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Emerging lessons from the FIGO LOGIC initiative on maternal death and near-miss reviews
International Journal of Gynecology and Obstetrics 127 (2014) S17–S20
Contents lists available at ScienceDirect
International Journal of Gynecology and Obstetrics journal homepage: www.elsevier.com/locate/ijgo
FIGO LOGIC INITIATIVE
Emerging lessons from the FIGO LOGIC initiative on maternal death and near-miss reviews Gwyneth Lewis ⁎ Institute for Women’s Health, University College London, London, UK
a r t i c l e
i n f o
Keywords: Confidential enquiry Maternal death review Facility based maternal death review FIGO LOGIC initiative Health professional association Maternal mortality Maternal morbidity Near-miss review
a b s t r a c t This short paper describes some early findings from an overview of the maternal death or severe morbidity “near-miss” reviews that have been undertaken to improve clinical care by the eight societies participating in the FIGO Leadership in Obstetrics and Gynecology for Impact and Change (LOGIC) Initiative in Maternal and Newborn Health aimed at strengthening the role of professional obstetric associations. While it is expected that each will publish its own report, generalizable lessons emerged and valuable solutions were implemented that will help others planning such reviews and audits in future. © 2014 Published by Elsevier Ireland Ltd. on behalf of International Federation of Gynecology and Obstetrics.
1. Introduction Improving clinical care through the introduction of maternal severe morbidity or mortality reviews by professional organizations was one of the aims of the FIGO Leadership in Obstetrics and Gynecology for Impact and Change (LOGIC) Initiative in Maternal and Newborn Health [1]. The approaches chosen were based on those in the WHO practical publication “Beyond the Numbers: Reviewing maternal deaths and disabilities to make pregnancy safer” [2] (Table 1). Due to individual circumstances, each program differed a little and developed along different timelines so there can be no direct comparison between them. However, as the underlying principles were similar, some generalizable lessons emerged. In line with the underpinning “Beyond the Numbers” ethos of confidentiality, these will be discussed in a general manner without identifying specific associations. Three papers in the present Supplement, from the participating societies in Ethiopia, India, and Nigeria, describe their own approaches and outcomes in more detail.
Once a methodology had been chosen, as shown in Table 2, more detailed training and technical meetings were usually held where participants worked through the steps in developing a review process. These are well described in chapter 3 of “Beyond the Numbers” [2] and are summarized in Box 1. The attendees at the in-depth technical workshops were similar to those who had attended the first but expanded to include more representatives from professional associations including midwives, participating hospitals, Ministries of Health, academic departments, nongovernmental organizations, and other key stakeholders. At these meetings the processes were finalized and tools and questionnaires developed. These were piloted and, as the program was implemented, refined over time. Those associations who were not already familiar with or engaged in some form of maternal death review chose the simplest approach—that of facility based maternal death review (MDR). Others, with previous experience, opted for near-miss reviews (NMR); and Burkina Faso and Ethiopia undertook both. 3. Audit or review?
2. Program planning and implementation Most professional associations developed their programs following an introductory workshop where the underlying principles and practical approaches to the methodologies for review were explored. Each country worked with one or two international experts in the field. ⁎ Institute for Women’s Health, University College London, 74 Huntley Street, London, WC1E 6AU, UK. Tel.: +44 20 3108 2040; fax: +44 20 3108 2036. E-mail address: [email protected].
During the process there were many discussions about suitable terminology and whether this was a process of audit or review. Audit generally refers to a quality improvement process through “a process that seeks to improve patient care and outcomes through systematic review of care against explicit criteria and the implementation of change” [3]. These may include clinical standards and guidelines, many of which were absent in the countries or facilities that took part in these reviews. As such stringency could not generally be achieved, the quality of care the mothers received was reviewed against what was considered by local experts to be acceptable in the specific circumstances under
http://dx.doi.org/10.1016/j.ijgo.2014.07.007 0020-7292/© 2014 Published by Elsevier Ireland Ltd. on behalf of International Federation of Gynecology and Obstetrics.
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G. Lewis / International Journal of Gynecology and Obstetrics 127 (2014) S17–S20
Table 1 The key methodologies used for learning lessons for action and improvement in care through the use of maternal death or severe morbidity near-miss reviews. Methodology
Definition
Facility based maternal death review (MDR)
An in-depth assessment of the causes and circumstances surrounding pregnant or recently delivered mothers who die in health facilities. Cases are identified at the facility level but, if possible, are also concerned with identifying community based factors that may have contributed to the death, and the lessons to be learned from these as well. Learning lessons for action and improvement through the identification and assessment of cases where pregnant women survive life-threatening complications or “near misses.” A method of helping identify women who die outside facilities and the probable medical causes for this. It also helps ascertain any personal, family, community, and other factors that may have contributed to the outcome. A qualitative and quantitative systematic and anonymous review of all or a representative sample of maternal deaths occurring at an area, regional (state), or national level. It identifies the numbers, causes, and avoidable or remediable factors associated with them and make recommendations for change.
