Volume 106, Issue 1 p. 89-94
Averting maternal death and disability
Free Access

Maternal death review in Africa

Luwei Pearson

Corresponding Author

Luwei Pearson

UNICEF Eastern and Southern Africa Regional Office, Nairobi, Kenya

Corresponding author. Tel.: +251 911 505 178.Search for more papers by this author
Luc deBernis

Luc deBernis

UNFPA Africa Division, Addis Ababa, Ethiopia

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Rumishael Shoo

Rumishael Shoo

UNICEF Eastern and Southern Africa Regional Office, Nairobi, Kenya

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First published: 09 May 2009
Citations: 27

Abstract

Objective

WHO, UNICEF, and UNFPA with other development partners have supported African Ministries of Health to institutionalize maternal death review (MDR) since 2003. To evaluate the program, its status, lessons learned, and the challenges to success were reviewed in 2007.

Methods

A standard self-administered questionnaire was sent to Ministries of Health in 46 Sub-Saharan African countries in May 2007. Completed questionnaires were returned by e-mail, processed, and analyzed.

Results

Thirty countries completed the survey questionnaire. Maternal death is a notifiable condition in 21 (67%) counties. A national committee has been set up to plan, coordinate, and implement MDR activities in 7 countries. Fifteen countries stated that facility-based MDR is the main method selected for conducting reviews of the causes of maternal death. Fourteen (47%) countries reported that national MDR guidelines had been developed and 12 (40%) had implemented the guidelines. Fifteen (50%) countries reported that maternal deaths were reviewed and analyzed. Only 7 countries reported that the government had allocated a budget for MDR. Implementation of MDR has led to local policy changes and improvement in quality of maternal health services in several countries. Ten of the 15 countries in which analysis has been conducted reported that recommendations have been implemented at least at the health facility level.

Conclusion

Although use of MDR is increasing in African countries, effective coverage is still low. The institutionalization of MDR requires political commitment, legal and administrative back-up, financial support, capacity development, simplified reporting forms and procedures, coordinated support of development partners, involvement of professional bodies, and regular supportive follow-up.

1 Introduction

Maternal death review (MDR) is a key element of a strategy to improve the quality of maternal healthcare services by focusing on the causes of deaths and what could have done to avert each death. MDR does more than count maternal deaths; it looks beyond the numbers to study the causes and avoidable factors behind each death, leading to actions to improve quality of care based on the findings. Universal reporting of maternal death is an important element of health management information systems as long as it leads to the allocation of resources and taking responsibility for actions to prevent these avoidable deaths [1]. Striving for the highest quality reporting, in terms of universal coverage and reliability, is essential to inform actions to prevent maternal deaths, and to support the human right to be acknowledged in life and in death [2].

South Africa is currently the only Sub-Saharan African country to institutionalize MDR into the health system. Since the introduction of Confidential Enquiry of Maternal Death (CEMD) in 1997, a majority of maternal deaths are reported, the causes of death are analyzed and reviewed, and actions are taken to improve the quality of maternal health care. MDR needs political buy-in and the force of legislation to work well. South Africa sets an example and inspires other low and middle resource countries in Africa to follow suit.

In many African countries maternal deaths have been reviewed at some health facilities. There are also documented successes in reducing maternal death, improving quality of care, and increasing client satisfaction and use of available services [3], [4]. However, in nearly all African countries, MDRs are carried out ad hoc, reporting is incomplete, and there is limited political, institutional or legal support. Institutionalizing MDR into the health system has been difficult for technical, human, and financial resource reasons, as well as inattention to quality and accountability of maternal health care.

2 Methods

2.1 Introducing maternal death review

The process of introducing MDR systematically into all African countries started in 2003 when 3 UN agencies (WHO, UNFPA, and UNICEF) collaborated with development partners and professional bodies to introduce MDR, aiming for institutionalization of MDR at the health system level. Four orientations for national MDR committees and program managers from 34 countries were held in 2003 and 2007 (Table 1). All countries drafted provisional national plans. During the orientations, 5 MDR methods were introduced: verbal autopsy; facility-based MDR; near miss review; confidential enquiry of maternal death; and criterion-based clinical audit. “Beyond the Numbers” a WHO publication published in October 2004 was the main reference for orientations [5].

