MATERNAL DEATH VERBAL AUTOPSY

MATERNAL DEATH VERBAL AUTOPSY : 

MATERNAL DEATH VERBAL AUTOPSY Sharing of district experiences from Tamil Nadu

Maternal Deaths Reporting, Analysis and Reviews : 

Maternal Deaths Reporting, Analysis and Reviews Sensitization of Health functionaries, line listing of all maternal deaths - 1996 Investigation and Institution based audit – 1996 Border District Cluster Strategy focusing on community analysis of Maternal Deaths , aimed at improving seeking care – UNICEF 1999-2002

Maternal Deaths Reporting, Analysis and Reviews : 

Maternal Deaths Reporting, Analysis and Reviews Almost 100% reporting and data analysis since 2001 Investigation of maternal deaths using verbal autopsy format from 2004 District level Maternal death audit State reviews

District Level Committee for Maternal Death Audit: 

District Level Committee for Maternal Death Audit District Collector - Chairperson Deputy Director of Health Services - Convenor Joint Director of Medical Services - Member Deputy Director of Medical Services and Family Welfare - Member Dean of the medical college - Member Regional Director of Municipal Administration - Member

District Level Committee for Maternal Death Audit: 

Obstetrician from the District Hospital -Member Obstetrician of the Medical college hospital - Member Chief Medical Officer/Hospital -Member Superintendent District MCH officer (DPHN) -Member District Level Committee for Maternal Death Audit

State Level Committee for Maternal Death Audit: 

Secretary to Govt.-H&FW Department MCH Commissioner Commissioner of Municipal Administration Director of IOG, Chennai State Level Committee for Maternal Death Audit

State Level Committee for Maternal Death Audit: 

Director of Public Health Director of Medical Services Director of Medical Services Expert Resource Persons State Level Committee for Maternal Death Audit

MATERNAL DEATH REVIEW - PROCESS: 

MATERNAL DEATH REVIEW - PROCESS Sensitization of health functionaries -1996 Line listing of maternal deaths Maternal death notification protocol Reporting of maternal deaths - multiple sources eg. Field health staff, Institutions, Nutrition workers, health related sector, urban local bodies, Left against medical advice cases, absconding mothers through health and related sectors

MATERNAL DEATH REVIEW - PROCESS: 

Notification by telegram / fax to Commissioner of MCH within 24 hours of occurrence Investigation of maternal deaths within 15 days using a structured format District level institutional based maternal death audit MATERNAL DEATH REVIEW - PROCESS

Positive Outcomes of Institutional Based Maternal Death Review: 

Positive Outcomes of Institutional Based Maternal Death Review All district health managers conducted regular monthly maternal death audit Clinical audit Case sheets of all maternal deaths reviewed by CMOs and district officers

Positive Outcomes of Institutional Based Maternal Death Review: 

Positive Outcomes of Institutional Based Maternal Death Review Regular reports with minutes of the audit meeting sent to Commissioner MCH& welfare Sensitized the district officers and CMOs about the importance of maternal death audit

Facility Based Maternal Death Review Challenges : 

Very little motivation of the service providers to conduct sincere audit Case sheets are rewritten Supervisory officers tend to protect their subordinates Reviews are more in favour of protecting the service providers rather than finding out the lapses in the provision of care Facility Based Maternal Death Review Challenges

Facility Based Maternal Death Review Challenges : 

Relatives are not involved in the process Very little information about the quality of care and delay in the provision of care in the institutions Blame is often put on the field health functionaries Non medical causes / contributory factors not identified Facility Based Maternal Death Review Challenges

VERBAL AUTOPSY OF MATERNAL DEATHS: 

Introduced in 1999 in two districts under BDCS Verbal autopsy systematically taken up in all the districts from 2004 VERBAL AUTOPSY OF MATERNAL DEATHS

Approach to Verbal Autopsy: 

Approach to Verbal Autopsy Is it because they are unaware of the need for care or unaware of the warning signs ? Is it because services do not exist or inaccessible due to distance, cost or socio cultural barriers ? Is it because they receive sub standard care ? What are the reasons for the delays ?

