Presentation is loading. Please wait.

Presentation is loading. Please wait.

Maternal death surveillance and response – Jamaica: What works

Similar presentations


Presentation on theme: "Maternal death surveillance and response – Jamaica: What works"— 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?

3 Introduction Jamaica Population 2.8 million Annual births 39,000
Crude birth rate /1000 Infant mortality rate 20/1000 Life expectancy (birth) Males 70.4 Females 78.0 Y S Falls – St Elizabeth, Jamaica

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

5 fertility & maternal mortality: 1981-2012, Jamaica
General fertility rate/ 1000 ♀ reproductive age Family 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 age Family 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: Coverage Links between levels of the health system Method of analysis Response and action Implementation and supervision Accountability mechanisms Lessons learnt

9 Coverage Identifying and addressing reporting gaps

10 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)

11 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

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 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

13 Maternal deaths missed by surveillance or not registered, Jamaica: 2008
Cause of death All sources Maternal mortality surveillance Registered, certified as maternal Number % TOTAL 50 43 86·0 34 68·0 (Pre-)eclampsia 16 15 93·8 13 81·3 Haemorrhage 8 7 87·5 Ectopic pregnancy 5 1 20·0 2 40·0 Abortion 100 Other direct 4 3 75·0 Subtotal – DIRECT 35 28 80·0 27 77·1 Cardiovascular 57·1 Sickle cell disease 33·3 Other indirect Subtotal – INDIRECT 46·7 MMR [95% CI] 117.8 [ ] 101.3 [ ] 80.1 [ ]

14 Information gap Memorandum of understanding needed
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

15 Linkages Movement of information Community  Region  Ministry
Between regions

16 Flowchart – Jamaica Maternal Mortality Surveillance & Response
Death - ♀ years Evidence of pregnancy last 12 months Facility Community Parish Notification (IDSR* form) Home visit (verbal autopsy) Antenatal summary Clinical [inpatient] 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

17 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

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

19 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

20 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

21 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)

22 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

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

24 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 Finally, 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 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 Finally, 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 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

27 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!

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

29 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

30 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?

31 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

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

33 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)

34 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!

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.

36 Beyond 2015 Recommendations

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 mother’s death threatens her children’s lives While 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 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

39 Summary 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

40 Acknowledgements Director Family Health Services
Dr Karen Lewis-Bell Regional Epidemiologists Dr Vittilus Holder – South Dr Maung Aung – 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

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


Download ppt "Maternal death surveillance and response – Jamaica: What works"

Similar presentations


Ads by Google