Maternal Death Audit Research Articles

Evaluation of the quality of audits of maternal deaths in hospitals in the health districts of communes IV and V of Bamako

Introduction: In Mali, the audit of maternal deaths instituted in 2017 aims to reduce maternal mortality. The objective of this study was to assess the quality of maternal death audits carried out in the hospitals of health districts in communes IV and V of Bamako between 2015 and 2019. Methodology: This was a descriptive, cross-sectional study of 108 maternal death audit reports over the period from 2015 to 2019. The exploitation of the said reports and the interview with the service providers were the techniques used. The ratio between the expected and obtained scores of each audit component allowed them to be assessed. When at least 80% of the expected scores are achieved, the component is considered to be of sufficient level, therefore favorable to quality audits. When the average score obtained for the components is at least 80%, the audit is judged to be of good quality. Results: The performance levels of the "inputs and processes" components of the audits were respectively 80.4% and 74.7% in commune IV and 56.9% and 63.2% in commune V. The performance in terms of results was 40.7% in the two municipalities. The quality of the audit was 70.1% in Commune IV and 56.9% in Commune V. Conclusion: From 2015 to 2019, the audit of maternal deaths was judged to be of average quality in Commune IV and insufficient in Commune V. Training and the active involvement of stakeholders are necessary to improve audit quality. Keywords: Audit, maternal death, district hospitals, Bamako.

Maternal mortality review in a major tertiary referral hospital in Liberia, 2018–2021

ObjectivesAnecdotal evidence showed increased maternal deaths at the major tertiary hospital over the past two years (2020–2021). We reviewed the maternal death audit data, identified the main causes of maternal death, and associated risk factors. Findings were shared with policymakers to help reduce maternal mortality. Study designWe conducted a secondary data review and descriptive analysis of maternal death at the tertiary hospital located in Monrovia. MethodThe maternal death data were extracted from patient medical records, including death certificates and maternal audit records. The record of live births was obtained from the delivery register. Data were analyzed using Epi Info version 7.2 Maternal mortality ratio (MMR) was estimated, the leading direct and indirect causes of maternal death were identified, and the factors associated with maternal death were explored using logistic regression at a 5% level of significance. ResultsThere are a total of 233 maternal deaths and 14, 879 live births giving a maternal mortality ratio (MMR) of 1565 per 100,000 live births during the period under review. The median age of the mothers at death was 29 (14–45) years. About 40.3% (94/233) of cases died within <1 day of admission, referrals accounted for 59% (137/233) of the cases. Direct causes of death accounted for 66% (147/223). Hemorrhage [30.6% (45/147)], Eclampsia [(30/147) 20.6%] and Sepsis [(30/147) 20.6%] were the main direct causes of death while cardiovascular-related [18.4% (14/76)] and HIV/AIDS [16% (12/76)] were the leading indirect cause of death. Patients from referred other facilities were 7.9 times more likely to die as compared to non-referral (pOR:7.9, 95%CI: 5.9–10.6, p < 0.001). ConclusionThe maternal mortality ratio remained high. Referrals were done late. The Liberia Ministry of Health should equip more secondary-level health facilities and tertiary hospitals to handle maternal emergencies and sensitize the populace and healthcare workers on prompt identification and referral of obstetric emergencies. The MoH also needs to improve the blood transfusion services to help in the management of postpartum hemorrhage.

Evaluation of the Reference - Evacuation Markala

The aim of this study was to evalute the performance of the referral system for evacuation of obstetric emergencies between the CSCom and the CS Réf in Markala from 1 January 2021 to 31 December 2021. This study enabled us to identify:  The performance of the evacuation reference system between the CSCom and the CS Réf in Markala; • The effectiveness of maternal death audits ; • Holding staff meetings; • The mother's condition.  The problems related to : • The functionality of the management committee; • The child's condition; • Payment of co-payments. At the end of the work, it was concluded that the evacuation reference system between the CSCom and the CS Réf in Markala was not performing well with regard to the criteria set by the evaluation team.

Maternal near miss at Kathmandu Medical College: An analysis of severe maternal morbidity at a Nepalese tertiary care facility.

