Maternal Death Audit & Review – a challenge

1. Maternal Death Audit & Review – a challenge Dr. S. S. Datta Dist. MCH Officer, Nadia

2. Key facts of maternal deaths – w.h.o, may, 2012 • Every day, approximately 800 women die from preventable causes related to pregnancy and childbirth. • 99% of all maternal deaths occur in developing countries. • Maternal mortality is higher in women living in rural areas and among poorer communities. • Young adolescents face a higher risk of complications and death as a result of pregnancy than older women. • Skilled care before, during and after childbirth can save the lives of women to achieve MDG 5 (to reduce maternal mortality by three quarters between 1990 and 2015 – for India=109) • The major complications that account for 80% of all maternal deaths are: • Severe bleeding (mostly bleeding after childbirth) • Infections (usually after childbirth) • High blood pressure during pregnancy (pre-eclampsia and eclampsia) • Unsafe abortion.

3. MMR – India & West Bengal

4. Prevent Maternal Deaths – concept of “Delays” 1. Delay in Seeking Care • Unawareness of danger signs • Illiteracy & Ignorance • Delay in decision making • No birth preparedness • Beliefs and customs • Non availability of health care professional • Any other/specify 2. Delay in reaching first level health facility • Delay in getting transport • Delay in mobilizing funds • Not reaching appropriate facility in time • Difficult terrain • Any other/specify 3. Delay in receiving adequate care in facility • Delay in initiating treatment • Substandard care in hospital • Lack of blood, equipment & drugs • Lack of adequate funds • Any other/specify

5. Why Maternal Death Review • Maternal Death Review lies in the fact that it provides detailed information on various factors at facility, district, community, regional and national level that are needed to be addressed to reduce maternal deaths. Analysis of these deaths can identify the delays that contribute to maternal deaths at various levels and the information used to adopt measures to fill the gaps in service. • The process of MDR should not be utilized for taking punitive action against service providers.

6. Guideline • The objectives of the guidelines are: • To establish operational mechanisms/modalities for undertaking MDR at selected institutions and in community level • To disseminate information on data collection tools, data/information flow, analysis • To develop systems for review and remedial follow up actions

7. Methods for investigating maternal deaths: • Community based maternal death reviews • The main purpose of the CBMDR is to identify the maternal deaths would be the first step in the process, the second step would be the investigation of the factors/causes which led to the maternal death – whether medical, social, systemic, and the third step would be to take appropriate and corrective measures on these. • Facility based maternal death reviews • Identifying maternal deaths would be the first step in the process of review, the second step would be the investigation of the causes which led to the maternal death mainly clinical and systemic and the third step would be to take appropriate and corrective measures.

8. Investigating Officer/Health Personnel For Facility Based Maternal Death Investigation: 1. MCH: G&O faculty to be nominated by HOD G&O Deptt. (G&O specialist looking after the deceased will not be entitled to investigate) 2. Health Facilities at Districts: Sub-Divisional ACMOHs For Community Based Maternal Death Investigation: 1. Community: BPHN/PHN

9. MDR Committees at District Level District Maternal Death Review Committee under the chairpersonship of District CMOH: • Every district will have a committee for maternal death review. DMCHO will be the nodal person for this committee. The District MDR Committee will review all the maternal deaths in the district once every month on a pre-fixed date. • District MDR Committee should have following members- • CMOH as the chairman. • DMCHO as Nodal Officer • Sub divisional ACMOHs as nodal officer for FBMDR • Medical officer of Gynaecology & Obstetrics • Anaesthetist / Physician • Officer in charge of blood bank/blood storage centre • Senior nurse nominated by the CMOHH • Invited members from the facilities where maternal death has taken place. • One representative from district administration (ADM), to be nominated by DM. • Facility Based MDR Committee: • At DH/SGH/SDH/RH/BPHC: Every facility will have a committee for maternal death review in the facility. Sub Divisional ACMOHs will be the Nodal Officer for FB-MDR. • Following are the members of this committee: Supdtt./MO-I/C, G & O specialist, Physician, Anesthetist, Nursing Personnel, MO-Blood Bank and any other relevant departments. The Nodal officer will be the member secretary of this committee. The FB MDR Committee will review all the maternal deaths in the facility once every month on a pre-fixed date.

