Community-linked maternal death review (CLMDR) to measure and prevent maternal mortality: a pilot study in rural Malawi

Transcription

1 Community-linked maternal death review (CLMDR) to measure and prevent maternal mortality: a pilot study in rural Malawi Tim Colbourn UCL Institute for Global Health 6 th January 2017

2 BMJ Open 2015;5:e

3 Key messages CLMDR identified twice as many maternal deaths More actions were taken Communities and facilities can work together Confidentiality is an issue but we found no adverse effects

4 Presentation Outline Background why did we do this? Methods how did we do it? Results what did we find? Discussion what does it mean? - How can we build on it?

5 Background Maternal mortality in Malawi is still high need to address the Three Delays Existing maternal death reviews are insufficient: - inadequate review and action at facility - community deaths missed

6 Weaknesses of the previous MDR system 1. Maternal death identification Only hospital deaths were notifiable 2. Review of maternal deaths 29% of facilities in Malawi in 2010 conducted MDRs these included only 26% of recorded deaths [1] Barriers: poor record keeping; staff/resource/skills shortages [2-4]

7 Weaknesses of the previous MDR system cont d 3. Quality & Quantity of Information Available Patient history, examination, monitoring, management not well recorded [4] Culture of blame prevents sharing of info 4. Stakeholder Involvement Needs non-clinical staff too e.g. pharmacists, lab workers, transport co-ordinators

8 Weaknesses of the previous MDR system cont d 5. The Potential of the Community was Overlooked 6. Accountability of Health Workers No check on whether actions were taken

9 Indicators of success (overcoming weaknesses)

10 Design of CLMDR MaiMwana, UCL, MoH Based on social autopsy studies in Indonesia, India [5-7] Input from Local Leaders, national Safe-Motherhood Task Force

11 Design of CLMDR 350 community teams formed + trained (GVH, HSA, volunteers) 12 Health Centre teams formed + trained Existing MDR team at Mchinji DHO expanded to also include drivers, pharmacy, laboratory, support staff + further training on roles and responsibilities

12 The CLMDR Process!! Monthly(Strategy(Evaluation(Meeting(using(Form(5A( the(team(meets(woman s(family(and(seeks(consent(for(community(feed(back( (! ( STAGE 4: Community!Feedback!Meeting STAGE 5: Bimonthly!Progress!Meeting ( STAGE 3:!Health!Facility!CLMDR!Meeting! ( ( STAGE 2:Community!CLMDR!Meeting ( ( ( STAGE 1: Community!Verbal!Autopsy! ( Volunteer!and!HSA(interview(family(using(Section!1(and(collect(Health!Passport!( Community!CLMDR!team(meet,(read(information,(discuss(and(complete(Section!2! GVH(notifies(TA( HSA(notifies(CLMDR(management(team(and(arranges(CLMDR(meeting! ( Health!facility!CLMDR!team!meet,(read( information,(discuss,(plan(strategies,( agree(action(points(for(health(centre(and( district(hospital(and(complete(section!3!! Monthly(Strategy(Evaluation(( Using(evaluation(form( HSA!meets(woman s(family(to(seek(consent(for( community(feedback(meeting(and(agree( information(to(be(shared( Community!CLMDR! team,!ta!and!health! facility!representative( hold(public(meeting,( discuss,(plan(strategies,( agree(action(points(and( complete(section!4( Monthly(Strategy(Evaluation( Using(evaluation(form( A!WOMAN!DIES! District!hospital!CLMDR! team,!chairpersons!of! health!centre!clmdr! teams!and!community! HSAs(discuss(progress(on( community,(health( centre(and(district( hospital(strategies(and( action(points.(suggest( modifications(and(agree.( Complete(Section!5!

13 Sample 1 year implementation: July 2011 to June 2012 Whole of Mchinji district (around 500,000 people) Maternal deaths of women resident in Mchinji

14 Results 1. Maternal Death Identification 52 in total Only 25 (48%) identified by existing system 43 deaths (83%) identified by community CLMDR teams, including 4 that happened at DH but were overlooked by existing system Estimated MMR: 300 per 100,000 similar to MaiMwana trial [8] CLMDR accurate method of measuring MMR

15 Results 2. Review of Maternal Deaths 45 / 52 (86%) subject to review 37 (71%) at community CLMDR meeting 44 (85%) at health facility CLMDR meeting 32 (62%) at community feedback meeting 35 (67%) at bimonthly review meeting 28 cases completed all 5 stages Non-completion due to: family declining community feedback meeting (5 cases); community meeting not happening (3); HSA failing to organise meeting (2); form lost (1); death outside of Mchinji (2)

16 Results 3. Quantity of Information Verbal Autopsy form available in 39 of 44 cases discussed at health facility CLMDR meeting Open-ended free text questions more information on delays: disrespectful treatment by health workers, being turned away from health centres, misdiagnoses, slow referral pathways, lack of hospital transport and unavailability of life-saving treatments Using information from the deceased family together with hospital records during reviews assists to come up with a root cause of the problem which enables us to come up with real contributing factor and good strategies [Midwife, HC]

17 Results 4. Stakeholder Involvement Lots of people involved!

18 Results 5. Community Mobilisation & Action Action points: Community meetings to explore traditional beliefs Bye-laws to prevent traditions posing a risk to pregnant women Educating men on their roles and responsibilities Lobbying health facility for more respectful treatment of women Establishing mobile antenatal clinic Mobilising community funds for bicycle ambulance maintenance Establishing youth club Organising female counsellors to support pregnant women Ave. 2.2 action points (range 1 4) made per community feedback meeting 1.8 action points (range 0 4) reported completed 82% of all proposed community action points were reported completed

