What gets counted matters: Why reviewing maternal deaths matters

Wednesday, 29 Apr 2020
To stop the majority of preventable maternal and newborn deaths, health facilities need systems like the Maternal Perinatal Death Surveillance and Response (MPDSR) to review factors leading to each death. A look at how it has transformed the health system in Kenya's Nandi county offers some lessons.

Globally, the great majority of maternal and perinatal deaths are preventable. In order to protect the lives of mothers and babies, health systems not only need to provide quality health care during pregnancy, delivery and the postnatal period. They also need a system that shares information on the magnitude of and factors leading to maternal and perinatal deaths so that actions to prevent further mortalities can be identified.

This system is referred to as Maternal Perinatal Death Surveillance and Response (MPDSR), which provides a continuous cycle of identification, notification, review and response to each maternal and perinatal death. But how does this system work, what progress has it helped achieve and how have health works responded to the implementation of MPDSR in their health facilities?

A closer look into what the system has changed in Nandi county, Kenya, where Options’ Maternal and Newborn Health Improvement- Quality of Care (MANI-QC) project supports the implementation of the MPDSR system as a core aspect of its health systems strengthening work, offers some valuable insights.

The MPDSR system explained

The goal of the MPDSR system is to ensure that every maternal and perinatal death provides useful lessons on how to prevent future cases. To do so, it involves all stakeholders from within and outside of the health sector (including communities) at the facility, sub-national and national level in the identification and review of the causes of maternal and perinatal deaths that occur at health facilities.

When a health facility implements an MPDSR system, it is recommended that they establish an MPDSR Committee that holds meetings on a monthly basis. These committees consist of nurses, gynecologists, doctors, health records officers, but depending on size ad workforce of each facility, can also include security guards, policy and civil registration representatives at timeIn the event that a maternal death or significant complications occurs, health care workers and other members of the facility MPDSR committee convene within one day to investigate and reflect on whether there were any gaps in provision of care provided to the mother as well as on any other relevant circumstances. This allows the committee to identify what steps the health system (facility and management staff) need to take to overcome these issues in the future.

The implementation of MPDSR has led to an improvement in patient documentation practices and a shift in attitudes 

Feedback from healthcare workers in Nandi county on the MPDSR system has been positive, and pointed to an improvement of documentation practices. This is because conducting a mortality review requires a health facility to have the most accurate information about the patient across the whole continuum of care; from the first contact with health workers during pregnancy, subsequent antenatal care (ANC) visits, labour, child birth to the post-delivery stage.

According to Alice, a nurse at the Kibwarenge health centre in Nandi county: “Our documentation had a few gaps in the past, health workers didn’t capture most details in the mother’s clinic record books during her antenatal care visits and it was therefore challenging to foresee possible complications when she came in for delivery.”

The implementation of MPDSR has therefore, over time, shifted the attitude of health workers to appreciate the importance of capturing the even the smallest details of each patient’s ANC visits. This helps monitor potential pregnancy related risk factors to offer more tailored care and ultimately improve maternal health outcomes.

As part of the MPDSR process, all patient records are uploaded to the national health information reporting system DHIS2 (District Health Information System 2). Nandi county’s health department supports health facilities to ensure that each maternal and perinatal death us reported into the DHIS2 and that a review, which will also need to be uploaded to the database, is undertaken within 24 hours reviews and adheres to set quality standards. The MPDSR Committees then reviews these patient records and shares a report with recommendations and findings with the sub-county – and eventually county representatives - to inform decisions on resource allocation and health system strengthening.

According to the sub-county Public Health Officer Choge, who is responsible for ensuring the quality of reviews: “Our role is to look at what the facilities are doing if there is a maternal or perinatal death case or even if there is no case. We ensure that they hold their monthly MPDSR meetings. And that at the end of each quarter all the cases recorded in each facility have been reviewed uploaded in the DHIS2. Once all that is done, we follow up on the recommended actions presented by the facility MPDSR committees until they are implemented”.

A systems approach is vital to avoiding maternal deaths

The MPDSR’s systems approach is critical to identifying solutions to preventing maternal and newborn deaths and has been embraced by key stakeholders in the health system in Nandi county. “Our facility has actively implemented MPDSR and already there are plans based on recommendations from the committee to improve issues like transport during referral from lower level facilities.”, according to David, hospital administrator at the Nandi Hills Referral Hospital and member of its MPDSR committee.

David also notes that the Nandi County government purchased new ambulances for the health facility in response to a recommendation from the committee, and has requested financial resources to strengthen the county referral system - ensuring that mothers can be referred and transported to upper level facilities from lower level facilities in the shortest amount of time possible and without any avoid any delay in care.  

As Options partnership with the Nandi County government continues to strengthen its health system and improve quality of care for mothers and babies’, systems like MPDSR will play a transformational role. The next steps would be to further institutionalising MPDSR and ensuring that the system is linked to the county’s annual work planning and budget cycle to make additional resources available to implement recommendations from the committees.

This blog was written by Options' Kenya based Communications Manager Meshack Acholla.

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