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Background: To reduce maternal mortality Tanzania introduced Maternal Death Surveillance and Response (MDSR) system in 2015 as recommended by World Health Organization (WHO). All health facilities are to notify and review all maternal deaths inorder to recommend quality improvement actions to reduce deaths in future. The system relies on consistent and correct categorization of causes of maternal deaths and three phases of delays. To assess its adequacy we compared the routine MDSR categorization of causes of death and three phases of delays to those assigned by an independent expert panel with additional information from Verbal Autopsy (VA). Methods: Our cross-sectional study included 109 reviewed maternal deaths from two regions in Tanzania for the year 2018. We abstracted the underlying medical causes of death and the three phases of delays from MDSR system records. We interviewed bereaved families using the standard WHO VA questionnaire. The obstetrician expert panel assigned underlying causes of death based on information from medical files and VA according to International Classification of Disease to Death in Pregnancy Childbirth and Puerperium (ICD-MM). They assigned causes to nine ICD-MM groups and identified the three phases of delays. We used Cohen’s K statistic to compare causes of deaths and delays categorization. Results: Comparison of underlying causes was done for 99 deaths. While 109 and 84 deaths for expert panel and MDSR respectively were analyzed for delays because of missing data in MDSR system. Expert panel and MDSR system assigned the same underlying causes in 64(64.6%) deaths (K statistic 0.60). Agreement increased in 80 (80.8%) when causes were assigned by ICD-MM groups (K statistic 0.76). The obstetrician expert panel identified phase one delays in 74 (67.9%), phase two in 24 (22.0%) and phase three delays in all 101 (100%) deaths that were assessed for this delay while MDSR system identified delays in 42 (50.0%), 10 (11.9%) and 78 (92.9%).The expert panel found human errors in management in 94 (93.1%) while MDSR system reported in 53 (67.9%) deaths. Conclusions: MDSR committees performed reasonably well in assigning underlying causes of death. The obstetrician expert panel found more delays than reported in MDSR system indicating difficulties within MDSR teams to critically review deaths.
A cross-sectional study was conducted including 132 maternal deaths from two regions in Tanzania. The deaths had occurred between 1st January and 31st December 2018. Routine MDSR categorization of cause of deaths and the three phases of delay was compared with those assigned by an independent expert panel of obstetricians with additional information from VA. To compute the completeness of maternal deaths reported by the MDSR we used the number of infants that received Bacillus Calmette-Guerin (BCG) vaccine,as a proxy for live births as previously recommended, [19] to calculate the MMR for the two regions in 2018. The study was conducted in Lindi and Mtwara regions in Southern Tanzania with a total population of about 2 million [20]. The two regions have two regional referral hospitals, 12 district hospitals, four private/mission hospitals, 40 health centres and 399 dispensaries. The MMR in Lindi and Mtwara was 456 and 579 per 100,000 live births in 2013 [21]. The fertility rate is one of the lowest (3.8) in Tanzania. Most women, 80.8% in Lindi and 81.3% in Mtwara give birth in health facilities (dispensary, health centres and hospitals). Caesarean section rates are 6.0% in Lindi and 10.3% in Mtwara [5]. Each health facility that provides delivery services in Tanzania has a standard MDSR committee as stipulated in the guideline [6]. In regional and district hospitals, where most deaths occur, MDSR committees are composed of a multidisciplinary team of clinical and non-clinical staff such as obstetricians (if available), medical doctors, clinical officers, nurses and midwives from maternity wards, facility management, laboratory personnel and other supporting staff. The committee meets within 7 days after a suspected maternal death has occurred. Before the meeting, a designated person prepares a narrative summary using information from medical files, interviews of health care providers and relatives who cared for the woman. There is no clear guide on how and which relatives should be interviewed. During the meeting the summary is discussed and when necessary more information is obtained from medical files or health care providers who cared for the woman. Findings from the meeting are summarised in a maternal death reporting form which includes demographic characteristics, medical information, underlying medical cause of death, description of contributing medical and non-medical factors along the three phases of delays and a plan of action [6]. The MDSR guideline recommends the underlying medical cause of death to be categorized following ICD MM rules, but the training and the guideline does not provide a formal training on this. The reporting form in MDSR guideline has a short list of example of causes and ICD 10 codes to be used during reporting. (See Table 6 in Appendix). Our main outcome was the underlying medical cause of death defined as disease or condition that started the chain of events that led to death e.g. postpartum haemorrhage (PPH) [12] . Underlying causes of deaths are grouped into nine groups that are mutually exclusive, totally inclusive and descriptive of all underlying causes of maternal deaths. The groups are; 1) Pregnancy with abortive outcome, 2) Hypertensive disorders in pregnancy, childbirth and the puerperium, 3) Obstetric Haemorrhage 