Maternal and perinatal death surveillance and response in Ethiopia: Achievements, challenges and prospects

RESEARCH ARTICLE Maternal and perinatal death surveillance and response in Ethiopia: Achievements, challenges and prospects Brhane Ayele ID1*, Hailay Gebretnsae1, Tsegay Hadgu1, Degnesh Negash1, Fana G/ silassie1, Tesfu Alemu2, Esayas Haregot1, Tewolde Wubayehu1, Hagos Godefay3 1 Tigray Health Research Institute, Mekelle, Tigray, Ethiopia, 2 UNFPA-Tigray, Ethiopia, 3 Tigray Regional Health Bureau, Mekelle, Tigray, Ethiopia a1111111111 a1111111111 a1111111111 a1111111111 a1111111111 * Abstract Background OPEN ACCESS Citation: Ayele B, Gebretnsae H, Hadgu T, Negash D, G/silassie F, Alemu T, et al. (2019) Maternal and perinatal death surveillance and response in Ethiopia: Achievements, challenges and prospects. PLoS ONE 14(10): e0223540. https://doi.org/ 10.1371/journal.pone.0223540 Editor: Animesh Biswas, United Nations Population Fund, BANGLADESH Received: May 21, 2019 Accepted: September 22, 2019 Published: October 11, 2019 Copyright: © 2019 Ayele et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Data Availability Statement: All relevant data are within the paper and its Supporting Information files. Funding: The study was funded by United Nations Population Fund Agency (UNFPA) in collaboration with Tigray Regional Health Bureau. The funder had no role in study design, data collection and analysis, and preparation of the manuscript. Competing interests: The authors have declared that no competing interests exist. Maternal and Perinatal Death Surveillance and Response (MPDSR) was a pilot program introduced in Tigray, Ethiopia to monitor maternal and perinatal death. However; its implementation and operation is not evaluated yet. Therefore, this study aimed to assess the implementation and operational status and determinants of MPDSR using a programmatic data and stakeholders involved in the program. Methods Institutional based cross-sectional study was applied in public health facilities (75 health posts, 50 health centers and 16 hospitals) using both qualitative and quantitative methods. Data were entered in to Epi-info and then transferred to SPSS version 21 for analysis. All variables with a p-value of � 0.25 in the bivariate analysis were included in to multivariable logistic regression model to identify the independent predictors. For the qualitative part, manual thematic content analysis was done following data familiarization (reading and rereading of the transcripts). Results In this study, only 34 (45.3%) of health posts were practicing early identification and notification of maternal/perinatal death. Furthermore, only 36 (54.5%) and 35(53%) of health facilities were practiced good quality of death review and took proper action respectively following maternal/perinatal deaths. Availability of three to four number of Health Extension Workers (HEWs) (Adjusted Odds Ratio (AOR) = 6.09, 95%CI (Confidence Interval): 1.51– 24.49), availability of timely Public Health Emergency Management (PHEM) reports (AOR = 4.39, 95%CI: 1.08–17.80) and participation of steering committee’s in death response (AOR = 9.19, 95%CI: 1.31–64.34) were the predictors of early identification and notification of maternal and perinatal death among health posts. Availability of trained nurse (AOR = 3.75, 95%CI: 1.08–12.99) and health facility’s head work experience (AOR = 3.70, 95%CI: 1.04– PLOS ONE | https://doi.org/10.1371/journal.pone.0223540 October 11, 2019 1 / 24 Maternal and perinatal death surveillance and response in Ethiopia Abbreviations: FBDA, Facility Based Data Abstractuion; FGD, Focus Group Discussion; HEWs, Health Extension Workers; HFs, Health Facilities; KIIs, Key Informant Interviw; MCH, Maternal and Child Health; MDSR, Maternal Death Surveillance and Response; MPDSR, Maternal and Perinatal Death Surveillance and Response; MPD, Maternal and/or Perinatal Death; MMR, Maternal Mortality Ratio; NMR, Neonatal Mortality Ratio; PHCU, Primary Health Care Unit; PHEM, Public Health Emergency Management; VA, Verbal Authopsy; WDA, Women Development Group, hrshours. 13.22) were also the predictors of quality of death review among health facilities. Furthermore; availability of at least one cluster review meeting (AOR = 4.87, 95%CI: 1.30–18.26) and uninterrupted pregnant mothers registration (AOR = 6.85, 95%CI: 1.22–38.54) were associated with proper response implementation to maternal and perinatal death. Qualitative findings highlighted that perinatal death report was so neglected. Community participation and intersectoral collaboration were among the facilitators for MPDSR implementation while limited human work force capacity and lack of maternity waiting homes were identified as some of the challenges for proper response implementation. Conclusion This study showed that the magnitude of: early death identification and notification, review and response implementation were low. Strengthening active surveillance with active community participation alongside with strengthening capacity building and recruitment of additional HEWs with special focus to improve the quality of health service could enhance the implementation of MPDSR in the region. Introduction The global maternal mortality ratio has been reduced significantly (by 43.3%) over the last fifteen years from 385 to 216 deaths per 100,000 live births. However, it still continues to be a public health challenge in low resource countries where 10.7 million women died since 1990 [1, 2]. Sub-Saharan Africa (SSA) is the hardest hit region and with unsatisfactory reduction over the previous years [3]. Compared to other regions, maternal mortality remains to be one of the highest (450 deaths per 100, 000) in SSA [4]. Maternal mortality in SSA varies between countries. For instance, maternal mortality in Nigeria was reported to be 448 per 100,000 live births [5] and institutional maternal death of 281 deaths per 100, 000 births [6] in Mozambique. Furthermore, another study conducted in 10 various SSA countries also reported 351 maternal deaths per 100, 000 live births [7]. Maternal mortality in Malawi was also reported to be 484 deaths per 100, 000 live births [8]. There is also big variation in, maternal mortality with in countries which ranged between 250 to 700 death per 100, 000 live births [9]. The major causes of maternal mortality worldwide are hemorrhage, hypertensive disorder and sepsis [10]. Similarly, hemorrhage, hypertensive disorder, abortion and obstructed labour are the major cause of maternal mortality in SSA [11–13]. Various factors such as socio-demographic factors and other health system related factors are distant causes that contribute to maternal mortality [14]. In addition, factors such as lack of skilled birth attendants, countries economic growth, health expenditure per capital are fundamental determinants of (...truncated)