investigation is completed
• It is desirable that the BMO should be part of the investigation team. In his absence, he may nominate another medical officer from the block PHC to be a part of the team.
• Scrutinize filled up forms to ensure the form is complete and filled correctly.
• Prepare Case summary for all the maternal deaths in consultation with the team which investigated and send it to the DNO along with the filled in investigation format , within a month of the date of notification.
• Conduct monthly meetings to review the whole process and take corrective actions at his level. Reporting system should be reviewed even if there are no cases in his block.
• The BMO will pay Rs. 200/- to the primary informant and Rs 300/- for conducting the investigation in the field.
Responsibilities of BMO
Facility Based Maternal Death Review
Facility Based Maternal Deaths Reviews will be taken up for all Government teaching hospitals, referral hospitals and other hospitals (District, Sub district, CHCs) where more than 500 deliveries are conducted in a year.
Steps of Facility Based Maternal Death Review
All Maternal deaths occurring in the hospital, including abortions and ectopic gestation related deaths, in pregnant women or within 42 days after termination of pregnancy irrespective of duration or site of pregnancy should be informed immediately by the Medical officer who has treated the mother and was on duty at the time of occurrence of death to the Facility Nodal officer (FNO)
NotificationThe FNO of the hospital should inform the maternal death to the District Nodal Officer (DNO) and state nodal officer by telephone within 24 hours of the occurrence of death. The Nodal officer of the hospital should complete the primary informant format Annex 6 and send it to the DNO within 24hrs of the occurrence of maternal death
Investigation
Any maternal death which occurred in the hospital should be immediately investigated within 24hrs by the Medical officer who had treated the mother and was on duty at the time of occurrence of death using the Facility Based Maternal Death Review (FBMDR) Format
The FBMDR format should be filled in triplicate, one copy would be retained by the FNO, one would be sent by the FNO to the DNO within 24hrs and the other to the Facility Maternal Death Review (MDR) committee of the Hospital.
Inform the District Nodal officer and state nodal officer on the occurrence of maternal death in the
hospital within 24hours.
Send the primary informant format (Annex 6) duly filled to the District Nodal officer within 24 hours
To review the FBMDR format filled by the medical officer and approve it.
Retain one copy of the FBR format with him/her, send one copy to the Facility based Maternal Death
Review Committee and the other to the DNO within 24hrs of the maternal death.
He/ She have to prepare a case summary and send it to the Facility based Maternal Death Review
Committee along with a copy of the case sheet.
The case sheet should be numbered and have the patient name and registration number on each page.
Will keep a register of all maternal deaths in the facility; line listing of maternal deaths (Annexure 4)
He/ She will be the nodal persons for organizing the FBMDR Committee at the hospital
He/ She will be attending the FBMDR Committee meeting at the District level and also the Review
conducted by the District Magistrate (DM). Another senior officer may be nominated in his/her absence.
Role of Facility Nodal Officer
• Hospital superintendent
• FNO (Obstetrician from the Dept)
• At least two obstetricians/MO in OBG department as members
• One Anaesthetist
• One Blood Bank MO
• Nursing Representative
• One Physician
Facility Based Maternal Death Review Committee (FBMDRC)
FBMDRC at District Hospital
• The FNO fixes the monthly meeting in discussion with the Hospital superintendent.
• Conducts monthly review meeting once in a month with the FBMDR format and case summary.
• Suggests corrective measures and steps to be taken to improve quality of care at the hospital
• Suggests steps to be taken at the District level and State level.
• Sends minutes of meeting to DNO along with the case summary prepared.
Responsibilities of Facility Based Maternal Death Review Committee
Maternal Death Review at District Level
The Chief Medical Officer (CMO) is mainly responsible for the Maternal Death Reviews at the District level. Both facility and community based reviews would be taken up at this level
CMO (chairman) DNO (member secretary) ACMO Head of Department of Obstetrics & Gynaecology (teaching hospital/district hospital) Anaesthetist Officer in charge of blood bank/blood storage centre Senior nurse nominated by the CMO/CS/DPHNO MO who had attended the case in the facility should be invited
District Level Maternal Death Review Committee under the chairmanship of CMO
At district level there will be two review meetings, one under the chairmanship of the CMO, second led by the District Magistrate.
Constitution of MDR committee at District level as per Govt order No. 324-HME of 2011 Dated 4-07-2011 is as follows:
• District Magistrate-Chairperson
• Chief Medical Officer-Member Secy./ Convener
• Dy. Chief Medical Officer-Member
• District Nodal Officer (MDR)-Member
• Facility Based Nodal Officer (MDR)-Member
• Representative of Federation of Obstetric and Gynecological Society of India (FOGSI)-Member
Maternal Death Review at District Level
District Level Maternal Death Review Committee under the chairmanship of District Magistrate
• Ensure the reception of all formats (facility and community) every month
• Review all the maternal deaths from both facility and community
• Hold monthly review meetings and recommend corrective measures.
