WHO recommendation on community participation in Maternal Death Surveillance and Response (MDSR)

Local health official conducting a verbal autopsy of a death of a mother, Bangladesh.

WHO recommendation on community participation in Maternal Death Surveillance and Response (MDSR)

 

Recommendation

Because of the paucity of evidence available, additional research on community participation in Maternal Death Surveillance and Response (MDSR) is recommended. The GDG affirms as a matter of principle the importance of sharing information on pregnancyrelated deaths with communities including discussion of the different factors causing these deaths and affecting access to skilled care.

 

Publication history

First published: 2015

Updated: No update planned

Assessed as up-to-date: 2015

 

Remarks

  • Additional research is required

 

Background

In 2003 the World Health Organization (WHO) published "Working with individuals, families and communities to improve maternal and newborn health", (1) the IFC framework that promotes integrating the health promotion approach set out in the Ottawa Charter (2) into national maternal and newborn health (MNH) strategies.

The IFC Framework was developed in response to analysis and global statements indicating that as well as strengthening services, MNH strategies need to improve the capacity of individuals, families and communities to provide appropriate care for pregnant women, mothers, and newborns in the home. It also addresses the reasons - over and above what happens in clinical services - why women do not reach good quality skilled care during pregnancy, childbirth and after birth. The Ottawa Charter's health promotion components(2) were translated into MNH programme language and 12 promising interventions - identified through reviews of country experiences and the literature - were categorized into four priority areas. Community and intersectoral participation was recommended to guide implementation. Exact interventions to be adapted by country programmes were to be identified through local assessment; however, the framework highlighted the need for interventions to address all four priority areas at the same time. All six WHO Regions integrated this guidance into the regional maternal mortality reduction strategies.

As indicated in the IFC Framework concept and strategy paper,(1) it is recognized that in order to assume a role in improving MNH, communities need information regarding local maternal and newborn health needs. There are different methodologies and tools designed for health systems to gather information regarding maternal and newborn death and morbidity. Several of these recognize the value of the community as a source of information.

In recent years, particularly under the UN Secretary- General's Global Strategy for Women's and Children's Health(3) and the Commission on Information and Accountability, increased attention has been given to Maternal and Perinatal Death Surveillance and Responseas it contributes to better information for action by promoting routine identification and timely notification of maternal deaths, review of maternal deaths, and implementation and monitoring of steps to prevent similar deaths in the future.

Community participation in this process may help provide more accurate information on the number of deaths and where and why the women died. Community participation in analysing information and in identifying possible solutions may help address social determinants, meet community needs, and incorporate a range of actors in the response. Members of the community may participate as family informants for maternal (and perinatal) death inquiries or in presentations of summary data to identify ways to improve health outcomes. Levels of participation can vary, e.g., providing views versus full decision-making. Delivery mechanisms can include involving community representatives in the MDSR coordinating group, or holding community group meetings to discuss maternal deaths, their causes and possible solutions.

 

Methods

The recommendation was developed using standardized operating procedures in accordance with the process described in the "WHO handbook for guideline development", guided by the GRADE approach.(4) Outcomes used for this recommendation were aligned with the prioritized outcomes from the WHO recommendations on health promotion interventions for maternal and newborn health (2015).(5)

A systematic review was conducted on interventions to involve communities in the analysis and dissemination of information from maternal and perinatal death.(6) In the review, randomized controlled trials relevant to the key question were screened by review authors, and data on relevant outcomes and comparisons were extracted. Evidence profiles (in the form of GRADE tables) were prepared for comparisons of interest, including the assessment and judgments for each outcome, and the estimated risks.

WHO convened a Guideline Development Group (GDG) meeting on recommendations on health promotion interventions for maternal and newborn health where this recommendation was developed. The GDG comprised of a group of independent experts, who used the evidence profiles to assess evidence on effects on the pre-specified outcomes. GDG members discussed the balance between desirable and undesirable effects, overall quality of supporting evidence, values and preferences of stakeholders, resource requirements, cost-effectiveness, acceptability, feasibility and equity, to formulate the recommendation. Remarks were added to clarify the recommendation, and aid implementation.

Further information on procedures for developing this recommendation are available here.

 

Recommendation question

For this recommendation, we aimed to answer the following question:

  • What strategies to involve communities in the analysis and dissemination of information from maternal and perinatal death reviews are effective in increasing birth with a skilled birth attendant/institutional birth and improving other key maternal and newborn health outcomes?

 

Evidence summary

Evidence on interventions to involve communities in the analysis and dissemination of information from maternal and perinatal death reviews was extracted from a systematic review conducted by Marston et al. (forthcoming).(6) The review was based on literature identified through the MASCOT/MH-SAR mapping and through two different existing systematic reviews identified.(7, 8) Two studies were included. One study (9) took place in Dinajpur, Bangladesh and included reviews as part of a broader intervention where general facts about maternal mortality and the results of a community diagnosis that included in-depth interviews with consenting families that had recently experienced a maternal death were shared in community meetings in order to understand what factors may have contributed to the death. This programme aimed to increase use of skilled care for obstetric complications. The other study(10) was specifically on maternal and perinatal death reviews using a detailed verbal autopsy questionnaire that took place in six states of India. As seem from the table below, on a spectrum of community participation, whereby community members are increasingly involved in health-related actions in their community, the type of community participation in each study was characterized as involved.

For the outcome of birth with a skilled birth attendant or facility birth, the quality of the evidence was rated as very low.

