3 Introduction Jamaica Population 2.8 million Annual births 39,000 Crude birth rate /1000Infant mortality rate 20/1000Life expectancy (birth)Males 70.4Females 78.0Y S Falls – St Elizabeth, Jamaica
4 Regions, Health Centres andHospitals WEST: 8,100 birthsNORTH EAST: 5,300 birthsThere are four health regions. Tourism is concentrated in the least populous western and north east regions where the best beaches are; while the southern region represents the breadbasket of the country. The capital Kingston is located in the most urbanised south est regions where twice as many births occur each year. Primary health care facilities are well distributed, those blue dots. 20 public hospitals attend over 95% of births, with at least one per parish. Each region has at least one comprehensive obstetric care facility however tertiary care is restricted to Montego bay in the west and Kingston in the south east, along with the teaching hospital.Tertiary referral hospitalsRegional CEmOC hospitalsSOUTH:8,600 birthsSOUTH EAST:17,300 birthsParish BEmOC hospitals
5 fertility & maternal mortality: 1981-2012, Jamaica General fertility rate/1000 ♀ reproductive ageFamily planning has been promoted as a strategy for reducing maternal deaths. It works to a point. Once the general fertility rate fell The changing fertility is shown as the general fertility rate (in red). This demographic shift toward older mothers with more health problems preceding pregnancy, and fewer overall births, has contributed to the stagnation in the maternal mortality ratio (in blue), whose denominator is total births. The maternal mortality rate (in green) which uses as the denominator the population of women of reproductive age, demonstrates that the age specific mortality rate among women of childbearing age has declined due to effective use of family planning. This has however has effectively delayed childbearing into the older age groups when the risk of complications are higher; with the rate of decrease of maternal deaths slower than the rate of decrease in fertility. As the global community promotes increased access to family planning to prevent maternal deaths, we will need to monitor both the maternal mortality ratio and the rate.
6 fertility & maternal mortality: 1981-2012, Jamaica General fertility rate/1000 ♀ reproductive ageFamily planning has been promoted as a strategy for reducing maternal deaths. It works to a point. Once the general fertility rate fell The changing fertility is shown as the general fertility rate (in red). This demographic shift toward older mothers with more health problems preceding pregnancy, and fewer overall births, has contributed to the stagnation in the maternal mortality ratio (in blue), whose denominator is total births. The maternal mortality rate (in green) which uses as the denominator the population of women of reproductive age, demonstrates that the age specific mortality rate among women of childbearing age has declined due to effective use of family planning. This has however has effectively delayed childbearing into the older age groups when the risk of complications are higher; with the rate of decrease of maternal deaths slower than the rate of decrease in fertility. As the global community promotes increased access to family planning to prevent maternal deaths, we will need to monitor both the maternal mortality ratio and the rate.
7 Maternal mortality trends, Jamaica:1981-2012 (ratio/100 000 live births) While the direct rate declined steadily, this was negated by increasing indirect mortality up to , after which it began to decline.
