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Assessing Implementation of Maternal and Perinatal Death Surveillance and Response in Rwanda.

ABSTRACT: Maternal deaths remain a major public health concern in low- and middle-income countries. Implementation of maternal and perinatal deaths surveillance and response (MPDSR) is vital to reduce preventable deaths. The study aimed to assess implementation of MPDSR in Rwanda. We applied mixed methods following the six-step audit cycle for MPDSR to determine the level of implementation at 10 hospitals and three health centers. Results showed various stages of implementation of MPDSR across facilities. Maternal death audits were conducted regularly, and facilities had action plans to address modifiable factors. However, perinatal death audits were not formally done. Implementation was challenged by lack of enough motivated staff, heavy workload, lack of community engagement, no linkages with existing quality improvement efforts, no guidelines for review of stillbirths, incomplete medical records, poor classification of cause of death, and no sharing of feedback among others. Implementation of MPDSR varied from facility to facility indicating varying capacity gaps. There is need to integrate perinatal death audits with maternal death audits and ensure the process is part of other quality improvement initiatives at the facility level. More efforts are needed to support health facilities to improve implementation of MPDSR and contribute to achieving sustainable development goal (SDG) 3.

SUBMITTER: Tayebwa E

PROVIDER: S-EPMC7345772 | biostudies-literature | 2020 Jun

REPOSITORIES: biostudies-literature

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Assessing Implementation of Maternal and Perinatal Death Surveillance and Response in Rwanda.

Tayebwa Edwin E Sayinzoga Felix F Umunyana Jacqueline J Thapa Kusum K Ajayi Efugbaike E Kim Young-Mi YM van Dillen Jeroen J Stekelenburg Jelle J

International journal of environmental research and public health 20200618 12

Maternal deaths remain a major public health concern in low- and middle-income countries. Implementation of maternal and perinatal deaths surveillance and response (MPDSR) is vital to reduce preventable deaths. The study aimed to assess implementation of MPDSR in Rwanda. We applied mixed methods following the six-step audit cycle for MPDSR to determine the level of implementation at 10 hospitals and three health centers. Results showed various stages of implementation of MPDSR across facilities. ...[more]

PMID: 32570817

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Project description:BackgroundThe global population impacted by humanitarian crises continues to break records each year, leaving strained and fractured health systems reliant upon humanitarian assistance in more than 60 countries. Yet little is known about implementation of maternal and perinatal death surveillance and response (MPDSR) within crisis-affected contexts. This scoping review aimed to synthesise evidence on the implementation of MPDSR and related death review interventions in humanitarian settings.MethodsWe searched for peer-reviewed and grey literature in English and French published in 2016-22 that reported on MPDSR and related death review interventions within humanitarian settings. We screened and reviewed 1405 records, among which we identified 25 peer-reviewed articles and 11 reports. We then used content and thematic analysis to understand the adoption, appropriateness, fidelity, penetration, and sustainability of these interventions.ResultsAcross the 36 records, 33 unique programmes reported on 37 interventions within humanitarian contexts in 27 countries, representing 69% of the countries with a 2023 United Nations humanitarian appeal. Most identified programmes focussed on maternal death interventions; were in the pilot or early-mid implementation phases (1-5 years); and had limited integration within health systems. While we identified substantive documentation of MPDSR and related death review interventions, extensive gaps in evidence remain pertaining to the adoption, fidelity, penetration, and sustainability of these interventions. Across humanitarian contexts, implementation was influenced by severe resource limitations, variable leadership, pervasive blame culture, and mistrust within communities.ConclusionsEmergent MPDSR implementation dynamics show a complex interplay between humanitarian actors, communities, and health systems, worthy of in-depth investigation. Future mixed methods research evaluating the gamut of identified MPDSR programmes in humanitarian contexts will greatly bolster the evidence base. Investment in comparative health systems research to understand how best to adapt MPDSR and related death review interventions to humanitarian contexts is a crucial next step.

