Identification and Notification of Maternal Deaths

Learning objectives By the end of this session, participants will be able to: Identify a maternal death using the screening tool (part of Annex 1) Know how notification forms are used within the Ethiopian MDSR Explain zero reporting and how it should be implemented

REMINDER! A Maternal death is the death of a woman   A Maternal death is the death of a woman while pregnant or within 42 days of the end of pregnancy (irrespective of duration and site of pregnancy) from any cause related to or aggravated by the pregnancy or its management but not from accidental or incidental causes (Source: ICD-10)

REMINDER 2!   Direct obstetric deaths are maternal deaths resulting from complications in pregnancy, labour or postpartum or from omissions or incorrect treatment. Indirect obstetric deaths are maternal deaths resulting from previously existing or newly developed medical conditions aggravated by the physiologic effects of pregnancy. Late maternal deaths are deaths from direct or indirect causes that occur from 42 to 365 days after the end of pregnancy (Source: ICD-10)

Individual Exercise: Death Scenarios Which are maternal deaths? Why or why not? How would you classify them? Should it be reported to the MDSR committee?

Who should notify maternal deaths at community level? Religious Leaders Health Development Army Community authorities Administrative leaders Health Extension Workers Members of the community HEW have formal responsibility for reporting deaths within the MDSR system

HEW identify ALL deaths to women of reproductive age . HEW identify ALL deaths to women of reproductive age HEW notify all identified deaths to HC within ONE WEEK Key staff at HC determine classification of death within 3- 4 weeks of notification Verbal Autopsy conducted for ALL confirmed maternal deaths, regardless of where they occurred, and report provided to HC Director The HC Director assigns 2 independent reviewers to produce a summary HC committee: Reviews the summary report Draws up a response plan Submits monthly report to woreda focal person

How will identification occur in facilities? Referral forms Medical records Log books (maternity, OR, OPD, anaesthesia) Attending health workers (maternity, OPD, OR) Other ... E.g. mortuary

Facility System of Identification Dedicated staff member responsible for checking death logs and other records from the previous 24 hours on a daily basis. Any death of a woman of reproductive age should trigger a review of her medical record to assess whether there was any evidence the woman was pregnant or within 42 days of the end of a pregnancy Head nurse of the ward reports to Medical Director within 24 hours of identification

Medical director submits summary reports to the next level Notification of maternal deaths to Medical Director by the maternity/ labour/ other ward head midwife/ nurse within 24 HOURS of death. Medical Director assigns two independent reviewers to review and produce summary reports within 1 WEEK of death The review committee at the health facility reviews the summary reports and produces response action monthly Medical director submits summary reports to the next level

Data collection Many sources involved family cards antenatal care records medical records from health facilities interviews with family members, community members/ leaders, traditional healers and health care workers Each data sources provide different information For community deaths, HC staff will be trained to use the VA tool The HC Medical Director responsible for that kebele will supervise the process Data collectors for both facility and community level should be fluent in the local language

Data Collection Speed is essential Notes will disappear People will be unavailable Establish who was around as soon as possible

How can duplication be avoided? There is a risk that a death that occurs at a facility (or on the way) might be reported TWICE to the woreda, from BOTH the facility review committee AND HC committee reviewing verbal autopsies HOW DOES WOREDA AVOID REPORTING THE SAME DEATH TWICE TO ZONE OR RHB? HEW HEARS ABOUT DEATH FROM FAMILY AND NOTIFIES HC HC sends midwife to conduct VA, reviews death, identifies action re: community and reports to woreda WOMAN DIES SOON AFTER ARRIVAL AT DISTRICT HOSPITAL Hospital Committee reviews death, identifies action re:quality , reports to woreda

How can duplication be avoided? MDSR Guidelines recommend that ALL maternal deaths should be counted through the VA process The Facility deaths are to assist in identifying actions NOT for contributing to aggregate figures HOW DOES WOREDA AVOID REPORTING THE SAME DEATH TWICE TO ZONE OR RHB? This will require careful data management practices to avoid confusion!

What is “Zero reporting” ZERO Reporting refers to ensuring all data abstraction and aggregation tools are filled out and sent on time, EVEN when no maternal deaths have occurred Reporting ZERO shows attention to the issue and proactive tracking of maternal mortality NO reports suggests that the MDSR is not functioning or the issue is neglected Reporting should be an active process even when there have been NO deaths

Watching out for silent areas Silent areas are geographical locations (woredas, zones) or facilities at any level that do not report or consistently report NO maternal deaths Silent areas could mean no deaths occurred BUT silent areas also are a potential warning sign of poor compliance with MDSR Woreda or regional review committees are responsible for further investigation Additional support or training may be required

Group Activity Work in groups of 5 people each Use Appendix 1 to fill out a maternal death notification form Don’t worry if your group doesn’t have time to get through all 4 scenarios!

Summary Points ALL deaths of women of reproductive age should be notified in communities HEW are responsible for reporting deaths to HC, where classification occurs and further investigations are authorised (VA) Facilities must ensure identification occurs through data collection in all departments Rapid extraction and summary of raw data crucial to ensure accurate information At woreda level, data are checked for duplication, zero reporting and “silent areas”