Near-miss/severe morbidity reviews (NMR) Community based maternal death reviews (verbal autopsies) (VA) Confidential enquiries into maternal deaths (CEMD)
Reproduced and adapted with permission from WHO [2].
review. This is why the term “review” was chosen, although the resultant guidelines will lead to the opportunity to conduct comprehensive clinical audits in future.
5. Emerging findings
4. An action-based process
In total, by August 2013, over 800 deaths and 3000 near-miss cases had been identified and the work is still on-going. As each country had different case definitions, and some did not collect deaths from indirect causes such as HIV, neurological, or cardiac disease, it is not possible to provide a comprehensive comparative breakdown. The actual numbers
All the approaches used the maternal mortality and morbidity review cycle as their backbone (Fig. 1). They are on-going, action-based programs where cases are identified, data are collected on standardized forms, results are systematically reviewed to an agreed format, and any deficiencies, errors, or opportunities for remediable action are identified. The next and, in terms of these reviews, the most challenging stages are to make practical and sensible recommendations for beneficial changes and to implement and evaluate these. This philosophy is identical to that of the recent complementary WHO program, maternal death surveillance and response (MDSR) [4], where the use of the term “response” reiterates the need to take actions on the results. Without an in-depth case review for each case and taking beneficial actions on the lessons learned, the process is no more than a method for improving surveillance or a survey or qualitative method for identifying overall risk factors and determinants of maternal deaths. Also, as has been seen during the LOGIC process, a lack of action can result in staff disenfranchisement and unwillingness to participate. This has been seen, or reported to have occurred, in at least two of the LOGIC review program countries. Conversely, where staff were enthusiastic and supported by administrative colleagues and others who can effect change, local results were rapidly seen. The program in Debre Berhan Hospital in Ethiopia, for example, which also worked with the surrounding communities, has resulted in an altruistic blood bank provided by patients and staff, better transport, a more respectful attitude to patients, privacy in labor, and a partnership with the local technical college to repair broken equipment. Other departments such as surgery were so impressed with the results that they have introduced similar reviews themselves.
Table 2 Methodologies chosen by the professional associations of participating countries. Country professional association
Definition
Burkina Faso
Facility based death reviews and near-miss reviews in three hospitals in the initial phase. Facility based death reviews in five hospitals. Facility based death and near-miss reviews in nine district hospitals, and feeder health centers, with community reviews where possible. Near-miss reviews in six teaching hospitals. Facility based death review in three hospitals. Near-miss reviews in 16 hospitals in the Kathmandu valley. Facility based death reviews to be piloted. Facility based death reviews in four hospitals.
Cameroon Ethiopia
India Mozambique Nepal Nigeria Uganda
5.1. Causes of death and severe morbidity
Box 1 Key steps in developing a maternal death or near-miss review program. 1. Form a small, active steering committee that includes representatives of all relevant professional groups including midwives, policy-makers, and other organizations and key stakeholders that can help implement the recommendation. Members should be chosen for their hands-on contribution to the work required and not just as figureheads of their respective associations or academic institutions. 2. Undertake a current needs assessment to obtain as complete a picture as possible of the current local/national situation in regard to maternal and newborn health. 3. Decide the approach and which cases will be subject to review. 4. Develop the process and identify a host institution and program manager. 5. Decide how expert assessors will be recruited and appoint these for a fixed term. 6. Consider how to ensure confidentiality and the “no name, no blame” principles. 7. Plan the process for the comprehensive identification and assessment of all cases, including specific and agreed clinical definitions for cases of severe morbidity if appropriate. 8. Design and pilot questionnaires and any other instruments that are required. 9. Agree how cases will be assessed and develop a standardized format for this. If available, collect existing protocols, standards, and any other evidence-based clinical guidelines that may be used as benchmarks during case evaluation. 10. Decide how and when the cases will be subject to expert review and assessment and recommendations for action developed. 11. Devise how and when to publish and disseminate the resulting recommendations. 12. Plan how to audit and evaluate the process and the implementation of recommendations and subsequent outcomes. 13. Learn lessons to refine and improve the process for the next cycle. Adapted with permission from WHO [2].
G. Lewis / International Journal of Gynecology and Obstetrics 127 (2014) S17–S20
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Box 2 Principles of facility based case review meetings. Define cases
Implement audit
• Meetings should be multidisciplinary and interactive. They should not be didactic. This is best achieved with participants sitting in a circle. • They should be held at regular times and protected time given for staff attendance. • Administrators and others who can act on the recommendations should be present.
Collect data
Meeting agenda
Make recommendaons
Review and assess data
Fig. 1. The maternal morbidity and mortality review cycle. Reproduced with permission from WHO [2].
of the leading causes of death, as far as it was possible to identify these, are summarized in Table 3. They were relatively consistent between each country and similar proportions were also seen for near-miss cases. Owing to a lack of detailed feedback, inconsistent definitions, or poor hospital records, it was not possible to accurately identify the underlying causes for the majority of cases of hemorrhage although it would appear that postpartum hemorrhage and uterine rupture were most common. While WHO published international case definitions for severe morbidity during the course of this project [5], there may be a need for further understanding, dissemination, and technical support for their implementation in low-income countries. 6. Professional practice Participating in regular case reviews and audits of serious adverse medical events, particularly those that are unexpected or avoidable, is seen as an essential part of professional practice and lifelong learning [6,7]. However, this was not a process that has become a routine, systematic part of clinical practice in all settings. The author personally experienced obfuscation and lack of full participation by some staff. The confrontational manner in which certain local review meetings were held also militated against complete support. 7. Facility based meetings The cornerstone of all of the approaches used was the facility based meeting where local staff discussed individual cases in detail. In this manner they learned local lessons and took steps to improve services. These require careful planning and need to cover issues of team working, quality, and guidelines [8]. There is little published guidance on the Table 3 Leading causes of death. Cause
No.
%
Hemorrhage (including ruptured uterus from obstructed labor) Eclampsia Anemia (underlying cause of death not stated) HIV Sepsis Consequences of unsafe abortion (precise cause not stated) Malaria Cardiac disease Anesthesia Other causes Total
292 131 86 83 76 48 46 46 18 18 844
35 16 10 10 9 6 5 5 2 2 100
1. Read and agree code of conduct. 2. Re-evaluate the recommendations of previous sessions and provide a short follow-up of actions decided at the last meeting – identify any further action required. 3. Present the clinical summary of case(s). 4. Conduct a systematic case review, using a common template and with reference to any clinical guidelines or standards available. 5. Prepare a case analysis and local recommendations. 6. Plan for implementation. 7. Prepare a case analysis and a report to be sent to the overall steering committee for the wider review program, if one exists. 8. Feedback general findings and recommendations to other staff who could not attend and hospital administrators.
procedures for such meetings although the FIGO LOGIC consultants have developed an explanatory paper and a tool kit for training, which are available on the FIGO website [9,10]. In most countries the findings were also sent to a wider review committee where all the cases were collated, usually anonymously, and evaluated by independent experts. The underlying principle on which these meetings were based is that of learning lessons for improvement and not to apportion blame or punishment. At first this was a concept that was difficult for some participants to understand, which led to a lack of openness in both reporting and discussion. Missing or poorly completed case notes did not help. In circumstances where the case reviews were not confidential and took place when representatives of the local authorities attended, the review process failed. Throughout the process, countries have followed the common principles and features of successful facility based reviews (Box 2). In a number of countries participants found it helpful to read, and in some cases sign, an agreed code of conduct drawn up for earlier studies (Box 3). Box 3 Suggested code of conduct for facility based review meetings. “We agree to respect the rules of good conduct during meetings reviewing deaths or near-miss cases in our facility. We will: • • • • • •
Arrive on time to the meeting. Respect everyone’s ideas and ways of expressing these. Respect the confidentiality of the discussions in the group. Participate actively to discussions. Accept discussion and disagreement without verbal violence. Agree not to hide useful information or falsify information that could allow the understanding of the audited case. • Try (as much as possible as it is not easy) to accept that our own actions may be questioned.” Adapted with permission from De Brouwere et al. [9].
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Box 4 Characteristics for practical and useable recommendations.
only a few focused and important ones, whose implementation can be audited and regularly reviewed. This is an area where more guidelines and training is needed.
Recommendations should be: • • • • • •
Simple Realistic Action orientated Auditable Achievable Supported by evidence from the review.
Not too many at once; 10 maximum.
8. Action based recommendations Developing and acting on realistic recommendations are essential parts of the review process, but this proved challenging. Most recommendations were well-meaning but impossible to implement. They comprised of general statements such as “something needs to be done to improve the economic condition of the women, “we must improve safe motherhood programs,” “more staff,” “the training curricula for doctors and midwives needs to be in sync with reality,” or the allencompassing “in order to address late referral and access to health care it is proposed to emphasize goal oriented antenatal care, and encourage skilled birth attendance and emergency preparedness and contraceptive use.” However, in some cases, practical recommendations led to real changes. At a national level these included the development of clinical guidelines, pathways for monitoring women for the first six hours after delivery, and protocols for the triage of sick mothers on admission as well as their timely transfer from private clinics. At local levels, outcomes similar to those already discussed for Debre Berhan Hospital in Ethiopia were seen, including an extra operating theatre, 24-hour specialist cover, and improved blood supplies and clinical protocols. One Indian facility stated “Our institutional death rate and case fatality rate have now come down…no deaths have occurred at home.” While this improvement cannot be directly ascribed to maternal death reviews, this statement shows the extent to which staff in the facility saw them as a useful approach to improve treatment and reduce maternal mortality. One of the leading causes of death and near-miss identified was obstructed labor and/or ruptured uterus. In many places when partograms were introduced, the number of deaths appeared to fall but, despite this, their introduction was not universal across all country programs. In one large hospital women continue to die of ruptured uterus at the same rate as before the reviews started because the introduction of the partogram was considered to be too onerous for busy staff and not recommended. This defeats the whole object of all of the hard work undertaken in the preparation of the local facility based report. Box 4 lists the basic principles for the development of realistic recommendations that have emerged from this overview. It is natural to want to make as many recommendations as possible, but experience has shown that it is easier to achieve their introduction if there are
9. Conclusions One of the concerns about the validity of these types of review is the limited evidence of their effectiveness. It is often not possible for overstretched staff in extremely busy or overwhelmed hospitals to write papers and publish their results, let alone to conform to the rigor required by peer reviewed, widely read journals. Certainly in most cases numbers will be too small to show a statistically relevant result. Indeed, it may take a number of years for large, even national programs to collect enough data to be able to demonstrate any populationbased changes with certainty. But this does not mean that the work is ineffective. These programs and other similar programs have already resulted in significant improvements, on a small scale, at local levels. It would therefore be a retrograde step if a lack of publications or statistically robust data led to the cessation of local facility based reviews, which are leading to more robust clinical governance, better resource allocation, and improved clinical care for the mothers in their locality. Challenges obviously remain and the present paper has highlighted a number of important issues that those developing and participating in maternal death audit and reviews in future should address. Conflict of interest The author has no conflicts of interest. References [1] International Federation of Gynecology and Obstetrics (FIGO). FIGO LOGIC initiative in maternal and newborn health. www.figo.org/projects/LOGIC_initiative. Accessed August 1, 2012. [2] World Health Organization. Beyond the Numbers: reviewing maternal deaths and disabilities to make pregnancy safer. Geneva: WHO; 2004. http://whqlibdoc.who. int/publications/2004/9241591838.pdf?ua=1. Accessed July 22, 2012. [3] Healthcare Quality Improvement Partnership. Review of ethics issues related to clinical audit and quality improvement activities. http://www.hqip.org.uk/assets/ Downloads/Ethics-and-Clinical-Audit-and-Quality-Improvement-LiteratureReview.pdf. Accessed July 3, 2014. [4] Danel I, Graham W, Boerma T. Maternal death surveillance and response. Bull World Health Organ 2011;89(11)779-779A. [5] World Health Organization. Evaluating the quality of care for severe pregnancy complications: The WHO near-miss approach for maternal health. Geneva: WHO; 2011. http://whqlibdoc.who.int/publications/2011/9789241502221_eng.pdf?ua=1. July 1, 2012. [6] Ludmerer K. Instilling professionalism in medical education. JAMA 1999;282(9): 881–2. [7] General Medical Council. Good Medical Practice. http://www.gmc-uk.org/static/ documents/content/Good_medical_practice_-_English_0414.pdf; 2013. Accessed July 3, 2014. [8] Richard F, Ouédraogo C, Zongo V, Ouattara F, Zongo S, Gruénais ME, et al. The difficulty of questioning clinical practice: experience of facility-based case reviews in Ouagadougou, Burkina Faso. BJOG 2009;116(1):38–44. [9] De Brouwere V, Zinnen V, Delvaux T. How to conduct maternal death reviews (MDR). Guidelines and tools for health professionals. London: FIGO; 2013. http://www.figo. org/projects/maternal-and-newborn-health/publications. Accessed July 2, 2014. [10] De Brouwere V, Zinnen V, Delvaux T. Maternal death reviews: training program for health professionals. London: FIGO; 2013. http://www.figo.org/files/figo-corp/ Edited%20MDR%20Training%20Curriculum%20final%202014.pdf. Accessed July 2, 2014.
