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

  • BMC Pregnancy and Childbirth, Volume 15, No. 1, Year 2015

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Study Justification:
– Maternal deaths are still a significant issue in many sub-Saharan countries, including Tanzania.
– The health systems may not effectively use lessons from maternal death reviews to improve maternal survival.
– This study aims to analyze data from maternal death reviews at Bugando Medical Centre in Tanzania to better understand the causes and factors contributing to maternal deaths.
Study Highlights:
– The study analyzed data from 80 maternal deaths at Bugando Medical Centre from 2008-2012.
– Most deaths were from direct obstetric causes, such as eclampsia, severe pre-eclampsia, sepsis, abortion, and anaesthetic complications.
– Information on antenatal care attendance and gestation age of the pregnancy resulting in death was lacking in a significant number of cases.
– The majority of deaths occurred after delivery.
– Documentation of relevant information and actions taken to address systemic weaknesses was not comprehensive.
Recommendations for Lay Reader and Policy Maker:
– Improve comprehensive documentation of all relevant information in maternal death reviews.
– Increase the recording of antenatal care attendance and gestation age of pregnancies resulting in death.
– Address systemic weaknesses identified through the reviews to improve the quality of maternity care.
– Conduct periodic analysis of available data to gain a better understanding of vital information for improving maternal care.
Key Role Players Needed to Address Recommendations:
– Senior obstetricians and gynecologists to lead the maternal death reviews.
– Resident doctors in obstetrics and gynecology to prepare case summaries.
– Undergraduate medical and nursing students to learn from the review process.
– Senior midwives, clinicians, and midwives involved in case management to participate in the reviews.
– Anaesthetists and pharmacists to be invited to participate in the reviews.
Cost Items to Include in Planning Recommendations:
– Training and capacity building for role players involved in the maternal death reviews.
– Resources for comprehensive documentation and data collection.
– Communication and reporting systems for sharing review findings.
– Monitoring and evaluation of the implementation of recommendations.

The strength of evidence for this abstract is 7 out of 10.
The evidence in the abstract is based on a retrospective analysis of maternal death reviews at a tertiary hospital in Tanzania. The study provides information on the number of deaths, causes of deaths, and some gaps in documentation. However, the abstract does not provide details on the methodology used for the analysis, such as the sample size or the specific statistical tests conducted. Additionally, the abstract does not mention any limitations of the study or potential biases. To improve the strength of the evidence, the authors could provide more information on the study design, sample size, and statistical methods used. They should also acknowledge any limitations or potential biases in the study.

Background: Unacceptably 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. Methodology: Retrospective 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. Results: There 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. Conclusion: Routine 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.

