Maternal Death Review Research Articles

Achieving accountability through maternal death reviews in Nigeria: a process analysis.

Maternal death reviews (MDRs) are part of the drive to increase accountability for maternal deaths and reduce their occurrence by identifying barriers to effective, quality care. However, conducting MDRs well is difficult; staff commitment and establishing a blame free environment are key challenges. By examining the communication strategies used in MDRs this study sought to understand how MDR members implement policy imperatives (e.g. 'no blame, no name') and manage the inevitable sensitivities of discussing a client's death in a multidisciplinary team. We observed and recorded four MDRs in Nigerian teaching hospitals and used conversation and discourse analysis to identify patterns in verbal and non-verbal interactions. MDRs were conducted in a structured way and had multidisciplinary representation. We grouped discursive strategies observed into three overlapping clusters: 'doing' no-name no-blame; fostering participation; and managing personal accountability. Within these clusters, explicit reminders, gentle enquiries and instilling a sense of togetherness were used in doing no-name, no-blame. Strategies such as questioning and invoking protocol were only partially successful in fostering participation. Regarding managing accountability, forms of communication which limit personal responsibility ('pass the buck') and resist passing the buck were observed. Detailed, lengthy eye witness accounts of dramatic events appeared to reduce staff's personal accountability. We conclude that interactional processes affect the meaningfulness of MDRs. In-depth, critical analysis depends on resisting 'passing the buck' by practitioners and chairs especially, who are also key to fostering participation and extracting value from multidisciplinary representation. Our innovative methods provide detailed insights into MDRs as an interactional process, which can inform design of training aimed at enhancing MDR members' skills. However, given the multitude of systemic challenges we should also adjust our expectations of MDRs and the individual practitioners tasked to perform them in the name of enhancing accountability for maternal death reduction.

Maternal death and near miss measurement: a case for implementation in developing countries in the sustainable development agenda, a review article

“Ending preventable maternal mortality (EPMM) remains an unfinished agenda and one of the world's most critical challenges. Maternal health, well-being and survival must remain a central goal and investment priority in the sustainable development goal agenda”. This statement from the World Health Organization (WHO) document Ending Preventable Maternal Death is most appropriate especially for developing nations.Using 2010 as baseline, the current global maternal health targets are achievement of average maternal mortality ratio (MMR) of 70/100,000 live births. Nations whose MMR are more than 420/100,000 live births (the group where Nigeria belong) should have MMR not higher than 140 by 2030.There was recognition of the need for improved measurement and data quality in other to track the progress or lack of it as we approach 2030. Maternal health services need to be accountable more than ever before. Maternal death and near miss measurement is one way to achieve this. In this paper a three levels of maternal death and near miss audit, surveillance and review is recommended for Nigeria and other developing nations. Both measurements can be done together.Maternal death measurement also called maternal death review (MDR), audit or surveillance answers pertinent questions about the death of pregnant women, how many died? Where did they died? When did they died? Why did they died? Can these deaths be prevented? When MDR is followed by response (evidence base intervention) it becomes MDRS and thereby eliminates all preventable deaths. Every maternity service department and hospital, state and national government should audit the outcome of maternal health care being provided as a matter of accountability.

The Economic Cost of Implementing Maternal and Neonatal Death Review in a District of Bangladesh.

