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Background: In Malawi, maternal mortality remains high. Existing maternal death reviews fail to adequately review most deaths, or capture those that occur outside the health system. We assessed the value of community involvement to improve capture and response to community maternal deaths. Methods: We designed and piloted a community-linked maternal death review (CLMDR) process in Mchinji District, Malawi, which partnered community and health facility stakeholders to identify and review maternal deaths and generate actions to prevent future deaths. The CLMDR process involved five stages: community verbal autopsy, community and facility review meetings, a public meeting and bimonthly reviews involving both community and facility representatives. Results: The CLMDR process was found to be comparable to a previous research-driven surveillance system at identifying deaths in Mchinji District (population 456 500 in 2008). 52 maternal deaths were identified between July 2011 and June 2012, 27 (52%) of which would not have been identified without community involvement. Based on district estimates of population (500 000) and crude birth rate (35 births per 1000 population), the maternal mortality ratio was around 300 maternal deaths per 100 000 live births. Of the 41 cases that started the CLMDR process, 28 (68%) completed all five stages. We found the CLMDR process to increase the quantity of information available and to involve a wider range of stakeholders in maternal death review (MDR). The process resulted in high rates of completion of community-planned actions (82%), and district hospital (67%) and health centre (65%) actions to prevent maternal deaths. Conclusions: CLMDR is an important addition to the established forms of MDR. It shows potential as a maternal death surveillance system, and may be applicable to similar contexts with high maternal mortality.
Malawi has a high, though declining, maternal mortality ratio.9 The most recent national survey estimated 574 maternal deaths/100 000 live births during the period 2008–2014.10 The leading biological causes of maternal death in Malawi are postpartum haemorrhage, postpartum sepsis, ruptured uterus, complications of abortion, antepartum haemorrhage, pregnancy-induced hypertension, and as indirect causes anaemia and HIV/AIDS.11 Behind each death is a complex story of social, behavioural, economic, logistical and health system factors which can be grouped into the ‘three delays’ model.12 A delay by the family in the decision to seek care, a delay in reaching appropriate care once the decision has been made and a delay in receiving adequate care after arriving at the health facility may all contribute to a maternal death.13 A recent study found that in Malawi, delay in receiving adequate care was the commonest delay due to referral delays, missed diagnoses, lack of blood, lack of drugs, inadequate care or severe mismanagement.13 The health system struggles with shortages of personnel with insufficient knowledge and low morale, inaccessible facilities, and irregular drug supplies.14 15 While a maternal death is a notifiable event in Malawi, the Ministry of Health notification system attempts to identify only those maternal deaths that occur in hospital. However, one-third of all deaths are known to occur outside health facilities, either at the woman’s home, the home of a traditional healer, or in transit to a facility, and these are presently not identified by the hospital-based notification system.16 The Ministry of Health aims to review all maternal deaths occurring in health facilities, but in reality this is not achieved. A review of emergency obstetric care services in Malawi in 2010 found that only 89 of 309 health facilities (29%) had conducted MDRs, and only 153 of 597 (26%) maternal deaths recorded were included in these reviews.17 Barriers to effective MDR include missing medical charts, poor documentation and record keeping, shortage of senior staff to conduct the reviews, a fear of blame and a lack of resources, commitment and knowledge or skills for the proper conducting of reviews.6 11 18 MDR is not even attempted for deaths occurring in the community where many women are either unable to access quality healthcare or avoid the formal health sector.19 The outcome of an MDR process is dependent on the quality of the data gathered. Current data comes from hospital records, which often fail to adequately record patient history, examination findings, monitoring, results and management.18 In one study, less than 20% of postnatal women’s charts were correctly completed.20 The lack of accurate written data may be compounded by a culture of blame that inhibits staff from sharing valuable information.6 In a context where substandard care has been found to contribute to approximately one-third (38%) of institutional deaths,21 good quality data is essential to the MDR process. Only a limited number of hospital staff are involved in the MDR process.22 Individuals such as community health workers and non-clinical staff such as pharmacists, laboratory technicians or transport coordinators whose actions may affect maternal outcomes, are not represented.6 There is no involvement of the woman’s community, meaning, that her family and traditional leaders are unable to contribute their insights to the process or put forward ideas for action. A recent study in Mchinji District, Malawi, added to the evidence that communities themselves have significant potential to reduce maternal and neonatal mortality when they are involved in planning and implementing community actions.23 24 Failing to involve communities in MDR, therefore, fails to utilise this potential. When health workers plan to take action following a MDR there is no official monitoring of whether these actions are taken, as completion of the maternal death follow-up form is almost non-existent.6 There is also no forum for communities to hold health workers accountable for the actions identified to prevent future deaths. Motivation for MDR among health workers is reported to be low, while communities are highly motivated to take steps to prevent maternal deaths.6 23 We hoped that these limitations could be overcome by involving the woman’s community in all stages of the process, from identifying the death, to holding review meetings and monitoring the completion of planned actions. We aimed for a blame-free process to review all maternal deaths, including those occurring in the community; supplement the limited hospital data with rich descriptive information from the community; and include a wider group of health facility staff and community representatives. We hoped that this new process would catalyse health facility and community actions to address the determinants of maternal death; improve the accountability of health workers; and, by elevating the community as partners in the process, generate a self-sustaining MDR process fuelled by community motivation to prevent maternal deaths. The CLMDR system was designed by MaiMwana, a Malawian non-governmental organisation focusing on women and children’s health, University College London, UK, and Ministry of Health of Malawi staff, taking into account evidence from published work on MDR and discussions with maternal death review experts. To design the process, we drew on evidence from a number of studies that have used social autopsy to enhance maternal health