Contents lists available at ScienceDirect
International Journal of Gynecology and Obstetrics journal homepage: www.elsevier.com/locate/ijgo
FIGO LOGIC INITIATIVE
Emerging lessons from the FIGO LOGIC initiative on maternal death and near-miss reviews Gwyneth Lewis ⁎ Institute for Women’s Health, University College London, London, UK
a r t i c l e
i n f o
Keywords: Confidential enquiry Maternal death review Facility based maternal death review FIGO LOGIC initiative Health professional association Maternal mortality Maternal morbidity Near-miss review
a b s t r a c t This short paper describes some early findings from an overview of the maternal death or severe morbidity “near-miss” reviews that have been undertaken to improve clinical care by the eight societies participating in the FIGO Leadership in Obstetrics and Gynecology for Impact and Change (LOGIC) Initiative in Maternal and Newborn Health aimed at strengthening the role of professional obstetric associations. While it is expected that each will publish its own report, generalizable lessons emerged and valuable solutions were implemented that will help others planning such reviews and audits in future. © 2014 Published by Elsevier Ireland Ltd. on behalf of International Federation of Gynecology and Obstetrics.
1. Introduction Improving clinical care through the introduction of maternal severe morbidity or mortality reviews by professional organizations was one of the aims of the FIGO Leadership in Obstetrics and Gynecology for Impact and Change (LOGIC) Initiative in Maternal and Newborn Health [1]. The approaches chosen were based on those in the WHO practical publication “Beyond the Numbers: Reviewing maternal deaths and disabilities to make pregnancy safer” [2] (Table 1). Due to individual circumstances, each program differed a little and developed along different timelines so there can be no direct comparison between them. However, as the underlying principles were similar, some generalizable lessons emerged. In line with the underpinning “Beyond the Numbers” ethos of confidentiality, these will be discussed in a general manner without identifying specific associations. Three papers in the present Supplement, from the participating societies in Ethiopia, India, and Nigeria, describe their own approaches and outcomes in more detail.
Once a methodology had been chosen, as shown in Table 2, more detailed training and technical meetings were usually held where participants worked through the steps in developing a review process. These are well described in chapter 3 of “Beyond the Numbers” [2] and are summarized in Box 1. The attendees at the in-depth technical workshops were similar to those who had attended the first but expanded to include more representatives from professional associations including midwives, participating hospitals, Ministries of Health, academic departments, nongovernmental organizations, and other key stakeholders. At these meetings the processes were finalized and tools and questionnaires developed. These were piloted and, as the program was implemented, refined over time. Those associations who were not already familiar with or engaged in some form of maternal death review chose the simplest approach—that of facility based maternal death review (MDR). Others, with previous experience, opted for near-miss reviews (NMR); and Burkina Faso and Ethiopia undertook both. 3. Audit or review?
2. Program planning and implementation Most professional associations developed their programs following an introductory workshop where the underlying principles and practical approaches to the methodologies for review were explored. Each country worked with one or two international experts in the field. ⁎ Institute for Women’s Health, University College London, 74 Huntley Street, London, WC1E 6AU, UK. Tel.: +44 20 3108 2040; fax: +44 20 3108 2036. E-mail address: [email protected].
During the process there were many discussions about suitable terminology and whether this was a process of audit or review. Audit generally refers to a quality improvement process through “a process that seeks to improve patient care and outcomes through systematic review of care against explicit criteria and the implementation of change” [3]. These may include clinical standards and guidelines, many of which were absent in the countries or facilities that took part in these reviews. As such stringency could not generally be achieved, the quality of care the mothers received was reviewed against what was considered by local experts to be acceptable in the specific circumstances under
http://dx.doi.org/10.1016/j.ijgo.2014.07.007 0020-7292/© 2014 Published by Elsevier Ireland Ltd. on behalf of International Federation of Gynecology and Obstetrics.
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G. Lewis / International Journal of Gynecology and Obstetrics 127 (2014) S17–S20
Table 1 The key methodologies used for learning lessons for action and improvement in care through the use of maternal death or severe morbidity near-miss reviews. Methodology
Definition
Facility based maternal death review (MDR)
An in-depth assessment of the causes and circumstances surrounding pregnant or recently delivered mothers who die in health facilities. Cases are identified at the facility level but, if possible, are also concerned with identifying community based factors that may have contributed to the death, and the lessons to be learned from these as well. Learning lessons for action and improvement through the identification and assessment of cases where pregnant women survive life-threatening complications or “near misses.” A method of helping identify women who die outside facilities and the probable medical causes for this. It also helps ascertain any personal, family, community, and other factors that may have contributed to the outcome. A qualitative and quantitative systematic and anonymous review of all or a representative sample of maternal deaths occurring at an area, regional (state), or national level. It identifies the numbers, causes, and avoidable or remediable factors associated with them and make recommendations for change.
