Maternal death surveillance and response (MDSR) constitutes a quality improvement approach to identify how many maternal deaths occur, what the underlying causes of death and associated factors are, and how to implement actions to reduce the number of preventable stillbirths and maternal and neonatal deaths. This requires a coordinated approach, ensuring both national- and district-level stakeholders are enabled and supported and can implement MDSR in a “ no name, no blame ” environment. This field action report from Kenya provides an example of how MDSR can be imple- mented in a “ real-life ” setting by summarizing the experiences and challenges faced thus far by maternal death assessors and Ministry of Health representatives in implementing MDSR. Strong national leadership via a coordinating secretariat has worked well in Kenya. However, several challenges were encountered including underreporting of data, difficulties with reviewing the data, and suboptimal aggregation of data on cause of death. To ensure progress toward a full national enquiry of all maternal deaths, we recommend improving the notification of maternal deaths, ensuring regular audits and feedback at referral hospitals lead to continuous quality improvement, and strengthening community linkages with health facilities to expedite maternal death reporting. Ultimately, both a top-down and bottom-up approach is needed to ensure success of an MDSR system. Perinatal death surveillance and response is planned as a next phase of MDSR implementa- tion in Kenya. To ensure the process continues to evolve into a full national enquiry of all maternal deaths, we recommend securing longer-term budget allocation and financial commitment from the ministry, securing a national legal framework for MDSR, and improving processes at the subnational level.
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resource settings, and most could have been prevented [6, 7]. The WHO African Region bore the highest burden with almost two-thirds of global maternal deaths occur- ring in the region . The burden is more pronounced in poor, rural areas where young adolescents face a higher risk of complications and death as a result of pregnancy . In Zimbabwe, according to WHO the maternal mor- tality ratio was 614/100000 live births in 2014 . The Millennium Development Goal (MDG) 5 of reducing the maternal mortality ratio to 71/100000 was far from being achieved . Like many other developing nations, Zimbabwe failed to achieve the target for MDG 5 by 2015. In the early 1990s, Zimbabwe established a Maternal Mor- tality Surveillance and Response (MMSR) with the aim of providing information that effectively guides actions to elim- inate preventable maternal mortality. In 2013 the name of the surveillance system was changed to MDSR in line with the WHO guide of ending preventable maternal mortality . The Sustainable Development Goals proposed that progress toward ending preventable maternal deaths should continue to be measured by monitoring the Maternal Mor- tality Ratio . When a maternal death occurs, three copies of the maternal death notification form are completed, and one form is retained at the facility where the death occurred. Two forms are then transmitted to the district for capturing into the District Health Information System (DHIS 2) then the two forms are sent to the province within 14 days of the death. At the province, the Provincial Maternal and Child Health Officer completes the relevant sections and retains
We conducted a secondary analysis of 10 case studies, selected from those submitted to the WHO Global MDSR Implementation Survey to represent countries at different stages of MDSR implementation: Bangladesh, Cameroon, Malawi, and Nigeria (where MDR is being introduced); India, Kenya and Moldova (implementation of MDR is ongoing); and Malaysia, South Africa, and UK (successful implementation of MDR, surveillance and response at national level). To produce this second- ary analysis we also draw on a series of articles on experiences of implementing maternal death review pub- lished in a special supplement on international reviews: quality of care in BJOG: an International Journal of Obstetrics & Gynecology . Case studies are in-depth descriptions of naturally occurring cases , are a method for studying planned change in real world set- tings, and particularly valuable in understanding why in- terventions succeed or fail. Each case study included in this paper describes a country experience of implement- ing notification and review of maternal deaths, and iden- tifies achievements and challenges. We conducted a secondary analysis of these cases to explore and compare country experiences collectively. Taken as a whole, the case studies offer important insight into the factors that can lead to successful transition from MDR to MDSR.
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In response to CoIA recommendations, the World Health Organization (WHO) released a Maternal Death Surveillance and Response (MDSR) technical guidance document in 2013 which builds on the continuous learning and action cycle under CoiA to bolster accountability for maternal health outcomes. MDSRs are a comprehensive system building on facility based maternal death reviews being implemented in many countries, but focuses more explicitly on notification of maternal death, findings being acted upon and accountability for responses undertaken. 7-9 It also provides
(FIGO-LOGIC) project in Cameroon, Kenya, Malawi and Nigeria; once the project ended all training ceased and the government has not allocated funds to scale up [20–22] In these countries professional societies have also taken on much of the coordination and implementation of MDR; without the goodwill of small teams of committed individ- uals MDR would not happen [17, 24]. Without govern- ment commitment and funds to scale-up countries are unable to continue to strengthening capacity of staff at all levels to conduct MDR – i.e. training on the MDR method in all facilities, and training for assessors on completing MDR forms, maternal death classification (using ICD- MM) and formulating recommendations [22, 27, 29]. In Nigeria, the government has proposed plans for the scale up of the MDR programme, but poor budget allocation for health and low prioritisation and poor planning for MDSR are significant barriers to making this happen . Setting up community based maternal death review also requires time, effort and resources, particularly since it depends on training community health workers to rou- tinely identify maternal deaths and complete death notifi- cation forms (usually with little supervision), collection of information surrounding the death via household inter- view, and a process to ensure this information is fed upwards to district MDR committees .
