myanmar a large proportion of child deaths are in the community. to meet the objective of cdsr which...

PART I: THE BASIS AND BACKGROUND

1. Introduction 3

2. Lessons learned from MDR and MDSR 3

PART II: THE TECHNICAL GUIDELINE for CDSR

3. Who is this guideline for? 7

4. Goals and objectives 7

5. The scope 8

5.1. The overall scope of CDSR – the three components 8

5.2. Scope with regard to place of death 8

5.3. Scope with regard to age of child 8

5.4. Confidentiality and anonymity 9

5.5. Assessing preventability of child deaths 9

5.6. Assessing substandard care contributing to death 9

5.7 Considering child protection concerns 9

6. Operating principles 10

6.1. Have clarity on the objective of CDSR 10

6.2. Create and enhance community awareness 10

6.3. Generate commitment, confidence and collaboration 10

6.4. Build on what exists 10

6.5. Nurture and sustain collective learning 10

7. Organizational considerations 11

7.1. The levels for conducting child death audit 11

7.2. Expertise for conducting CDSR 11

7.3. Linkage with MDSR 12

7.4. The responsibilities and terms of reference of each level 12

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8. The specific inputs for the process for child death review (CDR) 17

8.1. Notification of child deaths – in hospitals and in community 17

8.2. The number of deaths to be notified, triangulation of data 18

8.3. The review process – when to initiate 18

8.4. The tools/formats used for the review 18

8.5. The methods of review 21

8.6. The number of deaths to be reviewed at each level 21

8.7. Frequency of review at each level 22

8.8. Determination of cause of death 22

8.9. Identifying the factors leading to the death, and assessin 22preventability

9. From review to response 23

9.1. Timing of responses 23

9.2. Responses at the different levels 24

9.3. Guiding principles for response 25

10. Surveillance of child death 25

10.1. Types of surveillance 26

10.2. Data entry and quality check for completeness 26

10.3. Data aggregation, analysis and interpretation 26

10.4. Analytic plan and indicators 27

10.5. Trend analysis, and more complex analysis 27

11. Reporting, feedback and dissemination 28

11.1. Who should receive feedback and reports? 28

11.2. Method and channels of dissemination 29

11.3. Periodicity of reports 29

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PART III: THE IMPLEMENTATION PLAN

12. The initiation (pilot project) phase 33

12.1. Why? Where? When? How? 33

12.2. Translating and pre-testing the forms 33

12.3. Training 33

12.4. Monitoring of progress 34

13. Phased implementation and scaling up 34

14. Advocacy and gaining support 35

14.1. What is advocacy? 35

14.2. How to carry out advocacy, the successful factors 36

14.3. Target groups for advocacy 36

15. Monitoring and Evaluation 37

15.1. Monitoring 37

15.2. Supervision 37

15.3. Evaluation 38

15.4. The indicators 38

16. Resources needed for implementation 41

ANNEX 1 : Lessons learned from MDR/MDSR 43

ANNEX 2 : CDSR Form 1 – Notification form for child deaths 47

and investigation of the three delays

ANNEX 3 : CDSR Form 2 - Verbal autopsy form for child deaths 53

ANNEX 4 : CDSR Form 3 – Summary report of TMO 67

ANNEX 5 : CDSR Form 4 – Summary report of DMO/District CD Review Team 70

ANNEX 6 : Checklist for supervision and quality check by TMO on midwife 73

ANNEX 7 : Logical Framework for monitoring and evaluation 75

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ACKNOWLEDGEMENT

Under the overall guidance and leadership of the Ministry of Health (MoH) especiallyDr Myint Myint Than, Director, Child Health Division, Department of Public Health,this technical guideline was developed during the period from March to May 2015.MoH, first of all, would like to extend its deep appreciation to members of the LeadChild Health Working Group for their valuable inputs in pulling together this ChildDeath Surveillance and response (CDSR) technical guideline.

Special thanks goes to Dr NarimahAwin, international consultant, for her wonderfulfacilitationand valuable insights which she brought to the table. High gratitude alsogoes to UNICEF’s MNCH team for their unlimited technical support throughout theprocess of CDSR Guideline development.

Great appreciation is also extended to the other divisions and departments under theMinistry of Health, the Central Statistical Organization,State/Region/Township HealthDepartment, WHO, UNFPA, INGOs, local NGOs and 3 MDG Fund for their activeparticipation and great contribution.

Last but not least, sincere thanks also go to the representatives of Basic Health Staffparticularly Midwives as without their perspective and contribution, development ofthe realistic and meaningful technical guideline will not be accomplished in such asmooth manner.

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2 Technical Guideline for Child Death Surveillance and Response

Technical Guideline for Child Death Surveillance and Response 3

1. INTRODUCTION

The death of a child1, a young life full of promise and potential, is a tragedy. A largenumber of child (under-five) deaths are preventable, by interventions that areefficacious, effective and affordable. An important component of any eliminationstrategy is surveillance. A surveillance system counts and tracks the numbers and trendof child deaths, but also helps to understand the underlying factors that contribute tothe deaths and how they can be corrected and the death prevented. For this to happen,a Child Death Surveillance and Response (CDSR) should be put in place along withguidelines for the development and implementation of the CDSR. Besides surveillance,a central component of CDSR is the elicitation of the cause of death and the factorsthat contributed to the death, which is achieved by conducting a death review or audit,on which the third component, response is founded.

A maternal death review (MDR) system already exists, and efforts have begun tochange this to a maternal death surveillance and response (MDSR) as recommendedby the Commission on Information and Accountability (COIA) of the UN GlobalStrategy for Women’s and Children’s Health (GSWCH). In addition, Myanmar hasupdated its National Child Health Strategic Plan (NCHSP), and the plan for 2015-2018 is ready for roll-out. This strategic plan makes special mention of the need fordeveloping a CDSR as one of several efforts to improve the information system onchild health, especially to better understand the circumstances surrounding a childdeath

2. LESSONS LEARNED FROM MDR AND MDSR

In Myanmar, a community-based maternal death audit began as the first pilot in fivetownships of Sagaing Region in 2005, and it was intended to include perinatal (andlater replaced by neonatal) death review, but this was not implemented. CDSRguidelines have been developed with lessons learned from the MDR/MDSR experience,by asking two questions (1) What were the tools used for neonatal death audit; willthese be appropriate for use in CDSR (2) What lessons can CDSR learn from MDSR?.The answers to these are shown in ANNEX 1

1 A “child” is variously defined in different contexts and for different purposes; the Convention of the Rights ofthe Child defines it as below the age of 18. For legal purpose, different countries may use different age limits. Inthis guideline, a child is defined as from birth to 5 years old (0 to 60 months) of life, and child mortality is oftenreferred to as under-five mortality. In the context of death review this guideline includes still births


3. WHO IS THIS GUIDELINE FOR?

The Technical Guideline is for health care providers, health professionals, healthcare planners and managers, and policy makers working in the area of child healthwho strive to improve child survival by improving access to and quality of services;improving information on child death, both quantitatively (measuring accurately theburden of child death) as well as qualitatively (by identifying and understanding thefactors and circumstances, notably the preventable and avoidable in order to betterformulate strategies to prevent child deaths. This guideline will also be useful for non-government and civil society organizations (NGOs and CSOs) including faith-basedand religious organizations involved in child welfare and health.

Stakeholders with the ability to drive change for improving child survival should beinvolved in all aspects and processes of the CDSR to ensure that child deaths arenotified and reviewed, responses are implemented and surveillance is in place.

4. GOALS AND OBJECTIVES

Goal

To contribute to a more comprehensive and reliable information system in child healthand survival that will effectively leads to a reduction in child mortality in Myanmar.

General objective

To provide information on child deaths, through the conduct of a child death reviewthat identifies the causes and contributing factors to the deaths, followed by makingthe appropriate responses, and carrying out continuous surveillance on child deaths

Specific objectives

1. To receive notifications on as many child deaths as possible, preferably on ALL child deaths

2. To collect accurate data on number of child deaths by relevant variables

3. To collect information on the causes of child deaths and the contributing factors, to understand how and why the deaths occurred

4. To identify and assess the contributing factors that were avoidable or preventable

5. To make evidence-based recommendations for response to decrease child death

6. To contribute to an effective system of surveillance of child deaths


2 Verbal Autopsy Standards: The 2012 WHO Verbal Autopsy Instrument – Release Candidate 1

5. THE SCOPE

5.1. The overall scope of CDSR

There are three components: 1) Death Review, 2) Surveillance and 3) Response.