4) Pregnancy related infection, 5) Other obstetric complications, 6) Unanticipated complications of management, 7) Non-obstetric complications, 8) Unknown/undetermined and 9) Coincidental causes. As stipulated in Tanzania MDSR guideline, delays in health care seeking or provision of care deemed to have contributed to the maternal deaths were grouped using the three delays model, stipulating delays 1) to decide to seek care; 2) to reach health facilities for care including transport and 3) to receive appropriate care in facilities [6]. Several delays may contribute to one death. Phase one delays are delays at household and personal level that lead to late or lack of seeking care. It includes the time from the onset of disease at home until the decision to seek care is made by the woman, family or both. Phase two delays are concerned with access to health care such as availability of health facility, roads and transport issues, and constitute time from when the decision to seek care is made until arrival to proper health facility. Phase three delays occur in health facilities and are more concerned with time, equipment and supplies, structure, management errors, human resources and referral system, and constitutes time from admission until adequate treatment or care begins. Data collection followed three steps: 1) abstracting information from MDSR documents 2) performing VA and 3) independent obstetrician panel review. The first author AS, in close collaboration with regional Reproductive and Child Health Coordinators, abstracted information using a pre-defined checklist from maternal deaths narrative summaries, death review report forms and district monthly death report summaries (date of death, age, facility, village and cause of death). The field team (AS and VA interviewers) then traced families using demographic information such as names of the deceased woman, place of death, district and date of death, home address, name of village/street leader, name of husband/partner and other information, for VA interviews. Verbal Autopsy interviews were conducted using the translated standard questionnaire provided by WHO [18]. The questionnaire was piloted and the Swahili translation was reviewed and corrected accordingly. In addition to the standard inquiries, questions relating to the three phases of delay were added. The field team commenced the process of finding families for VA interviews by visiting and enquiring in the facility where death occurred or where the deceased woman attended antenatal clinic. They were then taken to the family through local government leaders. At the family’s home, after being introduced they explained in detail the purpose of VA. Then one of the interviewers identified person (s) that was (were) present during illness and death and conducted VA with them. Using the coded VA questionnaires as well as copies of available medical files a group of experts, consisting of three experienced obstetricians in MDSR reviewed all maternal deaths. Two of them were from Muhimbili University of Health and Allied Sciences and had never worked in the regions and one was from Mtwara regional hospital. The latter was included to help the panel understand the context better especially information in VA. The author, AS, was among the panel members and had previously been trained on using ICD-MM. All the three panel members neither conducted the VA interviews nor documented any information from the reviews. The three panel members reviewed all the deaths together by reading through the information in VA questionnaire and available medical files. Then they discussed the findings and made their decision by consensus. The cause of death was agreed if at least two of the panel members said the same cause of death. First, the expert panel went through VA questionnaires and determined the underlying cause from the information by consensus. Second, the panel went through the medical files and reviewed all available information. Based on these two sources, the panel determined the 1) underlying cause of death including the ICD coding, 2) contributing medical causes and 3) three phases of delays, all by consensus [12]. The three panel members reached consensus in all deaths that were reviewed even though there was a plan to consult another obstetrician in case of no agreement. This was never used since there was consensus in all deaths. Data were processed using MS Excel and then transferred to SPSS computer program version 25. Proportions of each underlying medical cause categorized by MDSR system and the expert panel of obstetricians were computed. Underlying medical causes and differences between the routine MDSR system and obstetricians panel were tabulated. As the routine MDSR system used a shortlist of ICD codes while the expert panel used the full number of ICD-MM codes and groups, comparison had to use a pragmatic approach. For example, when the obstetricians panel categorized a death to be caused by PPH due to atony, coagulopathy or retained placenta, this was considered to be in agreement if MDSR system categorized the same death as PPH (non traumatic). Also PPH (traumatic) for MDSR system was decided to be in agreement if obstetricians’ panel categorized the same case as PPH (vaginal tear, cervical tear, extension of uterine incision during caesarean section). Cohen’s K statistics were used to determine the level of agreement in categorizing the underlying causes and the three phases of delays. We defined < 0 as no agreement, 0–0.2 as slight agreement, 0.21–0.4 as fair, 0.41–0.6 as moderate, 0.61–0.8 as substantial and 0.81–1 as almost perfect agreement [22].
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