The World Health Organization (WHO) 'near miss' tool has been extensively used to audit maternal morbidity in low- and middle-income countries. Analysis of the cases of 'near miss' enables a better understanding of the associated factors, identifies deficiencies in the provision of maternity services and lays a foundation for better preventive measures in the future. To understand the epidemiology, aetiology and determine the aspects of preventability of maternal 'near miss' (MNM) at Kathmandu Medical College. A prospective audit of MNM and maternal deaths (MD) was undertaken at Kathmandu Medical College over a period of 12 months. The cases were identified using WHO 'near miss' criteria and areas of preventability in the provision of care determined using the modified Geller's criteria. The total number of deliveries and live births in the study period were 2747 and 2698 respectively. A total of 34 'near misses' and two MDs were identified. The common direct aetiologies of MNM and MDs identified were obstetric haemorrhage followed by hypertensive disorders with one-third of cases being of indirect aetiology. Fifty-five percent of cases had some aspects of provider- or system-related preventability with the leading delays being lack of diagnosis and recognition of high-risk status among patients and lack of interdepartmental communication. The WHO near miss rate at Kathmandu Medical College was 12.5/100 live births. Significant aspects of preventability, especially at the level of the provider, were noted among cases of MNM and MDs.

From Pre-Implementation to Institutionalization: Lessons From Sustaining a Perinatal Audit Program in South Africa.

Maternal and perinatal death surveillance and response (MPDSR), or related forms of maternal and perinatal death audits, can strengthen health systems. We explore the history of initiating, scaling up, and institutionalizing a national perinatal audit program in South Africa. Data collection involved 56 individual interviews, a systematic document review, administration of a semistructured questionnaire, and 10 nonparticipant observations of meetings related to the perinatal audit program. Fieldwork and data collection in the subdistricts occurred from September 2019 to March 2020. Data analysis included thematic content analysis and application of a tool to measure subdistrict-level implementation. This study expands on case study research applied to 5 Western Cape subdistricts with long histories of implementation. Although established in the early 1990s, the perinatal audit program was not integrated into national policy and guidelines until 2012 but was then excluded from policy in 2021. A network of national and subnational structures that benefited from a continuity of actors evolved and interacted to support uptake and implementation. Intentional efforts to demonstrate impact and enable local adaptation allowed for more ownership and buy-in. Implementation requires continuous efforts. Even in 5 subdistricts with long histories of practice, we found operational gaps, such as incomplete meeting minutes, signaling a need for strengthening. Nevertheless, the tool used to measure implementation may require revisions, particularly in settings with institutionalized practice. This article provides lessons on how to initiate, expand, and strengthen perinatal audit. Despite a long history of implementation, the perinatal audit program in South Africa cannot be assumed to be indefinitely sustainable or final in its current form. To monitor uptake and sustainability of MPDSR, including perinatal audit, we need research approaches that allow exploration of context, local adaptation, and underlying issues that support sustainability, such as relationships, leadership, and trust.

Review of maternal death audits in refugee camps in UNHCR East and Horn of Africa and Great Lakes Region, 2017-2019.

To review the quality of maternal death audits and identify factors contributing to refugee maternal deaths in the East and Horn of Africa. Maternal death audits submitted to The UN Refugee Agency (UNHCR) from 2017 to 2019 in 43 refugee camps in eight countries were analyzed for completeness, obstetric history, cause of death, and contributing factors. A total of 191 refugee maternal death audits were retrieved. The mean age of the deceased was 28 years (range, 15-45 years), and 13% were adolescents and 17% were of advanced maternal age. Most patients (55%) were grand multigravida (≥5 pregnancies). The majority (86%) attended antenatal care visits, with 51% attending four or more visits. Among women who delivered (n= 140), 91% were facility-based deliveries. Most (68%) deaths occurred postpartum. Obstetric hemorrhage (49%) was the leading direct cause of death (with 77 cases of postpartum hemorrhage), followed by hypertensive disorder (19%) and infection (15%). Delays in care were identified in 185 (97%) cases. Delays in receiving care were more prevalent (81%) than in seeking (61%) and reaching (26%) care. Factors contributing to delays in receiving care highlight the capacity gaps in provision of emergency obstetric care, including management of postpartum hemorrhage, requiring urgent additional investments. Audit findings also show the need for attention and action towards family planning, contraception, and adolescent sexual and reproductive health services.

