Vital Statistics in Midwifery, Bachelor of science in nursing (1).pptx

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1. Vital Statistics in Midwifery Vital Statistics By the end of the session the learner will be able to: Define vital statistics Identify definition of terms used in vital statistics Discuss situational analysis of maternal and infant mortality-rates and causes Explain documentation in midwifery Describe maternal audit-verbal autopsy Definition - Vital statistics -   statistics relating to births, deaths, marriages, health, and disease . Definition by the United Nations Vital statistics is the total process of (a) collecting information by civil registration or enumeration on the frequency or occurrence of specified and defined, as well as relevant characteristics of the events themselves and the person or persons concerned,

2. Vital Statistics in Midwifery and (b) compiling, processing, analyzing, evaluating, presenting, and disseminating these data in statistical form Civil registration is defined by the United Nations as the" continuous, permanent, compulsory, and universal recording of the occurrence and characteristics of vital events ( live births, deaths, fetal deaths, marriages, and divorces) and other civil status events pertaining to the population as provided by decree, law or regulation, in accordance with the legal requirements in each country . Another Def : Civil registration is an administrative system used by governments to record vital events which occur in their populations . Efforts to improve the quality of vital statistics will therefore be closely related to the development of civil registration systems in countries

3. Vital Statistics in Midwifery For instance, the importance of birth registration as the first legal recognition of the child is emphasized in Article 7 of the Convention on the Rights of the Child which states that "the child shall be registered immediately after birth and shall have the right from birth to a name, the right to acquire a nationality and, as far as possible, the right to know and be cared for by his or her parents". . United nations children's fund  (UNICEF) and a number of non-governmental organizations (Plan International, Save the Children Fund, World Vision, etc.) have particularly promoted the human rights aspects of registration while the United Nations Statistics Division (UNSD),  United Nations Population Fund  (UNFPA) and World Health Organization (WHO) have focused more on the statistical aspects of civil registration .

4. Vital Statistics in Midwifery Convention on Rights of the Child Countries which are signatories to the Convention on the Rights of the Child are therefore expected to set up systems to register the births of all children . Non-registration of a child can have negative consequences on the wider enjoyment of a child’s fundamental rights to benefits such as identity, inheritance, education, health and other social services.  Birth registration is also part of a broader strategy to ensure that children are less vulnerable to abuse and exploitation, especially if separated from their parents. In the absence of a functioning birth registration system, it is difficult to see how a country can enforce age-related legal concerns such as schooling, child labour, juvenile justice, early marriage, sexual exploitation and military recruitment

5. Vital Statistics in Midwifery   Recent natural disasters and calamities have also demonstrated the utility of a birth certificate for reuniting lost children with their families . Records of death and cause of death Many civil registration systems also collect information on causes of death. Statistics based on these death records are of particular importance in public health for identifying the magnitude and distribution of major disease problems, and are essential for the: design i mplementation monitoring and assessment of health programmes and policies.

6. Vital Statistics in Midwifery Global health records Despite the importance of tracking causes of death and the tradition since 1893 of standardization of definitions and coding for causes of death in the International Classification of Diseases and Injuries (ICD), global assessments of causes of death are a major analytical challenge Vital registration systems that include medical certification of the cause of death captured about 18.8 million deaths of an estimated annual total   of 51.7 million deaths in 2005, which is the latest year for which the largest number of countries reported deaths from a vital registration system. Even for these deaths , the comparability of findings on the leading causes of death is affected by variation in certification skills among physicians, the diagnostic and pathological data available at the time of completing a death certificate,

7. Vital Statistics in Midwifery variations in medical culture in choosing the underlying cause, and legal and institutional frameworks for governing mortality reporting. For the remaining deaths that are not medically certified, many different data sources and diagnostic approaches must be used from surveillance systems, demographic research sites, surveys, censuses, disease registries, and police records to construct a consolidated picture of causes of death in various populations. Because of the variety of data sources and their associated biases, causes of death assessments are inherently uncertain and subject to vigorous debate. Vital statistics in Kenya A well developed and functioning civil registration system ensures the registration of all vital events including births, marriages and deaths and issues relevant certificates as

8. Vital Statistics in Midwifery proof of such registration . Civil registration promotes: efficient government planning effective use of resources and aid and more accurate monitoring of progress towards achieving the Sustainable Development Goals . Registrars have been appointed for each local area under Section 7 of the RBD Act, 1969 for registration of births and deaths occurring in their jurisdiction.   The law governing registration of births/deaths in Kenya is known as  the Births and Deaths Registration Act Cap . 149 Laws of Kenya. It came into force in l928  . In respect of births and deaths in a hospital, health center, maternity or nursing home or other like institutions, responsibility of informing the events to the registrar is by the Institution as per Registration of Birth and Death Act, 1969. ( See the attached Caps 149 laws of Kenya)

9. Vital Statistics in Midwifery Issuance of Birth Certificate A Birth Certificate provides proof that one is a Kenyan Similarly it is required by pupils and students applying to sit for their National Examinations Useful when applying for a National Identification Card when one turns 18 Used in application for a Kenyan passport when in need to travel out of the country   Application for birth Certificate can be done at any Huduma Centre countrywide or Civil Registration Department offices near you.

