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MATERNAL DEATH SURVEILLANCE AND RESPONSE – JAMAICA: WHAT WORKS Prof. Affette McCaw-Binns, University of the West Indies GTR Meeting – Punta Cana, Dominican.

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Presentation on theme: "MATERNAL DEATH SURVEILLANCE AND RESPONSE – JAMAICA: WHAT WORKS Prof. Affette McCaw-Binns, University of the West Indies GTR Meeting – Punta Cana, Dominican."— Presentation transcript:

1 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

2 Where is Jamaica? 2

3 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 Females78.0 Y S Falls – St Elizabeth, Jamaica 3

4 Regions, Health Centres andHospitals Tertiary referral hospitals Regional CEmOC hospitals Parish BEmOC hospitals SOUTH EAST: 17,300 births SOUTH: 8,600 births WEST: 8,100 births NORTH EAST: 5,300 births 4

5 Click to edit Master title style FERTILITY & MATERNAL MORTALITY : , J AMAICA 5 Gen eral fertility rate/ 1000 reproductive age

6 Click to edit Master title style FERTILITY & MATERNAL MORTALITY : , J AMAICA 6 Gen eral fertility rate/ 1000 reproductive age

7 Click to edit Master title style Maternal mortality trends, Jamaica: (ratio/ live births ) 7

8 Click to edit Master title styleOutline of presentation Discuss the strengths and weaknesses of Jamaicas 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 8

9 Identifying and addressing reporting gaps Coverage 9

10 Click to edit Master title style 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 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) 10

11 Click to edit Master title styleMonitoring 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 11

12 Click to edit Master title style 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 12

13 Click to edit Master title style Maternal deaths missed by surveillance or not registered, Jamaica: 2008 Cause of death All sources Maternal mortality surveillance Registered, certified as maternal Number % % TOTAL504386·03468·0 (Pre-)eclampsia161593·81381·3 Haemorrhage8787·57 Ectopic pregnancy5120·0240·0 Abortion Other direct ·0 Subtotal – DIRECT352880·02777·1 Cardiovascular ·1 Sickle cell disease ·3 Other indirect ·0 Subtotal – INDIRECT ·7 MMR [95% CI] [ ]101.3 [ ]80.1 [ ] 13

14 Click to edit Master title styleInformation 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 14

15 Movement of information Community Region Ministry Between regions Linkages 15

16 Flowchart – Jamaica Maternal Mortality Surveillance & Response Death years Evidence of pregnancy last 12 months Post mortem Home visit (verbal autopsy) Antenatal summary Clinical [inpatient] summary Notification ( IDSR * form ) Multi-disciplinary case review (quarterly) Case report to MOH Local action National review (annually) National policy interventions *IDSR – infectious disease surveillance reporting Facility Community Parish Health region National 16

17 Click to edit Master title style 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 residence expected to: Do home visit (verbal autopsy) Provide antenatal care summary/clinical summary pre-transfer Facility of death should compile and share with 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 17

18 Regional review meetings Strategies to build local confidence Role of the national committee Method of analysis 18

19 Click to edit Master title styleGetting reviews going Enthusiasm for surveillance varied by health region e.g. west, south didnt 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 19

20 Click to edit Master title style 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 20

21 Click to edit Master title styleRegional 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) 21

22 Click to edit Master title styleCase 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 22

23 The weakest or strongest link Implementation and supervision Response and action 23

24 Click to edit Master title styleTechnical 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 24

25 Click to edit Master title styleResponse 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 25

26 Click to edit Master title style 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 3 rd trimester labour ward review by RM 26

27 Click to edit Master title style 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! 27

28 Monitoring and evaluation Confidentiality of the enquiry process Building trust Accountability mechanisms 28

29 Click to edit Master title styleMonitoring 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 29

30 Click to edit Master title styleConfidential 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? 30

31 MDSR successes – Jamaica: MMR by region WEST - Strong leadership by obstetric consultant at tertiary hospital NORTH EAST – most successful region re MDSR responsiveness Highest referral level: TERTIARY CARE 31

32 Importance of surveillance to understanding dynamics of maternal risk Successes and challenges Post MDGs – what next? Summary – lessons learnt 32

33 Click to edit Master title style Setting it up – early buy in: Case reviews Getting started – getting all the regions on board Solutions 1. Making maternal deaths a Class I notifiable condition 2. 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) 33

34 Click to edit Master title style 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 not always become institutionalized in other regions! 34

35 Click to edit Master title style Building responsive surveillance systems 35

36 Recommendations Beyond

37 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 mothers death threatens her childrens lives 37

38 Click to edit Master title styleBuilding political zeal Maternal deaths 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 deaths to events per year? Move away from mortality to morbidity prevention Embrace within maternal mortality prevention, the saving of babies lives 38

39 Click to edit Master title styleSummary Increasing indirect mortality, 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 39

40 Click to edit Master title styleAcknowledgements Director Family Health Services Dr Karen Lewis-Bell Regional Epidemiologists Dr Vittilus Holder – South Dr Maung Aung – West Dr Carla Hoo – North east Dr ONeil Watson – South east Mrs Kelly-Ann Gordon – South easst Surveillance Officers Mrs Sabrina Beeput Mrs Veneita Fyffe-Wright 40

41 Thank You!! Lets keep their mothers alive 41

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