8 Outline of presentation Discuss the strengths and weaknesses of Jamaica’s surveillance system by examining:CoverageLinks between levels of the health systemMethod of analysisResponse and actionImplementation and supervisionAccountability mechanismsLessons learnt
9 CoverageIdentifying and addressing reporting gaps
10 Case definition: Challenges & Solutions WHO definition of maternal death difficult to implement in practice for surveillanceDirect, indirect; pregnancy – 42 days postpartumCase definition simplified (2004) to:Death in woman yearsEvidence of pregnancy in last year, regardless of place of deathCase review classifies deaths and exclude as necessaryDirect, indirect, lateCoincidental (accidents, violence, not pregnancy related)
11 Monitoring completeness Initially validated coverage (2003, 2007) to plug gapsDeaths 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 causesProcess expanded to cover non-obstetric wards
12 Under-reporting of maternal deaths in vital data: 2008 Under-reporting of maternal deaths in official data: % annually!Maternal deaths identified from: surveillance, hospital validation, Coroners case review, vital registrationFor registered deaths – reviewed death certificatesQuality of certification, coding, transcription errors76% of maternal deaths missed due to -Delayed/Non-registration – 20% (10/50) - mostly Coroners casesInadequate certification – 8% (4/50) – pregnancy not recordedIncorrect coding – 42% (21/50)Coded to maternal conditions – 24% (12/50) – MMR=23.6/100,000
13 Maternal deaths missed by surveillance or not registered, Jamaica: 2008 Cause of deathAll sourcesMaternal mortality surveillanceRegistered, certified as maternalNumber%TOTAL504386·03468·0(Pre-)eclampsia161593·81381·3Haemorrhage8787·5Ectopic pregnancy5120·0240·0Abortion100Other direct4375·0Subtotal – DIRECT352880·02777·1Cardiovascular57·1Sickle cell disease33·3Other indirectSubtotal – INDIRECT46·7MMR [95% CI]117.8 [ ]101.3 [ ]80.1 [ ]
14 Information gap Memorandum of understanding needed Persistent bias - Coroners cases = Community deathsForensic pathologists = Ministry of National SecurityDo not share necropsy findings with Ministry of Healthincluding maternal deathsCommon causes of sudden maternal deathRuptured ectopic pregnanciesComplications of abortionDeaths 3-6 weeks post partum at homeStroke, heart disease, puerperal sepsisLate maternal deaths (>6 weeks post partum)including infection, stroke, cardiovascular eventsCoincidental deaths: accidents, violence, including suicideSuicide reclassified by WHO (2007) as a direct maternal deathMemorandum of understanding neededMinistries of Health, National Security
15 Linkages Movement of information Community Region Ministry Between regions
16 Flowchart – Jamaica Maternal Mortality Surveillance & Response Death - ♀ yearsEvidence of pregnancy last 12 monthsFacilityCommunityParishNotification (IDSR* form)Home visit(verbal autopsy)Antenatal summaryClinical [inpatient] summaryPost mortemMulti-disciplinary case review (quarterly)HealthregionCase report to MOHLocal actionNational review (annually)NationalNational policy interventions*IDSR – infectious diseasesurveillance reporting
17 Women crossing regional jurisdictions Mothers move across parish and regional borders for…Tertiary care (2 of 4 regions): ICU, highly specialized careHigh risk antenatal & comprehensive obstetric care (9 of 14 parishes) at deliveryFor some mountain communities, nearest hospital may be in the next regionFacility of death should:Notify Ministry of Health and parish of residenceParish/region of residence expected to:Do home visit (verbal autopsy)Provide antenatal care summary/clinical summary pre-transferFacility of death should compile and share with parish/region of origin:Clinical summary – referral carePost mortem reportRegion of death is responsible for the Case reviewCase summary provided to parish/region of residenceNational epidemiologist attributes the death to parish/region of residenceRates calculated by region of residence
18 Method of analysis Regional review meetings Strategies to build local confidenceRole of the national committee
19 Getting reviews goingEnthusiasm for surveillance varied by health regione.g. west, south didn’t come on board initiallyFacility review meetings:Sometimes deteriorated into ‘blame and shame’ sessionsMinistry of Health was committed to processTo bring all regions on board, Ministry of Health made it policy that all regions should have routine regional MM reviewsPolicy guidelines issued and training doneData collection instrumentsCase review processMeetings should occur at least quarterly, depending on case load
20 Understanding the causes of death: clinical and social Post mortem recommended - achieved in ~60% casesDeaths during pregnancy – 57%0-6 days post partum – 67%7-42 days post partum – 55%Home visit – to understand the social determinantsMay vary by region for the same UCOD, e.g. EclampsiaUrban setting – violence prevent mother getting to hospitalRural setting – transportation, distance, costSOLUTIONS DIFFERENTSometimes its only way to understand the clinical CODe.g. Uterine rupture – no clinical cause at post mortem
