MDRs: why we need a supportive legislation

The purpose of this policy briefing is to provide information on the importance of adopting a supportive legislative and policy framework for the effective implementation of maternal death reviews (MDRs) in Sierra Leone.
Maternal Death Review Policy BriefThe purpose of this policy briefing is to provide information on the importance of adopting a supportive legislative and policy framework for the effective implementation of maternal death reviews (MDRs) in Sierra Leone. The issue
  • Maternal mortality ratio for Sierra leone is 1,100 per 100,000 live births (WHO 2014), newborn mortality ratio is 39 per 1,000 live births (SLDHS 2013) amd under-five mortaliy rate is 142 per 1,000 live births (UNICEF 2013), on of teh highest in the world thus the Government has responded by makig maternal and child ealth a priority.
  • In April 2010, the Ministry of Health with support from partners implemented the Free Health Care Initiative targeting pregnant women, lactating mothers and children under five years old with free health service delivery since cost was identified as one of the major barrier to accessing health care. 
  • Though access to care has improved since the initiative began, the current challenge is the quality of care.
  • To improve on the quality of care, the Ministry of Health has rolled out a maternal death review programme [1].
  • MDR is a recognized effective approach to improving quality and accountability in maternal health care. It consists of aqualitative, in-depth investigation of the causes of and circumstances surrounding a maternal death at a health facility or in the community, in order to identify the combination of factors that contributed to the death, and which ones were avoidable.
  • The process of introducing MDR systematically into all African countries started in 2003 led by WHO, UNFPA, and UNICEF in collaboration with development partners and professional bodies.
  • In Sierra Leone, MDRs are at an early stage, and they are not supported by any legislative or policy framework. Having a supportive legislative and policy framework is important in ensuring that MDRs are recognised as mandatory, and are perceived as tools for quality improvement rather than a statutory regulation for punitive functions. Adopting a blame-free approach to the MDR process will be key to a meaningful review process that encourages personnel working within the health system to make necessary changes to improve quality of care
The rationale for maternal death reviewsMDRs are a key element of any strategy aimed at improving access to and the quality of maternal health services. By demonstrating “magnitude, trends, patterns and differentials” in maternal mortality, MDRs help prioritize, plan, implement, monitor and evaluate policy and programmes to reduce maternal deaths.[2]It is important that findings emerging from the MDR are acted upon to help improve access to and quality of care and not merely seen as a data collection tool.  Additionally, adopting a system-wide approach, identifying deficiencies in the demand and supply-side of the health system that can be addressed is important (e.g. related to need for training, equipment, staffing levels, referrals, etc.). This approach supports a blame-free approach for personnel and communities, and engenders a culture of mutual accountability  at all levels – from households through to national policy-makers.According to the 2011 MDR report:
  • 190, 299 and 224 women were reported dead from 13 major district maternity hospitals in 2009, 2010, 2011 respectively
  • 21% of the women that died in 2011 were teenagers aged 19 years and below
  • The major causes of death were haemorrhage (34%), eclampsia (23%) and sepsis (19%).
