Matern Child Health J DOI 10.1007/s10995-015-1678-1
NOTES FROM THE FIELD
Community Based Maternal Death Review: Lessons Learned from Ten Districts in Andhra Pradesh, India Samiksha Singh • Gudlavalleti V. S. Murthy • Anitha Thippaiah • Sanjeev Upadhyaya • Murali Krishna • Rajan Shukla • S. R. Srikrishna
Ó Springer Science+Business Media New York 2015
Abstract Maternal death is as much a social phenomenon as a medical event. Maternal death review (MDR), a strategy for monitoring maternal deaths, provides information on medical, social and health system factors that should be addressed to redress gaps in service provision or utilisation. To strengthen MDR implementation in the state of Andhra Pradesh, India. The project involved development of state specific guidelines, technical assistance in operationalization and analysing processes and findings of MDR in ten districts. 284 deaths were recorded over 6 months (April–September 2012) of which 193 (75.4 %) could be reviewed. Post-partum haemorrhage (24 %) and hypertensive disorders (27.4 %) followed by puerperal sepsis in the post-partum period (16.8 %) were the leading causes of maternal deaths. 68.3 % deaths occurred at health facilities. 67 % of mothers dying during the natal or postnatal period, delivered at home, though the death occurred in a health facility. Type 1 delay (58.9 %) was the most common underlying cause of death, followed by type 3 delay (33.3 %). Under or nil reporting from the facilities was observed. Program staff could identify broad areas of intervention but lacked capacity to monitor, analyse,
S. Singh G. V. S. Murthy (&) A. Thippaiah R. Shukla S. R. Srikrishna Indian Institute of Public Health, Public Health Foundation of India, ANV Arcade, 1-Amar Coop Society, Kavuri Hills, Madhapur, Hyderabad 500033, Andhra Pradesh, India e-mail: [email protected] S. Singh e-mail: [email protected] A. Thippaiah e-mail: [email protected] R. Shukla e-mail: [email protected]
interpret and utilize the generated information to develop feasible actionable plans. Information gathered was incomplete and inaccurate in many cases. Challenges observed showed that it will require more time and continuous committed efforts of health staff for implementation of high quality MDR. Successful implementation will improve the response of the health system and contribute to improved maternal health. Keywords Maternal mortality India Reproductive health Maternal death review
Introduction Preventable maternal deaths violate basic human rights [1]. Therefore United Nations highlighted reduction of maternal mortality in Millennium Development Goal (MDG)-5 [2]. Maternal Mortality Ratio (MMR) in India was estimated to be 178/100,000 live births in 2010–12 [3]. The 60 % reduction in MMR between 1990 and 2012 is unlikely to allow India achieve MDG-5 by 2015 [4].
S. R. Srikrishna e-mail: [email protected] S. Upadhyaya UNICEF Office for the States of Andhra Pradesh and Karnataka, 317/A, MLA Colony, Road No. 12, Banjara Hills, Hyderabad, Andhra Pradesh, India e-mail: [email protected] M. Krishna Department of Health and Family Welfare, NRHM Office, Koti, Hyderabad, India e-mail: [email protected]
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Common obstetric causes of maternal death in India are haemorrhage (25–48 %), eclampsia (10–17 %) and sepsis (15–17 %) [5–8]. Infections and haemorrhage are the most common causes during the antenatal period, haemorrhage during intra-partum and early postnatal period, and sepsis in postnatal period. Anaemia is the most common indirect cause [5–11]. Maternal death is both a social phenomenon and a medical event as access and use of services are influenced by contextual factors [2, 12]. Most maternal deaths can be averted if three delays in accessing care could be minimised—delay in deciding to seek professional care, delay in reaching health facilities and delay in receiving treatment after reaching health facilities [9, 13]. Maternal death review (MDR), a strategy for monitoring maternal deaths, provides information on medical, social and health system factors (including ‘delays’) that should be addressed to redress gaps in service provision or utilisation [13, 14]. MDR allows evidence- based decentralised planning and community participation and increases system accountability in terms of responsiveness and servicedelivery for maternal health [15]. MDR processes can increase identification of maternal deaths where vital registration systems are not well established and where maternal deaths occurring at home go unnoticed/unreported [16]. Different approaches can be used to review maternal deaths: (a) community based maternal death review (CBMDR)/verbal autopsy, (b) facility/hospital based maternal death review (FBMDR), (c) confidential enquiries into maternal deaths, (d) surveys of severe morbidity (near miss) and (e) clinical audit [14]. Both FBMDR and CBMDR have been widely used where MMR is high [17, 18]. Confidential enquiries and ‘near miss’ surveys are useful where MMR is low; and clinical audit where maternal deaths are very few. Most developing countries started with FBMDR, which may miss deaths occurring outside facilities and cannot provide an insight into factors playing a role before a woman reaches the hospital [14]. Different approaches for conducting MDR have been used in India. In Kerala confidential enquiry is being used since 2005 [19]. Tamil Nadu has been using CBMDR and FBMDR since 2003. Several CBMDR-based projects have been undertaken in the country as pilot efforts [6–8, 10, 11]. In 2011, the Government of India (GOI) rolled out guidelines for mandatory implementation of CBMDR and FBMDR in all states [20]. We report experiences of the operationalization of CBMDR in Andhra Pradesh (AP) where the GOI-mandated guidelines have been used. AP has recently been bifurcated into two states—AP and Telangana.