• The Death Review component involves the analysis of information of causesand contributing factors of child deaths and monitoring the trend at variouslevels of the health system

• The Surveillance component requires strengthening of existing surveillancesystems in child health, and these only need to be strengthened to meet thepurpose of CDSR. Surveillance in general exist in three main forms, and eachwill be applied to child health and survival – (i) routine surveillance throughthe HMIS, which can cover the whole country or from selected sites as sentinelsurveillance (ii) periodic surveys such as DHS, MICS and verbal autopsy forcauses of child deaths (for which a tool is available)2 (iii) ad-hoc surveys andstudies based on an identified need. CDSR itself can contribute to surveillanceof child death

• The Response component follows all reviews with recommendations for actions.The response must be robust, documented and monitored

5.2. Scope of CDSR with regard to place of death

Child deaths can happen either in facility/hospitals or outside the facility (home,school and other locations in the community). In Myanmar a large proportion ofchild deaths are in the community. To meet the objective of CDSR which is tounderstand the circumstances/factors contributing to the death so that in futuresuch deaths can be prevented, deaths in both settings must be audited. The CDSRshall include child deaths in facility (but only in public facilities) and in the community.At this early stage, deaths in private facilities shall not be subjected to the auditprocess, but the incident should be reported to allow for surveillance to be carriedout (only for tracking the number over time), and currently the HMIS captures andcounts the number of child deaths from private facilities.

5.3. Scope of CDSR with regard to age

For the scope of CDSR, any stillbirth beyond the gestational age of 22 weeks andany death of a child below five years will be included. This includes neonates, post-neonates, infants and older children from one to under five years. Therefore it isproposed that


• The CDSR shall consist of audit of deaths in two age cohorts – stillbirths and neonate (0-28 days) and child (29 days to under 5 years).

• The notification form will be common for the two age cohorts

• The verbal autopsy form (for a detailed investigation of some deaths that the TMO or DMO or review team deem necessary) shall also be common for thetwo age cohorts, and this shall be the form already used in the 2013 study on

cause of death

• There shall be only one committee or review team to conduct these reviews. The MDR committee that already exists shall be expanded in mandate, membership and terms of reference to include CDSR

5.4. Confidentiality and anonymity in the death review process

The CDSR aims to uncover causes and circumstances surrounding a child death inorder to identify preventable or avoidable factors so that similar deaths in future donot occur. There is no punitive intent, and therefore there is no need to keep thenames of care providers anonymous and confidential.

5.5. Assessing preventability of child death

Most child deaths in developing countries are preventable by simple effective andaffordable interventions. The optimistic outlook of prevention has led to the globaltarget of elimination of preventable child deaths. In the context of CDSR, the conceptof preventability or avoidability is used in the review/audit of individual deaths,and the assessment of factors that led to the death – whether they were preventable.A child death can be classified as avoidable if the death might have been avoided bya change in patient behavior, provider/institutional practices, and health care systempolicies. It is recognized that the determination of avoidability does not follow rigidcriteria and it is often open to interpretation. Preventability often overlaps withsubstandard care

5.6. Assessing substandard care contributing to death

Often, the preventable factor uncovered by the review is a form of substandardcare – for example, a child’s life could have been saved if antibiotics were availableto treat the pneumonia he was suffering from.

5.7 Considering child protection concerns

Determining child abuse or neglect as a cause of death is outside the scope of theCDSR, but any suspected cases should be reported to the police for investigation.


6. OPERATING PRINCIPLES

The operating principles must support all three essential components of the CDSR:1) Death Review, 2) Surveillance and 3) Response. (See 5.1 Scope of the CDSR).

6.1. Have clarity on the objective of CDSR

A child death review or audit is a comprehensive review of child deaths to betterunderstand how and why the child died, and to use the findings to take action toprevent other deaths. It is not meant to be a punitive exercise, and the findings arenot to be used for litigation or proof of malpractice.

6.2. Create and enhance awareness

The health staff especially those involved in the processes of CDSR need to beaware of the importance of CDSR, and what benefits it can bring. Increased awarenessamong health providers can lead to changes in knowledge and practice in caring fora sick child; among health managers and policy makers, it will lead to changes inpolicies and reallocation of resources. The community should also be aware of theimportance of CDSR and understand that it will reduce child deaths, and that thecommunity can have a role especially in reducing or eliminating delays in care seekingbehavior.

6.3. Generate commitment, confidence and collaboration

Health staff, after being made aware of the importance of CDSR must be committedto ensure its success, and they must be given knowledge and skills (and fear ofpunishment is dispelled) for them to gain confidence. The principle of anonymityand confidentiality (presented as “scope” of CDR in the preceding section) to someextent can allay this fear because the health staff (and the patient) is not identifiedin the review process. Collaboration among the levels of health care, and amongdisciplines within the health care is crucial to ensure a good effective CDSR

6.4. Building on what exists

There is already a child death notification form, which serves as a review or audittool. Forms were developed for neonatal death review which were not rolled out.The HMIS is a robust system which can provide many of the required information.There has been a verbal autopsy on cause of child deaths in a survey. All these toolshave been used to develop the CDSR.

6.5. Nurture and sustain collective learning

The review process involving a multi-disciplinary range of experts provides a goodopportunity for learning from each other. It is important for the team to promoteshared responsibility and teamwork, and foster collective learning for action atdifferent levels, including lessons for policy, clinical practice and community action.


3 Various terms are used for the group of experts who conduct a death review/audit – Committee, Panel, Team.In this Technical Guideline, as agreed by the CHLWG, the term used is TEAM

7. ORGANISATIONAL CONSIDERATIONS

An organisational structure, especially death review teams with clear terms of referenceand responsibilities is critical in CDSR. In CDSR there is need for the involvement ofthe district level. The main functions of identification and notification of deaths;review of the death; analyse and recommend; and response will involve the followingstructure (individuals, team, levels of care), each with their expertise, responsibilitiesand terms of reference.

7.1. The levels for conducting child death review

The different levels for CDSR especially the conduct of the review/audit will beessentially the same as that for MDSR, which starts at the operational area wherethe midwife is stationed, to township to district and region/state and then to nationallevel. For CDSR, the district level is important because the need for determiningcause of death as accurately as possible requires a paediatrician. There is apaediatrician (and some other specialists such as ObGy) in the district hospitals.Therefore the child death review team3 consisting of the various relevant expertiseshall be established at the district level.

Above the district level, the Region/State Review team shall be established but itsfunctions will be that of analysis and collation. At the national level, the NationalReview Team conducts even less review, and more in-depth analysis to see overalltrends. These responsibilities are described in the Section 8.4 below. It is necessaryto appoint a CDSR “Coordinator” (who shall be a member of the Review Team) ateach level to facilitate communication and receipt of forms, records and reports.The coordinator shoud be deputy regional/state health director.

7.2. Expertise for conducting CDSR

A child death review requires specific expertise. At the operational level where thedeath is notified, the midwife is considered an expert in this function of receivingand recording the notification, and also for the filling of the death notification/review forms. The TMO and his/her team members shall have the requisiteknowledge and skills to go through the review forms submitted by the midwives inthe township, and skills to collate the information, carry out basic analysis and writea summary report. The same applies to the DMO, but at the district level, there shallbe a Child Death Review Team whose members represent experts in paediatrics,neonatology, obstetrics, perinatology or maternal-feto medicine (if available), publichealth, nursing, midwifery – and any other as needed. An important expertise at thislevel is to check the cause of death assigned by the midwife and attested by theTMO, to either confirm or to amend the cause of death


Expertise in the review teams at region/state and national level shall consist ofmainly public health, epidemiology, health programme management, paediatrics,neonatology, perinatology, obstetrics and any other as and when needed. At centrallevel, there should be a representative from the Department of Medical Research

7.3. Linkage with MDSR

There shall be one review team to review maternal and child deaths at the variouslevels but there has not been MDR committee at district level. The terms of referenceof the existing MDR committee at all levels must be reviewed. The members shallbe the same (except there is a need to expand this to other subspecialists such asneonatologist and maternal-feto specialists). The activities being planned for MDSRincluding training shall take into account, wherever relevant, the needs and plansfor CDSR, and vice versa.

