The Maternal Death Audit Review

Published Date: 02 Nov 2017

In the past decade increased international attention has been directed to issues regarding maternal and reproductive health. Among the indicators (Maternal Mortality Ratio, Maternal Mortality Rate, the proportion of adult female deaths due to maternal causes, and the lifetime risk of maternal death), Maternal Mortality Ratio (MMR) has received the most attention. The safe motherhood initiative launched in 1987, and other initiatives to address the issue, have been successful in drawing the attention of policy-makers and donor agencies to the tragedy of pregnancy and birth-related deaths, and to the 100-fold difference between the best developed country and worst developing country maternal mortality ratios. [i] 

A growing focus on reducing maternal mortality has increased awareness of the need to measure and monitor levels of maternal mortality (Annexure 1). MMR is included among the World Health Organization (WHO)/United Nations Children’s Fund (UNICEF) common indicators for monitoring the goals of Health for All and the World Summit of Children. It also figures among the indicators for assessing the Programme of Action of the International Conference on Population and Development (UN 1995). Millennium Development Goal (MDG) 5 relates to maternal mortality and aims to reduce it by 75 percent between1990 and 2015.

The medical reasons for maternal deaths are intertwined with social factors such as low status of women, poor understanding by families on when to seek care, and inaccessibility of quality healthcare in rural areas. It is being increasingly realized that these social factors are sometimes more difficult to overcome, but nevertheless must be addressed if India is to achieve MDG 5. India’s MMR has declined from an estimated 570 deaths per 100,000 live births in 1990 to 212 [ii] in 2007-09, which means that the country could come very close to reaching the MDG 5 target of 75 percent decline (from 1990 to 2015). However a large number of pregnant women or new mothers are still dying every hour from preventable causes.

Maternal and child death inquiries have been conducted in many settings. Some examples include: (1) the routine practice of maternal death review by medical practitioners in the United Kingdom for more than 50 years; (2) hospital-based perinatal death reviews encouraged by the American College of Obstetricians and Gynecologists in the United States; (3) community and hospital inquiry into all maternal deaths required by the Sri Lanka Ministry of Health since 1985; (4) the community verbal autopsy and hospital-based confidential inquiry of maternal deaths encouraged by the Philippines Ministry of Health; and (5) maternal death reviews supported by WHO in selected hospitals of Bangladesh, Myanmar and Nepal.

"Maternal Death in terms of numbers, we don’t learn anything. Why the women died at home or in the way to the hospital or in the institution; there are multiple factors for the cause of maternal death; apart from that there is social and economic issues, delay in getting the transport etc. These three type of delays unless we discuss with the family of the deceased and with the service providers we may not get the whole picture (why women died during the process of labour). To get a whole picture, to identify system deficiencies, social and cultural issues; we need to have a system of reviews involving the various stakeholders." – Dr. Padmanabhan, NHSRC

In India, the Tamil Nadu Reproductive and Child Health Programme has reviewed all maternal deaths and a sample of infant deaths since 2003, and the Government of Kerala has reviewed all maternal deaths since 2005. In addition, WHO has supported maternal death reviews at Safdarjung Hospital in Delhi and at Christian Medical College in Vellore.

A key problem in tackling maternal mortality is how to accurately capture data and appropriately monitor it. Ascertaining the causes of maternal mortality is difficult even where there is a comprehensive registration of deaths. As most developing countries have weak vital registration and health information systems, they cannot provide an accurate assessment of maternal mortality, leave aside its causes. On the other hand, an estimate derived from the more complete vital registration systems such as those in developed countries, suffers from misclassification and under-reporting of maternal deaths.

In this case study two systems are described for capturing information about maternal deaths, and how the information has been used to improve the health system and to empower the community to take appropriate actions:

Maternal and Perinatal Death Enquiry and Response (MAPEDIR)

Maternal Death Review (MDR)

A. MAPEDIR

Since 2005, UNICEF has supported the Maternal and Perinatal Death Enquiry and Response (MAPEDIR) which is a tool that systematically captures the ground realities of maternal deaths, analyses the underlying medical, social and systemic factors and finally uses this evidence to generate community and programme action.

