Identification of maternal deaths, cause of death and contributing factors in Mangochi District, Malawi: a RAMOS study

Introduction: The recent World Health Organization (WHO) report on trends in Maternal mortality (MM), from 1990 to 2013, ranks Malawi as one of the fifteen sub-Saharan countries with the highest Maternal Mortality Ratio (MM) of above 500 per 100,000live births (WHO 2014b). Malawi has no registration system for recording births and deaths. MM estimates are based on direct sisterhood methods, (used in Demographic and Health Surveys) and WHO modelled estimates, which are both highly susceptible to inaccuracies because they are both indirect methods which do not identify individual deaths within a defined population. The difficulties in obtaining accurate MMR estimates highlight the need to explore other methodologies that give more reliable data on levels as well as the cause of maternal deaths (MDs). A Reproductive Age Mortality Survey (RAMOS) is one such approach and can provide more direct and complete estimation of MMR in countries without reliable vital registration or other data sources. This is the first RAMOS used in Malawi. The aim of this study was to identify the magnitude, causes of, and factors associated with MDs in the Mangochi district in Malawi. Methods: Deaths of women of reproductive age (WRA), (15 to 49 years) that occurred from December, 2011 to November, 2012 in the district were identified. Multiple data sources were used to identify deaths, including; health facilities, communities, mortuary records and police records. Classification the death as a MD or not was done according to the ICD-10 definition. Facility based audit were conducted for all facility based MDs and verbal autopsies for all MDs. Cause of death attribution was done in three ways, 1) by a panel of experts in maternal health using the WHO application of ICD-10 to deaths during pregnancy, childbirth and puerperium (ICD-MM) (WHO 2012c), 2) by health professionals working in health facilities and 3) by using an InterVA-4 computer model. Cause of death attributed by the three methods was then compared. The three delays model was used to identify delays associated with MDs. The number of MDs identified in this study was compared to the official register in the district. MMR was calculated based on three proxy denominators; 1) number of babies who received BCG vaccine, 2) live births from the census report and 3) live births calculated from general fertility estimates. Results: A total of 424 deaths of WRA were identified and 151 of these (35.6%) were identified to be MDs. Based on the three denominators, the MMR for the Mangochi district was within the range of 341-363 per 100,000 live births (95% CI: 289-425 per 100,000 live births). Only 86 MDs had been reported via existing registers, giving an underreporting rate of 43%. The highest MMR was in age group 25-29 years (494/100,000 live births (95% CI: 349-683 per 100,000). Most MDs (62.3% (94/151)) occurred in health facilities. Based on ICD-MM cause classification, 74.8% were direct MDs, 17.3% were indirect and 7.9% were due to unknown causes. The leading cause of direct MDs (n=113) was obstetric haemorrhage (35.8%) followed by pregnancy related infections (14.4%) and hypertensive disorders (12.6%). The most frequent indirect cause of MD (n=26) was malaria (56.7%). There was low level of agreement over the cause of death between the panel of experts and health the professionals (κ= 0.37), while a substantial level of agreement was observed between the panel of experts and the InterVA-4 model (κ= 0.66). Based on ICD-MM, health professionals identified contributory factors (morbidity group) to 15.1% of MDs (n=86) as the underlying cause of death. Substandard care for obstetric emergencies, lack of blood, lack of transport, failures to recognize the severity of a problem at community level and delays in starting the decision-making process to seek health care were frequently factors associated with MDs. Conclusion: The current MD reporting system in Malawi needs strengthening. The high numbers of health facility deaths, cause of MDs and their contributing factors in Mangochi reflect serious deficiencies in the quality of maternal care that need to be urgently rectified. Urgent orientation of health workers on ICD-MM is required to obtain accurate information on cause of MDs that can be used to design effective interventions. There is need to strengthen the referral system and educate women on obstetric danger signs

Measuring maternal mortality using a Reproductive Age Mortality Study (RAMOS)

Background Assessing the feasibility of conducting a prospective Reproductive Age Mortality Survey (RAMOS) study in the low-income setting of Mangochi District, Malawi to obtain cotemporaneous estimates of the number, cause of and conditions associated with maternal deaths (MD) in all women of reproductive age (WRA) (n = 207 688). Methods MD among all deaths of WRA were identified using the ICD-10 definition. Cause of death and contributing conditions identified by a panel of experts using the classification system for deaths during pregnancy, childbirth and puerperium (ICD-MM). Results Out of 424 deaths of WRA, 151 were MD giving a Maternal Mortality Ratio (MMR) of 363 per 100,000 live births (95 % CI: 307–425). Only 86 MD had been reported via existing reporting mechanisms representing an underreporting of 43 %. The majority of MD (62.3 %) occurred in a health facility and were the result of direct obstetric causes (74.8 %) with obstetric haemorrhage as the leading cause (35.8 %), followed by pregnancy-related infections (19.4 %), hypertensive disorders (16.8 %) and pregnancy with abortive outcome (13.2 %). Malaria was the most frequently identified indirect cause (9.9 %). Contributing conditions were more frequently identified when both verbal autopsy and facility-based death review had taken place and included obstructed labour (28.5 %), anaemia (12.6 %) and positive HIV status (4.0 %). Conclusion The high number of MD that occur at health facility level, cause of death and contributing conditions reflect deficiencies in the quality of care at health facility level. A RAMOS is feasible in low- and middle-income settings and provides contemporaneous estimates of MMR