Table 1. Countries invited to participate, attending orientation, and/or participating in evaluation of MDR in Sub-Saharan Africa, 2003–2007.
Country Invited Oriented Evaluated
Angola Y Y Y
Benin Y Y N
Botswana Y Y Y
Burkina Faso Y Y Y
Burundi Y Y Y
Cameroon Y Y N
Cape Verde Y Y N
Central African Rep Y Y Y
Chad Y N Y
Congo Y Y Y
Comoros Y N Y
Côte D'Ivoire Y Y Y
Democratic Rep. Congo Y Y Y
Djibouti Y N N
Equatorial Guinea Y N N
Eritrea Y N Y
Ethiopia Y Y Y
Gabon Y Y N
Gambia Y N N
Guinea Bissau Y Y Y
Guinea (Conakry) Y Y N
Ghana Y Y Y
Kenya Y Y Y
Lesotho Y Y N
Liberia Y N N
Madagascar Y Y N
Malawi Y Y Y
Mali Y Y Y
Mauritania Y Y N
Mozambique Y Y Y
Namibia Y Y Y
Niger Y Y Y
Nigeria Y Y N
Rwanda Y Y Y
São Tomé & Principe Y N Y
Senegal Y Y Y
Sierra Leone Y N Y
Somalia Y N Y
South Africa Y N Y
Swaziland Y Y N
Sudan Y N N
Tanzania Y Y Y
Togo Y Y Y
Uganda Y Y N
Zambia Y Y Y
Zimbabwe Y Y Y
Total 46 34 30

2.2 Evaluation

Three years after the first orientations, WHO, UNFPA, and UNICEF evaluated MDR progress in Sub-Saharan Africa. The objectives of the review were: (1) to review progress made in MDR since 2003; and (2) to identify lessons learned and challenges encountered.

Standard self-administered questionnaires (in English and French) were sent to Ministries of Health in 46 countries in Sub-Saharan Africa in May 2007. The questionnaires covered: (1) National MDR policy; (2) implementation of MDR in countries; (3) lessons learned; and (4) support required to institutionalize and scale up MDR. Ministries of Health were offered technical support from the UN to complete the questionnaires.

The completed questionnaires were sent by e-mail to the 3 UN agencies. Quantitative data were put into Excel spreadsheets for processing and analysis. The UNICEF regional office of East and Southern Africa carried out the final analysis.

3 Results

3.1 Participating countries

Thirty of the 46 countries (65%) responded by December 31 2007, 20 without prompting (Table 1).

The countries ranged in population size (2006) from 818 000 (Comoros) to 81 million (Ethiopia), in estimated maternal mortality ratio from 210 (Namibia) to 2100 (Sierra Leone) per 100 000 live births, and in per capita share of gross national income (2006) from US $150 (Somalia) to US $5900 (Botswana) [6].

3.2 National policy and guidelines for maternal death review

Eleven countries (37%) reported that their Ministries of Health had developed national MDR policies. Maternal death is a notifiable condition in 21 countries (70%). However, in only 10 countries is MDR part of the national reproductive and maternal health strategy.

3.3 Implementation of maternal death review

3.3.1 National committees

National committees have been set up in 7 countries (23%) to plan, coordinate, and implement MDR activities. Among them, 6 meet regularly. Seven countries reported that provincial or district MDR committees have been set up. However, in some countries where MDR started at the provincial or district level (such as Angola, Guinea, Malawi, Mozambique, Tanzania), and where there are provincial and/or district committees, national MDR committees may not yet be in place.

3.3.2 National guidelines

Thirteen countries (43%) have developed national MDR guidelines and 11 (37%) have begun to implement the guidelines. MDR guidelines must be disseminated widely to local health authorities.

3.3.3 Training

While having the necessary national capacity is important, skill transfer from national to local level is essential for scaling-up. In Zimbabwe, a 2-day national workshop introduced the concept of MDR and the different MDR approaches. Participants included provincial medical directors, provincial nursing officers, district medical officers, chief nursing officers for city health departments and hospital matrons (directors of nursing). The goal of the workshop was to advocate and get the commitment of managers to support the MDR in their provinces and health facilities. In addition, representatives of 7 countries took a study tour to South Africa after the orientation. They observed the processes and practices of conducting CEMD at local level, and conferred with program managers and healthcare providers about their experience and difficulties. They were able to compare the successful process of CEMD in South Africa with their own situation (Table 2).

