MDSR: Evidence of Effectiveness from the International Literature

From: http://hamlin.org.au/what-we-do/

Cycle of Data Collection, Reflection & Action

IDENTIFY THE PROBLEM

COLLECT DATA

PRESENT DATA IN USEFUL FORMATS

DISCUSS DATA WITH RELEVANT PEOPLE

ANALYSE DATA

PROPOSE SOLUTIONS

IMPLEMENT RECOMMENDATIONS

MONITOR ACTIONS &ADAPT IF REQUIRED

Cycle of Data Collection, Reflection & Action

IDENTIFY THE PROBLEM

COLLECT DATA

PRESENT DATA IN USEFUL FORMATS

DISCUSS DATA WITH RELEVANT PEOPLE

ANALYSE DATA

PROPOSE SOLUTIONS

IMPLEMENT RECOMMENDATIONS

MONITOR ACTION &ADAPT IF REQUIRED

REVIEW

ACTION

EVIDENCE

Example 1: Piloting a new MDSR

in ZAMBIA

(Evidence of improved quality of care)

Piloting MDSR in Zambia • In 2007, Zambia’s MMR estimated at 591• Data often not recorded outside labour wardEVIDENCE:• IMDA: Investigate Maternal Deaths and Act

Piloted over 12 months 2006-7• Facility & Community based data collection

(TBA trained to notify maternal deaths)• Narrative approach to record immediate

causes and wider social determinantsM. Hadley and M. Tuba (2011) Local problems; local solutions: an innovative approach to investigating and addressing causes of maternal deaths in Zambia’s Copperbelt. Reproductive Health 8:17

Piloting and MDSR in Zambia

REVIEW:• 4-5 anonymised cases discussed per meeting• 11 Data review meetings held, chaired by Provincial

Health Director• Participants: provincial & district officers, health

staff, blood transfusion reps, TBA, external obstetricians

• Total of 56 deaths reported (53 in tertiary hospital; 1 HC; 1 home)

• Meetings also reviewed progress on previously identified action points

Health Seeking Issues:• Families often sought traditional remedies first• Some husband didn’t give approval to seek care• Communities lack resources for transport

Health systems weaknesses:• Shortfall in supplies• Absence of Obstetricians• Inadequate blood supply

Case Management at facilities:• 67% cases had inaccurate diagnosis• Post mortems not routinely conducted• Malaria used as “default” cause of death in unclear

cases but not confirmed

ACTIONS (based on 68 recommendations):

• Obstetrician allocated to hospital• Post mortems conducted• Antibiotics stocked for post-abortion and

post-partum sepsis• Birth planning introduced in antenatal care• Measures to increase blood supply introduced

RE-STARTING THE CYCLE : Looking for Evidence of Progress one year later

• 61% recommendations implemented

• 12 % partially implemented• 27% not implemented

Example 2: Facility Based MDSR

in SENEGAL

(Evidence of improved clinical outcomes)

MDSR Effects on Clinical Outcomes in Senegal

Evidence:• Facility based MDR + interviews with family• Midwives responsible for identifying

maternal deaths• Senior Obstetrician reviewed cases and

collected data from others• Data analysed for baseline (1997) and 3 years

after MDSR introduced (1998-2000)

MDSR Effects on Clinical Outcomes in Senegal REVIEW:• 153 maternal deaths reviewed in total• District Health Manager chairs annual meetings

and evaluates progressACTION:• 13 recommendations implemented, mainly:– 24-hour availability of life saving services, drugs and

blood products– Improved availability of basic emergency obstetric care

• Recommendations NOT implemented included– Expansion of delivery unit– Staff recruitment

CHANGES IN QUALITY OF CARE:• Increased uptake of Antenatal care (in Year 1,

11% women had no ANC visit and by Year 2, just 4.2% did not attend)

• Rates of transfusion up from 1% in Year 2 to 2.1% in Year 3

CHANGES IN MATERNAL MORTALITY:Baseline: 50 deathsYear 1: 43 deathsYear 2: 33 deathsYear 3: 27 deaths

Number of maternal deaths fell by

almost 50% over the study period

From Dumont et al (2006) Facility Based Maternal Death Reviews: Effects on Maternal Mortality in a District Hospital in Senegal. Bulletin of the World Health Organization 84: 218-224.

Summary Points• MDSRs involve an ongoing cycle of collecting and

synthesising data, reviewing the determinants of maternal deaths, implementing actions, and monitoring them to ensure change

• Many countries have introduced MDSR and demonstrate positive effects on quality of care and health outcomes

• Responses should link with and strengthen existing quality improvement measures, rather than introduce parallel processes