1. MDSR: Evidence of Effectiveness from the International Literature

2. Cycle of Data Collection, Reflection & Action
IDENTIFY THE PROBLEM
MONITOR ACTIONS & ADAPT IF REQUIRED
COLLECT DATA
IMPLEMENT RECOMMENDATIONS
PRESENT DATA IN USEFUL FORMATS
PROPOSE SOLUTIONS
DISCUSS DATA WITH RELEVANT PEOPLE
ANALYSE DATA

3. Cycle of Data Collection, Reflection & Action
EVIDENCE
IDENTIFY THE PROBLEM
MONITOR ACTION & ADAPT IF REQUIRED
COLLECT DATA
IMPLEMENT RECOMMENDATIONS
PRESENT DATA IN USEFUL FORMATS
ACTION
DISCUSS DATA WITH RELEVANT PEOPLE
PROPOSE SOLUTIONS
ANALYSE DATA
REVIEW

4. Example 1: Piloting a new MDSR in ZAMBIA (Evidence of improved quality of care)

5. Piloting MDSR in Zambia
In 2007, Zambia’s MMR estimated at 591
Data often not recorded outside labour ward
EVIDENCE:
IMDA: Investigate Maternal Deaths and Act Piloted over 12 months
Facility & Community based data collection (TBA trained to notify maternal deaths)
Narrative approach to record immediate causes and wider social determinants
M. Hadley and M. Tuba (2011) Local problems; local solutions: an innovative approach to investigating and addressing causes of maternal deaths in Zambia’s Copperbelt. Reproductive Health 8:17  

6. Piloting and MDSR in Zambia
REVIEW:
4-5 anonymised cases discussed per meeting
11 Data review meetings held, chaired by Provincial Health Director
Participants: provincial & district officers, health staff, blood transfusion reps, TBA, external obstetricians
Total of 56 deaths reported (53 in tertiary hospital; 1 HC; 1 home)
Meetings also reviewed progress on previously identified action points

7. Families often sought traditional remedies first
 Health Seeking Issues:
Families often sought traditional remedies first
Some husband didn’t give approval to seek care
Communities lack resources for transport
Health systems weaknesses:
Shortfall in supplies
Absence of Obstetricians
Inadequate blood supply
Case Management at facilities:
67% cases had inaccurate diagnosis
Post mortems not routinely conducted
Malaria used as “default” cause of death in unclear cases but not confirmed

8. Obstetrician allocated to hospital Post mortems conducted
 ACTIONS (based on 68 recommendations):
Obstetrician allocated to hospital
Post mortems conducted
Antibiotics stocked for post-abortion and post-partum sepsis
Birth planning introduced in antenatal care
Measures to increase blood supply introduced

9. 61% recommendations implemented 12 % partially implemented
  RE-STARTING THE CYCLE :
Looking for Evidence of Progress one year later
61% recommendations implemented
12 % partially implemented
27% not implemented

10. Example 2: Facility Based MDSR in SENEGAL (Evidence of improved clinical outcomes)

11. MDSR Effects on Clinical Outcomes in Senegal
 Evidence:
Facility based MDR + interviews with family
Midwives responsible for identifying maternal deaths
Senior Obstetrician reviewed cases and collected data from others
Data analysed for baseline (1997) and 3 years after MDSR introduced ( )

12. MDSR Effects on Clinical Outcomes in Senegal
 REVIEW:
153 maternal deaths reviewed in total
District Health Manager chairs annual meetings and evaluates progress
ACTION:
13 recommendations implemented, mainly:
24-hour availability of life saving services, drugs and blood products
Improved availability of basic emergency obstetric care
Recommendations NOT implemented included
Expansion of delivery unit
Staff recruitment

13. Number of maternal deaths fell by almost 50% over the study period
 CHANGES IN QUALITY OF CARE:
Increased uptake of Antenatal care (in Year 1, 11% women had no ANC visit and by Year 2, just 4.2% did not attend)
Rates of transfusion up from 1% in Year 2 to 2.1% in Year 3
CHANGES IN MATERNAL MORTALITY:
Baseline: 50 deaths
Year 1: 43 deaths
Year 2: 33 deaths
Year 3: 27 deaths
Number of maternal deaths fell by almost 50% over the study period

14. From Dumont et al (2006) Facility Based Maternal Death Reviews: Effects on Maternal Mortality in a District Hospital in Senegal. Bulletin of the World Health Organization 84:

15. Summary Points
MDSRs involve an ongoing cycle of collecting and synthesising data, reviewing the determinants of maternal deaths, implementing actions, and monitoring them to ensure change
Many countries have introduced MDSR and demonstrate positive effects on quality of care and health outcomes
Responses should link with and strengthen existing quality improvement measures, rather than introduce parallel processes