Near-miss/severe morbidity reviews (NMR) Community based maternal death reviews (verbal autopsies) (VA) Confidential enquiries into maternal deaths (CEMD)
Reproduced and adapted with permission from WHO [2].
review. This is why the term “review” was chosen, although the resultant guidelines will lead to the opportunity to conduct comprehensive clinical audits in future.
5. Emerging findings
4. An action-based process
In total, by August 2013, over 800 deaths and 3000 near-miss cases had been identified and the work is still on-going. As each country had different case definitions, and some did not collect deaths from indirect causes such as HIV, neurological, or cardiac disease, it is not possible to provide a comprehensive comparative breakdown. The actual numbers
All the approaches used the maternal mortality and morbidity review cycle as their backbone (Fig. 1). They are on-going, action-based programs where cases are identified, data are collected on standardized forms, results are systematically reviewed to an agreed format, and any deficiencies, errors, or opportunities for remediable action are identified. The next and, in terms of these reviews, the most challenging stages are to make practical and sensible recommendations for beneficial changes and to implement and evaluate these. This philosophy is identical to that of the recent complementary WHO program, maternal death surveillance and response (MDSR) [4], where the use of the term “response” reiterates the need to take actions on the results. Without an in-depth case review for each case and taking beneficial actions on the lessons learned, the process is no more than a method for improving surveillance or a survey or qualitative method for identifying overall risk factors and determinants of maternal deaths. Also, as has been seen during the LOGIC process, a lack of action can result in staff disenfranchisement and unwillingness to participate. This has been seen, or reported to have occurred, in at least two of the LOGIC review program countries. Conversely, where staff were enthusiastic and supported by administrative colleagues and others who can effect change, local results were rapidly seen. The program in Debre Berhan Hospital in Ethiopia, for example, which also worked with the surrounding communities, has resulted in an altruistic blood bank provided by patients and staff, better transport, a more respectful attitude to patients, privacy in labor, and a partnership with the local technical college to repair broken equipment. Other departments such as surgery were so impressed with the results that they have introduced similar reviews themselves.
Table 2 Methodologies chosen by the professional associations of participating countries. Country professional association
Definition
Burkina Faso
Facility based death reviews and near-miss reviews in three hospitals in the initial phase. Facility based death reviews in five hospitals. Facility based death and near-miss reviews in nine district hospitals, and feeder health centers, with community reviews where possible. Near-miss reviews in six teaching hospitals. Facility based death review in three hospitals. Near-miss reviews in 16 hospitals in the Kathmandu valley. Facility based death reviews to be piloted. Facility based death reviews in four hospitals.
Cameroon Ethiopia
India Mozambique Nepal Nigeria Uganda
5.1. Causes of death and severe morbidity
Box 1 Key steps in developing a maternal death or near-miss review program. 1. Form a small, active steering committee that includes representatives of all relevant professional groups including midwives, policy-makers, and other organizations and key stakeholders that can help implement the recommendation. Members should be chosen for their hands-on contribution to the work required and not just as figureheads of their respective associations or academic institutions. 2. Undertake a current needs assessment to obtain as complete a picture as possible of the current local/national situation in regard to maternal and newborn health. 3. Decide the approach and which cases will be subject to review. 4. Develop the process and identify a host institution and program manager. 5. Decide how expert assessors will be recruited and appoint these for a fixed term. 6. Consider how to ensure confidentiality and the “no name, no blame” principles. 7. Plan the process for the comprehensive identification and assessment of all cases, including specific and agreed clinical definitions for cases of severe morbidity if appropriate. 8. Design and pilot questionnaires and any other instruments that are required. 9. Agree how cases will be assessed and develop a standardized format for this. If available, collect existing protocols, standards, and any other evidence-based clinical guidelines that may be used as benchmarks during case evaluation. 10. Decide how and when the cases will be subject to expert review and assessment and recommendations for action developed. 11. Devise how and when to publish and disseminate the resulting recommendations. 12. Plan how to audit and evaluate the process and the implementation of recommendations and subsequent outcomes. 13. Learn lessons to refine and improve the process for the next cycle. Adapted with permission from WHO [2].