Only one study in Bangladesh (Hossain and Ross, 2006) reported on this outcome. The study design is not clearly stated, but it seems to be a quasi-experimental pre and post study with a control group. The intervention was multiple and included community mobilization as well as quality of care interventions. Births in a facility are reported and imply significant increases in facility births in the intervention and comparison areas, but not in the control area. Very low-quality evidence.(9)

For the outcome of care with a skilled birth attendant or in a facility in case of maternal complications, the quality of the evidence was rated as very low.

One study reported on this outcome (Hossain and Ross, 2006); as described above the design is not clearly stated. The intervention involved multiple components. Results imply significant increases in the number of women expected to have obstetric complications who actually receive care in an EmOC facility in the intervention and comparison areas, but not the control area. There are errors in the outcome data reported, and it is unclear how many women were surveyed. Very low-quality evidence.(9)

 

Implementation considerations

  • Maternal death reviews can be a helpful approach to raise awareness of pitfalls and challenges on the pathway to survival and can stimulate discussion and proposals for solutions to address them.
  • Community members may participate in the review as family informants for maternal and perinatal death inquiries and in presentations of summary data to identify ways in which to improve health outcomes and take action to implement proposed solutions. The "three-delays" framework/pathway to survival and verbal autopsy are helpful tools to use in maternal death reviews.
  • It is important to ensure the confidentiality of all those involved in cases of maternal deaths. Using summaries of multiple cases was an effective strategy to do this in both studies reviewed.
  • Notification of maternal deaths can be a challenge. This may improve over time as the community becomes aware of interest in collecting this information. Both health providers and communities will require preparation to work together and it will be a learning process. Community involvement may heighten fear of recrimination for providers. Communities may have strong beliefs about death and pregnancy and initially may be reluctant to discuss these.
  • Where countries have advanced in maternal and perinatal death reviews, near-miss reviews should be added to determine how communities can best be involved in preventing future problems. This should be done sensitively, taking into account the circumstances of the death and the cultural practices of the community around the time of pregnancy and childbirth.
  • Processes evolve and often improve over time as experience increases and confidence builds, so it may be best to start more simply at first with maternal death reviews, then add perinatal death reviews, then progress to near-miss reviews.
  • All partners should be made aware that better reporting may result in apparently higher mortality as the programme improves notification systems. Mapping deaths according to physical location can help to target programme attention and interventions.

 

Research implications

The GDG suggested it would be useful to have more information about:

  • Areas for investigation identified as being of interest include better understanding of the interaction between interviewer and respondent for gathering information on deaths, particularly who should be collecting the information, how the community may best be involved, and how the information can best be gathered and communicated to facilitate community participation in the discussions.
  • Lessons could be applied from what is already known about community involvement in review of neonatal deaths. A review of this would be helpful.
  • Any planned intervention needs to address the possibility that health care providers may fear recrimination if there is community involvement in the reviews.

 

Related links

WHO recommendations on health promotion interventions for maternal and newborn health (2015) –full document and evidence tables

 

Supporting systematic reviews:

Marston C, Sequeira M, Portela A, Cavallaro F, CR M. Systematic Reviews on community participation and maternity care seeking for maternal and newborn health.

Managing Complications in Pregnancy and Childbirth: A guide for midwives and doctors

Pregnancy, Childbirth, Postpartum and Newborn Care: A guide for essential practice

WHO Programmes: Sexual and Reproductive health

Maternal Health

 

References

  1. Working with individuals, families, and communities to improve maternal and newborn health. Geneva: World Health Organization; 2010. [26 November 2014] http://wwwwhoint/maternal_child_adolescent/documents/who_fch_rhr_0311/en/.
  2. The Ottawa Charter for Health Promotion [website]. Geneva: World Health Organization; 1986. [30 March 2014] http://wwwwhoint/healthpromotion/conferences/previous/ottawa/en/.
  3. UN Secretary-General global strategy for women's and children's health. New York: United Nations. 2010.
  4. WHO Handbook for Guideline Development - 2nd edition. Geneva: World Health Organization; 2014. World Health Organization. 2014.
  5. WHO recommendations on health promotion interventions for maternal and newborn health 2015: World Health Organization; 2015.
  6. Marston C, Sequeira M, Portela A, Cavallaro F, CR M. Systematic Reviews on community participation and maternity care seeking for maternal and newborn health. (forthcoming).
  7. Lee AC, Lawn JE, Cousens S, Kumar V, Osrin D, Bhutta ZA, et al. Linking families and facilities for care at birth: what works to avert intrapartum-related deaths? International journal of gynaecology and obstetrics: the official organ of the International Federation of Gynaecology and Obstetrics. 2009;107 Suppl 1:S65-85, s6-8.
  8. Marston C, Renedo A, McGowan CR, Portela A. Effects of community participation on improving uptake of skilled care for maternal and newborn health: a systematic review. PloS one. 2013;8(2):e55012.
  9. Hossain J, Ross SR. The effect of addressing demand for as well as supply of emergency obstetric care in Dinajpur, Bangladesh. International journal of gynaecology and obstetrics: the official organ of the International Federation of Gynaecology and Obstetrics. 2006;92(3):320-8.
  10. Maternal and perinatal death inquiry and response: empowering communities to avert maternal deaths in India. New Delhi: United Nations Children's Fund; 2008. [26 November 2014] http://wwwuniceforg/india/MAPEDIR-Maternal_and_Perinatal_Death_Inquiry_a....

 

Citation: WHO recommendation on community participation in Maternal Death Surveillance and Response (MDSR) (2015). WHO Reproductive Health Library; Geneva: World Health Organization.