Impact of maternal death reviews at a rural hospital in Zambia: a mixed methods study

Abstract

Background: Maternal mortality in sub-Saharan Africa remains high despite programmatic efforts to improve maternal health. In 2007, the Zambian Ministry of Health mandated facility-based maternal death review (MDR) programs in line with World Health Organization recommendations. We assessed the impact of an MDR program at a district-level hospital in rural Zambia. Methods: We conducted a mixed methods convergent study using hospital data on maternal mortality and audit reports of 106 maternal deaths from 2007 to 2011. To evaluate the overall impact of MDR on maternal mortality, we compared baseline (2007) to late (2010-11) post-intervention inpatient maternal mortality indicators. MDR committee reports were coded and dominant themes were extracted in a qualitative analysis. We assessed potential risk factors for maternal mortality in a before-and-after design comparing the periods 2008-09 and 2010-11. Results: In-hospital maternal mortality declined from 23 per thousand live births in 2007 to 8 per thousand in 2010-11 (P < 0.01). Maternal case fatality for puerperal sepsis and uterine rupture decreased significantly from 63 and 32% in 2007 to 10 and 9% in 2010-11 (P < 0.01). No significant reduction was seen in case fatality due to postpartum hemorrhage. Qualitative analysis of risk factors for maternal mortality revealed four core themes: standards of practice, health systems, accessibility, and patient factors. Specific risk factors included delayed referral, missed diagnoses, intrahospital delays in care, low medication inventory, and medical error. We found no statistically significant differences in the prevalence of risk factors between the before-and-after periods. Conclusions: Implementation of MDR was accompanied by a significant decrease in maternal mortality with reductions in maternal death from puerperal sepsis and uterine rupture, but not postpartum hemorrhage. Qualitative analysis of audit reports identified several modifiable risk factors within four core areas. Comparisons of potential explanatory factors did not show any differences over time. These results imply that MDR offers a means for hospitals to curtail maternal deaths, except deaths due to postpartum hemorrhage, suggesting additional interventions are needed. Documentation of MDR meetings provides an instrument to guide further quality improvements.

Reducing maternal and neonatal mortality through integrated and sustainability-focused programming in Zambia

“…While this pre-post evaluation approach without comparison group has some limitations, it has been considered justifiable for projects using best practice interventions that have been previously proven to work under similar conditions [11,31]. Finally, the community surveillance approach used for population mortality data was established to be beneficial not only for purposes of program evaluation but as a sustainable solution for capturing community mortality data, strengthening the ability of the government to carry out MPDSR reviews for all community and facility deaths, and increasing levels of community buy-in and stakeholder support, which can in turn facilitate further reductions in mortality [17,32]. While our approach cannot completely isolate the impact of this program from generalized ecological trends, there were no major partner-supported reproductive health programs taking place in Northern Province at the time of this work, which supports impact attribution for this program.…”

Operational demonstration and process evaluation of non-pneumatic anti-shock garment (NASG) introduction to the public health system of Northern Province, Zambia

“…In 2018, it was estimated that Zambia’s maternal mortality ratio (MMR) was 282 per 100,000, and the majority of the maternal deaths were directly caused by OH [ 2 , 3 ]. A recent evaluation of maternal death reviews (MDRs) at a rural hospital in Zambia found that maternal deaths from all causes decreased over the course of five years, with the exception of deaths from postpartum hemorrhage, a key type of OH [ 4 ]. Case reviews showed that issues of accessibility, such as poor road conditions, as well as issues related to the health system, such as delayed referrals, as well as lack of stabilizing measures before referral are major contributors to this persistent problem.…”

Socioeconomic Determinants of Maternal HealthCare Utilisation in Zambia: 1997-2014

“…In 2007, the Zambian Ministry of Health implemented a new WHO-recommended roadmap for reproductive health including the maternal death review (MDR) system in line with World Health Organization recommendations which was able to reduce maternal mortality rates to a great extent in the country. 9 Another mention-worthy example of private-private partnership the Saving Mothers, Giving Life (SMGL) program that is target to reduce maternal mortality through a systems approach and healthcare capacity building. 4 …”

“…7,8 A large number of studies have highlighted the importance of socioeconomic factors in maternal health and healthcare service utilization related outcomes. 4,[8][9][10] Although healthcare seeking as a behavior is considered to be driven to a great extent by perceived need of care and health literacy, the critical role one's financial capacity to medical services cannot be overestimated especially in the low-income countries like Zambia where there is not universal healthcare system to safeguard the health needs of the disadvantaged communities. This growing popularity of social cash transfer programs to promote maternal health provides a strong evidence on the role of socioeconomic determinants as well.…”

“…In 2007, the Zambian Ministry of Health implemented a new WHO-recommended roadmap for reproductive health including the maternal death review (MDR) system in line with World Health Organization recommendations which was able to reduce maternal mortality rates to a great extent in the country. 9 Another mention-worthy example of private-private partnership the Saving Mothers, Giving Life (SMGL) program that is target to reduce maternal mortality through a systems approach and healthcare capacity building. 4 The causes of low maternal healthcare services uptake are numerous and multifaceted, and broadly classified into behavioral, cultural, economic, and sociodemographic factors at individual level and remoteness of health facility, inadequate infrastructure and skilled human resource for healthcare at community level.…”