Maternal death audit in Rwanda 2009–2013: a nationwide facility-based retrospective cohort study

Abstract

ObjectivePresenting the results of 5 years of implementing health facility-based maternal death audits in Rwanda, showing maternal death classification, identification of substandard (care) factors that have contributed to death, and conclusive recommendations for quality improvements in maternal and obstetric care.DesignNationwide facility-based retrospective cohort study.SettingsAll cases of maternal death audited by district hospital-based audit teams between January 2009 and December 2013 were reviewed. Maternal deaths that were not subjected to a local audit are not part of the cohort.Population987 audited cases of maternal death.Main outcome measuresCharacteristics of deceased women, timing of onset of complications, place of death, parity, gravida, antenatal clinic attendance, reported cause of death, service factors and individual factors identified by committees as having contributed to death, and recommendations made by audit teams.Results987 cases were audited, representing 93.1% of all maternal deaths reported through the national health management information system over the 5-year period. Almost 3 quarters of the deaths (71.6%) occurred at district hospitals. In 44.9% of these cases, death occurred in the post-partum period. Seventy per cent were due to direct causes, with post-partum haemorrhage as the leading cause (22.7%), followed by obstructed labour (12.3%). Indirect causes accounted for 25.7% of maternal deaths, with malaria as the leading cause (7.5%). Health system failures were identified as the main responsible factor for the majority of cases (61.0%); in 30.3% of the cases, the main factor was patient or community related.ConclusionsThe facility-based maternal death audit approach has helped hospital teams to identify direct and indirect causes of death, and their contributing factors, and to make recommendations for actions that would reduce the risk of reoccurrence. Rwanda can complement maternal death audits with other strategies, in particular confidential enquiries and near-miss audits, so as to inform corrective measures.

Understanding variation in maternal health service coverage and maternal health outcomes among districts in Rwanda

“…Neither did the study try to assess whether health workers had the right technical background to provide quality maternal health services. It is worth noting though, that Rwanda does have a mechanism in place to conduct maternal death audits, and the country is currently in the process of institutionalizing ‘near-miss’ audits and confidential enquiries into maternal deaths [20]. Some studies recently reported rather high rates of postpartum haemorrhage and infection, as causes of maternal near miss and death [21,22].…”

Strengthening data availability for community health programming - A review of current practices

“…Viable integrated community health platforms rely on a key function of local learning and adaption which implies availability of the data at the local level for decision making. In a review conducted by Ibe et al (4) on CHWs documents from 22 countries, it was shown that although policy and related documents provide guidance for all CHWs cadres to track data from home visits, case management and other services, document life events, manage commodities and/or monitor outbreaks in all the 22 countries, very few specific guidance on data use at the community level and how to involve the community in data analysis or decision making -16 out of 22 countries,72% - (33).…”

“…Quality data are indispensable for filling knowledge gaps, but also for determining the needs for additional information necessary for action. Scott et al (33) have defined community health worker as a person with the following characteristics i) has a supportive function in health service delivery, including provision of direct health services, health advocacy, and community agency ii) is directly connected to the communities the CHW serves, living in the community and accountable to the people there iii) has a lower level of education than trained health workers such as doctors and nurses. Health information collected at the household and community levels by community health workers (CHWs) are necessary for demonstrating efficacy, success, potential for replication and scale up (33).…”

Improving Maternal Health in Rwanda: The Role of Community-Based Interventions: A Systematic Review (2005-2015)

“…Those reforms included namely decentralization of health services and community participation, improved financial access to health care through a 'Community-Based Health Insurance' scheme; health systems strengthening approach. In this context, community health workers played a critical role in linking up individuals, families and communities to the health facilities and in providing relevant support for health promotion, maternal health service delivery and referral system, family planning, HIV prevention as well as data collection for health system management [19][20][21].…”