Maternal death surveillance and response – Jamaica: What works

Maternal death surveillance and response – Jamaica:What works Prof. Affette McCaw-Binns, University of the West Indies GTR Meeting – Punta Cana, Dominican Republic – 14 November 2013

Where is Jamaica?

Introduction Jamaica • Population 2.8 million • Annual births 39,000 • Crude birth rate 17/1000 • Infant mortality rate 20/1000 • Life expectancy (birth) • Males70.4 • Females 78.0 Y S Falls – St Elizabeth, Jamaica

Regions, Health CentresandHospitals WEST: 8,100 births NORTH EAST:5,300 births Tertiary referral hospitals Regional CEmOC hospitals SOUTH: 8,600 births SOUTH EAST: 17,300 births Parish BEmOC hospitals

fertility & maternal mortality:1981-2012, Jamaica General fertility rate/ 1000 ♀ reproductive age

Maternal mortality trends, Jamaica:1981-2012 (ratio/100 000 live births)

Outline of presentation Discuss the strengths and weaknesses of Jamaica’s surveillance system by examining: • Coverage • Links between levels of the health system • Method of analysis • Response and action • Implementation and supervision • Accountability mechanisms • Lessons learnt

Coverage Identifying and addressing reporting gaps

Case definition:Challenges & Solutions • WHO definition of maternal death difficult to implement in practice for surveillance • Direct, indirect; pregnancy – 42 days postpartum • Case definition simplified (2004) to: • Death in woman 10-50 years • Evidence of pregnancy in last year, regardless of place of death • Case review classifies deaths and exclude as necessary • Direct, indirect, late • Coincidental (accidents, violence, not pregnancy related)

Monitoring completeness • Initially validated coverage (2003, 2007) to plug gaps • Deaths in A& E (pre-admission) • Deaths on medical and surgical wards (puerperal admissions) • Deaths in ICU (transfers in particularly get missed) • ICU physicians less interested in underlying obstetric causes • Process expanded to cover non-obstetric wards

Under-reporting of maternal deaths in vital data: 2008 • Under-reporting of maternal deaths in official data: 0-35% annually! • Maternal deaths identified from: surveillance, hospital validation, Coroners case review, vital registration • For registered deaths – reviewed death certificates • Quality of certification, coding, transcription errors • 76% of maternal deaths missed due to - • Delayed/Non-registration – 20% (10/50) - mostly Coroners cases • Inadequate certification – 8% (4/50) – pregnancy not recorded • Incorrect coding – 42% (21/50) • Coded to maternal conditions – 24% (12/50) – MMR=23.6/100,000

Maternal deaths missed by surveillance or not registered, Jamaica: 2008

Information gap • Persistent bias - Coroners cases = Community deaths • Forensic pathologists = Ministry of National Security • Do not share necropsy findings with Ministry of Health • including maternal deaths • Common causes of sudden maternal death • Ruptured ectopic pregnancies • Complications of abortion • Deaths 3-6 weeks post partum at home • Stroke, heart disease, puerperal sepsis • Late maternal deaths (>6 weeks post partum) • including infection, stroke, cardiovascular events • Coincidental deaths: accidents, violence, including suicide • Suicide reclassified by WHO (2007) as a direct maternal death • Memorandum of understanding needed • Ministries of Health, National Security

Linkages Movement of information Community  Region  Ministry Between regions

Flowchart – JamaicaMaternal Mortality Surveillance & Response Death - ♀ 10-49 years Evidence of pregnancy last 12 months Facility Community Parish Notification (IDSR* form) Clinical [inpatient] summary Home visit (verbal autopsy) Antenatal summary Post mortem Multi-disciplinary case review (quarterly) Health region Case report to MOH Local action National review (annually) National National policy interventions *IDSR – infectious disease surveillance reporting

