Maternal Death Audit Research Articles

The Impact of Audits of Maternal Deaths and Near Miss at University Hospital of Mother and Child Lagoon (Benin)

Introduction: The maternal deaths audit is one of the three major strategies recommended by WHO for the reduction of maternal and neonatal mortality. Objective: To measure the impact of maternal death and nears miss review on maternal mortality and morbidity after 7 years of practice at the University Hospital of Mother and Child “Lagoon” of Cotonou. Methodology: It was a transversal, descriptive, and analytical study with retrospective data from 1st January 2007 to 31st December 2013. The studied population consisted of maternal deaths cases and of near miss occurred in the hospital during the study period. Results: During the study period, the hospital registered a total of 321 maternal deaths, 3825 perinatal deaths and 3827of near miss. The frequency of maternal death review was 18.7%, the perinatal death of 0.2% and the near miss 0.4%. The most frequent disorders were inadequate reference (69.7%), inadequate treatment (53%), poor supervision (62.1%) and poor files documentation (49.9%). Globally, the period of conducting clinical review was significantly associated with decreased postpartum hemorrhage (p<0.001), pre-eclampsia and eclampsia episodes (p<0.001) and the occurrence of uterine rupture (p=0.02). The occurrence of HRP decreased from 2007 to 2013, but this decrease was not statistically significant (p=0.09). However, there was a significant decrease between 2006 and 2007 (reference period), between 2008 and 2006 and between 2010 and 2006. There is a tendency to lower placenta praevia episodes from 2008-2013 but this decrease does is not statistically significant (p=0.18). Moreover, a significant increase in cases of placenta praevia is observed between 2006 and 2007 (p=0.02). Conclusion: The introduction of maternal death audits is a good approach to reducing maternal mortality and morbidity. However the decrease in indicators of our study can’t be solely attributed to the effect of audits.

Emergency referral transport for maternal complication: lessons from the community based maternal death audits in Unnao district, Uttar Pradesh, India.

An effective emergency referral transport system is the link between the home of the pregnant woman and a health facility providing basic or comprehensive emergency obstetric care. This study attempts to explore the role of emergency transport associated with maternal deaths in Unnao district, Uttar Pradesh (UP). A descriptive study was carried out to assess the causes of and factors leading to maternal deaths in Unnao district, UP, through community based Maternal Death Review (MDR) using verbal autopsy, in a sample of 57 maternal deaths conducted between June 1, 2009, and May 31, 2010. A facility review was also conducted in 15 of the 16 block level and district health facilities to collect information on preparedness of the facilities for treating obstetric complications including referral transportation. A descriptive analysis was carried out using ratios and percentages to analyze the availability of basic facilities which may lead to maternal deaths. It was found that there were only 10 ambulances available at 15 facilities against 19 required as per Indian Public Health Standards (IPHS). About 47% of the deaths took place in a facility, 30% enroute to a health facility and 23% at home. Twenty five percent of women were taken to one facility, 32% were taken to two facilities, and 25% were taken to three facilities while 19% were not taken to any facility before their death. Sixteen percent of the pregnant women could not arrange transportation to reach any facility. The mean time to make arrangements for travel from home to facility-1 and facility-2 to facility-3 was 3.1 hours; whereas from facility-1 to facility-2 was 9.9 hours. The mean travel time from home to facility-1 was 1 hour, from facility-1 to facility-2 was 1.4 hours and facility-2 to facility-3 was 1.6 hours. The public health facility review and MDR, clearly indicates that the inter-facility transfers appropriateness and timeliness of referral are major contributing factor for maternal deaths in Unnao district, UP. The UP Government, besides strengthening Emergency Obstetric and Newborn Care (EmONC) and Basic Emergency Obstetric and Newborn Care (BEmONC) services in the district and state as a whole, also needs to focus on developing a functional and effective referral system on a priority basis to reduce the maternal deaths in Unnao district.