Measuring maternal mortality using a Reproductive Age Mortality Study (RAMOS)

BackgroundAssessing the feasibility of conducting a prospective Reproductive Age Mortality Survey (RAMOS) study in the low-income setting of Mangochi District, Malawi to obtain cotemporaneous estimates of the number, cause of and conditions associated with maternal deaths (MD) in all women of reproductive age (WRA) (n = 207 688).MethodsMD among all deaths of WRA were identified using the ICD-10 definition. Cause of death and contributing conditions identified by a panel of experts using the classification system for deaths during pregnancy, childbirth and puerperium (ICD-MM).ResultsOut of 424 deaths of WRA, 151 were MD giving a Maternal Mortality Ratio (MMR) of 363 per 100,000 live births (95 % CI: 307-425). Only 86 MD had been reported via existing reporting mechanisms representing an underreporting of 43 %. The majority of MD (62.3 %) occurred in a health facility and were the result of direct obstetric causes (74.8 %) with obstetric haemorrhage as the leading cause (35.8 %), followed by pregnancy-related infections (19.4 %), hypertensive disorders (16.8 %) and pregnancy with abortive outcome (13.2 %). Malaria was the most frequently identified indirect cause (9.9 %). Contributing conditions were more frequently identified when both verbal autopsy and facility-based death review had taken place and included obstructed labour (28.5 %), anaemia (12.6 %) and positive HIV status (4.0 %).ConclusionThe high number of MD that occur at health facility level, cause of death and contributing conditions reflect deficiencies in the quality of care at health facility level. A RAMOS is feasible in low- and middle-income settings and provides contemporaneous estimates of MMR

"We are the ones who should make the decision" - knowledge and understanding of the rights-based approach to maternity care among women and healthcare providers.

BackgroundExperiences and perceptions of poor quality of care is a powerful determinant of utilisation of maternity services. With many reports of disrespect and abuse in healthcare facilities in low-resource settings, women's and healthcare providers' understanding and perception of disrespect and abuse are important in eliminating disrespect and abuse, but these are rarely explored together.MethodsThis was a qualitative study assessing the continuum of maternity care (antenatal, intrapartum and postnatal care) at the Maternity Unit of Bwaila Hospital in Lilongwe, Malawi. Focus group discussions (FGDs) were conducted separately for mothers attending antenatal clinic and those attending postnatal clinic. For women who accessed intrapartum care services, in-depth interviews were used. Participants were recruited purposively. Key informant interviews were conducted with healthcare providers involved in the delivery of maternal and newborn health services. Topic guides were developed based on the seven domains of the Respectful Maternity Care (RMC) Charter. Data was transcribed verbatim, coded and analysed using the thematic framework approach.ResultsA total of 8 focus group discussions and 9 in-depth interviews involving 64 women and 9 key informant interviews with health care providers were conducted. Important themes that emerged included: the importance of a valued patient-provider relationship as determined by a good attitude and method of communication, the need for more education of women regarding the stages of pregnancy and labour, what happens at each stage and which complications could occur, the importance of a woman's involvement in decision-making, the need to maintain confidentiality when required and the problem of insufficient human resources. Prompt and timely service was considered a priority. Neither women accessing maternity care nor trained healthcare providers providing this care were aware of the RMC Charter.ConclusionsThis study has highlighted the most essential aspects of respectful maternity care from the viewpoint of both women accessing maternity care and healthcare providers. Although RMC components are in place, healthcare providers were not aware of them. There is the need to promote the RMC Charter among both women who seek care and healthcare providers

Dataset for the article: Standards-based audit to improve quality of maternal and newborn care – a stepped-wedge cluster randomised trial in Malawi