Women crossing regional jurisdictions • Mothers move across parish and regional borders for… • Tertiary care (2 of 4 regions): ICU, highly specialized care • High risk antenatal & comprehensive obstetric care (9 of 14 parishes) at delivery • For some mountain communities, nearest hospital may be in the next region • Facility of death should: • Notify Ministry of Health and parish of residence • Parish/region of residenceexpected to: • Do home visit(verbal autopsy) • Provide antenatal care summary/clinical summary pre-transfer • Facility of death should compile and sharewith parish/region of origin: • Clinical summary – referral care • Post mortem report • Region of death is responsible for the Case review • Case summary provided to parish/region of residence • National epidemiologist attributes the death to parish/region of residence • Rates calculated by region of residence

Method of analysis Regional review meetings Strategies to build local confidence Role of the national committee

Getting reviews going • Enthusiasm for surveillance varied by health region • e.g. west, south didn’t come on board initially • Facility review meetings: • Sometimes deteriorated into ‘blame and shame’ sessions • Ministry of Health was committed to process • To bring all regions on board, Ministry of Health made it policy that all regions should have routine regional MM reviews • Policy guidelines issued and training done • Data collection instruments • Case review process • Meetings should occur at least quarterly, depending on case load

Understanding the causes of death: clinical and social • Post mortem recommended - achieved in ~60% cases • Deaths during pregnancy – 57% • 0-6 days post partum – 67% • 7-42 days post partum – 55% • Home visit – to understand the social determinants • May vary by region for the same UCOD, e.g. Eclampsia • Urban setting – violence prevent mother getting to hospital • Rural setting – transportation, distance, cost • SOLUTIONS DIFFERENT • Sometimes its only way to understand the clinical COD • e.g. Uterine rupture – no clinical cause at post mortem

Regional review meetings • Multidisciplinary meeting • Cases discussed by practitioners and supervisors from all parishes within region • Primary (PHC) and secondary (SHC) care teams represented • PHC: Midwives, public health nurses, medical officers of health • SHC: Obstetrician(s), Matron or obstetric sister, pathologist • Elements of case presented by each investigator • PHN/RM (home visit; antenatal care summary) • Attending physician/obstetrician (clinical summary) • Pathologist (post mortem report) • Supervisory oversight • Regional supervisors: Regional technical director, epidemiologist • National committee: Director - Family Health Services, surveillance officer, reproductive health epidemiologist (AMcB)

Case Review & Decision Making • Try to focus on the systemic failures why women died • Review similar cases together to identify common threads, e.g. • Pre-eclampsia (non-compliance with referral)  • Monitor with repeat visit to community ANC one week later • Home visit, if no-show • Diabetes in pregnancy (late diagnosis)  • Screen obese women (no diabetic deaths in last triennium) • Late deaths (mostly women with medical complications) • Post natal referral to general medical clinic at end of puerperium • Was the death avoidable? At what point? • Recognition of problem by women; not seeking care early • Health promotion at antenatal clinic • At the health facility • Challenges with diagnosis; appropriate treatment • Stigma (abortion, HIV) • Timely transfer of women to appropriate level of care

Response and action The weakest or strongest link Implementation and supervision

Technical assistance to teams • Health teams needed: • Technical assistance in interpreting findings • Training in how to code and classify the deaths • Next round of guidelines included Access database with: • Data entry screens • Layout similar to data collection tools to reduce transcription errors • Drop down menu to quickly code underlying cause of death • Some regions use it – others still send paper records to the Ministry of Health

Response and resource limitations • Some interventions have policy implications which require national leadership, e.g. • Development of clinical guidelines • Training • Health promotion • Upgrade of facilities (2 basic hospitals upgraded to comprehensive) • Long term maintenance of equipment • Ultrasound machines • Other high tech equipment • Multiple providers • Multiple spare parts • Technical support/skills

Case Review & Decision Making: Low/no cost solutions • Working around identified roadblocks • Delays accessing referral high risk AN care • Referred patients must be triaged by midwife if clinic over crowded and patients must go home without being seen • South-east region now taking high risk clinics out of the hospital into selected primary care locations • Delays accessing EmOC in pregnancy – long A&E wait • Bypass A&E in 3rd trimester  labour ward review by RM

Use of findings to improve care • Financing structural improvements – extra budgetary • National committee/Director of Family Health leads the preparation of proposal for international financing • Upgrade CEMoC hospitals (years in the making) by establishing dedicated high dependency units on the obstetric wards • Project now funded and awaiting implementation • Another round of RFP for supplies, equipment, training of staff etc. • Patience a valuable asset!

