MATERNAL DEATH SURVEILLANCE AND RESPONSE – JAMAICA: WHAT WORKS Prof. Affette McCaw-Binns,...
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Transcript of MATERNAL DEATH SURVEILLANCE AND RESPONSE – JAMAICA: WHAT WORKS Prof. Affette McCaw-Binns,...
MATERNAL DEATH SURVEILLANCE AND RESPONSE – JAMAICA:WHAT WORKS
Prof. Affette McCaw-Binns, University of the West IndiesGTR Meeting – Punta Cana, Dominican Republic – 14 November 2013
2
Where is Jamaica?
3
Introduction Jamaica
Population 2.8 million Annual births 39,000 Crude birth rate
17/1000
Infant mortality rate 20/1000
Life expectancy (birth) Males 70.4 Females 78.0
Y S Falls – St Elizabeth, Jamaica
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Regions, Health Centres andHospitals
Tertiary referral hospitals
Regional CEmOC hospitals
Parish BEmOC hospitals SOUTH EAST:17,300 births
SOUTH:8,600 births
WEST: 8,100 births NORTH EAST:5,300 births
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Click to edit Master title styleFERTILITY & MATERNAL MORTALITY:
1981-2012, JAMAICA
1981-83 1984-6 1993-95 1998-00 2001-3 2004-6 2007-9 2010-1240
50
60
70
80
90
100
110
120115
52
108
87
97
GFR MM Ratio
Maternal mortality ratio/
100,000 live births
General fertility rate/1000 ♀ reproductive age
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Click to edit Master title styleFERTILITY & MATERNAL MORTALITY:
1981-2012, JAMAICA
1981-83 1984-6 1993-95 1998-00 2001-3 2004-6 2007-9 2010-1240
50
60
70
80
90
100
110
120
130
115
52
108
87
97
GFR MM Ratio MM Rate
Maternal mortality ratio/
100,000 live births
General fertility rate/1000 ♀ reproductive age
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Click to edit Master title styleMaternal mortality trends, Jamaica:1981-2012 (ratio/100 000 live births)
1981-3 1986-7 1993-5 1998-0 2001-3 2004-6 2007-9 2010-120
20
40
60
80
100
120
9992
7567 67
58 56
70
17 18 15 1926
3933
27
108 111101
8794 96
8997
Direct Indirect Total
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Click to edit Master title styleOutline of presentation
Discuss the strengths and weaknesses of Jamaica’s surveillance system by examining:
Coverage Links between levels of the health system Method of analysis Response and action
Implementation and supervision Accountability mechanisms Lessons learnt
Identifying and addressing reporting gaps
Coverage9
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Click to edit Master title styleCase definition:Challenges & Solutions
WHO definition of maternal death difficult to implement in practice for surveillance Direct, indirect; pregnancy – 42 days postpartum
Case definition simplified (2004) to: Death in woman 10-50 years Evidence of pregnancy in last year, regardless of place of death
Case review classifies deaths and exclude as necessary Direct, indirect, late Coincidental (accidents, violence, not pregnancy related)
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Click to edit Master title styleMonitoring completeness
Initially validated coverage (2003, 2007) to plug gaps Deaths in A& E (pre-admission) Deaths on medical and surgical wards (puerperal
admissions) Deaths in ICU (transfers in particularly get missed)
ICU physicians less interested in underlying obstetric causes Process expanded to cover non-obstetric wards
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Click to edit Master title styleUnder-reporting of maternal deaths in vital data: 2008
Under-reporting of maternal deaths in official data: 0-35% annually! Maternal deaths identified from: surveillance, hospital
validation, Coroners case review, vital registration For registered deaths – reviewed death certificates
Quality of certification, coding, transcription errors
76% of maternal deaths missed due to - Delayed/Non-registration – 20% (10/50) - mostly Coroners cases Inadequate certification – 8% (4/50) – pregnancy not recorded Incorrect coding – 42% (21/50) Coded to maternal conditions – 24% (12/50) – MMR=23.6/100,000
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Click to edit Master title styleMaternal deaths missed by surveillance or not registered, Jamaica: 2008
Cause of death
All sources Maternal mortality surveillance
Registered, certified as maternal
Number Number % Number %
TOTAL 50 43 86·0 34 68·0(Pre-)eclampsia 16 15 93·8 13 81·3Haemorrhage 8 7 87·5 7 87·5Ectopic pregnancy 5 1 20·0 2 40·0Abortion 2 2 100 2 100Other direct 4 4 100 3 75·0Subtotal – DIRECT 35 28 80·0 27 77·1Cardiovascular 7 7 100 4 57·1Sickle cell disease 3 3 100 1 33·3Other indirect 5 5 100 2 40·0Subtotal – INDIRECT 15 15 100 7 46·7MMR [95% CI] 117.8 [85.2-150.4] 101.3 [71.0-131.6] 80.1 [53.2-107.0]