7.4. The responsibilities and terms of reference of the different levels

The responsibilities and functions of the various levels are described here. Howeverthese functions require specific inputs (including tools) that are described in Section 9

1. The midwife is the focal point for all child deaths reported from the community

a. Auxilliary Midwife (AMW), Community Health Worker (CHW), villageleaders/community volunteers etc will inform the midwife of any childdeath in the community. In contexts where there is no midwife in thevillage and it is possible for the AMW/CHW, the AMW/CHW shall fill inthe CDSR Form 1. These will be shared with the midwives on a monthlybasis. The AMW/CHW shall have the required education and training todo this.

b. The midwife will fill in in Form 201 (requirement of CSO); and the prescribedCDSR forms – for notification of child death, as well as for investigationof the three delays (CDSR Form 1 – see Section 9.4) either in consultationover telephone or in person with a direct contact of the child (who couldbe a health worker who provided treatment or parent/caregiver whoaccompanied the child during the illness) or receive it from the CHW/AMW.

c. Midwife transfers all notification forms to the Township Medical Officer(TMO) on a monthly basis during the monthly CME at the township whileretaining a copy

d. If the midwife has heavy workload and requires assistance, the PublicHealth Supervisor Grade II (PHS II) can fill up the required notificationform


2. The Township Medical Officer (TMO) and team at township health office

a. Reviews all the CDSR Form 1 (notification/review forms and the threedelay investigation) submitted by the midwives

b. Analyses all notification forms for accuracy; in case of inaccuracies, TMOverifies with the concerned midwife and rectifies death notification form

c. If he/she feels it necessary, TMO shall conduct, or direct the HA or LHVat the concerned health unit to conduct, a verbal autopsy using theprescribed forms (CDSR Form 2 - see Section 9.4)

d. Prepares the quarterly summary report (CDSR Form 3 - see Section 9.4)which he submits to the DMO

e. Reports through a reporting system to Region/State Health Departmentand Child Health Department on a monthly basis – this entire process willbe automated with introduction of mobile technology, while retaining acopy, whenever it becomes available

3. The District Medical Officer (DMO)

a. On a quarterly basis after receipt of notification forms from every township,reviews the cause of death as per need, based on discussion with TMO

b. Identifies 5 top causes of death and randomly picks up 3 notificationforms per cause of death during that quarter, from each of the two agecohorts - hence selecting 15 notification forms from each (total 30 forms).If there are fewer deaths than the required number then all deaths will beselected for review

c. May also identify any other cause of death to be reviewed, such as if it isepidemiologically important, for example any illness that is consistentlyincreasing over a period of time, or any illness that is not acceptable to bea cause of death

d. Convenes the Child Death Review (CDR) Team on a quarterly basis toconduct the death review

The District Child Death Review team comprises of the DMO, all TMOs inthe district, and medical specialists from relevant disciplines. This Team hasthe following TORs:

a. Reviews all the 30 selected notification forms (and any other identified forreview) in detail, ascertains the immediate cause of death and the underlying


cause of death. In case further clarifications are needed, the team calls theconcerned midwife to investigate further

b. Identifies gaps and bottlenecks in the system that have contributed tothese deaths, identifies actions or intervene (immediate and long term)that can prevent similar deaths in future, indicating who is responsible forimplementing these actions

c. Shares the outcome of the audit with all townships, Region/State HealthDepartments and the Child Health Department MOH, within one weekof the District CDR team meeting, through a summary report (CDSRForm 4 - see Section 9.4)

d. If needed the team may decide to trigger a verbal autopsy in which case,the a member of the district team along with the TMO and midwife willtravel to do a verbal autopsy (VA); some indications for VA are (but notlimiting to) causes of death that do not come down after a period time ofmore than one year, in spite of successful implementation of interventions,unusual causes of death that cannot be investigated by midwife or TMO;causes of death that are epidemiologically important as identified above,death due to possible criminal acts, etc.4

e. During every meeting the team reviews the actions taken by both theDistrict and the Township based on the previous quarter and those thathave not been acted upon or have been inadequately acted upon; theseneed to be identified as priorities in this report in addition to new actionpoints as identified by current quarter review

4. Region/State level – at this level, a CDR review team is also established butits functions will be less of review and more of analysis

a. Analyses data based on the monthly reporting format (on a quarterly orsemester basis) to profile the townships, identify epidemiological trendsthat need immediate interventions, and share the analysis and actionsidentified based on a standard reporting format with Child HealthDepartment, every semester/ 6months

b. Analyses the report from the District CDR team on a semester basis, trackactions, check quality of reports, identify areas for improvement andprovide feedback to District CDR teams and TMOs based on finding;report the outcome of analysis and actions taken, to Child HealthDepartment

4 All health staff should be sensitized to the possibility of child protection concerns, such as childabuse or neglect, which should be reported to the police for investigation.


c. Based on the findings of the analysis, conduct appropriate responses- e.g.improve training programme, increase monitoring and mentoring, triggerVA studies, modify or introduce programme interventions etc

5. National level (Department of Child Health. MOH)

a. Analyse data based on the monthly reporting format, on a semester orannual basis, to profile the townships, identify epidemiological trends thatneed immediate attention

b. Analyse the report from the region/state on a semester or annual basis,track actions taken, check quality of the reports, identify areas forimprovement and provide feedback to region/state

c. Based on the findings of the analysis, conduct appropriate responses – e.g.improve training programme, increase monitoring and mentoring, triggerVA and other disease surveillance, modify or introduce programmeinterventions

d. Produce an annual report of CDR which profiles the cause of death, keyinterventions/actions identified, status of implementation of theseinterventions, trend in that year, compared to previous year, priorities forthe next year, etc

e. Present findings of the CDSR to the CHLWG at suitable intervals(either 6 monthly or annually)

The functions are as follows. Membership and chairmanship of the Review Team atdistrict level –the chair of the Review Team is to be based on co-chairmanship withthe Department of Public Health and Department of Medical Service to chair eachreview meeting or chair on a rotation/alternate basis. Members of the team are selectedon area of expertise, which can be from both Public Health and Medical Service.

Procedures for deaths that occur in hospitals are reviewed (or not reviewed) inthe hospital (See Section 8.1).


8. THE SPECIFIC INPUTS FOR THE PROCESS OF CHILD DEATH REVIEW (CDR)

Some of the specific inputs and actions (particularly the tools/forms) may differbetween the two age cohorts of deaths to be reviewed (i) neonatal deaths (ii) deathsin children from 29 days to below one year:

8.1. Notification of a child death

A child death can occur in a health facility or outside a facility in the community.Information flows from the community starting with the midwife, who fills up theprescribed forms currently on paper or receives them from the trained CHW/AMW(See Section 8.4)

Reporting and review of deaths outside hospital / in the community - The midwife will bemade aware of a child death in the community either from a notification from thefamily (for the family near to where the midwife is stationed) or from her periodicfield/home visits, or from community volunteers (AMW, CHW, village head,community volunteers, etc). It is therefore critical that as many deaths are reportedin this manner, and it is suspected that some (even many) child deaths are unreported,especially stillbirths and deaths of very young children. All efforts must be made toencourage the community to report death of a child at every age including stillbirths.The midwife fills in the required form (CDSR 1 – see section 9.4). If there is nomidwife in the village and the CHW/AMW is educated and trained in the use of theforms, they will fill this form.

Reporting and review of hospital death - One can reasonably assume that all deaths(including child deaths) in a hospital are reviewed/audited by the hospital as a clinicalaudit as part of quality assurance. In Myanmar while this is encouraged, it is onlycarried out by some hospitals. In addition, in big hospitals (with 150 beds or more),there is already a perinatal and neonatal database. There are existing tools for thesereviews, therefore these death reviews will not use the CDSR forms as described inthis guideline.

For hospitals that carry out death audits, it is necessary that they are reported to theTMO (for station and township hospitals), DMO (for district hospitals) and Region/State health department for Regional hospital. These levels will ensure that thesehospitals deaths which have been reviewed by the hospitals are counted in the deathrecords/statistics. If a death in a hospital is reported but has not been reviewed, therespective level will see that the review is carried out by the relevant staff in thehospital using the CDSR forms in this guideline.


8.2. The number of deaths to be reported/notified, triangulation of data

The intent of any death review system is to gather as complete as possible theinformation related to the deaths, so that it is adequate for the formulation ofstrategies and interventions to prevent future deaths. Use of community volunteersshould be encouraged to report child deaths to the midwife. It is important to avoidduplicating notification of the same child death. Triangulation of data betweensources using personal identifiers can be helpful to ensuring each death is reportedonly once. For instance, a facility and community may both report the same death.The midwife and community volunteers who inform the midwife (AMW, CHW,village heads and others), must ensure that deaths are not reported and countedmore than once

8.3. The review process - when to initiate

It is hypothesized that a verbal autopsy conducted too many days after the eventwill be less reliable. The midwife should try to conduct the review (CDSR Form1) assoon as possible, within 7 days after the death notification. This initial review, whileit does not amount to a full in-depth verbal autopsy, does involve an interview of afamily member of the deceased child or a health care provider who cared for thechild before death. More in depth interview (verbal autopsy) may need to beconducted as deemed necessary by either the TMO or DMO, based on the formssubmitted.

8.4. The tools/forms used for the death review

The forms used consist of (a) Notification and brief review form (in which is alsoincorporated the investigation for any delay in seeking care) (b) Verbal autopsy form,in the event that a death reviewed as part of the notification needs further review/investigation by detailed verbal autopsy and (c) Summary forms/reports by TMOand DMO

a . Notification, brief review and investigating for delay in seeking care: Upon achild death being made known, the midwife fills up Form 201 which is requiredby the CSO and is filled for all deaths. For the CDSR, the midwife fills a commondeath notification form, which is common for the two age cohorts (CDSR 1) –ANNEX 2. Part 1 of this form is the notification of death with causes indicated.Part 2 of the form seeks to elicit some basic information on any delay in theseeking of care for the child using the Three-Delay5 model. It is recommendedthat in circumstances where the workload burden needs to be lessened for the

5 The first delay is failure in recognising the need to seek care; the second delay is although there is recognition toseek care, there are barriers to do so such as geographical, cultural or financial barriers; the third delay is whenafter having sought care, the care provided is of poor quality


midwife, this task of filling CDSR Form 1 can be carried out by the PHS II.Currently the volunteers (AMW and CHW) are only responsible to inform themidwife of the death. In areas where the AMW/CHW are educated and aretrained to fill in this form, they can be do this and submit to the midwife on amonthly basis.

b . More detailed review by verbal autopsy: The TMO or DMO may request afterthe review, that a verbal autopsy on some of these deaths be conducted, usingthe CDSR 2 Form (ANNEX 3). This verbal autopsy can be carried by any stafffrom the township as directed by the TMO, or by the Health Assistant (HA) incharge of the RHC or Lady Health Visitor (LHV) where the death was notifiedfrom. This verbal autopsy shall not apply to stillbirths. The form has 10 sectionswith separate sections for cause of neonatal (Section 8) and post-neonatal deaths(Section 9) and a section (Section 6) for deaths due to accidents. It also hasseveral questions in Section 10 (reports and returns) if a death certificate wasissued, and it requires the interviewer to see the death certificate, and record thecauses of death (immediate and underlying) and contributing factors stated inthe certificate

c . Summary forms/reports: At the township level, the TMO after receiving allthese forms from all midwives in the township, shall fill up the Summary ReportA (CDSR Form 3) as in ANNEX 4. The TMO also sends all notification/reviewforms to the DMO, not for the District to conduct a review but to confirm orascertain the cause of death in each from, because the review to be conductedat this level is on a sample/selection of forms to be selected based on cause. Atthe district level, the DMO (and District CD Review Team) after receiving thenotification forms reviews the cause of death. The DMO, in consultation withthe paediatrician, sees all the forms, confirms or amends the cause of death,compiles the forms by cause, takes the top 5 leading cause in each age cohort,randomly takes 3 forms from the top 5 causes, (thus deriving 30 forms) and thenthe District Review Team conducts death review on these 30 deaths. If there arefewer than the required number the maximum available should be reviewed.The District CD Review team shall also prepare a summary report, based on thesummary reports submitted by the TMOs - CDSR Form 4 (ANNEX 5).


8.5. Methods of child death review

The methods of review to be used shall be mainly facility-based review (of medicalrecords) and a verbal autopsy (for deaths in the community).

8.6. The number of deaths to be reviewed at each level

The number (and frequency – see 8.7. below) of any death review depend on thenumber of cases identified and the resources available to collect the necessary data.Unlike maternal deaths, the number of child deaths is much larger, as many as twohundred-fold more. Child death audit shall be conducted on a sample of deaths, tobe determined by a reasonable and practical method. This sample shall be based oncause of death, even though we recognize the low accuracy of cause of deathespecially for deaths in the community. However surveillance in terms of numbersreported and tracking this number over time and by location shall be done for allunder-5 deaths

It has to be borne in mind that a death review/audit is a time consuming process atevery level, right from the midwife who initiates the process who is likely to berequired to fill a long format. The midwife and member/experts of the reviewcommittee carry out this function as an additional task over and above their normaltasks. The number of deaths to be reviewed at the various levels are:

• The midwife reviews all child deaths that are reported to her using thenotification form, (CDSR Form 1) which incorporates the three-delayinvestigation

• The TMO reviews all the forms sent by all the midwives in the township; itthen sends all of these to the District Medical Officer (DMO). If TMO findsit necessary, a verbal autopsy is conducted using CDSR Form 2.

• At the District level, selection is to be made on the number of deaths to bereviewed. It is possible that the district can receive as many as 60 death reports(with 5 or 6 townships making up a district). As has been described earlier,the number to be reviewed by the District Team is arrived at by first pickingthe top 5 causes of death from each of the two cohorts (neonatal deaths anddeaths in children aged 29 days to 5 years), and then taking randomly 3 formsfrom each top cause in each cohort, thus deriving a total of 30 forms selectedfor review.

• At Region/State and National level, only the summary reports from the Districtare received, unless the review team requests for specific information fromsome of the notifications. These levels conduct an in-depth analysis, detectingany epidemiological trends, and assessing the responses carried out at thedistrict and township levels


8.7. Frequency of review, and structure for review at each level

The frequency of review will be quarterly as described earlier. The midwife sends inthe audit forms to the township every month; the TMO and DMO conduct quarterlyreviews. All TMOs will participate at the quarterly review meeting at district level;and if the TMO is not able to attend, he/she shall be represented by a staff from thetownship office. The Region/State conducts reviews every six months and at Nationallevel, the review is done annually.

8.8. Determination of cause of death

Determining and assigning the cause of death requires a good level of clinicalknowledge and acumen. Additionally, it also uses ICD coding and classification. Itis acknowledged that the level and coverage of knowledge of this is relatively poorin Myanmar. This will require additional training.

For neonatal deaths, the causes are also quite clear and covers a narrow range ofpossibilities – preterm births (often with respiratory distress syndrome), birth asphyxia,sepsis, congenital malformations.

In the case of death of older infants (post neonate) and children below 5, the causeof death covers a wider range of possibilities. Therefore, CDSR Form 1 for notificationrequires the midwife to assign the cause of death in terms of sign/symptom (fever,cough, etc) or a clinical diagnosis (tetanus, measles, malaria a case definition protocolfor common conditions. Once these forms are submitted by the midwife to thetownship level, this cause of death may or may not be reassessed. It is when thereports reach the district level that a paediatrician is available to review/reassessthe cause or causes assigned to each death, and a final cause of death is determined.The TMO submits all notification/review forms to the District level, where eachform is assessed for the cause of death assigned by the midwife and TMO, andwhere this cause is either confirmed or amended based on the best evidence availableto the District Review Team, as has been described earlier

8.9. Identifying the factors leading to the death, and assessingpreventability

Knowing the clinical cause of a child death does not provide all the informationneeded for understanding why the child died. The next step is to look for the eventsbefore the death, especially to identify any preventable factor that could have avertedthe death; and if there was any possibility of substandard care being given. Fromthe findings from the three delay investigation from (CDSR Form 1) an assessmentcan be made if there was a delay in failure for the family to recognise the need toseek care (Delay 1), failure /inability to do seek care (Delay 2), after having soughtcare and reaching the point of care, was the quality of care adequate (Delay 3).


For deaths in hospitals, in addition, the medical records of the management of thechild will be used. For this the TMO writes a narrative report for each notification/audit form he receives, on the preventability of the deaths, as the last item in thesummary report (CDSR Form 3). These shall be reviewed by the District CD ReviewTeam, which shall fill up CDSR Form 4 - in which it writes a concise narrative onthe preventability of deaths in the district in that quarter

The CDR shall identify preventable factors, and shall not be used to punish staff, forreasons mentioned earlier in Section 6. Preventability and substandard care canoverlap, for example - shortage of antibiotics or other life-saving supply/commodity,a staff who came in too late to attend to the child, staff not skilled in neonatalresuscitation, etc.

9. FROM REVIEW TO RESPONSE

One of the weak points in many death review systems is the review-to-action link.Following the review, recommendations for Review will be documented withresponsibilities for action assigned to specific staff and with time lines. Responsesneed to be appropriately and optimally timed, and at the various levels of the healthsystem. There are some general guiding principles related to response.

9.1. Timing of response

Response following a review may be immediate or periodic

• Immediate response - Findings from reviews of nearly every child death can leadto immediate actions to prevent similar deaths from occurring. This may beeasier in the case of deaths at health facilities but is true for deaths both athome and facility. A child death review can identify gaps in areas that shouldbe addressed quickly both in health facilities and communities. Child deaths inhealth facilities often point out needed improvements in quality of care suchas inadequate coverage of emergency services by skilled providers; lack ofessential medications or supplies; need to improve knowledge or skills ofproviders in the management of child illnesses; or need to improve overallservices. Deaths that take place in communities can also identify some actionsthat can be implemented quickly. There is no need to wait for aggregated datato begin implementing actions to prevent child deaths.

• Periodic response - Monthly, quarterly or semi-annual reviews (depending onnumbers) of aggregated findings should take place at larger health facilitiesand at the district level where there is a District CD Review Team These periodicreviews may begin to show a pattern of particular problems that are contributingto child deaths, or particular geographic areas where child deaths are occurring


in greater numbers. Such findings should result in a more comprehensiveapproach to addressing the problem across multiple facilities or across multiplecommunities. Where areas at greater risk are identified, discussion with theinvolved communities should be a priority to identify solutions.