IntroductionMaternal and neonatal death review (MNDR) introduced in Bangladesh and initially piloted in a district during 2010. MNDR is able to capture each of the maternal, neonatal deaths and stillbirths from the community and government facilities (hospitals). This study aimed to estimate the cost required to implement MNDR in a district of Bangladesh during 2010-2012.Materials and methodsMNDR was implemented in Thakurgaon district in 2010 and later gradually extended until 2015. MNDR implementation framework, guidelines, tools and manual were developed at the national level with national level stakeholders including government health and family planning staff at different cadre for piloting at Thakurgaon. Programme implementation costs were calculated by year of costing and costing as per component of MNDR in 2013. The purchasing power parity conversion rate was 1 $INT = 24.46 BDT, as of 31st Dec 2012.ResultsOverall programme implementation costs required to run MNDR were 109,02,754 BDT (445,738 $INT $INT) in the first year (2010). In the following years cost reduced to 8,208,995 BDT (335,609 $INT, during 2011) and 6,622,166 BDT (270,735 $INT, during 2012). The average cost per activity required was 3070 BDT in 2010, 1887 BDT and 2207 BDT required in 2011 and 2012 respectively. Each death notification cost 4.09 $INT, verbal autopsy cost 8.18 $INT, and social autopsy cost 16.35 $INT. Facility death notification cost 2.04 $INT and facility death review meetings cost 20.44 $INT. One death saved by MNDR costs 53,654 BDT (2193 $INT).ConclusionsProgrammatic implementation cost of conducting MPDR give an idea on how much cost will be required to run a death review system for a low income country settings using government health system.Significance for public healthMaternal and neonatal death review (MNDR) system in a low income county is one of the key indicators to improve quality of health care services. The MNDR also support in the reduction of maternal and newborn deaths. However, to run a comprehensive death review system need to know costs associated with the system. This is crucial in low income countries for planning and designing a public health intervention. Very few studies yet perform to look at the costs to run a death review system. This paper describes health economic cost of death review system in Bangladesh for future public health research in low income countries

The St Vincent Declaration–25 years on: review of maternal deaths reported to the Confidential Enquiry in the UK and the lessons learnt

The St Vincent Declaration–25 years on: review of maternal deaths reported to the Confidential Enquiry in the UK and the lessons learnt

Barriers and enablers to guideline implementation strategies to improve obstetric care practice in low- and middle-income countries: a systematic review of qualitative evidence.

BackgroundMaternal mortality remains a major international health problem in low- and middle-income countries (LMIC), and most could have been prevented by quality improvement interventions already demonstrated to be effective, such as clinical guideline implementation strategies. The aim of this systematic review was to synthesise qualitative evidence on guideline implementation strategies to improve obstetric care practice in LMIC in order to identify barriers and enablers to their successful implementation.MethodsWe searched MEDLINE and CINAHL databases for articles reporting research findings on barriers and enablers to guideline implementation strategies in obstetric care practice in LMIC. We conducted a “best fit” framework synthesis of the included studies. We used an organisational “stages of change” model as our a priori framework for the synthesis.ResultsNine studies were included: all were based in Sub-Saharan Africa and in hospital health care facilities. The majority of studies (seven) evaluated one particular guideline implementation strategy: clinical audit and feedback (both criterion-based audit and maternal death reviews), and a minority (two) evaluated educational interventions. A range of barriers and enablers to successful guideline implementation was identified. A key finding of the framework synthesis was that “high” and “low” intrinsic health care professional motivation are overall enablers and barriers, respectively, of successful guideline implementation. We developed a modified “stages of change” model to take account of these findings.ConclusionWe have identified a number of quality improvement processes that are amenable to change at limited or no additional cost, although some identified barriers may be difficult to address without increased resources. We note the pathways to implementation may be complex and require further research to develop our understanding of individual and organisational behaviours and motivation in LMIC settings.Trial registrationPROSPERO CRD42015016062 Electronic supplementary materialThe online version of this article (doi:10.1186/s13012-016-0508-1) contains supplementary material, which is available to authorized users.