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Description AP initiated CBMDR across the state in 2011. The program was not being implemented effectively. Therefore to strengthen the implementation and operations of MDR processes, AP Government (with financial support from UNICEF) sought technical support from Indian Institute of Public Health, Hyderabad (IIPHH) for operationalizing MDR. The work included development of state-specific guidelines, assessment and technical assistance in operationalization, and analysing findings of MDR in 10 of 23 districts. The districts included Adilabad, Warangal, Medak, Khammam, Nalgonda (now Telangana) and Kurnool, Ananthapur, East Godavari, Vishakhapatnam and Guntur (AP). These districts were chosen as they reported moderate to high MMR. Five of these districts have large tribal populations (14–26 %) and pockets of civil unrest. The total population of these ten districts was 38.03 million (45 % of AP’s population) [21]. A project technical support team (PTST) comprising six medical doctors/public health experts and three field assistants was constituted. A 10-month timeline (March 2012–December 2012), including a month’s preparation, 6 months of improvising processes and support to districts (including quantitative analysis) and 3 months for workshops, dissemination of lessons learnt and continuous strengthening was envisaged. Analysis Qualitative findings and challenges faced in operationalization were documented. Quantitative analysis was done using data collected between April and September 2012. Regular feedback was provided to all stake-holders. State-Run CBMDR Process in AP Frontline health workers routinely record deaths among females aged 15–45 years and notify suspected maternal deaths within 24 h to the Primary Health Centre (PHC) Medical Officer (MO). PHC MO confirms the maternal death and informs the Senior Public Health Officer (SPHO) within 24 h of receiving information (SPHOs are trained medical doctors posted at sub-district level facilities). SPHO maintains a line-list of maternal deaths and submits it to district authorities monthly. SPHO also conducts verbal autopsy within 3 weeks of a death, using standardized verbal autopsy formats designed by GOI. Data is compiled and investigated at district level by MDR District Nodal Officer (DNO) and MDR Committee. District MDR Committee is constituted under the chairmanship of the
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district administrative head (‘Collector’) and includes public and private obstetricians, health administrators, nursing professionals, non-governmental organizations, ambulance services, community-based organisations etc. The committee discusses maternal deaths reviewed and recommends interventions to improve maternal health. Districts submit reports to State MDR committee. Training for the SPHOs and DNOs were conducted by a team from AP Government. State-level experts also sensitised District MDR committee members about the purpose and processes of MDR and distributed maternal death reporting formats, verbal autopsy formats and guidelines. Support Provided by PTST The PTST supported operationalization and assessment of MDR processes in two phases. Phase 1: Understanding and Improving MDR Processes PTST facilitated formation of MDR committees. It reviewed MDR training at the district level and conducted post- training assessments to identify gaps and specific needs of SPHOs. To bridge the identified gaps and provide handholding support, PTST provided on-the-job training and locally-adaptable solutions for SPHOs and DNOs. It conducted in-depth analysis for the MDR process (Table 1). The findings were discussed with concerned
district and state officials and weaknesses identified were rectified. Based on the experience in the field, PTST developed a mechanism for state-specific timelines and information flow. A framework for monitoring the collection, collation and reporting of data was developed. Processes were established to ensure timeliness, correctness and completeness of the reports for monitoring quality. Phase 2: Support to District and State in Interpreting Findings and Developing Interventions PTST trained and provided assistance to DNOs for analysing and interpreting MDR data. PTST members attended district MDR committee meetings and documented all deliberations. They assisted in making recommendations, planning interventions and monitoring implementation of plans. State-level MDR meetings were attended by PTST to share experiences from the districts and plan interventions for state-level implementation. Ethical Approval Approval was given by Institutional Ethics Committee of IIPHH. Informed oral consent was obtained before each verbal autopsy and confidentiality was maintained in recording, storing and reporting information.
Table 1 Strengths, Weaknesses, Opportunities and Threats (SWOT) analysis at baseline Strengths
Weaknesses
Commitment of the government of AP, support from international donors
No state level task force for monitoring maternal deaths and provide technical guidance to districts
Availability of guidelines and tools for maternal death review
Non-availability of state specific guidelines and detailed operational procedures
Availability of technical experts
Peripheral staff not sensitised regarding reporting of maternal deaths
Involvement of district magistrates and scope of inter-sectorial coordination
District level program officers not clear about their roles and ways to monitor, analyse and plan interventions for improvement
Financial support for conduct of reviews and follow up
No mechanism for monitoring and quality assurance of the MDR process
Media reporting maternal deaths in the state
No data of no. of maternal deaths and causes; poor HMIS
Training conducted for the senior public health officers for conduct of verbal autopsies
Data from private facilities not accessible Fear of blame among health staff Missing documentation (poor record keeping) Lack of clarity on source of incentives
Opportunities
Threats
Maternal Death surveillance
Media investigating and assigning responsibilities on personnel and hospitals and dramatizing the events
Inter-sectorial convergence
Lack of confidentiality of existing process
Regulating quality of services in private sector
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Assessment 284 maternal deaths were recorded over 6 months against an expected 391 which was calculated based on the product of the district population, crude birth rate (18/1,000) and MMR (134/100,000) (Table 2). Implementation was assessed using process indicators (Table 3). Only 193 (75.4 %) of the 284 deaths could be reviewed through CBMDR. Among the ten districts, two conducted three MDR review meetings, four conducted two meetings and the remaining four could conduct only one review meeting over 6 months. As per guidelines, all maternal deaths should be reviewed and one review meeting should be conducted monthly. We observed that these guidelines were not practiced. PTST attended two thirds of the district review meetings. Operational Challenges Since MDR process was recently initiated, many challenges had to be addressed (Table 4). Maternal deaths due to abortion (especially illegal) or early in antenatal period could be missed. Underreporting was higher in the tribal regions, which had higher MMR. SPHOs were therefore instructed to regularly sensitise staff at peripheral centres regarding importance of listing every female death and suspected maternal deaths. Under/nil reporting from PHCs was observed, which staff attributed to fear of punitive action. On PTST’s insistence, concerned SPHOs and PHC MO were also invited to participate at district MDR meetings and witness proceedings. This
initiative decreased their fear of reporting and gave them an opportunity to seek support wherever required. Lack of adequate staff and time constraint of available staff covering up for inadequate staff numbers were responsible for 25 % reported deaths not being reviewed. PTST conducted 27 verbal autopsies in the field to validate the observations recorded by SPHOs. Of the 27, 18 diagnoses were correctly made but the verbatim was incompletely written and some formats incorrectly filled, which hampered understanding of social and other contributory factors of deaths. Specific measures to improve verbal autopsies were suggested during the re-orientation meetings with SPHOs. The committee tended to focus only on medical causes of death rather than socio-cultural and other factors that could have contributed to death. The members had a tendency to blame the private sector or subordinate staff for any shortcomings. The district health administration did not give adequate attention to the quality of conducting reviews. No uniformity was observed in ascertaining indirect and contributory causes. To redress such shortcomings, two workshops were conducted for DNOs, to sensitise them to the correct approach and processes, and identifying solutions for challenges faced. Program staff was able to identify broad areas of intervention; however they lacked skills in using generated information to develop practical actionable plans. DNOs lacked clarity on how resources could be procured to implement recommended interventions. PTST provided support during the project phase but to ensure sustainability, the State MDR committee was advised to establish a team of 2–3 trained public health managers to support districts.
Table 2 Profile of districts covered and MDR process from April 2012–September 2012 District Adilabad Ananthapur
Popln. (Mill.)
