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

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Where is Jamaica?

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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

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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

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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)

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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

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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

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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

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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

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40

60

80

100

120

140

160

180

200

86 82

122

169

103

67

100

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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!

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Click to edit Master title styleBuilding responsive surveillance systems

Hypertensiv

e disord

ers

Obstetri

c Haemorrh

age

Cardiovascu

lar

Diabetes mellit

usHIV

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5

10

15

20

25

30

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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

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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

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1981-3 1993-95 2001-3 2010-12% deaths

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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

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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