programmes. In Indonesia, social autopsy and medical records were used together to review deaths, with some community involvement.25 Another programme, based in India, used community-based maternal verbal social autopsies to generate data regarding maternal deaths, which was then shared with the community to encourage participatory development of health interventions.26 A number of studies of child deaths have also used verbal autopsy data to feed back to communities, but to a lesser degree.27 The CLMDR project was discussed with local leaders who gave their consent and input. The project was initially piloted in four of the 12 health centre catchment areas in Mchinji District. Following feedback from all participants and the Malawi national-level safe motherhood taskforce, the process was modified (shortening and combining reporting into one form) and then rolled out across the whole district for a 1-year period (July 2011–June 2012). Project staff trained 350 community teams, made up of the group village headman, community health workers (called Health Surveillance Assistants (HSA) and volunteers. Health centre teams were created at all 12 health centres providing maternity care in the district. The existing MDR team at the district hospital was expanded (to include non-health professionals—drivers, pharmacy, laboratory, support staff) and strengthened with further training on their roles and responsibilities. The process (figure 1) was triggered in the event of any maternal death, by community CLMDR team members hearing about a death in their area. Stage 1 began with the woman’s family giving consent for the process, followed by a verbal autopsy, or structured interview, including multiple open-ended free-text questions about the events leading up to her death. This form (see web appendix 1) was used to record data at all stages of the process and designed to facilitate discussion and communication between participants. Flow chart of CLMDR process. CLMDR, community-linked maternal death review; GVH, group village headman; HSA, health surveillance assistant; TA, traditional authority. Stage 2 was a meeting held in the woman’s local area by the community team. They recorded factors they believed contributed to the woman’s death, and suggested strategies to prevent future deaths. Stage 3 was a meeting held at the woman’s local health facility or at the district hospital dependent on where the death occurred, with a broad spectrum of health centre staff, district hospital staff and the HSA. The HSA reported the information from the verbal autopsy and the community team discussions. Participants agreed on a medical cause of death and health facility factors that may have contributed to the death, after which they recorded the strategies that they planned to prevent future deaths. Action points were assigned to individual health centre and district hospital staff to implement. Stage 4 was a public meeting held in the woman’s local community, attended by district hospital and health centre representatives, the HSA, community leaders and community members—all were welcome to attend. The HSA sought the family’s consent to summarise the case in order to facilitate an open discussion of all relevant factors. The health workers presented their planned action points. The community agreed on community factors that may have contributed to the death and planned their own strategies, assigning action points for individuals to implement. Stage 5 was a bimonthly meeting, which provided an opportunity for community and health facility representatives to hear about progress on implementing action points, celebrate successes, and to identify and overcome any barriers to action. An additional meeting of traditional leaders was held quarterly in order to share innovations and lessons learned across the whole district. Over a 1-year period, from July 2011 until June 2012, we attempted to review every maternal death of a woman resident in Mchinji District. The district population was 456 500 in the 2008 census. With a growth rate of 2%, the population at the time of the study was probably close to half a million. A maternal death was defined as the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and the site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management, but not from accidental or incidental causes.28 All maternal deaths of Mchinji women were included even if they died outside the district, such as at the central hospital in the capital city, Lilongwe. Women who died in the district but who were resident outside the district (ie, from neighbouring Zambia, Mozambique or surrounding Malawian districts) were excluded from the sample as it would be impossible to complete the CLMDR process without involvement of a community team in the woman’s home village. Data collection was via the combined form (see web appendix 1), completed by either the community CLMDR team or the health facility CLMDR team at each stage of the process. Process data was collected by the research team and included information on who initiated the process, numbers of people attending the community feedback meetings, and feedback from all participants during the pilot and rollout phases of the project. We assessed the CLMDR process against the weaknesses of the pre-existing MDR process. We measured indicators relating to each identified weakness of the existing system (table 1). Identified weaknesses of existing maternal death review (MDR) process and indicators used to assess community-linked maternal death review (CLMDR) Each form was collected by the study team once the maternal death review process had been completed. A total of two forms could not be traced after completion and are therefore not included in this analysis. Descriptive statistics (counts and percentages) were produced from the quantitative data, which was analysed in Stata V.12.1 for Mac. Qualitative data was extracted (following translation of the relevant sections of the forms) and grouped into themes. Confidentiality is a norm of MDRs, enforced in order to improve the accuracy of reporting events, to protect the confidentiality of the deceased woman and her family, and to protect health workers from blame and recriminations resulting from the publication of their actions. The potential negatives of a more open process were carefully considered during the design phase. On balance, we hoped that the motivation of a community affected by a death would be one of the drivers of the process. The community required some details of the case in order to draw meaningful conclusions and generate relevant actions. Family consent (both written and verbal) was an absolute pre-requisite of the CLMDR process and this was also sought again formally prior to the public community feedback meeting. It could also be withdrawn at any stage. The HSA publicised only the summary of the case that had been previously agreed with the family prior to the meeting. All other discussions were confidential and this was reinforced in training and at the beginning of each meeting using a standardised text read out by the chairperson. We recognised that discussion of a maternal death can result in blame and recriminations. In order to avoid this, the blame-free nature of the process was emphasised during training and was reiterated at the beginning of each meeting using standardised text on the form (see web appendix 1).
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