English

Maternal death audits (MDAs) are the key to reducing maternal mortality.&nbsp; However, there are some barriers to the involvement of midwives in carrying out maternal death audits. This article aimed to explore midwives&#39; perceptions and experiences of maternal death audits in Burkina Faso. This was a qualitative study conducted in December 2018. Data were collected from individual semi-structured interviews. Thematic analysis of the data was performed using Qualitative Data Analysis (QDA) Miner software. Shortcomings in applying the audit charter and implementation of recommendations, financial rewards and non-invitation of providers compromise midwives&#39; participation. However, the study found that midwives had good experience and perception of MDAs. The study highlighted shortcomings in the conduct of the audits and difficulties in implementing the recommendations. This requires more significant involvement of the various administrative and clinical actors in the health system and the integration of maternal death audits into routine activities. Key words: Maternal death, midwives, death audits, qualitative stud, Burkina Faso.

Causes of Maternal Mortality in 2020 in the Kara Region (Togo)

Objective: Determine the maternal mortality rate, the epidemiological profile, the causes of death and the dysfunctions noted. Patients and method: This was a cross-sectional and descriptive study from January 1 to December 31, 2020. All maternal deaths during pregnancy or within 42 days after its termination fitting the World Health Organisation definition criteria that occurred in the seven districts of Kara region were included. The data were processed using Excel microsoft. Results: A total of 41 maternal deaths occurred among 23,456 live births, accounting for a maternal mortality ratio of 174.8 deaths per 100,000 live births. The followings were observed: the average age of 30 years; 88% married; 39% multiparous; 78% housewives without income; 5% students. Hemorrhage, preeclampsia, and complications of abortion were the main direct obstetric causes, while anemia was the main indirect obstetric cause. Factors related to deaths were inadequate quality of health care and lack of universal health insurance. The various maternal death audit reports found that 94.4% of deaths were preventable. Conclusion: Most maternal deaths would be prevented in the Kara region if women during pregnancy and the postpartum period received quality health care and the community was involved in decision-making about their health.

\u201cSharp downward, blunt upward\u201d: district maternal death audits\u2019 challenges to formulate evidence-based recommendations in Indonesia - a qualitative study

BackgroundIndonesia, the largest archipelago globally with a decentralized health system, faces a stagnant high maternal mortality ratio (MMR). The disparity factors among regions and inequities in access have deterred the local assessments in preventing similar maternal deaths. This study explored the challenges of district maternal death audit (MDA) committees to provide evidence-based recommendations for local adaptive practices in reducing maternal mortality.MethodsA qualitative study was conducted with four focus-group discussions in Central Java, Indonesia, between July and October 2019. Purposive sampling was used to select 7–8 members of each district audit committee. Data were analyzed using the thematic analysis approach. Triangulation was done by member checking, peer debriefing, and reviewing audit documentation.ResultsThe district audit committees had significant challenges to develop appropriate recommendations and action plans, involving: 1) non-informative audit tool provides unreliable data for review; 2) unstandardized clinical indicators and the practice of “sharp downward, blunt upward”; 3) unaccountable hospital support and lack of leadership commitment, and 4) blaming culture, minimal training, and insufficient MDA committee’ skills. The district audit committees tended to associated maternal death in lower and higher-level health facilities (hospitals) with mismanagement and unavoidable cause, respectively. These unfavorable cultures discourage transparency and prevent continuing improvement, leading to failure in addressing maternal death’s local avoidable factors.ConclusionA productive MDA is required to provide an evidence-based recommendation. A strong partnership between the key hospital decision-makers and district health officers is needed for quality evidence-based policymaking and adaptive practice to prevent maternal death.

Audit of maternal deaths at the Saint Louis regional hospital from 2017 to 2019

Objective: To audit maternal deaths at the regional hospital center of Saint-Louis. Materials and methods: This was a retrospective cross-sectional study of all maternal deaths that occurred between January 1, 2017 and December 31, 2019 at the Saint-Louis regional hospital center. Data were entered on EXCEL 2013 software. Analysis was performed on Epi Info version 3 software. Results: During our study, 73 cases of maternal death were collected. Maternal mortality was 520 per 100 000 live births. The mean age of the patients was 28.1 years±6.8. Multiparous women accounted for 43.8% and nulliparous women for 1.3%. The causes of maternal death were obstetric hemorrhage (28.77%), hypertension and its complications (20.55%), labour dystocia (15.07%) and anemia (6.85%). Direct obstetric causes of death were responsible for 64.38% of cases and indirect obstetric causes were seen in 35.62%. Death occurred postpartum in 68% of cases, during pregnancy in 25% and during labor in 7%. Death was preventable in 77.5% of cases. Conclusion: Maternal mortality is a real health problem in our practice. It affects young women. Indirect causes of death are becoming more significant causes of death in our practice. Maternal mortality is avoidable in the majority of cases.

Do perinatal and maternal death reviews and audits reduce perinatal and maternal mortality?

Do perinatal and maternal death reviews and audits reduce perinatal and maternal mortality?

Maternal and perinatal death surveillance and response in low- and middle-income countries: a scoping review of implementation factors.

Maternal and perinatal death surveillance and response (MPDSR), or any form of maternal and/or perinatal death review or audit, aims to improve health services and pre-empt future maternal and perinatal deaths. With expansion of MPDSR across low- and middle-income countries (LMIC), we conducted a scoping review to identify and describe implementation factors and their interactions. The review adapted an implementation framework with four domains (intervention, individual, inner and outer settings) and three cross-cutting health systems lenses (service delivery, societal and systems). Literature was sourced from six electronic databases, online searches and key experts. Selection criteria included studies from LMIC published in English from 2004 to July 2018 detailing factors influencing implementation of MPDSR, or any related form of MPDSR. After a systematic screening process, data for identified records were extracted and analysed through content and thematic analysis. Of 1027 studies screened, the review focuses on 58 studies from 24 countries, primarily in Africa, that are mainly qualitative or mixed methods. The literature mostly examines implementation factors related to MPDSR as an intervention, and to its inner and outer setting, with less attention to the individuals involved. From a health systems perspective, almost half the literature focuses on the tangible inputs addressed by the service delivery lens, though these are often measured inadequately or through incomparable ways. Though less studied, the societal and health system factors show that people and their relationships, motivations, implementation climate and ability to communicate influence implementation processes; yet their subjective experiences and relationships are inadequately explored. MPDSR implementation contributes to accountability and benefits from a culture of learning, continuous improvement and accountability, but few have studied the complex interplay and change dynamics involved. Better understanding MPDSR will require more research using health policy and systems approaches, including the use of implementation frameworks.

Audit of Early and Late Maternal Deaths in Georgia: Potential for Improving Substandard Obstetric Care.

IntroductionQuality of care is an important factor in reducing preventable maternal deaths, yet it is a significant challenge in many countries. Substandard and poor quality of care is the leading factor in two-thirds of maternal deaths in European countries. Our study investigated the deaths of all women of reproductive age in 2012 in Georgia. The aim was to define the underlying causes of maternal deaths and to identify the factors in women’s care which contributed to the fatal outcomes.MethodsA national Reproductive Age Mortality Survey was conducted in Georgia in 2014–15. Data from multiple sources was triangulated to identify all deaths of women of reproductive age. This was followed by verbal autopsy diagnoses. Each case of early and late maternal death was investigated through interviews and medical record reviews at the last medical facility providing care for the deceased woman. A specialist panel reviewed and assigned underlying causes of death, assessed the management of each woman’s condition, and identified elements of suboptimal care.ResultsWe identified a total of 23 maternal deaths, including 15 (65%) early and eight (35%) late deaths. The maternal mortality ratio was 26.3 per 100 000 live births. The four leading causes of early maternal deaths were: sepsis, hemorrhage, embolism, and pregnancy-induced hypertension. Embolism and sepsis were the direct causes of the eight late maternal deaths. Cancer, tuberculosis, and postpartum suicide constituted the indirect causes of death. Improvements in care which would have made a difference to the outcomes were identified in 87% of early maternal deaths and 67% of late maternal deaths due to direct obstetric causes.DiscussionDelayed recognition and inappropriate management of maternal complications were common across almost all cases studied. The findings from Georgia highlight the conclusion that most maternal deaths were preventable and that improvement in obstetric care is urgently required.

Audit of Maternal Deaths in the Context of the Free Obstetrical Care at the Maternity of the Ignace Deen National Hospital of Conakry Chu

Objectives: To describe the evolution of half-yearly maternal mortality ratios, to describe the socio-demographic characteristics of the patients who died in the facility, to analyse the causes and determining factors of maternal deaths that have occurred in the facility, and to implement strategies to reduce this maternal mortality. Methodology: this was a descriptive, cross-sectional and analytical study carried out at the maternity ward of the Ignace Deen National Hospital of the Conakry University Hospital with data collection in two phases, including a retrospective lasting 6 months from July 1 to December 31, 2018, and the other prospective for a period of 18 months from January 1, 2019, to June 30, 2020. Result: During the study period, 224 deaths were recorded out of a total of 8,539 live births, for an intra-hospital maternal mortality ratio of 2,623.25 per 100,000 live births. The profile of women at risk of maternal death was as follows: patients aged 20-31 (56.26%), married (87.6%), low-income (41.96%), multiparous (33, 1%), evacuated from a peripheral maternity hospital (79.91%), multi guest (34.9%). The majority of deaths occurred within the first 24 hours (75%). The majority of deaths were due to direct obstetric causes: postpartum haemorrhage (52.68%), eclampsia (21.88%). Indirect obstetric causes were dominated by anaemia (16.07%). But in some cases, two or even three factors were associated with the occurrence of the same maternal death. The most frequently encountered obstetric period of death was postpartum (77.68%). The average recovery time was 31.96 minutes. The lack of blood products and the inadequacy of the technical platform were the main associated factors. Also, it appears that all our cases of death were preventable. The causes of the dysfunctions were attributable: to the person by their attitude (delay in specific care); in the hospital for the lack of equipment and blood products and in the consultation. Free obstetric care was not complete in some cases. Conclusion: maternal mortality is a major health problem in our structure. Its reduction requires the mobilization of all actors in society involving good health education; improving the quality of prenatal consultations and emergency obstetric care by consciously taking charge of staff and strengthening the technical platform.

Factors Affecting Maternal Mortality at the Komfo Anokye Teaching Hospital Using the Audit Committee Report

Objective: The aim of the study aimed at identifying maternal mortality at the Komfo Anokye Teaching Hospital (KATH), using the audit committee report. Design: The study adopted a retrospective descriptive study by reviewing the folders of women who died in KATH using maternal mortality audit committee report. Settings: The study included all cases of maternal death audited by the KATH audit report committee between January and December 2017. Population: The study involved audited cases of maternal death at KATH. Main Outcome Measures: The main variables measured were demographics and characteristics of deceased women, the timing of onset of complications, place of death, antenatal clinic attendance, reported cause of death, service factors and individual factors identified by committees as having contributed to death, and recommendations made by audit committee. Results: 101 cases of maternal deaths were audited from January to December 2017. Out of these cases, deaths occurred mostly in the post-partum period. Fifty-three, representing 52.48% were due to direct causes, with post-partum hemorrhage as the leading cause (49.06%), followed by sepsis (28.3%) then amniotic fluid embolism (9.43%). Indirect causes reported were cardiovascular disease, hepatitis B and, anemia with a percentage of 37.5%, 14.58% and, 6.25% respectively. Conclusions: Accessing maternal death using an audit approach will help the teams in the hospital to identify the direct and indirect causes of death, and their contributing factors, and to make recommendations for actions that would reduce the risk of reoccurrence. KATH can balance maternal death audits with other strategies to inform corrective measures.

Averting Maternal Death and Disability in an Urban Network of Care in Dar es Salaam, Tanzania: A Descriptive Case Study

ABSTRACT The non-governmental organization Comprehensive Community Based Rehabilitation in Tanzania (CCBRT) developed a multi-facility maternal and neonatal Network of Care (NOC) among 22 government hospitals and catchment facilities operating across Dar es Salaam. While facility delivery rates were above 90% in the Dar es Salaam region, the quality of services was substandard, leading to an excess of preventable maternal and neonatal morbidity and mortality. In partnership with the Dar es Salaam regional health authorities CCBRT developed a plan to improve the quality of service delivery at childbirth by through a system strengthening approach, capacitating lower-level facilities to provide routine care during pregnancy and uncomplicated deliveries, as well as improving care at secondary level referral hospitals and developing an inter-connected strengthened referral system. The Regional–CCBRT partnership implemented interventions across the continuum of care that included clinical training in basic and comprehensive emergency obstetric care, investments in infrastructure, and a rigorous maternal and perinatal death audit and follow-up program. Routine data generated were reflected upon at quarterly quality improvement meetings to follow up on problems identified. The government has initiated the replication of the model. This descriptive case study uses the four domains of the Networks of Care framework to document the wide-ranging efforts made to build and maintain the CCBRT Network of Care in order to solve for specific challenges in maternal and neonatal health service delivery in the urban context of the Dar es Salaam region.