Table 2. Comparison of MDR process in eight countries with South Africa, August 2004.
Key steps of implementing MDR Ethiopia Kenya Malawi Mozambique Swaziland Tanzania Uganda Zambia South Africa
1. Active concerned group created Yes Yes Yes Yes Yes Yes Yes Yes Yes
2. Development of Tools Not started Started Not Started Not Started Done Not started Ongoing Not started Done
3. Coverage
    i. Pilot phase No Yes No No Started at No Dist. Hosp No Done
    ii. Implementation No No No No all levels No No No Done
    iii. National level No No No No No No No Done
    iv. District level. No No No No No No No Done
4. Government endorsement of MDR Yes Yes ? Yes Yes ? Yes Yes Yes
5. Consultation
    i. Professional bodies Yes Yes No No Yes No No Yes Yes
    ii. Civil society No No No No No Yes No No Yes
    iii. Donor agencies Yes Yes No Yes Yes No Yes Yes Yes
6. Legal Reforms for MDR
    i. Recognizing RH Rights No No No No No No No No Yes
    ii. MDR as notifiable No No No No Yes No No No Yes
7. Governmental Structure for SMP
    i. Ministry of women affairs No No No No No No No No No
    ii. Directorate No No No No No No No No No
    iii. Unit/Department Yes Yes Yes Yes Yes Yes Yes Yes Yes
8. Training
    i. Orientation/introduction No Yes ? No Yes No No No Yes
    ii. In-service/C.M.E. No Yes No No Yes No No No Yes
    iii. Pre-service
        a. Nurses Yes Yes Yes Yes? ? Yes Yes Yes Yes
        b. Doctors Yes? ? ? ? ? ? ? ? Yes
        c. Paramedicals Yes Yes ? Yes Yes Yes Yes Yes Yes
9. Community involvement
    Preparing the program No No No No No No No No Yes
    Creating awareness No No No No No No No No Yes
    MDR Implementation No No No No No No No No Yes
10. Implementation stages No No No No Yes No No No Yes

3.3.4 Implementation

Program managers acknowledged that MDR was not being conducted regularly in all countries, even though all were aware of its role in improving maternal health services and reducing maternal morbidity and mortality. National policy should insist as a minimum that all central, provincial, and district hospitals should conduct MDR (Tables 3 and 4).

Table 3. Status of implementing maternal death review in thirty Sub-Saharan African countries, Nov 2008: Part 1.
Country MDR policy MDR in MNCH package MD a notifiable condition MD reviewed and analyzed MDR report from health facilities to district Any MDR report produced Recommendations implemented Government budget for MDR Financial support from partners
Angola N N Y Y Y N N N Y
Burkina Faso Y N Y Y Y Y Y Y Y
Botswana Y Y N Y N N N Y Y
Burundi N N Y Y Y N Y N Y
Chad N N N N N N N N N
Central African Rep. N N Y N Y N N N N
Comoros N N N N Y N N N N
Congo Y Y Y Y Y Y Y Y Y
Côte d'Ivoire N N Y N Y Y N N Y
Dem. Rep. Congo N N Y Y N N N N Y
Eritrea Y Y Y N Y Y Y N Y
Ethiopia N N N N N N N/A N Y
Ghana Y Y Y Y Y Y Y Y Y
Guinea N N Y N Y N N N Y
Kenya Y N N Y Y Y Partially N Y
Malawi N Y Y Y Y N Y Y Y
Mali Y Y Y Y N Y Y N Y
Mozambique N Y Y Y Y N Y N Y
Namibia N N N N Y N N N Y
Niger N N Y N Y Y N N N
Rwanda N N N N N N N N N
Senegal Y N Y N Y Y N N Y
Sierra Leone N N N N N N N N N
Somalia N N N N N N NA N N
South Africa Y Y Y Y Y Y Y Y Y
São Tomé & Principe N N Y N Y Y Y N N
Tanzania Y Y Y Y Y Y Y Y Y
Togo N N Y N Y N N N N
Zambia Y N Y Y Y Y Y N Y
Zimbabwe Y Y Y Y N Y N N Y
Table 4. Status of implementing maternal death review in thirty Sub-Saharan African countries, Nov 2008: Part 2.
Country MDR method National MDR committee National committee meet regularly District and provincial committee Professional body involvement National guideline developed National guidelines in use Number received MDR training MDR work plan updated
Angola FB MDR, VA N N/A Y N Y Y 5 N
Burkina Faso FB MDR Y Y Y N Y Y ? Y
Botswana FB MDR Y Y N Not available Y Y N/A Y
Burundi FB MDR N N N Y N N 5 Y
Chad Not specified N N N N N N NA N
Central African Rep. Not specified N NA N N N NA 0 N
Comoros Not specified N N N N N N N N
Congo Not specified N N/A N/A Y Y Y ? N/A
Cote d'Ivoire Not specified N N N N N N ? N
Dem. Rep. Congo FB MDR N N N N N N 6 N
Eritrea FB MDR N N Y N Y Y 300 N
Ethiopia FB MDR N N N N N N/A 12 N
Ghana FB MDR N N Some Y Y Y Y Y
Guinea Not specified N N Y Y N N 15 N
Kenya FB MDR Y Y 1 province Not active Y Y 100 Y
Malawi FB MDR N N Y N N N N N
Mali Not specified Y Y N Y Y Y 5 Y
Mozambique FB MDR N N Y Y Y N NA N
Namibia Not specified N N N N Y N NA N
Niger Not specified Y N N N N N N/A N/A
Rwanda FB MDR N N N N N N 3 N
Senegal FB MDR Y Y N Y Y Y 15 N
Sierra Leone Not specified N N N N N N NA N
Somalia Not specified N N N N N N N N
South Africa CEMD Y Y Y Y Y Y Many Y
São Tomé & Principe Not specified N N N N N N NA N
Tanzania FB MDR N N Y Y Y Y ? Y
Togo Not specified N N N N N N 6 N
Zambia FB MDR N N Y Y Y Y 270 N
Zimbabwe FB MDR N NA N Y N NA NA N

