Facing realities of maternal death reviews

What you need to know:

  • Did you know that a meeting must be called by health facility to review death of a pregnant woman, in case it occurs.
  • But there is still a lot to be done to improve the way maternal deaths are reviewed at hospitals. Here are some of the weaknesses and lessons.

For any death of a pregnant woman that occurs in Tanzania, a meeting must be called by the health facility within 24 hours to review or audit why the woman died.

Amidst the daunting reality, lessons must be learnt after the review meeting, to avoid a similar scenario in future. But, the question that currently begs an answer is: have enough of these lessons been learnt?

Famously known as Maternal Death Reviews (MDRs), the review meetings were rolled out 12 years ago in the country; alongside the introduction of guidelines for reviewing maternal and newborn deaths, known as the Maternal and Perinatal Death Reviews (MPDRs).

However, it turned out that they could not be fully scaled up across the country, with experts citing poor monitoring and lack of enough expertise to implement them.

Three years ago, the government replaced the MPDRs with an improved version, known as the Maternal and Perinatal Death Surveillance and Response guidelines (MDSR) which were widely supplied to all health stakeholders, including service providers who conduct the reviews at health facilities.

Despite the government and stakeholders’ effort in emphasising on the reviews, maternal mortality has remained persistently high, with current reports from the Ministry of Health, Community Development, Gender, Elderly and Children, saying 556 deaths occur for every 100,000 live births in Tanzania.

What doctors in practice say

Dr Serijo Kusekwa, a medic in Masasi District, Mtwara Region, believes there is still a lot to be done to improve the way maternal deaths are reviewed at hospitals, especially on how to implement what’s agreed/ recommended during the meetings.

Yet, a recent report by USAID and the Maternal and Child Survival Program (MCSP), published online, found that there is no routine tracking system for the rollout of the death reviews (MDSR) among health authorities.

But, according to Dr Kusekwa, the reviews have continued being of much help in some districts where some health authorities take them seriously.

He says that if it were not for such death reviews, maternal mortality in the country could have been even higher than it is now.

“I am imagining what would be the mortality rate now, if at all there was no such a thing as maternal death audit or review,’’ he tells Your Health during an interview in Dodoma.

Attitude problems can be addressed

Kusekwa recalls, in the past years, how poor communication between his hospital and the authorities at the Zonal blood bank in Mtwara region—over 200 km away—could create grounds for maternal death.

“Take this scenario, where an emergency occurs and a woman has developed post-partum bleeding. She needs blood. Your hospital and the district blood bank have run out of blood because many patients needed blood that day,’’ Dr Kusekwa tells Your Health.

“You now have only one option,’’ he says, “And that is to call at the zonal blood bank. But, unfortunately, you are told [from the Zonal blood bank] that there is no suitable vehicle to deliver the blood to your hospital.”

“And, in fact, you are told to make arrangements for a vehicle (at your hospital) to travel all those kilometers to pick the blood. How do you promptly save that woman who is bleeding profusely? At that moment, she needs nothing else except blood or else she dies,’’ says the medic.

How review meeting helped

“A moment came when the hospital could not put up with such scenarios. In one of our maternal death review meetings, we decided to invite officials from the zonal blood bank to attend,’’ says Dr Kusekwa, who is now the Medical Officer in Charge of Masasi District Hospital.

“The meeting taught them lessons. They [officials from the Zonal blood bank] now could understand what our hospital usually went through in emergencies that required blood transfusion. It seems they used not to take us seriously.”

“After participating in our maternal death review meeting, we could now begin working together with them as a team. This helped so much in reducing the risk of maternal death,” he says.

In other districts, where there is shortage of specialists, the review meetings have had shortfalls because of lack of enough expertise in identifying the gaps and giving proper recommendations.

In Nagara District, Kagera Region, the medical officer in charge of Murugwanza Hospital, Dr Remmy Andrew says some development organisations have decided to intervene by facilitating specialists to take part in the review meetings at his hospital.

“We realised that there was a weakness in our meetings, but through a project known as USAID Boresha Afya, we got a gynaecologist and a paedriatician to be taking part in our review meetings. It has helped greatly,’’ he says.

Why past death review mechanisms failed

A 2015 study carried out in Northwestern Tanzania revealed that routine maternal death reviews did not usually involve comprehensive documentation of all relevant information, including actions taken to address some identified systemic weaknesses.

“Periodic analysis of available data may allow better understanding of vital information to improve the quality of maternity care,’’ suggested the study, published in the BMC Pregnancy & Childbirth and titled: Maternal death reviews at Bugando hospital north-western Tanzania: a 2008–2012 retrospective analysis.

Since then, the government has worked to improve how the reviews are carried out but according to researchers, weaknesses of the country’s health system may not favour effective use of lessons learnt from maternal death reviews as part of the effort to improve maternal health.

What’s done at review meetings

At a health facility, a review session for a maternal death takes about one to two hours. Usually, a person who was not involved in treating the patient that died is called to present the summary of how the deceased was earlier handled.

Gaps and strengths are identified by the whole committee, and an action plan is drawn, with timelines and what to act on to prevent similar deaths in future.

These committees for reviewing maternal deaths are required at all other levels of health administration in the country (district, region and national).

External auditor/ party needed

A doctor who spoke to Your Health on condition of anonymity says it has proved challenging at times for doctors to regulate themselves, especially when a colleague is found with a mistake.

Although the reviews were not introduced for retribution and blame-game, he says, there has to be some level of responsibility when death occurs because of mere negligence.

“I know cases where a patient was brought into hospital, critically ill but the doctor on duty arrived nine hours later, despite being called several times. The patient died. His colleagues knew this but no one dared raise the voice against the doctor during the review meeting,’’ said the medic.

“That’s why I believe, that the review of these deaths needs some sort of an eternal auditor, or decision-maker who can decide without bias. If that’s done, extra care will be taken by medical staff in handling such cases,’’ suggests the doctor.

The referral system, a big snag

A clinical services coordinator at Lindi Regional Hospital, Dr Kassim Njarita, believes that the recommendations made by maternal death review committees can better be implemented if the national referral system is made more efficient.

“In hospitals where such meetings are held and recommendations made, the staff may be willing and are committed to improve, but at times, systemic problems related to lack of equipment and poor transport systems may hold them back,’’ says Dr Njarita.

“Issues of delays: whether it’s delay at home, on the road or even in the facility, have to be addressed to prevent deaths that are attributed to delays; from happening again. If not the case, the review meetings could be held without learning lessons,’’ he suggests.