"MAPDIER is much more than only the process of counting maternal deaths, so it starts from counting but goes on from investigating and then sharing it with the community and health systems and taking actions. The process has been simple. The front line workers and key informants inform about any maternal death in their area; the death gets investigated not only for the medical reasons but also the social circumstances. This information is analyzed and fed back to the communities and to the health systems and subsequently action is taken upon them by the communities or by the system" – Dr. Pavitra Mohan, Health Specialist, UNICEF, India

Context

MAPEDIR’s genesis lies in UNICEF’s Maternal Mortality Reduction Advocacy Project, supported by the United Kingdom’s Department for International Development (DFID). The MAPEDIR initiative underscores the need for information about the underlying causes of maternal deaths in remote and inaccessible villages. It grew out of UNICEF’s decision to support maternal death inquiry as a component of the ongoing second phase of the Reproductive and Child Health Programme (RCH II) and the National Rural Health Mission (NRHM). It emphasizes increasing the demand for quality healthcare and greater community participation in the planning of public health interventions. Piloted in Purulia, one of the poorest and most backward districts of West Bengal in June 2005, MAPEDIR was implemented in 16 districts in six Indian states with high maternal mortality. These are: West Bengal (Purulia); Rajasthan (Dholpur, Tonk, Udaipur); Jharkhand (Ranchi); Madhya Pradesh (Guna, Shivpuri); Orissa (Nuapada, Koraput, Kalahandi, Bolangir, Sonepur, Malkangiri, Nabarangpur, Rayagada); and Bihar (Vaishali).

The objectives of MAPEDIR are manifold:

Sensitizing communities to maternal and perinatal health issues, including the need for birth preparedness and complication readiness;

Inquiring into maternal and perinatal deaths by identifying recent maternal deaths and conducting community-based inquiries with close acquaintances of the women so as to find ways by which future deaths might be prevented;

Sharing the findings of the death inquiries with communities and helping them interpret the data to develop appropriate interventions, as also advocate for improvements in healthcare to tackle identified problems; and

Using the findings of the inquiries to advocate with policy makers for necessary improvements in healthcare systems.

The primary scope of MAPEDIR as conceptualized was to examine all maternal and perinatal deaths (i.e. intrauterine deaths from 24 weeks gestation) and each live birth resulting in a neonatal death (up to 28 days of life). In the first stage, only maternal deaths were covered. It was thought that investigation of perinatal deaths might be introduced at a later stage.  Secondly, it was originally a scientific investigation tool meant for research. UNICEF adapted it for transforming it also into a tool for action.

What is MAPEDIR?

MAPEDIR is a tool that systematically investigates maternal deaths. It underscores the logic that it is important to stimulate community participation in probing why women die during pregnancy and/or delivery in order to develop feasible solutions. The entire process includes identifying and investigating maternal deaths, sensitizing the community, spurring communities and health systems into action, and monitoring and adjusting interventions through continuing inquiries.

The tool is a structured verbal autopsy questionnaire used to interview relatives and/or those who were close to the deceased women. The findings can be aggregated and inferences drawn, corrective action can be taken at the block, district, state and national level. Such inquiries support evidence based decision making.

The inquiry involves ascertaining the personal, familial, social and community factors that led to the mortality without blaming anyone. Interviews at the household level conducted under the MAPEDIR project in selected districts in India identify the immediate, intermediate and underlying causes of maternal deaths. Typically, medical records capture only the immediate, biological causes of maternal deaths. The personal, familial, socio-cultural, economic and environmental factors contributing to these deaths are left out. MAPEDIR seeks to restore and record these missing links. It provides a confidential, non- threatening environment for the respondent to furnish all the details giving a clearer picture of the sequence of events. The findings of the structured questionnaire (translated into the local language), enquiring minutely into the circumstances of the maternal death, are then widely shared with communities and with local health authorities. The new knowledge stemming from the scrutiny of maternal deaths in rural areas bridges a crucial gap.

