1. Maternal, and Neonatal death audit. What is killing the women? Jolly Beyeza Kashesya AOGU

2. What is maternal mortality? Is the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and the site of the pregnancy Maternal Mortality Ratio (MMR): The number of maternal deaths for 100,000 live births. Not only a medical issue, but also a social, economic, political and human rights issue Differences in maternal mortality constitute the greatest inequality in health between developed and developing countries A neonatal death is defined as death during the first 28 days of life (0-27 days)

3. Magnitude of the problem Globally, at least 350,000 women die from pregnancy, childbirth or related complications MMR for Uganda virtually unchanged over past decade – modest reduction to 435/100,000 live births This is approximately 4,000-5000 deaths per year 16 deaths per day For every death, 20-30 suffer long term complications and disability. ( Fistulae, infertility, sepsis, foot drop)

4. Only a tip of the iceberg!!

5. Counting deaths is not enough We need to know – why they died – How – What killed them – How we can stop it

6. Audit and the audit cycle. Is a process whereby careful review and evaluation of care given to a pregnant woman, her unborn baby or neonate is undertaken? The Maternal and Perinatal death review (MPDR) is a qualitative, in-depth investigation of the causes and circumstances surrounding number of maternal deaths occurring at selected health facilities and communities. The main aim of such an audit is to identify avoidable factors so that the deaths could be reduced by taking appropriate actions against the identified preventable factors

7. MMR cycle

8. Reasons for Conducting the MPDR Done to improve on the quality of maternal and perinatal healthcare services at the health facility and community. To raise awareness among health professionals, administrators, programme managers, policy makers and community members about avoidable factors that contribute to maternal or perinatal death. To stimulate actions to address these avoidable factors and so prevent further maternal and perinatal deaths.

9. Principle of Conducting a MPDR 1 1.The meeting is meant to be an educational experience for all participants 2.The meeting is neither a court of law nor a disciplinary hearing! It must not be turned into witch hunting sessions 3.No names of patients or health professionals must be used when discussing a case 4.Anonymity of the people involved in management of the case under discussion should by all means be preserved 5.The problem must be addressed, not the person. Everyone makes mistakes. It is far better for one person to make a mistake and discuss it with others, so that the mistake is made only and not repeated by all the other people

10. Principle of Conducting a MPDR 2 5.Data must be collected at these meetings, e.g. an attempt must be made to find avoidable factors or missed opportunities, cause of death and whether the death was preventable or not. 6.Information must be given out at the meetings 7.Successes should also be discussed 8.Teaching, explaining or discussing protocols should be performed.

11. Maternal Death & perinatal death Case Review Report Forms: Summarizes the maternal death case review Summarizes the perinatal death case review Two parts: –Technical information –Maternal death review committee assessment

12. Conduct of the maternal death case review 3 phases: A.Reconstruct the woman’s itinerary: door-to- door. B.Analyze reasons and/or factors that resulted in positive and negative events of clinical management. C.Identify avoidable factors, actions and solutions to prevent such tragedies from re- occurring.

13. Woman’s itinerary & management: 1.Information on the woman’s transport to emergency obstetric care 2.Admission 3.Diagnosis 4.Treatment 5.Treatment monitoring and provision 6.Record keeping

14. B. Reasons or factors explaining positive & negative events: 1.When did this problem occur? 2.Is the staff sufficiently qualified to handle a situation of this gravity? 3.What caused the problem?

15. C. Identification of factors that can be improved upon & recommendations: 1.Infrastructure 2.Equipment 3.Drugs 4.Staff 5.Management Note: Health manager has a central role in availability and functionality of all the above

16. 1 st Delay Occurs within the household/family level Is related to the limited ability of the woman and her close relatives to make a decision to seek care. This is closely linked to the inability to appreciate danger signs of pregnancy, delivery and postpartum due to inadequate knowledge. In addition, some cultural practices restrict women from seeking health care, Poverty at the household level also limits decision making to seek health care.

17. 2 nd Delay Is related to inability of pregnant women with labour complications to access available health facilities when need arises. This is due to inadequate community support, lack of timely means of transport or resources to pay for it, long distances to health facilities, poor roads and communication. More than 38% of the population lives below the absolute poverty line, underpinning the role of poverty in birth preparedness.