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The institutional Maternal Mortality Ratio (iMMR) is high across all LGAs where deaths were recorded and highlights the need to pay more attention tostrengthen- ing health systems around maternal and child health care in Nigeria. In the same vein, the order of risk at a reference value of 0.5 showed that the proportionate risk of dying from Haemorrhage is highest (0.80 or 80%) followed by that of eclampsia or pre-eclampsia (0.66 or 66%). This is similar to findings from another study . Though complication of anesthesia and surgery may not be categorized among the major causes of death, they are significantly important among the indirect causes, and the risk is also significantly high (0.20). This trend should serve as warning signal to care providers that more serious efforts should be put into the care of women who come down with these diagnosis. In Table 4 The Institutional Maternal Mortality Ratio (iMMR) per LGA and The Proportionate risk (PR) of dying from the common causes
In Kenya, the national government is responsible for policy formulation, health legislation and regulation, while health service planning and delivery is a mandate of the county government. Bungoma is one of Kenya ’ s 47 counties, and is situated in the Western region, which experiences one of the lowest proportions of women de- livering with a skilled birth attendant (48%) and a high perinatal mortality rate (29%) . In Bungoma county, substantial progress has been made in strengthening perinatal death reviews and taking action to prevent fur- ther perinatal deaths. The UKAID supported Maternal and Newborn Health Improvement (MANI) project con- tributed to this progress through training sub-county health management teams (CHMTs) and facility staff in six out of the county’s ten sub-counties in Bungoma on the national MPDSR guidelines. Similar training was provided by another development partner in the other four sub-counties of Bungoma. In all sub-counties, MPDSR review committees met regularly to review deaths. Facilities that had high volumes of clients usually recorded higher numbers of mortalities. In these cases, the MANI project provided technical support to the MPDSR committees to conduct in- depth reviews of a sample of perinatal deaths. Smaller facilities with fewer mortalities received technical sup- port to routinely review all perinatal deaths.
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As the study used secondary data, there were incomplete or mislabelled variables, restricted variable data, inconsist- ent values, and missing records. In addition, the VA codes used to assign the cause of death were mainly limited to the direct causes, rather than the indirect causes. This could be related to the fact that the cause of death was de- termined by physicians using the VA questionnaire, which depends on the subjective response of the interviewee. This might most likely suffer from respondents’ informa- tion bias, which may lead to misclassification of the underlying cause of death. Due to the sensitive nature of the issue, abortion-related maternal deaths were likely to be underreported. Using the current data, we are unable to make inferences that compare the women who died with the women who survived childbirth. Moreover, the use of a small sample for the analysis made it difficult to draw inferences to the general population. However, our intent was to describe maternal mortality at the local level in the Kersa HDSS.
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We created separate variables for tobacco use during preg- nancy, maternal diabetes, and maternal anemia, which are coded as complications of pregnancy on the California birth certificate. A combined variable was created for 2 other complications of preg- nancy that tend to occur together, previous premature infant and previous low birth weight infant. A medical complications vari- able was created for the presence of at least 1 of the following pregnancy complications: cardiac disease, chronic hypertension, and renal disease. A variable was created also for any of the following labor and delivery complications: abnormal presenta- tion, abruptio placenta, amnionitis and sepsis, cord prolapse, fe- ver, labor eclampsia, placenta previa, precipitous labor, or labor preeclampsia.
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The “Neonatal Death” field obtained from PeriData. Net also was limited, as it did not include those who transferred from Aurora Health Care to another hospital and died. These neonates were dropped from PeriData. Net (i.e. they were not included in the numerator or the denominator). However, most transfers went to Children’s Hospital of Wisconsin, which provides an update that is included in PeriData.Net. Therefore, the extent of lost deaths is unknown but believed to be relatively minor. The consistency of our death rates and ratios with those of overall infant death rates nationally and regionally suggests general integrity of our data. As with all such studies, the significant outcomes are epidemiologic associations; cause and effect is not proven.
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Various studies examined maternal response to a child’s disclosure of sexual abuse, mostly in terms of the mother’s belief, protection, and support of her child (Alaggia, 2002; Cyr et al., 2003; Everson et al., 1989). Alaggia’s grounded theory study (2002) illuminated dimensions of those categories that indicate a continuum within each (see Chapter II) rather than a fixed response. Further, Alaggia defined the dimensions of support through the concept of a mother’s belief about the allegations, in that her beliefs determine her level of support. Coohey and O’Leary (2008) also suggest that a mother’s protective actions are grounded first in her beliefs about the allegations. Although both studies clearly indicate that belief is critical to support and protection, neither study suggests any mechanism to determine how a mother arrives at her beliefs. The findings of this study contribute to this gap in the literature in that, for this sample of women, the nature of their involvements with the accused and whether they had suspicions that something was wrong prior to their children’s disclosures are important factors in understanding how they decided whom to believe.
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For each maternal death, the pregnancy was matched with pregnancies that did not result in death. The pregnancies were matched on yearly income the year before termination of the pregnancy (1st–3rd, 4th–7th, and 8th–10th deciles), calendar year (1-year intervals), parity, and maternal age (±365 days). Because of the rarity of both epilepsy and death, up to 100 control pregnancies were chosen. Data were analyzed with a conditional logistic model with the diagnosis of epilepsy before the termination of pregnancy as the exposure. We estimated the mortality in women of childbearing age (age 18–50 years) diagnosed with epilepsy within the previous 5 years regardless of pregnancy status. 6 Women were followed up from their 18th birthday or January 1, 2000, whichever came last, until the date of death/emigration or December 31, 2013, whichever came ﬁrst. Relative mortality rates aggre- gated over 2-year periods were calculated with a Poisson model adjusted for income, calendar year, and parity. Standard protocol approvals, registrations, and patient consents
Cycle of maternal death audit. Maternal death audit (reviews) process consists of five steps. (a) Identification of maternal deaths: this can be difficult where many deaths take place outside health facilities. Even in health facilities, mater- nal deaths in other wards other than the maternity ward can be missed. (b) Data collection: data can be collected from many sources such as hospital registers, case notes, referral letters and interviews of family members and relatives. (c) Analysis of findings: data is analysed to identify the causes of maternal deaths and avoidable factors. (d) Recommendations and actions: recommendations are made to implement changes that will prevent the occurrence of similar deaths in the future. (e) Evaluation and refinement: the implementation of recommendations is followed up and evaluated and pro- fessional practice refined if necessary.
lead and build functional, integrated systems, we must include not only how to evaluate surveillance systems but also how to implement and support them with skills for planning, managing and integrating these systems. As a result of the global direction for early detection of emerging public health threats such as pandemic influ- enza, there is increased demand from high-level policy makers to demonstrate results with disease control resources and to be informed about disease events in advance of the media or competing interests. Countries must also respond to the call to implement WHO Interna- tional Health Regulations (2005), and meet the Millen- nium Development Goals. These demands illuminate the practical concern for better trained and more health staff and more responsive health systems. Public health leaders who must respond to this demand need accessible and clear tools for rapid implementation of public health interventions and strategies that simplify the organization of multiple and complex systems with single, integrated systems. When implementing new initiatives, the activi- ties, skills, and resources necessary for successful perform- ance are not always defined. By making the skills and activities explicit, public health leaders and program developers can produce objective-based criteria and clear expectations for successful outcomes. Attention can then be focused on realistic target setting, training, supervision, resource mobilization, monitoring and evaluation. We believe the IDSR matrix contributes to our ability to create integrated systems that meet the needs of policy makers and improve the community wellbeing. The use- fulness of the matrix warrants further evaluation in other settings including the analysis of costs as well as benefits. Conclusion
Studies have reported that a higher age is also an important risk factor for hypertension in preg- nancy, especially in developed countries (19, 20). Assis et al. (20) found that age above 30 years was associated with a risk for preeclampsia super- imposed on chronic hypertension (OR: 5.218; 95% CI: 1.873 to 14.536) (20). A similar result was reported by Suzuki et al. (19) who found that, in singleton pregnancies, the developing pre- eclampsia was associated with maternal age 35 years or above. Both studies reported the associ- ation of infertility treatment with an increased risk for hypertensive disorders in pregnancy as this was also recently reported by Poon et al. (21), but Maroua, Cameroon is a semi-urban area and few women are likely to be under ovulation treat- ment.
