Maternal Death Surveillance and Response

Dr. Mitasha Singh

Contents• Definitions

• Global and Indian scenario

• Future target to reduce maternal deaths

• Causes and barriers

• Method of estimation

• MDSR-goals and objective

• Steps of MDSR

• MDSR Implementation plan

• Women in reproductive age group (15-49 year

age group) constitute 55.1% of total

population.

• Maternal health refers to the health of women

during pregnancy, childbirth and the

postpartum period.

Maternal death• Definition

• Maternal death is the death of a woman while

pregnant or within 42 days of termination of

pregnancy, irrespective of the duration and site of the

pregnancy, from any cause related to or aggravated by

the pregnancy or its management but not from

accidental or incidental causes.

Maternal Mortality Ratio• The maternal mortality ratio represents the risk

associated with each pregnancy, i.e. the

obstetric risk.

• It is also a MDG indicator.

• The MMR is defined as the number of

maternal deaths during a given time period per

100,000 live births during the same time

period.

Maternal mortality rate

(MMRate)• Maternal mortality rate (MMRate) is defined as the

number of maternal deaths in a population divided by

the number of women aged 15–49 years (or woman

years lived at ages 15–49 years

• The MMRate captures both the risk of maternal death

per pregnancy or per total birth (live birth or

stillbirth), and the level of fertility in the population.

• Almost 800 women die every day due to

complications in pregnancy and childbirth.

523000

289000

0

100000

200000

300000

400000

500000

600000

1990 2013

Maternal Deaths

45%

World Health Organization 2014

ONE THIRD of total global maternal deaths are in two

countries

Global deaths

India Nigeria

Rest

INDIA- 40000, NIGERIA- 50000 World Health Organization 2014

510

190

140

0 100 200 300 400 500 600

South Africa

Southern Asia

South eastern Asia

MMR(2013)

MMR(2013)

WHO, UNICEF, UNFPA, The World Bank and the United Nations Population Division estimates

INDIA

0

100

200

300

400

500

600

1990 1995 2000 2005 2013

560460

370280

190

MMR

MMR

65% Decrease

WHO, UNICEF, UNFPA, The World Bank and the United Nations Population Division estimates

INDIA

301

254

212

178 167

0

50

100

150

200

250

300

350

2001-3 2004-6 2007-09 2010-12 2011-13

MMR(SRS)

MMR(SRS)

Registrar General of India - Sample Registration System (RGI-SRS).

MDG 5: Improve maternal health

• Target 5.A. Reduce by three quarters, between 1990

and 2015, the maternal mortality ratio

• maternal mortality has fallen by 45 percent over the past 2

decades.

• Target 5.B. Achieve, by 2015, universal access to

reproductive health

• A global target for a maternal mortality ratio (MMR) of less

than 70/100,000 live births by 2030 has been set, with no

single country having an MMR greater than 140.

• To achieve the target, USAID has a vision of “A world where

no woman dies from preventable maternal causes and

maternal and fetal health are improved”

Source: Targets and Strategies for Ending Preventable Maternal Mortality. Consensus Statement. April 2014. Geneva: WHO

Future Target

What Are Pregnant Women Dying From?

28

2714

11

3

8

9

Percentage

Preexisting medical

condition

Severe bleeding

PIH

Infections

Blood clots

Abortion

complications

Obstructed labour and

other direct causesWorld Health Organization 2014

Major barriers to improving

chances of survival

1st DelayDecision to

seek care

2nd DelayIdentifying and

reaching medical facility

3rd DelayReceipt of adequate

and appropriate treatment

Issue of access to care

Encompassing factors in the family and community, including transportation

Contributing factors to maternal deaths

COMMUNITY-BASED FACTORS HEALTH SERVICE FACTORS

Lack of awareness of danger signs of illness No health service available or nearby

Delay in seeking care due to lack of family

agreement

No staff available when care was sought

Geographical isolation Medicine not available at the hospital;

dependence on family to provide it

Lack of transportation or money to pay for it Lack of clinical care guidelines

Other family or household responsibilities Woman not treated immediately after arriving

at the facility

Cultural barriers, such as prohibitions on

mother leaving the house

Lack of necessary supplies or equipment at the

facility

Lack of money to pay for care Lack of staff knowledge/skills to diagnose and

treat the mother

Belief in use of traditional remedies Long waiting time before qualified staff could

see the mother

Belief in fate controlling outcome No transport available to reach referral hospital

Dislike of or bad experiences with health-care

system

Poor staff attitude

Methods of estimationMeasuring maternal mortality accurately is difficult except

where comprehensive registration of deaths and of causes of

death exists.