No. of maternal deaths expecteda
No. of maternal deaths reported (% of estimated)
No. of maternal deaths reviewed by CBMDR 5 34
Commonest medical cause of maternal death as per CBMDR
2.74 4.08
30 45
18 (60) 34 (76)
PPH, Sepsis PPH, Eclampsia
East Godavari
5.15
56
22 (39)
9
PPH, Sepsis,
Guntur
4.89
53
56 (106)
32
PPH, Sepsis,
Kurnool
4.05
22
34 (155)
19
Pre-eclampsia, Sepsis
Khammam
2.80
31
10 (32)
10
Eclampsia
Medak
3.03
33
30 (91)
18
PPH, Pre-eclampsia
Nalgonda
3.48
38
18 (47)
8
PPH, Pre-eclampsia
Warangal
3.52
38
12 (32)
4
Visakhapatnam
4.29
47
50 (106)
50
38.03
391
Total
284 (73)
PPH, Sepsis Sepsis, Eclampsia
193 (68)
CBMDR community based maternal death review, PPH post-partum haemorrhage a
Expected maternal deaths = Population 9 Crude Birth Rate 9 MMR; assuming Crude Birth Rate of 18/1,000 and MMR of 134/100,000 live births for AP
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Matern Child Health J Table 3 Key performance indicators in 6 months of implementation Indicator
Frequency
%
Maternal death reporting and verbal autopsies Number of maternal deaths reported versus estimated in ten districts
284/391
72.6
Number of maternal deaths reviewed (CBMDR) versus reported
193/284
68.0
Number of maternal deaths investigated through district MDR meetings
141/193
73.1
Number of districts reporting more than 60 % of estimated maternal deaths
6/10
60.0
Number of districts studying distribution of maternal deaths with respect to time, place, cause of death and type of delays
5/10
50.0
Number of districts conducting district MDR meetings monthly
6/10
60.0
Number of actionable interventions planned
4
MDR process at district-interpretation, planning and implementation
–
Number of planned interventions implemented successfully
0
No. of verbal autopsies conducted by project team for quality assurance No. of verbal autopsies examined had correct diagnosis
27/193 18/27
–
Involvement of community via community based organisations and NGOs in the ten districts
0/10
14.0 66.7 0
Key indicators were developed by the project team for monitoring the progress of this project Table 4 Challenges faced and action initiated for enhancing the MDR process Challenges
Measures to redress challenge
MDR Process recently commenced in the State and therefore lack of understanding among nodal officers
Repeated visits made to districts Orientation sessions organized Facilitating CBMDR by helping in conducting interviews
Improper diagnosis and recording
Orientation sessions organized Each case evaluated at district and in case of doubt re-discussed with the concerned SPHO
MDR formats incorrectly/incompletely filled
Orientation sessions organized
Universal death review not being done and some maternal deaths missed out
Importance of covering all deaths reiterated to DMHO and SPHOs. They were advised to reiterate it to the PHC staff and ASHAs during their supervisory visits Triangulation of information through Department of WDCW and vital registration recording maternal deaths
Tendency to concentrate on medical causes only
Re-orientation done and support provided to district team in identifying social causes
Lack of uniformity in assessing indirect causes and non-medical causes contributing to the death
Strengthened role of State MDR team to supervise districts
Blaming subordinate staff and private practitioners
Repercussions of blaming subordinates explained to district and state MDR teams Explained need of unbiased enquiry into governments own health system. Advised them to take a more supportive supervisory role
Weak health information system—lot of under and nil reporting from the facilities due to the fear of punitive action
Orientation sessions organized at each level
Lack of participation of the private sector
Approached private associations of obstetricians for support
Under reporting from tribal regions
Orientation sessions organized with community volunteers and accredited social activists to support health staff
Profile of Maternal Deaths During the 6-month period, 193 maternal deaths were reviewed (Table 5). Postpartum haemorrhage (PPH-24 %), hypertensive disorders (27.4 %) followed by puerperal sepsis in the post-partum period (16.8 %) were the leading cause of maternal deaths.
One of three maternal deaths occurred in the antenatal period while two occurred either during delivery or within 42 days of delivery. Nearly three-fifths of post-partum deaths occurred in the first week after delivery. Most deaths (68.3 %) occurred at health facilities. Most of the deceased received some antenatal care at government or private health facilities. Consumption of Iron–Folic Acid
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Matern Child Health J Table 5 Distribution of maternal death with time, place and type of delay during the time period April 2012 to September 2012
Number
%
Time of death (N = 193) Antenatal
64
33.2
Natal
31
18.7
Post-natal
98
48.2
Place of death (N = 193) Home
32
16.6
Facility
131
67.9
Transit
30
15.5
Type-1 (delay in decision to seek professional care)
76
58.9
Type-2 (delay in reaching the appropriate health facility)
29
22.4
Type-3 (delay in receiving care after arriving at a hospital)
44
33.3
Type of delay (N = 129)a a
Multiple delays possible in the same individual and therefore the total would be more than 100 %
supplements during antenatal period was low. Of the total natal or postnatal deaths, 67 % delivered at home and many deaths occurred at hospitals or during transportation when complications occurred.
implementation of maternal health programs: to strengthen supportive supervision and monitoring, develop quality assurance mechanisms and provide supportive technical and infrastructure resources. Suggestions by PTST were implemented only in two districts (Table 6).
