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For permission to use where not already granted under a licence please go to http: Abstract Background In Malawi, maternal mortality remains high. Existing maternal death reviews fail to adequately review most deaths, or capture those that occur outside the health system.
We assessed the value of community involvement to improve capture and response to community maternal deaths. Methods We designed and piloted a community-linked maternal death review CLMDR process in Mchinji District, Malawi, which partnered community and health facility stakeholders to identify and review maternal deaths and generate actions to prevent future deaths.
Results The CLMDR process was found to be comparable to a previous research-driven surveillance system at identifying deaths in Mchinji District population in Based on district estimates of population and crude birth rate 35 births per populationthe maternal mortality ratio was around maternal deaths per live births.
We found the CLMDR process to increase the quantity of information available and to involve a wider range of stakeholders in maternal death review MDR.
It shows potential as a maternal death surveillance system, and may be applicable to similar contexts with high maternal mortality.
Communities and health facility representatives worked in partnership to investigate and respond to maternal deaths occurring in communities and health facilities. Confidentiality of the death review was limited to allow participation of, gain information from, and spur action from the community.
No adverse effects of this openness were reported. Our pilot study delineated key issues to consider for scale-up: Raising the status of the community involved is essential to ensure the sustainability of the process.
Introduction Around the world, many women continue to die as a result of pregnancy and childbirth. In an estimated maternal deaths occurred worldwide, 1 most preventable with proven interventions.
The UN Secretary General's Commission on Information and Accountability recommends the introduction of better methods to count maternal deaths and to review and monitor progress.
Maternal death audit covers three approaches: The existing system in Malawi fails to adequately achieve these objectives due to weaknesses in the six key areas detailed in the Methods section below.
Although the Malawi Ministry of Health does conduct national-level confidential enquiries into maternal deaths, they are mainly limited to the use of facility-based MDR. WHO and UNFPA recognise the value of accurate and timely investigation of maternal deaths to stimulate actions to prevent maternal deaths in future.
Our study describes the Malawian context and identifies six weaknesses of the current MDR system. We present the pilot study of the CLMDR process over a 1-year period, and the results of how it can overcome these weaknesses and provide an estimate of maternal mortality.
Methods Location Malawi has a high, though declining, maternal mortality ratio. Maternal death identification While a maternal death is a notifiable event in Malawi, the Ministry of Health notification system attempts to identify only those maternal deaths that occur in hospital. However, one-third of all deaths are known to occur outside health facilities, either at the woman's home, the home of a traditional healer, or in transit to a facility, and these are presently not identified by the hospital-based notification system.
Review of maternal deaths The Ministry of Health aims to review all maternal deaths occurring in health facilities, but in reality this is not achieved. Quality and quantity of information available The outcome of an MDR process is dependent on the quality of the data gathered.
Current data comes from hospital records, which often fail to adequately record patient history, examination findings, monitoring, results and management. Stakeholder involvement Only a limited number of hospital staff are involved in the MDR process.
Community mobilisation and action A recent study in Mchinji District, Malawi, added to the evidence that communities themselves have significant potential to reduce maternal and neonatal mortality when they are involved in planning and implementing community actions.
Accountability of health workers When health workers plan to take action following a MDR there is no official monitoring of whether these actions are taken, as completion of the maternal death follow-up form is almost non-existent.
Motivation for MDR among health workers is reported to be low, while communities are highly motivated to take steps to prevent maternal deaths.
We aimed for a blame-free process to review all maternal deaths, including those occurring in the community; supplement the limited hospital data with rich descriptive information from the community; and include a wider group of health facility staff and community representatives.
We hoped that this new process would catalyse health facility and community actions to address the determinants of maternal death; improve the accountability of health workers; and, by elevating the community as partners in the process, generate a self-sustaining MDR process fuelled by community motivation to prevent maternal deaths.
To design the process, we drew on evidence from a number of studies that have used social autopsy to enhance maternal health programmes.
In Indonesia, social autopsy and medical records were used together to review deaths, with some community involvement. The project was initially piloted in four of the 12 health centre catchment areas in Mchinji District.
Following feedback from all participants and the Malawi national-level safe motherhood taskforce, the process was modified shortening and combining reporting into one form and then rolled out across the whole district for a 1-year period July —June Start studying Macroeconomics - Chapter 5 - An Introduction to Macroeconomics.
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