MATERNAL DEATH SURVEILLANCE AND RESPONSE MEDICAL CERTIFICATION OF Cause of death, TONGA November, 2018

Technical guidance available

What is MDSR MDSR is a form of continuous surveillance linking the health information system and quality improvement processes from local to national levels It includes the routine identification, notification, quantification, and determination of causes and avoidability of all maternal deaths, as well as the use of this information to respond with actions that will prevent future deaths

MDSR Goal & Objectives Goal of MDSR: To eliminate preventable maternal mortality Reporting system "S" focuses on surveillance for a rare but important problem To generate accurate and timely maternal mortality data Review system To identify major medical and non-medical causes of maternal death To formulate appropriate interventions to address these causes To institute improvements in the service delivery system "R” focuses on the response—the action portion of surveillance MDSR builds on maternal death reviews (MDR) and underlines the critical need to respond to every maternal death. Has 3 Rs – reporting, review and response Rare but important system – tip of an iceberg with 20 – 30 cases of morbidity for every maternal death

Why surveillance? Surveys e.g. DHS depend on recall Retrospective (60 mo. prior to survey); identifies pregnancy related deaths - not maternal deaths; estimates/wide confidence intervals Underreporting remains a problem, esp. deaths occurring at home, deaths at extremes of maternal age, abortion related deaths, deaths occurring in late puerperium, and deaths in early pregnancy Reliability of data depends on reliable reporting and recording of births and deaths. Underreporting and misclassification common, CRVs systems in most developing countries incomplete with respect to MM data. Hospital data: In some areas high frequency of Home births dilutes reliance on facility data . Challenges with surveys – DHS – expensive, undertaken at about 5 year intervals

MDSR cycle Surveillance Response Vital registration QoC improvement Case definition Identify deaths (all WRA) Response action Notify deaths Review deaths Standards in place MDSR cycle and links with other systems and vital registration Deaths occurring in health facilities should be identified and notified to the appropriate authorities within 24 hours, and deaths in communities within 48 hours. Notification should include “zero reporting,” an active process of notifying suspected maternal deaths, whether or not any occurred. Response MMR tracking QoC measurement

Why is MDSR important? Maternal mortality reduction is a UN MDG target that remained far from achievement at the end of 2015 To respond to calls for ending preventable deaths requires better measurement – one of the SDG goals Reduce global MMR < 70 per 100,000 live births Reduce NMR < 12 per 1000 live births in every country Reduce under-5 mortality < 25 per 1000 live births in every country

Why is MDSR important? Provides maternal death data in real time Makes maternal death visible at local and national level Provides information for action to prevent deaths at local, health facility, district and national levels Sensitizes communities and facility health workers Connects actions to results – permits measurement of impact Successful MDSR helps strengthen national civil registration and vital statistics, quality improvement and other health information systems Country ownership of data in real time

What is new about MDSR? Maternal death is a notifiable event gives it greater visibility and highlights importance Identify all maternal deaths – facility and community phased approach Greater emphasis on response – and accountability for response Monitoring and evaluation of MDSR itself MDSR builds on existing systems – e.g. Maternal death review (MDR) Communicable disease surveillance system (IDSR) MDSR is an evolution of maternal death reviews (MDR) It Endorses maternal death as a notifiable event, (This gives it greater visibility and highlights its importance) It demands Identification and timely reporting of ALL maternal deaths through a systematic and continuous surveillance It calls for a review process for all maternal deaths that produces recommendations to prevent future deaths, It places greater emphasis on a response that includes the implementation of the recommendations; and accountability for the response. It involves Monitoring and evaluation of MDSR itself.

MDSR Steps Identify deaths of all Women of Reproductive Age Ascertain whether maternal death (or probably maternal) Notify authorities (e.g. Province) Review all probable maternal deaths Facility-based review or community review with verbal autopsy Identify medical cause(s) of death Identify contributing factors including quality of care

MDSR Steps RESPOND (at different levels) For each maternal death - recommend and implement actions to prevent similar future deaths Aggregate cases - make and implement further recommendations Annual report including assessment of whether recommendations have been implemented Facility-based report District report M&E the MDSR system MDSR M&E Overall system indicators Maternal death is a notifiable event National maternal death review committee exists that meets regularly National maternal mortality report published annually % of districts with maternal death review committees % of districts with someone responsible for MDSR Response and impact indicators RESPONSE Facility % of committee recommendations that are implemented quality of care recommendations other recommendations District IMPACT Quality of care – fresh still birth rate District MMR Facility MMR and case fatality rate

The Setting-Up Phase: What needs to be in place Committee (National and or subnational) with clear Terms of Reference Who appoints committee? How many members on the committee? How are the committee members chosen? Who does the committee report to? Tasks of the committee MD notifiable? Need for advocacy? Guide on structures and tools to be put in place Flow of information Report Need to secure “BUY-IN” at different levels Forms to report maternal death (MDNF) Method of assessment (Assessors Form) Database Pathological conditions Health system failures Analysis Report Recommendations THINGS TO CONSIDER: The Health System is decentralized. Local Health System composition – responsible for implementation of health programs and deliver basic health services. The Local Health System administration – autonomy? DOH provides technical assistance and over-all policy directions Sub-National Committees? Health facility Committee Community level

The Setting-Up Phase: What needs to be in place Reporting process and flow of information Focal persons at different levels – Who reports Community Facility To Whom Consensus on tools to facilitate the process Reporting Review/Assessment Quality assurance measures Database for data collation and analysis

The Setting-Up Phase: What needs to be in place Review Approach and tools to facilitate the process (e.g. Review Form) Relevant standards in place? Policies, guidelines, protocols Report with: Causes of maternal death Health system failures Recommendations

Tools for MDSR Facility identification and/or notification form Community identification of WRA – screen for suspected maternal deaths Community notification form for suspected maternal deaths Verbal autopsy tool Maternal death facility abstraction tool Committee review form Review summary sheet Summary data base (aggregate of all MDR performed – facility; district; national ) Automated analyses and table production for reporting Report generation tools Implementation planning tool Share national policies and regulations Stakeholder communication and collaboration tools Menu of tools available for MDSR to choose from and contextualize Maternal death facility abstraction form: Abstraction form (list of variables from review for district/national analysis)

What Works Identify champions Engage professional associations System-wide linkages and communication and collaboration at all levels Shared responsibility and teamwork Optimize opportunities Develop a culture of accountability and quality of care Phased approach Stages of Implementation Involving more partners Capacity building activities

Challenges with implementation of MDSR Resources: Human and financial Reporting and notification including low participation of private sector, community level maternal deaths Concern with litigation and Confidentiality issues Confidentiality difficult to maintain in small countries Tension between confidentiality and accountability Poor capacity for MDR Lack of training and tools for MDR Review of maternal deaths Lack of legal framework for notification, protection of information and health providers against litigation

Challenges with implementation of MDSR Operationalization of MDSR within the existing IDSR or HIMS Leadership and Coordination M&E - Data quality – timeliness and completeness, consensus on indicators to monitor and report on progress Communication results Weak response to gaps identified and poor monitoring of response actions Weak multi-sectoral collaboration – involvement of communities Lack of legal framework for notification, protection of information and health providers against litigation

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