It is also useful for hypotheses-generating stu- dies, or studies directed at one specific association between risk factors and maternal or fetal out- comes in order to confirm or refute possible asso- ciation. This is in view of the future planning and implementation of the policies and guidelines in the management of advanced maternal age as high risk group.
During a maternal death audit in a rural area, it was found that Mrs. Meena, a 28 year-old mother of two children died during her third pregnancy, at 38 weeks of gestation during her delivery. Her first baby was delivered at home in the presence of a local Dai and the second one was delivered by caesarean section in a facility after trying at home. She became pregnant within one and half years of her last confinement, a pregnancy which was unplanned. She went for occasional antenatal check-ups to her local community health care providers (CHW) and did not have any birth plan. Recently she separated from her husband and resided in her very poor maternal house.
Results: A total of 10,379 deliveries were attended A total of 242 uterine rupture cases were included in this study. The magnitude of uterine rupture was 2.44% (1 in 41 deliveries). Sixteen (6.6%) mothers died from uterine rupture. Fourteen (5.8%) had experienced Vesico Vaginal Fistula. The majority of the mothers, 72% (176), admitted for uterine rupture stayed in hospital for 6 – 10 days. Fetal outcome was grave, 98.3% (238) were stillborn. Place of labor [Adjusted odds ratio (AOR): 6.92, 95% confidence interval (CI): (1.16, 33.74)], occurrence of hypo volume shock [AOR: 3.48, 95% CI: (1.01, 11.96)] and postoperative severe anemia [AOR: 0.092, 95% CI: (0.01, 0.956)] were significantly associated with maternal death secondary to uterine rupture.
Mothers are expected to use environmental cues to modify maternal investment to optimize their fitness. However, when the environment varies unpredictably, cues may not be an accurate proxy of future conditions. Under such circum- stances, selection favors a diversifying maternal investment strategy. While there is evidence that the environment is becoming more uncertain, the extent to which mothers are able to respond to this unpredictability is generally unknown. In this study, we test the hypothesis that Daphnia magna increase the variance in maternal investment in response to unpredictable variation in temperature consistent with global change predictions. We detected significant variability across temperature treatments in brood size, neonate size at birth, and time between broods. The estimated variability within-brood size was higher (albeit not statistically significant) in mothers reared in unpredictable temperature conditions. We also detected a cross-generational effect with the temperature history of mothers modulating the phenotypic response of F1’s. Notably, our results diverged from the prediction that increased variability poses a greater risk to organisms than changes in mean temperature. Increased unpredictability in temperature had negligible effects on fitness-correlated traits. Mothers in the unpredictable treatment, survived as long, and produced as many F1’s during lifetime as those produced in the most fecund treatment. Further, increased unpredictability in temperature did not affect the probability of survival of F1’s. Collectively, we provide evidence that daphnia respond effectively to thermal unpredictability. But rather than increasing the variance in maternal investment, daphnia respond to uncertainty by being a jack of all temperatures, master of none. Importantly, our study highlights the essential need to examine changes in variances rather than merely on means, when investigating maternal responses.
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ABSTRACT A signiﬁcant number of infants acquire HIV-1 through their infected moth- er’s breast milk, primarily due to limited access to antiretrovirals. Passive immunization with neutralizing antibodies (nAbs) may prevent this transmission. Previous studies, how- ever, have generated conﬂicting results about the ability of nAbs to halt mother-to-child transmission (MTCT) and their impact on infant outcomes. This study compared plasma neutralizing activity in exposed infants and the infected mothers (n ⫽ 63) against heter- ologous HIV-1 variants and the quasispecies present in the mother. HIV-exposed unin- fected infants (HEU) (n ⫽ 42), compared to those that eventually acquired infection (n ⫽ 21), did not possess higher nAb responses against heterologous envelopes (P ⫽ 0.46) or their mothers’ variants (P ⫽ 0.45). Transmitting compared to nontransmitting mothers, however, had signiﬁcantly higher plasma neutralizing activity against heterologous enve- lopes (P ⫽ 0.03), although these two groups did not have signiﬁcant differences in their ability to neutralize autologous strains (P ⫽ 0.39). Furthermore, infants born to mothers with greater neutralizing breadth and potency were signiﬁcantly more likely to have a serious adverse event (P ⫽ 0.03). These results imply that preexisting anti-HIV-1 neutral- izing activity does not prevent breast milk transmission. Additionally, high maternal neu- tralizing breadth and potency may adversely inﬂuence both the frequency of breast milk transmission and subsequent infant morbidity.
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