The study is a retrospective analysis of maternal death reviews at a tertiary hospital north-western Tanzania in the period 2008–2012. This is a 900 bed capacity and the main referral hospital for the population in the Lake and western zones constituting almost 37 % of the entire Tanzania mainland population, estimated at 43,625,354 people in 2012. [18] There are about 7000 deliveries at this hospital annually, most being referrals from lower level health facilities. All copies of the reviewed maternal deaths covering the study period were accessed (80 deaths). Typically, maternal deaths reviews are conducted as they occur, usually within a week of occurring by a team led by senior obstetricians in a morning meeting. Case summaries of deaths are prepared by resident doctors in obstetrics and gynaecology not involved in the case management (usually one such doctor is assigned a case to summarize and present). In contrast to what is stipulated in the national guidelines on who should be involved in the reviews, the circumstance at the hospital demands teaching of both undergraduate medical and nursing students who are invited in such meeting as part of learning the process. Senior midwives in the department are also involved in the review besides clinicians and midwives involved in the case management. However, anaesthetists and pharmacists are rarely invited to participate. Once the review has been done, copies of the review findings are sent to the hospital Director and the zonal reproductive and child health office housed at the hospital. The latter is responsible for forwarding the filled forms to various levels of reporting; usually to the district reproductive and child health coordinator who also forwards the information to the regional and national offices quarterly. We reviewed multiple data sources at the hospital for deaths that occurred in this period: labour ward, medical records, theatre registers and emergency and casualty department. Missing information for two deaths not included in the existing maternal deaths review forms were identified. Corresponding review forms were found in the deceased patients’ files and included in the analysis. Information on the forms were entered into an excel spreadsheet and missing information was extracted from case notes in patients’ files if available. Data were then transferred into Stata statistical package in windows version 12 (StataCorp LP College Station, Texas, USA) for cleaning, coding and analysis. Categorical data were analysed into frequencies to understand the various components of review that were completed and filled and causes of deaths and associated factors while numerical data into means ± SD, range as well as median with 95 % CI. The analysis is part of a larger study titled “Improving quality of maternal and newborn care in Tanzanian health facilities: Lessons from a mixed method assessment of health facility maternal deaths reviews in the Lake zone of north-western Tanzania” with research permits from the Catholic University of Health and Allied Sciences (CUHAS)/Bugando Medical Centre and National Institute for Medical Research (NIMR) ethical committees (no CREC/018/2013 & NIMR/HQ/R.8a/Vol.IX/1543 respectively). Permission for the retrospective access to the deceased patients’ hospital records was also requested and obtained from the administration of Bugando Medical Centre, including the head of the department of obstetrics and gynaecology as required by the national regulations. Data extraction was done by one of the authors who was not involved in the management of any of the patients and de-linked the deceased patients’ information to ensure data anonymity in the subsequent steps of data handling.

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Based on the information provided, here are some potential innovations that could improve access to maternal health:

1. Comprehensive Documentation: Implement a system that ensures comprehensive documentation of all relevant information during maternal death reviews. This would include recording information such as ANC attendance, gestation age of the pregnancy resulting in death, mode of delivery, place of delivery, and delivery assistant.

2. Improved Data Analysis: Develop a more systematic and periodic analysis of available data from maternal death reviews. This would allow for a better understanding of vital information and identification of systemic weaknesses, which can then be addressed to improve the quality of maternity care.

3. Inclusion of Relevant Stakeholders: Ensure the involvement of all relevant stakeholders in maternal death reviews, including anaesthetists and pharmacists. This would provide a more comprehensive perspective and enable a more holistic approach to improving maternal health.

4. Enhanced Training: Provide training to healthcare professionals involved in maternal death reviews, including resident doctors, midwives, and other clinicians. This training should focus on improving their understanding of the review process and their ability to identify and address systemic weaknesses.

5. Strengthened Reporting System: Improve the reporting system for maternal death reviews, ensuring that review findings are effectively communicated to the appropriate authorities at various levels. This would facilitate the implementation of necessary interventions and the monitoring of progress in reducing maternal deaths.

It is important to note that these recommendations are based on the specific context and findings of the study mentioned. Further research and evaluation would be needed to determine the feasibility and effectiveness of these innovations in improving access to maternal health in other settings.
AI Innovations Description
Based on the information provided, the recommendation to improve access to maternal health is to implement comprehensive and standardized maternal death reviews. The study found that routine maternal death reviews at Bugando Medical Centre in Tanzania did not involve comprehensive documentation of all relevant information, including actions taken to address identified systemic weaknesses. Therefore, implementing comprehensive maternal death reviews would allow for better understanding of vital information to improve the quality of maternity care.

To implement this recommendation, the following steps can be taken:

1. Establish a multidisciplinary team: Form a team consisting of senior obstetricians, resident doctors, midwives, anaesthetists, pharmacists, and other relevant healthcare professionals. This team should be responsible for conducting maternal death reviews.

2. Develop standardized review forms: Create standardized review forms that capture all relevant information, including demographic data, medical history, antenatal care attendance, gestation age, mode and place of delivery, delivery assistant, and any actions taken to address systemic weaknesses.

3. Conduct regular reviews: Schedule regular meetings to conduct maternal death reviews for all maternal deaths that occur at the hospital. These reviews should be conducted within a week of the occurrence.

