Maternal Death Audit

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					Maternal Death Audit

  Why is it important and how is it
 It is critical to determine the levels
  and causes of maternal mortality
 This will tell us the public health
  importance of specific maternal
  health problems
 We can then design appropriate
  interventions to reduce maternal
 For example, a large number of
  maternal deaths due to hemorrhage
  will point to the need for:

   Early management of bleeding
   Timely referral
   Access to emergency transport
 Or, high levels of maternal death due
  to puerperal sepsis, for example, may
  indicate the need for:

   Improved management during
   Improved management after delivery
 Maternal Death Audit

What is Maternal Death Audit?

   Step 1: Examine case records and interview
   Step 2: Interview the household of the
    deceased person
   Step 3: Use this information to reconstruct
    the circumstances leading to the death
   Step 4: Assign a Cause of Death
Step 1: Examine case records and
interview staff
 Visit the health premises where she
  was treated to examine case records
  and interview staff
   Take note of the recorded obstetric
   Ask staff about any special
    circumstances regarding the death
Step 2: Interview the household
of the deceased person
 Meet the relatives of the deceased to
  collect information on:
   the location of the death
   the economic, social and educational
    profile of the family
   the deceased’s obstetric history and
    record of antenatal, delivery and
    postnatal care, referral and
   the circumstances of death
Step 3: Reconstruct the
circumstances of the death
 Obstetrician to analyze the direct and
  indirect obstetrical causes which led to
 Other team members to examine non-
  medical causes of death: antenatal care,
  risk factors, complications, delay in referral
  or in initiation of treatment, non-availability
  of specialists, equipment, blood, etc.
 Highlight system failures
Step 4: Assign a Cause of Death
 Use all the information to assign,
  as a team, the primary cause of
 Ask yourselves - Was it
 Ask yourselves – Was it because of
  a systems failure?
The Process (1)
  Step 1: Report the death to the Deputy
  Director of Health Services at the
  District level
 When? Within 24 hours of death
 Who will do it?
   If the death occurs at home, in transit, at the
    sub-center: ANM to PHC Medical Officer
   At the PHC: PHC Medical Officer
   Public Hospital or Private Hospital: Respective
    hospital authorities
The Process (1) contd…
 Report deaths of all pregnant
  women, including due to
  abortion, suicide, accidents etc.
The Process (2)
  Step 2: Form a Maternal Death
  Investigation Team at PHC
 When? Within 15 days of the death
 Who will be in the team?
     PHC Medical Officer
     Administrator
     1 Nursing Staff
     BHE
The Process (3)
 Place the findings of the team before the
  district-level Maternal Deaths Medical Audit
  Committee on a monthly basis
 Place all reports before the District RCH
  Committee chaired by the District Collector,
  which receives relatives of the deceased
  who give their account of the events
 Place the minutes of both meetings before
  the Commissioner, H&FW
The Process (4)
 Provide feedback to relevant FRUs
  and PHCs
 Provide feedback to relevant
  personnel involved in the case
 Conduct annual analysis of
  maternal deaths to understand
  causes of death and formulate
  appropriate response
Analysis – What does the Maternal
Death Audit tell you? (TN example)
Analysis – What does the Maternal
Death Audit tell you?
 Poor distribution of first referral units
 Unnecessary referrals
 Poor quality of care
 Delay in accessing emergency
 Obstetric first aid not provided before
 etc
Analysis – Possible Solutions
 Making FRUs functional by
  contracting in additional staff

 Ensuring emergency transport –
  either by using untied funds to
  establish a tie-up with local
  transport facility or by setting up
  an ambulance facility
Analysis – Possible Solutions
 Establishing blood storage facilities
  at the PHCs
 Providing additional training to PHC
  staff in emergency obstetric care
 Ensuring that all staff are aware of
  Emergency Obstetric Care
 Medical Officer and Administrator to
  place the findings of the Audit before
  the Arogya Raksha Samithi (ARS)
 ARS to present the findings to the
  next Gram Sabha in the presence of
  the Medical Officer and Administrator
 ARS to facilitate the process of PHC
  staff and community taking
  ownership of the findings of the Audit

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