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Objective: To set up a global system for monitoring maternal and perinatal health in 54 countries worldwide. Methods: The WHO Global Survey for Monitoring Maternal and Perinatal Health was implemented through a network of health institutions, selected using a stratified multistage cluster sampling design. Focused information on maternal and perinatal health was abstracted from hospital records and entered in a specially developed online data management system. Data were collected over a two- to three-month period in each institution. The project was coordinated by WHO and supported by WHO regional offices and country coordinators in Africa and the Americas. Findings: The initial survey was implemented between September 2004 and March 2005 in the African and American regions. A total of 125 institutions in seven African countries and 119 institutions in eight Latin American countries participated. Conclusion: This project has created a technologically simple and scientifically sound system for large-scale data management, which can facilitate programme monitoring in countries.
The survey eventually will be implemented in 54 countries, four from each of the 14 WHO defined subregions. WHO subregions, classified by the levels of under-five child and adult mortality rates2 were used as a proxy for the burden of maternal and perinatal mortality. A stratified multistage cluster sampling design was used to obtain a sample of countries and health institutions worldwide. From each subregion, four countries were selected with probability proportional to population size (Table 1). When there were less than four countries in a subregion, all countries within that subregion were included. This process resulted in 12 subregions having four countries each, and two subregions having three countries each (Table 1). It was decided that no replacement would be made for a country that did not participate. AFRO, African Region; AMRO, Americas Region; EMRO, Eastern Mediterranean Region; EURO, European Region; SEARO, South-east Asian Region; WPRO, Western Pacific Region.a See reference 2 for further details on the WHO regions which are subdivided based on child and adult mortality strata: A, very low child and very low adult mortality; B,low child and low adult mortality; C, low child and high adult mortality; D, high child and high adult mortality; E, high child and very high adult mortality. In each country, the capital city was always included in the sample. In addition, two provinces were randomly selected from the other administrative areas. The third-stage sampling unit was obtained by drawing a random sample of up to seven health institutions, each of which reported at least 1000 deliveries in the year before the implementation of the survey. If there were fewer than seven eligible health institutions in the capital city or other provinces, then all available health institutions were selected. In each country, an up-to-date census of health institutions in the selected areas was obtained. In the absence of a recent census, a list of health institutions was prepared by the country coordinators, in collaboration with WHO country offices and ministries of health. All women who were delivered in the participating sites during the specified period comprised the study population. Those delivered elsewhere were not included. Data were collected over a two- or three-month period depending on the annual number of deliveries in each health institution. For those health facilities with less than 6000 deliveries, data were collected for three months; for those with over 6000 deliveries, data were collected for a two-month period. As a one-time event, an institutional level data collection form (available at: http://www.who.int/making_pregnancy_safer/health_systems/global_survey/en/index.html) was completed by institution’s medical director. Data were collected on services influencing maternal and perinatal care and outcomes such as laboratory tests, anaesthesiology resources, intrapartum care including emergency obstetric care, and human resources for maternal and perinatal health. Individual level data were abstracted directly from medical records onto a two-page data collection form (available at: http://www.who.int/making_pregnancy_safer/health_systems/global_survey/en/index.html) by trained data collectors. These included: maternal risk indicators, mode of delivery, and maternal and newborn outcomes up to hospital discharge or up to a maximum stay of seven days. These forms were completed after delivery and before hospital discharge of the woman and newborn. Incomplete data in medical records were updated in consultation with attending staff before patients’ discharge. Data were entered online (via Internet) at the health institutions and/or country level using existing computing facilities. Criteria for medical record data abstraction and definitions were described in the operational manual, available to all participating health institutions. A cross-checking mechanism was also incorporated to identify missing data. A separate manual was available for data transfer from individual forms to the online data entry system; this described data entry, cross-checking of data and mechanisms for handling missing data. Data abstraction instruments were pre-tested on a convenience sample of records and at the hospital level in 4 countries. A pilot test was performed after a two-week training period to check the skills acquired by data collectors and to identify further problems with individual forms. Revisions were made based on these pre-tests. Country coordinators were trained during two coordinators’ meetings at WHO Headquarters. Hospital coordinators and data collectors were trained by country coordinators and the WHO coordinating unit, with the support of regional staff. One person, usually a labour ward midwife, was responsible for daily data collection in each health institution, while the hospital coordinator (midwife or obstetrician) was responsible for supervision and data quality monitoring before forwarding to the provincial or country coordinator. Data were entered online at hospital, provincial and/or national level depending on available resources. The numbers of completed forms were checked against the number of deliveries recorded in the logbook in the health institution. Completed data forms were sent to the provincial or country coordinator. When data entry was not possible in the health institution, it was done by the national coordinating unit. Random checks were performed periodically by the country coordinator using the online data entry system to check for completeness and accuracy of data. Online data were also checked for quality by the overall project coordinator. Problems identified were addressed immediately by the country coordinator; technical questions were resolved in consultation with the project coordinator. Survey data were managed in collaboration with the WHO coordinating unit by an online systems provider (MedSciNet AB, Stockholm, Sweden), which developed and provided the application and stores the data on its server. The system enables data collection and storage in a user-friendly format that allows for reporting and downloading data for analysis. It also allows for use of different languages and for data to be entered online using Microsoft Explorer and a dial-up connection. The system was pilot tested in Africa and Latin America and modified wherever required. Online screens corresponded to the sections of the individual data collection form. The system prompted for the next field to be filled in; nonapplicable fields were automatically skipped. During data entry, fields were validated on screen according to pre-specified validation rules. A cross-checking validation was performed to ensure that only forms without errors were saved. Data were transmitted after encryption using 128-bit key security. The system provided the facility to search, sort and update patient information, and to generate descriptive analysis reports; system description, manuals, and data entry tutorials; the facility to share information by uploading and downloading other documents; and, at project coordinating unit level, the facility to create and modify user information. The application permitted different types of access to the site and data at global, national, sub-national and health institutional levels. Each data entry operator could access only the data that they had entered. Administrators had access to information at their level and below, but not to information at higher level. The project coordinator had administrative rights to access all data. Preparatory work commenced in mid-2003. This included discussions with WHO regional offices, the selection of countries and provinces, and the preparation of a sampling framework obtained from the participating countries. Following the first meeting, with investigators from Africa and the Americas, to explore the feasibility of the study, all health institutions randomly selected were informed about the nature of the project. Institutional consent was obtained from the responsible authorities. Plans for data collection were tested, from September to November 2003, in both regions in selected health facilities. The second global preparatory meeting, in November 2003, concentrated on finalization of individual and institutional data forms, training plans for the health institution staff, as well as data monitoring and management. At the third global meeting, in June 2004, final decisions on the implementation of the project in both regions were made. The country coordinator was responsible for project supervision at the national level, while the overall project was coordinated by WHO Headquarters in Geneva, supported by the WHO regional offices and country coordinators in Africa and the Americas. Each institution submitted the ethical clearance approval before commencing the project. Ethical clearance was provided by the institutional committees of the participating facilities, where available, or by the national review committees (available at: http://www.who.int/making_pregnancy_safer/health_systems/global_survey/en/index.html). In addition, ethical clearance was obtained from WHO’s Scientific and Ethical Review Group and Ethics Review Committee. Individual informed consent was not obtained as this was a cluster-level study, where data were extracted from medical records without any subject identification. However, key subject information (name, study number, birth date and delivery date) was recorded in the logbook at the institution level by the data collector to assist with follow-up if required.
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