MDSR The Role of Government Agencies & Professional Bodies

Transcription

1 MDSR The Role of Government Agencies & Professional Bodies Dr J Ravichandran Malaysia

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4 Members Obstetricians Physicians Anaesthetists Forensic Pathologist Family Medicine Specialists Public Health Specialists Rep. from Ministry of Defence Rep. from Ministry of Education Rep. from Academy of Medicine Rep. from OGSM Co-opted members

5 Members Co-opted members Ministry of Home Affairs Ministry of Women Ministry of Social Welfare Police Department of Statistics National Registration Dept.

6 The Investigations are Anonymous Non punitive Tiered Process Hospital District State National Consensus Reccommendations Report Dissemination Remedial Actions

7 Malaysia Diverse country Land area: 329,847 square km 13 states 3 Federal Territory Varied social status 30m 2014 Urban... rich & poor Rural Marginalized

8 Malaysia Official Religion: Islam Other religions Christianity, Buddhism, Hinduism, Sikhism Various Ethnic groups Malays Chinese Indians Natives

9 Maternal Death the death of a woman while pregnant or within 42 days of termination of pregnancy, from any cause related to or aggravated by the pregnancy or its management, but not from accidental or incidental causes International Federation of Gynaecology & Obstetrics (FIGO)

10 Classification of Maternal Deaths Direct Maternal Deaths Indirect Maternal Deaths Fortuitous Maternal Deaths

11 Direct Maternal Deaths Deaths resulting from obstetric complications of the pregnant state (pregnancy, labour, puerperium) from interventions, omissions, incorrect treatment or from a chain of events resulting from any of the above

12 Indirect Maternal Deaths Deaths resulting from previous existing disease, or disease that developed during pregnancy which was not due to direct obstetric causes but which was aggravated by the physiologic effects of pregnancy

13 Fortuitous Deaths Deaths resulting from causes not related to or influenced by pregnancy, deaths from drowning and road accidents, where the pregnancy is unlikely to have contributed significantly to the death, although it may be possible to postulate a remote association

14 Maternal Mortality Ratio Number of maternal deaths in a year x 100,000 Number of live births in the same year Only direct and indirect deaths are included Illegal immigrants are not included in the calculation of MMR though each case is investigated MMR for international reporting & comparison

15 MMR Malaysia 40 s to 90 s A steep decline occurred in the MMR in the decade between 1970 and 1980 when it fell from 141 to 56 per 100,000 live births, a decline of 40 per cent. The rapid decline continued throughout the 1980s such that by 1990 the MMR was reported as 19 per 100,000 births. The main factor for this decline is the national commitment to improve maternal health.

16 MMR

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18 s MIDWIFERY LEGISLATION s Training SCHOOLs for NURSES MMR 1950s SKILLED BIRTH ATTENDANTS 1960s MIDWIFERY ACT, FAMILY Planning 1970s FAMILY Planning + PHC, Reg of TBA

19 Home based maternal assessment cards Implementation of risk approach Strategy for prenatal risk assessment CEMD, OA Program Alternative birthing centers, Introduced partogram Training nurses, Introduced HIV screening Training manuals: PPH, HPT, Heart disease, Midwives: IM MgSO4 for eclamspsia, Revised Heath Management and Information systems s MIDWIFERY LEGISLATION 1940s Training SCHOOLs for NURSES 1950s MMR 1980s SKILLED BIRTH ATTENDANTS 1960s MIDWIFERY ACT, FAMILY Planning 1990s 1970s FAMILY Planning + PHC, Reg of TBA 2000s

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21 Members Obstetricians Physicians Anaesthetists Forensic Pathologist Family Medicine Specialists Public Health Specialists Co-opted members

22 Investigations Anonymous Non punitive Tiered Process Hospital District State National Consensus Reccomendations Report Dissemination Remedial Actions

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24 Key Elements Strategy to Improving Maternal Health Malaysia 40 s To 90 s 1. Maternal Health Services Improve access and quality of care Including family planning Expanding health care facilities rural and urban areas