Maternal mortality audit in a tertiary health institution in Nigeria: Lessons from direct causes and its drivers

Nigeria has the second highest number of maternal deaths in the world.The study aimed at determining the causes of and non-obstetric contributors to maternal mortality at a tertiary referral hospital.It was a prospective audit of all consecutive maternal deaths in the hospital over a three-year period. Immediately after the death, information wvas retrieved via a data collection form. Data were analysed with SPSS-20.Seventy deaths were examined over the study period. Maternal mortality ratio was 1,265/100,000 live births. The annual ratio decreased steadily over the study period. Most of the deaths were of multiparous women who had not received any antenatal care, and were mostly postpartum,within 24 hours of delivery. Most of them were critically ill on admission to the hospital. Major causes of death were haemorrhage (36%), sepsis (17%) and hypertensive disorders (16%).Delays were identified in 34.3% of cases; most (70.1%) were Phase III delays.Direct causes of maternal mortality are consistent with those found in literature. Steps which the centre has been taken to counter direct and non-obstetric causes are discussed. Possible strategies to improve health financing and referral system are proffered.

Maternal death audit- institutional based maternal death review in four major hospitals of Municipal Corporation of Delhi

Objective : In India not much importance is still being given to Medical Audit &amp; Death Audit which requires an in-depth analysis of maternal deaths with reference to the cause of death, ways in which the death could have been prevented and deficiencies in health care facilities. Methods: Audit was conducted by Facility BMDR approach, across the various Municipal Corporation of Delhi Hospitals namely, 980 bedded Hindu Rao Hospital, 450 bedded Kasturba Hospital, 250 bedded Swamy Dayanand Hospital and 97 bedded Girdhari Lal Maternity Hospital. Results: The total deliveries combing all hospitals was 113237 out of which 86859 were normal deliveries, 1572 deliveries were assisted forceps or vacuum deliveries and remaining 23403 patients underwent lower segment caesarean section (LSCS) . The total patients who lost life are 194. Out of 194 maternal deaths highest deaths are found in the age group of 20 to 24 i.e 74(38.1%) and almost similar pattern in the age group between 25 to 29 is 73(37.6%) and, maximum deaths (135-69.6%) were observed amongst women who were pregnant for the first time in their life,. Haemorrhage was the major cause of maternal deaths N=61(31.4%) hypertension N=25(12.9) and septicaemia N=24(24.4). 84(43.3%) cases were unstable at the time of admission. 72 (37.1%) cases haemoglobin percentage in blood was not documented and of the remaining only15(7.7%) had above 11 Hb%. Conclusion: Death Audit can become a continuous evolving process to create awareness in health care facilities regarding their deficiencies and scope for improvements which unfortunately is well below par and requires standardization along with a comprehensive policy. DOI: http://dx.doi.org/10.3126/ajms.v6i4.11237 Asian Journal of Medical Sciences Vol.6(4) 2015 67-75

Surveillance and response system for maternal deaths in Sri Lanka: an audit

BackgroundMany women in low-income countries die from pregnancy-related causes. Review of maternal deaths can help to prevent such deaths and improve delivery of maternal care services, but audits of maternal deaths are not easy to do in resource-poor settings. We audited probable maternal deaths reported during 2012 in Sri Lanka. MethodsWe analysed data for death collected by the Family Health Bureau, which coordinates audits of maternal death in Sri Lanka. Field and hospital health staff are required to notify deaths, do post mortems, investigate, and report to national level each maternal death. We analysed each death related to three delays: in seeking health care, in reaching a health facility, and in treatment. We asked health-care workers in 26 districts to suggest strategies to change and improve service delivery. FindingsOf 218 probable maternal deaths, we classified 134 as maternal deaths (WHO definition) and calculated the national maternal mortality rate (37·7 per 100 000 live births). Haemorrhage (n=22) and heart disease (n=15) were leading causes of death. Women who died tended to be well educated (n=109, 81%) and from rural regions (n=106, 79%). 92 (69%) of these women died in the postnatal period. Delays in seeking health care contributed to 64 deaths (71%), whereas delays in receiving treatment contributed to 54 (60%) and delays in reaching a health facility contributed to two (2%). Not promoting family planning, substandard management, and inadequate field post-natal care were identified as deficiencies. InterpretationSri Lanka implements a systematic surveillance of maternal deaths at low cost, with involvement of key partners to further reduce deaths and improve care. Such a system is replicable in any setting if launched methodically and in collaboration with committed partners. FundingNone.