This information for which action will be taken would not have been possible if the cases were not reviewed by the hospital teams and analysed with support from the technical lead and the Reproductive Health Division.  But this is just the tip of the iceberg as still more deaths are unaccounted for in facilities and communities. MDRs do more than merely count maternal deaths; “By focusing on the causes of deaths and what could have done to avert each death”, MDRs  provide a learning opportunity and lead to actions to prevent further tragedies  based on the findings,[3] as discussed in the table below.The Benefits of MDRs[4]Improved professional practice: by identifying where the clinical care pathways that a particular patient received was below standard, MDR allows steps to be taken to ensure that this is not repeatedImproved training: where substandard care is identified, appropriate teaching methods, continual medical education, curricula and feedback mechanisms may be introduced or adapted , more appropriate teaching methods, curricula and feedback mechanisms may be introducedMore efficient management of resources: MDR findings help identify, prioritize and advocate for service needs in terms of staffing, equipment, supplies and drugsBetter understanding of community barriers and challenges to the timely uptake of care: by reviewing deaths at home as well as those in health facilities, lessons are learnt on all types of delays in receiving timely and effective life-saving care. The establishment of a legal framework on MDR policy In 1997, South Africa was the first country in sub-Saharan Africa to institutionalize MDRs. Since then, Botswana, Burkina Faso, Ethiopia, Ghana, Kenya, Malawi, Mali, the Republic of the Congo, Rwanda, Senegal, Swaziland, the United Republic of Tanzania and Zambia have adopted policies that include MDRs.However, in nearly all African countries, maternal death reviews are carried out on an ad hoc basis, reporting is often incomplete, and current efforts are not adequately accompanied by political, institutional or legal support (South Africa and Swaziland being the only countries having introduced legal reforms tackling MDR).MDRs need political buy-in and the support of legislation to work well. The lack of a legal framework may result in misconceptions and fears regarding possible punitive measures, and the perception that audits are judgments on the actions of professional medical staff.MDR implementation framework and key legal reformsBased on the experience of South Africa, the following steps can be considered as key to support the broad implementation framework of MDR in Africa: MDR Implementation Framework: Key Elements[5]
  1. Active advocacy group at the national level
  2. Development of policy, guidelines, and tools for conducting MDR
  3. Expansion of coverage from pilot to district and national scale
  4. Enthusiastic government endorsement of MDR[6] and assurances that no punitive action will be taken
  5. Collaboration with professional bodies, civil society, donor agencies
  6. Supporting legislative environment (recognizing reproductive health rights, making maternal death a notifiable event)
  7. Incorporation of MDRs into  routine reproductive and maternal health programmes adopting a blame-free, system wide approach to identifying deficiencies
  8. Training (orientation/introduction, in-service and pre-service) at national, district, and health facility levels
  9. Community involvement in developing program, creating awareness, community participation in MDR implementation                                                                                                                                                          
With regard to legal reforms (#6), two areas of legislation deserve particular attention: Key Legal Reforms
  • Make maternal death a notifiable event: in order to capture all maternal deaths nationally, notification of all maternal deaths to national or local authorities within 24 hours should be mandatory[7]
  • Recognize and protect reproductive health rights: making maternal death a notifiable event requires a legal framework to allow cases that are sensitive in nature, such as deaths due to unsafe abortion, to be reported to local health authorities without fear of retribution[8]
 MDR in Sierra LeoneIn 2010, the Ministry of Health and Sanitation (MoHS) with support from the UNFPA, ADB, World Health Organization, Strengthen district health services project and UNICEF developed framework, manual and tools and trained core medical staff on MDR. MDR national and district committees were establishedMoHs with support from World Health Organization, International Rescue Committee, CARE and Amnesty International help capacity building on MDRs among health staff and also community sensitization activities in Kenema, Koinadugu, Kambia Government HospitalsHospital superintendents and midwife investigators were trained in all district hospitals and regional leads nominatedCARE, with funding from the Leveraging Information from the Field to Transform US Policy (LIFT UP) Initiative, worked with the MoHS to implement facility-based and community-based MDRs in seven chiefdoms in Koinadugu District and to share their learning and experience to inform MoHS effortsSupportive legislation could enable MDR to be undertaken as learning mechanism without the fear of punitive action, ensuring that data is not only collected, but used effectively to identify feasible means of reducing health system weaknesses and tangible action at each level of the care continuum. Success story on Maternal Death Review: Kenema District HospitalMaternal Death Reviews are held at Kenema Government Hospital on a monthly basis. Meetings are chaired by the matron and the co-chair is the primary physician for the maternity