Contributory Causes Different types of delays were identified in 129 maternal deaths. In most cases there was more than one type of ‘delay’. Type 1 delay was the most common (58.9 %) followed by type 3 (33.3 %) (Table 5). Inappropriate referrals and non-availability of emergency obstetric care for women who were at high risk or had complications contributed to delays. Emergency ambulance services had a good reach in rural but not in tribal areas. On average mothers went to 2–3 referral points before reaching an appropriate facility. Standard referral protocols were not in place and no referral slips were given at peripheral facilities. Some complications went unrecognised during antenatal check-ups and were diagnosed only at delivery. Key Areas of Interventions Identified by MDR Committees Based on CBMDR MDR Committees identified key areas of intervention based on CBMDR including (1) training of nurses and midwives to watch for danger signs during postpartum period. To educate every mother before discharge regarding postpartum care and implementation of home based post-partum care is made mandatory; (2) Providing injectable iron through primary health centres; (3) Training peripheral centre staff in standard treatment protocols for anaemia, post-partum haemorrhage and hypertensive disorders in pregnancy; (4) Distributing ‘palkies’ (nonmechanized chariots) for PHCs in tribal regions and (5) Extensive community mobilisation programs in tribal areas. They also identified areas of improvement in routine
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Discussion Maternal Deaths The medical and indirect causes of maternal mortality observed are similar to previous reports from India and other parts of the world [17, 22, 23]. Type 1 and 3 delays were more common in Indonesia [24], while Type 1 and 2 delays were more common in Bangladesh [22]. We observed that unlike other studies almost all dead mothers had received some antenatal check-up and that transportation to health facility was found to be problematic only in tribal regions. We observed that the diagnosis of high risk pregnancy was missed during the routine antenatal checkup and there were some inappropriate referrals. It highlights the need for improving quality of antenatal care and referrals. MDR Operations At the end of the project the ten districts were at different stages of progress in MDR implementation. MDR is a core public health function and needs to be completely institutionalised in the health system to have the desired impact [12]. India has reported success stories from Tamil Nadu using CBMDR findings for improving health systems. However, other states in India struggle to institutionalize MDR [25], like in Africa [16]. The capacity of the public health system to conduct and utilise MDR was poor. Lack of skills for project planning
Matern Child Health J Table 6 Some specific findings and case studies with type of delays Type of delay
Findings
Type-1 (delay in decision to seek professional care)
Ignoring danger signs specially in postpartum period Unaware of danger signs in post-partum period No post-partum home visits by health care provider Emergency Obstetric services not yet available to all in close vicinity Tribal people despite of being aware of birth waiting rooms do not prefer to stay in those and visit only after the labour pains have started Some get all ANC check-ups at health institutions but prefer to deliver at home by traditional birth attendants A few cases were reluctant to go to district hospitals despite of being explained and referred timely for complications
Type-2 (delay in reaching the appropriate health facility)
In tribal areas, although emergency ambulance service was available, the road did not reach up to the tribal village thus the villagers had to carry the mother long distances up to the main road No means of tele-communication for calling ambulances. (In one case in tribal village, there was no landline phone. Mobile phone signal could be received only after climbing trees in some portion of the village. The mother died during labour as they could not call the ambulance at night and waited till morning for any support) There is only one free ambulance service at all cluster levels which is often busy carrying nonpregnancy cases as well. People are aware of the service but often can’t access it and some don’t have any other backup plan
Type-3 (delay in receiving care after arriving at a hospital)
Undetected risks and complications during antenatal check-ups. (In many cases there were no blood pressure recordings on the antenatal cards of the dead mother. Few of these mothers had died of Eclampsia. Only after visiting the referral centre, was the blood pressure found to be high. Such cases were more amongst those receiving antenatal care at the Primary Health Care Centres. Another case died in the referral institute where she was found to be having a congenital heart problem. She went undetected throughout the antenatal period) Anaemia was found to be the most common indirect cause of death. There was no routine practice of injectable iron and blood transfusion for moderate to severe anaemic cases during antenatal period Private institutions commonly referred the very sick cases to the district level government institutions in the last stages; The patient lost time and when they reached the referral centre, it was too late to do anything No referral protocols and guidelines in place. On an average, mothers went to 2–3 facilities before reaching the place of death. No referral slips were given and patient lost time in re-evaluations at each place
and management were also observed in other states in India [23, 25], and in other developing countries [23]. An expert team at state level may help provide support to districts for efficiently using information and develop local interventions. Indonesia reported success of maternal death audit and the success is particularly attributed to the process of accountability of both health providers and policy-makers and improved working relationships between health providers at different levels and between providers and the community [24]. MDR has great potential only if investment is also made to assess completeness of reporting and data accuracy [26]. Inadequate/inaccurate completion of MDR formats [27], and the tendency to blame subordinate health professionals has been reported [24]. Such practices can be eliminated by repeated sensitisation and involvement of third parties or local NGOs in district and state meetings [12]. We observed that staff was recording all female deaths in the reproductive age group and identifying probable maternal
deaths. However, deaths after illegal abortions and in early pregnancy, when woman herself is not aware, could still be missed. Concerned PHC MOs and SPHOs were included in district level review meetings and provided support as necessary, to overcome fear of punitive actions. The review was kept confidential and details were not shared with media as a policy. Interventions identified were mostly about strengthening the existing program components by finding local solutions. A problem relating to the referral system, communications and transportation in tribal areas requires planning at the state level. Limitations Technical support could not change some processes. One fourth of reported maternal deaths were not reviewed. SPHOs did not provide feedback or involve community leaders/local NGOs in assessment and planning of
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interventions. At district level, other sectors (e.g. roads and communications) were not involved to address non-health system factors.
Conclusion The project contributed to redressing some gaps in MDR. Unless completeness and accuracy of information is ensured and capacity of staff enhanced for planning at district level, sustainability and impact of MDR on health systems cannot be ensured. The State government should invest resources in addressing concerns which may hamper effective implementation.
Conflict of interest
None.