Lessons from the confidential enquiry into maternal deaths, Malaysia.

Malaysia has successfully reduced maternal mortality through several efforts which, in the broad sense, include (i) the overall socio-economic development of the country; (ii) strengthened health services; and (iii) specific efforts and initiatives for the reduction of maternal mortality, one of which is the audit of maternal deaths by the confidential enquiry into maternal deaths.

Suboptimal care and maternal mortality among foreign-born women in Sweden: maternal death audit with application of the 'migration three delays' model.

BackgroundSeveral European countries report differences in risk of maternal mortality between immigrants from low- and middle-income countries and host country women. The present study identified suboptimal factors related to care-seeking, accessibility, and quality of care for maternal deaths that occurred in Sweden from 1988–2010.MethodsA subset of maternal death records (n = 75) among foreign-born women from low- and middle-income countries and Swedish-born women were audited using structured implicit review. One case of foreign-born maternal death was matched with two native born Swedish cases of maternal death. An assessment protocol was developed that applied both the ‘migration three delays’ framework and a modified version of the Confidential Enquiry from the United Kingdom. The main outcomes were major and minor suboptimal factors associated with maternal death in this high-income, low-maternal mortality context.ResultsMajor and minor suboptimal factors were associated with a majority of maternal deaths and significantly more often to foreign-born women (p = 0.01). The main delays to care-seeking were non-compliance among foreign-born women and communication barriers, such as incongruent language and suboptimal interpreter system or usage. Inadequate care occurred more often among the foreign-born (p = 0.04), whereas delays in consultation/referral and miscommunication between health care providers where equally common between the two groups.ConclusionsSuboptimal care factors, major and minor, were present in more than 2/3 of maternal deaths in this high-income setting. Those related to migration were associated to miscommunication, lack of professional interpreters, and limited knowledge about rare diseases and pregnancy complications. Increased insight into a migration perspective is advocated for maternity clinicians who provide care to foreign-born women.

Easier said than done!: methodological challenges with conducting maternal death review research in Malawi

BackgroundMaternal death auditing is widely used to ascertain in-depth information on the clinical, social, cultural, and other contributing factors that result in a maternal death. As the 2015 deadline for Millennium Development Goal 5 of reducing maternal mortality by three quarters between 1990 and 2015 draws near, this information becomes even more critical for informing intensified maternal mortality reduction strategies. Studies using maternal death audit methodologies are widely available, but few discuss the challenges in their implementation. The purpose of this paper is to discuss the methodological issues that arose while conducting maternal death review research in Lilongwe, Malawi.MethodsCritical reflections were based on a recently conducted maternal mortality study in Lilongwe, Malawi in which a facility-based maternal death review approach was used. The five-step maternal mortality surveillance cycle provided the framework for discussion. The steps included: 1) identification of cases, 2) data collection, 3) data analysis, 4) recommendations, and 5) evaluation.ResultsChallenges experienced were related to the first three steps of the surveillance cycle. They included: 1) identification of cases: conflicting maternal death numbers, and missing medical charts, 2) data collection: poor record keeping, poor quality of documentation, difficulties in identifying and locating appropriate healthcare workers for interviews, the potential introduction of bias through the use of an interpreter, and difficulties with locating family and community members and recall bias; and 3) data analysis: determining the causes of death and clinical diagnoses.ConclusionConducting facility-based maternal death reviews for the purpose of research has several challenges. This paper illustrated that performing such an activity, particularly the data collection phase, was not as easy as conveyed in international guidelines and in published studies. However, these challenges are not insurmountable. If they are anticipated and proper steps are taken in advance, they can be avoided or their effects minimized.

