This case study was written by Dr. Animesh Biswas. It was published in 2015 in WHO-Maternal newborn, child and adolescent health.
Maternal and Perinatal Death Review (MPDR) is an evidence based approach that cross examines both health system and social factors through a systematic process. The MPDR in Bangladesh covers maternal and neonatal deaths including stillbirths in both the community and at facility level, maintaining anonymity as well as a no-blame and non-punitive environment with participation at all levels.
The intervention was initially piloted in January 2010 for the first time in Bangladesh by the Line Director, Maternal Newborn Child and Adolescent Health (MNCAH) of the Directorate General of Health Services (DGHS) in collaboration with the Line Director of the Health Monitoring Information System (HMIS) and e-Health, the Line Director of Maternal, Child, Reproductive and Adolescent Health (MCRAH) of the Directorate General of Family Planning (DGFP) within the scope of the Joint Government of Bangladesh (GoB) and United Nations (UN) Maternal and Newborn Health (MNH) Initiatives in Thakurgaon district.
UNICEF in Bangladesh and Centre for Injury Prevention and Research, Bangladesh (CIPRB) provided technical support in the implementation process.
MPDR was piloted in Thakurgaon district during 2010. The system, tools and guidelines were developed through participatory process among national experts and programmers and later endorsed by the Bangladesh Government for implementation.
MPDR follows WHO surveillance scheme for maternal death “Beyond the numbers”1and was designed for reviewing maternal, neonatal deaths and still births both at community and facility level.
The intervention starts with death notification at the community and the facility followed by verbal and social autopsy at community for identifying medical and social causes of maternal and neonatal deaths and stillbirths. The autopsy also includes the factors influencing different forms of delay to access health care services.2 Facility death reviews helped to identify the facility gaps and challenges including underlying causes which gives support to improvement of quality care at facility level. The intervention has set a good example of coordination and collaboration between DGHS, DGFP and GoB partners – UNICEF, UNFPA, WHO, CIPRB and local Non-governmental organizations (NGO) in implementation of MPDR. The intervention is financially supported by the Canadian CIDA through UNICEF, Bangladesh.
Results from implementing MPDR has shown visible outcomes in terms of identification of deaths in the community:
- During the 12 month pilot period, Thakurgaon district reported 59 maternal deaths, 739 neonatal deaths and another 633 stillbirths from the community in 20102.
- Causes of deaths were established, followed by appropriate and time-bound utilization of the findings by the local health managers at the sub-district (upazila) and district level3.
- Implementation of remedial action plans at the community and facility level helped to reduce maternal and neonatal deaths in Bangladesh (in comparison to 2010, the deaths notified 2014 in Thakurgaon district, showed a reduction from 59 to 47 maternal deaths, 739 to 683 neonatal deaths and 633 to 535 stillbirths).
Kashipur, a sub-district in Thakurgaon, was identified having high number of deaths in 2010. A total number of 40 deaths (4 maternal deaths, 21 neonatal deaths and 15 stillbirths) occurred. Death mapping showed that the Kashipur sub-district had a high death density. Further investigation indicated that it was also a hard-to-reach area and about 30 kilometers away from the upazila health complex. The remedial action plan included a number of activities to improve poor care seeking behavior and utilization of health care services in the community. This resulted in a reduction in maternal and neonatal deaths including stillbirths from 29 in 2011 to 22 in 20123.
Kashipur is a good example on how to use MPDR death mapping by the health managers to reduce maternal and perinatal deaths.
Another example of the positive effect of MPDR was the identification of scarcity of blood as a contributing cause of death in 12 mothers who died due to postpartum hemorrhage in Thakurgaon district hospital in 2010. The facility death reviews helped the MPDR committee to take measures to improve blood availability through blood donation campaigns, listing local volunteers for blood donation, and upgrading the blood bank. As a consequence, when a mother came to the Thakurgaon district hospital with postpartum hemorrhage in 2011, she was successfully transfused with 17 units of blood and survived because of a functional blood bank in the hospital using a volunteer blood donor panel.
Following the pilot phase in Thakurgaon, MPDR was gradually scaled up in four other districts during 2011-12 and after that to another six districts in Bangladesh by 2013, corresponding to a population of approximately 20 million. It is planned to expand to additionally two districts of Bangladesh to cover additionally 4 million people during 2015.
Key lesson learnt in MPDR
- MPDR was implemented through the existing health system with an excellent collaboration between DGHS and DGFP under a supportive environment of government- non government organization partnership.
- Field level health staff from the health and family department is doing death notification without overlapping or over reporting deaths.
