Elsevier

Women's Health Issues

Volume 19, Issue 1, January–February 2009, Pages 14-20
Women's Health Issues

Article
Facility-Based Maternal Death Review In Three Districts In The Central Region of Malawi: An Analysis of Causes and Characteristics of Maternal Deaths

https://doi.org/10.1016/j.whi.2008.09.008Get rights and content

Purpose

We sought to determine the causes and characteristics maternal deaths that occur in health facilities in Malawi.

Methods

Forty-three maternal deaths were reviewed in 9 hospitals in 3 districts in Central Malawi over a 1-year period. Causes and avoidable factors of maternal deaths were identified during the review, and recommendations made and implemented.

Main Findings

There were 28 (65.1%) direct obstetric deaths and 15 (34.9%) indirect obstetric deaths. The major causes of maternal deaths were postpartum hemorrhage (25.6%), postpartum sepsis (16.3%), HIV/AIDS (16.3%), ruptured uterus (7.0%), complications of abortion (7.0%), anemia (7.0%), antepartum hemorrhage (4.7), and eclampsia (4.7). Two thirds of the women were referred either from another health facility (51.2%) or by a traditional birth attendant (TBA; 11.6%), and up to 79.1% were critically ill on admission. Four groups of factors that contributed to maternal deaths were identified: 1) health worker factors, 2) administrative factors, 3) patient/family factors, and 4) TBA factors. The major health worker factors were inadequate resuscitation (69.8%), lack of obstetric life-saving skills (60.5%), inadequate monitoring (55.8%), initial assessment incomplete (46.5%), and delay in starting treatment (46.5%). The most common administrative factor was lack of blood for transfusion (20.9%). The major problems encountered include shortage of staff and other resources, difficulty in maintaining anonymity, poor quality of data, and difficulty in implementing recommendations.

Conclusion

Adequate training on obstetric life-saving skills, addressing HIV/AIDS, and raising community awareness could be important factors for reducing maternal mortality in Malawi and countries with similar socioeconomic profiles.

Introduction

The World Health Organization (WHO) estimates that of the half million women who die of pregnancy-related deaths each year, >99% are found in low- and middle-income countries (WHO, 2007). More than 80% of these deaths can be prevented by improving the availability, utilization, and quality of skilled birth attendance, and emergency obstetric care (WHO, 2005). One way of improving the quality of obstetric care is through auditing of maternal deaths. There are 3 approaches to maternal death audit, namely, confidential enquiry into maternal deaths (CEMD), facility-based death reviews, and community-based death reviews (also called verbal autopsy).

CEMD was established in the United Kingdom in 1952 to identify the causes of maternal death and avoidable factors contributing to the death of women during pregnancy and childbirth (Papworth & Cartridge, 2005). CEMD has subsequently been carried out in a number of countries, including Australia, the United States, and certain European countries (WHO, 2004). More recently, CEMD has been introduced in Malaysia, Israel, Kenya, Indonesia, Malawi, and the Republic of South Africa using an adapted UK CEMD methodology (Supratikto et al., 2002, Malaysia Ministry of Health, 1988, Ratsma, 2002). Confidential enquiries are carried out at a regional (state) or national level, usually by the country's Ministry of Health.

It is now considered good clinical practice to review each case of maternal death that occurs in the health facility so that the lessons learned from the management of the case could be used to improve future clinical practice (World Health Organization (WHO), 2004, Bullough et al., 2005). This is called facility-based maternal death review, and is an educational process for health care professionals providing care to the woman during pregnancy, childbirth, and postpartum. In settings where many maternal deaths occur in the community, community-based maternal death review is a useful complement to facility-based maternal death review (Hofman & Sibande, 2005). Both facility-based and community-based maternal death reviews are strongly supported by expert opinion and have received recently been endorsed by the WHO (Bullough et al., 2005).

Malawi has a Maternal Mortality Ratio of 1,100 per 100,000 live births, which is among the highest in the world (WHO, 2007). First visit antenatal care coverage is 93%, health facility delivery rate is 57%, and postnatal care coverage is 31% (National Statistics, 2005). Malawi has 1.8 comprehensive emergency obstetric care facilities per 500,000 population (greater than the recommended minimum of 1 comprehensive emergency obstetric care facility per 500,000 population), and only 2% of the recommended number of basic emergency care facilities (Leigh, Mwale, Lazaro, & Lunguzi, 2008). The met need for emergency obstetric care is only 18.5%, population-based caesarean section rate is 2.8% and the case fatality rate for emergency obstetric complications is 3.4% (Leigh et al., 2008). Three major barriers to accessing maternal health have been identified in Malawi: 1) suboptimal quality of care, which includes communication, attitudes, and cooperation, 2) cultural barriers such as traditional view of pregnancy and perception of danger signs, and 2) unsatisfactory availability and accessibility of skilled delivery care in terms of transport, distance, costs, and critical shortage of skilled attendants (Seljeskog, Sundby, & Chimango, 2006).