Severe acute maternal morbidity in a tertiary care institution

Introduction: As the absolute numbers of maternal deaths in an institution are few, maternal death audits may not provide the true picture of service provision. Therefore severe acute maternal morbidity (SAMM), also referred to as near misses, has been proposed as a supplementary indicator for the assessment of the quality of maternity care. Objective: To study SAMM in order to identify strategies which could be adopted to improve quality of care. Design, Setting and Methods: Using the WHO near-miss criteria, a clinical audit was carried out in all five consultant units of the Castle Street Hospital for Women (CSHW), Colombo from 1st February 2011 to 31st January 2012. Of the admissions to the intensive care, only those who conformed to the WHO near-miss inclusion criteria were studied. Results: There were 91 cases of SAMM and five maternal deaths out of 16511 live births, giving a maternal mortality ratio of 30.3/100,000 live births, a maternal near-miss ratio of 5.5/1000 live births and a maternal near miss: mortality ratio of 18.2. Of the 91 cases of SAMM, there were 35 (38.5%) cases of major post partum hemorrhage (PPH), 18 (19.8%) cases of thrombocytopenia and coagulopathy due to Dengue fever, nine (9.9%) cases with cardiac dysfunction, five (5.5%) cases of liver disease and six (6.6%) cases of eclampsia. There were 45 cases who had more than one inclusion criterion. Suboptimal management processes identified included incomplete documentation in some cases, non documentation of estimated blood loss in PPH, deficiencies in monitoring in labor and instrumental delivery, non use of uterine tamponade prior to proceeding to hysterectomy, and inadequate knowledge and experience of uterine tamponade insertion. Conclusions: SAMM is approximately 18 times greater than maternal deaths in the CSHW and approximately 39% of SAMM is due to major PPH. Dengue fever is an important course of SAMM in the CSHW. Appropriate steps should be adopted to correct the sub optimal practices identified. DOI: http://dx.doi.org/10.4038/sljog.v34i4.5930 Sri Lanka Journal of Obstetrics and Gynaecology 2012; 34 : 135-143

Preventable maternal mortality in Morocco: the role of hospitals

In 2009, the Ministry of Health of Morocco launched a national confidential enquiry around maternal deaths based on the newly implemented routine maternal death surveillance system (MDSS). The objective of this paper is to show the importance of substandard care among the factors associated with maternal deaths. The Moroccan National Expert Committee (NEC) organised an audit of maternal deaths identified by the MDSS to determine the medical cause, the preventability of the deaths and the type of substandard care involved. Three hundred and three cases of maternal deaths were analysed for the year 2009. Direct causes accounted for 80.8%. 75.9% were considered avoidable by the NEC. The three main factors were insufficient follow-up of care in 45.6% of cases, inadequate treatment in 43.9% and delay in seeking care in 41.3%. The auditors found that 54.3% of all maternal deaths could have been avoided if appropriate action had been taken at the health facilities. The audit of maternal deaths in Morocco enabled a better understanding of the circumstances contributing to maternal deaths and pinpointed that more than half of maternal deaths were associated with substandard care in hospitals.

Assessment of infection control practices in maternity units in Southern Nigeria

Puerperal sepsis accounts for 12% of maternal deaths in Nigeria. To date, little is known about the background hospital factors that predispose pregnant women to puerperal infection that leads to mortality. The objective of this study was to investigate the nature and pattern of existing policies and practices relating to infection control in maternity care centres in Edo state, South-South Nigeria. Cross-sectional study consisting of in-depth interviews with service providers, observation of clinical practices and examination of medical records. Public and private health-care facilities in eight local government areas (LGAs) selected from the three senatorial districts of Edo State, Nigeria. Health providers from 63 primary, secondary and tertiary maternity care centres. Sixty-three health-care facilities were sampled from eight LGAs from the three senatorial districts in Edo State. Three pre-tested tools were adapted to the local setting and used to interview key informants in the health facilities and to observe for practices and records relating to infection control. Of the 63 health facilities, 68% (43) reported that they had infection control procedures in place, while only 25% (16) reported that they documented these as manuals or charts. Only 13% (8) of facilities had infection control committees; 11% (7) routinely carried out audits of maternal deaths, while 33% (21) reported that they had an ongoing programme for staff training on infection control. A high proportion of the health facilities reported that staff routinely wash their hands before and after sterile procedures, but only half of the facilities were observed to have 24-h running water and only two-thirds had soap and antiseptic solutions in delivery and operating theatre areas. Although more than 90% (57) of the health facilities reported that they use sterile gloves routinely, unused sterile gloves were found in only 60% (38) of these facilities, and recycled gloves in 11.1% (7). The results of this study suggest the need for improved record-keeping procedures, the development of appropriate policies and protocols for infection control and staff training on infection control in maternity care facilities in Edo State. A public health education and advocacy programme to create awareness on clean delivery places as an approach for reducing maternal morbidity and mortality and to build political will for implementing related activities is also urgently needed.