G. Lewis / International Journal of Gynecology and Obstetrics 127 (2014) S17–S20
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Box 2 Principles of facility based case review meetings. Define cases
Implement audit
• Meetings should be multidisciplinary and interactive. They should not be didactic. This is best achieved with participants sitting in a circle. • They should be held at regular times and protected time given for staff attendance. • Administrators and others who can act on the recommendations should be present.
Collect data
Meeting agenda
Make recommendaons
Review and assess data
Fig. 1. The maternal morbidity and mortality review cycle. Reproduced with permission from WHO [2].
of the leading causes of death, as far as it was possible to identify these, are summarized in Table 3. They were relatively consistent between each country and similar proportions were also seen for near-miss cases. Owing to a lack of detailed feedback, inconsistent definitions, or poor hospital records, it was not possible to accurately identify the underlying causes for the majority of cases of hemorrhage although it would appear that postpartum hemorrhage and uterine rupture were most common. While WHO published international case definitions for severe morbidity during the course of this project [5], there may be a need for further understanding, dissemination, and technical support for their implementation in low-income countries. 6. Professional practice Participating in regular case reviews and audits of serious adverse medical events, particularly those that are unexpected or avoidable, is seen as an essential part of professional practice and lifelong learning [6,7]. However, this was not a process that has become a routine, systematic part of clinical practice in all settings. The author personally experienced obfuscation and lack of full participation by some staff. The confrontational manner in which certain local review meetings were held also militated against complete support. 7. Facility based meetings The cornerstone of all of the approaches used was the facility based meeting where local staff discussed individual cases in detail. In this manner they learned local lessons and took steps to improve services. These require careful planning and need to cover issues of team working, quality, and guidelines [8]. There is little published guidance on the Table 3 Leading causes of death. Cause
No.
%
Hemorrhage (including ruptured uterus from obstructed labor) Eclampsia Anemia (underlying cause of death not stated) HIV Sepsis Consequences of unsafe abortion (precise cause not stated) Malaria Cardiac disease Anesthesia Other causes Total
292 131 86 83 76 48 46 46 18 18 844
35 16 10 10 9 6 5 5 2 2 100
1. Read and agree code of conduct. 2. Re-evaluate the recommendations of previous sessions and provide a short follow-up of actions decided at the last meeting – identify any further action required. 3. Present the clinical summary of case(s). 4. Conduct a systematic case review, using a common template and with reference to any clinical guidelines or standards available. 5. Prepare a case analysis and local recommendations. 6. Plan for implementation. 7. Prepare a case analysis and a report to be sent to the overall steering committee for the wider review program, if one exists. 8. Feedback general findings and recommendations to other staff who could not attend and hospital administrators.
procedures for such meetings although the FIGO LOGIC consultants have developed an explanatory paper and a tool kit for training, which are available on the FIGO website [9,10]. In most countries the findings were also sent to a wider review committee where all the cases were collated, usually anonymously, and evaluated by independent experts. The underlying principle on which these meetings were based is that of learning lessons for improvement and not to apportion blame or punishment. At first this was a concept that was difficult for some participants to understand, which led to a lack of openness in both reporting and discussion. Missing or poorly completed case notes did not help. In circumstances where the case reviews were not confidential and took place when representatives of the local authorities attended, the review process failed. Throughout the process, countries have followed the common principles and features of successful facility based reviews (Box 2). In a number of countries participants found it helpful to read, and in some cases sign, an agreed code of conduct drawn up for earlier studies (Box 3). Box 3 Suggested code of conduct for facility based review meetings. “We agree to respect the rules of good conduct during meetings reviewing deaths or near-miss cases in our facility. We will: • • • • • •
Arrive on time to the meeting. Respect everyone’s ideas and ways of expressing these. Respect the confidentiality of the discussions in the group. Participate actively to discussions. Accept discussion and disagreement without verbal violence. Agree not to hide useful information or falsify information that could allow the understanding of the audited case. • Try (as much as possible as it is not easy) to accept that our own actions may be questioned.” Adapted with permission from De Brouwere et al. [9].
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Box 4 Characteristics for practical and useable recommendations.
only a few focused and important ones, whose implementation can be audited and regularly reviewed. This is an area where more guidelines and training is needed.
Recommendations should be: • • • • • •
Simple Realistic Action orientated Auditable Achievable Supported by evidence from the review.
Not too many at once; 10 maximum.