ward. Attendees include heads of departments and staff, such as the hospital administration, maternity ward, laboratory services, blood bank, ambulance services, theatre and district health management team leadership. In addition, representatives from the district and city councils, Health for All Coalition and the Chairman of the Nongowa Township Health Development Committees are invited.The MDR meetings provide a forum for review of cases of maternal death as well as an opportunity for discussion of issues related to quality delivery of maternal health care, such as the emergency referral system, safe blood transfusions, and reliability of the power supply to the maternity ward and Theatre and availability of essential drugs, medical supplies and equipment. Key decision makers within the district are present to immediately inform and address problems raised. Case reviews are presented by the maternity ward staff. Subsequent discussion focuses on identifying factors that may have contributed, specifically looking at the three delays. Action plans are then agreed upon to mitigate these factors in the future. The focus of these meetings is on constructive approaches that may be far reaching in their effects.A case in point related to a maternal death in late 2011. “This patient was a 26 year old woman from an outlying village who had attempted an abortion using traditional methods. Within a short time, she suffered from fever, abdominal pain and profuse vaginal discharge. She had received antibiotics at a city clinic and private hospital without improvement. She was then sent to Kenema General Hospital where she was also given parenteral antibiotics. Her condition worsened and she died two weeks later.”  Using the three delays as a starting point, this case was discussed in great detail, identifying the third delay as having directly contributed to her death: access to proper treatment for a septic abortion, which should initially have been evacuation of the infected products of conception. However, the discussion did not end there. The root cause of lack of access to family planning services was also identified by the participants. This case highlighted the need for more sensitisations around birth spacing and birth delaying and how such services could reduce the maternal mortality rate. Radio programs followed and training was provided to maternity ward staff on family planning methods so they could begin to provide postpartum teaching to all patients. Further sensitisations were begun at the PHUs in the district.This case illustrates the critical discussions that occur monthly and the importance the staff place on learning from errors or omissions and making a concerted effort to prevent recurrent deaths from these same factors. To read the original brief click here and to find out more about MDRs in Sierra Leone, click here. References
  1. Dumont A, Gaye A, de Bernis L, Chaillet N, Landry A, Delage J, et al. 2006 “Facility-based maternal death reviews: effects on maternal mortality in a district hospital of Senegal”, in Bull World Health Org 2006;84(3):218–24.
  2. Graham, W. J. and J. Hussein 2006 “Universal reporting of maternal mortality: An achievable goal?” in International Journal of Gynecology and Obstetrics (2006) 94:234-242.
  3. Hailu, S., Enqueselassie, F. and Y. Berhane 2009 “Health facility-based maternal death audit in Tigray, Ethiopia”, in The Ethiopian Journal of Health Development (2009) 23(2):115-119.
  4. Kongnyuy, E. J. and N. van den Broek 2008 “The difficulties of conducting maternal death reviews in Malawi”, in BMC Pregnancy and Childbirth (2008) 8:42.
  5. Pearson, L., deBernis, L. and R. Shoo 2009 “Maternal death review in Africa”, in International Journal of Gynecology and Obstretrics 106(2009):86-94.
  6. United Nations Fund for Population Activities [UNFPA] (2011) “State of the World’s Midwifery Report 2011”
  7. Available Online: http://www.unfpa.org/sowmy/resources/docs/country_info/profile/en_Ethiopia_SoWMy_Profile.pdf
  8. World Bank 2011 “Maternal Death Audit as a Tool Reducing Maternal Mortality”, in HPNPNotes March 2011.
  9. 11.     World Health Organisation [WHO] (2009) “WHO Country Co-operation Strategy 2008-11: Ethiopia”
  10. Available Online: http://www.who.int/countryfocus/cooperation_strategy/ccs_eth_en.pdf
  11. World Health Organization 2004 Beyond the Numbers, Geneva: WHO.
  12. Zimbabwe Ministry of Health 2008 Institutional Maternal Mortality - A national summary report 2007, vol. 3, August 2008.
  13. Swaziland Ministry of Health 2011 Improving the Quality of Maternal and Neonatal Health Services in Swaziland: A Situational Analysis, May 2011.
  14. The Lancet 2008 “Every death counts: use of mortality audit data for decision making to save the lives of mothers, babies, and children in South Africa”, South Africa Every Death Counts Writing Group in The Lancet vol. 371(9620):1294-1304.
 [1] This is based on the MoHS maternal death review institutional framework.[2] Graham, W. J. and J. Hussein 2006 “Universal reporting of maternal mortality: An achievable goal?” in International Journal of Gynecology and Obstetrics (2006) 94:234-242, p. 235.[3] Pearson, L., de Bernis, L. and R. Shoo 2009 “Maternal death review in Africa”, in International Journal of Gynecology and Obstretrics 106(2009):86-94, p. 89.[4] World Health Organization 2004 Beyond the Numbers, Geneva: WHO, p.61.[5] Pearson et al. 2009, pp. 92-93.[6] In Kenya there was no government budget to support this interest group, but the professional commitment of the members working on their own time ensured the drafting of the national guidelines (Pearson et al. 2009, 93).[7] World Bank 2011 “Maternal Death Audit as a Tool Reducing Maternal Mortality”, in HPNP Notes March 2011, p.4.[8] Ibid. 

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