Maternal and perinatal death surveillance and response in Ethiopia: Achievements, challenges and prospects

Abstract

BackgroundMaternal and Perinatal Death Surveillance and Response (MPDSR) was a pilot program introduced in Tigray, Ethiopia to monitor maternal and perinatal death. However; its implementation and operation is not evaluated yet. Therefore, this study aimed to assess the implementation and operational status and determinants of MPDSR using a programmatic data and stakeholders involved in the program.MethodsInstitutional based cross-sectional study was applied in public health facilities (75 health posts, 50 health centers and 16 hospitals) using both qualitative and quantitative methods. Data were entered in to Epi-info and then transferred to SPSS version 21 for analysis. All variables with a p-value of ≤ 0.25 in the bivariate analysis were included in to multivariable logistic regression model to identify the independent predictors. For the qualitative part, manual thematic content analysis was done following data familiarization (reading and re-reading of the transcripts).ResultsIn this study, only 34 (45.3%) of health posts were practicing early identification and notification of maternal/perinatal death. Furthermore, only 36 (54.5%) and 35(53%) of health facilities were practiced good quality of death review and took proper action respectively following maternal/perinatal deaths. Availability of three to four number of Health Extension Workers (HEWs) (Adjusted Odds Ratio (AOR) = 6.09, 95%CI (Confidence Interval): 1.51–24.49), availability of timely Public Health Emergency Management (PHEM) reports (AOR = 4.39, 95%CI: 1.08–17.80) and participation of steering committee’s in death response (AOR = 9.19, 95%CI: 1.31–64.34) were the predictors of early identification and notification of maternal and perinatal death among health posts. Availability of trained nurse (AOR = 3.75, 95%CI: 1.08–12.99) and health facility’s head work experience (AOR = 3.70, 95%CI: 1.04–13.22) were also the predictors of quality of death review among health facilities. Furthermore; availability of at least one cluster review meeting (AOR = 4.87, 95%CI: 1.30–18.26) and uninterrupted pregnant mothers registration (AOR = 6.85, 95%CI: 1.22–38.54) were associated with proper response implementation to maternal and perinatal death. Qualitative findings highlighted that perinatal death report was so neglected. Community participation and intersectoral collaboration were among the facilitators for MPDSR implementation while limited human work force capacity and lack of maternity waiting homes were identified as some of the challenges for proper response implementation.ConclusionThis study showed that the magnitude of: early death identification and notification, review and response implementation were low. Strengthening active surveillance with active community participation alongside with strengthening capacity building and recruitment of additional HEWs with special focus to improve the quality of health service could enhance the implementation of MPDSR in the region.

Beyond No Blame: Practical Challenges of Conducting Maternal and Perinatal Death Reviews in Eastern Ethiopia

“…In a study from facilities in Northern Ethiopia, only slightly more than half of the facilities were practicing good quality death reviews and took proper action for identified problems. 15 The Ethiopian MDSR, although reported as a success by some 21 is characterized by low coverage (captured 7.4% of expected maternal deaths), low review (reviewed 8% of identified deaths), and low staff participation. 20 Often, factors contributing to bad outcomes (deaths or delays) are stated to be the result of factors outside the control of local health workers and policy makers.…”

“…20 Often, factors contributing to bad outcomes (deaths or delays) are stated to be the result of factors outside the control of local health workers and policy makers. 8,15 In a recent qualitative study of MDSR implementation in Ethiopia, Melberg et al showed that highly politicizing maternal deaths, as indicated by the common slogan of "no mother should die while giving birth" everywhere hinders the identification, reporting, review, or assignment of causes to maternal deaths. Health workers and officers leading MDSRs are under so much pressure to meet the political requirement of zero maternal deaths that there is a strong incentive to substantially underreport.…”

“…23 But, the existing practice seems to focus on the delays in deciding to seek care (delay 1) and delays in reaching care (delay 2), which are partly out of the control of reviewing health staff and facility and sometimes totally outside the realm of the health system. 15 Previous reviews indicated that focusing on delay 1 and Successfully institutionalizing the MDSR requires having strong political commitment, adequate financial support, adequate legal framework, and a "no shame, no blame" culture.…”

“…14 However, one of the challenges in the current MDSR implementation is its weak support at the lower-level facilities where the review process and identification of response are identified and implemented. 15 Lower-level facilities were found to receive little support, and many review processes were directed toward avoiding conflicts through deflecting responsibility for adverse outcomes to factors out of control 8 -thereby affecting both the conclusion and the actions to be taken to avoid similar deaths in the future.…”

Evaluation of Maternal Death Surveillance and Response System in Dewachefa Woreda, Oromia Zone, Amhara Region, Ethiopia, 2018

“…MDSR makes each maternal death a notifiable event, and con rms that communities and facilities report and respond to end preventable maternal deaths (19). Despite the importance of MDSR in producing up to date information for decision making, evidence on the process and implementation is lacking (20).…”