Evaluation of the Maternal Death Surveillance and Response System, Sierra Leone, 2019

Kadijatu Nabie Kamara^1,2, Adel Hussein Elduma^1,3, Joseph Sam Kanu^2,4, James Sylvester Squire^2,4, Gebrekrstos Negash Gebru^1,3

 

¹Sierra Leone Field Epidemiology Training Program, ²National Disease Surveillance Program, Ministry of Health, Sierra Leone, ³African Field Epidemiology Network, Sierra Leone, ⁴Department of Community Health, College of Medicine and Allied Health Sciences, University of Sierra Leone

 

 

^&Corresponding author
Adel Hussein Elduma, Sierra Leone Field Epidemiology Training Program, National Public Health Institute, Wilkinson Road, Freetown, Sierra Leone.

 

 

 

 

Maternal death is defined as “the death of a woman while pregnant or within 42 days of the termination of their pregnancy, regardless of the duration and site of pregnancy, from any cause related to or aggravated by the pregnancy or its management but not from accidental or incidental causes”[1]. In 2017, there were an estimated 295,000 maternal deaths globally in comparison to 451,000 deaths in 2000. The global maternal mortality ratio, 211 per 100,000 live births in 2017, decreased from 342 in 2000 [2]. Despite this progress in global maternal death reduction, many women die from serious health problems during pregnancy and childbirth. Most of these deaths occur in low- and middle-income countries, with two-thirds occurring in sub-Saharan Africa [3], [4]. In 2017, Sierra Leone recorded the highest maternal mortality ratio in West Africa, with 1,120 maternal deaths per 100,000 live births, making it one of the highest globally [2]. A woman in Sierra Leone faces a lifetime risk of 1 in 7 of dying from pregnancy or childbirth, and maternal deaths account for 36% of all deaths among women aged 15-49 [5].

 

In order to address the high occurrence of maternal deaths, the WHO introduced the Maternal Death Surveillance and Response (MDSR) technical guidance in 2013 [6]. Sierra Leone, in 2015, developed its national MDSR technical guideline which was implemented throughout the country in 2016. The MDSR system is a continuous action cycle of identifying, reporting, investigating, and quantifying maternal deaths. Its objectives are to provide actionable information for reducing preventable maternal mortality in healthcare facilities and communities and ensure the counting of every maternal death to assess the true magnitude of the problem and the effectiveness of interventions. The system also helps to determine the cause of maternal-related deaths. [6, 7]. The MDSR approach builds on the maternal death review implemented in the country since 2009 [8]. Even though the country established the MDSR system, its effectiveness remains unknown. A pilot study in four districts on MDSR community-based surveillance system in Sierra Leone revealed that MDSR captured 90% of the maternal deaths [9]. Therefore, we evaluated the MDSR system to assess whether the intended objectives have been met and review the performance of key surveillance attributes and indicators. The findings shall serve as a basis for planning and making data-driven decision to improve the MDSR system at all levels.

 

 

Evaluation setting and sampling

 

Sierra Leone is located on the southwest coast of West Africa, bordered by Guinea to the northeast, Liberia to the southeast, and the Atlantic Ocean to the west. The country is divided into five regions and 16 districts with an estimated population of 8 million. In 2018 there were 1.9 million women of reproductive age and the maternal death rate was 111 deaths per 1,000 live births [10]. For this evaluation, we reviewed maternal death records in three districts: Western Area Urban (WAU) and Kenema and Bonthe districts, representing the Western, Eastern, and Southern regions respectively (Figure 1). WAU, which exclusively houses the country´s capital, Freetown, is served by 125 health facilities including 29 Community Health Centers (CHC), 19 Community Health Posts (CHP), 13 Maternal Child Health Posts (MCHP), 59 clinics, and 30 hospitals. Kenema district, in the Eastern Region served by 141 health facilities including, 32 CHC, 37 CHP, 61 MCHP, 6 clinics, and 5 hospitals. Bonthe district, in the Southern Region has 61 health facilities including, 16 CHC, 19 CHP, 22 MCHP, 1 clinic, and 3 hospitals [11].