19 Results 6. Accountability of Health Workers Action points: Designing new antenatal form to better capture risk factors Improving drug supplies (antihypertensive drugs) Training for clinicians following maternal deaths Health education events for communities Improved emergency transport, incl. motorcycle ambulance Increased fuel allowance Changing protocols to improve access to rural hospitals HC: Ave. 2.4 action points (range 1 4) made per meeting (2.2 for DH) 1.5 action points (range 0 3) reported completed (HC & DH) 65% of all proposed HC action points reported completed (67% for DH)

20 Discussion Community elevated from passive data collectors to active partners in Maternal Death Surveillance and Response (MDSR) CLMDR doubled number of deaths reviewed Valuable Discussions & Action to address the Three Delays

21 Discussion Improved Data Evidence-based Decision Making Lots of people involved creative solutions & more action points completed Publicised actions increased motivation to fulfil commitments; increased trust in system CLMDR challenges power hierarchy positive change to patient-provider relationships

22 Issues to consider for scale-up CLMDR adds to existing workload (but in long term: actions from CLMDR less deaths less work) CLMDR not started for some cases (HIV? Abortion?) Raising the status of the community is essential for sustainability of CLMDR Communities can transform maternal health challenges when given an opportunity to do so

23 What has happened since this pilot? 14th August 2012 UNFPA consultants from Uganda and Malawian Reproductive Health Unit (RHU) Ministry of Health staff discuss the CLMDR model for adoption into Malawi s Maternal Death Surveillance and Response (MDSR) system. They visit MaiMwana Project and the Mchinji district health office to learn about CLMDR. December 2012 stakeholder meetings, lobbying by the district health officer and community leaders for continuation of CLMDR through incorporation into the annual costed district implementation plan. April 2013 Malawian Ministry of Health and UNFPA hold MDSR briefing in Lilongwe for maternal health stakeholders to review the CLMDR model, which is presented by MaiMwana, with a view to incorporating it into the MDSR system. CLMDR data collection tools were reviewed and most aspects of them were adopted to be included in the MDSR tool. 30th September to 3rd October 2013 MaiMwana participate in a capacity building workshop held by RHU in Blantyre to present CLMDR to stakeholders in maternal health including UNFPA, health officers from all five health zones (groups of districts) in Malawi, UNICEF, Save the Children, College of Medicine, MCHIP.

24 What has happened since this pilot? 11th October, 2013 National dissemination to Malawian Ministry of Health and maternal, newborn and child health organisations and stakeholders. Held in Lilongwe as part of dissemination of the results of trials of MaiMwana women s group and infant feeding interventions. 5th to 9th November, 2013 MaiMwana involved in development of the MDSR verbal autopsy tool in a workshop organised by the Malawian Reproductive Health Directorate (formerly RHU), Ministry of Health and UNFPA. Malawian Ministry of Health adopt MaiMwana CLMDR verbal autopsy tools to be used in MDSR. June 2014 Capacity building workshop held in Lilongwe for partners showing interest in CLMDR and MDSR. July 2014 Evidence for Action (E4A), a pan-african project funded by the UK government, support the Malawian Ministry of Health in Salima district and engage MaiMwana and Mchinji district health office to finalise tools for verbal autopsy and a training manual for verbal autopsy use in MDSR in Salima.

25 What has happened since this pilot? September 2014 Training of trainers for implementing CLMDR as part of MDSR in the six districts of Malawi where E4A operates and five districts of Malawi where UNFPA operates. October to December 2014 Training and revamping of CLMDR teams in two Traditional Authorities in Mchinji district to act as beacons from which other organisations can learn about the CLMDR process. Other organisations and projects seeking to support CLMDR and MDSR in the remaining of Malawi s 28 districts include Concern Worldwide and MCHIP.

26 Zikomo Kwambiri! Questions? Comments? Tim Colbourn:

27 References 1. Republic of Malawi Ministry of Health. Malawi 2010 EmONC needs assessment final report Kongnyuy EJ, van den Broek N. The difficulties of conducting maternal death reviews in Malawi. BMC Pregnancy Childbirth 2008;8: Kongnyuy EJ, Mlava G, van den BN. Facility-based maternal death review in three districts in the central region of Malawi an analysis of causes and characteristics of maternal deaths. Womens Health Issues 2009;19: Combs Thorsen V, Sundby J, Meguid T, et al. Easier said than done!: methodological challenges with conducting maternal death review research in Malawi. BMC Med Res Methodol 2014;14: Supratikto G, Wirth ME, Achadi E, et al. A district-based audit of the causes and circumstances of maternal deaths in South Kalimantan, Indonesia. Bull World Health Organ 2002;80: UNICEF. Maternal and perinatal death inquiry and response: empowering communities to avert maternal deaths in India. New Delhi: UNICEF, Maternal_and_Perinatal_Death_Inquiry_and_Response-India.pdf (accessed 17 Dec 2014). 7. Kalter HD, Salgado R, Babille M, et al. Social autopsy for maternal and child deaths: a comprehensive literature review to examine the concept and the development of the method. Popul Health Metr 2011;9: Lewycka S, Mwansambo C, Rosato M, et al. Effect of women s groups and volunteer peer counsellors on rates of mortality, morbidity and health behaviours in mothers and children in rural Malawi (MaiMwana): a factorial, cluster-randomised controlled trial. Lancet 2013;381: