This case study was written by Helen Smith, Charles Ameh and Nynke van den Broek at the Liverpool School of Tropical Medicine (LSTM). The original article has been published previously in the BJOG supplement, on September, 2014. Reprinted with permission.
Context
Understanding the factors contributing to maternal deaths can assist in developing interventions. Verbal autopsy (VA) has been part of the Demographic and Health Survey in Bangladesh since the 1990’s and is used to gather information on cause of and factors contributing to maternal deaths at community level. In 2010, it was introduced as a method across four districts as a method to be used to capture and review all maternal deaths in these districts.
Key actors
The Government of Bangladesh identified the four target districts for implementation of VA based upon their rural location and weaker maternal and newborn health indicators. The Directorate General of Health Services approved the final VA tools. Training materials in the use of the VA questionnaire were developed by the Centre for Injury Prevention, Health Development and Research together with a group of national experts including reproductive health specialists and programme managers.
Grass roots health and family planning workers (Health Assistants (HA) and Family Welfare Assistants (FWA)) were trained in how to identify a maternal death (using the WHO definition) and how to complete the death notification slip. Assistant Health Inspectors (AHI) and Family Planning Inspectors (FPI) received training on the conduct of a VA, facilitated by social scientists and medical doctors. UNICEF Bangladesh provided funding through a Joint UN-Government project.
Process
Conducting VA is a participatory process used to gather information about a maternal death from family and household members. Trained HA or FWAs receive information from the community network when a death has occurred within the population (catchment area) they are responsible for. They then follow up with a household visit to confirm it is a maternal death, and if so, complete a death notification slip. Upon receipt of the notification slip, trained HI, AHI or FPIs conduct a VA within 15-30 days of the death.
Interviews are held with three family members and/or the Traditional Birth Attendant or other healthcare professional who provided care to the woman who died. The process in Bangladesh was closely monitored by social scientist supervisors in each catchment area who reviewed completed VA forms on a monthly basis, revisiting families to clarify any identified inconsistencies.
Findings/observations
All 571 deaths in the four districts over two years were analysed; the majority of VAs were conducted on time with 19.6% taking place within 15 days, 43.1% within 1 month and 67.8% within 2 months of the death. Two obstetricians independently reviewed all VAs and assigned a cause of death with consensus reached via discussion where needed. Of the 571 deaths identified, 273 (47.8%) died in a health facility, 97 (17.0%) died during transfer and 201 (35.2%) occurred at home suggesting that poor access to care was less frequently a contributing factor than expected.
Poor quality or sub-standard care or delay in receiving effective care once a woman was seen at a health facility (Type 3 delay) was considered to have contributed to maternal deaths. The most frequently identified causes of death were haemorrhage (38%), pre-eclampsia/eclampsia (20%) and sepsis (8.1%) and most deaths occurred in the first 24 hours postpartum.
The VA findings also reveal that women did access care for obstetric complications and either died in the health facility or in transit when referred. This is contrary to previous findings from Bangladesh which suggested that most maternal deaths occurred at home. The VA data identify a need to strengthen quality of care rather than access to care. Improved skills and knowledge of health workers to recognise and manage emergency obstetric complications could help to further reduce maternal mortality.
Implementation lessons
The VA approach to gathering data on cause of maternal death and contributing factors has several limitations:
- The majority maternal deaths occurred at a health facility but it was not possible to additionally obtain patient records or information obtained via facility based death review to verify cause of death or contributing factors.
- VA data is based upon information provided by community members; underreporting of certain conditions and/or misclassification of deaths is a possibility.
- Additional qualitative data on delays might provide a more comprehensive understanding, as delays tend to be underestimated when gathered through survey questioning alone.
Source
This is a shortened version of a case study first published in “BJOG: An International Journal of Obstetrics & Gynaecology”. Halim A, Utz B, Biswas A, Rahman F, van den Broek N. Cause of and contributing factors to maternal deaths; a cross-sectional study using verbal autopsy in four districts in Bangladesh. BJOG 2014; 121 (Suppl. 4): 86–94. A full version is available at http://onlinelibrary.wiley.com/doi/10.1111/1471-0528.13010/abstract