Hospital work shifts and days of occurrence of maternal deaths in 6 hospitals in the Upper West Region of Ghana

In efforts to reduce the high rates of maternal mortality in low-resource countries the maternal death audit is one of the effective tools used to improve service delivery and subsequently reduce deaths. The “3 delays” model has identified the managerial and technical factors contributing to deaths as being associated with decision making at the household level reaching a health facility and receiving care at the health facility. The interplay of several factors at each stage of delay contributes to determine the outcomes of obstetric and neonatal emergencies. The Upper West Region in Ghana has the worst maternal health indicators in the country and to reverse this trend the Regional Health Service has conducted audits for 99 maternal deaths since 2009. The present study was a retrospective study on maternal deaths occurring over a 3-year period in 6 hospitals in the Upper West Region that serve a population of approximately 700000 inhabitants. The audits documented the availability of doctors midwives and essential services according to the hospital work shifts on each day of the week. Although the numbers of maternal deaths involved are inadequate for a more precise scientific analysis the conduct of this study means that hospitals in low-resource settings are beginning to unravel other “hidden” managerial and administrative factors contributing to maternal deaths. This study has gone farther in documenting the causes of deaths and their occurrence based on day of the week and hospital work shift. Although it is difficult to draw definite conclusions on the linkages between the hospital shifts and the maternal deaths the low numbers of doctors and midwives available on any given day of the week might be an area to be reviewed by hospital managers. Copyright © 2013 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.

‘She was referred from one hospital to another’: evidence on emergency obstetric care in Karnataka, India

Launching of the the National Rural Health Mission (2005) has brought a sharp policy attention to maternal health with its several initiatives such as (a) cash and material benefits to pregnant women; (b) strengthening health institutions especially of First Referral Units (FRUs); and (c) conducting regular maternal death audits to ensure quality Emergence Obstetric Care (EmOC). In spite of these efforts, the decline in maternal mortality ratio is rather slow and not achieved as per the MDG 5 goal. This study was undertaken to understand why despite infusion of such vast resources into the health system, timely and quality EmOC services have not been implemented.

Profile of Maternal and Foetal Complications during Labour and Delivery among Women Giving Birth in Hospitals in Matlab and Chandpur, Bangladesh

Worldwide, for an estimated 358,000 women, pregnancy and childbirth end in death and mourning, and beyond these maternal deaths, 9-10% of pregnant women or about 14 million women per year suffer from acute maternal complications. This paper documents the types and severity of maternal and foetal complications among women who gave birth in hospitals in Matlab and Chandpur, Bangladesh, during 2007-2008. The Community Health Research Workers (CHRWs) of the icddr,b service area in Matlab prospectively collected data for the study from 4,817 women on their places of delivery and pregnancy outcomes. Of them, 3,010 (62.5%) gave birth in different hospitals in Matlab and/or Chandpur and beyond. Review of hospital-records was attempted for 2,102 women who gave birth only in the Matlab Hospital of icddr,b and in other public and private hospitals in the Matlab and Chandpur area. Among those, 1,927 (91.7%) records were found and reviewed by a physician. By reviewing the hospital-records, 7.3% of the women (n=1,927) who gave birth in the local hospitals were diagnosed with a severe maternal complication, and 16.1% with a less-severe maternal complication. Abortion cases--either spontaneous or induced--were excluded from the analysis. Over 12% of all births were delivered by caesarean section (CS). For a substantial proportion (12.5%) of CS, no clear medical indication was recorded in the hospital-register. Twelve maternal deaths occurred during the study period; most (83%) of them had been in contact with a hospital before death. Recommendations include standardization of the hospital record-keeping system, proper monitoring of indications of CS, and introduction of maternal death audit for further improvement of the quality of care in public and private hospitals in rural Bangladesh.

Maternal health in fifty years of Tanzania independence: Challenges and opportunities of reducing maternal mortality.