Sensitize the community

Engage Health Officials

Identify Maternal Deaths – Ways to improve death reporting

Investigate the death with verbal autopsy interviews

Analyze and interpret data

Share the data and the findings with the community

Develop effective local interventions

Monitor interventions

Qualitative and Quantitative

Biological causes & Social causes

Sensitize community informants

Modify and Develop

NGOs, PRI, VHCs, SHGs

Facilitating environment Non-blaming, non-punitive

Figure 1 - The MAPDIER Process

Overall impact of the model

West Bengal has started implementing Referral Transport Scheme (Nishchay Yan) since October 2010. Salient features of the service in 2011-12:

The service is free for pregnant women and sick newborns

Second referral and drop back facility is being provided

In order to ensure maximum utilization dedicated vehicles have been retained at all BEmOC (having >100 deliveries/year) and CEmOC centres.

Extensive IEC for information dissemination amongst beneficiaries, smooth funds flow, fully functional (24 x7) call centre have also been arranged.The report on "Maternal and Perinatal Death Inquiry and Response – Empowering communities to avert maternal deaths in India" published by UNICEF, India 2008, is about the MAPDIER project in India. It gives examples of positive changes that took place in the health system because of the findings of MAPDIER. The findings have led to a Community Based Obstetric Referral Initiative (Obstetric Helpline) in Rajasthan, a district health system led initiative in Madhya Pradesh and the design and implementation of a referral transport scheme in West Bengal (Refer to box for details). As a result of these initiatives, thousands of women with obstetric complications have been transported to quality healthcare in these states. Many states have decided to broaden the outreach of these initiatives that will, in turn, save the lives of many more pregnant women and new mothers.

In Dholpur, Rajasthan an obstetric helpline implemented in conjunction with a range of interventions to reduce delays in care seeking is a comprehensive effort at preparing mothers and communities for child birth, enabling transportation, ensuring high quality facilities, and follow up. The obstetric helpline has been implemented in one block of Dholpur district of Rajasthan, and subsequently attempted in the entire district through the government machinery. Key strategies adopted include:

Mapping transport facilities,

Instituting a toll free number

Involving an NGO to engage local taxis/transporters and to escort women to the health facility (the Community Health Centre),

Negotiate the services and ensure timely payments of financial entitlements

Community mobilization and ownership of government functionaries

Beginning on a small scale in some districts, MAPEDIR has gained wide acceptance as a viable strategy for preventing maternal deaths by offering much needed data and information. One of the most heartening indicators of its success is community initiated action to ensure safe motherhood. There is greater awareness about the factors leading to maternal deaths as well as the relevance of birth preparedness and complication-readiness. There is also greater willingness to demand service from the healthcare delivery system. This has been a revolutionary step for rural, remote Indian communities that previously had minimal interface with the healthcare system. The referral initiative conceived by village leaders in Purulia is one such example. In Dholpur (Rajasthan), village-level transporters (local taxi drivers) have become part of the movement to reduce maternal deaths. These are but two examples of the dynamic potential and promise of MAPEDIR. At the institutional level, the MAPEDIR process has spawned new strategic partnerships between government agencies, non-governmental organizations (NGOs), academic institutions and the UN system. A collaborative initiative, it has elicited the involvement of several key institutions and groups including the Government of India, State Governments, District Administrations, Panchayati Raj (village-level) institutions, women’s self-help groups, local NGOs, medical faculties of Indian universities, the Johns Hopkins Bloomberg School of Public Health (USA), WHO, the United Nations Population Fund (UNFPA) and UNICEF.

Establishment of the above links are generating greater awareness of existing government facilities and schemes for safe motherhood, such as the conditional cash transfer scheme for below poverty line women, the Janani Suraksha Yojana (JSY) in rural communities. Even in tribal-dominated districts where community structures may be lacking, MAPEDIR is acting as a catalyst and serving as an alert mechanism. Households deprived of education and other basic amenities are beginning to realize that delays at critical junctures can lead to maternal deaths. In many cases, the arrival of MAPEDIR interviewers in a village has sparked a sense of urgency among local authorities to modernize maternal care facilities by using Rogi Kalyan Samiti funds made available by the NRHM. The tool has also underscored the need for better reporting of maternal deaths in states with weak healthcare systems and infrastructure.