Although 15 countries (50%) reported that maternal deaths are reviewed and analyzed at national, local or health institution level, only two countries report maternal deaths.

Twenty (67%) countries reported that while maternal death cases are reported from health facilities to district level, only 10 (33%) of them reported that the data had been analyzed. However, 14 (47%) reported that MDR reports have been produced, and 12 (40%) reported that, based on the results of MDR, recommendations have been made and implemented, at least in the institutions involved in the program.

Only 7 countries reported that the government has allocated budget for conducting MDR. In 18 countries financial support for MDR was provided by development partners.

3.3.5 Type of review selected

Facility-based MDR is the most common method, chosen by 15 (50%) countries, followed by CEMD in South Africa and Swaziland, and facility-based MDR with verbal autopsy in Angola.

3.3.6 Collaboration with professional bodies

Ten countries (33%) reported that the professional bodies and medical and OBGYN associations have supported MDR activities.

4 Lessons learned

4.1 Key actions

The key steps to institutionalize MDR, based on the experience of South Africa, are the following (This serves as the broad implementation framework of MDR in Africa) (Table 2):
  • Active advocacy group at the national level.

  • Development of policy, guidelines, and tools for conducting MDR.

  • Expansion of coverage from pilot to district and national scale.

  • Enthusiastic government endorsement of MDR.

  • Collaboration with professional bodies, civil society, donor agencies.

  • Legal reforms to support MDR (recognizing reproductive health rights, making maternal death a notifiable event).

  • Incorporation of MDR into the formal governmental structure as part of the reproductive and maternal health program; for example, identifying a focal person, assigning a budget line.

  • Training (orientation/introduction, in-service and pre-service) at national, district, and health facility levels.

  • Community involvement in developing program, creating awareness, community participation in MDR implementation.

4.2 Success is possible!

MDR can lead to local policy changes and improvement in quality of maternal health services. Examples include:
  • Following facility-based MDR in Roi Baudouin district hospital of Dakar, Senegal, 13 specific interventions were recommended by the audit committee and implemented. These focused on the 24-hour availability of services, essential drugs, and blood products; and on the availability of basic emergency obstetric care at both hospitals and primary care facilities [4].

  • In Garissa provincial hospital (Kenya) the blood bank, laboratories, pharmacies, and other supporting services now operate 24/7. Emergency medicines are available in the labor room. Efforts to improve privacy, infection control, and communication with clients have increased client satisfaction. A maternity waiting home has been established in an unused tuberculosis ward for patients from remote areas. The MDR revealed that case fatality was very high among eclampsia cases. The hospital organized orientation for eclampsia management, and put in place clinical protocols for all major obstetric complications [7].

  • In Mozambique, MDR improved accountability, timely decision-making, and availability of supplies and equipment, and led to additional training for health staff.

5 Discussion

A national interest group and dedicated national committee supported by the government and professional bodies are a critical driving force behind MDR in those countries where progress is being made. Development of national guidelines may require a long process of consensus building among partners. The Kenyan group that participated in the first MDR orientation organized by the UN in 2003, met weekly, for about one year, to develop the national guidelines. A strong national interest group on MDR keeps pressure to act on the Ministry of Health, facilitates the development of necessary instruments and guidelines, and trains program managers and healthcare providers. In Kenya there was no government budget to support this interest group, but the professional commitment of the members working on their own time ensured the drafting of the national guidelines.