18. Lack of timely means of transport

19. 3 rd Delay Is delay in receiving appropriate care at the health facilities. – At the facility level, preparedness to respond to obstetric and newborn emergencies is critical to the survival of women and the newborn. – Many health facilities, particularly HC IIIs and IIs lack adequate skilled attendants, equipment, drugs and supplies for appropriate care during pregnancy and after child birth. The functioning health centre or hospital is a critical factor in reducing the life-threatening delays and the subsequent prevention of maternal death and disability. – For example, post-partum haemorrhage can kill a woman in less than two hours! – But for most other complications, a woman has about 12 hours or more to get life-saving emergency care.

20. Medical causes of maternal mortality ** include anaemia,malaria, heart diseases *include ectopic pregnancy, embolism, anaethesia related

21. AUDIT IN MULAGO, MASAKA and BUHINGA

22. Status at Admission CharacteristicFrequencyPercentage Referrals (102) Home TBA Health Centre Hospital Private Clinic I 6 3 33 34 26 5.6 2.8 30.8 36.5 24.3 Admission Status Abortion ectopic Antenatal Labour Post partum 32 2 64 62 65 14.2 0.9 24.4 27.6 28.9 Condition on admission Stable Critically ill Dead on arrival 74 159 3 31.4 67.4 1.3

23. Comments on avoidable factors Personal/family factors – Poverty – Unsafe abortion from unwanted pregnancy – Delay in reaching hospital form home or other clinics – Waiting for husband

24. Comments on avoidable factors Health facility factors – Shortage of Blood and its products – Anesthetic accidents – Patient load, no theatre space – Delayed consultation/review by Drs (seniors) – Supplies shortage – Investigations are inadequate – Delay in instituting treatment (Antibiotics, quinine, TB) – Shortage of staff (anaesthesia and Midwives)

25. Underlying issues 41% attended to by skilled birth attendants Un met need for emergency obstetric care ( EMoC) 50% High fertility: Uganda has 1,500,000 pregnancies annually of which 775,000 are either unplanned, mistimed or completely unwanted [unmet need for FP– 41%] Total Fertility Rate [TFR]6.7% [Most women desire 4 children] Contraceptive prevalence rate [CPR] 24% ◦ [lower in younger people where most pregnancies occur] Birth interval: < 2 years – most women desire up to 3-4 years

26. Health system challenges Shortage of human resources Road and communication infrastructural Shortages of equipment, supplies & their management Poor referral mechanisms & infrastructure

27. Challenges cont... Weaknesses in policy interpretation & implementation – including funding Lack of community participation including failure to make decisions to seek care Poor health care financing Gaps in monitoring and evaluation of health programs

28. Maternal Health Goes Beyond Health Services low perception of risk; low level of male involvement in reproductive health and rights, harmful and negative culture on reproduction, food/nutrition, gender relations, health seeking behaviour and hygiene poor infrastructure i.e. power, light, sanitation facilities and safe water. Underlying factors include: – high disease burden (e.g. malaria, HIV/AIDS), – high prevalence of protein/calorie malnutrition and micronutrient deficiencies; – Low education levels; – gender inequalities and low status of women.

29. Prevention of Maternal Mortality Linked to; – Effective family planning Up to 32% of maternal deaths can be prevented – Skilled birth attendants are proven to reduce maternal deaths through provision of quality maternity care Only 42% of births attended by skilled birth attendants – Quality Emergency Obstetric Care [EmOC] National met need for EmOC is 24% C-section 2.7% vs 5%

30. Maternal mortality is a massive problem but the way you look at it matters!!! Weaknesses in policy interpretation & implementation – including funding Lack of community participation Health system challenges “I am going to fetch a baby. The journey is harzardous and I may not return …”

31. Key strategies to reduce maternal mortality Access to contraceptives, to avoid unintended pregnancies Access to skilled care at the time of birth Timely access to emergency obstetric care in the event of complications Up to 32% of maternal deaths can be prevented Up to 74% of maternal deaths can be prevented

33. "Women are not dying of diseases we can't treat.... They are dying because societies have yet to make the decision that their lives are worth saving.” – Mahmoud Fathalla, past president of the International Federation of Obstetricians and Gynecologists The litmus test of a country's worth should be measured by how the country has cared for its mothers – Jolly Beyeza Kashesya believes

34. What is the role of media? The media is respected and listened to How can the media help? – Appropriate & factual health reporting? – Reaching out to policy makers and program managers – Interfacing with funders and those who decide to fund maternal health or not 1.What roles would you play to impact on this problem? 2. Where do we start? 1.What roles would you play to impact on this problem? 2. Where do we start?