Conclusions

In India, as elsewhere, maternal deaths happen due to a combination of inter-related factors. The initiative helped generate awareness in the community and in turn increased reporting of maternal deaths from the community by grass root level functionaries. An understanding of the contributing factors has enabled decision makers and stakeholders to address the obstacles to improving the quality of obstetric care. MAPEDIR also discovers the barriers related to care-seeking for complications that lead to these deaths. It focuses on finding out exactly why mothers die. Despite signs of progress in MAPEDIR pilot districts, hurdles remain. Effective monitoring and supervision are critical tools which must be put in place to ensure the complete success of the initiative. Further, teething problems noticed and which must be addressed, include the reluctance of health workers to report maternal deaths for fear of repercussions, reluctance of families to discuss details of women’s care, and the varying quality of training and supervision of interviewers.

The innovation can address issues that are high on the policy agenda and also priority for beneficiaries. The project is unique in the sense that it is the first death audit of its kind where community involvement is given due recognition and importance.

B. Maternal Death Review (MDR)

Overview

A Maternal Death review provides a rare opportunity for a group of health personnel and community members to learn from a tragic – and often preventable – event. Maternal death reviews should be conducted as learning exercises that do not include finger-pointing or punishment. The purpose of a maternal death review is to improve the quality of safe motherhood programming to prevent future maternal and neonatal morbidity and mortality.

Government is implementing the Maternal Death Review (MDR) in two forms – Facility Based Maternal Death Review (FBMDR) and Community Based Maternal Death Review (CBMDR). FBMDR is a process to investigate and identify causes, mainly clinical and systemic, which lead to maternal deaths in the health facilities; and to take appropriate corrective measures to prevent such deaths. CBMDR is a process in which deceased’s family members, relatives, neighbours or other informants and care providers are interviewed, by means of a technique called Verbal Autopsy, to elicit information on various factors – medical, socio-economic or systemic - which lead to maternal deaths, thereby enabling the health system to take the appropriate corrective measures at various levels.

The MDR, a strategy to improve the quality of obstetric care and reduce maternal mortality and morbidity has been spelt out clearly in the RCH – II National Programme Implementation Plan document. The importance of MDR lies in the fact that it provides detailed information on various factors at facility, district, community, regional and national levels which need to be addressed in order to improve service and thereby reduce maternal deaths. MDR has been conducted as an established intervention for the last few years by some states such as Tamil Nadu, Kerala and West Bengal.

Tamil Nadu Experience and Process [iii] 

Tamil Nadu is the first state in India which has setup a system to register all maternal deaths and developed a maternal death audit [iv] . The state started compulsory audit of all maternal deaths occurring in the state since 1994 and the system became fully established when the Government of Tamil Nadu issued an order in 2004, stating that all maternal deaths should be audited. It mandates that each maternal death be reported to the Maternal and Child Health (MCH) Commissioner within 24 hours of occurrence, irrespective of place of death—public facility or private nursing home or during the time of transit. Maternal deaths are reported by auxiliary nurse midwives, medical officers posted at the periphery, first referral units (FRUs), non-government hospitals, the district public-health nurse, and the Deputy Director of Health Services. Investigations are carried out through community-based maternal review (verbal autopsy) and facility-based maternal death review/clinical audit as described below. The results were encouraging and there was an increase in reporting of maternal deaths from 1994 to 2005. The number of reported maternal deaths increased from 640 in 1995 to 1,600 in 2001, followed by a decline in the number of deaths registered.

Three Delays Model

Phase 1 delay. Delay in decision to seek care

Failure to recognize complications

Acceptance of maternal death

Low status of women

Socio-cultural barriers to seeking care: women’s mobility, ability to command resources, decision making abilities, beliefs and practices surrounding childbirth and delivery, nutrition and education

Phase 2 delay. Delay in reaching care

Poor roads, mountains, islands, rivers – poor organization

Phase 3 delay. Delay in receiving care

Inadequate facilities, supplies, personnel

Poor training and demotivation of personnel

Lack of finances

Community-based maternal reviews (verbal autopsy)

Information on maternal deaths is obtained through telegram/fax/email, and medical officers perform the follow-up investigation within 15 days. This investigation tries to document the specific circumstances that led to the maternal death, including the first and the second delay (see side box for details) in the community. Members of health staff are reassured that the review of death is not a fault-finding exercise to punish individuals but to improve the system of care.