Maternal Death Surveillance and Response Systems in driving accountability and influencing change

Good progress has been made in reducing maternal deaths from 1990–2015 but accelerated progress is needed to achieve the Sustainable Development Goals (SDGs) in ending preventable maternal deaths through a renewed focus on accountability and actions. This paper looks at how Maternal Death Surveillance and Response (MDSR) systems are strengthening response and accountability for better health outcomes by analyzing key findings from the WHO and UNFPA Global MDSR Implementation Survey across 62 countries. It examines two concrete examples from Nigeria and Ethiopia to demonstrate how findings can influence systematic changes in policy and practice. We found that a majority of countries have policies in place for maternal death notification and review, yet a gap remains when examining the steps beyond this, including reviewing and reporting at an aggregate level, disseminating findings and recommendations, and involving civil society and communities. As more countries move toward MDSR systems, it is important to continue monitoring the opportunities and barriers to full implementation, through quantitative means such as the Global MDSR Implementation Survey to assess country progress, but also through more qualitative approaches, such as case studies, to understand how countries respond to MDSR findings.

Effective non-drug interventions for improving outcomes andquality of maternal health carein sub-Saharan Africa: a systematic review.

BackgroundMany interventions have been implemented to improve maternal health outcomes in sub-Saharan Africa (SSA). Currently, however, systematic information on the effectiveness of these interventions remains scarce. We conducted a systematic review of published evidence on non-drug interventions that reported effectiveness in improving outcomes and quality of care in maternal health in SSA.MethodsAfrican Journals Online, Bioline, MEDLINE, Ovid, Science Direct, and Scopus databases were searched for studies published in English between 2000 and 2015 and reporting on the effectiveness of interventions to improve quality and outcomes of maternal health care in SSA. Articles focusing on interventions that involved drug treatments, medications, or therapies were excluded. We present a narrative synthesis of the reported impact of these interventions on maternal morbidity and mortality outcomes as well as on other dimensions of the quality of maternal health care (as defined by the Institute of Medicine 2001 to comprise safety, effectiveness, efficiency, timeliness, patient centeredness, and equitability).ResultsSeventy-three studies were included in this review. Non-drug interventions that directly or indirectly improved quality of maternal health and morbidity and mortality outcomes in SSA assumed a variety of forms including mobile and electronic health, financial incentives on the demand and supply side, facility-based clinical audits and maternal death reviews, health systems strengthening interventions, community mobilization and/or peer-based programs, home-based visits, counseling and health educational and promotional programs conducted by health care providers, transportation and/or communication and referrals for emergency obstetric care, prevention of mother-to-child transmission of HIV, and task shifting interventions. There was a preponderance of single facility and community-based studies whose effectiveness was difficult to assess.ConclusionsMany non-drug interventions have been implemented to improve maternal health care in SSA. These interventions have largely been health facility and/or community based. While the evidence on the effectiveness of interventions to improve maternal health is varied, study findings underscore the importance of implementing comprehensive interventions that strengthen different components of the health care systems, both in the community and at the health facilities, coupled with a supportive policy environment.Systematic review registrationPROSPERO CRD42015023750Electronic supplementary materialThe online version of this article (doi:10.1186/s13643-016-0305-6) contains supplementary material, which is available to authorized users.

The conduct of maternal and perinatal death reviews in Oyam District, Uganda: a descriptive cross-sectional study.