4. Involve relevant stakeholders: Invite undergraduate medical and nursing students, as well as senior midwives, to participate in the reviews as part of their learning process. This will help educate future healthcare professionals on the importance of maternal health and improve their understanding of the review process.

5. Ensure data completeness: Review multiple data sources, such as labour ward records, medical records, theatre registers, and emergency and casualty department records, to ensure all relevant information is captured. If any missing information is identified, extract it from the patients’ files.

6. Analyze and disseminate findings: Enter the review data into a statistical package for analysis. Analyze the data to identify causes of deaths, associated factors, and any systemic weaknesses that need to be addressed. Prepare summary reports of the findings and distribute them to the hospital director, zonal reproductive and child health office, and other relevant stakeholders.

7. Use findings to improve maternity care: Use the findings from the reviews to inform and guide improvements in maternity care. Address any identified systemic weaknesses and implement interventions to prevent future maternal deaths.

By implementing comprehensive and standardized maternal death reviews, healthcare facilities can gain a better understanding of the factors contributing to maternal deaths and take targeted actions to improve access to maternal health services.
AI Innovations Methodology
Based on the provided information, here are some potential recommendations to improve access to maternal health:

1. Improve documentation: Implement a standardized and comprehensive documentation system for maternal death reviews that includes all relevant information, such as actions taken to address systemic weaknesses and factors contributing to the deaths. This will provide a better understanding of vital information to improve the quality of maternity care.

2. Strengthen interdisciplinary collaboration: Ensure that all relevant healthcare professionals, including obstetricians, midwives, anaesthetists, and pharmacists, are actively involved in the maternal death reviews. This will provide a more comprehensive and multidisciplinary perspective on the cases and help identify areas for improvement.

3. Enhance training and education: Provide regular training and education sessions for healthcare professionals, including undergraduate medical and nursing students, on the process of maternal death reviews. This will help improve their understanding of the importance of these reviews and their role in identifying and addressing maternal health issues.

4. Establish a feedback mechanism: Develop a system to provide feedback on the findings and recommendations from the maternal death reviews to the hospital director, zonal reproductive and child health office, and other relevant stakeholders. This will ensure that the identified issues are addressed and improvements are implemented.

To simulate the impact of these recommendations on improving access to maternal health, a methodology could be developed as follows:

1. Define the indicators: Identify key indicators that reflect access to maternal health, such as the number of maternal deaths, ANC attendance rates, mode of delivery, place of delivery, and availability of skilled birth attendants.

2. Collect baseline data: Gather data on the identified indicators before implementing the recommendations. This will serve as a baseline for comparison.

3. Implement the recommendations: Introduce the recommended interventions, such as improving documentation, strengthening interdisciplinary collaboration, enhancing training and education, and establishing a feedback mechanism.

4. Monitor and collect data: Continuously monitor the implementation of the recommendations and collect data on the identified indicators. This can be done through routine data collection systems, surveys, and interviews.

5. Analyze the data: Use statistical analysis software, such as STATA, to analyze the collected data. Calculate frequencies, means, standard deviations, medians, and confidence intervals to assess the impact of the recommendations on the identified indicators.

6. Compare with baseline data: Compare the post-implementation data with the baseline data to determine the impact of the recommendations on improving access to maternal health. Look for changes in the indicators and assess the significance of these changes.

7. Evaluate and adjust: Evaluate the results of the analysis and assess the effectiveness of the recommendations. If necessary, make adjustments to the interventions to further improve access to maternal health.

By following this methodology, it will be possible to simulate the impact of the recommendations on improving access to maternal health and identify areas for further improvement.


Statistics:
Citations: 11
Identifiers:
DOI: 10.1186/s12884-015-0781-z
Research Areas:
Health System and Policy, Maternal and Child Health, Quality of Care, Sexual and Reproductive Health, Social Determinants, Workforce
Study Countries:
Tanzania
Study Design:
Cohort Study, Cross Sectional Study
Study Approach:
Mixed-methods, Quantitative, Systematic Review
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