• Annually - every health facility should summarize its child mortality findingsannually. In larger health facilities where multiple deaths may have occurred,the findings should contribute to continuous quality improvement plans. Atthe township and district level, findings from the analysis of aggregated dataand the aggregated recommendations from the death reviews are incorporatedin a district report. Actions at the district level may include health-systemstrengthening and staff retention, resource mobilization, increasing communityand institutional awareness of maternal mortality, fostering community-facilitypartnerships and building alliances with the private sector, and advocacyactivities.

9.2. Responses at the different levels

Responses can be at a health facility at the various levels, or in the community.

• Community level: Responses may include actions in the community. Findings from thecommunity may point to the need for the development of health promotionand education programs as well as possible changes in community serviceprovision; changing home practices or the attitudes of health care providers; orimproved infrastructure such as roads, bridges, and communication technology.Some findings, like the latter, may require a longer time period to plan, implementand obtain the necessary government support. Information from health facilitiesmay point to the need for changes in clinical practice or modification of serviceprovision

• Health facility/hospital: A child death in a health facility such as a hospital shouldbe considered an unacceptable event that needs a review. Each death, if properlyreviewed, should identify systemic problems that contributed and can becorrected. These may include (1) staffing issues — whether there are sufficientstaff to meet the demands for quality child health care including essentialnewborn care (2) knowledge and skills – including all those who are involvedin providing care or supportive services; and (3) deficiencies related toinfrastructure, medications, equipment and other supplies that may have led toinadequate management of complications

• At higher management levels: At township, district, region/state, there will be appropriateresponses depend on the findings of the review. At the national level, analysisis conducted from all aggregated data that contributes to a national child health


plan.. Actions may include allocating required resources to the most affectedareas and populations. Actions at the national level may also include changingor updating national policies, laws or guidelines. Responses taken in the previousquarter shall be an agenda item in each CD Review Meeting at district level,and that shall be one of the functions in the list of responsibilities of theDistrict Public Health Officer

9.3. Guiding principles for responses

Some guiding principles for response are

• Start with avoidable factors identified during the death review process

• Make sure response is evidence-based, however remember that not all problemsidentified have evidence-based solutions, particularly those related to family,community, transportation issues and access to care. Ideally, actions that arenot based on known evidence will be evaluated to ensure they are having theexpected effect.

• Prioritise the responses — It is likely that many problems will be identified; notall can be tackled simultaneously so it is important to prioritize them. Somecharacteristics should be considered when prioritizing problems and theirsolutions. One important factor is prevalence¾how common is a problem?Resolving common problems may have a greater impact than resolving unusualproblems. Another factor is the feasibility of implementing the intervention. Isit technologically and financially possible? Are there sufficient human resources?What are the costs? Finally, what is the potential impact of the intervention? Ifit were successfully implemented, how many children could be reached andhow many lives saved?

• Decide how to monitor progress, effectiveness, impact - Remember, CDSRunlike CDR requires that responses are not only robust, but also monitoredand documented

• Integrate recommendations within annual child health strategic plans

• Finally, it is useful to bear in mind that recommendations should be specificand link with avoidable factors.

10. SURVEILLANCE OF CHILD DEATHS

For this third component of CDSR, we need to recollect the types of surveillance,and then proceed to the handling and management of data and information, which isthe central feature of surveillance


10.1. Types of surveillance

In Section 6.1, it is stated that while the Surveillance component may imply a newinput, in almost all countries there are existing surveillance systems for child health,and these only need to be strengthened for meeting the purpose of CDSR. TheCDSR may use any of the three main methods of surveillance – (i) Routinesurveillance through the HMIS, which can cover the whole country (as in Myanmar),and if necessary supplemented by sentinel surveillance (ii) Periodic surveys such asDHS, MICS and verbal autopsy for causes of child death, as have been carried outusing the WHO tool (iii) Ad-hoc surveys and studies based on an identified need.CDSR itself is a form of surveillance of child death which contributes informationto both the number (and trend) as well as the factors contributing to child mortality.

10.2. Data entry, quality and completeness

In preparation for analyses, a clear framework for data transmission, aggregation,processing, and storage needs to be defined. In the initial stages of implementationof CDSR, the data collected are relatively simple and not voluminous. However thecheck for quality and completeness are important so that analysis is based on validinformation. The CDSR coordinators at the various levels will check the informationfound in the notification/review forms.

10.3. Data aggregation, analysis and interpretation

Data analysis and interpretation of results are critical components of any surveillancesystem. The initial data analysis should be done at the level closest to the communitywith the appropriate analytic skills. This is the township level and more robustly atdistrict level where there is a Child Death Review Team with various expertise amongthe members.

Through CDSR, all facilities will know their facility specific number of child deaths,be able to calculate indicators for their facility, and report on the causes of deaththat occur in their facility. Each child death must trigger the question “why did ithappen?” and, when appropriate actions are available, immediate responses must beset in motion. The aim of aggregated data analysis is to identify causes of death,identify factors contributing to the deaths, assess the emerging data patterns, andprioritize the most important health problems

At the district level, the CDSR coordinator will maintain a data-base and checks forcompleteness and inconsistencies between data items. The review team will benotified of any problems, if necessary, including inconsistencies or inadequatereporting of certain items. The review team will also be informed of differencesencountered in the number of entries and asked to verify the counts or to determine


the nature of the inconsistencies. The database will be utilized for analyses of allthe child deaths that have been reviewed. The review team fills in CDSR Form 5(summary report) and sends it to Region/State

When performing CDSR analyses, the following factors are prerequisites:

• Knowledge of surveillance (sources, mechanisms, data collection instruments, completeness of reporting, abstraction, data entry and validation)

• Good understanding of the indicators to be calculated and denominator issues

• Changes over time in case definitions, detection, or data collection

• Knowledge of the limitations of the data, such as incomplete coverage, poor quality, and changes over time in data processing may also influence the analysis.

These prerequisites imply additional resources – there is need to move towardscomputerisation and electronic data management at district and national levels, andto assign a dedicated information (HMIS) personnel for CDSR at national level. Atthe moment, one focal person should be from child health division of the Departmentof Public Health.

10.4. Analytic plan and indicators

An analytic plan is important to guide the analytic process and identify problems inthe health system that may contribute to child deaths, especially those that areamenable to change. The plan should include: the identification of appropriate andfeasible indicators prior to data collection; guidelines to calculate rates and proportionsand how to display data; how to compare rates with expected or reference values.When the volume of data becomes large, statistical probability methods may benecessary to examine apparent. Interpretation of the findings should focus on aspectsthat will lead to prevention of death.

10.5. Trend analysis, and more complex analysis

On-going surveillance can provide more detailed information about changes overtime (temporal trend), as well as over place (spatial trend). Specific analyses can beconducted at district level to identify patterns and trends. These may be used toinfluence district action and response. At region/state level, it can show whichdistricts are in greatest need, similarly at national level, the regions/states most inneed can be detected.

More complex analyses may be needed to answer specific questions that arise. Theseanalyses may require approaches beyond what are routinely performed. Time seriesanalyses and analyses using geographical information systems (GIS) are very valuableapproaches that should be considered when appropriate resources exist.


11. REPORTING, FEEDBACK AND DISSEMINATION

There should always be a feedback of the findings and the recommendations down tothe level of the hospital or the community where the information was collected.Government accountability for child health requires the periodic and transparentdissemination of key results, particularly child mortality and the progress made inachieving international goals such as the MDGs.

11. 1. Who should receive feedback and reports?

Any death review systems must build in a system for the dissemination of findingsand recommendations to stakeholders who have direct interests:

• Individuals and agencies within the formal health system who provide informationand are involved in the process of CDSR, from the midwives to the TMO andother staff at township level to, district and state levels, for them to takeimmediate actions.

• Senior management staff in the health system need to be made aware of thefindings in order to formulate develop strategies and interventions, andstrengthen the current system.

• Policy makers need to be aware of the findings of the CDSR to furnish themwith the information and evidence for support and commitment, and to increasetheir awareness about the magnitude, social effects, and preventability of childmortality.

• The impact of interventions needs to be shared with those who are involved inimplementing these interventions. This awareness and commitment will leadto specific actions including allocation of resources more effectively andefficiently by identifying specific needs. Feedback also enhances accountabilityfor child health, including accountability for getting reliable data for calculationof child mortality rates which calls for efforts toward complete civil registration/vital statistics.

• It will guide and prioritize research related to child mortality.

• Dissemination of findings to relevant government agencies should be pursued,especially the agencies whose mandate covers determinants related to childsurvival, including those that have a role in reducing the first and second delays(poverty alleviation, transport, etc.)