Accountability mechanisms Monitoring and evaluation Confidentiality of the enquiry process Building trust

Monitoring and evaluation (M&E) • Evaluation – completeness & effectiveness • Done episodically by national committee within the health sector • Resolution of problems outside health sector challenging • National team must work through the public sector to address challenges from without, e.g. • Access to Forensic pathologists cases • Vital registration issues • Effective M&E process lacking! • No consistent strategy to follow-up decisions made by regional review teams • Review teams mostly clinical, administrative support restricted to technical supervisors • Need to improve participation of managers at these meetings

Confidential enquiry process • MDSR is based on the concept of confidential enquiry • Challenge: how to respond when obvious malpractice identified • Who is to blame? • Obstetrician assigned to basic EmOC hospital • Facility not equipped to deal with complications • e.g. managing preterm infants – no nursery • Practices specialty skill • Patient develops complications • Death, serious morbidity • What to do when gentle persuasion fails?

MDSR successes – Jamaica: MMR by region Highest referral level: TERTIARY CARE WEST - Strong leadership by obstetric consultant at tertiary hospital NORTH EAST – most successful region re MDSR responsiveness

Summary – lessons learnt Importance of surveillance to understanding dynamics of maternal risk Successes and challenges Post MDGs – what next?

Setting it up – early buy in: Case reviews • Getting started – getting all the regions on board • Solutions • Making maternal deaths a Class I notifiable condition • Introduction of quarterly multidisciplinary regional review meetings • Supported by attendance of national level officers • Director of Family Health Services • National Surveillance Officer • National Reproductive Health Epidemiologist (AMcB)

Use of findings to improve care data synthesis, action cycles, demonstrating impact • Case review process & action: • Teams encouraged to review similar cases together • Focus on structural failures in care, versus whose was at fault • Some regions better at focusing attention on: • Most successful region identify change agent to lead response • Addressing service delivery deficits • Attitudes – willingness to change established behaviours • National meetings are opportunities for training and allow teams to share experiences and best practices, • however these did notalways become institutionalized in other regions!

Building responsive surveillance systems

Beyond 2015 Recommendations

Maternal mortality: Changing epidemiology MDSR has allowed Jamaica to better understand why mothers die Need to include coincidental and late maternal death in case definition Any mother’s death threatens her children’s lives

Building political zeal • Maternal deaths 35-50 per year • Infant deaths 900 per year • Stillbirths  800 per year • Births  39,000 • Preventing maternal deaths will not capture votes • Babies, not mothers grab voters and votes • How do we get politicians interested in reducing 39-50 deaths to 12-15 events per year? • Move away from mortality to morbidity prevention • Embrace within maternal mortality prevention, the saving of babies lives

Summary • Increasing indirectmortality, resurgence of (pre)-eclampsia, AIDS, reinforces need for active surveillance • Dynamic problem solving required • Qualitative studies needed to better understand the social challenges women face in: • Accessing care • Making reproductive choices • Surveillance is not expected to be comprehensive, but you need to understand the biases in the data and correct methodological flaws • Surveillance only useful if we are empowered to act on our findings

Acknowledgements • Director Family Health Services • Dr Karen Lewis-Bell • Regional Epidemiologists • Dr Vittilus Holder – South • Dr MaungAung – West • Dr Carla Hoo – North east • Dr O’Neil Watson – South east • Mrs Kelly-Ann Gordon – South easst • Surveillance Officers • Mrs Sabrina Beeput • Mrs Veneita Fyffe-Wright

Let’s keep their mother’s alive Thank You!!

Maternal death surveillance and response – Jamaica: What works