Article abstract Background Audit is a quality improvement approach used in maternal and newborn health. Our objective was to introduce the practice of standards-based audit at healthcare facility level, and to examine if this would improve compliance with standards of care developed and agreed with healthcare providers. Our focus was on emergency obstetric and newborn care in a low resource setting. Methods A multidimensional incomplete stepped-wedge cluster randomised trial with 8 steps (months) was conducted in 44 healthcare facilities in Malawi. A total of 25 standards were developed. Each facility had two consecutive audit cycle periods in each of which one (health centres) or two standards (hospitals) were audited in each period. Each audit cycle consisted of five steps: (i) agree the standard to be audited, (ii) measure compliance with standard, (iii) review findings and identify what changes are required to increase compliance (iv) implement changes, (v) re-measure compliance. For steps ii) and v), compliance with a standard was to be assessed for 25 women. Multilevel mixed effects logistic regression models were used to analyse data for all standards. Results Standards-based audit was an effective method to improve the quality of care. The crude overall compliance rate rose from 45% in the control phase (pre-action in audit cycle) to 63% in the intervention phase (post-action). There was a statistically significant improvement in compliance for standards audited: the adjusted (for standard, facility type, month, and healthcare facility by month clustering) OR (95% CI) was 2.80 (1.65,4.76). The most frequently taken actions to improve compliance with standards included: i) providing support to improve staff performance to better carry out clinical duties and improve general conduct through re-orientation and staff meetings as well as improved supervision, and, ii) ensuring basic equipment and consumables were available on site (thermometers, rapid diagnostics, partograph). LINK TO ARTICLE TO BE ADDED SHORTLY

‘Even when you are afraid, you stay’: Provision of maternity care during the Ebola virus epidemic: A qualitative study

Objective: to explore nurse-midwives understanding of their role in and ability to continue to provide routine and emergency maternity services during the time of the Ebola virus disease epidemic in Sierra Leone. Design: a hermenuetic phenomenological approach was used to discover the lived experiences of nursemidwives through 66 face to face interviews. Following verbatim transcription, an iterative approach to data analysis was adopted using framework analysis to discover the essence of the lived experience. Setting: health facilities designated to provide maternity care across all 14 districts of Sierra Leone. Participants: nurses, midwives, medical staff and managers providing maternal and newborn care during the Ebola epidemic in facilities designated to provide basic or emergency obstetric care. Findings: the healthcare system in Sierra Leone was ill prepared to cope with the epidemic. Fear of Ebola and mistrust kept women from accessing care at a health facility. Healthcare providers continued to provide maternity care because of professional duty, responsibility to the community and religious beliefs. Key conclusions: nurse-midwives faced increased risks of catching Ebola compared to other health workers but continued to provide essential maternity care. Implications for practice: future preparedness plans must take into account the impact that epidemics have on the ability of the health system to continue to provide vital routine and emergency maternal and newborn health care. Healthcare providers need to have a stronger voice in health system rebuilding and planning and management to ensure that health service can continue to provide vital maternal and newborn care during epidemic

“We are the ones who should make the decision” – knowledge and understanding of the rights-based approach to maternity care among women and healthcare providers

Background: Experiences and perceptions of poor quality of care is a powerful determinant of utilisation of maternity services. With many reports of disrespect and abuse in healthcare facilities in low-resource settings, women’s and healthcare providers’ understanding and perception of disrespect and abuse are important in eliminating disrespect and abuse, but these are rarely explored together. Methods: This was a qualitative study assessing the continuum of maternity care (antenatal, intrapartum and postnatal care) at the Maternity Unit of Bwaila Hospital in Lilongwe, Malawi. Focus group discussions (FGDs) were conducted separately for mothers attending antenatal clinic and those attending postnatal clinic. For women who accessed intrapartum care services, in-depth interviews were used. Participants were recruited purposively. Key informant interviews were conducted with healthcare providers involved in the delivery of maternal and newborn health services. Topic guides were developed based on the seven domains of the Respectful Maternity Care (RMC) Charter. Data was transcribed verbatim, coded and analysed using the thematic framework approach. Results: A total of 8 focus group discussions and 9 in-depth interviews involving 64 women and 9 key informant interviews with health care providers were conducted. Important themes that emerged included: the importance of a valued patient-provider relationship as determined by a good attitude and method of communication, the need for more education of women regarding the stages of pregnancy and labour, what happens at each stage and which complications could occur, the importance of a woman’s involvement in decision-making, the need to maintain confidentiality when required and the problem of insufficient human resources. Prompt and timely service was considered a priority. Neither women accessing maternity care nor trained healthcare providers providing this care were aware of the RMC Charter. Conclusions: This study has highlighted the most essential aspects of respectful maternity care from the viewpoint of both women accessing maternity care and healthcare providers. Although RMC components are in place, healthcare providers were not aware of them. There is the need to promote the RMC Charter among both women who seek care and healthcare providers