ROAD TO MATERNAL DEATH: 

ROAD TO MATERNAL DEATH Poor Socio-Economic Development Excessive Fertility High Risk Pregnancy Life Threatning Complications Raising the Status of women Family Planning Services Community Based Maternity Services Access to First Level care DEATH

Three Delay Framework: 

Three Delay Framework Delay in seeking care Delay in arriving at appropriate level of care Delay in getting adequate treatment after reaching the institution

Process of Verbal Autopsy: 

Process of Verbal Autopsy Notification of maternal deaths within 24 hours Notification includes all pregnancy related deaths including suicides, accidents Use of semi structured verbal autopsy format to conduct community based audit and facility based review of each maternal death by PHC Medical Officer

Verbal Autopsy Format: 

Verbal Autopsy Format Background information Availability of health facilities and services Availability of transport facilities Awareness and birth preparedness of the family History of past pregnancies History of previous deliveries

Verbal Autopsy Format: 

Verbal Autopsy Format Current pregnancy Delay in decision making Delay in mobilising funds for treatment/ transport Treatment in the referral institutions Re Referrals Intra natal services Factors perceived to be the cause of death Facility survey

District Verbal Autopsy Meeting: 

District Verbal Autopsy Meeting District collectors conduct the meeting once in a month All Maternal deaths occurred during the previous month are reviewed All the service providers including the private service providers, district health managers and the relatives of the deceased participate in the verbal autopsy meeting

District Verbal Autopsy Meeting: 

District Verbal Autopsy Meeting Findings of the verbal autopsy format discussed in the meeting Relatives narrate the events leading to the death The various delays, barriers in accessing care, the delay in providing care and quality of care including informal payment in the institutions discussed

District Verbal Autopsy Meeting: 

All the service providers are sensitized about the various delays and the quality of care All the contributory factors for each maternal death are analysed The minutes of the meeting sent to Commissioner MCH& Welfare every month Common factors are identified and informed to state level for policy changes District Verbal Autopsy Meeting

Year wise Maternal Deaths: 

Year wise Maternal Deaths District 2000-01 2001-02 2002-03 2003-04 2004-05 2005-06 2006-07 Vellore 61 63 60 49 34 37 27 Theni 43 49 36 29 28 16 6

Positive outcomes: 

Positive outcomes Helps to gain insight into the lapses Emotionally moves the service providers on seeing the motherless child Helps to formulate strategies Helps to develop interventions Motivates staff Accountability increases Quality of care improves

Strategies from experiences: 

Strategies from experiences Communication network Team work- the key behind success PHC staff posted to CEmONC centres for 15 days - teacher student relationship Oxytocin usage Money lenders Private emergencies taken care For Rereferral from CEmONC centre requires Dean/JDMS/DDHS permission

contd: 

contd Police help No borders for obstetric emergencies Organisation of emergency blood donors Staff uniform Accompanying instead of referral Confirmation of situation Absconding information to trackdown

contd: 

contd All fever in PN mothers are treated as Puerperal Sepsis unless proved otherwise Aggressive Campaign against botched abortions TBAs role as birth companion Methyldopa Magnesium Sulphate M.B.,B.S., as the change masters

Mrs.x ?: 

Mrs.x ? Who is she ? When it will happen ? Where it will happen? How it will happen ? Insight to trackdown Mrs.X

INTERVENTIONS: 

INTERVENTIONS Community based blood donation camps Medical emergency and referral control rooms Establishment of BEmONC centres Multiskilling of MBBS doctors Increasing of CEmONC centres

Challenges in the conduct of verbal autopsy: 

Challenges in the conduct of verbal autopsy PHC MO who conduct verbal autopsy had difficulties in assessing the quality of care in the institutions. Wage loss for the relatives who attend verbal autopsy meeting Fear of disciplinary action against service providers

Challenges in the conduct of verbal autopsy: 

Enthusiasm of District Collectors ? Coordination between field health functionaries and institutional service providers Legal issues Challenges in the conduct of verbal autopsy

PowerPoint Presentation: 

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