25 Key Elements Strategy to Improving Maternal Health Malaysia 40 s To 90 s 2. Quality of Essential Obstetric Care In Hospitals Invest in upgrading Focus on emergency obstetric care services

26 Key Elements Strategy to Improving Maternal Health Malaysia 40 s To 90 s 3. Referral and Feedback Systems Streamline & improve efficiency Prevent delays in service delivery

27 Key Elements Strategy to Improving Maternal Health Malaysia 40 s To 90 s 4. Trained Delivery Attendants Increase the professional skills of to manage pregnancy and delivery complications

28 Key Elements Strategy to Improving Maternal Health Malaysia 40 s To 90 s 5. Remove Social and Cultural Constraints Work closely with communities to and improve acceptability of modern maternal health services

29 Key Elements Strategy to Improving Maternal Health Malaysia 40 s To 90 s 6. Reporting of Maternal Deaths through Confidential Enquiry System ( CEMD)

30 Year of Death Year of Publication

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32 Analysis of CEMD Malaysia Reports

33 600 Maternal Mortality Ratio (uncertainty interval) per 100,000 LB by Region and Country Malaysia Cambodia Indonesia Brunei China Philippine s Thailand Vietnam S'pore Source - WHO World Health statistics 2012

34 No. of deaths Cause of Death by Categorization (Direct, Indirect and Fortuitous) Malaysia p Direct Indirect Fortuitous Total Source : : Reports on the Confidential Enquiries into Maternal Deaths in Malaysia : BPKK, KKM

35 Precentage CLASSIFICATION OF PREGNANCY RELATED DEATH (DIRECT, INDIRECT AND FORTUITOUS) MALAYSIA : p 100% 90% 80% % 60% 50% Fortuitous Indirect 40% Direct 30% 20% % 0% p 2013p p 2013p Direct Indirect Fortuitous Total Source of data : : Reports on the Confidential Enquiries into Maternal Deaths in Malaysia : FHDD, MOH

36 Obstetric embolism, PPH, Medical conditions, HDP remain high CAUSES of MATERNAL DEATH (3 yearly) Source : : Reports on the Confidential Enquiries into Maternal Deaths in Malaysia : BPKK, KKM

37 80.0 CAUSES OF MATERNAL DEATH IN MALAYSIA : p to to to to to to to to 2013 PPH HDP Obs. Emb Med. Cond Obst. Trauma Puerp. Sepsis 1991 to to to to to to to 2011 PPH HDP Obs. Emb Med. Cond Obst. Trauma Puerp. Sepsis to 2013 p 5 Source of data : : Reports on the Confidential Enquiries into Maternal Deaths in Malaysia : FHDD, MOH

38 Causes of Maternal Death (direct/indirect) : Malaysia p Obstetric embolism Hemorrhage Medical conditions HDP Source : BPKK, KKM Direct cause Indirect cause

39 MMR Source of data: : Reports on the Confidential Enquiries into Maternal Deaths in Malaysia p: FHDD, MOH MMR by ethnicity : MALAYSIA p Malay Chinese Indians Other bumi Others (p) Ethnic n (p) MM R n MM R n MM R n MM R n MM R n MMR n MMR n MMR n MMR n MMR n MMR n MMR Malay Chinese Indians Other bumi Others

40 Percentage Maternal Death (direct & indirect) based on Age Malaysia p Source : BPKK, KKM < unknown

41 Age Specific Fertility Rates (ASFR) among Girls Aged years (1991 to 2011) Fertility rates

42 Bilangan Kes Kematian Ibu MATERNAL DEATHS by PHASE OF PREGNANCY: MALAYSIA % : During Postpartum 15-25% : Antenatal Antenatal Intrapartum Postpartum Abortion Source: Reports on the Confidential Enquiries into Maternal Deaths in Malaysia

43 percentage Maternal Deaths by Phase of Pregnancy Malaysia p Antenatal Intrapartum Immediate postpartum up to 48 hrs 48 hrs - 42 days Abortion Source : BPKK, KKM