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10. Prakasamma, M. (2009). Maternal mortality reduction programme in Andhra Pradesh. Journal of Health, Population, and Nutrition, 27, 220–234. 11. Tayade, S., Bagde, M., Shivkumar, P. V., Tayade, A., & Bagde, N. (2012). Maternal death review to know the determinants of maternal mortality in a district hospital in central India. International Journal of Biomedical Research, 3, 157–163. 12. Berg, C. J. (2011). From identification and review to action— Maternal mortality in the United States. Seminars in Perinatology, 36, 7–13. 13. WHO. (2005). The world health report 2005: Make every mother and child count. Geneva: WHO. 14. WHO. (2004). Beyond the numbers: Reviewing maternal deaths and complications to make pregnancy safer. Geneva: Department of Reproductive Health and Research, WHO. 15. Kalter, H. D., Mohan, P., Mishra, A., Goankar, N., Biswas, A. B., Balakrishnan, S., et al. (2011). Maternal Death enquiry and response in India—The impact of contextual factors on defining an optimal model to help meet critical maternal health policy objectives. Health Research Policy and Systems, 9, 41. 16. Pearson, L., deBernis, L., & Shoo, R. (2009). Maternal death review in Africa. International Journal of Gynecology and Obstetrics, 106, 89–94. 17. Kongnyuy, E. J., Mlava, G., & van den Broek, N. (2009). Facility-based maternal death review in three districts in the central region of Malawi: An analysis of causes and characteristics of maternal deaths. Womens Health Issues, 19, 14–20. 18. Hoffman, J. J., & Ndemera, S. M. (2005). Review of community based maternal deaths in Mangochi district. Malawi Medical Journal, 17, 81–84. 19. Mathai, M. (2005). Reviewing maternal deaths and complications to make pregnancy and childbirth safer. WHO Regional Health Forum 9(1), 27–29. 20. Maternal Health Division, New Delhi. (2010). Maternal death review: Guidebook. Government of India, New Delhi: Ministry of Health and Family Welfare. 21. Registrar General of India, Census 2011. http://www.census2011. co.in/census/state/andhra?pradesh.html. Availed on 26 June, 2013. 22. Khanam, R. A., Khan, M., Abdul Halim, M., Begum, K., & Jahan, S. (2009). Facility and community based maternal death review in Bangladesh. Bangladesh Journal of Obstetrics and Gynaecology, 24, 18–21. 23. Kongnyuy, E. J., & Broek, N. V. D. (2008). The difficulties of conducting maternal death reviews in Malawi. BMC Pregnancy and Child Birth, 8, 8–42. 24. Supratikto, G., Wirth, M. E., Achadi, E., Cohen, S., & Ronsmans, C. (2002). A district-based audit of the causes and circumstances of maternal deaths in South Kalimantan, Indonesia. Bulletin of the World Health Organization, 80, 228–235. 25. SAMA (2011). Maternal deaths and denial of maternal care in Barwani district, Madhya Pradesh: Issues and concerns. http:// www.esocialsciences.org/Articles/showArticle.aspx?acat=Report s&aid=3724. Availed on June 20, 2013. 26. Daniel, I., Graham, W. J., & Boerma, T. (2011). Maternal death surveillance and response. Bulletin of the World Health Organization, 89, 779–779A. 27. George, A. (2007). Persistence of high maternal mortality in Koppal district, Karnataka, India: Observed service delivery constraints. Reproductive Health Matters, 15, 91–102.
NOTES FROM THE FIELD
Community Based Maternal Death Review: Lessons Learned from Ten Districts in Andhra Pradesh, India Samiksha Singh • Gudlavalleti V. S. Murthy • Anitha Thippaiah • Sanjeev Upadhyaya • Murali Krishna • Rajan Shukla • S. R. Srikrishna
Ó Springer Science+Business Media New York 2015
Abstract Maternal death is as much a social phenomenon as a medical event. Maternal death review (MDR), a strategy for monitoring maternal deaths, provides information on medical, social and health system factors that should be addressed to redress gaps in service provision or utilisation. To strengthen MDR implementation in the state of Andhra Pradesh, India. The project involved development of state specific guidelines, technical assistance in operationalization and analysing processes and findings of MDR in ten districts. 284 deaths were recorded over 6 months (April–September 2012) of which 193 (75.4 %) could be reviewed. Post-partum haemorrhage (24 %) and hypertensive disorders (27.4 %) followed by puerperal sepsis in the post-partum period (16.8 %) were the leading causes of maternal deaths. 68.3 % deaths occurred at health facilities. 67 % of mothers dying during the natal or postnatal period, delivered at home, though the death occurred in a health facility. Type 1 delay (58.9 %) was the most common underlying cause of death, followed by type 3 delay (33.3 %). Under or nil reporting from the facilities was observed. Program staff could identify broad areas of intervention but lacked capacity to monitor, analyse,
S. Singh G. V. S. Murthy (&) A. Thippaiah R. Shukla S. R. Srikrishna Indian Institute of Public Health, Public Health Foundation of India, ANV Arcade, 1-Amar Coop Society, Kavuri Hills, Madhapur, Hyderabad 500033, Andhra Pradesh, India e-mail: [email protected] S. Singh e-mail: [email protected] A. Thippaiah e-mail: [email protected] R. Shukla e-mail: [email protected]
interpret and utilize the generated information to develop feasible actionable plans. Information gathered was incomplete and inaccurate in many cases. Challenges observed showed that it will require more time and continuous committed efforts of health staff for implementation of high quality MDR. Successful implementation will improve the response of the health system and contribute to improved maternal health. Keywords Maternal mortality India Reproductive health Maternal death review
Introduction Preventable maternal deaths violate basic human rights [1]. Therefore United Nations highlighted reduction of maternal mortality in Millennium Development Goal (MDG)-5 [2]. Maternal Mortality Ratio (MMR) in India was estimated to be 178/100,000 live births in 2010–12 [3]. The 60 % reduction in MMR between 1990 and 2012 is unlikely to allow India achieve MDG-5 by 2015 [4].
S. R. Srikrishna e-mail: [email protected] S. Upadhyaya UNICEF Office for the States of Andhra Pradesh and Karnataka, 317/A, MLA Colony, Road No. 12, Banjara Hills, Hyderabad, Andhra Pradesh, India e-mail: [email protected] M. Krishna Department of Health and Family Welfare, NRHM Office, Koti, Hyderabad, India e-mail: [email protected]
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Common obstetric causes of maternal death in India are haemorrhage (25–48 %), eclampsia (10–17 %) and sepsis (15–17 %) [5–8]. Infections and haemorrhage are the most common causes during the antenatal period, haemorrhage during intra-partum and early postnatal period, and sepsis in postnatal period. Anaemia is the most common indirect cause [5–11]. Maternal death is both a social phenomenon and a medical event as access and use of services are influenced by contextual factors [2, 12]. Most maternal deaths can be averted if three delays in accessing care could be minimised—delay in deciding to seek professional care, delay in reaching health facilities and delay in receiving treatment after reaching health facilities [9, 13]. Maternal death review (MDR), a strategy for monitoring maternal deaths, provides information on medical, social and health system factors (including ‘delays’) that should be addressed to redress gaps in service provision or utilisation [13, 14]. MDR allows evidence- based decentralised planning and community participation and increases system accountability in terms of responsiveness and servicedelivery for maternal health [15]. MDR processes can increase identification of maternal deaths where vital registration systems are not well established and where maternal deaths occurring at home go unnoticed/unreported [16]. Different approaches can be used to review maternal deaths: (a) community based maternal death review (CBMDR)/verbal autopsy, (b) facility/hospital based maternal death review (FBMDR), (c) confidential enquiries into maternal deaths, (d) surveys of severe morbidity (near miss) and (e) clinical audit [14]. Both FBMDR and CBMDR have been widely used where MMR is high [17, 18]. Confidential enquiries and ‘near miss’ surveys are useful where MMR is low; and clinical audit where maternal deaths are very few. Most developing countries started with FBMDR, which may miss deaths occurring outside facilities and cannot provide an insight into factors playing a role before a woman reaches the hospital [14]. Different approaches for conducting MDR have been used in India. In Kerala confidential enquiry is being used since 2005 [19]. Tamil Nadu has been using CBMDR and FBMDR since 2003. Several CBMDR-based projects have been undertaken in the country as pilot efforts [6–8, 10, 11]. In 2011, the Government of India (GOI) rolled out guidelines for mandatory implementation of CBMDR and FBMDR in all states [20]. We report experiences of the operationalization of CBMDR in Andhra Pradesh (AP) where the GOI-mandated guidelines have been used. AP has recently been bifurcated into two states—AP and Telangana.