• Dissemination to agencies outside the formal health system and governmentagencies can be considered – academic institutions, professional bodies, NGO/CSOs, the private sector


11. 2. Dissemination methods and channels

The findings from CDSR can be disseminated using a variety of channels to enablea wide range of people to access it and ensure that the information gets to the rightaudience, namely those who can act on the recommendations. Methods fordissemination of results can take many forms, for all interested parties (includinghealth staff) some are more appropriate for a certain level, for example

• At community and first level of facility, townships – Regular team meetings,thematic seminars held at facilities, regular Village Health Committee and RuralHealth Centre meetings, community meetings, radio programmes , printedreports, training programmes, posters, text messages, video clips

• At subnational (district and region/state) and national level - Printed reports forpolicymakers, statistical publications, scientific articles, professional conferences.training programmes, media, press releases, websites, newsletters and bulletins,fact sheets, video clips

11.3. Periodicity of reports

Reports are to be generated by the various levels with reasonable periodicity.

• The township and district levels are to generate quarterly reports that focus onsalient findings, and recommendations for immediate action and suggestionsfor improvement in the next quarter. These need not be comprehensive reports.

• For the Region/State level and national, an annual report that highlights thefindings of the audit including the responses, as well as what the surveillancesystem has shown should take place. An epidemiological profile of the childdeaths in the region/state, and the country is given in the report

• Periodic workshops to disseminate and share the findings will be conductedat state/region level, and an annual workshop held as a national workshop


The implementation of CDSR will necessarily be a slow incremental process that islikely to take several years, starting with a pilot project.

12. THE INITIATION FIRST PHASE

12.1. Why? Where? When? How?

A First Phase will be implemented to see the feasibility of the CDSR processes asdescribed in this technical guideline, and to detect any problem in theimplementation, so that changes are made before the system is implemented in awider area, until nationwide coverage.

The First Phase shall be in the townships that are already receiving funding by the3MDG Component 1 initiative. A total of 36 Townships are in this category. Thesetownships will be selected, recognizing that that some of these townships are notsuitable either due to particular challenges such as geographical remoteness or becausethey are in conflict areas.

A training manual for the staff in the pilot townships will be developed, and afterthe training is conducted, the First Phase will commence. It is reasonable to assumethat enough lessons can be learned after 12 months of this first phase ofimplementation.

12.2. Translating and pre-testing the forms

The forms CDSR Form 1 (part 1) and CDSR Form 2 are already in current use anddo not require translation into the Myanmar language, and require no pre-testing.Part 2 of CDSR Form 1 on investigation of three delays is new and will needtranslation before pre-testing. Pretesting can be conducted in a conveniently locatedtownship(s), which is expected to need only one day to two days. The summaryforms (CDSR 3 and 4) for the TMO and DMO respectively will be reviewed at thenational workshop and will not need pretesting; it will need translation into Myanmar.

12.3. Training of staff in pilot townships

There is a need for training of the staff in the First Phase area and the followingsteps carried out:

• training plan/module developed – this is not a complex exercise, because thetraining needs to only give a brief background of CDSR, and practical sessionson how to use the tools/forms, of which CDSR 1 and CDSR 2 (for themidwives) are already being used, and they need to be familiarised with formCDSR 3; while the TMOs and DMOs need to be familiarized with the SummaryReports A and B.

• trainers need to be identified – Director of Child Health and senior staff of theDepartment, and selected members of the CHLWG.


realized, and before that the scaling up shall occur according to three dimensions(Figure 10.1 taken from the MDSR guideline, but is applicable to CDSR).

a. The first (horizontal) dimension is the place where the child death occurs –for the initial phase, the CDSR shall capture both facility deaths (but onlypublic facilities) and deaths outside the facility (at home, school, playgrounds,and other sites in the community). It is envisioned that in future, CDSR willbe conducted for deaths in private facilities (for the audit and responsecomponents because the surveillance component in terms of number of deathsis already in place with the HMIS).

b. The second (vertical) dimension is the geographical coverage of the CDSRitself, especially the audit component. This will be better assessed and decidedafter the completion of the First Phase.

c. The third (diagonal) dimension is the extent and depth of the review/auditprocess. It is proposed that the CDSR in Myanmar at this initial stage ofintroduction, uses only medical (hospital and other facility) records and theverbal autopsy conducted to complete the two notification/review forms(CDSR Forms 1 and 2) supplemented by CDSR Form 3 which identifies anydelay is seeking care. In later phases of implementation, these tools shall beimproved or expanded or new tools introduced.

Needless to say, the extent and speed of implementation depends on several factors.The enabling factors in MDR/MDSR will apply to CDSR, and these include (1)political will and a clear agenda for child health (2) good collaboration andcommunication among the different levels of review (3) Knowledge and skills ofstaff involved in the processes especially of death review (4) proper and completedocumentation (5) user-friendly and simple tools and formats, supplied in adequatenumbers (6) checklists and supervision, and (7) adequate resources

6 The seven thematic areas are 1.Civil Registration and Vital Statistics (CRVS), 2.Monitoring and evaluation, 3.Maternal Death Surveillance and Response (MDSR). 4. Innovation and e-health, 5. Monitoring and tracking ofresources, 6. Review process and 7. Advocacy and outreach

14. ADVOCACY AND GAINING SUPPORT

From the experience with MDSR, advocacy is found to be useful, it is one of theseven thematic areas6 in the country road map to implement the recommendations ofthe Commission on Information and Accountability (COIA) under the Global Strategyfor Women’s and Children’s Health (GSWCH).

14.1. What is advocacy?

Advocacy is understood as “an organized, deliberate systematic process intended tobring about a positive change” This definition has been adopted in the country road


map for implementation of the recommendations of COIA. In the TechnicalGuidelines for MDSR, advocacy is defined as “A political process by an individual orgroup that aims to influence behavior, policy and resource allocation within political economic andsocial systems and institutions”7 Changes in behavior and clinical practice are oftendifficult to achieve without widespread promotion and visible support from leadingand well respected advocates, professionals and professional organisations.

14.2. How to carry out advocacy for child health and CDSR?

Advocacy can happen in many different ways, and choosing the best option dependson what needs to change to improve child survival in Myanmar. Some of the topicsthat can be used in advocacy exercise in the context of CDSR are:

• Highlighting the magnitude of the problem, which is unacceptable level ofchild mortality in Myanmar, and the fact that most of these deaths can beprevented by effective and affordable intervention

• Highlighting the socio-economic dimensions of child death especially inabilityto access health care and life-saving interventions

• Demonstrating patterns and trends of child mortality and the slow progressmade towards international goals and targets

• Exposing bottlenecks to influence change – eg. access to drugs

• Identifying gaps or absent protocol or policies

Successful advocacy takes rigorous, in-depth research, careful planning, and clearly-defined practical goals. It needs clear purpose, well-framed arguments and soundcommunication with audiences.

14.3. Target groups for advocacy for CDSR

Four groups should be targeted as priority:

• Health professionals, for them to be aware of the need for CDSR, and howCDSR can benefit the health status of children

• Parliamentarians, in order to collect support for CDSR including procurementof government resources

• The media, which use a variety of channels for a wide audience

• Civil society organisations (CSOs), which can harness community resources

7 Maternal Death Surveillance and Response – Technical Guidance : Information for Action to Prevent maternalDeaths, WHO (2012)


15. MONITORING AND EVALUATION

15.1. Monitoring

While monitoring is a critical activity in CDSR, the scope of monitoring lies withinthe three components of CDSR which are death review, surveillance and response,and not for the child health programme. For example, if the service is found to havea shortfall in quality which led to the death, it is not the function of the CDSR M&Esystem to remedy this – this is the function of the child health programme managers,who should respond to findings of CDSR and improve the programme. The M&Eof CDSR on the other hand shall detect shortfalls in the CDSR processes themselves,and take remedial actions to improve these processes. In this regard, monitoring ofthe CDSR system is needed to ensure that the steps in the system are functioningadequately and improving with time, and that information is adequate and timely.Monitoring of the CDSR system should be carried out at all levels.

15.2. Supervision

Supervision and quality checks are essential components of monitoring. In the contextof CDSR, supervision is necessary and to be formalised for the midwife. The checklistfor supervision of the midwife is in ANNEX 6. Supervision and quality checks ofthe midwife are carried out according to the normal hierarchy in the health system,as follows:

• In the existing organisational protocol, the midwife must be supervised by theLady Health Visitor (LHV) or the Health Assistant (HA) in the rural healthunit. Supervision for CDSR shall be conducted along with the regularsupervision that is already being done; there is an existing supervision checklist.Therefore the supervision checklist for CDSR (ANNEX 6) will need to beincorporated into the existing checklist.

• The midwife along with her supervisors (LHV and HA) will discuss with theTMO when she submits her monthly forms and reports at the monthly meetingwith the TMO.

• The DMO and CD Review Team at district level discusses with the TMOs inthe district who are invited for the quarterly death review meetings. Thismeeting is an opportunity for the DMO to do quality checks with the TMOs.If deemed necessary, the DMO may make a visit to the townships (perhapson a rotational basis for one visit per township in a year) to observe for himself/herself the way the TMO manages the CDSR process, especially with regardto ascertaining cause of death. While a checklist is not necessary, the DMOshould write a report of his supervisory visit to the TMOs.