BackgroundUganda like many developing countries still experiences high levels of maternal and perinatal deaths despite a decade of maternal and perinatal death review (MPDR) program. Oyam district has been implementing MPDR since 2008 with varying successes among the health facilities. This paper presents the factors that influence the conduct of maternal and perinatal death reviews in Oyam District, Uganda.MethodsThis was a cross-sectional study where both qualitative and quantitative data were collected. Semi-structured interviews were administered to 66 health workers and ten key informants (KIs) to assess the factors influencing the conduct of MPDR. Univariate and Bivariate analysis of quantitative data was done using SPSS version 17.0. A Pearson Chi-Square test was done to determine factors associated with conduct of MPDR. Factors with a p-value < 0.05 were considered statistically significant. Qualitative data was analyzed using content analysis.ResultsOnly 34.8 % of the health workers had ever participated in MPDR. The factors that influenced conduct of MPDR were existence of MPDR committees (p < 0.001), attendance of review meetings (p < 0.001) and knowledge of objectives of MPDR (p < 0.001), implementation of MPDR recommendations (p < 0.001), observed improvement in maternal and newborn care (p < 0.001) and provision of feedback (p < 0.001). Hindrance to conduct of MPDR was obtained from KIs: the health workers were not made aware of the MPDR process, committee formation and training of MPDR committee members was not effectively done, inadequate support supervision, and lack of financial motivation of MPDR committee members. Challenges to MPDR included: heavy workload to health workers, high number of perinatal deaths, and non-implementation of recommendations.ConclusionThe proportion of maternal and perinatal death reviews conducted in Oyam was low. This was due to poor initiation of the review process and a lack of support supervision. The district and Ministry of Health needs to put more emphasis on monitoring the conduct of maternal and perinatal death reviews by: forming and training MPDR committees and ensuring they are financially supported, providing overall coordination, and ensuring effective support supervision.Electronic supplementary materialThe online version of this article (doi:10.1186/s12905-016-0315-5) contains supplementary material, which is available to authorized users.

Evaluating the Quality of Recommendations From Maternal Death Reviews—Fort Portal, Uganda [13R

INTRODUCTION: Facility-based Maternal Death Reviews (MDRs) aim to identify contributors to maternal deaths, generate recommendations to prevent future deaths, and implement and follow-up those recommendations. Globally, MDR committees' recommendations lack clearly-defined achievable and measureable actions, and an internationally-recognized standard framework for evaluating recommendations does not exist. METHODS: We developed a scoring framework for MDR recommendations based on International Federation of Gynecology and Obstetrics recommendation structuring guidelines. We piloted the framework to evaluate the quality of 2014 MDR recommendations generated by three facility-based MDR committees in Fort Portal, Uganda. We developed a composite score for grading quality of recommendations (0–6) composed of: specificity (0-vague, 1-clear, 2-explicit), relevance to a committee identified “avoidable factor” (0-no, 1-yes), presence of implementation method (0-no, 1-yes), individual responsibility for implementation (0-no, 1-yes), and timeline (0-no, 1-yes). Two scorers coded recommendations independently and reviewed differences to reach consensus. RESULTS: Committees generated 83 recommendations during 42 MDRs; 61% prescribed facility-based changes. The mean composite score was poor (1.8, range 0–5). Recommendation specificity was “vague” in 20% of recommendations, “clear” in 58%, and “explicit” in 22%. Half (51%) of recommendations were relevant, although 81% of recommendations lacked a method of implementation, and 88% had no implementer assigned. All recommendations lacked a timeline. CONCLUSION: A framework for evaluating the quality of MDR recommendations was developed and identified specific areas for improvement. Clearly defining method, implementer and timeline, and improving recommendations' specificity and relevance should lead to better implementation which will help to reduce maternal mortality.

Maternal Mortality in Rwanda [13I

INTRODUCTION: Maternal death review is an important tool for categorizing causes of maternal mortality, as this data can then be used to guide interventions to reduce maternal deaths. Rwanda has achieved a 76% reduction in maternal mortality since 1990. We aimed to analyze the specific causes of maternal mortality in Rwanda over the last 6 years, as well as the demographic characteristics of those women who died in pregnancy, during delivery or in the postpartum period. METHODS: The Rwandan maternal death audit database for the years 2009–2014 was analyzed. Causes of death were categorized according to the “WHO Application of ICD-10 to deaths during pregnancy, childbirth and the puerperium.” Maternal demographic data and causes of death were analyzed using descriptive statistics and chi-square tests. RESULTS: There were 1,160 maternal deaths reported during 2009–2014. Obstetric hemorrhage was the most frequent cause of death (39%), followed by non-obstetric complications (19.3%), pregnancy-related infection (11.3%), and hypertensive disorders (10.2%). When stratified by age, however, non-obstetric complications were the most common cause of death for women younger than 20 (P<.001). Other causes of death (such as those with an abortive outcome and other obstetric complications) were the most common cause of death among primiparous women, while obstetric hemorrhage was the most common cause of death in multiparous women. CONCLUSION: Obstetric hemorrhage remains an important contributor to maternal mortality in Rwanda. A more detailed examination of the causes of maternal mortality is needed in order to identify areas for intervention and improvement in outcomes.