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Description AP initiated CBMDR across the state in 2011. The program was not being implemented effectively. Therefore to strengthen the implementation and operations of MDR processes, AP Government (with financial support from UNICEF) sought technical support from Indian Institute of Public Health, Hyderabad (IIPHH) for operationalizing MDR. The work included development of state-specific guidelines, assessment and technical assistance in operationalization, and analysing findings of MDR in 10 of 23 districts. The districts included Adilabad, Warangal, Medak, Khammam, Nalgonda (now Telangana) and Kurnool, Ananthapur, East Godavari, Vishakhapatnam and Guntur (AP). These districts were chosen as they reported moderate to high MMR. Five of these districts have large tribal populations (14–26 %) and pockets of civil unrest. The total population of these ten districts was 38.03 million (45 % of AP’s population) [21]. A project technical support team (PTST) comprising six medical doctors/public health experts and three field assistants was constituted. A 10-month timeline (March 2012–December 2012), including a month’s preparation, 6 months of improvising processes and support to districts (including quantitative analysis) and 3 months for workshops, dissemination of lessons learnt and continuous strengthening was envisaged. Analysis Qualitative findings and challenges faced in operationalization were documented. Quantitative analysis was done using data collected between April and September 2012. Regular feedback was provided to all stake-holders. State-Run CBMDR Process in AP Frontline health workers routinely record deaths among females aged 15–45 years and notify suspected maternal deaths within 24 h to the Primary Health Centre (PHC) Medical Officer (MO). PHC MO confirms the maternal death and informs the Senior Public Health Officer (SPHO) within 24 h of receiving information (SPHOs are trained medical doctors posted at sub-district level facilities). SPHO maintains a line-list of maternal deaths and submits it to district authorities monthly. SPHO also conducts verbal autopsy within 3 weeks of a death, using standardized verbal autopsy formats designed by GOI. Data is compiled and investigated at district level by MDR District Nodal Officer (DNO) and MDR Committee. District MDR Committee is constituted under the chairmanship of the
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district administrative head (‘Collector’) and includes public and private obstetricians, health administrators, nursing professionals, non-governmental organizations, ambulance services, community-based organisations etc. The committee discusses maternal deaths reviewed and recommends interventions to improve maternal health. Districts submit reports to State MDR committee. Training for the SPHOs and DNOs were conducted by a team from AP Government. State-level experts also sensitised District MDR committee members about the purpose and processes of MDR and distributed maternal death reporting formats, verbal autopsy formats and guidelines. Support Provided by PTST The PTST supported operationalization and assessment of MDR processes in two phases. Phase 1: Understanding and Improving MDR Processes PTST facilitated formation of MDR committees. It reviewed MDR training at the district level and conducted post- training assessments to identify gaps and specific needs of SPHOs. To bridge the identified gaps and provide handholding support, PTST provided on-the-job training and locally-adaptable solutions for SPHOs and DNOs. It conducted in-depth analysis for the MDR process (Table 1). The findings were discussed with concerned
district and state officials and weaknesses identified were rectified. Based on the experience in the field, PTST developed a mechanism for state-specific timelines and information flow. A framework for monitoring the collection, collation and reporting of data was developed. Processes were established to ensure timeliness, correctness and completeness of the reports for monitoring quality. Phase 2: Support to District and State in Interpreting Findings and Developing Interventions PTST trained and provided assistance to DNOs for analysing and interpreting MDR data. PTST members attended district MDR committee meetings and documented all deliberations. They assisted in making recommendations, planning interventions and monitoring implementation of plans. State-level MDR meetings were attended by PTST to share experiences from the districts and plan interventions for state-level implementation. Ethical Approval Approval was given by Institutional Ethics Committee of IIPHH. Informed oral consent was obtained before each verbal autopsy and confidentiality was maintained in recording, storing and reporting information.
Table 1 Strengths, Weaknesses, Opportunities and Threats (SWOT) analysis at baseline Strengths
Weaknesses
Commitment of the government of AP, support from international donors
No state level task force for monitoring maternal deaths and provide technical guidance to districts
Availability of guidelines and tools for maternal death review
Non-availability of state specific guidelines and detailed operational procedures
Availability of technical experts
Peripheral staff not sensitised regarding reporting of maternal deaths
Involvement of district magistrates and scope of inter-sectorial coordination
District level program officers not clear about their roles and ways to monitor, analyse and plan interventions for improvement
Financial support for conduct of reviews and follow up
No mechanism for monitoring and quality assurance of the MDR process
Media reporting maternal deaths in the state
No data of no. of maternal deaths and causes; poor HMIS
Training conducted for the senior public health officers for conduct of verbal autopsies
Data from private facilities not accessible Fear of blame among health staff Missing documentation (poor record keeping) Lack of clarity on source of incentives
Opportunities
Threats
Maternal Death surveillance
Media investigating and assigning responsibilities on personnel and hospitals and dramatizing the events
Inter-sectorial convergence
Lack of confidentiality of existing process
Regulating quality of services in private sector
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Assessment 284 maternal deaths were recorded over 6 months against an expected 391 which was calculated based on the product of the district population, crude birth rate (18/1,000) and MMR (134/100,000) (Table 2). Implementation was assessed using process indicators (Table 3). Only 193 (75.4 %) of the 284 deaths could be reviewed through CBMDR. Among the ten districts, two conducted three MDR review meetings, four conducted two meetings and the remaining four could conduct only one review meeting over 6 months. As per guidelines, all maternal deaths should be reviewed and one review meeting should be conducted monthly. We observed that these guidelines were not practiced. PTST attended two thirds of the district review meetings. Operational Challenges Since MDR process was recently initiated, many challenges had to be addressed (Table 4). Maternal deaths due to abortion (especially illegal) or early in antenatal period could be missed. Underreporting was higher in the tribal regions, which had higher MMR. SPHOs were therefore instructed to regularly sensitise staff at peripheral centres regarding importance of listing every female death and suspected maternal deaths. Under/nil reporting from PHCs was observed, which staff attributed to fear of punitive action. On PTST’s insistence, concerned SPHOs and PHC MO were also invited to participate at district MDR meetings and witness proceedings. This
initiative decreased their fear of reporting and gave them an opportunity to seek support wherever required. Lack of adequate staff and time constraint of available staff covering up for inadequate staff numbers were responsible for 25 % reported deaths not being reviewed. PTST conducted 27 verbal autopsies in the field to validate the observations recorded by SPHOs. Of the 27, 18 diagnoses were correctly made but the verbatim was incompletely written and some formats incorrectly filled, which hampered understanding of social and other contributory factors of deaths. Specific measures to improve verbal autopsies were suggested during the re-orientation meetings with SPHOs. The committee tended to focus only on medical causes of death rather than socio-cultural and other factors that could have contributed to death. The members had a tendency to blame the private sector or subordinate staff for any shortcomings. The district health administration did not give adequate attention to the quality of conducting reviews. No uniformity was observed in ascertaining indirect and contributory causes. To redress such shortcomings, two workshops were conducted for DNOs, to sensitise them to the correct approach and processes, and identifying solutions for challenges faced. Program staff was able to identify broad areas of intervention; however they lacked skills in using generated information to develop practical actionable plans. DNOs lacked clarity on how resources could be procured to implement recommended interventions. PTST provided support during the project phase but to ensure sustainability, the State MDR committee was advised to establish a team of 2–3 trained public health managers to support districts.