 

For the evaluation, four health facilities were included from each district: three randomly selected peripheral health units (CHC, CHP, & MCHP) and the district hospitals, which were purposively selected, totaling 12 facilities. We enrolled 36 stakeholders involved in the MDSR system, including three public health professionals at the national level (one each from the Directorate of Reproductive and Child Health, National Disease Surveillance Programme, and Reproductive and Family Planning Programme), twelve from the District Health Management Team (DHMT) at the district level, and twenty-one staff from the health facilities.

 

Evaluation design and period

 

A descriptive cross-sectional study was used to assess the MDSR surveillance system. This evaluation was conducted from October to November 2019. One year data, from January to December 2018 was reviewed.

 

Data collection and analysis

 

Participants were interviewed face-to-face to obtain their responses to questions on the usefulness, acceptability, and simplicity of the MDSR system [4]. Responses were captured on the questionnaire based on the United States Centers for Disease Control and Prevention Updated Guidelines for Evaluating Public Health Surveillance Systems and the National MDSR Technical Guidelines [6,12]. Observation, another qualitative tool to collect data, was used to obtain information on the general condition of the health facilities and to determine the presence of bulletin boards, display of data (as summary tables, graphs, charts, or maps), and posters of the case definition of maternal death.

 

To evaluate the key quantitative attributes such as timeliness and data quality, we reviewed the MDSR reporting forms, Integrated Disease Surveillance and Response (IDSR) reporting forms, maternal death data from the DHIS2 system, and maternity clinical registers. We assessed data quality issues such as over-reporting and under-reporting by comparing the data in the clinic and department registers to the data entered in MDSR. The data was checked for duplicate entries and disordinate data and outliers. We conducted thematic descriptive analysis for qualitative data. Quantitative data were analyzed using Excel and results were expressed as frequencies and percentages.

 

Ethical considerations

 

Ethical clearance from an IRB was not sought because this evaluation was undertaken by staff from the Ministry of Health and Sanitation (MOHS) as part of their routine program activities. However, administrative permission was received from MOHS leadership prior to undertaking this evaluation. No personally identifiable information was disclosed to any party except the main investigator since only summary of the data was used to describe the operation and performance of the system. Data were stored for a minimum of five years in a password-protected computer. This project was also approved through the CDC project determination clearance process.

 

 

Operation of the Maternal Death Surveillance and Response System in Sierra Leone  

The Reproductive Health and Family Planni ng Program, under the Directorate of Reproductive and Child Health, coordinates and manages MDSR activities at the national level. At the district level, the DHMT monitors reporting patterns such as health care facilities that are not reporting. District Surveillance Officers (DSOs) and District Health Sisters (DHS) at DHMT receive and collate maternal death data and send them to the national level. The DSOs report aggregated notified maternal deaths with other notifiable disease data weekly to the national surveillance officers through the IDSR system, whilst the DHSs report case-based maternal death data monthly to the national MDSR coordinator through the MDSR system (Figure 2).

 

The MDSR system is a passive surveillance system that collects data on maternal deaths. Maternal deaths in the community are reported by community members to health facility staff and community health workers (CHWs) enter this data in MDSR. CHWs who are trained to use standard case definitions to identify and report notifiable diseases, conditions, or events in communities are attached to each peripheral health unit (PHU) in districts. When a maternal death is identified in the community, the CHW completes the screening and case notification forms and submits them immediately to the nearest health facility. The MDSR focal person then notifies the DHMT. Traditional birth attendants (TBA), community leaders (including traditional, religious or women´s group leaders), and adjunct informants also pass on information on suspected community maternal deaths to the CHWs, who immediately notify the nearest health facility (Figure 2).

 

Each hospital or PHU has a maternal death investigator (MDI) and MDSR focal points. Maternal deaths occurring in health facilities and communities are notified to the district (DHMT) within 24 and 48 hours, respectively. When the district is notified, the district maternal death investigation team (comprising the MDI, DHS, and DSO) immediately investigates the maternal death and collects all relevant information about the causes and circumstances that contributed to the death, through interviews and review of documents. They also notify the national level as well. The DHMT reviews maternal death reports and gives regular feedback to the lower levels.