Malawi is one of the countries that have adopted the WHO recommendation of combining community-based and facility-based maternal death reviews to improve professional practice and reduce maternal mortality (Hofman and Sibande, 2005, Ratsma, 2002). The Malawi Ministry of Health developed 3 forms currently used for maternal death review: 1) The Maternal Death Notification Form contains the particulars of the deceased notifies the District Health Office within seven days of the maternal death; 2) The Maternal Death Review Form is filled during maternal death review meetings and contains details of the causes of maternal death, factors that contributed to the death, and recommendations made during maternal death review; and 3) The Maternal Death Follow-up Form is used to follow up the implementation of recommendations made during the maternal death reviews.

Previous studies on facility-based maternal death reviews in Malawi have been carried out in the southern region (Ratsma, 2002, Lema et al., 2005). A recent study found that the facility-based delivery rate in 3 districts in the Central Region was 40.6%, which is lower the national average of 56% (Kongnyuy et al., 2008, National Statistics Office (NSO) [Malawi]ORC Macro, 2005). This suggests that characteristics of maternal deaths in the central region might differ from those previously reported in the south.

The aim of the current study was to determine the causes and characteristics maternal deaths that occur in health facilities in 3 districts in the Central Region of Malawi. The study reports summary data on the causes of maternal deaths, avoidable factors, recommendations made, and problems encountered during the maternal death review process.

Section snippets

Study design

This cross-sectional study described the implementation of facility-based maternal death reviews in 3 districts (Salima, Kasungu, and Lilongwe) in Central Malawi. All 43 maternal deaths that occurred in 9 hospitals in the 3 districts between January and December 2007 were audited. Maternal deaths that occurred before arrival to the hospitals were not included in this analysis.

Study setting

There are a total of 9 hospitals in the 3 districts and all these hospitals were involved in the maternal death audit.

Pregnancy-related characteristics

A total of 43 maternal deaths were reviewed. The mean age was 28.6 years (standard deviation [SD], 7.3). The median parity was 2 (range, 0–11) and median gestational age was 38.0 weeks (range, 8–42). The median length of hospital stay was 2 days (range, 0–24). Four fifths (79.1%) of women were critically ill at the time of admission and two thirds were referred either from another health facility (51.2%) or by a traditional birth attendant (TBA; 11.6%). A majority (69.8%) of these women died

Discussion

This paper describes the causes of maternal deaths, avoidable factors, and recommendations made during facility-based maternal death reviews in 3 districts in Malawi. During the process of maternal death review in the 3 districts, several problems were encountered, including inadequate staff, confidentiality and anonymity, quality of data, and difficulties to implement recommendations.

One of the major problems was shortage of staff, especially senior staff, to conduct maternal death reviews. It

Authors’ Contributions

EJK: Conception, design, drafting of the protocol, analysis, interpretation and write-up of all versions of the manuscript. GM and NVDB: Critically reviewed the manuscript for important intellectual content.

Acknowledgment

The authors acknowledge the Health Foundation for providing financial support for this study. Thanks to maternity and administrative staff of all the hospitals that participated in this study.

Eugene J Kongnyuy, MD, MPH, is Clinical Lecturer in Sexual and Reproductive Health in the Liverpool School of Tropical Medicine, University of Liverpool, United Kingdom. He is a Gynaecologist-Obstetrician with several of experience in developing countries. His research work focuses on emergency obstetric and neonatal care, audit, quality improvement, and HIV/AIDS.

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Eugene J Kongnyuy, MD, MPH, is Clinical Lecturer in Sexual and Reproductive Health in the Liverpool School of Tropical Medicine, University of Liverpool, United Kingdom. He is a Gynaecologist-Obstetrician with several of experience in developing countries. His research work focuses on emergency obstetric and neonatal care, audit, quality improvement, and HIV/AIDS.

Grace Mlava, MPH, is a Registered Nurse-Midwife who works for the Health Foundation Consortium in Malawi as Maternal and Neonatal Health Officer.

Nynke van den Broek, PhD, FRCOG, is Senior Clinical Lecturer in the Liverpool School of Tropical Medicine, University of Liverpool, United Kingdom. She is Director of the Royal College of Obstetricians and Gynaecologists International Office. Her areas of research include emergency obstetric care, skilled birth attendance, and capacity building.

Supported by funding from the Health Foundation Consortium, UK.

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