• Select a few cases for review by the DM. Ensure participation of the family members.
• Conduct quarterly review meetings with analyzed data and process indicators identified.
• Find means of sharing the district level data from the verbal autopsy with the communities to create awareness and initiate action at village level.
• Facilitate, through the DNO, the monthly review meeting with the District Magistrate (DM), and send minutes of both meetings (District MDR committee meeting and the meeting with DM) to state level.
• Facilitate the data entry and analysis at the district level (including HMIS).
Responsibilities of CMO
The minutes of the meeting will be recorded in a register. The corrective measures will be grouped into 3 categories with time lines:
• Corrective measures at the community level
• Corrective measures needed at the facility level
• Corrective measures for which state support is needed
Minutes of Meeting
• Supervise MDR implementation in the district - both at facility and community level.
• Receive notification of all suspected maternal deaths from the BMO and maternal deaths from the nodal officer of the hospital (by phone and by format)
• Receive investigation format and case summary of CBMDR from the blocks and FBMDR from the hospitals.
• Create a combined Line-listing of Maternal deaths based on the case summary formats from both facility and community from all blocks
• Prepare a compiled case summary, when applicable
• Coordinate the District MDR committee meeting and the review meeting with the district magistrate (DM)
• Arrange to bring two relatives of the deceased to attend the review meeting with DM. Only relatives who were with the mother during the treatment of complications may be invited for the meeting.
• Ensure that the training of the block level interviewers and the BMO have taken place
• Facilitate the printing of formats by the District Health Society (DHS) (forms used at all levels) and ensure its availability at blocks and facilities.
• Represent the district in state level review meetings
• Prepare the minutes of the District MDR committee meeting and the meeting with the DM
• Follow up the recommendations/corrective actions at district, block and facility level
• Orientation to the Medical Officers of the hospital on use of FBMDR formats
Responsibilities of District Nodal Officer
• Maternal Death reporting: -
A provision of Rs 200.00 has been kept for reporting maternal death by ASHA.
• Maternal Death Investigation: -
An amount of Rs. 300 per investigation shall be provided for Death Investigation (Verbal Autopsy). Investigations reports are to be furnished to GOI through State Health Society on monthly basis.
Monetary Incentives
Formats for Maternal Death and Its Review……………
Contd.
CBMDR
FBMDR
Anex-3
Formats for Maternal Death and Its Review……………
Community Based Review CBMDR Format + Anex-3 MDR Case Summary
Facility Based Review FBMDR Format + Anex-3 MDR Case Summary
Maternal Death Review Format need be used
Point to be remember: Line listing of each maternal death should be maintained by block and district Listing of MDR status should be maintained by district
Maternal Death Surveillance and Response (MDSR) system
“A maternal death surveillance and response system that includes maternal death identification, reporting, review and response can provide the essential information to stimulate and guide action to prevent future maternal deaths and improve the measurement of maternal mortality.”
……………. Danel, Graham & Boerma
Need for Maternal Death Surveillance & Response ( MDSR)
Maternal death surveillance provides information for taking appropriate action to prevent deaths MDSR involves systematic notification of pregnancy related death, continuous analysis of the cause
and geographic distribution of these deaths, and the use of that information to inform and evaluate public health practices
An MDSR system aim to identify every maternal death in order to accurately monitor maternal mortality and the impact of intervention to reduce it
Aim of MDSR
Surveillance
Identify Deaths
Report deaths
Response
Review Deaths
Response action
Maternal death surveillance and response system : a continuous action cycle at community, facility, regional and national level
Set Up
Awareness creation among health care workers and the community
Process of the MDSR system
Analysis (aggregation of multiple case reviews) –perspective on national, regional and provincial level
Dissemination of results
Response
M& E for MDSR
For successful implementation of maternal death review the following settings are needed
Establish National, regional and local committee
Determine roles and responsibilities of key actor
Availing tools and guidelines for MDSR
Legal and ethical consideration
MDSR System
Set Up
Awareness creation among health care workers and the community
Process of the MDSR system
Analysis (aggregation of multiple case reviews) –perspective on national, regional and provincial level
Dissemination of results
Response
M& E for MDSR
In MDSR system, health workers will be involved in a
variety of ways such as data collection, revision or care
provision
Orientation is needed for health care staff on objectives,
processes and principles of MDSR
Awareness creation to community is important as death
occur there and for establishment of ownership of the
review process
For community based reviews, the support of local
village leaders and religious and cultural leaders is
essential
MDSR System
Set Up
Awareness creation among health care workers and the community
Process of the MDSR system
Analysis (aggregation of multiple case reviews) –perspective on national, regional and provincial level
Dissemination of results
Response
M& E for MDSR
Source of information Community:
For identification: community health workers, ASHA community leader
For verbal autopsy: person primarily attended the women during illness, delivery, person present at the site of the women at the time of death
Health facility For notifying: head of maternity/labour wardFor facility deaths reviews: referral sheets, medical
records, log books, attending health workers, others
Identification and reporting of maternal deathsIdentification: In community (CHW, ANM, ASHA,
community leader) In facility (Sister in charge/SNs)
Data content and data collection: Demographic data, prenatal history, delivery information, death information, avoidable factor
Reviewing the event
MDSR System
Set Up
Awareness creation among health care workers and the community
Process of the MDSR system
Analysis (aggregation of multiple case reviews) –perspective on national, regional and provincial level
Dissemination of results
Response
M& E for MDSR
Data analysis is critical to provide useful information to
guide action
The best approach is a combination of both qualitative
and quantitative analysis
Qualitative analysis of each case identifies the medical
and non medical problems that contributed to the death
The use of qualitative and quantitative analysis together
allows one to both understand what the problems and
prioritize the action to remediate them
Analysis need to be done at all level like block, district,
state, regional and national level
MDSR System
Set Up
Awareness creation among health care workers and the community
Process of the MDSR system
Analysis (aggregation of multiple case reviews) –perspective on national, regional and provincial level
Dissemination of results
Response
M& E for MDSR
Whom to inform of the resultsMinistry of Health, local, regional and national
health care planners,
Method for dissemination of resultsTeam meeting, community meeting, training programme etc.