 

The maternal death review committee (District Medical Officer, DHS, Medical Superintendent, Hospital Matron, Hospital Pharmacist, Birth & Death Registrar, DSO, M&E officers, Head of the Maternity ward, Council and CHO in charge of the affected Chiefdom and Community Leader) examine the investigation records to determine the medical and non-medical causes of death, contributing factors and preventability. The review findings lead to immediate actions to prevent future deaths from a similar cause in health facilities and in communities. Feedback is provided to reporters where maternal death data was collected using language and dissemination methods tailored to target audiences. Monitoring and evaluations are being done to improve the timeliness, quality and completeness of the information and ensure that the main steps of the system work adequately and improve with time. The monitoring of the MDSR system is carried out primarily at the national level (Figure 2).

 

System attributes

 

Usefulness

 

Sixty-one percent (22/36) of the participants responded they were using the MDSR data for various purposes. Of which, 100% (22/22) used it for capturing maternal mortality statistics, 82% (18/22) to make an informed decision, and 68% (15/22) to monitor the performance of public health interventions. In addition, 55% (12/22) used the data to determine the causes and prevention of maternal deaths, and 14% (3/22) for research purposes (Figure 3). Fifteen out of the 36 respondents (42%) had taken public health actions based on MDSR data which included intensifying the health education campaigns and community awareness, and installation of ambulances for emergency response, especially for hard-to-reach areas. Minutes, audits, and annual reports were available, which were shared with the relevant stakeholders for decision-making.

 

Simplicity

 

The MDSR system involves multiple levels of reporting, and every pregnancy-related death requires thorough investigation to confirm if it a true maternal death. Among the 21 health facility staff interviewed, 52% (11/21) reported they had recorded a maternal death at their facility and filled out the notification form. Of those, 64% (7/11) said it took them 10-15 minutes to fill out the form, while 36% (4/11) took 16-20 minutes. Additionally, 27% (3/11) of the staff who acknowledged identifying a maternal death and completing the notification form were directly observed while filling out the form. They took an average of 14 minutes to complete the form. Almost all health personnel (91%, 19/21) felt that training was necessary for completion of the maternal death notification forms and understanding the standard operating procedures (SOPs) of the MDSR system, particularly for new staff. Both national and DHMT respondents noted that poor data quality, including inconsistent and misspelt variables, made it difficult to manage and analyze the MDSR data.

 

Acceptability

 

All respondents reported that it was their duty to notify maternal deaths and they were willing to continue participating in the MDSR system. All DHMT participants stated that findings of the MDSR data reviewed are being shared with the relevant stakeholders. One-third of the respondents (33%, 12/36) held regular MDSR meetings.

 

Stability

 

All health facilities visited (12) had standard case definition posters on the walls of their consultation rooms. All health facilities had at least one health worker trained on MDSR but only 50% (6/12) of health facilities had adequate notification forms on-site. All health facility staff (21) use cell phones or IDSR tablets to submit data and communicate with the DHMT. However, there were some challenges such as access to computers, printers, and mobile internet connectivity in most of these facilities. Only 25% (3/12) of health facilities had the Sierra Leone MDSR SOPs and technical guidelines on site. Community health workers had been trained on the need to identify and report maternal deaths in the community to the health facility.

 

Timeliness

 

Eighty-six percent (31/36) of health workers knew that maternal deaths notification in health facilities should be reported within 24 and community deaths within 48 hours. Of the 588 maternal deaths recorded in 2018, 466 had a date of notification to the DHMT, with 458 (78%) having both the date of death and notification. Sixty-three percent (282/458) of the health facility deaths were notified within 24 hours, while 64% (49/76) of community deaths were notified within 48 hours. The overall timeliness of reporting was 76% (350/458). Of the 588 maternal deaths, 494 (84%) were reviewed by the maternal deaths review committee, but the date of review was available only for 374 (76%). Of these, 41% (153/374) were reviewed within one month, 54% (203/374) reviewed after one month.

 

Data quality

 

In 2018, a total of 588 maternal deaths were reported through the MDSR system, while 86% (504/588) were recorded in DHIS2 through the IDSR system (Table 1). Seventy-six percent (447/588) of these deaths occurred in health facilities, 11% (65/588) in transit to a health facility, and 13% (76/588) in the community. Among the 588 line-listed maternal deaths, the percentage of variables with incomplete data (such as age, place of residence, specific cause of death, contributing factors, outcome of delivery, and date of maternal death notification) ranged from 0% (for epidemiological week of death, district of death, district of residence, and place of maternal death) to 71% (for contributing cause of death) (Table 2). Completeness of report for key variables from documents reviewed was 89.9% (719/800). Furthermore, of the 466 maternal deaths with a notification date to the DHMT, 4% (19/466) had a notification date that preceded the actual date of death. Additionally, 18 cases (5%) had the review date listed before the notification date.

