Evaluation of the Maternal Death Surveillance and response system in Hwange District, Zimbabwe, 2017

Research article Open Access Open Peer Review Evaluation of the Maternal Death Surveillance and response system in Hwange District, Zimbabwe, 2017 Mpumelelo Maphosa1, Tsitsi P. Juru1Email authorView ORCID ID profile, Nyasha Masuka2, More Mungati3, Notion Gombe1, Peter Nsubuga4 and Mufuta Tshimanga1 BMC Pregnancy and Childbirth201919:103 https://doi.org/10.1186/s12884-019-2255-1 ©  The Author(s). 2019 Received: 14 March 2018Accepted: 20 March 2019Published: 29 March 2019 Open Peer Review reports Abstract Background Maternal Death Surveillance and Response (MDSR) system was established to provide information that effectively guides actions to eliminate preventable maternal mortality. In 2016, Hwange district sent six maternal death notification forms (MDNF) to the province without maternal death audit reports. Timeliness of MDNF reaching the province is a challenge. Two MDNF for deaths that occurred in February and May 2016 only reached the provincial office in September 2016 meaning the MDNF were seven and four months late respectively. We evaluated the MDSR system in Hwange district. Methods A descriptive cross-sectional study was conducted. Health workers in the sampled facilities were interviewed using questionnaires. Resource availability was assessed through checklists. Epi Info 7 was used to calculate frequencies, means and proportions. Results We recruited 36 respondents from 11 facilities, 72.2% were females. Inadequate health worker knowledge, lack of induction on MDSR, unavailability of guidelines and notification forms and lack of knowledge on the flow of information in the system were reasons for late notification of maternal deaths. Workers trained in MDSR were 83.8%. Only 36.1% of respondents had completed an MDNF before. Respondents who used MDSR data at their level were 91.7%, and they reported that MDSR system was useful. Responsibility to complete the MDNF was placed on health workers. Maternal death case definitions were available in 2/11 facilities, 4/11 facilities had guidelines for maternal death audits. It costs $60.78 to notify a maternal death. Conclusion Reasons for late notification of maternal deaths were inadequate knowledge, lack of induction, unavailability of guidelines and notification forms at facilities. The MDSR system is useful, acceptable, flexible, unstable, reliable but not simple. Maternal case definitions and maternal death audit guidelines should be distributed to all facilities. Training of all health workers involved in MDSR is recommended. Keywords EvaluationMaternal Death Surveillance and responseHwangeZimbabwe Background Maternal Death Surveillance and Response (MDSR) refers to continuous, systematic collection, analysis, interpretation and dissemination of data regarding maternal deaths. It links the health information system and quality improvement processes from local to national levels [1]. The World Health Organization (WHO) defines a maternal death, as the death of a woman while pregnant or within 42 days of termination of pregnancy. This is irrespective of the duration and the site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management but not from accidental or incidental causes [2–4]. In 2015, the maternal mortality ratio was estimated at 216/100,000 live births globally [5]. This maternal mortality ratio translates to approximately 830 women dying every single day due to the complications of pregnancy and childbirth. Almost all these deaths occurred in low 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 occurring in the region [8]. 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 [9]. In Zimbabwe, according to WHO the maternal mortality ratio was 614/100000 live births in 2014 [10]. The Millennium Development Goal (MDG) 5 of reducing the maternal mortality ratio to 71/100000 was far from being achieved [11]. Like many other developing nations, Zimbabwe failed to achieve the target for MDG 5 by 2015. In the early 1990s, Zimbabwe established a Maternal Mortality Surveillance and Response (MMSR) with the aim of providing information that effectively guides actions to eliminate 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 [12]. The Sustainable Development Goals proposed that progress toward ending preventable maternal deaths should continue to be measured by monitoring the Maternal Mortality Ratio [13]. 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 one copy. The last copy of the form is then submitted to the Reproductive Health unit at the head office within 30 days of the occurrence of a maternal death. Feedback is given at each level of the health care system [Fig. 1]. Fig. 1 Current flow of the Maternal Death Notification Form in Zimbabwe In 2016, Matabeleland North province recorded 24 maternal deaths compared to 17 deaths in 2015. Of the 24 deaths recorded, Hwange district contributed 10, which is a third of all deaths in the province. Six maternal death notification forms from Hwange district that were sent to the provincial office were not accompanied by maternal death audit reports as per requirement. Timeliness of the maternal death notification forms reaching the provincial office was also a challenge. For two maternal deaths that occurred in Hwange in February and May 2016, the forms only reached the provincial office in September 2016 meaning that the forms were 7and 4 months late respectively. Deaths that are notified very late are often missed by the surveillance system and missing maternal deaths creates a potential for seriously underestimating the magnitude of maternal mortality within facilities. Information from the MDSR system is important in refining, targeting and ensuring efficient allocation of resources in the fight against maternal mortality. The study was conducted to evaluate the MDSRin Hwange district in 2017.Specifically, we assessed health worker knowledge on MDSR, assessed the systems’ usefulness and its attributes. We also determined reasons for late notification of maternal deaths in Hwange District, 2017. Methods Study design We conducted a descriptive cross-sectional study using the updated US Centers for Disease Control and Prevention guidelines for (...truncated)