Facility-based review of maternal deaths

The second part of the review of maternal death is carried out in the facility where the woman was treated and/or died. In the facility-based review, the causes, treatment given, and circumstances of deaths are investigated to see whether these deaths could have been avoided. This addresses the third delay and quality of care in a facility.

The findings of these reviews are placed before the Medical Death Audit Committee on a monthly basis. Minutes of the committee meetings are placed before the District Reproductive and Child Health (RCH) Committee chaired by the District Collector, who also receives relatives of the deceased to give their account of the events. Minutes of the review meetings are sent to the MCH Commissioner.

Review of Findings by District Magistrate (DM) - The relatives of the deceased first narrate the events leading to the death of the mother in front of the DM and the service providers who attended the deceased mother. The case histories of each of the selected maternal deaths are heard separately. After the deposition and providing clarifications, the relatives leave. Thereafter the various delays, decision making at the family level, obtaining transport and institutional delays are discussed in detail. The outcome of the meeting is recorded as minutes and corrective actions are listed with a time line to prevent similar delays in future.

Positive outcomes of the maternal death verbal autopsy system include greater accountability of service providers, advance information to referral centres, better coordination between referring and referral institutions, and a very few unrecorded referrals. Reviews of maternal deaths have indicated several problems in the healthcare-delivery system which may lead to maternal mortality. Examples include improper distribution of FRUs in the state, shortage of staff at the FRUs, and unnecessary multiple referrals.

MATERNAL DEATH

Place of death - Community

Place of Death – Health Facility

Reporting – By ANM/ AWW/ ASHA to MO

Verification process by ANM/LHVs

Investigation – Within 24 hours – MO on duty in consultation with facility nodal officer

Reporting – By MO to Institution head

Investigation – Within 15 days – MO/LHV/ANM etc (3 member team)

Review of Findings by

District Maternal Death Review Committee

Review of Findings by District Magistrate (DM)

(Reports are prepared and placed before the district collector)

DM invites relatives of deceased women for further investigation of social and governance factors

Figure 2: Maternal Death Review Process [v] 

Impact on the Health System of Tamil Nadu

Based on the reviews of maternal deaths and other evidence on how to reduce the MMR, the Government of Tamil Nadu has initiated various programmatic improvements as summarized below:

Enhancement of skilled care providers in rural areas

Attracting doctors and staff nurses to work in rural areas

Increasing availability of specialists at FRUs

Establishment of comprehensive emergency obstetric and newborn care centres with round-the-clock emergency obstetric and newborn services

Special programme for conditional cash transfer to pregnant women

Increasing availability of blood

Birth-companion programme to improve social support during delivery

Maternity picnic

Contracting private anaesthetist, obstetrician and gynaecologist for emergency C-section

Contracting with private partners for ambulances

Certification of comprehensive emergency obstetric care centres for making the facility accountable for EmOC functions

MDR has been rolled out across the country. Trainings are being given to the care givers and the teams involved at various levels. A pilot was done in the state of UP to get some insights into the review process. MDR has the potential to strengthen the health system but this can only be established once the data starts coming in.

Box 1: Community-based maternal death audit (MDA) in one district of Uttar Pradesh

Maternal death audits (MDA), have been shown to contribute to the reduction in maternal deaths, by providing insight into why women die. MDAs have been carried out in the states of Kerala and Tamil Nadu, where they have been identified as an important tool used to achieve one of the lowest MMRs in the country. Keeping in view that UP has one of the highest maternal deaths in the country, the Government of Uttar Pradesh (GoUP) is in the process of initiating MDA in the state, based on the Government of India guidelines, to provide an in-depth understanding of processes and causes leading to maternal deaths, including social-cultural, economic factors, and medical causes. The objectives of this study were to identify the operational problems in conducting maternal death audits at community level and their potential solutions, based on government guidelines and to make recommendations to the government on ways to improve maternal health services at the community and or facility level.

The key findings were the following:

The major direct causes of the reported deaths were: haemorrhage (38.5%), anaemia (26.3%), sepsis (14%), eclampsia (10.5%) and obstructed labour (7%).

Places of maternal death were 16% of the cases in private facilities, 30% in government hospitals, 23% at home and 30% en-route to a formal health facility.