Improving reporting of infant deaths, maternal deaths and stillbirths in Haryana, India.

Underreporting hampers the accurate estimation of the numbers of infant and maternal deaths and stillbirths in India. In Haryana state, a surveillance-based model – the Maternal Infant Death Review System – was launched in 2013 to try to resolve this issue. The system is a mixture of routine passive data collection and active surveillance by specially recruited and trained field volunteers. The volunteers gather the relevant data from child day-care centres, community health centres, cremation grounds, hospitals, the municipal corporation’s offices and primary health centres and regularly visit health subcentres. The collected data are triangulated against the standard death registers and discussions with relevant community members. The details of any unregistered death are rapidly uploaded on the system’s web-based platform. In April 2014, we made field observations, reviewed records and conducted in-depth interviews with the key stakeholders to see if the system’s performance matched the state government’s planned objectives. The data collected indicate that implementation of the system has led to quantitative and qualitative improvements in reporting of infant and maternal deaths and stillbirths. Completeness and consistency in the reporting of deaths are essential for focused policy and programmatic interventions and there remains scope for improvement in Haryana via further reform and changes in policy. The model in its current form is potentially sustainable and scalable in similar settings elsewhere.

Knowledge for effective action to improve the health of women, children and adolescents in the sustainable development era.

January 2016 marked the beginning of a new era for health and development. It was the start of Transforming our world: the 2030 agenda for sustainable development and its accompanying sustainable development goals (SDGs).1 All governments have committed to this ambitious sustainable agenda and its goals. The Global strategy for women’s, children’s and adolescents’ health (2016–2030)2 and its operational framework are aligned with the SDGs and provide an evidence-based roadmap for ending preventable deaths of women, children and adolescents by 2030. The global strategy can guide collective action so that every woman, child and adolescent – even those living in the most challenging settings – can achieve their full potential and rights to health and well-being. Governments are aligning their work with the SDGs and the global strategy’s three objectives – survive, thrive and transform – in ways that meet their countries’ priorities and unique contexts. The survival, health and well-being of women, children and adolescents are essential to achieving the SDGs. Analysis of lessons from the millennium development goal (MDG) implementation process – what has worked and what hasn’t – is needed to effectively implement the agenda set by the SDGs and the global strategy. Achieving the global strategy and the SDGs will require the use of the best available knowledge for action, as well as investment in new research and innovation. This month’s Bulletin theme issue seeks to broaden the evidence on effective country implementation and lessons learnt from the MDGs. Kuruvilla et al.3 summarize the current global strategy, show how the objectives of the strategy are aligned with the SDGs and how selected countries are already making progress. Several papers in this issue deal with progress on the survival objective of the global strategy; Negandhi et al.4 present a surveillance-based maternal and infant death review system in India; Murguia-Peniche et al.5 and McKinnon et al.6 address under-researched topics, such as the factors associated with stillbirths in Mexico and the high prevalence of suicidal behaviours among adolescents in low- and middle-income countries, respectively. The strategy’s thrive objective addresses the overall health and well-being of mothers, children and adolescents. Chai et al.7 determine how exposure to violence hinders child development and can affect health across the life-course and subsequent generations. Askew et al.8 describe the importance of ensuring sexual and reproductive health and rights in humanitarian settings. The transform objective of the strategy focuses on expanding enabling environments and aims to transform societies so that women, children and adolescents everywhere can realize their rights to the highest attainable standards of health and well-being. Several papers address the global strategy’s transform objective. Newberry et al.9 present a formal emergency response infrastructure developed in India for gender-based violence. This special issue also includes papers on approaches that have helped countries achieve improved health outcomes for women, children and adolescents. Marston et al.10 discuss the importance of community engagement in achieving results. Ahmed et al.11 describe policies and programmes that contributed to reductions in child and maternal mortality. Frost et al.12 explain how multistakeholder dialogues are used to clarify what works and does not work in policy-making and implementation. To drive the global strategy forward, governments, civil society, the private sector and other partners have mobilized under the banner of Every Woman Every Child and a group of political champions has been formed. A global financing facility has been established as a country-led partnership that combines domestic, external, and innovative financing for health and development. An independent accountability panel has been appointed by the United Nations Secretary-General to report on results, resources and rights for women’s children’s and adolescents’ health. This month, the World Health Assembly will consider a resolution on implementing the global strategy, giving delegations an opportunity to discuss its content and shape their own commitments. In addition, this theme issue illustrates the importance of continued investments in research and learning to support country implementation. The generation and sharing of knowledge for action is essential to achieve the global strategy’s objectives, to secure a healthy and transformative future for women, children and adolescents, their families and communities in the SDG era.