8. Action based recommendations Developing and acting on realistic recommendations are essential parts of the review process, but this proved challenging. Most recommendations were well-meaning but impossible to implement. They comprised of general statements such as “something needs to be done to improve the economic condition of the women, “we must improve safe motherhood programs,” “more staff,” “the training curricula for doctors and midwives needs to be in sync with reality,” or the allencompassing “in order to address late referral and access to health care it is proposed to emphasize goal oriented antenatal care, and encourage skilled birth attendance and emergency preparedness and contraceptive use.” However, in some cases, practical recommendations led to real changes. At a national level these included the development of clinical guidelines, pathways for monitoring women for the first six hours after delivery, and protocols for the triage of sick mothers on admission as well as their timely transfer from private clinics. At local levels, outcomes similar to those already discussed for Debre Berhan Hospital in Ethiopia were seen, including an extra operating theatre, 24-hour specialist cover, and improved blood supplies and clinical protocols. One Indian facility stated “Our institutional death rate and case fatality rate have now come down…no deaths have occurred at home.” While this improvement cannot be directly ascribed to maternal death reviews, this statement shows the extent to which staff in the facility saw them as a useful approach to improve treatment and reduce maternal mortality. One of the leading causes of death and near-miss identified was obstructed labor and/or ruptured uterus. In many places when partograms were introduced, the number of deaths appeared to fall but, despite this, their introduction was not universal across all country programs. In one large hospital women continue to die of ruptured uterus at the same rate as before the reviews started because the introduction of the partogram was considered to be too onerous for busy staff and not recommended. This defeats the whole object of all of the hard work undertaken in the preparation of the local facility based report. Box 4 lists the basic principles for the development of realistic recommendations that have emerged from this overview. It is natural to want to make as many recommendations as possible, but experience has shown that it is easier to achieve their introduction if there are
9. Conclusions One of the concerns about the validity of these types of review is the limited evidence of their effectiveness. It is often not possible for overstretched staff in extremely busy or overwhelmed hospitals to write papers and publish their results, let alone to conform to the rigor required by peer reviewed, widely read journals. Certainly in most cases numbers will be too small to show a statistically relevant result. Indeed, it may take a number of years for large, even national programs to collect enough data to be able to demonstrate any populationbased changes with certainty. But this does not mean that the work is ineffective. These programs and other similar programs have already resulted in significant improvements, on a small scale, at local levels. It would therefore be a retrograde step if a lack of publications or statistically robust data led to the cessation of local facility based reviews, which are leading to more robust clinical governance, better resource allocation, and improved clinical care for the mothers in their locality. Challenges obviously remain and the present paper has highlighted a number of important issues that those developing and participating in maternal death audit and reviews in future should address. Conflict of interest The author has no conflicts of interest. References [1] International Federation of Gynecology and Obstetrics (FIGO). FIGO LOGIC initiative in maternal and newborn health. www.figo.org/projects/LOGIC_initiative. Accessed August 1, 2012. [2] World Health Organization. Beyond the Numbers: reviewing maternal deaths and disabilities to make pregnancy safer. Geneva: WHO; 2004. http://whqlibdoc.who. int/publications/2004/9241591838.pdf?ua=1. Accessed July 22, 2012. [3] Healthcare Quality Improvement Partnership. Review of ethics issues related to clinical audit and quality improvement activities. http://www.hqip.org.uk/assets/ Downloads/Ethics-and-Clinical-Audit-and-Quality-Improvement-LiteratureReview.pdf. Accessed July 3, 2014. [4] Danel I, Graham W, Boerma T. Maternal death surveillance and response. Bull World Health Organ 2011;89(11)779-779A. [5] World Health Organization. Evaluating the quality of care for severe pregnancy complications: The WHO near-miss approach for maternal health. Geneva: WHO; 2011. http://whqlibdoc.who.int/publications/2011/9789241502221_eng.pdf?ua=1. July 1, 2012. [6] Ludmerer K. Instilling professionalism in medical education. JAMA 1999;282(9): 881–2. [7] General Medical Council. Good Medical Practice. http://www.gmc-uk.org/static/ documents/content/Good_medical_practice_-_English_0414.pdf; 2013. Accessed July 3, 2014. [8] Richard F, Ouédraogo C, Zongo V, Ouattara F, Zongo S, Gruénais ME, et al. The difficulty of questioning clinical practice: experience of facility-based case reviews in Ouagadougou, Burkina Faso. BJOG 2009;116(1):38–44. [9] De Brouwere V, Zinnen V, Delvaux T. How to conduct maternal death reviews (MDR). Guidelines and tools for health professionals. London: FIGO; 2013. http://www.figo. org/projects/maternal-and-newborn-health/publications. Accessed July 2, 2014. [10] De Brouwere V, Zinnen V, Delvaux T. Maternal death reviews: training program for health professionals. London: FIGO; 2013. http://www.figo.org/files/figo-corp/ Edited%20MDR%20Training%20Curriculum%20final%202014.pdf. Accessed July 2, 2014.