A Sri Lankan Case Study Dr. Hiranthi Wijemanne SRI LANKA

1. International RoundtableMaternal Mortality, Human Rights and AccountabilityWhat are Maternal Death Audits A Sri Lankan Case Study Dr. Hiranthi WijemanneSRI LANKA

2. Key Approaches to the Conduct of an Audit / Maternal Death Review • Community Based / Verbal Autopsies ~ Deaths which occur outside health facilities, ascertaining personal/ family/ community issues. ~ Determining medical causes. ~ Requires co-operation from the family. Needs sensitivity in discussing the circumstances of the death.

3. Facility Based Maternal Death Reviews ~ In-depth, qualitative investigation of the causes of and circumstances in which maternal deaths occur at health facilities. Needs the identification of a combination of factors in the community and facility which may have contributed to the death, and determining which ones were preventable. ~ Requires the co-operation of care providers to the women who died, their willingness to report accurately on management of the case.

4. Confidential Inquiries ~ A systematic, multi disciplinary, anonymous investigation of all or a representative sample of maternal death occurring in an area, region or at national level. It identifies numbers, causes, avoidable and remedial factors. ~ Requires a functioning statistical system (vital records of analysis of births and deaths, human resources etc) or nominated staff in each facility to regularly report maternal deaths to the inquiry.

5. Surveys of Severe Morbidity (“near misses”) ~ The identification and assessment of cases in which the pregnant woman survives obstetric complications. No universally applicable definition. But definition used in any survey must be applicable to the local situation and enable improvements in maternal care. ~ Needs a good quality medical record system, a management culture free of the fear of blame, strong commitment by management and clinical staff to act upon findings.

6. Clinical Audit ~ Clinical Audit is a process of quality improvement that seeks to improve patient care and outcome through a systematic reviewing of the structure, processes and outcome of care, judged on the basis of specific criteria, with implementation of changes at individual, team and service levels to remedy the situation. Further monitoring is required to confirm such improvements have occurred in the maternal health care delivery. ~ It must be possible to identify relevant cases from facility registers and retrieve case notes. Health personnel should feel free to openly discuss case management and apply revised care protocols.

7. History of Maternal Death Surveillance in Sri Lanka 1950’s • Maternal deaths were investigated by Public Health midwives who reported the findings to medical officers of health of the areas concerned. In hospitals, a more informal investigation occurred. Less deliveries occurred in institutions. 1960’s • First time, a maternal death investigation format was introduced, but it lacked completeness and there were no routine, formal reviews.

8. 1985 • First formal Maternal Death review was introduced, linked to the reviews of immunization coverage, chaired by the Secretary of Health. Maternal Death investigation and review processes were systematized, and guidelines for investigation introduced to hospitals and MOH areas. 1989 • Further strengthening of Maternal Death investigation and review processes. Guidelines for investigation sent to all hospitals, institutions and MOH units. Maternal deaths were made notifiable. Notification was mandatory by both institutional and public health staff. Notified maternal deaths were investigated by both the field institutions where it occurred by the relevant health staff.

9. 1996 • A review was undertaken of the estimates and causes of Maternal Deaths in Sri Lanka. The study aimed to obtain accurate estimates of Maternal Deaths and reviewed factors contributing to the deaths; both patient responsibilities and the institutions providing care, were included. The pooled estimate of Maternal Deaths for 1996 (246) was 3 times the estimate made in the civil registration system. • Conduct of a Needs Assessment Study in 2001 on Women’s Right to life and Health. It sought to address Maternal Mortality and Morbidity as a Human Rights Issue.

10. Annual reviews continued to be held by the Ministry of Health, chaired by the Secretary of Health with the participation of the Family Health Bureau in collaboration and the Sri Lanka College of Obstetricians. They were joined by the Sri Lanka College of Anesthesiologists and Sri Lanka College of Forensic Pathologists. It was at these reviews that the exact cause of death for each individual Maternal death was established, and the key contributory factors according to the 3 Delay model adopted for Sri Lanka. • There are Maternal Deaths which occur in Sri Lanka which are still preventable. Maternal Morbidity can be further reduced.