High rate of maternal death is one of the major public health concerns in Tanzania. Most of maternal deaths are caused by factors attributed to pregnancy, childbirth and poor quality of health services. More than 80% of maternal deaths can be prevented if pregnant women access essential maternity care and assured of skilled attendance at childbirth as well as emergency obstetric care. The objective of this review was to analyse maternal mortality situation in Tanzania during the past 50 years and to identify efforts, challenges and opportunities of reducing it. This paper was written through desk review of key policy documents, technical reports, publications and available internet-based literature. From 1961 to 1990 maternal mortality ratio in Tanzania had been on a downward trend from 453 to 200 per 100,000 live births. However, from 1990's there been an increasing trend to 578 per 100,000 live births. Current statistics indicate that maternal mortality ratio has dropped slightly in 2010 to 454 per 100,000 live births. Despite a high coverage (96%) in pregnant women who attend at least one antenatal clinic, only half of the women (51%) have access to skilled delivery. Coverage of emergence obstetric services is 64.5% and utilization of modern family planning method is 27%. Only about 13% of home deliveries access post natal check-up. Despite a number of efforts maternal mortality is still unacceptably high. Some of the efforts done to reduce maternal mortality in Tanzania included the following initiatives: reproductive and child survival; increased skilled delivery; maternal death audit; coordination and integration of different programs including maternal and child health services, family planning, malaria interventions, expanded program on immunization and adolescent health and nutrition programmes. These initiatives are however challenged by inadequate access to maternal health care services. In order to considerably reduce maternal deaths some of recommended strategies include: (i) strengthening the health system to provide skilled attendance during child birth; (ii) upgrading rural health centres to provide emergency obstetric services; (iii) providing adolescent and male friendly family planning services; (iv) strengthening public-private partnership to ensure continuum of care; (v) supporting operational research to answer the immediate concerns of the health system; and (vi) strengthening community participation and women empowerment to take role of their own health and the family at large. In conclusion, maternal mortality ratio in Tanzania is unacceptably high and still very far from reaching the millennium development goals. Maternal health care services should focus on ensuring there is continuum of care through strengthening the health system; provision of good quality of health care in a well organized referral health system and operation research to support programme implementation.

An audit of Maternal Deaths from a referral University Teaching Hospital in Nigeria: The Emergence of HIV/AIDS as a leading cause

To analyse the characteristics and causes of maternal death in a referral tertiary health facility in Southern Nigeria. This is a facility- based review of 184 maternal deaths that occurred from January 2005 to June 2009. Primary causes of death and factors that contributed to maternal death including delay in accessing health care were identified. During the study period, the Maternal Mortality Ratio (MMR) was 2230/100,000 live births. There was a progressive reduction in the annual MMR from 2901/100,000 live birth in 2005 to 1459/100,000 live birth in 2009. More than four fifth (84.9%) of the maternal deaths occurred among women of low socio-economic class (IV and V). The leading causes of direct maternal deaths (64.1%) were Puerperal sepsis (17.8%), Pre-eclampsia/Eclampsia (15.8%) and complications of unsafe abortion (11.4%). HIV/AIDS was the third commonest overall cause of maternal death (15.2%). Half of the women experienced Type 1 delay (50%), Type 2 and 3 delay occurred in 7.6% and 18.5% of maternal deaths respectively. About two thirds of the women (58.2%) experienced more than one form of delay. Although direct obstetric deaths remain the leading cause of maternal mortality, HIV/AIDS is becoming an important primary cause of maternal mortality in our environment. Organization of health service delivery with an effective referral system and the provision of optimal care for HIV infected women are recommended.

Social autopsy for maternal and child deaths: a comprehensive literature review to examine the concept and the development of the method

