MDSR: Evidence of Effectiveness from the International Literature From:

Cycle of Data Collection, Reflection & Action IDENTIFY THE PROBLEM COLLECT DATA PRESENT DATA IN USEFUL FORMATS DISCUSS DATA WITH RELEVANT PEOPLE ANALYSE DATA PROPOSE SOLUTIONS IMPLEMENT RECOMMENDATIONS MONITOR ACTIONS & ADAPT IF REQUIRED

Cycle of Data Collection, Reflection & Action IDENTIFY THE PROBLEM COLLECT DATA PRESENT DATA IN USEFUL FORMATS DISCUSS DATA WITH RELEVANT PEOPLE ANALYSE DATA PROPOSE SOLUTIONS IMPLEMENT RECOMMENDATIONS MONITOR ACTION & ADAPT IF REQUIRED REVIEW ACTION EVIDENCE

Example 1: Piloting a new MDSR in ZAMBIA (Evidence of improved quality of care)

Piloting MDSR in Zambia In 2007, Zambia’s MMR estimated at 591 Data often not recorded outside labour ward EVIDENCE: IMDA: Investigate Maternal Deaths and Act Piloted over 12 months Facility & Community based data collection (TBA trained to notify maternal deaths) Narrative approach to record immediate causes and wider social determinants M. Hadley and M. Tuba (2011) Local problems; local solutions: an innovative approach to investigating and addressing causes of maternal deaths in Zambia’s Copperbelt. Reproductive Health 8:17

Piloting and MDSR in Zambia REVIEW: 4-5 anonymised cases discussed per meeting 11 Data review meetings held, chaired by Provincial Health Director Participants: provincial & district officers, health staff, blood transfusion reps, TBA, external obstetricians Total of 56 deaths reported (53 in tertiary hospital; 1 HC; 1 home) Meetings also reviewed progress on previously identified action points

Health Seeking Issues: Families often sought traditional remedies first Some husband didn’t give approval to seek care Communities lack resources for transport Health systems weaknesses: Shortfall in supplies Absence of Obstetricians Inadequate blood supply Case Management at facilities : 67% cases had inaccurate diagnosis Post mortems not routinely conducted Malaria used as “default” cause of death in unclear cases but not confirmed

ACTIONS (based on 68 recommendations): Obstetrician allocated to hospital Post mortems conducted Antibiotics stocked for post-abortion and post-partum sepsis Birth planning introduced in antenatal care Measures to increase blood supply introduced

RE-STARTING THE CYCLE : Looking for Evidence of Progress one year later 61% recommendations implemented 12 % partially implemented 27% not implemented

Example 2: Facility Based MDSR in SENEGAL (Evidence of improved clinical outcomes)

MDSR Effects on Clinical Outcomes in Senegal Evidence: Facility based MDR + interviews with family Midwives responsible for identifying maternal deaths Senior Obstetrician reviewed cases and collected data from others Data analysed for baseline (1997) and 3 years after MDSR introduced ( )

MDSR Effects on Clinical Outcomes in Senegal REVIEW: 153 maternal deaths reviewed in total District Health Manager chairs annual meetings and evaluates progress ACTION: 13 recommendations implemented, mainly: – 24-hour availability of life saving services, drugs and blood products – Improved availability of basic emergency obstetric care Recommendations NOT implemented included – Expansion of delivery unit – Staff recruitment

CHANGES IN QUALITY OF CARE: Increased uptake of Antenatal care (in Year 1, 11% women had no ANC visit and by Year 2, just 4.2% did not attend) Rates of transfusion up from 1% in Year 2 to 2.1% in Year 3 CHANGES IN MATERNAL MORTALITY: Baseline:50 deaths Year 1: 43 deaths Year 2:33 deaths Year 3:27 deaths Number of maternal deaths fell by almost 50% over the study period

From Dumont et al (2006) Facility Based Maternal Death Reviews: Effects on Maternal Mortality in a District Hospital in Senegal. Bulletin of the World Health Organization 84:

Summary Points MDSRs involve an ongoing cycle of collecting and synthesising data, reviewing the determinants of maternal deaths, implementing actions, and monitoring them to ensure change Many countries have introduced MDSR and demonstrate positive effects on quality of care and health outcomes Responses should link with and strengthen existing quality improvement measures, rather than introduce parallel processes