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Click to edit Master title styleInformation gap
Persistent bias - Coroners cases = Community deaths Forensic pathologists = Ministry of National Security
Do not share necropsy findings with Ministry of Health including maternal deaths
Common causes of sudden maternal death Ruptured ectopic pregnancies Complications of abortion Deaths 3-6 weeks post partum at home
Stroke, heart disease, puerperal sepsis Late maternal deaths (>6 weeks post partum)
including infection, stroke, cardiovascular events Coincidental deaths: accidents, violence, including suicide
Suicide reclassified by WHO (2007) as a direct maternal death
Memorandum of understanding needed Ministries of Health, National Security
Movement of information Community Region MinistryBetween regions
Linkages15
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Flowchart – JamaicaMaternal Mortality Surveillance & Response
Death - 10-49 years♀
Evidence of pregnancy last 12 months
Post mortemHome visit
(verbal autopsy)Antenatal summary
Clinical [inpatient] summary
Notification (IDSR* form)
Multi-disciplinary case review (quarterly)
Case report to MOH Local action
National review (annually)
National policy interventions
*IDSR – infectious disease surveillance reporting
FacilityCommunityParish
Health region
National
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Click to edit Master title styleWomen crossing regional jurisdictions
Mothers move across parish and regional borders for… Tertiary care (2 of 4 regions): ICU, highly specialized care High risk antenatal & comprehensive obstetric care (9 of 14 parishes) at delivery For some mountain communities, nearest hospital may be in the next region
Facility of death should: Notify Ministry of Health and parish of residence
Parish/region of residence expected to: Do home visit (verbal autopsy) Provide antenatal care summary/clinical summary pre-transfer
Facility of death should compile and share with parish/region of origin: Clinical summary – referral care Post mortem report
Region of death is responsible for the Case review Case summary provided to parish/region of residence National epidemiologist attributes the death to parish/region of residence
Rates calculated by region of residence
Regional review meetings
Strategies to build local confidence
Role of the national committee
Method of analysis 18
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Click to edit Master title styleGetting reviews going
Enthusiasm for surveillance varied by health region e.g. west, south didn’t come on board initially
Facility review meetings: Sometimes deteriorated into ‘blame and shame’ sessions
Ministry of Health was committed to process To bring all regions on board, Ministry of Health made it
policy that all regions should have routine regional MM reviews
Policy guidelines issued and training done Data collection instruments Case review process Meetings should occur at least quarterly, depending on case load
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Click to edit Master title styleUnderstanding the causes of death: clinical and social
Post mortem recommended - achieved in ~60% cases Deaths during pregnancy – 57% 0-6 days post partum – 67% 7-42 days post partum – 55%
Home visit – to understand the social determinants May vary by region for the same UCOD, e.g. Eclampsia
Urban setting – violence prevent mother getting to hospital Rural setting – transportation, distance, cost SOLUTIONS DIFFERENT
Sometimes its only way to understand the clinical COD e.g. Uterine rupture – no clinical cause at post mortem
21
Click to edit Master title styleRegional review meetings
Multidisciplinary meeting Cases discussed by practitioners and supervisors from all parishes
within region Primary (PHC) and secondary (SHC) care teams represented
PHC: Midwives, public health nurses, medical officers of health SHC: Obstetrician(s), Matron or obstetric sister, pathologist
Elements of case presented by each investigator PHN/RM (home visit; antenatal care summary) Attending physician/obstetrician (clinical summary) Pathologist (post mortem report)
Supervisory oversight Regional supervisors: Regional technical director, epidemiologist National committee: Director - Family Health Services, surveillance officer,
reproductive health epidemiologist (AMcB)
22
Click to edit Master title styleCase Review & Decision Making
Try to focus on the systemic failures why women died Review similar cases together to identify common threads, e.g.
