Training of health workers for Maternal Death Surveillance and Response program in India: knowledge assessment and analytical evaluation

Training of health workers for Maternal Death Surveillance and Response program in India: knowledge assessment and analytical evaluation Suneela Garg (MD)1, Saurav Basu (MD)2*, Dinesh Baswal (MD)3, Warisha Mariam (MD)4, Ruchir Rustagi (MD)5 Director Professor, Department of Community Medicine, Maulana Azad Medical College, Delhi, India Senior Resident, Department of Community Medicine, Maulana Azad Medical College, Delhi, India 3 Deputy Commissioner Maternal Health (in-charge), Ministry of Health and Family Welfare, Delhi, India 4 Junior Resident, Department of Community Medicine, Maulana Azad Medical College, Delhi, India 5 Senior Resident, Department of Community Medicine, Maulana Azad Medical College, Delhi, India 1 2 ARTICLE INFO ABSTRACT Article type: Original article Background & aim: Most maternal mortalities are preventable; however, there are significant regional and global disparities in this regard. Maternal Death Surveillance and Response (MDSR) launched in India is a continuous cycle of identification, notification, and review of maternal mortalities to improve the quality of care and prevent future deaths. The Ministry of Health and Family Welfare in India conducted five national capacity-building workshops for MDSR during October 2017 and February 2018 with the objective of training medical doctors as future trainers and developing competency-based skills for each component of the program. Methods: A training evaluation study was carried out on 144 workshop participants. Workshop outcomes in terms of trainees’ knowledge were assessed using a 20-item pre-post questionnaire and skill evaluations through group work. The data were analyzed using SPSS software (version 25). The difference in proportions was ascertained using the Chi-square test. Results: The mean score of the participants (n=144) increased from 13.2±2.3 in the pretest to 17±1.9 in the posttest (maximum score: 20). Themes generated during community and facility review sessions indicated the need for the capacity building of peripheral health facilities, sensitization for mandatory birth preparedness, complication readiness of all pregnant mothers by the frontline health workers, and regional-level MDSR training of all stakeholders involved in maternal mortality reporting. Conclusion: Training sessions were effective in the skill development of the participants in understanding the structure and function of the MDSR program. Article History: Received: 07-Feb-2019 Accepted: 08-Sep-2019 Key words: Maternal mortality Surveillance Training evaluation Please cite this paper as: Garg S, Basu S, Baswal D, Mariam W, Rustagi R. Training of health workers for Maternal Death Surveillance and Response program in India: knowledge assessment and analytical evaluation. Journal of Midwifery and Reproductive Health. 2020; 8(1): 2041-2049. DOI: 10.22038/jmrh.2019.38320.1427 Introduction The death of a woman during pregnancy, childbirth or puerperium is termed maternal mortality and considered a key indicator of socioeconomic development, gender equality, and healthcare system functionality of a nation [1]. Over 303,000 maternal mortalities occur each year more than 99% of which happen in low and middle-income countries [2]. Most maternal mortalities are preventable and related to gender disparity, lack of access to quality antenatal services, and failure to provide skilled obstetric care during delivery. The denial of safe motherhood represents a grave moral failing on the part of all those responsible for maternal wellbeing, including family, community, and health systems. The global pace in the reduction of maternal mortality burden has been slow that is evident * Corresponding author: Saurav Basu, Senior Resident, Department of Community Medicine, Maulana Azad Medical College, Delhi, India. Email: Garg S et al. JMRH from the failure to meet the Millennium Development Goals in terms of decreasing maternal mortality burden by three quarters during 1990 and 2015 [3]. There is an enormous global and regional disparity in maternal health status in the contemporary world. Developed countries, such as the UK, Germany, and Australia, have single-digit maternal mortality ratio (MMR); however, countries in Sub-Saharan Africa registered an average MMR of 546 in 2015. The MMR of India has declined from 167 (20112013) to 130 (2014-2016) with significantly higher gains in the southern Indian states [4]. The gains in maternal health reflect an enhancement in the delivery of quality antenatal care services, especially in the government sector, improved birth preparedness by frontline health workers (FHWs), promotion of institutional delivery, and augmentation of maternal and child health referral facilities, including basic and emergency obstetric care or specialist comprehensive emergency obstetric care. India has also launched several national programmatic initiatives for the promotion of safe motherhood that focus upon the increase of antenatal coverage and content without any expenses, development of institutional delivery, Training of Health Workers for MDSR in India and enhancement of hospital care quality during parturition and early postpartum period [5]. India is striving towards further accelerated lowering MMR to meet the Sustainable Development Goals interim target of 100 by 2020 and less than 70 maternal mortalities per 1,00,000 live births by 2030 [6]. The reduction of maternal mortality in developing countries requires ascertaining the social, economic, cultural, and medical causes of every maternal death, as well as initiating timebound actions for their prevention. However, in the absence of an effective and continuous maternal death surveillance system, over half of all maternal mortalities remain unrecorded. Consequently, there was a failure to undertake quality Maternal Death Review (MDR), especially at primary and secondary healthcare levels and the inability to generate evidence for initiating corrective actions [7]. Maternal Death Surveillance and Response (MDSR) system is a continuous cycle of identification, notification, and review of maternal mortalities followed by learning-based actions to improve the quality of care and prevent avoidable deaths (Figure 1). Figure 1. Maternal Death Surveillance and Response: A continuous-action cycle 2042 J Midwifery Reprod Health. 2020; 8(1):2041-2049. JMRH Training of Health Workers for MDSR in India The MDSR was developed as a sequel to the preexisting MDR program that incorporated Garg S et al. countrywide learnings (Figure 2). Figure 2. Transition from Maternal Death Review to Maternal Death Surveillance and Response deletion of columns), (ii) lack of focus on The limitations of pre-MDSR strategies were nonmedical causes with rarely reported systemic (i) irregular underreporting of maternal gaps, and lack of focus on translating review mortalities due to the suboptimal quality of findings into coordinated measures for the reports ( (...truncated)