44 Percentage Safe Delivery and Antenatal Coverage: Malaysia p Safe Delivery Antenatal coverage Source : Health Informatics Centre, MOH

45 Percentage SAFE DELIVERY AND ANTENATAL COVERAGE MALAYSIA p p Safe delivery Antenatal Coverage Source : Health Informatic Centre FHDD, MOH

46 Rates by place of delivery 120 MMR Place of Delivery Government Private Home Home deliveries associated with high MMR per 100,000 deliveries

47 Cause Specific MMR per 100,000 LB (PPH) Deaths due to PPH PPH

48 No. of Deaths HDP Maternal Deaths HDP % Total deaths Decrease in No. of deaths but contributed to % of the deaths

49 No. of Deaths Death Due to Obstetric Embolism Obs Emb % Total 0 Proportion of deaths have increased from 10% in 1991 to high of 30% in Most were amniotic fluid embolism than thromboembolism. Only in a few cases postmortem done. In 2008 it was the number one cause of maternal death.

50 Maternal Deaths By Practice of Family Planning In Malaysia Family Planning n % n % n % Ever User None user Don't know Total Source: Report on Confidential Enquiries on Maternal Deaths ,

51 Analysis of Contributory Factors (Based on Preventable Deaths 2012) Patient factor 38% Clinical Factors 41% Non clinical Factors 21%

52 Contributory factors Clinical factors (analysis based on preventable deaths 2012) Failure of adherence to protocols 2.9 Failure of home visits / defaulter tracing 2.4 Delayed / failure of referral 4.0 Inadequate, inappropriate or delayed Failure to appreciate severity Failure to diagnose Failure of communication Failure of combined care Failure to inform other specialists Failure to inform seniors Inappropriate delegation of duties Percentage

53 Contributory Factors Non Clinical Factors (Analysis Based on Preventable Deaths 2012) Inadequate handling of emergency cases 6.2 Inaccessibility/Remoteness 2.7 No Transport no ICU available No Blood support No Laboratory services No Surgeon/Physician No Theatre staff No experienced MO in anaesthesia No MO with >6/12 experience in O&G No Specialist Percentage

54 Contributory Factors Patient Factors (Analysis Based on Preventable Deaths 2012) Non Compliance to Therapy 6.2 Non-compliance to admission 7.8 Non -compliance to advice 10.4 Inadequate visit (less 8 visit) or unbooked 13.8 Percentage

55 Training Training Manual in Heart Disease Training Manual in Thrombhoprophylaxis Improved training of midwives From a certificate course to an Advanced Diploma

56 MMR / 100,000 live births 27 / 100,000 live births / 100,000 live births?

57 per 100,000 live birth MDG 5a: Maternal Mortality Ratio (MMR) Achievement against Set Target MDG MDG 5 by 2015 ~ 50 deaths p Target (MDG 5) Achievement (no. of deaths) Source: Department of Statistics Malaysia (131) (137) (134) (128) (126)

58 MDG 5 : Improve Maternal Health Targets MDG Indicators Baseline Target (2015) Latest achievement Remarks TARGET 5.A : Reduce by three-quarters between 1990 and 2015, the maternal mortality ratio 5.1 Maternal Mortality Ratio 5.2 Proportion of birth attended by skilled health 44 per 100,000 LB (1991) 74.2% (1990) 11 per 100,000 LB 26.1 per 100,000 LB (2010) 95% 98.6% (2011) TARGET 5.B : Achieve, by 2015, universal access to reproductive health 5.3 Contraceptive prevalence rate 5.4 Adolescent birth rate 5.5 Antenatal care coverage (1st visit) 5.6 Unmet need for family planning 54.6% (1994) Increasing 51.8% ( 2004) 28 births per 1000 adolescent Decreasing 14 births per 1000 adolescent (2010) 78% (1990) 90% 94% (2011) 24.5 % (2004) Decreasing

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60 Decision for MDSR Top down decision Chaired by the DG of Health KPI of Minister of Health and DG Other ministries & agencies High level committee Representation by all stake holders Senior ministry officers Multidisciplinary

