Addressing Maternal Mortality in Malawi through Maternal

Death Audits

Jennifer Weiss, MPH Health and Nutrition Coordinator,

Concern Worldwide Malawi

CORE Global Health Practitioner Conference,

Spring 2015

Background: Maternal Health in Malawi

Demographics: • Total population: 15MN • Total # births (2012): 639,000 • Total maternal deaths (2013): 3,400 • After 15 years of stagnation, SBA

has increased to 71% in 2010 • Despite these and other gains,

Malawi will not meet maternal mortality MDG target

Source: Countdown to 2015: Maternal, Newborn and Child Survival 2014 Report

Background: Maternal Health in Malawi

Of the 977 health facilities in Malawi: • 54% offer normal delivery

services (health centers and hospitals)

• 7% offer Caesarean delivery (hospital only)

Source: 2013-2014 Service Provision Assessment IMPAC = Integrated Management of Pregnancy and Childbirth

Percent of facilities offering normal delivery services (N=528) that have:

Background: Maternal Health in Malawi

Percent of facilities offering normal delivery services (N=528) that have:

Source: 2013-2014 Service Provision Assessment

Essential medicines for labor and delivery mostly available at hospitals and health centers

Project Overview

• Project Name: Improving Opportunities

and Use of Reproductive Health Among Women and Youth (OUR WAY)

• Dates: 2013-2016 • Location: Nkhotakota District, Central

Region, Malawi • Donors: Scottish Government, Merck for

Mothers, Elizabeth Taylor AIDS Foundation

Project Overview

Goal: Contribute to the reduction of maternal morbidity and mortality among vulnerable women of child bearing age in Nkhotakota District

S.O 1: Improved utilization of high quality maternal &

reproductive health services through increased availability and accessibility of services

S.O 2: Improved utilization of high quality community-based family planning

services, including youth friendly reproductive health

through increased availability and accessibility of services

S.O 3: Improved government & traditional leadership structures &

community members have increased capacity to plan,

manage, support and monitor key maternal and

reproductive health activities

Maternal Death Surveillance and Response (MDSR) in Malawi

• 2003: Maternal death reviews commenced at

district hospitals • Maternal deaths made notifiable event in 2009 • In 2013, MOH Reproductive Health Department

moved to more robust system of MDSR: • Form of continuous surveillance linking health

information system and quality improvement processes

• Promotes routine identification and timely notification of maternal deaths

• Helps in quantification and determination of causes and avoidability of maternal deaths.

MDSR: Key Principles

1. Every maternal death is a tragedy.

2. Understanding the underlying factors leading to the deaths is critical to preventing future mortality.

3. Data collection must be linked to action. A commitment to act upon findings is a key prerequisite for success.

MDSR Processes: Facility Level

• Facilitated by District Safe Motherhood Coordinator

• Attending clinicians at delivery present results

• Participation by NGOs, health facility safe motherhood committee

• Ideally takes place within two weeks of death

• Tone is participatory and constructive

• After audit, there is report and recommendations made to DHO.

• Findings also shared with each health facility safe motherhood committee

Dr. Wanangwa Chisenga and his team at the Nkhotakota District Hospital

MDSR Processes: Facility Level Top Three Issues Identified: 1. Referrals from health centers to hospital

• Triage by hospital switchboard operator – how to prioritize where to send ambulance?

• Who accompanies woman to hospital (in ambulance or private vehicle)?

• Lack of documentation (clinician’s notes, partographs) during referrals

• Time from onset of complications to the decision to make referral

2. Lack of training for attending clinician 3. Laboratory capacity, specifically

around availability of blood (lack of storage for re-agents, power cuts)

MDSR Processes: Community Level

Safe Motherhood Committee established at village level with participation from community leaders, TBAs

Safe Motherhood Volunteer selected from this committee to identify any death of a WRA

Safe Motherhood Volunteer reports any WRA death to HSA who determines if it is a maternal death

Within 2 weeks of death, HSA and Safe Motherhood Volunteer visit household to obtain additional information about death, review health passport

Findings reported to community Safe Motherhood Committee, with participation from District Safe Motherhood Coordinator

Data reported to District Hospital and HMIS

MDSR Processes: Community Level

• Community MDSR process not yet fully implemented. Key learning to date: • Sensitization of communities is

critical. Traditionally, maternal deaths are not discussed, especially during the grieving period. Sensitization must focus on how the MDSR process will help reduce maternal deaths.

• Focus away from diagnosing clinical cause of death but rather on ‘actionable intelligence’, identifying who influenced decisions during delivery

Next Steps

• Ideally, MDSR process at community and facility levels will be more integrated

• M&E of MDSR process: follow-up actions at both facility and community levels

Thank you

Mida Mateketa with her husband Kenneth at their home in Mandindi village, Malawi. Mida spent six weeks in the district hospital following complications during the delivery of her child.