Maternal death and obstetric care audits in Nigeria: a systematic review of barriers and enabling factors in the provision of emergency care

BackgroundMaternal death reviews and obstetric audits identify causes and circumstances related to occurrence of a maternal death or serious complication and inform improvements in quality of care. Given Nigeria’s high maternal mortality, the lessons learned from past experiences can provide a good evidence base for informed decision making. We aimed to synthesise findings from maternal death reviews and other obstetric audits conducted in Nigeria through a systematic review, seeking to identify common barriers and enabling factors related to the provision of emergency obstetric care.MethodsWe searched for maternal death reviews and obstetric care audits reported in the published literature from 2000–2014. A ‘best-fit’ framework approach was used to extract data using a structured data extraction form. The articles that met the inclusion criteria were assessed using a nine point quality score.ResultsOf the 1,841 abstracts and titles at initial screening, 329 full text articles were reviewed and 43 papers fulfilled the inclusion criteria. Four types of barriers were reported related to: transport and referral; health workers; availability of services; and organisational factors. Three elements stand out in Nigeria as contributing to maternal mortality: delays in Caesarean section, unavailability of magnesium sulphate and lack of safe blood transfusion services.ConclusionsObstetric care reviews and audits are useful activities to undertake and should be promoted by improving the processes used to conduct them, as well as extending their implementation to rural and basic level health facilities and to the community. Urgent areas for quality improvement in obstetric care, even in tertiary and teaching hospitals should focus on organisational factors to reduce delays in conducting Caesarean section and making blood and magnesium sulphate available for all who need these interventions.

Determinants of Maternal Mortality in Mezam Division in the North West Region of Cameroon: A Community-based Case Control Study