61 Why MDSR Increasing Maternal Deaths To identify causes of maternal death To identify shortfalls in care To identify remedial measures To plan interventional strategy To implement strategy To assess and analyse impact of MDSR

62 MDR Process Human resource / rapid turn-over Weak capacity and capability Poor data gathering Validity of the data Delayed transmission of reports Hospital audit

63 All methods: common principles, but have specific objectives and requirements All methods: are based on maternal mortality surveillance cycle Key Points Purpose: to stimulate action to prevent maternal deaths and morbidity Essential: those persons with the ability to promote and effect the necessary changes be involved in the process Inter country Workshop on Maternal Death Review, KL, 1-4 Nov 2011

64 Key Points All methods: identify causes, review local cases, look for avoidable factors, promote change in local/national practices, review the outcome of these changes May involve community interventions, as well as address clinical or health service issues Confidential and noblame approach Inter country Workshop on Maternal Death Review, KL, 1-4 Nov 2011

65 MDR Process - Issues Forms voluminous, tedious, lack of supply Digitalizing and archiving? Not all health facilities conduct MDSR Provincial Reviews National and Provincial/State/District Reviews Composition: Central/Provincial/County Review Committee? Champion?

66 MDSR => Drive Change for MMR Local level => local changes, and learning National level => policy changes inside and outside the health system DO NOT get confused by forms DO NOT get sidetracked by notification issues AVOID blame

67 Conclusion

68 MDSR Process NOTIFICATION INVESTIGATION FEEDBACK

69 Issues in MDR implementation The Don ts (1) Focus on process less focus on actions for preventing maternal death/morbidity Focus on statistics: while it should be beyond the numbers Complicated process takes a lot of scarce resources MDSR activity is treated as a research activity Lack of criteria for selecting maternal death cases when not all maternal deaths reviewed Establishment and roles of MDSR committee No supervision on how to hold effective & efficient MDSR

70 Issues in MDR implementation The Don ts (2) Forms to be used: too lengthy and complicated Data on maternal death is not complete/accurate lead to poor analysis and conclusion Recommendations for action are beyond control Results of MDSR are not well documented Poor monitoring of implementation of recommendations Lack of quality improvement in implementing MDSR No annual report of MDSR activities at all levels

71 Improving MDR implementation The Dos Focus on finding effective actions that can be done locally with existing resources Keep things simple: processes, tools/forms, reports MDSR to be made a part of routine activities using existing resources Recommendations: realistic and can be done locally Monitoring, supervision and quality improvement MDSR activities should be built in MDSR activities to be documented at all levels summarized in a national annual report

72 Micro Clinics & Community Protocol Behavioral change Macro Systems gaps Infrastructures, logistics & health insurance Laws & Policies

73 Maternal Mortality Surveillance Cycle Evaluate and refine Identify cases Recommendations for action Collect information Analyse results Intercountry Workshop on Maternal Death Review Kuala Lumpur, 1-4 November 2011

74 Achievements of MDSR National Agenda Medical Post Cabinet updates Collaboration from other ministries Home ministry.. Police Women s Ministry Education Ministry Social Welfare Ministry

75 Achievements of MDSR Impact Consensus Statement Misoprostolol Placenta Accreta Contraception TOP guidelines Drugs Availability Downgrading Policy Practice. Midwives

76 Achievements of MDSR Post mortems Reduced event-information, time delay SMS to DG/DDG Media involvement National Audit on Reccomendations

77 FIVE YEAR PLAN ACCELERATING PROGRESS TOWARDS ACHIEVING MDG 5 & Beyond 77 Majority deaths in hospitals Strengthening quality obstetric care in hospitals through: 100 % of hospitals with specialist Combined Clinic Pre-pregnancy Clinic Emergency obstetric drills Red Alert System Gaps in surveillance National roll out (National Obstetric Registry) Existing 14 states hospitals Expanded to other hospitals Deaths amongst higher parity still predominant Expand Promotion and provision of family planning services Increase by 10% of new and active users in health clinics every year All post natal wards provide family planning service All Specialist Clinics must provide Family planning services/ promotion

