Maternal Death Audit

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Maternal Death Audit

• Why is it important and how is it done?

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Background

• It is critical to determine the levels and causes
  of maternal mortality
• This will tell us the public health importance of
  specific maternal health problems
• We can then design appropriate interventions to
  reduce maternal mortality

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Background

• For example, a large number of maternal deaths
  due to hemorrhage will point to the need for
• Early management of bleeding
• Timely referral
• Access to emergency transport

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Background

• Or, high levels of maternal death due to
  puerperal sepsis, for example, may indicate the
  need for
• Improved management during delivery
• Improved management after delivery

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Method

• Maternal Death Audit
• What is Maternal Death Audit?
• Step 1 Examine case records and interview staff
• Step 2 Interview the household of the deceased
  person
• Step 3 Use this information to reconstruct the
  circumstances leading to the death
• Step 4 Assign a Cause of Death

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Step 1 Examine case records and interview staff

• Visit the health premises where she was treated
  to examine case records and interview staff
• Take note of the recorded obstetric history
• Ask staff about any special circumstances
  regarding the death

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Step 2 Interview the household of the deceased
person

• Meet the relatives of the deceased to collect
  information on
• the location of the death
• the economic, social and educational profile of
  the family
• the deceaseds obstetric history and record of
  antenatal, delivery and postnatal care, referral
  and
• the circumstances of death

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Step 3 Reconstruct the circumstances of the death

• Obstetrician to analyze the direct and indirect
  obstetrical causes which led to death
• Other team members to examine non-medical causes
  of death antenatal care, risk factors,
  complications, delay in referral or in initiation
  of treatment, non-availability of specialists,
  equipment, blood, etc.
• Highlight system failures

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Step 4 Assign a Cause of Death

• Use all the information to assign, as a team, the
  primary cause of death
• Ask yourselves - Was it preventable?
• Ask yourselves Was it because of a systems
  failure?

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The Process (1)

• Step 1 Report the death to the Deputy Director
  of Health Services at the District level
• When? Within 24 hours of death
• Who will do it?
• If the death occurs at home, in transit, at the
  sub-center ANM to PHC Medical Officer
• At the PHC PHC Medical Officer
• Public Hospital or Private Hospital Respective
  hospital authorities

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The Process (1) contd

• Report deaths of all pregnant women, including
  due to abortion, suicide, accidents etc.

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The Process (2)

• Step 2 Form a Maternal Death Investigation Team
  at PHC
• When? Within 15 days of the death
• Who will be in the team?
• PHC Medical Officer
• Administrator
• 1 Nursing Staff
• BHE

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The Process (3)

• Place the findings of the team before the
  district-level Maternal Deaths Medical Audit
  Committee on a monthly basis
• Place all reports before the District RCH
  Committee chaired by the District Collector,
  which receives relatives of the deceased who give
  their account of the events
• Place the minutes of both meetings before the
  Commissioner, HFW

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The Process (4)

• Provide feedback to relevant FRUs and PHCs
• Provide feedback to relevant personnel involved
  in the case
• Conduct annual analysis of maternal deaths to
  understand causes of death and formulate
  appropriate response

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Analysis What does the Maternal Death Audit
tell you? (TN example)
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Analysis What does the Maternal Death Audit
tell you?

• Poor distribution of first referral units (FRUs)
• Unnecessary referrals
• Poor quality of care
• Delay in accessing emergency transport
• Obstetric first aid not provided before referral
• etc

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Analysis Possible Solutions

• Making FRUs functional by contracting in
  additional staff
• Ensuring emergency transport either by using
  untied funds to establish a tie-up with local
  transport facility or by setting up an ambulance
  facility

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Analysis Possible Solutions

• Establishing blood storage facilities at the PHCs
• Providing additional training to PHC staff in
  emergency obstetric care
• Ensuring that all staff are aware of Emergency
  Obstetric Care protocols

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Follow-up

• Medical Officer and Administrator to place the
  findings of the Audit before the Arogya Raksha
  Samithi (ARS)
• ARS to present the findings to the next Gram
  Sabha in the presence of the Medical Officer and
  Administrator
• ARS to facilitate the process of PHC staff and
  community taking ownership of the findings of the
  Audit