"Social autopsy" refers to an interview process aimed at identifying social, behavioral, and health systems contributors to maternal and child deaths. It is often combined with a verbal autopsy interview to establish the biological cause of death. Two complementary purposes of social autopsy include providing population-level data to health care programmers and policymakers to utilize in developing more effective strategies for delivering maternal and child health care technologies, and increasing awareness of maternal and child death as preventable problems in order to empower communities to participate and engage health programs to increase their responsiveness and accountability.Through a comprehensive review of the literature, this paper examines the concept and development of social autopsy, focusing on the contributions of the Pathway Analysis format for child deaths and the Maternal and Perinatal Death Inquiry and Response program in India to social autopsy's success in meeting key objectives. The Pathway Analysis social autopsy format, based on the Pathway to Survival model designed to support the Integrated Management of Childhood Illness approach, was developed from 1995 to 2001 and has been utilized in studies in Asia, Africa, and Latin America. Adoption of the Pathway model has enriched the data gathered on care seeking for child illnesses and supported the development of demand- and supply-side interventions. The instrument has recently been updated to improve the assessment of neonatal deaths and is soon to be utilized in large-scale population-representative verbal/social autopsy studies in several African countries. Maternal death audit, starting with confidential inquiries into maternal deaths in Britain more than 50 years ago, is a long-accepted strategy for reducing maternal mortality. More recently, maternal social autopsy studies that supported health programming have been conducted in several developing countries. From 2005 to 2009, 10 high-mortality states in India conducted community-based maternal verbal/social autopsies with participatory data sharing with communities and health programs that resulted in the implementation of numerous data-driven maternal health interventions.Social autopsy is a powerful tool with the demonstrated ability to raise awareness, provide evidence in the form of actionable data and increase motivation at all levels to take appropriate and effective actions. Further development of the methodology along with standardized instruments and supporting tools are needed to promote its wide-scale adoption and use.

Maternal and neonatal survival and mortality in the Upper West Region of Ghana

Objective To describe the health facility-based factors affecting maternal/neonatal health and the outcomes of maternal death notifications and audits in the Upper West Region of Ghana. Methods Maternal death notifications and audits were conducted at 6 hospitals and in communities in the Upper West Region of Ghana in 2009. Furthermore, a kangaroo mother care strategy was implemented at 5 health facilities in the region to improve neonatal survival. The results of these implementations were recorded between July and December 2009. Results Forty-seven maternal deaths were reported and audited, with 46.5% occurring within 24 hours after admission. Twenty-three deaths were linked to delays in receiving care and non-adherence to treatment protocols. Of 155 midwives expected to provide skilled care, 129 (83.2%) were between 46 and 59 years of age. The kangaroo mother care strategy resulted in 622 (89.5%) of 695 targeted infants surviving. At the end of 2009, only 30% of the recommendations of audit committees had been implemented. Conclusion Maternal death notifications and audits are useful tools for improving quality of care and outcomes. With almost half of maternal deaths occurring within 24 hours of admission, emergency care in the Upper West Region of Ghana must be improved.

Analysis of maternal deaths in Shanghai from 2000 to 2009

Analysis of maternal deaths in Shanghai from 2000 to 2009

A critical analysis of maternal morbidity and mortality in Liberia, West Africa

Objective to conduct a secondary analysis of maternal death and near-miss audits conducted at the community and facility level to explore the causes and circumstances surrounding maternal mortality and severe morbidity in one rural county in Liberia, West Africa. Design a non-experimental, descriptive design utilising maternal death and near-miss audit surveys was utilised for data collection. Thaddeus and Maine's Three Delays Model was used as a framework for analysis. Setting one rural county in north-central Liberia. Participants interviews were conducted with (1) women who suffered a severe morbidity or nearmiss event, (2) family members of women who died or presented with a severe morbidity, and (3) community members or health workers involved in the care of the woman. Measurements (1) maternal mortality, (2) near-miss events, and (3) delays related to problem identification, transportation challenges and delays after reaching the referral site. Findings 120 near-miss events and 28 maternal mortalities were analysed. 16% of all deliveries at the referral hospital were classified as near-miss events. Near-miss events were six times more common than deaths. The majority of women experiencing a near-miss event (85%) were in critical condition upon arrival at the hospital suggesting important delays were encountered in reaching the facility. Key conclusions maternal mortality and near-miss audits allow exploration of medical and non-medical factors leading up to a severe complication or maternal death. Delays in reaching a referral hospital can have a significant impact on maternal survival rates. Implications for practice audits can stimulate a change in clinical practice and help identify areas for county health departments to focus their scant resources. Audits can be used as a quality improvement tool in facilities. Results can be used to identify communities with high rates of delay to target educational programmes.