78 FIVE YEAR PLAN ACCELERATING PROGRESS TOWARDS ACHIEVING MDG 5 & Beyond 78 Expanding scope and multi-skilling of primary care personnel Adequate number Continuous professional education for the maternal and child health staff All Clinics must have one nurse with midwifery: In -service training on maternal and child health Lack of monitoring indicators Introduce new NIA indicators : Orang Asli Native/Interior Sabah Native/Interior Sarawak Urban poor Single/Young mothers Family Planning Amongst High Risk PPH incidence reporting Obstetric trauma incidence reporting Performance :Targeted population

79 STRATEGIES TOWARDS ACHIEVING MDG 5 Deaths amongst high risk mothers eg medical conditions, obese Deaths among non-clinic case / loss to follow up Strategies Strengthen pre pregnancy care Ensure accessibility, continuous and seamless care for pregnant mothers Activities Early detection and intervention of women with medical conditions before going into pregnancy stage at health clinics / hospitals Introduction of thromboprophylaxis for post LSCS mothers & development of guidelines for nurses to continue the treatment at peripheries. Mobile antenatal services estates, islands Government hospitals to alert health clinics on admission/discharge of high risk mothers esp AOR. Private hospital/clinics to inform health clinics on high risk mothers who refuse referral / default treatment, having social problems etc (Arahan Pekeliling KPK) 79

80 STRATEGIES TOWARDS ACHIEVING MDG 5 Deaths amongst mothers with social problems Strategies Management of mothers via personalised care Activities Staffs need to be more sensitive and responsive understands the underlying gender, social, economic and determinants of reproductive health Provide client friendly services privacy, non judgemental, confidential Collaborates with other agencies JKM Suboptimal care Continuous supervision at all level of care Internal or external inquiries Disciplinary actions 80

81 Screen shot of NOR Web Application

82 MDG 5 : Improve Maternal Health Targets MDG Indicators Baseline Target (2015) Latest achievement Remarks TARGET 5.A : Reduce by three-quarters between 1990 and 2015, the maternal mortality ratio 5.1 Maternal Mortality Ratio 5.2 Proportion of birth attended by skilled health 44 per 100,000 LB (1991) 74.2% (1990) 11 per 100,000 LB 25.6 per 100,000 LB (2012) 95% 98.8% (2013) TARGET 5.B : Achieve, by 2015, universal access to reproductive health 5.3 Contraceptive prevalence rate 5.4 Adolescent birth rate 5.5 Antenatal care coverage (1st visit) 5.6 Unmet need for family planning 54.6% (1994) Increasing 51.8% ( 2004) 28 births per 1000 adolescent Decreasing 13 births per 1000 adolescent (2012) 78% (1990) 90% 97% (2013) 24.5 % (2004) Decreasing Survey 2014???

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84 Agreements No blame its ok we all make mistakes we forgive you, but we do want to forget! Learning process to move on and rectify mistakes, don t do it again Powerful tool to effect reforms, quality assurance

85 Points to Remember Central support helps but is not a prerequisite Local enquiries provide a stimulus for change Change can be driven from bottom up & top down Staff become motivated and become advocates for change Intercountry Workshop on Maternal Death Review Kuala Lumpur, 1-4 November 2011

86 Points to Remember Can be done in countries with limited vital statistics Approaches do not have to be epidemiologically or statistically sound Even a simple MDR can lead to saving women s life Intercountry Workshop on Maternal Death Review Kuala Lumpur, 1-4 November 2011

87 Points to Remember Keep it simple only collect data that will be used Computer is not a prerequisite paper based systems work Every health worker can be self-reflective why a mother died can change attitudes and practices Intercountry Workshop on Maternal Death Review Kuala Lumpur, 1-4 November 2011

88 Points to Remember Preventing maternal deaths is possible, even in resource poor settings BUT this requires the right kind of information on which to base programmes Knowing MMR is not enough need to know the underlying causes and determinants Actions taken based on the findings of these reviews is key to success Intercountry Workshop on Maternal Death Review Kuala Lumpur, 1-4 November 2011