The national interest group, or some version of it, may become official. In South Africa, the Minister of Health appointed a National Committee on Confidential Enquiries into Maternal Deaths (NCCEMD). The NCCEMD is responsible for the confidential enquiry into maternal mortality in South Africa. Their task is: "To make recommendations, based on the confidential study of maternal deaths to the Department of Health such that the implementation of the recommendations will result in a decrease in the maternal mortality." The recommendations are specific so that their implementation is measurable.

While a national policy and guidelines are critical they do not guarantee MDR implementation at scale. Dissemination of the guidelines and program support to the program managers at the provincial and district level are also essential. A specific budget line for MDR in the health sector budget helps to ensure that it is not lost among competing priorities.

Government ownership and commitment are critical. Among the 7 countries with government allocations for MDR, all have a system in place to report maternal death from health facilities to district level and all have received financial support from development partners. Six have a national MDR committee, 6 have made maternal death a notifiable condition, 6 have developed national guidelines, and 5 update their work plan regularly.

On the other hand, among the 19 countries without government financial support, only 4 have developed national guidelines, 4 have a national MDR committee, and 4 have implemented recommendations after analysis.

MDR is more sustainable when integrated into the maternal and reproductive health program (skilled care, emergency obstetric care, and newborn care) rather than a vertical program. Causes and solutions are then more likely to be related to the availability, use, and quality of maternal and reproductive health care, especially the life saving services [8], [9].

Most countries indicate that external technical support is required to develop national MDR policy and strategies. Capacity building through training, experience exchange, and technical assistance to set up the MDR guidelines, database, and legal framework is needed. In addition, adequate financial support from the government and development partners can help to prioritize MDR. Active external support and follow-up to national MDR groups help ensure that technical support is provided at the right time. Facilitators of the MDR orientation workshops and program managers from South Africa visited selected countries during 2004 and 2006 and worked with key policy makers and program managers. These visits helped consolidate the local MDR processes.

Generally speaking, more affluent countries with better health systems are more likely to undertake MDR, yet MDR may escape their attention. For example, in Namibia, where nearly 80% of women deliver with skilled attendants, MDR is not yet a national policy. While Eritrea, where less than a third of women deliver with skilled attendants, has made significant efforts in that direction.

Developing a nationwide system of MDR is not without constraints. Systemic challenges commonly mentioned include lack of national policy and guidelines and a responsible oversight body, inadequate resources allocated by governments and development partners, shortage of staff, and limited awareness of the benefits and methodology of MDR due to lack of exposure and training. Coordination, so that the different parts of MDR proceed in parallel is also important and sometimes difficult. Lack of a legal framework may result in misconceptions and fears regarding possible punitive measures, and the perception that audits are judgments on the actions of professional medical staff.

In addition, frequent turnover of program managers and staff, competing priorities, incomplete and inconsistent reporting in some districts, and a nonparticipating private sector threaten the implementation of MDR (and other reproductive health programs).

Another critical gap in nearly all countries is that although maternal deaths are reported from health facilities to district health offices, the regular review of deaths does not take place. Hence causes of deaths and recommendations for actions—usually done by senior obstetricians and program managers—are lacking. Few obstetricians work in government and are usually stretched too thin to have time for reviews and providing critical feedback to the reporting institutions. Most government doctors also have private practices, and unless their services are adequately compensated it is unrealistic to expect them to allocate their own time regularly for MDR.

Failure to act on recommendations, perhaps due to lack of will or resources, is commonly reported and can be discouraging.

Only 30 (65%) of the 46 countries responded, despite frequent reminders. Among the nonrespondents, some (e.g. Nigeria and Swaziland) are known to have some MDR activities. The survey lacks the in-depth answers that would have resulted from a face-to-face interview, and the quality of completed questionnaires varies significantly. Nevertheless, we believe the survey to be sufficiently representative to guide future action.

The most common method chosen by countries in Africa is facility-based MDR. This method is easier to conduct than other methods and can be initiated at the district and provincial level or in a single institution. Not including near misses in the review involves fewer cases and is thus less burdensome. However, it does not need to be carried out in isolation. While moving from data collection to action, facility-based MDR may generate establishment of clinical standards and guidelines, which is the basis for a criterion-based clinical audit. And nationwide CEMD becomes feasible when a majority of districts are conducting facility-based MDR and most maternal deaths are captured by the system. Facility-based MDR can also be combined with community verbal autopsy and criterion-based audit of management issues.

Acknowledgments

The authors are grateful to the Ministries of Health of Sub-Saharan Africa, WHO, UNFPA, and UNICEF regional and country offices for the valuable information provided. The evaluation was supported by the three participating UN agencies.