Leveraging MPCDSR implementation to reduce maternal, newborn deaths

Latest figures from the World Health Organisation (WHO) indicate that Nigeria is the country with the second highest maternal and newborn deaths in the world. It is estimated that 58,000 women die yearly in Nigeria as a result of childbirth.

As part of efforts to reverse the trend, the Federal Government had in June, last year, launched the revised guidelines and tools for Maternal Perinatal and Child Death Surveillance and Response (MPCDSR).

The MPDSR is an intervention for improving maternal, perinatal, and neonatal survival by understanding the number and causes of deaths.

The Federal Government said it is committed to improving maternal, perinatal, neonatal morbidity and learning lessons that would help the country avert future occurrences.

The initiative has been expanded to incorporate child mortality audits, making it now MPCDSR.

The enabling bill was passed by the last National Assembly but was not assented to by former President Muhammadu Buhari.

The WHO, in 2013, launched the MDSR guidance to strengthen notification, review, and response to maternal deaths.

This guide, the WHO said, emphasises the need for each maternal death to be a notifiable event and reviewed to be able to understand the underlying causes to create a response mechanism to avert future deaths; a continuous cycle of surveillance and response.

A Consultant Obstetrician and Gynaecologist and Medical Director of Optimal Specialist Hospital, Surulere, Lagos, Dr. Celestine U. Chukwunenye, said MPDSR is recognised as a priority initiative that gave the serious subject of maternal, perinatal and infant mortality and morbidity audit the attention required to learn lessons that would help the country avert future occurrences.

Chukwunenye said signing the MDCPR bill into law would fast track death reporting, a process aimed at curbing as well as preventing unnecessary maternal deaths.

The Bill is for an Act to Provide for Effective Surveillance, Review and Prevention of Maternal and Perinatal Deaths and Related Matters for the Federal Republic of Nigeria 2020 (SB. 581).

According to Chukwunenye, that over 58,000 Nigerian women die from pregnancy-related causes yearly was sufficient for the authority to declare a state of emergency.

Sadly, he noted that irrespective of the high number of deaths, many people from communities, states and national level where such deaths occur don’t report the deaths of the affected women and newborn.

Although the high death rate has prompted the National Council of Health to push for the legislation to guide the operations of the MPDSR, Chukwunenye cautioned: “death reporting for the MPDSR is not to be punished or blamed; neither is it to be used for litigation.

Mrs. Otti

Meanwhile, Lagos is blazing the trail in states adopting and implementing the programme with its characteristic style of pioneering innovative health initiatives. The Lagos State government has launched a fully digitised auditing scheme of the MPDSR.

The launch concludes the transition from paper-based Maternal Death Review (MDR) to Maternal and Perinatal Death Surveillance and Response (MPDSR) and digitisation of the scheme, which started a year ago.

Already, the Lagos State University Teaching Hospital (LASUTH), and 23 secondary health facilities, have commenced electronic auditing of maternal and perinatal deaths to improve survival of vulnerable groups.

The initiative was flagged off with distribution of electronic tablets to Heads of the 23 facilities.

The tablets, which were procured by MamaYe-Evidence for Action (E4A), a maternal and neonatal health support programme funded by the Bill and Melinda Gates Foundation, were configured and supplied by InstratGobal Health Solutions of the United States.

A statement by MamaYe noted that MPDSR adds perinatal death audits and provides additional public health benefits of quality of care improvements and real-time data capture on the characteristics of both categories of deaths.

On lessons for implementing effective community MPDSR from Nigeria, Dr. Moshood Salawu said across Nigeria, three out of every five women give birth at home without the services of skilled birth attendants, according to the National Demographic Health Surgery 2018 (NDHS, 2018). Salawu said a better understanding of the realities of maternal and newborn health at the community level is important for increasing skilled birth attendance at delivery and preventing avoidable deaths going forward.

He said the MPDSR system is a very useful way to track and monitor deaths and understand their causes. However, at present, implementation of MPDSR in Nigeria is limited to deaths in secondary and tertiary facilities. This means that many deaths go unaudited and preventable causes go unaddressed.

Salawu advocated Community-MPDSR, referred to as c-MPDSR, as a model that ensures maternal and perinatal deaths are identified, documented and audited regardless of the place of death, including those that occur at home, in transit to a health facility or at the facility.

“Our model supports communities in the use of verbal and social autopsies to gather data on the root causes of death and develop actions to prevent future occurrences,” he said.