• Civil registration system

• Household survey

• Sisterhood methods

• Reproductive age mortality studies (RAMOS)

• Verbal autopsy

• Census

• To understand how well we are progressing, however,

accurate information on how many women died,

where they died and why they died is essential, yet

currently inadequate.

• a system is needed that measures and tracks all

maternal deaths in real time, helps us understand the

underlying factors contributing to the deaths, and

stimulates and guides actions to prevent future deaths.

MDSR• is a form of continuous surveillance

• which includes the routine identification, notification,

quantification and determination of causes and

avoidability of all maternal deaths, as well as the use

of this information to respond with actions that will

prevent future deaths

• The primary goal of MDSR is to eliminate

preventable maternal mortality.

• Because each death provides information that, if

acted on, can prevent future deaths.

• emphasizes the link between information and

response.

• the measurement of maternal mortality ratios and the

real-time monitoring of trends that provide countries

with evidence about the effectiveness of

interventions.

• The overall objectives of MDSR are

• to provide information that effectively guides immediate as

well as longer term actions to reduce maternal mortality; and

• to count every maternal death, permitting an assessment of the

true magnitude of maternal mortality and the impact of actions

to reduce it.

continuous-action cycle

Respond and

monitor response Identify and notify

deaths

Analyse and make

recommendations Review maternal deaths

1.Identification and notification of

maternal deaths

Facility-baseddeaths

Community-baseddeaths

Maternal death – a notifiable event

• classifying an event or disease as notifiable means it

must be reported to the authorities within 24 hours

and followed up by a more thorough report of

medical causes and contributing factors.

• Notification should be systematic, including absence

of cases (“zero reporting”).

Sources of information

• Healthcare facilities (where women give birth and

are attended when they have pregnancy

complications) and

• communities (when women give birth at home or on

the way to a health-care facility or die during

pregnancy without receiving medical care).

Identification and notification of suspected and probable

maternal deaths in health facilities

• usually easier to identify

• to ensure that none are missed- someone should have a daily

responsibility to check death logs and other records from the

previous 24 hours and collect a line listing of deaths of all

WRA.

• Any death of a WRA should trigger a review of her medical

record to look for evidence that she could have been pregnant

or within 42 days of the end of a pregnancy.

Identification and notification of suspected

maternal deaths in the community

• by community health workers (CHW) or, in their

absence, by other community representatives.

• This process is more complicated than reporting from

health facilities for several reasons:

• 1) Deaths are far less frequent, and communities will need periodic

reminders about their importance and the reporting process;

• 2) supervising every single community is difficult, especially if there are no

CHWs; and

• 3) there may be no way to report quickly.

Innovative uses of technology for

maternal death notification

• Personal digital assistant devices and tablet

computers are becoming more affordable and offer

additional benefits to data collection.

• Programmes such as mHealth and Epi Info 7.0 offer

options for data collection and entry on mobile

devices, including touch-screen questionnaires,

photographs, and GIS coordinates

2.Maternal death review

• World Health Organization’s publication of Beyond the

Numbers (BTN) in 2004, defined MDR as “qualitative, in-

depth investigation of the causes of, and circumstances

surrounding, maternal deaths” and includes methods designed

for reviewing deaths that occur in both health-care facilities

and communities.

• Implemented and institutionalized by all states of India as a

policy since 2010.

Maternal deaths in communities

Maternal deaths in facilities

Determine if probable maternal death; collect data

for review including verbal autopsy

Determine if probable maternal death; collect data

for review including patient record review

Actions at andfeedback to facility andcommunity

level

Investigations compiled and sent to district level

with recommendations for action

Aggregated analysis and multidisciplinary higher-level responses

Tamil Nadu

• Tamil Nadu initiated identification and compulsory reporting

of maternal deaths in 1994.

• It was mandated that each and every maternal death be

reported by the Village Health Nurse working at the level of

the Health Sub-Centre, the medical officers of primary health

centers, first referral unit (FRU) and non-FRU government

hospitals, district public health nurses, and Deputy Directors of

Health Services.

• Following recommendations of the maternal death review

committees, a quality-improvement process aiming to benefit

patient care and outcomes through clinical audits was

introduced.

