Dr Mitasha Singh JR Dptt of Community Medicine DRPGMC Kangra at Tanda Himachal Pradesh

1. Maternal Death Surveillance
and Response
Dr. Mitasha Singh

2. Contents
• Definitions
• Global and Indian scenario
• Future target to reduce maternal deaths
• Causes and barriers
• Method of estimation
• MDSR-goals and objective
• Steps of MDSR
• MDSR Implementation plan

3. • Women in reproductive age group (15-49 year
age group) constitute 55.1% of total
population.
• Maternal health refers to the health of women
during pregnancy, childbirth and the
postpartum period.

4. Maternal death
• Definition
• Maternal death is the death of a woman while
pregnant or within 42 days of termination of
pregnancy, irrespective of the duration and site of the
pregnancy, from any cause related to or aggravated by
the pregnancy or its management but not from
accidental or incidental causes.

5. Maternal Mortality Ratio
• The maternal mortality ratio represents the risk
associated with each pregnancy, i.e. the
obstetric risk.
• It is also a MDG indicator.
• The MMR is defined as the number of
maternal deaths during a given time period per
100,000 live births during the same time
period.

6. Maternal mortality rate
(MMRate)
• Maternal mortality rate (MMRate) is defined as the
number of maternal deaths in a population divided by
the number of women aged 15–49 years (or woman
years lived at ages 15–49 years
• The MMRate captures both the risk of maternal death
per pregnancy or per total birth (live birth or
stillbirth), and the level of fertility in the population.

7. • Almost 800 women die every day due to
complications in pregnancy and childbirth.
523000
289000
0
100000
200000
300000
400000
500000
600000
1990 2013
Maternal Deaths
45%
World Health Organization 2014

8. ONE THIRD of total global maternal deaths are in two
countries
Global deaths
India Nigeria
Rest
INDIA- 40000, NIGERIA- 50000 World Health Organization 2014

10. 510
190
140
0 100 200 300 400 500 600
South Africa
Southern Asia
South eastern Asia
MMR(2013)
MMR(2013)
WHO, UNICEF, UNFPA, The World Bank and the United Nations Population Division estimates

11. INDIA
0
100
200
300
400
500
600
1990 1995 2000 2005 2013
560
460
370
280
190
MMR
MMR
65% Decrease
WHO, UNICEF, UNFPA, The World Bank and the United Nations Population Division estimates

12. INDIA
301
254
212
178 167
0
50
100
150
200
250
300
350
2001-3 2004-6 2007-09 2010-12 2011-13
MMR(SRS)
MMR(SRS)
Registrar General of India - Sample Registration System (RGI-SRS).

14. MDG 5: Improve maternal health
• Target 5.A. Reduce by three quarters, between 1990
and 2015, the maternal mortality ratio
• maternal mortality has fallen by 45 percent over the past 2
decades.
• Target 5.B. Achieve, by 2015, universal access to
reproductive health

15. • A global target for a maternal mortality ratio (MMR) of less
than 70/100,000 live births by 2030 has been set, with no
single country having an MMR greater than 140.
• To achieve the target, USAID has a vision of “A world where
no woman dies from preventable maternal causes and
maternal and fetal health are improved”
Source: Targets and Strategies for Ending Preventable Maternal Mortality. Consensus Statement.
April 2014. Geneva: WHO
Future Target

16. What Are Pregnant Women Dying From?
28
27
14
11
3
8
9
Percentage
Preexisting medical
condition
Severe bleeding
PIH
Infections
Blood clots
Abortion
complications
Obstructed labour and
other direct causes
World Health Organization 2014

18. Major barriers to improving
chances of survival
1st Delay
Decision to
seek care
2nd Delay
Identifying and
reaching
medical facility
3rd Delay
Receipt of adequate
and appropriate
treatment
Issue of access to care
Encompassing factors in the family and community,
including transportation

19. Contributing factors to maternal deaths
COMMUNITY-BASED FACTORS HEALTH SERVICE FACTORS
Lack of awareness of danger signs of illness No health service available or nearby
Delay in seeking care due to lack of family
agreement
No staff available when care was sought
Geographical isolation Medicine not available at the hospital;
dependence on family to provide it
Lack of transportation or money to pay for it Lack of clinical care guidelines
Other family or household responsibilities Woman not treated immediately after arriving
at the facility
Cultural barriers, such as prohibitions on
mother leaving the house
Lack of necessary supplies or equipment at the
facility
Lack of money to pay for care Lack of staff knowledge/skills to diagnose and
treat the mother
Belief in use of traditional remedies Long waiting time before qualified staff could
see the mother
Belief in fate controlling outcome No transport available to reach referral hospital
Dislike of or bad experiences with health-care
system
Poor staff attitude

20. Methods of estimation
Measuring maternal mortality accurately is difficult except
where comprehensive registration of deaths and of causes of
death exists.
• Civil registration system
• Household survey
• Sisterhood methods
• Reproductive age mortality studies (RAMOS)
• Verbal autopsy
• Census

21. • To understand how well we are progressing, however,
accurate information on how many women died,
where they died and why they died is essential, yet
currently inadequate.
• a system is needed that measures and tracks all
maternal deaths in real time, helps us understand the
underlying factors contributing to the deaths, and
stimulates and guides actions to prevent future deaths.