The Evidence for Action (E4A)-MamaYe project, managed by Options Consultancy Services with partners that include the Kaduna State Government, implemented a pilot c-MPDSR project over a six-month period from January to June 2022 in one urban community, Soba, and in one rural community, Yakasai – both in the Soba Ward (district) of the Soba local government area (LGA), one of the 23 LGAs in Kaduna State, Nigeria. The project adapted the tools used in a study in rural Malawi, and an end-line evaluation of the project can be accessed at this link.

“Health care workers and selected representatives of a local c-MPDSR committee conduct a verbal autopsy with the family of the deceased to gather information on both medical and non-medical (focusing on the economic and sociocultural) factors that led to the death. The social autopsy brings together all stakeholders to discuss and agree on actions to prevent future deaths using information collected during verbal autopsies,” Salawu said.

Salawu is the MPDSR Advisor for Evidence for Action (E4A)-MamaYe, a project managed by Options Consultancy Services and funded by the Bill & Melinda Gates Foundation.

Also, according to MSD for Mothers, to achieve high quality maternity care, every maternal death, wherever it occurs, should be counted, reported and examined—and the findings from these reviews should drive action to prevent future deaths.

MSD for Mothers, in a report titled “Strengthening Maternal Death Reviews to Improve the Quality of Maternity Care”, said meeting the Sustainable Development Goal target for reducing maternal mortality will require doubling the progress over the last decade and using data to focus efforts more intensively. Health care providers, policymakers, women and families need timely and accurate information about where, how and why women are dying so they can prevent future loss of life.

Unfortunately, data on the true burden and causes of maternal deaths in low-and-middle income countries (LMICs) are often unreliable. Countries rely on estimates and statistical models that are subject to error and do not include the full picture of why a woman died during pregnancy, childbirth or the postpartum period, especially if she gives birth outside of a facility.

According to the report, maternal death reviews, often referred to as MPDSR and Maternal Mortality Review Committees in the United States, are recognised as an effective strategy to help reduce maternal mortality. A well-functioning surveillance system supports a country’s efforts to determine why a woman died from complications of pregnancy and childbirth and steers decision makers, donors and local stakeholders toward evidence-based and evidence-informed lifesaving interventions.

According to the report, findings from maternal death reviews provide countries with critical information to identify opportunities to improve the quality of clinical care as well as care that takes place outside of health facilities. It said based on trends identified in the data, decision makers can allocate time and resources more strategically to help build the capacity of health systems to recognise and respond effectively to life-threatening complications that arise during pregnancy, childbirth and the year after giving birth when many deaths occur.

Elsewhere, the United Kingdom (U.K.) has set the standard for maternal death surveillance and case reviews through its Confidential Enquiry into Maternal Deaths. This system, which examines every death, has been in operation for more than 60 years, during which time maternal mortality has declined ten-fold. It has since expanded to include reviews of the care received by women who experienced severe maternal morbidities.

Several countries, including LMICs, have also invested in building their capabilities in maternal death surveillance. For example, in 2014 Ethiopia, implemented a national MPDSR system and now reports on maternal deaths that occurred in both community and facility settings through the Integrated Disease Surveillance and Response system, maternal death reviews take place at the subnational level and review committees include community representatives.

According to the MSD for Mothers report, countries are at various stages of adopting, implementing and institutionalising maternal death reviews at the national and/ subnational levels. Of 110 LMICs, 89 per cent have a national policy to notify the surveillance system of all maternal deaths and 88 per cent instituted a policy to review all maternal deaths. Of these countries, 76 per cent have a national maternal death review committee in place, but only 48 per cent meet, at least, on a biannual basis.

Death Reviews in MSD for Mothers’ Focus Countries showed that in India, though fragmented, more states are strengthening their MPDSR system. Kenya mandated maternal death review in 2004, but underreporting and inaccurate reporting of cause of death remain challenges.

In Nigeria, the Federal Government is considering a bill to mandate MPDSR across the country. In the United States (US), Preventing Maternal Deaths Act of 2018 provided resources to help states strengthen their maternal mortality review committees.

Indeed, the WHO and United Nations Children’s Fund (UNICEF) recommend that all countries institutionalise maternal death reviews as a key strategy to prevent maternal deaths.

The WHO has developed guidelines for implementing maternal death surveillance systems, which call for action from national and subnational governments, health care facilities and local communities.

It said collaboration across all levels of the healthcare system—government, facility, provider and community—is required to design an effective system that reports, analyses and acts on all maternal deaths to prevent future maternal deaths.