 

Maternal Death Surveillance and Response System Performance Indicators Sierra Leone, 2019

 

All indicators assessed at the national level were met except that the National MDSR committee does not meet regularly, there are delays in timely reporting from the district to the national level, also low percentage of annual reports being produced at district level and some hospitals lack a review committee at the facility level (Table 3).

 

 

This study evaluated the MDSR system in Sierra Leone. We assessed the system´s operation, key attributes and performance indicators The MDSR system collects and analyzes maternal death data, and uses it to take action to minimize preventable maternal deaths. The system was found to be useful, producing annual reports that influenced public health actions such as the installation of the National Emergency Management System (NEMS). While most national-level MDSR indicators were met, challenges persist in regular committee meetings, timely district-to-national reporting, district-level annual reporting, and establishing review committees in some hospitals. Despite these challenges, the system contributes to reducing maternal mortality through data-driven decision-making and targeted interventions.

 

According to our findings, the MDSR data were used for multiple purposes, such as capturing maternal mortality statistics, making an informed decision, and monitoring the performance of public health interventions. These results are similar to the findings of a maternal mortality surveillance system evaluation in Zimbabwe, 2017 [13]. Although the system requires multiple levels of reporting, respondents felt that filling out the forms was simple which implies that the death notification form is user-friendly, and it needs to be maintained in its current condition. Though the form is simple to fill out, there are several variables commonly missed which could be attributed to lack of knowledge among the staff on the importance of the variables. Moreover, all health workers felt that they needed training for new staff since some of the trained members had been transferred to other health facilities, some left for further studies, and some to greener pastures. This is of utmost importance as training greatly influenced the running of the system [14].

 

Even though all respondents interviewed reported that it was their duty to notify maternal deaths and were willing to continue participating in the MDSR system, the proportion of facility based maternal deaths notified to the district within 24 hours of death is below the national target of above 90%. This shows that although the willingness of staff to participate in a surveillance system is crucial in achieving the system´s goals, it is important to further review the factors which led to late notification of deaths. Our findings are consistent with findings reported from Zimbabwe in 2017, which also found that all health workers participated and were willing to continue participating in the Maternal Mortality Surveillance System (MMSS) [13]. The study also found that the notification of maternal deaths within 24 hours and 48 hours for both facility and community deaths, respectively, was below the WHO and Sierra Leone national targets of >90% (for facility-based deaths) and >80% (for community-based deaths). These findings are similar to the findings reported by Ayele et. Al., in Ethiopia where maternal death notification was not made within the required24 hours for 82.2% of the health posts [15]. Timely reporting and notification of maternal deaths are of utmost importance, as it increases the accuracy of the information and adds value to the surveillance system and initiates corrective actions. Additionally, the percentage of notified maternal deaths that the district reviewed was also below the WHO and national targets of >90%. Furthermore, only one of the three hospitals visited had a review committee, but was not functional. According to the Sierra Leone MDSR technical guidelines, each referral hospital and district-level hospital should set up committees and perform monthly reviews [1]. This is of concern as maternal death reviews at the facility level ensure the report´s completeness and accuracy, which help district review committees in determining causes of death, avoidable conditions, and associated factors, and offer actions to prevent future deaths from a similar cause.

 

Our study also found that the MDSR system was unstable. Although all health facilities had access to reporting through cell phones and IDSR tablets, some facilities have difficulty due to poor mobile network resulting delays in the transmission of data to the DHMT. Furthermore, some of the health facilities visited did not have maternal deaths notification forms, MDSR standard operating procedures, and technical guidelines on site at the time of data collection. A study conducted in Guinea had similar findings where some health facilities did not have maternal death notification forms [16]. Also, the DHMT and district health facilities visited had challenges with computers and printers. The inaccessibility of functional computers and printers, MDSR guidelines, and notification forms may also affect the system´s stability.