Assessing Implementation of Maternal and Perinatal Death Surveillance and Response in Rwanda.

Maternal deaths remain a major public health concern in low- and middle-income countries. Implementation of maternal and perinatal deaths surveillance and response (MPDSR) is vital to reduce preventable deaths. The study aimed to assess implementation of MPDSR in Rwanda. We applied mixed methods following the six-step audit cycle for MPDSR to determine the level of implementation at 10 hospitals and three health centers. Results showed various stages of implementation of MPDSR across facilities. Maternal death audits were conducted regularly, and facilities had action plans to address modifiable factors. However, perinatal death audits were not formally done. Implementation was challenged by lack of enough motivated staff, heavy workload, lack of community engagement, no linkages with existing quality improvement efforts, no guidelines for review of stillbirths, incomplete medical records, poor classification of cause of death, and no sharing of feedback among others. Implementation of MPDSR varied from facility to facility indicating varying capacity gaps. There is need to integrate perinatal death audits with maternal death audits and ensure the process is part of other quality improvement initiatives at the facility level. More efforts are needed to support health facilities to improve implementation of MPDSR and contribute to achieving sustainable development goal (SDG) 3.

Death audits and reviews for reducing maternal, perinatal and child mortality.

© 2018 The Cochrane Collaboration. This is a protocol for a Cochrane Review (Intervention). The objectives are as follows: To assess the impact and cost-effectiveness of different types of death review in reducing maternal, perinatal and child mortality.

Tuberculosis deaths are predictable and preventable: Comprehensive assessment and clinical care is the key

The goal of reducing tuberculosis (TB) mortality in the END TB Strategy can be achieved if TB deaths are considered predictable and preventable. This will require programs to examine and address some key gaps in the understanding of the distribution and determinants of TB mortality and the current model of assessment and care in high burden countries.Most deaths in high-burden countries occur in the first eight weeks of treatment and in those belonging to the age group of 15–49 years, living in poverty, with HIV infection and/or low body mass index (BMI). Deaths result from extensive disease, comorbidities like advanced HIV disease complicated with other infections (bacterial, fungal, bloodstream), and moderate-severe undernutrition. Most early deaths in patients with TB, even with TB-HIV co-infection, are due to TB itself.Comprehensive assessment and clinical care are a prerequisite of patient-centered care. Simple independent predictors of death like unstable vital signs, BMI, mid-upper arm circumference, or inability to stand or walk unaided can be used by programs for risk assessment. Programs need to define criteria for referral for inpatient care, address the paucity of hospital beds and develop and implement guidelines for the clinical management of seriously ill patients with TB, advanced HIV disease and severe undernutrition as co-morbidities. Programs should also consider notification and audit of all TB deaths, similar to audit of maternal deaths, and address the issues in delays in diagnosis, treatment, and quality of care.

Assessment of knowledge and Practices of Midwives in Labor Room Regarding Infection Control in the Main Governmental Hospitals at Sana'a city

Background: Infection control is a more substantial area of concern in labor and delivery room where nosocomial infection can be acquired in the maternal and child health facility. This study aimed to assess knowledge and practice of midwives in labor room regarding infection control. Design: A descriptive cross-sectional design was conducted. Setting: five main governmental hospitals at Sana'a city. Subjects: 84 midwives who work in delivery rooms were selected. Tools: two tools were used tool I: structured questionnaire consist of two parts, part 1: demographic data and part 2 to assess their knowledge related to universal precaution, tool II: checklist was used to assess the practice. Results: the total knowledge about universal precaution and infection control, slightly more than half of the subjects had good knowledge whereas few had poor knowledge. The majority of them had excellent practice for universal precaution and the there was no statistical significant between total knowledge score and total practice score. Conclusion: The total score of midwife’s knowledge related to universal precaution of infection control in the delivery units was fairly enough and the majority of them had excellent score of practice. Recommendations: There should be active hospital infection control committees set up, combined with maternal death reviews, audits, training and feedback on infection rates.