21 Regional review meetings Multidisciplinary meetingCases discussed by practitioners and supervisors from all parishes within regionPrimary (PHC) and secondary (SHC) care teams representedPHC: Midwives, public health nurses, medical officers of healthSHC: Obstetrician(s), Matron or obstetric sister, pathologistElements of case presented by each investigatorPHN/RM (home visit; antenatal care summary)Attending physician/obstetrician (clinical summary)Pathologist (post mortem report)Supervisory oversightRegional supervisors: Regional technical director, epidemiologistNational committee: Director - Family Health Services, surveillance officer, reproductive health epidemiologist (AMcB)
22 Case Review & Decision Making Try to focus on the systemic failures why women diedReview similar cases together to identify common threads, e.g.Pre-eclampsia (non-compliance with referral) Monitor with repeat visit to community ANC one week laterHome visit, if no-showDiabetes 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 puerperiumWas the death avoidable? At what point?Recognition of problem by women; not seeking care earlyHealth promotion at antenatal clinicAt the health facilityChallenges with diagnosis; appropriate treatmentStigma (abortion, HIV)Timely transfer of women to appropriate level of care
23 Response and action The weakest or strongest link Implementation and supervision
24 Technical assistance to teams Health teams needed:Technical assistance in interpreting findingsTraining in how to code and classify the deathsNext round of guidelines included Access database with:Data entry screensLayout similar to data collection tools to reduce transcription errorsDrop down menu to quickly code underlying cause of deathSome regions use it – others still send paper records to the Ministry of HealthFinally, we hope that these lessons learned can help to improve the MMSS at the country, regional and global level. We believe that a strong MMSS, can generate awareness at all levels, and is a contributor to the improvement of the health and care of mothers, newborns and families.Thank you very much for letting us share this with you.
25 Response and resource limitations Some interventions have policy implications which require national leadership, e.g.Development of clinical guidelinesTrainingHealth promotionUpgrade of facilities (2 basic hospitals upgraded to comprehensive)Long term maintenance of equipmentUltrasound machinesOther high tech equipmentMultiple providersMultiple spare partsTechnical support/skillsFinally, we hope that these lessons learned can help to improve the MMSS at the country, regional and global level. We believe that a strong MMSS, can generate awareness at all levels, and is a contributor to the improvement of the health and care of mothers, newborns and families.Thank you very much for letting us share this with you.
26 Case Review & Decision Making: Low/no cost solutions Working around identified roadblocksDelays accessing referral high risk AN careReferred patients must be triaged by midwife if clinic over crowded and patients must go home without being seenSouth-east region now taking high risk clinics out of the hospital into selected primary care locationsDelays accessing EmOC in pregnancy – long A&E waitBypass A&E in 3rd trimester labour ward review by RM
27 Use of findings to improve care Financing structural improvements – extra budgetaryNational committee/Director of Family Health leads the preparation of proposal for international financingUpgrade CEMoC hospitals (years in the making) by establishing dedicated high dependency units on the obstetric wardsProject now funded and awaiting implementationAnother round of RFP for supplies, equipment, training of staff etc.Patience a valuable asset!
28 Accountability mechanisms Monitoring and evaluationConfidentiality of the enquiry processBuilding trust
29 Monitoring and evaluation (M&E) Evaluation – completeness & effectivenessDone episodically by national committee within the health sectorResolution of problems outside health sector challengingNational team must work through the public sector to address challenges from without, e.g.Access to Forensic pathologists casesVital registration issuesEffective M&E process lacking!No consistent strategy to follow-up decisions made by regional review teamsReview teams mostly clinical, administrative support restricted to technical supervisorsNeed to improve participation of managers at these meetings
30 Confidential enquiry process MDSR is based on the concept of confidential enquiryChallenge: how to respond when obvious malpractice identifiedWho is to blame?Obstetrician assigned to basic EmOC hospitalFacility not equipped to deal with complicationse.g. managing preterm infants – no nurseryPractices specialty skillPatient develops complicationsDeath, serious morbidityWhat to do when gentle persuasion fails?
31 MDSR successes – Jamaica: MMR by region Highest referral level:TERTIARY CAREWEST- Strong leadership by obstetric consultant at tertiary hospitalNORTH EAST– most successful region re MDSR responsiveness
32 Summary – lessons learnt Importance of surveillance to understanding dynamics of maternal riskSuccesses and challengesPost MDGs – what next?
