Rajshree Dayanand Katke
Department of Obstetrics and Gynecology, Grant Government Medical College, Byculla, Mumbai-400008, India
For Article Link
https://www.researchgate.net/publication/272420630
Maternal death is defined as the death of a woman who dies from any cause related to or aggravated by pregnancy or its management (excluding accidental or incidental causes) during pregnancy or child birth or within 42 days of termination of pregnancy, irrespective of duration and site of the pregnancy.
Maternal Mortality Ratio (MMR) is the number of women who die from any cause related to or aggravated by pregnancy or its management (excluding accidental or incidental causes) during pregnancy and childbirth or within 42 days of termination of pregnancy, irrespective of the duration and site of the pregnancy, per 1,00,000 live births.
• Maternal Mortality Ratio (MMR) in India has shown an appreciable decline from 398/100,000
live births in the year 1997–98 to 254/100,000 live births in the year 2004–06 as per the latest
RGI-SRS survey report, released in April 2009. However, to accelerate the pace of decline of
MMR in order to achieve the NRHM and MDG Goal of less than 100 per 100,000 live births
by 2015, there is a need to give impetus to implementation of the technical strategies and
interventions for maternal health.
• Kerala and Tamil Nadu have achieved the NRHM goal, while Maharashtra is close.
• Andhra Pradesh, West Bengal, Gujarat and Haryana are within striking distance.
• EAG states and Assam would need to further intensify efforts.
Maternal Death Review (MDR) as a strategy has been spelt out clearly in the RCH-II National Programme Implementation Plan document.
Five approaches to help understand why women die:
• Maternal deaths in the community (CBMDR)
• Maternal deaths in facilities (FBMDR)
• Confidential enquiries into maternal deaths
• Learning from women who survived: “Near miss” cases
• Evidence-based clinical audit
ANM cross checks and submits final report to SMO BLOCK PHC by 10th of following month.
SMO BLOCK PHC deputes the designated investigation team for investigation as per Annexure 2
to be completed within 3 weeks of death
Sends report in Annexure 3 to Civil Surgeon within 4 weeks of death.
SMO BLOCK PHC maintains CBMDR Register as per Annexure 5.
Department of Obstetrics and Gynecology, Grant Government Medical College, Byculla, Mumbai-400008, India
For Article Link
https://www.researchgate.net/publication/272420630
Maternal Death Review
India contributes one-fifth of the global burden of absolute maternal deaths; however, it has experienced an estimated 4.7% annual decline in maternal mortality ratio (MMR) and 3.5% annual increase in skilled birth attendance since 1990. While not on track to meet Millennium Development Goal 5, India is making progress in reducing maternal mortality.
Within India, there is marked variation in MMR and health care access between regions and in socioeconomic factors.
Within India, there is marked variation in MMR and health care access between regions and in socioeconomic factors.
Maternal death is defined as the death of a woman who dies from any cause related to or aggravated by pregnancy or its management (excluding accidental or incidental causes) during pregnancy or child birth or within 42 days of termination of pregnancy, irrespective of duration and site of the pregnancy.
Maternal Mortality Ratio (MMR) is the number of women who die from any cause related to or aggravated by pregnancy or its management (excluding accidental or incidental causes) during pregnancy and childbirth or within 42 days of termination of pregnancy, irrespective of the duration and site of the pregnancy, per 1,00,000 live births.
• Maternal Mortality Ratio (MMR) in India has shown an appreciable decline from 398/100,000
live births in the year 1997–98 to 254/100,000 live births in the year 2004–06 as per the latest
RGI-SRS survey report, released in April 2009. However, to accelerate the pace of decline of
MMR in order to achieve the NRHM and MDG Goal of less than 100 per 100,000 live births
by 2015, there is a need to give impetus to implementation of the technical strategies and
interventions for maternal health.
• Kerala and Tamil Nadu have achieved the NRHM goal, while Maharashtra is close.
• Andhra Pradesh, West Bengal, Gujarat and Haryana are within striking distance.
• EAG states and Assam would need to further intensify efforts.
Maternal Death Review (MDR) as a strategy has been spelt out clearly in the RCH-II National Programme Implementation Plan document.
It is an important strategy:
• To improve the quality of obstetric care and reduce maternal mortality and morbidity
• To generate evidence for determining interventions, to fill the gaps in service.
• To improve the quality of obstetric care and reduce maternal mortality and morbidity
• To generate evidence for determining interventions, to fill the gaps in service.
To provide the data needed to feed into the national civil registration system for the
computing of MMR.
• A commitment to Act upon the findings. Not for punitive action Avoiding maternal death is possible even in resource-limited countries, but the correct information on which to base maternal health programmes is required. Maternal death review is one of the oldest and the most documented.
computing of MMR.