11. Beyond the NumbersSri Lanka’sSurveillance Cycle of Maternal Deaths Identify individual Cases Evaluate and refine, Take action Collect accurate Information Recommend action Analysis

12. Criteria for Maternal Death Notification • All Deaths of women who died during pregnancy and within 42 days of termination of pregnancy irrespective of the cause of death. • All late Maternal Deaths. (42 days up to one year after termination following direct/indirect maternal causes) • Since 1986 it was compulsory to notify and investigate each death.

13. National Structure of Maternal Death Investigation F E E D B A C K & F O L L O W U P Maternal Death Notification by field & hospitals by the RDHS, FHB I N V E S T I G A T I O N Field Investigation Reporting Field – H677 To RDHS, FHB Hospital Investigation Reporting Field – H677 To RDHS, FHB Preventive action at MOH/ institutional/ district/ provincial level Quarterly District Review R E V I E W Annual National Review Preventive action at National Level

14. 3 Delay Model modified for Sri Lanka Delay 1 – In deciding to seek health care* Could be due to: - The low economic status of the family - The low educational status of the family - Not recognizing danger signals in time by mother / family/ friends Delay 2 – In reaching a medical facility* with adequate care Could be due to: - The distance from the primary health care facility - Lack of proper transport - Poor roads - The high cost of transport to reach the health facility Delay 3 – In receiving quality care at the facility* Could be due to: - System delay (e.g. Inadequacy of emergency obstetric car within the facilities (existing system not geared to address the service needs of the patients) - Substandard quality of services provided.

15. Lessons Learned from Audits(Information analysed up to end 2006) • Out of a total of 380,000 deliveries annually, 15% had morbidity issues, 140 have died. • Need to move towards “Near Miss inquiries” • Avoiding publicity and stigma useful. • Advantageous that no action is taken regarding professional negligence/rather the focus is on confirming the cause of death and gaps in management which need to be improved. • Still important that it is not confidential. • Still possibilities exist that 100% of the information may have not been exposed. • Maternal Death review information continues to be more accurate than that collected by the Registrar General's Office.

16. From a Rights perspective, Audits are important. • Strong leadership, at the highest policy level of the Secretary of Health valuable. • The active participation of high level policy makers from Colombo in district audits, with high numbers of Maternal Deaths important. • Desk reviews held in Colombo for districts affected by the conflict where local audits were not possible, but can now be held at local level. • A special focus on high mortality areas must continue.

17. The active collaboration of Public Health and institutional staff and the Sri Lanka College of Obstetricians of advantage. • Use of local protocols important. • Works well in Sri Lanka as the majority of deliveries (98%) were in institutions. • The field Public Health midwife plays a key role in investigations on the circumstances which lead to the death. • Investigations may not be entirely accurate in all instances as it is not a confidential inquiry. • In selected instances of gross negligence, if proven, the Sri Lanka Medical Council could enter into a process of establishing accountability and taking action on individual cases.

18. Action parallel to the Introduction of Maternal Death Audits • Conduct of a needs assessment in 1986 to improve the quality of maternal care and to further reduce Maternal Mortality/Morbidity. This identified gaps and deficiencies in the Maternal Health Care System. • Inputs identified to provide quality EmOC both basic and comprehensive/ Resources obtained and distributed. • Promotion of better management techniques to improve efficiency and effectiveness; leadership and motivation, self confidence and teamwork of the health staff/ Resources mobilized for training. • Introduction of a Rights based Approach.

19. Promotion of Rights aspects/ Treating clients and service providers with dignity. • Improving technical skills of health staff by training and the development of standard protocols on EmOC, particularly at peripheral hospitals. • Improving MIS in hospitals and establishing a monitoring system using process indicators. • Introduction of newborn care/ resuscitation/ thermal control for newborns, early initiation of BF.

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