Background: Since 2008, an average of 358,000 women die annually worldwide of pregnancyrelated causes. About 99% of these deaths occur in developing countries, 43% of which occur in Sub-Saharan Africa alone. In Cameroon, the rate has increased from 669 maternal deaths/100,000 live births in 2005 to 1000/100,000 live births in 2010. Socio-economic, cultural, and obstetric factors have been found to account for this jump. Objectives: The aims of this study were 1) to identify the causes, both direct and indirect, of maternal mortality, 2) to investigate the factors associated with maternal deaths, and 3) to describe Original Research Article Egbe et al.; IJTDH, 15(2): 1-15, 2016; Article no.IJTDH.24927 2 the age distribution of maternal mortality in Mezam Division in the North West Region of Cameroon. Materials and Methods: We carried out a retrospective, community-based case-control study from January 1, 2011 to November 30, 2014 on 89 maternal deaths (cases), and 178 women who survived delivery (controls). Cases were identified with the aid of key community leaders. A questionnaire for maternal death review or verbal autopsy was administered and controls effected among the sisters or neighbours of the cases. Microsoft Excel, Epi Info and InterVA-4 were used for data analysis. Results: A total of 89 maternal deaths (cases) were identified during the study period, sixty-nine (77.53%) of which were from direct causes, mainly post-partum haemorrhage (30.43%), unsafe abortion (26.09%), and hypertensive disorders of pregnancy (14.49%); 21.35% from indirect causes, while 1.12% were incidental deaths, mainly severe malaria (5.6%), HIV/AIDS (5.6%). Among the risk factors of maternal death were inadequate antenatal care (RR=1.87: 95% CI; 1.332.63, P=0.0003), pre-existing co-morbidities (RR=1.45: 95% CI; 1.03-2.03, P =0.03), place of delivery(RR= 2.44: 95% CI; 1.79-3.32,P<0.0001), healthcare provider qualification(RR= 2.87: 95% CI 2.17-3.79; P<0.0001), and delays in arrival at health facilities(RR=1.420: 95% CI 1.01-2.0; P=0.04). The peak age of maternal death ranged from 20-24 years (24.72%). Conclusion: Post-partum haemorrhage, unsafe abortion and hypertensive disorders of pregnancy were the leading causes of maternal death. Effectively combating the factors associated with maternal deaths will reduce if not eliminate maternal morbidity.

Maternal mortality: scenario, causes and prevention of the tragedy in Indian context with special consideration to Assam, India

Though child birth gives joy to mother and family, yet this joy may transform to tragedy in the event of maternal death. Maternal mortality has been identified as a priority on health policy and research agendas for developing countries. MMR has been decreased from 398/100,000 live births in 1997 to 178 in 2013 India and 347 in 2011 to 301 in 2013 in Assam, India. Maternal death may occur during antenatal, intranatal or postnatal period thus necessitating services during these periods. For pregnant women during antenatal, intranatal or postpartum period – ante natal care services, institutional delivery, access to basic emergency obstetric care (BEmOC) and comprehensive emergency obstetric care ( CEmOC), post natal care, referral services should be provided. In the event of injection oxytocin not being available due to constraints of optimal storage conditions or other logistical barriers, misoprostol is recommended to be given for prevention of PPH. Government of India policies and strategies (NPP/RCH II) have focused on enhancing-access and availability of comprehensive abortion care services in both the public and private sector. Maternal death review should be done in case of any maternal death to find out the associated factors. “Maternal near miss” surveillance is an effective tool for improving safe motherhood programs. Government of Assam has kept goal 2 under Assam bikas yojna: reduction in maternal mortality ratio to 210 per 100000 live births. Some planned strategy taken for achieving this goal. But for success in reducing maternal death the community will need to be involved not only through educating them about the signs and symptoms of emergency but also to develop appropriate mechanisms for ensuring that women in distress get the quality care .

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.

Facility Based Maternal Death Review at Tertiary Care Hospital: A Small Effort to Explore Hidden Facts

Aim: Maternal mortality is one of the most important indicators of quality of health care. One of the United Nations’ Millennium Development Goals is to reduce the maternal mortality rate to 75% by 2015 and India is lagging behind in achieving the goal. The current study is designed to evaluate various aspect of maternal death at tertiary care centre. Methods: Facility based maternal death review conducted at tertiary referral centre with around 6500 deliveries a year. Observational cross sectional study was carried out from January 2010 to September 2014. A pre-structured coded Performa provided by National Rural Health Mission was used for present study. Results: The mean maternal mortality ratio in the study period was 203.42/100000 births. 21(35%) patients did not attended any health facilities during ante natal period. Forty six(60%) deaths occurred in the age group of 20-29 years. Out of 60 maternal deaths, 18 (30%) were primigravida and 42(70%) were multiparous. Thirty nine (65%) mothers died of direct causes in which the most common was haemorrhage in i.e. 21 (35%) Twenty one (35%) mothers died of indirect causes in which 7(11.66%) mothers died because of anaemia. Conclusion: Maternal deaths were higher in reproductive age group i.e. between 20-29 yrs and more in multiparous as compared to primigravida. Among the direct causes haemorrhage and among the indirect causes anaemia was the most common cause contributing to maternal deaths.

