1. Understanding Maternal Death Reviews MDR Workshop Lucknow India June 17-18, 2010

2. Definitions and Concepts Maternal Death (MD): Death of a women while pregnant or within 42 days of the end of pregnancy –Irrespective of the duration and the site of the pregnancy (e.g., ectopic pregnancy) –From any cause related to or aggravated by the pregnancy or its management Does not include deaths from accidental or incidental causes Maternal Death Review (MDR): A qualitative in-depth investigation of the medical and underlying social causes of and circumstances surrounding maternal death – BEYOND THE STATISTICS AND TO THE WHY MDRs can be both facility based or community based (e.g., verbal autopsies) Verbal Autopsy (VA): A community based MDR that: Explores the medical and non-medical causes of the death of the woman Identifies personal, family and community factors that may have contributed to the death of a woman Is conducted for all maternal deaths, regardless of where the woman’s death occurs

3. Definitions and Concepts 2 Facility Based Maternal Death Review (FB-MDR): A qualitative, in-depth investigation of causes of and circumstances surrounding maternal death occurring at the health facility Conducted for deaths that are initially identified at a health facility A facility based MDR will always be followed by a verbal autopsy at the community level Clinical Review (sometimes called Clinical Audit) Systematic critical analysis of the quality of care provided to patients at a health facility primarily to improve clinical practice. Involves comparing the care received against standards The comprehensive review of data collected at the Hospital and Chiefdom levels done by experts and persons involved

4. Definitions and Concepts 3 Confidential Enquiries into Maternal Death Systematic multidisciplinary anonymous investigation for –All (or a representative sample) of maternal deaths in an area, region or at the national level –Identifies numbers and avoidable factors for MD –These enquiries can be done at various levels in the health system. In this project it will be performed at National, District and Chiefdom level in the MDR committees Near Miss Defined as a woman who nearly died but survived a complication that occurred during pregnancy, childbirth or within 42 days of termination of pregnancy

5. Objective of Maternal Death Review To improve care in maternal health by “Going Beyond the Numbers”: Identifying social, cultural, epidemiological and other factors that lead to maternal deaths at the health facility and community levels Help us answer if: women are unaware of the need for care, or unaware of the warning signs of problems in pregnancy? the services do not exist, or are inaccessible for other reasons, such as distance, cost or socio-cultural barriers? the care they receive is inadequate or actually harmful?

6. Target Audience: Who are MDRs for? Using data to: –Programme Managers ask: “"Where are things going wrong and what can be done to rectify them?" Raise awareness among professional health workers and community about the risk factors and reasons leading to maternal deaths –Policymakers ask: “Why do maternal deaths occur and what can be done to prevent them?” Empower policy makers, professional health workers and the community to design appropriate interventions to address maternal death –Others?

7. Confidentiality MDRs confidential, usually anonymous, non-threatening environment in which to describe and analyse the factors leading to adverse maternal outcomes Will lead to an openness in reporting which provides a more complete picture of the precise sequence of events Sole purpose is to learn from the past and save lives and not blame

8. Advantages In contexts where most deliveries and deaths take place outside of health facilities, it can be the only way of ascertaining the cause of death In addition to medical causes of death, can be coupled with other questions to provide important information on social and community factors associated with a maternal death and identifies barriers to accessing obstetric care

9. Limitations Assumes most causes of death have distinct symptom complexes (and that these can be recognized, remembered and reported by lay respondents), and that it is possible to classify causes into meaningful categories Causes of death have limited reliability when reported by lay-persons and can be subjective Causes of death may be subject to under or over-reporting Data collection is subject to the quality of training provided to field workers and interviewers as well as the quality of the VA questionnaire

10. Other Data Measurement Issues Measurement issues: Can be supplemented with information from medical documents if available in the household or from health facilities Measurement requirements: duplicate deaths need to be excluded sub-causes of maternal deaths must be coded and classified as maternal deaths data on births are needed

11. Key Messages Avoiding maternal deaths is possible, even in resource- poor countries, but it requires the right kind of information on which to base programs Knowing the level of maternal mortality is not enough; we need to understand the underlying factors that led to the deaths Each maternal death or case of life-threatening complication has a story to tell and can provide indications on practical ways of addressing the problem A commitment to act upon the findings of these reviews is a key prerequisite for success – and can be a health intervention itself – often leading to positive impact in service delivery