MDSR System
Set Up
Awareness creation among health care workers and the community
Process of the MDSR system
Analysis (aggregation of multiple case reviews) –perspective on national, regional and provincial level
Dissemination of results
Response
M& E for MDSR
Taking action to prevent maternal deaths is the primary
objective of MDSR
In most reviews, multiple problems will be identified,
and a number of potential actions will be recommended
Possible action include interventions in the community,
within health services, and in the public sector
MDSR System
Set Up
Awareness creation among health care workers and the community
Process of the MDSR system
Analysis (aggregation of multiple case reviews) –perspective on national, regional and provincial level
Dissemination of results
Response
M& E for MDSR
Indicators for monitoring of MDSR
Overall system indicators: Maternal deaths is notifiable event National Maternal death review task force exist that meets regularly National maternal mortality report published annually % of facilities with maternal death review committees % of provinces with someone responsible for MDSR
Identification and reporting % of maternal deaths reported within 48 hours in facilities % of community maternal deaths reported within 1 week
MDSR System
Place of deaths identified
Depth of review process
Deaths in govt. facilities
Deaths in the community
Deaths in all facilities
All deaths in facilities and community
Urban areas only
Sample of districts
National coverage
Scale of converge of MD
SR system
Summary of
sample deathsSummary of
all deathsIn depth
enquiry of sample
Full confidential
enquiry of all
death
Main Dimensions for a Phased Roll-out of MDSR system
MATERNAL DEATH INDICATOR AND ANALYSIS
• Process indicators
• Program indicators
• HMIS
Types of Indicator
CB-MDR PROCESS INDICATORS
Proportion of maternal deaths investigated in the district Reported versus expected/estimatedInvestigated versus reported
Proportion of eligible institutions that conducted FBMDRNumber of maternal deaths reportedProportion of maternal deaths investigatedProportion of eligible institutions that conducted FBMDR meetingsProportion of minor gaps resolvedProportion of major gaps on which action is initiated (proposals submitted)Proportion of major gaps on which action taken (proposals approved and
process begun)
FBMDR PROCESS INDICATORS
DISTRICT LEVEL PROCESS INDICATORS:
• Proportion of maternal deaths notified vs. estimated.
• Proportion of maternal deaths investigated vs notified.
• Proportion of maternal deaths reviewed versus investigated
• Proportion of MDR meetings conducted by the DM
• Proportion of maternal deaths (among all deaths of RH age group)
PROGRAM INDICATORS-DISTRICT & STATE LEVEL
Proportion of deaths among adolescents (15-49 yrs)
Distribution of maternal deaths, by district, block
Distribution of maternal deaths, by education status, age at marriage, age of death
Distribution of maternal deaths, by caste, religion
PROGRAM INDICATORS
Distribution of deaths, in antenatal, intra-natal and post-partum period
Proportion of deaths during or after abortion-spontaneous & induced
Distribution of deaths, by place of death-home, institution, transit
Distribution of deaths, by ANC & PNC received
Distribution of deaths, by delays (first, second and third)
Distribution of deaths by causes
HMIS INDICATORS:
• Number of deaths, by district
• Number of deaths, by month
• Proportion of deaths, by cause• Bleeding• Severe hypertension/fits• Obstructed labor• Fever related• Others
CHALLENGES... TO ROLL OUT THE PROCESS
Creating awareness in community... Need for effective BCC/IEC
Mobilising communities and the health system
Resolving infrastructure and human resource issues
Building partnerships between govt. systems and others (prof. bodies ,tech. agencies ,NGOs )
Resolving ethical issues
Developing guidelines and simple implementable tools
Orientation of a wide range of functionaries --policy makers, programme officers, frontline HWs,
community workers, PRIs...capacity building of the states
There is a woman behind every number….!