Table 2 Profile of districts covered and MDR process from April 2012–September 2012 District Adilabad Ananthapur
Popln. (Mill.)
No. of maternal deaths expecteda
No. of maternal deaths reported (% of estimated)
No. of maternal deaths reviewed by CBMDR 5 34
Commonest medical cause of maternal death as per CBMDR
2.74 4.08
30 45
18 (60) 34 (76)
PPH, Sepsis PPH, Eclampsia
East Godavari
5.15
56
22 (39)
9
PPH, Sepsis,
Guntur
4.89
53
56 (106)
32
PPH, Sepsis,
Kurnool
4.05
22
34 (155)
19
Pre-eclampsia, Sepsis
Khammam
2.80
31
10 (32)
10
Eclampsia
Medak
3.03
33
30 (91)
18
PPH, Pre-eclampsia
Nalgonda
3.48
38
18 (47)
8
PPH, Pre-eclampsia
Warangal
3.52
38
12 (32)
4
Visakhapatnam
4.29
47
50 (106)
50
38.03
391
Total
284 (73)
PPH, Sepsis Sepsis, Eclampsia
193 (68)
CBMDR community based maternal death review, PPH post-partum haemorrhage a
Expected maternal deaths = Population 9 Crude Birth Rate 9 MMR; assuming Crude Birth Rate of 18/1,000 and MMR of 134/100,000 live births for AP
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Matern Child Health J Table 3 Key performance indicators in 6 months of implementation Indicator
Frequency
%
Maternal death reporting and verbal autopsies Number of maternal deaths reported versus estimated in ten districts
284/391
72.6
Number of maternal deaths reviewed (CBMDR) versus reported
193/284
68.0
Number of maternal deaths investigated through district MDR meetings
141/193
73.1
Number of districts reporting more than 60 % of estimated maternal deaths
6/10
60.0
Number of districts studying distribution of maternal deaths with respect to time, place, cause of death and type of delays
5/10
50.0
Number of districts conducting district MDR meetings monthly
6/10
60.0
Number of actionable interventions planned
4
MDR process at district-interpretation, planning and implementation
–
Number of planned interventions implemented successfully
0
No. of verbal autopsies conducted by project team for quality assurance No. of verbal autopsies examined had correct diagnosis
27/193 18/27
–
Involvement of community via community based organisations and NGOs in the ten districts
0/10
14.0 66.7 0
Key indicators were developed by the project team for monitoring the progress of this project Table 4 Challenges faced and action initiated for enhancing the MDR process Challenges
Measures to redress challenge
MDR Process recently commenced in the State and therefore lack of understanding among nodal officers
Repeated visits made to districts Orientation sessions organized Facilitating CBMDR by helping in conducting interviews
Improper diagnosis and recording
Orientation sessions organized Each case evaluated at district and in case of doubt re-discussed with the concerned SPHO
MDR formats incorrectly/incompletely filled
Orientation sessions organized
Universal death review not being done and some maternal deaths missed out
Importance of covering all deaths reiterated to DMHO and SPHOs. They were advised to reiterate it to the PHC staff and ASHAs during their supervisory visits Triangulation of information through Department of WDCW and vital registration recording maternal deaths
Tendency to concentrate on medical causes only
Re-orientation done and support provided to district team in identifying social causes
Lack of uniformity in assessing indirect causes and non-medical causes contributing to the death
Strengthened role of State MDR team to supervise districts
Blaming subordinate staff and private practitioners
Repercussions of blaming subordinates explained to district and state MDR teams Explained need of unbiased enquiry into governments own health system. Advised them to take a more supportive supervisory role
Weak health information system—lot of under and nil reporting from the facilities due to the fear of punitive action
Orientation sessions organized at each level
Lack of participation of the private sector
Approached private associations of obstetricians for support
Under reporting from tribal regions
Orientation sessions organized with community volunteers and accredited social activists to support health staff
Profile of Maternal Deaths During the 6-month period, 193 maternal deaths were reviewed (Table 5). Postpartum haemorrhage (PPH-24 %), hypertensive disorders (27.4 %) followed by puerperal sepsis in the post-partum period (16.8 %) were the leading cause of maternal deaths.
One of three maternal deaths occurred in the antenatal period while two occurred either during delivery or within 42 days of delivery. Nearly three-fifths of post-partum deaths occurred in the first week after delivery. Most deaths (68.3 %) occurred at health facilities. Most of the deceased received some antenatal care at government or private health facilities. Consumption of Iron–Folic Acid
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Matern Child Health J Table 5 Distribution of maternal death with time, place and type of delay during the time period April 2012 to September 2012
Number
%
Time of death (N = 193) Antenatal
64
33.2
Natal
31
18.7
Post-natal
98
48.2
Place of death (N = 193) Home
32
16.6
Facility
131
67.9
Transit
30
15.5
Type-1 (delay in decision to seek professional care)
76
58.9
Type-2 (delay in reaching the appropriate health facility)
29
22.4
Type-3 (delay in receiving care after arriving at a hospital)
44
33.3
Type of delay (N = 129)a a
Multiple delays possible in the same individual and therefore the total would be more than 100 %
supplements during antenatal period was low. Of the total natal or postnatal deaths, 67 % delivered at home and many deaths occurred at hospitals or during transportation when complications occurred.
implementation of maternal health programs: to strengthen supportive supervision and monitoring, develop quality assurance mechanisms and provide supportive technical and infrastructure resources. Suggestions by PTST were implemented only in two districts (Table 6).