Project description:Maternal and perinatal death surveillance and response (MPDSR), or any form of maternal and/or perinatal death review or audit, aims to improve health services and pre-empt future maternal and perinatal deaths. With expansion of MPDSR across low- and middle-income countries (LMIC), we conducted a scoping review to identify and describe implementation factors and their interactions. The review adapted an implementation framework with four domains (intervention, individual, inner and outer settings) and three cross-cutting health systems lenses (service delivery, societal and systems). Literature was sourced from six electronic databases, online searches and key experts. Selection criteria included studies from LMIC published in English from 2004 to July 2018 detailing factors influencing implementation of MPDSR, or any related form of MPDSR. After a systematic screening process, data for identified records were extracted and analysed through content and thematic analysis. Of 1027 studies screened, the review focuses on 58 studies from 24 countries, primarily in Africa, that are mainly qualitative or mixed methods. The literature mostly examines implementation factors related to MPDSR as an intervention, and to its inner and outer setting, with less attention to the individuals involved. From a health systems perspective, almost half the literature focuses on the tangible inputs addressed by the service delivery lens, though these are often measured inadequately or through incomparable ways. Though less studied, the societal and health system factors show that people and their relationships, motivations, implementation climate and ability to communicate influence implementation processes; yet their subjective experiences and relationships are inadequately explored. MPDSR implementation contributes to accountability and benefits from a culture of learning, continuous improvement and accountability, but few have studied the complex interplay and change dynamics involved. Better understanding MPDSR will require more research using health policy and systems approaches, including the use of implementation frameworks.

Project description:BackgroundMaternal and Perinatal Death Surveillance and Response (MPDSR) was a pilot program introduced in Tigray, Ethiopia to monitor maternal and perinatal death. However; its implementation and operation is not evaluated yet. Therefore, this study aimed to assess the implementation and operational status and determinants of MPDSR using a programmatic data and stakeholders involved in the program.MethodsInstitutional based cross-sectional study was applied in public health facilities (75 health posts, 50 health centers and 16 hospitals) using both qualitative and quantitative methods. Data were entered in to Epi-info and then transferred to SPSS version 21 for analysis. All variables with a p-value of ≤ 0.25 in the bivariate analysis were included in to multivariable logistic regression model to identify the independent predictors. For the qualitative part, manual thematic content analysis was done following data familiarization (reading and re-reading of the transcripts).ResultsIn this study, only 34 (45.3%) of health posts were practicing early identification and notification of maternal/perinatal death. Furthermore, only 36 (54.5%) and 35(53%) of health facilities were practiced good quality of death review and took proper action respectively following maternal/perinatal deaths. Availability of three to four number of Health Extension Workers (HEWs) (Adjusted Odds Ratio (AOR) = 6.09, 95%CI (Confidence Interval): 1.51-24.49), availability of timely Public Health Emergency Management (PHEM) reports (AOR = 4.39, 95%CI: 1.08-17.80) and participation of steering committee's in death response (AOR = 9.19, 95%CI: 1.31-64.34) were the predictors of early identification and notification of maternal and perinatal death among health posts. Availability of trained nurse (AOR = 3.75, 95%CI: 1.08-12.99) and health facility's head work experience (AOR = 3.70, 95%CI: 1.04-13.22) were also the predictors of quality of death review among health facilities. Furthermore; availability of at least one cluster review meeting (AOR = 4.87, 95%CI: 1.30-18.26) and uninterrupted pregnant mothers registration (AOR = 6.85, 95%CI: 1.22-38.54) were associated with proper response implementation to maternal and perinatal death. Qualitative findings highlighted that perinatal death report was so neglected. Community participation and intersectoral collaboration were among the facilitators for MPDSR implementation while limited human work force capacity and lack of maternity waiting homes were identified as some of the challenges for proper response implementation.ConclusionThis study showed that the magnitude of: early death identification and notification, review and response implementation were low. Strengthening active surveillance with active community participation alongside with strengthening capacity building and recruitment of additional HEWs with special focus to improve the quality of health service could enhance the implementation of MPDSR in the region.

