Strengthening maternal and perinatal deaths surveillance and response in Tanzania
This case study was written by Moke Magoma, Craig Ferla and Corinne Armstrong from Evidence for Action-Mama Ye.
Tanzania has been undertaking maternal death reviews since 1984 though at different levels and in only certain health facilities. In 2006, national guidelines for Maternal and Perinatal Deaths Review (MPDR) were launched, making MPDR a required routine practice in Tanzanian health facilities. However, scale up of the MPDR had been weak, with poor monitoring and evaluation, and inadequate expertise to analyse problems and solutions, although there was some provider commitment observed. The continuous feedback cycle was ineffective as review meetings of aggregate findings were not generally taking place. A revision process was begun in 2013 to improve the MPDR guidelines, coinciding with the global movement to implement maternal death surveillance and response (MDSR) mechanisms.
Stakeholders including WHO, UNFPA, UNICEF, Evidence for Action (E4A), national professional bodies, and Tanzanian and international academic and research institutions, collaborated with the Ministry of Health and Social Welfare (MOHSW) to revise the existing system of MPDR in light of the latest technical guidance (MDSR) and country-specific evidence drawn together at a workshop in October 2013. A technical working group comprised of MOHSW staff was assigned responsibility to progress the guideline document and design training materials for what would now be referred to as a system of Maternal and Perinatal Deaths Surveillance and Response (MPDSR).
The proposed MPDSR system, despite not being finalised, was embedded within the monitoring and evaluation framework of the 2014 Sharpened One Plan – the national accelerated plan to reduce preventable maternal, newborn and child deaths before end of MDGs. It was further informed by the WHO maternal death surveillance and response: technical guidance information for action to prevent maternal death and FIGO’s guidelines and tools in how to conduct maternal death reviews. The MPDSR national guidelines have been completed, signed off by the relevant authorities at the Ministry of Health and Social Welfare and phased countrywide roll-out completed in two regions November 2015.
Unlike the MDR guidelines launched in 2006, the current guidelines have accompanying tools which have been pre-tested. Dissemination of the new guidelines and tools will be made to all stakeholders, including service providers who conduct the reviews is on-going.
A phased approach to dissemination is planned such that each phase informs subsequent steps to ensure better understanding of the guidelines and tools and to obtain uniform implementation across the country. Formulation and dissemination of the new guidelines are largely by Tanzanians. This not only gave them ownership of the guidelines, but due to their understanding of the country context and previous challenges, ensured that the guidelines were implemented informed from previous experience and therefore with better envisioned outcomes.
This dissemination strategy is in contrast to how the previous were introduced to users, requiring them to independently interpret and understand what was needed, leading to fragmented and differing approaches in implementation.
Tools for the roll-out of the guidelines have been developed with technical assistance from E4A and have been pre-tested in Mara and Kagera regions as part of the initial roll-out in the country. The pre-test identified a number of opportunities and challenges in rolling out MPDSR tools and approaches to inform next steps as highlighted in the table below:
|1. The MPDSR implementation has universal support and participants understand the value||1. For effective implementation, the dissemination of guidelines will require training of not only health care providers but also health administrators such as the head of some departments in health facilities, councils and regional health management members. To cover the entire country will thus require significant financial resources and personnel, both currently limited||1. Guideline and tools are being printed for roll-out across the country|
|2. The developed tools emphasize the skills of health facility staff in MPDR- an identified weakness in the roll-out of the previous guidelines||2. As noted by participants in the two regions where the roll-out has been conducted so far, most lacked the appropriate skills for implementing quality MPDSR. The roll- out of the previous guidelines did not factor this in and as a result, implementation has been dependent on individual understanding of the guidelines. For example, i) membership of the review team did not always follow the guidelines and some eligible members rarely attended, including those involved in case management ii) reviews are almost exclusively relying on case notes from patients files which were often incompletely filled and reviews case summaries were never prepared a priori iii) health system related dysfunctions which might have contributed to the maternal or perinatal deaths were rarely explored such that blame shift to the demand side was a norm iv) some managers would use results from reviews to reprimand providers who were identified to be at fault in management of cases v) results from the reviews were rarely shared outside those involved in the review and the reporting authority leading to limited involvement of those employed in other sectors.||2. Efforts to mobilise funding for the roll-out have begun|
|3. The roll-out emphasizes use of maternal and perinatal death cases in the same region (in contrast to a review of cases from many different regions) elicited debates and re-organization of service delivery to improve the quality of services. The focus on one region such as Mara meant actions and tasks discussed were specific to that area. Real-time accountability started immediately after the training.||Initial experience suggests that sources for information for effective maternal and perinatal reviews such as file case notes, anaesthetist notes, pre, intra and post-surgery notes and treatment sheets are often incompletely filled to allow in-depth understanding of systemic dysfunctions to address for better survival||3. Phased roll-out should include addressing gaps in attitude and practice, including on better recording of patient information in health facilities|
|Perinatal deaths reviews were a component of the previous guidelines and are also prioritized in the new guidelines||Perinatal death reviews were not previously prioritized and despite efforts to improve the required skills by training health facility staffs, perinatal deaths may still not be given as much weight as maternal||Emphasis on the importance of perinatal death reviews in the roll-out of the new guidelines|
|4. Overall, participants are adequately skilled to learn and conduct effective MPDSRs||4. Although the proposed phased approach of disseminating the guidelines and tools may be the best approach conceptually, chances are abound for differences in the quality of such trainings with potential for differing skill levels across the country. Training and roll-out of the tools will also not be implemented concurrently due to different partner timelines.||Initial roll-out should include training of TOTs to be used across all regions in the country|
With limited human resource capacity, and competing priorities, it is possible that the MPDSR workload may be overwhelmed by other competing processes, but inclusion of MPDSR as systemic accountability in the One Plan 2-a national strategy for accelerated reduction of maternal, newborn and child deaths 2016-2020 is an important step to address the priority attached to the MPDSR process. Further, health facility staff ought to understand the value of MPDSR on their daily work rather than perceive the process as a way of generating information to feed higher level health administration and service delivery.
The future, next step
The sustainability and quality of the revised system of surveillance and response will require improved leadership from MOHSW as well as continued integration of the new mechanism into national strategies and policies, and a systematic approach to rolling out the training packages across the country. Integration of maternal death notification with the Integrated Disease Surveillance and Response system is the longer-term goal.
Training and supervision packages should focus on strengthening the quality of reviews taking place within health facility teams, particularly on the action and response cycle, based on available evidence of the challenges and barriers found in the existing MPDR system -an approach followed in the recent training in Mara and Kagera regions. Further, ensuring appropriate capacity and resources for holding technical review meetings at council, regional and national levels is imperative for aggregated information on maternal and perinatal death surveillance and response.