• In a similar manner, the state/regional supervisor may wish to make asupervisor visit to districts for any particular reason, including to observe the


functioning of the District CD Review team during the audit meeting. It issuggested that one district receives one supervisory visit per year from state/regional supervisor especially with regard to epidemiological analysis and trendsof child death and its profile. While a checklist is not necessary, the supervisorshould write a report of his supervisory visit to the DMOs.

15.3. Evaluation

In addition to the monitoring indicators that provide a quick snapshot of whetherthe system is improving, periodically a more detailed evaluation is useful. The mainpurpose of CDSR is to lead to action to reduce child deaths, therefore if this is nothappening the system is not meeting its objectives, and the system should beimplemented using resources appropriately.

Effectiveness - In the early stages of implementation, evaluation is limited toeffectiveness to determine if the recommendations for action have been implemented(inputs, processes or activities), if they are achieving the desired results (outcomes)and if not, where any problems may lie. Exactly how this effectiveness evaluationshould be carried out will depend on the particular circumstances in each community,facility, or health care system. It starts with a determination of if and how the specificCDSR findings and recommendations have been implemented.

Impact – This evaluation will be to assess whether the system has achieved its goalreduction of child deaths and lowering of child mortality.

Efficiency - Later, evaluation can extend to efficiency, to see whether the systemcan function more efficiently. This includes an assessment of its key processes:identification and notification, review, analysis, reporting and response. IT solutionscan help reduce inefficiencies, but require trained staff. Ideally the system will becomputerized, at all levels in a phased manner. Midwives can be provided withmobile phones to improve speed of notification and review.

15.4. Indicators

The indicators will be for effectiveness (processes/output and outcome) and impact;no attempt shall be made in the early stages of implementation to measure andidentify indicators for efficiency or cost-effectiveness. This however may becomerelevant in the later stages especially when there is need to procure resources andjustify for them.

Effectiveness (process and outcome) indicators: These are considered together inthe following table with the assumption that the input/processes/output will leadto changes which are the outcomes. In a relatively small project such as CDSR (unlikeprojects or programmes with wider scope and activities) it is convenient andreasonable to place inputs, processes/activities and outputs together.


16. RESOURCES FOR IMPLEMENTATION

Besides the First Phase implementation, which has to be costed separately, theimplementation of CDSR will depend on the availability of required resources, whichat the very least will be for:

• Time and the travel needed, with their cost implications – in the evaluation ofimplementation of MDR in 2011-2012 by SEARO, some midwives statedthat they often had to pay for travel to reach the deceased’s house to conductthe verbal autopsy.

• Printing of tools/formats in adequate numbers - the evaluation of MDR in2011-2012 revealed that the forms were often in short supply and midwivessometimes had to make photocopies at their own cost

• Supervisory and monitoring visits by supervisory staff

• Printing of periodical and annual reports

• Advocacy activities – use of media (print or radio/television etc) has costimplications. In the road map of MDSR, briefing sessions are recommendedfor parliamentarians, media and civil society organisations media

• Training that may be needed from time to time

• Convening of meetings, seminars, workshops etc related to CDSR

• Resources for the development of electronic formats, systems and tools, socommunication technology can be used to facilitate timely and comprehensivereporting in the longer term. Computerization at all the levels of review willalso facilitate the CDSR, particularly for the review and surveillancecomponents.


This ANNEX provides answers to the two questions:

(1) What were the tools used for neonatal death audit and will these be appropriate for use in CDSR?

(2) What lessons can CDSR learn from MDSR?

ANNEX 1

Lessons learned fromMDR/MDSR experience


ANNEX 1 : Lessons learned from MDR/MDSR experience

Q1 : What were the tools developed under the MDR for neonatal death audit,will these be appropriate for use in CDSR?

In Myanmar, as mentioned earlier, there was an attempt to introduce perinatal (lateron replaced by neonatal) death audit, using the MDR platform. However, thiscomponent did not get implemented as planned, and did not progress as MDR did;justifiably because maternal death is given a much higher priority than perinatal/neonatal death. An attempt was made to introduce neonatal death audit with thefollowing forms – (i) Cause of neonatal death. While this detailed form on cause ofdeath can be used as a verbal autopsy tool in CDSR, it is proposed that this will not beused, as it is too detailed and complex for the midwife (ii) Referral form (iii) Form toidentify the three delays” (iv) Terms and definitions used in verbal investigation ofnewborn death.

For the purpose of CDSR, these forms are not needed except the cause of neonataldeath, for which there is an existing form - the verbal autopsy forms developed by theWHO3, and Myanmar had used this before in 2013 study on cause of child death.

Q2 : What lessons can CDSR learn from MDSR ?

The lessons learned from the MDSR experience include:

• Maternal death review is beneficial: MDR has shown that the understandingthe causes of maternal deaths and the of factors and circumstances surroundingthe death provides an excellent opportunity for formulating policies, strategiesand actions to prevent several maternal deaths, and reduce maternal mortality

• Maternal death review is feasible: The experience with MDR has shown thatit is feasible to elicit and understand the factors and circumstances that leadthe maternal death, in other words to ‘go beyond the numbers’ or statistics onmortality rate and ratio; so that an opinion can be formed if the death waspreventable or avoidable, and what could have been done to prevent the death.There are of course lessons for CDSR to learn from MDSR, and these include

• Methods of death review: The methods of review are likely to be the samefive methods described for MDSR found in the WHO guide “Beyond TheNumbers” , except the near-miss method. Similarly, some relevant informationcan be obtained from the guide on MDSR especially in the flowcharts forreporting, auditing, responding and conduct of surveillance

• Getting reliable sources of information: Any death audit system relies heavilyon reliable information system and sources of data especially from civilregistration and vital statistics (CRVS). This has been found to be a majorproblem in MDSR. The MDSR guidelines recommend that countries makematernal death a notifiable event, which may not be possible/realistic for


child deaths. The M&E Technical Strategic Group of the M-HSCC s proposingto the GFATM for funding to strengthen birth and death registration andmortality analysis in Myanmar, which will directly benefit the development ofCDSR

• Difficulty in determining cause of death: Information is particularly lackingin determining cause of death. In MDSR, there is a further inherent difficultyof definition and classification of death, which will not apply to CDSR – adeath in a woman of reproductive age may be pregnancy-related death, butnot necessarily a maternal death, and indeed it is only through a careful auditof pregnancy-related deaths can the maternal deaths be identified9 . In theinformation on 863 maternal deaths in 2013, the assignment of the cause ofdeath was inaccurate

• The number of deaths: Child death far outnumbers maternal deaths by asmuch as twenty times or more. MDSR has called for every maternal death tobe notified, counted and preferably all are reviewed. Indeed in some countrieswhere the number is too small to allow lessons to be learned, audits are donefor maternal “near-miss’ cases as well. For CDSR, only a sample of deaths canreasonably and practically be reviewed.

• Selection of variables for the review process: The investigation/review toolsfor CDSR such as reporting formats will be guided by the example of MDSRincluding the selection of variables to be studied. In the analysis of 863 maternaldeaths in 2013, the quality of the analysis was especially compromised byinformation on the cause of death and the three-delay model

• When to initiate review?: It was reported by a few midwives that the 7-dayprotocol to initiate the verbal autopsy was not appropriate (too soon) for somefamilies, who could not adequately respond to the interview while they werestill in a state of grief

• Staff knowledge, attitude and motivation: It has to be recognized that a deathreview involving specific actions and tools requires specific knowledge. Inaddition, attitude can also be a problem. Adequate training has to be conducted.It has been reported in several studies that sometimes staff deliberately notreport a maternal death for fear of being punished for possible substandardcare that the MDR may reveal. While this may not be the case in CDSR, it isstill critical that health staff are informed from the beginning that the audit is

9 A pregnancy related death includes maternal deaths and deaths from incidental causes to which the pregnancy,childbirth and puerperium has not contributed. The maternal deaths (which exclude these incidental deaths) maybe direct maternal deaths due to obstetric causes or indirect maternal deaths due to underlying conditions such asheart disease etc


not for punitive purposes. Sometimes, the higher level managers themselveswere not convinced of the importance of MDR, and therefore did not giveenough support.