• A commitment to Act upon the findings. Not for punitive action Avoiding maternal death is possible even in resource-limited countries, but the correct information on which to base maternal health programmes is required. Maternal death review is one of the oldest and the most documented.
Five approaches to help understand why women die:
• Maternal deaths in the community (CBMDR)
• Maternal deaths in facilities (FBMDR)
• Confidential enquiries into maternal deaths
• Learning from women who survived: “Near miss” cases
• Evidence-based clinical audit
The Maternal Death Surveillance Cycle Key
Key Steps in MDR Implementation
• Implementation of MDR has to be supported by a State Government order
• Notification of Maternal Deaths
• Facility based Review and Community based Review
• All health functionaries have a role in MDR
• District Collector (DC) to be involved in MDR with the relatives of the deceased and service
providers
• Implementation of MDR has to be supported by a State Government order
• Notification of Maternal Deaths
• Facility based Review and Community based Review
• All health functionaries have a role in MDR
• District Collector (DC) to be involved in MDR with the relatives of the deceased and service
providers
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, through a technique called Verbal Autopsy, to elicit information for the purpose of identification of various factors—whether medical, socioeconomic or systemic, which lead to maternal deaths; and thereby enabling the health system to take appropriate corrective measures at various levels to prevent such deaths.
Committee will meet and review the following
a. Circumstances under which the death took place
b. Cause of maternal death: Direct obstetric, indirect obstetric and non-obstetric cause.
c. What steps are required to prevent such deaths in future:
i. Action related to infrastructural strengthening
ii. Action required to augment human resource availability
iii. Action required to strengthen protocols and competence of staff
iv. Supplies and equipment
v. Demand-side interventions to address first and second delays
vi. Management interventions
vii. Other interventions based on the findings of MDR
a. Circumstances under which the death took place
b. Cause of maternal death: Direct obstetric, indirect obstetric and non-obstetric cause.
c. What steps are required to prevent such deaths in future:
i. Action related to infrastructural strengthening
ii. Action required to augment human resource availability
iii. Action required to strengthen protocols and competence of staff
iv. Supplies and equipment
v. Demand-side interventions to address first and second delays
vi. Management interventions
vii. Other interventions based on the findings of MDR
ORIENTATION TRAININGS
For implementing interventions on MDR, one day orientation trainings undertaken.
Power-point presentations on the background: Maternal mortality—causes, current status, rationale of MDR, process of FBMDR, roles and responsibilities, data flow and analysis, monitoring and supervision, review process.
Question by question training on filling up of the formats with help of the reference manuals; interpreting the filled up questionnaire to develop the case summaries. Time lines and incentives given.
List of registers to be maintained at various levels
List of registers to be maintained at various levels
MDR FORMATS
Annexure 1: Facility Based Maternal Death Review Form
Annexure 2: Verbal Autopsy Questionnaire
Annexure 3: MDR Case Summary
Annexure 4: MDR Line Listing Form for All Cases of Maternal Deaths
Annexure 5: Block Level MDR Register for All Women’s Death (15–49 years)
Annexure 6: Format for Primary Informer
The questionnaire has 3 modules that should be filled up according to the type of death,however module 1 must be filled for all.
Annexure 1: Facility Based Maternal Death Review Form
Annexure 2: Verbal Autopsy Questionnaire
Annexure 3: MDR Case Summary
Annexure 4: MDR Line Listing Form for All Cases of Maternal Deaths
Annexure 5: Block Level MDR Register for All Women’s Death (15–49 years)
Annexure 6: Format for Primary Informer
The questionnaire has 3 modules that should be filled up according to the type of death,however module 1 must be filled for all.
Module I
Should be used for collection of general information for all maternal deaths irrespective of whether deaths occurred during antenatal or intranatal or postnatal period or due to abortion.
Module II
Should be used for the deaths occurring during the antenatal period including abortion.
Module III
Should be used for the deaths occurring during delivery or postnatal period.
Should be used for collection of general information for all maternal deaths irrespective of whether deaths occurred during antenatal or intranatal or postnatal period or due to abortion.
Module II
Should be used for the deaths occurring during the antenatal period including abortion.
Module III
Should be used for the deaths occurring during delivery or postnatal period.
FBMDR
Information
Maternal Death reported as follows:
Medical Officer on duty telephonically
Information
Maternal Death reported as follows:
Medical Officer on duty telephonically
|
| Telephonic-ally
Facility Nodal Officer
Facility Nodal Officer
|
| Through Annexure 6
Civil Surgeon, District Comissioner, District Nodal Officer
Civil Surgeon, District Comissioner, District Nodal Officer
Investigation
Completion of Facility Based MDR Form (Annexure 1) in duplicate for every maternal death within 24 hours of its occurrence by the MO on duty in consultation with Facility Nodal Officer and signed by both.
