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

2. Technical guidance available

3. 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

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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.

10. 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

11. 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

13. 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

14. 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

15. 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

16. 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)

17. 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

18. 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

19. 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

20. Thank you