10. FLOW OF CBMDR PROCESS

11. FLOW OF FBMDR PROCESS

12. Maternal Death Review April 2012-March 2013 Nadia

13. Status of MDR in the district - Reporting • Total live births: 72,817 • No. of maternal deaths reported: 54 • No. of facilities reportedMDs (names & no.s): 13 (DH -10, Chapra RH-1, Nabadwip SGH - 1, Tehatta SDH -1) • No. of blocks reported MDs (names & no.s): 50 (Chapra – 8, Karimpur II – 7, Maheshganj , Nakashipara & Ranaghat II – 6, Santipur, Tehatta I, Krishnagar I & Krishnagar II -3, Hanskhali – 2, Haringhata, Kaliganj & Karimpur I-1) • Blocks not reported a single MD: Ranaghat-I, Tehatta-II, Nabadweep & Krishnaganj

14. Status of MDR in the districtInvestigation & Review • No. of MDs investigated: 54 • By only FBMDR: 04 • By only CBMDR: 41 • Both : 9 • No. of review meetings held: • Chaired by CMOH: 7 • Chaired by DM: 1

15. Major Findings • Place of death: • On road-09, Home–04, Private facility-2, Public facility-39(with in district – 21, outside district - 18) • Time of Death: • Antepartum-17, Intrapartum-04, Postpartum-32 (L.B-23, S.B-9) • Age of women at death: Mean age-25yrs. • Age ≤ 20yrs. - 13 • Gravida: Primi-19, 2nd Gravida-16 • Religion: Hindu = 34/ Muslim = 20 • Risk factors identified: 08 (High BP-3, out of which 1 died of eclampsia)

16. Major findings – Mortality profile

17. Major findings – Service provided • Comments on: • Delays: • Delay in seeking treatment: 07 (Hge-2, Obst. Labor-1, Sepsis-1, Others-3) • Delay in transport: 01 • Delay in treatment: 04 (Blood transfusion) • Care received: • ≥ 4 ANC: 15 • 3 ANC: 17 • 2 ANC: 03 • 1 ANC: 03 • No ANC: 04 (Ectopic-1, Sepsis-1, Hge.-1, Other-1) • PNC: No PNC in 2 cases

18. Key issues identified • Community Issues: • Early age of marriage & Childbirth • Lack of planning of delivery & transport • Lack of identification of danger sign • Lack of quality of post natal care • Supply side Issues: • Lack of quality ANC – birth planning,, transport planning, risk factor identification • 102 – Ambulance many a times found busy • Poor functioning of B.B / BSU • Poor quality intranatal care • lack of adherence to labour room protocol.

19. Key Action Points/recommendations emerged from the maternal death reviews • Action points for facility level: Monthly MDR meeting with corrective measures to be taken to avoid delay 3, Strict adherence to L.R (partograph etc.) & JSSK protocol, Avoid indiscriminate use of ‘Misoprostol’ for induction of labour • Action points for community level: Fill up of case summery by BMOH, Provision of quality ANC by the ANM, BCC by ASHAs, Involvement of Social welfare, Education, PRI & Civil administration for prevention of early marriage • Action points for district level: Ensuring availability of ambulance service, drugs & investigations (JSSK) and Functioning of BSU/BB. District Level MDR training for both, facility and community level. • Action points for state level: HR crisis management for proper functioning of CEmOC center. Arrange requisite fund for District level training.

20. Challenges • Poor involvement of ACMOHs for conducting regular FBMDR meetings • FBMDR forms (Annexure 1) were not properly filled up by the Superintendent / ACMOH • Poor involvement of Specialists doctors in fill up of BHT, cause of death (Direct, indirect & underlying) • Quality of CBMDR (Annexure 2) reporting is poor – all the points were not filled up & no case summery (Annexure 3) given by the BMOHs • Crisis of Human Resources at facility level • Social factors for early age of marriage & pregnancy

21. Opportunities • Optimum use of: • JSSK • Nischay-Yan • Adolescent / Annwesha counselor to impart IEC for birth preparedness & avoid early marriage and early pregnancy • B.B & BSU – 24x7 functioning • SC untied fund could be utilized for patient ref. in absence of Nischay-Yan (provision is there in the order)