The mean cost of the transport from home to facility 1 was Rs. 254, facility 1 to facility 2 Rs.1042 and facility 2 to facility 3 is Rs. 910

The average cost of the care in facility 1 is Rs. 3044, facility 2 is Rs.10, 319 and facility 3 is Rs. 11,900

The mean travel time between facility 1, facility 2 and facility 3 is 2 hours

Source: Personal communication with Dr. Sunil S. Raj, additional professor Indian Institute of Public Health Delhi

Annexure 1: Evaluating the delaying factors contributing to maternal deaths

WHO describes five main approaches to evaluate the delays:

Community based maternal death reviews conducted at the community level to ascertain common community factors that may have contributed to the maternal deaths, and to act upon the findings;

Definition: A method of finding out the medical causes of death and ascertaining the personal, family or community factors that may have contributed to the death of a woman who died outside of a medical facility.

Requirements: Cooperation from the family of the woman who died. Sensitivity is needed in discussing the circumstances of the death.

Advantages: Provides means to arrive at medical cause of death when a woman dies at home, allows both medical and non-medical factors to be explored, and provides the opportunity to include the family’s perspective on health services.

Disadvantages: Different assessors may arrive at different causes of death; deaths from indirect causes may be overlooked /underreported.

Facility-based maternal death reviews conducted at the facilities by the providers as in-depth investigations of the causes of and circumstances surrounding maternal deaths, with the primary objective of improving the quality of care;

Definition: A qualitative, in-depth investigation of the causes of and circumstances surrounding a maternal death at a health facility; the death is initially identified at the facility level but such reviews are also concerned with identifying the combination of factors at the facility and in the community that contributed to the death, and which ones were avoidable.

Requirements: Cooperation from those who provided care to the woman who died, and their willingness to report accurately on the management of the case.

Advantages: Is a well-understood process in some settings, allows for complete review of medical aspects, provides a learning opportunity for all staff, and can stimulate improvements to medical care.

Disadvantages: Requires committed leadership at the facility level, does not provide information about deaths occurring in the community.

Confidential enquiries [vi] that constitute systematic multi-disciplinary anonymous investigations of maternal deaths within a region or country. These help to identify the numbers, causes and associated remedial factors;

A national or sub-national multidisciplinary committee meets periodically to systematically investigate a representative sample of (or all) maternal deaths to identify the causes and associated factors; the committee then gives written guidelines to health personnel and administrators on how to prevent similar deaths in future. The investigation is carried out in a confidential manner ("No blame, no shame"). It requires a complete and functioning civil registration or health management information system. A sub-national or district-level panel might be more appropriate in countries with high mortality, so that the guidelines issued can be tailored to local situations.

Surveys of near-misses or survivors [vii] of obstetric complications for ensuring improvements in maternal care; and, programmes with the necessary capacity:

Definition: The identification and assessment of cases in which a pregnant woman survives an obstetric complication; there is no universally acceptable definition for such cases and it is important that the definition used be appropriate to local circumstances to enable local improvements in maternal care.

Requirements: Good-quality medical record system, a management culture where life-threatening events can be discussed freely without fear of blame, and a commitment from management and clinical staff to act upon findings.

Advantages: A "near-miss" may occur more frequently than a maternal death, it is possible to interview the woman herself during the review process, and can reduce the likelihood of future maternal deaths through quality improvement.

Disadvantages: Requires clear definition of severe maternal morbidity, selection criteria are required for settings with a high volume of life-threatening events.

Clinical audit, a quality improvement process that seeks to improve patient care and outcomes through a systematic review of various aspects of the structure, processes and outcomes of care against explicit criteria and ensures the subsequent implementation of change.

The process entails a systematic review or audit of the obstetric care provided to pregnant women against established protocols or criteria, aimed at improving the quality of care. Protocols for the management of obstetric complications will have to be established beforehand in order to ascertain whether cases are being properly managed at health facilities. If properly implemented, it leads to standardized and improved care across health facilities.

Different approaches have been used across the world, including India, to evaluate the delays in both community and facility settings. Experience in the use of these approaches has shown that successful implementation can take place at all levels. A commitment to act upon these findings is a key prerequisite for success.