Pre-eclampsia (non-compliance with referral) Monitor with repeat visit to community ANC one week later Home visit, if no-show
Diabetes in pregnancy (late diagnosis) Screen obese women (no diabetic deaths in last triennium)
Late deaths (mostly women with medical complications) Post natal referral to general medical clinic at end of puerperium
Was the death avoidable? At what point? Recognition of problem by women; not seeking care early
Health promotion at antenatal clinic At the health facility
Challenges with diagnosis; appropriate treatment Stigma (abortion, HIV) Timely transfer of women to appropriate level of care
The weakest or strongest link
Implementation and supervision
Response and action23
24
Click to edit Master title styleTechnical assistance to teams
Health teams needed: Technical assistance in interpreting findings Training in how to code and classify the deaths
Next round of guidelines included Access database with: Data entry screens
Layout similar to data collection tools to reduce transcription errors Drop down menu to quickly code underlying cause of death
Some regions use it – others still send paper records to the Ministry of Health
25
Click to edit Master title styleResponse and resource limitations
Some interventions have policy implications which require national leadership, e.g. Development of clinical guidelines Training Health promotion Upgrade of facilities (2 basic hospitals upgraded to comprehensive)
Long term maintenance of equipment Ultrasound machines Other high tech equipment
Multiple providers Multiple spare parts Technical support/skills
26
Click to edit Master title styleCase Review & Decision Making: Low/no cost solutions
Working around identified roadblocks Delays accessing referral high risk AN care
Referred patients must be triaged by midwife if clinic over crowded and patients must go home without being seen
South-east region now taking high risk clinics out of the hospital into selected primary care locations
Delays accessing EmOC in pregnancy – long A&E wait Bypass A&E in 3rd trimester labour ward review by RM
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Click to edit Master title styleUse of findings to improve care
Financing structural improvements – extra budgetary National committee/Director of Family Health leads
the preparation of proposal for international financing Upgrade CEMoC hospitals (years in the making) by
establishing dedicated high dependency units on the obstetric wards
Project now funded and awaiting implementation Another round of RFP for supplies, equipment, training of
staff etc. Patience a valuable asset!
Monitoring and evaluation
Confidentiality of the enquiry process
Building trust
Accountability mechanisms28
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Click to edit Master title styleMonitoring and evaluation (M&E)
Evaluation – completeness & effectiveness Done episodically by national committee within the health sector
Resolution of problems outside health sector challenging National team must work through the public sector to address
challenges from without, e.g. Access to Forensic pathologists cases Vital registration issues
Effective M&E process lacking! No consistent strategy to follow-up decisions made by regional
review teams Review teams mostly clinical, administrative support restricted to
technical supervisors Need to improve participation of managers at these meetings
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Click to edit Master title styleConfidential enquiry process
MDSR is based on the concept of confidential enquiry Challenge: how to respond when obvious malpractice
identified Who is to blame?