22. MDSR
• is a form of continuous surveillance
• which includes the routine identification, notification,
quantification and determination of causes and
avoidability of all maternal deaths, as well as the use
of this information to respond with actions that will
prevent future deaths

23. • The primary goal of MDSR is to eliminate
preventable maternal mortality.
• Because each death provides information that, if
acted on, can prevent future deaths.
• emphasizes the link between information and
response.
• the measurement of maternal mortality ratios and the
real-time monitoring of trends that provide countries
with evidence about the effectiveness of
interventions.

24. • The overall objectives of MDSR are
• to provide information that effectively guides immediate as
well as longer term actions to reduce maternal mortality; and
• to count every maternal death, permitting an assessment of the
true magnitude of maternal mortality and the impact of actions
to reduce it.

25. continuous-action cycle
Respond and
monitor response Identify and notify
deaths
Analyse and make
recommendations Review maternal deaths

26. 1.Identification and notification of
maternal deaths
Facility-based
deaths
Community-based
deaths

27. Maternal death – a notifiable event
• classifying an event or disease as notifiable means it
must be reported to the authorities within 24 hours
and followed up by a more thorough report of
medical causes and contributing factors.
• Notification should be systematic, including absence
of cases (“zero reporting”).

28. Sources of information
• Healthcare facilities (where women give birth and
are attended when they have pregnancy
complications) and
• communities (when women give birth at home or on
the way to a health-care facility or die during
pregnancy without receiving medical care).

29. Identification and notification of suspected and probable
maternal deaths in health facilities
• usually easier to identify
• to ensure that none are missed- someone should have a daily
responsibility to check death logs and other records from the
previous 24 hours and collect a line listing of deaths of all
WRA.
• Any death of a WRA should trigger a review of her medical
record to look for evidence that she could have been pregnant
or within 42 days of the end of a pregnancy.

30. Identification and notification of suspected
maternal deaths in the community
• by community health workers (CHW) or, in their
absence, by other community representatives.
• This process is more complicated than reporting from
health facilities for several reasons:
• 1) Deaths are far less frequent, and communities will need periodic
reminders about their importance and the reporting process;
• 2) supervising every single community is difficult, especially if there are no
CHWs; and
• 3) there may be no way to report quickly.

31. Innovative uses of technology for
maternal death notification
• Personal digital assistant devices and tablet
computers are becoming more affordable and offer
additional benefits to data collection.
• Programmes such as mHealth and Epi Info 7.0 offer
options for data collection and entry on mobile
devices, including touch-screen questionnaires,
photographs, and GIS coordinates

32. 2.Maternal death review
• World Health Organization’s publication of Beyond the
Numbers (BTN) in 2004, defined MDR as “qualitative, in-
depth investigation of the causes of, and circumstances
surrounding, maternal deaths” and includes methods designed
for reviewing deaths that occur in both health-care facilities
and communities.
• Implemented and institutionalized by all states of India as a
policy since 2010.

33. Maternal deaths in
communities
Maternal deaths in
facilities
Determine if probable maternal death;
collect data
for review including verbal autopsy
Determine if probable maternal death; collect
data
for review including patient record review
Actions at and
feedback to
facility and
community
level

34. Investigations compiled
and sent to district level
with recommendations for
action
Aggregated analysis and multidisciplinary higher-level
responses

35. Tamil Nadu
• Tamil Nadu initiated identification and compulsory reporting
of maternal deaths in 1994.
• It was mandated that each and every maternal death be
reported by the Village Health Nurse working at the level of
the Health Sub-Centre, the medical officers of primary health
centers, first referral unit (FRU) and non-FRU government
hospitals, district public health nurses, and Deputy Directors of
Health Services.

36. • Following recommendations of the maternal death review
committees, a quality-improvement process aiming to benefit
patient care and outcomes through clinical audits was
introduced.