• Staff workload: The MDR is an extra burden on the workload of the staff;hence it is critical to factor this in when developing the system. It has to beborne in mind that a death audit is an extra task/function of the midwiveswhose existing responsibilities are already heavy to begin with. In Myanmar,some midwives found the 32-page audit form too long and takes time to fill;in addition, the forms are often in short supply

• Supervision and support: The support and supervision given by senior managerswas found to be critical for ensuring that the midwife conducts the auditproperly, and eventually for the success of MDR

• Logistical problem: Besides the shortage of the audit form mentioned above,there were reports of difficulties faced by the midwife in transport to thefacility of to the house of the deceased to conduct a verbal autopsy

• The management and administration: For CDSR, this can be modelled afterMDSR such as the committees and review teams, logistics involved, processessuch as reporting and dissemination (indeed this technical guidelinerecommends that the same review committee be used for both MDSR andCDSR

• The cycle of actions: Finally, the overall approach to a death review used inMDSR is a cyclical approach. These four cyclical steps are applicable to CDSR(i) identifying deaths, (ii) reviewing the deaths, (iii) analyzing the findings ofthe review and (iv) response – with an ongoing monitoring and evaluation(surveillance)


This form is filled by the midwife who receives information that a child has died. Part 1 of the formis a simple form (not detailed as in a verbal autopsy) with fixed options on possible cause of deathbased on signs and symptoms. If needed (midwife not able to do so), this form can be filled by thePHS II

Part 2 of the form his form is for the midwife (or PHS II) to investigate if there was any delay inseeking care based on the three-delay model

ANNEX 2

CDSR Form 1 : Notification Form for Child Death and questionnaire to

investigate the three delays


Q1: Were you aware that you had to take the child to a clinic or a hospital for theillness?

No ----- stop

Yes ----- go to Q2

Q2 : Did you or someone else take the child to the clinic/hospital?

No ----- go to Q3

Yes ----- go to Q4

Q3 : Why did you not take the child to the clinic/hospital? (Allow the respondent toexplain in his/her own words but be aware of the possible reasons that may need tobe probed by some leading questions – see LIST 1)

………………………………………………………………………………………………………….

Q4: Did you have any difficulty in taking the child for care as soon as you decidedthat your child needed further care?

Not sure ----- stop

Yes, I had some difficulty and I was late in taking my child for further care? ----- go to Q5 and 5a

No, I had no difficulty and I took my child on time ----- go to Q6

Q5 : What difficulty did you have in taking the child on time to the clinic/hospital?

(Allow the respondent to explain in his/her own words but be aware of the possiblereasons as in Q3 and the LIST 1)

……………………………………………………………………………………………………………

…………………………………………………………………………………………………………

Q5a : After you arrived at the clinic/hospital, were you satisfied with the servicesprovided?

Yes ----- Stop

No ----- go to Q7

Q6 :Were you satisfied with the services or care given?

Yes ----- stop

Not sure-----stop

No ----- do to Q7


Q7 : What are the reasons you were not satisfied with the service /care given at the clinic/ hospital?

(Allow respondent to answer freely but be aware of the possible reasons –see LIST 2)

……………………………………………………………………………………………………………….

……………………………………………………………………………………………………………….

LIST 1 - Possible reasons for not seeking care or delayed in seeking care (Delay 1 and 2)- patient factors

Delay 1

• Not aware of need to seek care

• Did not think the illness was serious and can cause death

• Wanted to treat the child at home

• Went to alternative health provider - traditional healer, quack

Delay 2

• Clinic/hospital too far, cannot get there easily

• No transport available

• No money for transport

• No money to pay for medical care and medicines

• No one to look after other children at home

LIST 2 : Possible reasons for dissatisfaction with the service at point of care (Delay 3)– health system factors

• There was no health staff

• Clinic/hospital was closed

• There was no available bed

• Staff came late to attend to the child

• Staff told us nothing could be done to save the life of the child

• Staff did not appear skilled or competent

• Staff was unfriendly, rude

• Staff not willing or not able to answer questions

• We were informed there was no medicine and we had to buy them ourselves

• The clinic/hospital was dirty/uncomfortable/had no basic amenities


This form is to be filled up for any child death notified in which the Township Medical Officer(TMO) or District Medical Officer (DMO) or the District Maternal and Child Death ReviewTeam/Committee deems it necessary to be investigated further. The TMO or DMO or any teammember may decide to conduct the autopsy themselves, or may direct the Health Assistant (HA) orthe Lady Health Visitor (LHV) at the RHU to conduct the autopsy

This form is available in Myanmar language in which it has more details (compared to the Englishversion below) following revisions and editions

CDSR Form 2 : (Verbal autopsy from for child

ANNEX 3

deaths)


ANNEX 4 AND 5

Summary reports from TMO and DMO

These two forms are the summary forms to be filled by the TMO (Annex 4 – CDSRForm 3) and DMO (Annex 5 – CDSR Form 4)


ANNEX 4 : CDSR Form 3 (Summary Report filled by TMO to send to DMO)

1. How many child deaths had occurred in your township in this quarter? ……..

2. How many were neonatal deaths and how many were death in children aged 29days to 5 years? …….. and ……….

3. Of this number, how many were notified and reviewed by the midwifeusing the prescribed notification form (CDSR Form 1) ……………… andhow many deaths were reported from hospitals? ……. Of this number reportedfrom hospitals, how many have been reviewed/ audited by the hospital?………..

4. Were all these deaths in children resident in your township? If some were fromother areas, how many were these? …..

5. Of Part 1 of CDSR Form 1 (notification/review forms) submitted by themidwives, how many were filled

a. Completely and properly – fully satisfactory …….

b. Partially – but satisfactory overall …….

c. Poorly – not satisfactory at all ………

6. For the cause of death how many notification/review forms provided

a. A clear one single cause of death

b. Clear but more than one cause of death

c. Unclear cause of death

d. No cause of death

7. From Part 2 of the CDSR Form 1 (Three Delay Investigation), how many

a. Were filled properly and it was possible to identify if there was a delay,and the type of delay

b. Were partially clear and some idea of the delay could be ascertained

c. Were filled poorly and they did not elicit any useful information on thedelay


8. Of the child deaths reported and reviewed by hospitals (Question 3 above),from the review reports, were you able to ascertain if there were preventablefactors for the death?

a. There was no preventable deaths in ….. (number)…. deaths

b. Not able to ascertain in … (number)… deaths

c. Yes, there were preventable factors? In how many deaths?....(number)....

9. Were you required to take actions or to respond to the findings

a. Yes

b. No

10. If you needed to respond were you able to?

a. Yes fully

b. Yes but only partially …. Please give reasons

c. No ….. please give reasons

Please briefly describe any action (response) that you have taken or are planning to take on preventablechild deaths, in order to prevent similar deaths in future

……………………………………………………………………………………………………………

…………………………………………………………………………………………………………..

Please write a concise narrative if you wish to sumamrise the above information or tosupplement it with other information………………………………………………………………………………………………..


ANNEX 5 – CDSR Form 4 (Summary Report filled by DMO, sent to Region/State)

1. How many child deaths had occurred in your district in this quarter?……..

2. How many were stillbirths/neonatal deaths …….…., and how many weredeath in children aged 29 days to 5 years………

3. From the review forms of the 15 perinatal/neonatal deaths and 15 deaths,in children 29 days to 5 years, was the District CD Review Team inagreement with the cause of death given

a. Yes in all of them

b. Yes but only in …….. of them

c. In none of them

Please elaborate if necessary ………………………………………..

4. Please indicate the leading cause and number of deaths by cause in thedistrict this quarter

Perinatal/neonatal deaths Deaths in children 29 days-5 years

……………………… …………………………….

……………………… …………………………….

……………………… …………………………….

……………………… …………………………….

……………………… …………………………….

5. In Part 2 of CDSR Form 1 (Three Delay Investigation) on these 30deaths, did the District Review Team in agreement with the findings onthe 3 delays

a. Yes in all of them

b. Yes but only in …..

c. None of them

Please elaborate if necessary …………………………………..


6. From the Three Delay investigation, please indicate the number of deathsby the type of delay

a. No delay ……

b. First delay ……

c. Second delay ……

d. Third delay ……..

7. Of the summary report from the townships, how many were

a. Completely and clearly filled ….

b. Partially filled …….

c. Incomplete and /or unclear ……

8. Of the summary reports from the townships, for the section on the narrativefor assessment of preventability of death, how many were

a. Clearly had factors that indicate death was preventable or avoidable……..

b. Probably had such factors, but cannot be ascertained ……

c. Had no such factors ………

Please briefly describe any action (response) that you have taken or are planning to take onpreventable child deaths, in order to prevent similar deaths in future

……………………………………………………………………………………………………………

Please write a concise narrative if you wish to sumamrise the above information or tosupplement it with any other information……………………………………………………………………………………………….


ANNEX 6

Checklist for supervision of midwife by LHV or HA

This supervision checklist is customised for CDSR, but the supervisor of the midwife(LHV and HA) will use this checklist as part of their regular supervision of the midwife.The filled checklists will be discussed at the monthly meeting at the Township HealthOffice


ANNEX 7

Logical framework for monitoring and evaluation ofCDSR

In the main body of the guideline, these indicators are linked from process/output (3indicators) to outcome (13 indicators) to impact (4 indicators). In this logframe, these20 indicators are listed serially in the first column.

myanmar a large proportion of child deaths are in the community. to meet the objective of cdsr which...

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