33 Setting it up – early buy in: Case reviews Getting started – getting all the regions on boardSolutionsMaking maternal deaths a Class I notifiable conditionIntroduction of quarterly multidisciplinary regional review meetingsSupported by attendance of national level officersDirector of Family Health ServicesNational Surveillance OfficerNational Reproductive Health Epidemiologist (AMcB)
34 Use of findings to improve care data synthesis, action cycles, demonstrating impact Case review process & action:Teams encouraged to review similar cases togetherFocus on structural failures in care, versus whose was at faultSome regions better at focusing attention on:Most successful region identify change agent to lead responseAddressing service delivery deficitsAttitudes – willingness to change established behavioursNational meetings are opportunities for training and allow teams to share experiences and best practices,however these did not always become institutionalized in other regions!
35 Building responsive surveillance systems In summary, the risk of dying in pregnancy is dynamic as the reproductive age population changes over time. As we solve todays problem, nature provides other challenges, requiring continuous surveillance to keep pace with the evolving epidemiology. In the post MDG era, development partners must enable countries to make the hard choice and invest in developing health information systems to effectively inform their health policies and programmes.
37 Maternal mortality: Changing epidemiology MDSR has allowed Jamaica to better understand why mothers dieNeed to include coincidental and late maternal death in case definitionAny mother’s death threatens her children’s livesWhile direct complications such as hypertension and haemorrage as causes of maternal death have declined over the last 20 years, abortive outcomes, which include complications of abortion and ectopic gestations are on the rise. We note from maternal mortality reviews that women are subject to discriminatory practices from the health team when they attend hospital seeking care after attempting to terminate an unwanted pregnancy. Every year in the last 4-5 years we have deaths from ectopic gestations which were not properly investigated because women reported attempting to terminate the pregnancy. A pregnancy test should still be done to determine whether the woman is still pregnant or not and an abdominal ultrasound should be done to rule out an ectopic gestation if women complain about abdominal pain during the first trimester. Indirect deaths – medical complications arising during pregnancy are on the rise especially from heart disease and other lifestyle related conditions associated with the growing incidence of obesity in the population, even among adolescents. All obese patients should be screened in pregnancy for gestational diabetes and all obese patients and women with sickle cell disease should be attended at a Type B or higher hospital as the possible need for medical consultations during labour, delivery and the puerperium are high. The growing prevalence of violence in society has not excluded the pregnant and postpartum population, with the majority of coincidental deaths due to violence. There are however cases of motor vehicle accidents and other accidents as well. While better antenatal care has contributed to the decline in the leading direct causes of death, efforts are needed to improve our identification and referral of women with medical problems early enough to increase their chances of a successful pregnancy. For our community midwives, it is important that at the end of the puerperium, the traditional six week visit, women with medical problems should be referred to the general medical clinic for continued supervision and care. That also includes women with the hypertensive disorders whose blood pressures have not returned to normal by then.
38 Building political zeal Maternal deaths per yearInfant deaths 900 per yearStillbirths 800 per yearBirths 39,000Preventing maternal deaths will not capture votesBabies, not mothers grab voters and votesHow do we get politicians interested in reducing deaths to events per year?Move away from mortality to morbidity preventionEmbrace within maternal mortality prevention, the saving of babies lives
39 SummaryIncreasing indirect mortality, resurgence of (pre)-eclampsia, AIDS, reinforces need for active surveillanceDynamic problem solving requiredQualitative studies needed to better understand the social challenges women face in:Accessing careMaking reproductive choicesSurveillance is not expected to be comprehensive, but you need to understand the biases in the data and correct methodological flawsSurveillance only useful if we are empowered to act on our findings
40 Acknowledgements Director Family Health Services Dr Karen Lewis-BellRegional EpidemiologistsDr Vittilus Holder – SouthDr Maung Aung – WestDr Carla Hoo – North eastDr O’Neil Watson – South eastMrs Kelly-Ann Gordon – South easstSurveillance OfficersMrs Sabrina BeeputMrs Veneita Fyffe-Wright
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