- MPDR death notification in community was proven to be possible and achievable. Under the joint Government UN-MNH initiative’s, the Health and Family Planning Department are working under a good coordination able to capture each of the maternal and perinatal deaths from the district which contributed to the estimations of maternal mortality ratio (MMR) and the neonatal mortality ratio (NMR) and monitor the progress of maternal and neonatal health of the district.
- Death mapping is an innovative approach at the upazila level by plotting with multicolor dots showing the residences of the deceased mothers (red), neonates (yellow) and stillbirths (blue). It indicates the incidence and distribution by geographic and administrative location within the district and upazila providing the managers with a geographical understanding of the situation of maternal and perinatal deaths. Focused initiatives can be taken using this simple death mapping.4
- Special initiatives by Upazila and district managers were taken to reduce maternal and perinatal deaths in areas with high mortality.3 Among the examples of these initiatives were awareness programs through organizing health camps for pregnant women to ensure registration of every pregnancy and coverage of antenatal care with birth planning. Kashipur created a good example by revitalizing deliveries by family welfare visitor (who are trained to perform deliveries and are counted as skilled birth attendants) in community clinic. It was found most effective to bring the pregnant mothers to the community clinic to seek antenatal care and birthing services. The managers also strengthened the referral system of high risk pregnancies. In 2011, Kashipur community clinic referred four mothers with a pregnancy complication immediately to the district hospital and the timely interventions enabled the women to survive.
- Community verbal autopsy findings used analysis of causes of death and social factors related to the woman’s death which helped the mangers to initiate a local action plan.5
- Social autopsy at the community level sensitizes the community about the maternal and neonatal complications, influences the community to take corrective decisions for the coming future to prevent such deaths. Engaging community leaders, elites and senior persons in the community creates a positive environment to commit to improve the health seeking behavior.
- Facility based death reviews identified gaps and challenges in the health facility which helped to improve the facility quality care.
- Death review meetings at the upazila level and district level is the platform to share and discuss deaths on a monthly basis for taking corrective measures based on the findings by the upazila and district managers.
- HMIS of DGHS are using the online based District Health Information system (DHIS-2) and has now incorporated maternal and neonatal deaths in the reporting system. The local health bulletin of the districts used the number of maternal and neonatal deaths from the MPDR system estimate MMR and NMR.6
- Local level MNH planning in MNH districts used MPDR findings for yearly planning of specific interventions.
- Technical, analytic and implementing support of partner organizations such as CIPRB and UNICEF strengthened the Government to roll out MPDR in 10 districts.
Capturing deaths from the community, especially from hard-to-reach areas is challenging with the risk of missing information and under-reporting. According to the National guidelines for death notification, community based death notification should occur within seven days. However, in hard-to-reach areas this can take up to one month.
Further, verbal autopsies in the community is sometimes challenging due to recall bias if there is a delay in performing the autopsy. In hard-to-reach areas, the health care workers may spend from half a day up to a whole day to perform a verbal or social autopsy. Other challenges in death notification of neonates and stillbirths in the community can be confusion as to the criteria for classification of neonatal deaths and stillbirths due to misinformation given by the families. Secondly, the community may sometimes try to hide stillbirths due to social customs. Finally, sustainability is the key issue for MPDR. The Government of Bangladesh has already initiated the scale-up of MPDR throughout the country using the existing MPDR system and incorporating death notification and causes of maternal and neonatal deaths in the routine health system using District Health Information System-2 (DHIS-2). The Government of Bangladesh has already agreed to expand to all 64 districts with well-established monitoring systems under government supervision.
1 WHO. Beyond the numbers: Reviewing maternal deaths and complications to make pregnancy safer: The World Health Organization (WHO);2004.
2 Biswas A, Rahman, F., Eriksson, C. Community Notification of Maternal, Neonatal Deaths and Still Births in Maternal and Neonatal Death Review ( MNDR ) System: Experiences in Bangladesh September 2014 2014
3 Biswas A, Rahman, F., Halim, A. Maternal and Neonatal Death Review ( MNDR): A Useful Approach to Identifying Appropriate and Effective Maternal and Neonatal Health Initiatives in Bangladesh July 2014 2014.
4 Biswas A. MDSR Action Network Mapping for action. 2015:1-5. http://mdsr-action.net/case-studies/mapping-for-action-bangladesh/.
5 Halim A, Utz B, Biswas A, Rahman F, van den Broek N. Cause of and contributing factors to maternal deaths; a cross-sectional study using verbal autopsy in four districts in Bangladesh. BJOG : an international journal of obstetrics and gynaecology. Sep 2014;121 Suppl 4:86-94.
6 Biswas A. Using eHealth to support MPDR: Early experiences from Bangladesh 2015. http://mdsr-action.net/case-studies/using-ehealth-to-support-mpdr-early-experiences-from-bangladesh/.