Maternal death reviews at Bugando hospital north-western Tanzania: a 2008-2012 retrospective analysis.

BackgroundUnacceptably high levels of maternal deaths still occur in many sub-Saharan countries and the health systems may not favour effective use of lessons from maternal death reviews to improve maternal survival. We report results from the analysis of data from maternal death reviews at Bugando Medical Centre north-western Tanzania in the period 2008–2012 and highlight the process, challenges and how the analysis provided a better understanding of maternal deaths.MethodologyRetrospective analysis using maternal death review data and extraction of missing information from patients’ files. Analysis was done in STATA statistical package into frequencies and means ± SD and median with 95 % CI for categorical and numerical data respectively.ResultsThere were 80 deaths; mean age of the deceased 27.1 ± 6.2 years and a median hospital stay of 11.0 days [95 % CI 11.0–15.3]. Most deaths were from direct obstetric causes (90); 60 % from eclampsia, severe pre-eclampsia, sepsis, abortion and anaesthetic complications. Information on ANC attendance was recorded in 36.2 % of the forms and gestation age of the pregnancy resulting into the death in 23.8 %. Sixty one deaths (76.3 %) occurred after delivery. The mode of delivery, place of delivery and delivery assistant were recorded in 44 (72.1), 38 (62.3) and 23 (37.7 %) respectively.ConclusionRoutine maternal death reviews in this setting do not involve comprehensive documentation of all relevant information, including actions taken to address some identified systemic weaknesses. Periodic analysis of available data may allow better understanding of vital information to improve the quality of maternity care.

State-based Maternal Death Reviews

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The triple threat of pregnancy, HIV infection and malaria: reported causes of maternal mortality in two nationwide health facility assessments in Mozambique, 2007 and 2012.

BackgroundThe paper’s primary purpose is to determine changes in magnitude and causes of institutional maternal mortality in Mozambique. We also describe shifts in the location of institutional deaths and changes in availability of prevention and treatment measures for malaria and HIV infection.MethodsTwo national cross-sectional assessments of health facilities with childbirth services were conducted in 2007 and 2012. Each collected retrospective data on deliveries and maternal deaths and their causes. In 2007, 2,199 cases of maternal deaths were documented over a 12 month period; in 2012, 459 cases were identified over a three month period. In 2007, data collection also included reviews of maternal deaths when records were available (n = 712).ResultsInstitutional maternal mortality declined from 541 to 284/100,000 births from 2007 to 2012. The rate of decline among women dying of direct causes was 66 % compared to 26 % among women dying of indirect causes. Cause-specific mortality ratios fell for all direct causes. Patterns among indirect causes were less conclusive given differences in cause-of-death recording. In absolute numbers, the combination of antepartum and postpartum hemorrhage was the leading direct cause of death each year and HIV and malaria the main non-obstetric causes. Based on maternal death reviews, evidence of HIV infection, malaria or anemia was found in more than 40 % of maternal deaths due to abortion, ectopic pregnancy and sepsis. Almost half (49 %) of all institutional maternal deaths took place in the largest hospitals in 2007 while in 2012, only 24 % occurred in these hospitals. The availability of antiretrovirals and antimalarials increased in all types of facilities, but increases were most dramatic in health centers.ConclusionsThe rate at which women died of direct causes in Mozambique’s health facilities appears to have declined significantly. Despite a clear improvement in access to antiretrovirals and antimalarials, especially at lower levels of health care, malaria, HIV, and anemia continue to exact a heavy toll on child-bearing women. Going forward, efforts to end preventable maternal and newborn deaths must maximize the use of antenatal care that includes integrated preventive/treatment options for HIV infection, malaria and anemia.