Project description:INTRODUCTION:Maternal and perinatal death surveillance and response (MPDSR), or any related form of audit, is a systematic process used to prevent future maternal and perinatal deaths. While the existence of MPDSR policies is routinely measured, measurement and understanding of policy implementation has lagged behind. In this paper, we present a theory-based conceptual framework for understanding MPDSR implementation as well as a scoping review protocol to understand factors influencing MPDSR implementation in low/ middle-income countries (LMIC). METHODS AND ANALYSIS:The Consolidated Framework for Implementation Research will inform the development of a theory-based conceptual framework for MPDSR implementation. The methodology for the scoping review will be guided by an adapted Arksey and O'Malley approach. Documents will include published and grey literature sourced from electronic databases (PubMed, CINAHL, SCOPUS, Web of Science, JSTOR, LILACS), the WHO Library, Maternal Death Surveillance and Response Action Network, Google, the reference lists of key studies and key experts. Two reviewers will independently screen titles, abstracts and full studies for inclusion. All discrepancies will be resolved by an independent third party. We will include studies published in English from 2004 to July 2018 that present results on factors influencing implementation of MPDSR, or any related form. Qualitative content and thematic analysis will be applied to extracted data according to the theory-based conceptual framework. Stakeholders will be consulted at various stages of the process. ETHICS AND DISSEMINATION:The scoping review will synthesise implementation factors relating to MPDSR in LMIC as described in the literature. This review will contribute to the work of the Countdown to 2030 Drivers Group, which seeks to explore key contextual drivers for equitable and effective coverage of maternal and child health interventions. Ethics approval is not required. The results will be disseminated through various channels, including a peer-reviewed publication.

Project description:BackgroundMaternal and perinatal death surveillance and response (MPDSR) is a system of identifying, analysing and learning lessons from such deaths in order to respond and prevent future deaths, and has been recommended by WHO and implemented in many low-and-middle income settings in recent years. However, there is limited documentation of experience with MPDSR in humanitarian settings. A meeting on MPDSR in humanitarian settings was convened by WHO, UNICEF, CDC and Save the Children, UNFPA and UNHCR on 17th-18th October 2019, informed by semi-structured interviews with a range of professionals, including expert attendees.Consultation findingsInterviewees revealed significant obstacles to full implementation of the MPDSR process in humanitarian settings. Many obstacles were familiar to low resource settings in general but were amplified in the context of a humanitarian crisis, such as overburdened services, disincentives to reporting, accountability gaps, a blame approach, and politicisation of mortality. Factors more unique to humanitarian contexts included concerns about health worker security and moral distress. There are varying levels of institutionalisation and implementation capacity for MPDSR within humanitarian organisations. It is suggested that if poorly implemented, particularly with a punitive or blame approach, MPDSR may be counterproductive. Nevertheless, successes in MPDSR were described whereby the process led to concrete actions to prevent deaths, and where death reviews have led to improved understanding of complex and rectifiable contextual factors leading to deaths in humanitarian settings.ConclusionsDespite the challenges, examples exist where the lessons learnt from MPDSR processes have led to improved access and quality of care in humanitarian contexts, including successful advocacy. An adapted approach is required to ensure feasibility, with varying implementation being possible in different phases of crises. There is a need for guidance on MPDSR in humanitarian contexts, and for greater documentation and learning from experiences.