Contributory Causes Different types of delays were identified in 129 maternal deaths. In most cases there was more than one type of ‘delay’. Type 1 delay was the most common (58.9 %) followed by type 3 (33.3 %) (Table 5). Inappropriate referrals and non-availability of emergency obstetric care for women who were at high risk or had complications contributed to delays. Emergency ambulance services had a good reach in rural but not in tribal areas. On average mothers went to 2–3 referral points before reaching an appropriate facility. Standard referral protocols were not in place and no referral slips were given at peripheral facilities. Some complications went unrecognised during antenatal check-ups and were diagnosed only at delivery. Key Areas of Interventions Identified by MDR Committees Based on CBMDR MDR Committees identified key areas of intervention based on CBMDR including (1) training of nurses and midwives to watch for danger signs during postpartum period. To educate every mother before discharge regarding postpartum care and implementation of home based post-partum care is made mandatory; (2) Providing injectable iron through primary health centres; (3) Training peripheral centre staff in standard treatment protocols for anaemia, post-partum haemorrhage and hypertensive disorders in pregnancy; (4) Distributing ‘palkies’ (nonmechanized chariots) for PHCs in tribal regions and (5) Extensive community mobilisation programs in tribal areas. They also identified areas of improvement in routine
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Discussion Maternal Deaths The medical and indirect causes of maternal mortality observed are similar to previous reports from India and other parts of the world [17, 22, 23]. Type 1 and 3 delays were more common in Indonesia [24], while Type 1 and 2 delays were more common in Bangladesh [22]. We observed that unlike other studies almost all dead mothers had received some antenatal check-up and that transportation to health facility was found to be problematic only in tribal regions. We observed that the diagnosis of high risk pregnancy was missed during the routine antenatal checkup and there were some inappropriate referrals. It highlights the need for improving quality of antenatal care and referrals. MDR Operations At the end of the project the ten districts were at different stages of progress in MDR implementation. MDR is a core public health function and needs to be completely institutionalised in the health system to have the desired impact [12]. India has reported success stories from Tamil Nadu using CBMDR findings for improving health systems. However, other states in India struggle to institutionalize MDR [25], like in Africa [16]. The capacity of the public health system to conduct and utilise MDR was poor. Lack of skills for project planning
Matern Child Health J Table 6 Some specific findings and case studies with type of delays Type of delay
Findings
Type-1 (delay in decision to seek professional care)
Ignoring danger signs specially in postpartum period Unaware of danger signs in post-partum period No post-partum home visits by health care provider Emergency Obstetric services not yet available to all in close vicinity Tribal people despite of being aware of birth waiting rooms do not prefer to stay in those and visit only after the labour pains have started Some get all ANC check-ups at health institutions but prefer to deliver at home by traditional birth attendants A few cases were reluctant to go to district hospitals despite of being explained and referred timely for complications
Type-2 (delay in reaching the appropriate health facility)
In tribal areas, although emergency ambulance service was available, the road did not reach up to the tribal village thus the villagers had to carry the mother long distances up to the main road No means of tele-communication for calling ambulances. (In one case in tribal village, there was no landline phone. Mobile phone signal could be received only after climbing trees in some portion of the village. The mother died during labour as they could not call the ambulance at night and waited till morning for any support) There is only one free ambulance service at all cluster levels which is often busy carrying nonpregnancy cases as well. People are aware of the service but often can’t access it and some don’t have any other backup plan
Type-3 (delay in receiving care after arriving at a hospital)
Undetected risks and complications during antenatal check-ups. (In many cases there were no blood pressure recordings on the antenatal cards of the dead mother. Few of these mothers had died of Eclampsia. Only after visiting the referral centre, was the blood pressure found to be high. Such cases were more amongst those receiving antenatal care at the Primary Health Care Centres. Another case died in the referral institute where she was found to be having a congenital heart problem. She went undetected throughout the antenatal period) Anaemia was found to be the most common indirect cause of death. There was no routine practice of injectable iron and blood transfusion for moderate to severe anaemic cases during antenatal period Private institutions commonly referred the very sick cases to the district level government institutions in the last stages; The patient lost time and when they reached the referral centre, it was too late to do anything No referral protocols and guidelines in place. On an average, mothers went to 2–3 facilities before reaching the place of death. No referral slips were given and patient lost time in re-evaluations at each place
and management were also observed in other states in India [23, 25], and in other developing countries [23]. An expert team at state level may help provide support to districts for efficiently using information and develop local interventions. Indonesia reported success of maternal death audit and the success is particularly attributed to the process of accountability of both health providers and policy-makers and improved working relationships between health providers at different levels and between providers and the community [24]. MDR has great potential only if investment is also made to assess completeness of reporting and data accuracy [26]. Inadequate/inaccurate completion of MDR formats [27], and the tendency to blame subordinate health professionals has been reported [24]. Such practices can be eliminated by repeated sensitisation and involvement of third parties or local NGOs in district and state meetings [12]. We observed that staff was recording all female deaths in the reproductive age group and identifying probable maternal
deaths. However, deaths after illegal abortions and in early pregnancy, when woman herself is not aware, could still be missed. Concerned PHC MOs and SPHOs were included in district level review meetings and provided support as necessary, to overcome fear of punitive actions. The review was kept confidential and details were not shared with media as a policy. Interventions identified were mostly about strengthening the existing program components by finding local solutions. A problem relating to the referral system, communications and transportation in tribal areas requires planning at the state level. Limitations Technical support could not change some processes. One fourth of reported maternal deaths were not reviewed. SPHOs did not provide feedback or involve community leaders/local NGOs in assessment and planning of
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interventions. At district level, other sectors (e.g. roads and communications) were not involved to address non-health system factors.
Conclusion The project contributed to redressing some gaps in MDR. Unless completeness and accuracy of information is ensured and capacity of staff enhanced for planning at district level, sustainability and impact of MDR on health systems cannot be ensured. The State government should invest resources in addressing concerns which may hamper effective implementation.
Conflict of interest
None.
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