 

Our study revealed that while most maternal deaths in 2018 occurred in health facilities, 13% were reported from the community. There is a probability that more maternal deaths occur in the community, but they are not captured due to the lack of a functional system to identify and report maternal deaths in the community [16]. These deaths may be missed and lead to maternal death under-reporting and lost opportunity to take corrective action to prevent mothers from dying in the community. Sierra Leone is using a passive surveillance system to report maternal death which is prone to miss some maternal deaths, especially at community level. Therefore, enhancing active case search especially at the community levels is key to minimize unreported maternal deaths. The MDSR could function well if all maternal deaths are identified, notified, and reviewed, so we can understand the causes of maternal death and take corrective measurements [17].

 

Our study found that the MDSR system reported more maternal deaths compared to the IDSR system in 2018. may be due to the way the two systems report maternal deaths. Although the MDSR reports maternal deaths in both private and public health facilities, the IDSR captures MDs mainly in public facilities and very few in private facilities. The discrepancy in MD reporting between the MDSR and IDSR systems could result in underreporting in certain sectors, especially if private facilities are underrepresented in the IDSR. This gap indicates the need for system integration and data interoperability across both public and private health facilities. furthermore, our study observed missing data for many variables including place of residence, the specific cause of death, the contributory cause of maternal death, other contributing factors, the outcome of delivery and the date of notification of maternal death, especially for the Western Area Urban District. Missing data for critical variable - such as place of residence and specific cause of death - compromises the utility of the data in identifying high-risk areas and specific maternal mortality risk factors. Additionally, data entry errors were also identified as there were entries with the date of review of maternal death review before the date of death notification and the date of death notification before the date of actual maternal death. The incorrect sequencing of death and notification dates, can distort the accuracy of reporting and analysis, leading to flawed insights and delayed response.

 

One limitation of this study was that our analysis was constrained by incomplete data in some of the records, this incompleteness potentially limited the comprehensiveness of our analysis, as we may have missed valuable information that could have further informed our findings. However, we objectively evaluated some attributes that provide useful information on the performance of the MDSR system in Sierra Leone. This current evaluation was also done in three districts which cannot provide representative data for the whole country.

 

 

The MDSR system shows moderate stability and acceptability, partially meeting its objectives. However, the system is relatively complex, contains some variables with missing data, and timeliness and completeness of reporting below the national target. Even though the system did not meet its target for all the performance indicators, the system produces data for informing corrective public health actions. Poor mobile network connectivity, especially in rural areas, lack of active case search in the community, and poor data quality, were key challenges facing the MDSR system. To enhance the MDSR system's effectiveness, we recommend to distribute of MDSR SOPs and technical guidelines to all health facilities, provide on-the-job training for healthcare workers on data entry protocols and quality checks, establish regular national MDSR committee meetings, improve timeliness and completeness of reporting, increase district level annual reporting, and ensure functional review committees in all hospitals.

 

 

The authors declare no competing interest.

 

 

Kadijatu Nabie Kamara, Adel Hussein Elduma, Gebrekrstos Negash Gebru, James Sylvester Squire, Joseph Sam Kanu: Conception and design, acquisition of data, or analysis and interpretation of data, drafting the article, revising the manuscript critically for important intellectual content and final approval of the version to be published.

 

 

We thank and appreciate Dr. Alden Henderson, US CDC, for his technical, emotional, and intellectual input in designing the concept note, guiding the data collection, analysis and writing, editing, and proofreading this manuscript. We are also grateful to the Sierra Leone Ministry of Health, District Health Management Teams in Western Area Urban, Bonthe, and Kenema districts, and the Sierra Leone Field Epidemiology Training Network.

 

 

Table 1: Comparison of MDSR and IDSR systems´ maternal deaths data, Sierra Leone, 2018

Table 2: Data completeness of the maternal death surveillance and response system, Sierra Leone, January - December 2018

Table 3: Maternal deaths surveillance and response system, Sierra Leone performance indicators assessed, 2019

Figure 1: Districts in dark red are where we evaluated the Maternal Death Surveillance and Response Surveillance System, Sierra Leone, 2018.

Figure 2: Maternal Death Surveillance and Response System operation, Sierra Leone, 2019

Figure 3: Uses of maternal deaths data, Sierra Leone, 2019

 

 

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