Obstetrician assigned to basic EmOC hospital Facility not equipped to deal with complications
e.g. managing preterm infants – no nursery Practices specialty skill Patient develops complications
Death, serious morbidity What to do when gentle persuasion fails?
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MDSR successes – Jamaica: MMR by region
WEST
- Strong leadership by obstetric consultant at tertiary hospital
NORTH EAST
– most successful region re MDSR responsiveness
South east West South North east0
20
40
60
80
100
120
140
160
180
200
86 82
122
169
103
67
100
73
1981-83 1993-95 1998-00 2001-3 2004-6 2007-9 2010-12
Highest referral level:COMPREHENSIVE CARE
Highest referral level:TERTIARY CARE
Importance of surveillance to understanding dynamics of maternal risk
Successes and challenges
Post MDGs – what next?
Summary – lessons learnt32
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Click to edit Master title styleSetting it up – early buy in: Case reviews
Getting started – getting all the regions on board
Solutions1. Making maternal deaths a Class I notifiable condition2. Introduction of quarterly multidisciplinary regional
review meetings Supported by attendance of national level officers
Director of Family Health Services National Surveillance Officer National Reproductive Health Epidemiologist (AMcB)
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Click to edit Master title styleUse of findings to improve care data synthesis, action cycles, demonstrating impact
Case review process & action: Teams encouraged to review similar cases together
Focus on structural failures in care, versus whose was at fault
Some regions better at focusing attention on: Most successful region identify change agent to lead response Addressing service delivery deficits Attitudes – willingness to change established behaviours
National meetings are opportunities for training and allow teams to share experiences and best practices, however these did not always become institutionalized in other
regions!
35
Click to edit Master title styleBuilding responsive surveillance systems
Hypertensiv
e disord
ers
Obstetri
c Haemorrh
age
Cardiovascu
lar
Diabetes mellit
usHIV
0
5
10
15
20
25
30
35
0 0 0
1981-3 1993-95 1998-00 2001-3 2004-6 2007-9 2010-12
PMTCT/ART roll out
Field test & roll out: HTN guidelines/
high risk AN clinics
Screening obese mothersInternists in selected high risk ANCs
With resurgence in HTN/HAEM deaths since 2007, an audit of cases & staff retraining is needed
Recommendations
Beyond 201536
37
Maternal mortality: Changing epidemiology
MDSR has allowed Jamaica to better understand why mothers die
Need to include coincidental and late maternal death in case definition
Any mother’s death threatens her children’s lives
Hypertension Haemorrhage Abortive outcomes
Other direct Indirect Coincidental0
5
10
15
20
25
30
1981-3 1993-95 2001-3 2010-12% deaths
38
Click to edit Master title styleBuilding political zeal
Maternal deaths 35-50 per year Infant deaths 900 per year Stillbirths 800 per year Births 39,000
Preventing maternal deaths will not capture votes Babies, not mothers grab voters and votes
How do we get politicians interested in reducing 39-50 deaths to 12-15 events per year?
Move away from mortality to morbidity prevention
Embrace within maternal mortality prevention, the saving of babies lives
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Click to edit Master title styleSummary
Increasing indirect mortality, resurgence of (pre)-eclampsia, AIDS, reinforces need for active surveillance Dynamic problem solving required
Qualitative studies needed to better understand the social challenges women face in: Accessing care Making reproductive choices
Surveillance is not expected to be comprehensive, but you need to understand the biases in the data and correct methodological flaws
Surveillance only useful if we are empowered to act on our findings
40
Click to edit Master title styleAcknowledgements
Director Family Health Services Dr Karen Lewis-Bell
Regional Epidemiologists Dr Vittilus Holder – South Dr Maung Aung – West Dr Carla Hoo – North east Dr O’Neil Watson – South east Mrs Kelly-Ann Gordon – South easst
Surveillance Officers Mrs Sabrina Beeput Mrs Veneita Fyffe-Wright
Thank You!!Let’s keep their mother’s alive 41