Project description:BackgroundMaternal and Perinatal Death Surveillance and Response (MPDSR) systems provide an opportunity for health systems to understand the determinants of maternal and perinatal deaths in order to improve quality of care and prevent future deaths from occurring. While there has been broad uptake and learning from low- and middle-income countries, little is known on how to effectively implement MPDSR within humanitarian contexts - where disruptions in health service delivery are common, infrastructural damage and insecurity impact the accessibility of care, and severe financial and human resource shortages limit the quality and capacity to provide services to the most vulnerable. This study aimed to understand how contextual factors influence facility-based MPDSR interventions within five humanitarian contexts.MethodsDescriptive case studies were conducted on the implementation of MPDSR in Cox's Bazar refugee camps in Bangladesh, refugee settlements in Uganda, South Sudan, Palestine, and Yemen. Desk reviews of case-specific MPDSR documentation and in-depth key informant interviews with 76 stakeholders supporting or directly implementing mortality surveillance interventions were conducted between December 2021 and July 2022. Interviews were recorded, transcribed, and analyzed using Dedoose software. Thematic content analysis was employed to understand the adoption, penetration, sustainability, and fidelity of MPDSR interventions and to facilitate cross-case synthesis of implementation complexities.ResultsImplementation of MPDSR interventions in the five humanitarian settings varied in scope, scale, and approach. Adoption of the interventions and fidelity to established protocols were influenced by availability of financial and human resources, the implementation climate (leadership engagement, health administration and provider buy-in, and community involvement), and complex humanitarian-health system dynamics. Blame culture was pervasive in all contexts, with health providers often facing punishment or criminalization for negligence, threats, and violence. Across contexts, successful implementation was driven by integrating MPDSR within quality improvement efforts, improving community involvement, and adapting programming fit-for-context.ConclusionsThe unique contextual considerations of humanitarian settings call for a customized approach to implementing MPDSR that best serves the immediate needs of the crisis, aligns with stakeholder priorities, and supports health workers and humanitarian responders in providing care to the most vulnerable populations.

Project description:BackgroundIn Ethiopia, Maternal Death Surveillance and Response (MDSR) was integrated into the existing Integrated Disease Surveillance and Response (IDSR) system in 2014. Despite providing valuable evidence to inform policies and actions, system implementation has not been evaluated. Thus, a national-level evaluation was conducted to assess the level and status of system implementation.MethodsA national cross-sectional study was conducted using a multi-stage sampling approach in 2020. A total of 629 health facilities were included in the study. A modified tool, adapted from the World Health Organization (WHO) and the Centers for Disease Control and Prevention (CDC), was employed to assess each functional component of the system, encompassing structure, core, supportive, and system attributes. The score for each component was based on Ethiopian Public Health Institute's mid-term evaluation metrics. To objectively evaluate the implementation status, a composite score of the Maternal Death Surveillance and Response Performance Index (MDSRPI) was calculated based on five performance indicators. Descriptive statistics, independent t-tests, and one-way analysis of variance (ANOVA) with Bonferroni correction were used to examine the variations in scores among the different characteristics.ResultsOf the total sample size, 82.5% (519/629) of health facilities were assessed. Among the assessed health facilities, 77.0% (400/519) fulfilled the criteria for final analysis. Accordingly, the overall readiness score was 44.9% (95% CI: 43.9% to 45.9%), which is rated as less functional. The structures of the system were rated at 51.7% (95% CI: 49.9% to 53.4%), and the system attributes were rated at 69.6% (95% CI: 68.0% to 71.2%), which were considered fairly functional. In contrast, the core functions were rated at 20.0% (95% CI: 18.9% to 21.1%), and the supportive functions were rated at 38.4% (95% CI: 36.4% to 40.4%), which were categorized as not functioning and less functional, respectively. Regionally, Tigray's overall readiness score (54.8%, 95% CI: 50.4-59.1%) was significantly higher than Oromia (41.6%, 95% CI: 40.2-43.0%, P = 0.0001), Amhara (47.7%, 95% CI: 43.9-45.9%, P = 0.05), and SNNPR (42.3%, 95% CI: 39.3-45.3, P = 0.0001). Additionally, Amhara's score was significantly higher than Oromia and SNNPR. Secondary-level healthcare facilities (49.6%, 95% CI: 45.7-53.7, P = 0.029) had a significantly higher readiness score compared to primary health facilities (44.6%, 95% CI: 43.5-45.6). The overall score for the Maternal Death Surveillance and Response Performance Index (MDSPI) was 33.9%.ConclusionDespite the noticeable regional variation, the overall system readiness and status to implement MDSR were suboptimal, characterized by low representativeness, completeness, and community engagement. Efforts should be directed toward improving community surveillance and enhancing all components of the system to address regional variations and improve overall performance through triangulation and integration with various data sources.

Dataset Information

Assessing Implementation of Maternal and Perinatal Death Surveillance and Response in Rwanda.

Publications

Assessing Implementation of Maternal and Perinatal Death Surveillance and Response in Rwanda.

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