37. 3.Analysis – data aggregation
and interpretation
Identify deaths, establish which occur during or within 42 days of
pregnancy, notify and report maternal deaths, and conduct MDR
Send data to district level for analysis
Enter data, check completeness and
quality
Perform standard
data analysis plan
Perform specialized complex
analysis or sub analysis

38. Analyze preventable factors
Translate data analysis for broader audience
Respond, disseminate results and recommendations,
implement M&E,
and refine the system

39. IMPACT INDICATORS AVAILABILITY/ACCESS INDICATORS
Maternal mortality ratio % of deaths that occurred within 24 hours of arrival
at facility
Maternal mortality rate % of deaths among women who were delivered by
skilled birth attendant/facility delivery
Proportion of deaths to WRA that are maternal % of deaths among women who had recommended
prenatal care
Proportion of maternal deaths by medical cause of
death (haemorrhage,eclampsia/preeclampsia, sepsis,
abortion, obstructed labour, other direct cause,
Indirect causes)
% of deaths where limited drugs and/or supplies was
a factor
% of deaths where limiting staff was a factor
% of deaths where guidelines are not followed
Case fatality rate % of deaths for a given complication
Proportion of maternal deaths with avoidable factors % of deaths where lack of transport was a factor
% of deaths where health care cost were unaffordable
% of deaths where lack of recognition at the
community level was a factor

40. Descriptive analysis of maternal deaths
• Women: Age group, race/ethnicity, gravidity/parity, gestational age at time of death,
pregnancy outcome (undelivered, stillbirth, live birth), socioeconomic status of family,
education
• Place: Where family lived (urban or rural, district/sub-district, town or village); where
woman died
• Time: Date of death (day, month, year), time of day when death occurred, weekday or
weekend, season when death occurred
• ANC: Week or month of pregnancy when the woman first attended antenatal care, how many
visits, type of care provider and type of place, distance of facility from place of residence
• Delivery: Date and time of birth, day of the week, season, place of delivery, type of place,
type of delivery attendant, type of delivery (vaginal, forceps, caesarean)
• Data source: Notification only, facility-based review, verbal autopsy
• Medical cause of death
• Contributing factors and preventability

41. 4.Response
• types of responses that may be needed to address the
problems found by MDSR and discusses criteria that
can be used to prioritize recommendations for action,
the primary MDSR objective.

42. Identify deaths, establish which occur during or
within 42 days of pregnancy, notify and report
maternal deaths, conduct MDR, analyse data
Respond immediately, as appropriate, to each
maternal death
Determine priority actions based on aggregated
analysis
Disseminate and discuss findings and
recommendations with key stakeholders, including
community
Incorporate recommendations in annual plan
Perform monitoring and evaluation and
reporting

43. Guiding principles for response
• Start with the avoidable factors identified during the review
process
• Use evidence-based approaches
• Prioritize (based on prevalence, feasibility, costs, resources,
health-system readiness, health impact)
• Establish a timeline (immediate or short-, medium-, or long-
term)
• Decide how to monitor progress, effectiveness, impact
• Integrate recommendations within annual health plans and
health-system packages
• Monitor to ensure that recommendations are being
implemented

44. 5.Dissemination of results,
recommendations, and responses
• The two main types of reports from the MDSR
system are
• annual reports on maternal deaths and
• reports on the monitoring and evaluation (M&E) of
the system itself

45. Annual reports
• single-facility death review report
• annual facility-based MDSR report
• district MDSR report
• national MDSR report

47. Whom to inform of the results
The general principle is to get the key messages to those who can
implement the findings and make a real difference towards saving
mothers’ lives. They may include:
• Ministries of Health;
• local, regional, or national health-care planners, policy-makers, and
politicians;
• professional organizations and their members, including obstetricians,
midwives, pediatricians, general physicians, anesthetists, and pathologists
who are involved at each level;
• medical directors and chief executive officers;
• leaders in other health-care systems, such as social security and the private
sector;
• health promotion and education experts;

48. • health insurance companies (if applicable);
• public health or community health departments;
• academic institutions;
• local health-care managers or supervisors;
• local governments;
• national or local advocacy groups;
• the communications media;
• representatives of specific faith or cultural institutions
or other opinion leaders who can promote and
facilitate beneficial changes in local customs;
• all participants in the survey.

49. Hountonetal.Reproductvehealth2013

50. 6.Monitoring and Evaluation of the MDSR
system
• A periodic evaluation should examine how efficient the system
is.
• This includes an assessment of its key processes: identification
and notification, review, analysis, reporting and response, and
whether there are barriers to their operation that should be
addressed.

51. • Evaluation of effectiveness determines if the correct
recommendations for action have been implemented, if they
are achieving the desired results and, if not, where any
problems may lie.
• A monitoring framework with indicators should be agreed to
and indicators assessed annually. A sample framework, with
indicators, is shown in next slide.

54. Development of an MDSR
implementation plan
• The final structure and scope of MDSR will differ
according to the local context and challenges.
• A classic approach in planning a standard public health
surveillance system is illustrated below
• 1.Establish objectives
• 2.Develop case definitions
• 3.Determine data sources and the data-collection mechanism
• 4.Determine data-collection instruments
• 5.Field-test methods
• 6.Develop and test analytical approach
• 7.Identify dissemination mechanisms
• 8.Assure use of analysis and interpretation

55. “women are not dying of diseases we cannot treat … they are dying
because societies have yet to make the decision that their lives are worth
saving.” – Mahmoud Fathalla
Thank You