1. Click to edit Master title style Click to edit Master subtitle style Maternal and Perinatal Death Reviews: An effective way to improve quality in delivery and new-born care. Experience from three regions in Tanzania S. Pestilli, T. Yasuda, A. Kassim Husseim, Y. Yoshida, S. Sharma 5 th National Quality Improvement Forum Dar es Salaam 26 August 2015

2. Outline of Presentation Maternal and Perinatal Death Reviews (MPDR) UNICEF support to MPDR Methodology Results Conclusion

3. 2.9 million newborn die 2.6 million babies still born 290,000 women die in childbirth ¹William M. Callaghan, from “Strategies to reduce pregnancy-related deaths: from identification and review to action”. Atlanta, GA, Centers for Disease Control and Prevention, 2001.

4. Maternal and Perinatal Death Review MPDR What is MPDR A qualitative, in-depth investigation of the causes and circumstances surrounding maternal and perinatal deaths Inform actions to improve quality of care and prevent MPD It is a QI process with specific focus on MPD Why MPDRCivil registration of maternal and perinatal deaths and their causes is weak Most MPD can be averted knowing their causes Where Community, facility, regional and national level

5. MPDR in Tanzania MPDR started in 2006 MPDR at all levels (community, facility, district, region and national level) recommended as strategic activity in the National Road Map Strategic Plan Key activity in the implementation of Commission on Information and Accountability (CoIA) recommendations in Tanzania Still the routine process of death reviews has not been fully implemented Previous research reports: positive view of MPDR, main focus on reporting, poor quality of action plans

6. UNICEF support to MPDR 6 districts of Mbeya, Iringa and Njombe Technical and financial support to LGA from 2012-2013 Training of health workers on MPDSR guidelines Supervision of MPDR meetings

7. UNICEF MPDR support- Study Aim of the study Identify knowledge of MPDR, views, achievements, challenges and lessons learned to scale-up the initiative Methodology Qualitative study (May-July 2015) 15 semi-structured interviews to key informants at facility, district and regional level in Mbeya, Iringa and Njombe Data collection ‘Data saturation’ guided the end of data collection Sampling Purposive sampling to ensure maximum variation within the sample Data analysis Inductive process Identification of anticipated and emergent themes

8. Results: Knowledge and view of MPDR All informants knew the scope of MPDR “It is helpful to understand the causes of deaths, to understand the problems and make a plan to tackle them and improve quality of health care” MPDR was positively perceived by most informant as: “ Unique forum” to gather people from facility, district and region to discuss MPD “ Powerful way to collect data” “ Mechanism to be accountable” in the implementation of quality improvements “ Process of learning” to improve health care and prevent deaths

9. Results: Achievements Improvement in staff attitude (accountability and pro- activeness) reported by most respondents “ Staff is more responsible and motivated to find solutions” Implementable action plans developed by HF reported as major achievement Case study from Njombe region: -many MD in Makete DC due to lack of blood for transfusion in lower HF -Action plan: collect blood in all district HF- send blood for screening to Ikonda hospital- screened blood back to HF -Increased blood availability in lower HF “ HF staff developed a plan to address lack of blood at lower facilities within the district”

10. Results: Achievements Case study from Njombe region: - PD due to congenital syphilis because of lack of diagnostic tests -Action plan to redistribute syphilis test in HF -Improved availability of diagnostic kits and other supply in HF “deaths from syphilis motivated the staff to address lack of supply with a plan to share and redistribute diagnostic kits and equipment” Case study from Mbeya region: -Several MD due to lack of blood -Action plan: creation of blood committees to sensitize community in blood donation -More than 1,000 Units of blood donated “ staff formed blood transfusion committee at district level to sensitize the community on blood donation”

11. Results: Achievements Close follow-up from regions “ We look at partograms during MPDR, before mostly were not ok but now the staff complete the partograms” “If they do not implement the action plans they need to present good reasons, they are hold accountable” Improvement of quality of care “ MPDR is a learning process, we understand causes of death, we make plans, we improve quality of care, we prevent other deaths”

12. Results: Challenges MPDR implementation: - Fear of blame was mostly reported as initial challenge “ Staff was afraid of being questioned and of the consequences” - lack of resources - gather all the people for MPDR meeting - lack of information from communities “ few VHW are trained so we have no information of what happened in the community” - lack of in-depth knowledge of perinatal deaths

13. Results: Challenges MPDR action plans: - lack of resources, equipment, medical supply “ sometimes we do not have the resources to put in place the action plans for example ambulance to improve referral” - lack of proper training (BEMOC, newborn resuscitation)

14. Results: Lessons learned Key elements reported by most respondents for successful MPDR Confidentiality and lack of blame Timely execution after MP deaths occur Presence of all people involved in MP deaths Action plans developed by staff (bottom-up approach) Follow-up on action plans at all levels Budget for MPDR Commitment at all levels especially at high level “ It is important that the people who lead, the ones that can make the decisions support MPDR ”

15. Conclusions Knowledge of MPDR scope “sole purpose is to learn from past tragedies and save lives in the future—not to apportion blame”¹ Commitment at all levels “since action is the ultimate goal of MPDR, people with the ability to implement the changes have to actively participate in the process” ¹ Adequate resources for all stages of MPDR: conduction of MPDR, implementation of action plans, follow-up and supervision. ¹ World Health Organization, 2004 Beyond the Numbers Reviewing maternal deaths and complications to make pregnancy safer

16. Asante sana

17. References 1.Ministry of Health and Social Welfare Tanzania. The National Road Map Strategic Plan -2008 - 2015 2.The Partnership for Maternal, Newborn and Child Health 2013.PMNCH Knowledge Summary #27 ² 3.Death reviews: maternal, perinatal and child. (accessed on the 10th June2015http://www.who.int/pmnch/knowledge/publicati ons/summaries/ks27/en/) 4.Armstrong CE et al Strengths and weaknesses in the implementation of maternal and perinatal death reviews in Tanzania: perceptions, processes and practice. Trop Med Int Health. 2014 Sep;19(9):1087-95. doi: 10.1111/tmi.12353. Epub 2014 Jul 8.