Completion of Facility Based MDR Form (Annexure 1) in duplicate for every maternal death within 24 hours of its occurrence by the MO on duty in consultation with Facility Nodal Officer and signed by both.
|
Monthly review meeting of the Facility MDR Committee on a prefixed date of the following month to review all the maternal deaths occurred in the facility during the month and implementation of the suggested corrective measures. Every maternal death occurring in the facility is given a yearly serial number.
|
Review and Corrective actions taken are reported to Civil Surgeon as “CONFIDENTIAL”
Community Based MDR
Information
ASHA/AWW
Annexure 6 |
ANM
Annexure 6 |
BLOCK Medical Officer PHC
|
Civil Surgeon, District Comissioner, District Nodal Officer
Line listing of all deaths of women of age 15–49 yrs.
ASHA/AWW line lists as per Annexure 4 and submits to ANM by 5th of following month.
ASHA/AWW line lists as per Annexure 4 and submits to ANM by 5th of following month.
ANM cross checks and submits final report to SMO BLOCK PHC by 10th of following month.
SMO BLOCK PHC deputes the designated investigation team for investigation as per Annexure 2
to be completed within 3 weeks of death
Sends report in Annexure 3 to Civil Surgeon within 4 weeks of death.
SMO BLOCK PHC maintains CBMDR Register as per Annexure 5.
(FBMDR + CBMDR)
Monthly review meeting of the District MDR Committee chaired by Civil Surgeon and convened by District Nodal Officer every month on a prefixed date.
Monthly review meeting chaired by D.C., convened by the Civil Surgeon and assisted by the District Nodal Officer (2 relatives of the deceased to attend).
Monthly review meeting of the District MDR Committee chaired by Civil Surgeon and convened by District Nodal Officer every month on a prefixed date.
Monthly review meeting chaired by D.C., convened by the Civil Surgeon and assisted by the District Nodal Officer (2 relatives of the deceased to attend).
STATE LEVEL MATERNAL DEATH REVIEW BY STATE LEVEL TASK FORCE (SLTF)
Review meeting once in 6 months chaired by PSHFW.
The SLTF will meet once in 6 months under the chairmanship of Principal Secretary Health and Family Welfare to discuss the actions taken on the minutes of the last meeting and make recommendations to Government for policy and strategy formulations.
Every year an annual maternal death report for the State prepared and a dissemination workshop organized to sensitise various service providers and managers. The annual report may contain interesting maternal death case studies which may be used during the training of medical and paramedical functionaries.
A serial record of all confirmed maternal death reports received from all districts during the calendar year kept in the Maternal Death Record Register to be maintained in the office of the Director Family Welfare asper the format at Annexure 6A and will be linked with the reporting in the HMIS.
The SLTF will meet once in 6 months under the chairmanship of Principal Secretary Health and Family Welfare to discuss the actions taken on the minutes of the last meeting and make recommendations to Government for policy and strategy formulations.
Every year an annual maternal death report for the State prepared and a dissemination workshop organized to sensitise various service providers and managers. The annual report may contain interesting maternal death case studies which may be used during the training of medical and paramedical functionaries.
A serial record of all confirmed maternal death reports received from all districts during the calendar year kept in the Maternal Death Record Register to be maintained in the office of the Director Family Welfare asper the format at Annexure 6A and will be linked with the reporting in the HMIS.
Current Challenges and Issues in Implementation of MDR Process
• Under-reporting (only 17.6% of total expected deaths reported).
• Quality of maternal death reviews at district/facility level Focus on high case load facilities in high mortality district—need to prioritize on constitution of FBMDR Committees at High Case Load “Delivery Points”
• Capacity building of health care providers and community health workers
• Under-reporting (only 17.6% of total expected deaths reported).
• Quality of maternal death reviews at district/facility level Focus on high case load facilities in high mortality district—need to prioritize on constitution of FBMDR Committees at High Case Load “Delivery Points”
• Capacity building of health care providers and community health workers
Looking Forward to
• Complete reporting through web-based Central Health Management Information System sustainability
• MDR software to be linked with MCTS—in process of development
• Sharing analysed data on maternal deaths is a good way to raise awareness about the issue with the local communities and improve birth preparedness.
• Complete reporting through web-based Central Health Management Information System sustainability
• MDR software to be linked with MCTS—in process of development
• Sharing analysed data on maternal deaths is a good way to raise awareness about the issue with the local communities and improve birth preparedness.
BIBLIOGRAPHY
1. Maternal Death Review Guidebook Maternal Health Division Ministry of Health and Family Welfare
1. Maternal Death Review Guidebook Maternal Health Division Ministry of Health and Family Welfare
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