3.Analysis – data aggregation

and interpretation

Identify deaths, establish which occur during or within 42 days ofpregnancy, notify and report maternal deaths, and conduct MDR

Send data to district level for analysis

Enter data, check completeness and quality

Perform standarddata analysis plan

Perform specialized complexanalysis or sub analysis

Analyze preventable factors

Translate data analysis for broader audience

Respond, disseminate results and recommendations, implement M&E,

and refine the system

IMPACT INDICATORS AVAILABILITY/ACCESS INDICATORS

Maternal mortality ratio % of deaths that occurred within 24 hours of arrival

at facility

Maternal mortality rate % of deaths among women who were delivered by

skilled birth attendant/facility delivery

Proportion of deaths to WRA that are maternal % of deaths among women who had recommended

prenatal care

Proportion of maternal deaths by medical cause of

death (haemorrhage,eclampsia/preeclampsia, sepsis,

abortion, obstructed labour, other direct cause,

Indirect causes)

% of deaths where limited drugs and/or supplies was

a factor

% of deaths where limiting staff was a factor

% of deaths where guidelines are not followed

Case fatality rate % of deaths for a given complication

Proportion of maternal deaths with avoidable factors % of deaths where lack of transport was a factor

% of deaths where health care cost were unaffordable

% of deaths where lack of recognition at the

community level was a factor

Descriptive analysis of maternal deaths

• Women: Age group, race/ethnicity, gravidity/parity, gestational age at time of death,

pregnancy outcome (undelivered, stillbirth, live birth), socioeconomic status of family,

education

• Place: Where family lived (urban or rural, district/sub-district, town or village); where

woman died

• Time: Date of death (day, month, year), time of day when death occurred, weekday or

weekend, season when death occurred

• ANC: Week or month of pregnancy when the woman first attended antenatal care, how many

visits, type of care provider and type of place, distance of facility from place of residence

• Delivery: Date and time of birth, day of the week, season, place of delivery, type of place,

type of delivery attendant, type of delivery (vaginal, forceps, caesarean)

• Data source: Notification only, facility-based review, verbal autopsy

• Medical cause of death

• Contributing factors and preventability

4.Response

• types of responses that may be needed to address the

problems found by MDSR and discusses criteria that

can be used to prioritize recommendations for action,

the primary MDSR objective.

Identify deaths, establish which occur during or within 42 days of pregnancy, notify and report maternal deaths, conduct MDR, analyse data

Respond immediately, as appropriate, to each maternal death

Determine priority actions based on aggregated analysis

Disseminate and discuss findings and recommendations with key stakeholders, including community

Incorporate recommendations in annual plan

Perform monitoring and evaluation and reporting

Guiding principles for response

• Start with the avoidable factors identified during the review

process

• Use evidence-based approaches

• Prioritize (based on prevalence, feasibility, costs, resources,

health-system readiness, health impact)

• Establish a timeline (immediate or short-, medium-, or long-

term)

• Decide how to monitor progress, effectiveness, impact

• Integrate recommendations within annual health plans and

health-system packages

• Monitor to ensure that recommendations are being

implemented

5.Dissemination of results,

recommendations, and responses

• The two main types of reports from the MDSR

system are

• annual reports on maternal deaths and

• reports on the monitoring and evaluation (M&E) of

the system itself

Annual reports

• single-facility death review report

• annual facility-based MDSR report

• district MDSR report

• national MDSR report

Whom to inform of the results

The general principle is to get the key messages to those who can

implement the findings and make a real difference towards saving

mothers’ lives. They may include:

• Ministries of Health;

• local, regional, or national health-care planners, policy-makers, and

politicians;

• professional organizations and their members, including obstetricians,

midwives, pediatricians, general physicians, anesthetists, and pathologists

who are involved at each level;

• medical directors and chief executive officers;

• leaders in other health-care systems, such as social security and the private

sector;

• health promotion and education experts;

• health insurance companies (if applicable);

• public health or community health departments;

• academic institutions;

• local health-care managers or supervisors;

• local governments;

• national or local advocacy groups;

• the communications media;

• representatives of specific faith or cultural institutions

or other opinion leaders who can promote and

facilitate beneficial changes in local customs;

• all participants in the survey.

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6.Monitoring and Evaluation of the MDSR

system

• A periodic evaluation should examine how efficient the system

is.

• This includes an assessment of its key processes: identification

and notification, review, analysis, reporting and response, and

whether there are barriers to their operation that should be

addressed.

• Evaluation of effectiveness determines if the correct

recommendations for action have been implemented, if they

are achieving the desired results and, if not, where any

problems may lie.

• A monitoring framework with indicators should be agreed to

and indicators assessed annually. A sample framework, with

indicators, is shown in next slide.

Development of an MDSR

implementation plan • The final structure and scope of MDSR will differ

according to the local context and challenges.

• A classic approach in planning a standard public health surveillance system is illustrated below

• 1.Establish objectives

• 2.Develop case definitions

• 3.Determine data sources and the data-collection mechanism

• 4.Determine data-collection instruments

• 5.Field-test methods

• 6.Develop and test analytical approach

• 7.Identify dissemination mechanisms

• 8.Assure use of analysis and interpretation

“women are not dying of diseases we cannot treat … they are dying because societies have yet to make the decision that their lives are worth saving.” – Mahmoud Fathalla

Thank You