Strengths and weaknesses in MPDR implementation
Maternal death reviews have been mandatory and institutionalised for many years in Tanzania, with the MPDR system introduced in 2006.
This article, published in Tropical Medicine and International Health, presents the findings of a study conducted by researchers from Evidence for Action Tanzania and The London School of Hygiene and Tropical Medicine.
It investigates the implementation of MPDR in Tanzania, specifically in terms of its role and practices at district and regional hospitals, as well as the involvement of health system and administration staff in MPDRs and their perceptions of the system.
The study involved two-parts. First a review of the national MPDR guidelines. Second a qualitative study using semi-structured interviews with thirty-seven key informants within the health administration and hospitals in Mara Region and at the central level.
Key findings from the review of the National MPDR Guidelines
- The guidelines state that the MPDR system is an adaptation of facility-based reviews as described in the World Health Organization’s (WHO) Beyond the Numbers. This indicates that analysis of maternal deaths should be in-depth and not too prescriptive. However, the reporting forms provided in the guidelines are all structured to mainly collect data on medical causes of death with little space for detailed investigation into the problems and solutions.
- Despite the emphasis on confidentiality and anonymity, the reporting forms include the names of the deceased and the facility.
- The guidelines provide instructions on analysing each case review and an example of an action plan. However, both are very brief.
- The guidelines focus in greater detail on reporting structures, technical committees, and the management of data.
Key findings from informant interviews
- There were generally positive views and commitment towards MPDRs from the informants interviewed. Reviewing maternal deaths were seen as useful to better understand and improve quality of care, were inclusive, and not blame orientated.
- Whilst MPDRs were viewed as a valuable mechanism, there was evidence suggesting a dysfunction in the established system, with poor quality reviews and limited action taken. More opportunities need to be taken up to improve quality of care at the hospital level.
- The current MPDR system in Tanzania was found to focus mainly on reporting mechanisms.
- Health workers in general were dedicated to the process, with routine documentation and reporting, but needed more skills or training in analysing the challenges of each case review.
- Staff held different understandings of the purpose of maternal death reviews, some incorrectly perceiving it as a data collection exercise or to discover the person at fault.
- Action plans were of poor quality, as the review teams failed to identify appropriate challenges and solutions at the facility level, often finding fault to lie with the community or individual.
The researchers conclude that governments who wish to collect better data for public health decision-making at the central level should ensure that facility staff have capacity to collect and generate good quality evidence from the front line.
A well-functioning maternal death review system can provide data for action at other levels, but it relies on quality analysis in the facility review in order for appropriate and responsive action to be possible.