10. Vital Statistics in Midwifery Requirements for a Birth Certificate include the following; 1. Birth notification 2. ID's for both parents/Death Certificate if parents are deceased Persons who qualify for this service include: 1. Parents/ guardians of a newly born baby 2. Rescue centers/ children’s homes taking charge of the child Current Cost : Birth certificate with no amendments - Ksh 60 Birth certificate with amendments on the child's names - Ksh 100 Birth certificate with amendments on the parent's names - Ksh 100 Birth certificate with amendments on the child's and parent's names-Ksh 140 Timelines: 10 days

11. Vital Statistics in Midwifery Late registration of birth requirements Clinic Card. Parents Original ID Card/Passport/Births Certificate. Additional Documents may be requested e.g Antenatal records or letter from Lawyer or Chief . Components of Vital Statistics Vital statistics involves: Quantities and rates of births, Important characteristics of births, such as births by sex, location and maternal age , Deaths by essential characteristics such as age, sex, location and cause of death

12. Vital Statistics in Midwifery Vital statistics comprises a number of important events in human life including  birth, death, fetal death, marriage, divorce, annulment, judicial separation, adoption, legitimation, and recognition . The term “vital statistics” is also applied to individual measures of these vital events . They are compilations of data on marriage, divorce, birth, and death. Births and deaths directly determine changes in the size of a population Marriages and divorces create and dissolve, respectively, the conditions under which most births occur . Importance of vital statistics Provide insight into important trends in health, including the impact of changes in the incidence of non-medically indicated cesarean deliveries

13. Vital Statistics in Midwifery Number of deliveries, their outcome and preterm birth, chronic conditions, progress on reducing deaths due to motor vehicle accidents, and the evolving challenge of substance abuse . Key vital statistics Birth data. Mortality data. Fetal death data. Linked birth and death data . Marriages and divorces. National Maternal and Infant Health Survey. National Mortality Follow back Survey Methods of data collecting in Vital statistics Vital statistics is accumulated data gathered on live births, deaths, migration, foetal deaths, marriages and divorces.

14. Vital Statistics in Midwifery The most common way of collecting information on these events is through civil registration   Civil registration is an administrative system used by governments to record vital events which occur in their populations . Efforts to improve the quality of vital statistics will therefore be closely related to the development of civil registration systems in countries. Civil registration followed the practice of churches keeping such records since the 19th century . Methods of vital statistics data collection While the number of births and deaths can be obtained by enumeration at certain points in time (e.g. censuses and surveys), civil registration collects this information on a continuous basis and is the only source that provides individuals with a legal document.

15. Vital Statistics in Maternal death and Neonatal Health Definitions in Vital Statistics: Maternal death: death of a woman while pregnant, or within 42 days of termination of pregnancy, from any cause related to, or aggravated by, the pregnancy or its management, but not from accidental or incidental causes . Types of Maternal Death Direct Indirect Coincidental (Fortuitous ) Direct deaths: resulting from obstetric complications of the pregnant state (pregnancy, labour and puerperium) , from interventions, omissions, incorrect treatment or from a chain of events resulting from any of the above (e.g. death from major postpartum haemorrhage in a previously well woman ).

16. Vital Statistics in Midwifery A suspected maternal death is defined here as the death of any woman while pregnant or within 42 days of the termination of pregnancy This is reported so because in many settings, a pregnancy is not confirmed until the second trimester or until it is physically evident. Therefore, any death where there is a suggestion of a pregnancy should be notified as a suspected maternal death Maternal deaths often indicate weaknesses in the health-care system.

17. Vital Statistics in Midwifery Indirect deaths: resulting from previous existing disease, or disease that developed during pregnancy and was not due to direct obstetric causes, but was aggravated by the physiologic effects of pregnancy (e.g. death from a cardiac lesion). Late deaths : occurring between 42 days and 1 year after abortion, miscarriage or delivery that are due to direct or indirect maternal causes. Coincidenta l (fortuitous) deaths : from unrelated causes that happen to occur in pregnancy or the puerperium (e.g. road traffic accident) Vital statistics in obstetric/midwifery Maternal mortality rate Maternal mortality ratio Perinatal mortality C onception rates Fertility Rates Birth Rates

18. Vital Statistics in Midwifery Infant Mortality Rates Maternal Mortality Rate The WHO, defines the maternal mortality rate as the number of maternal deaths per women of reproductive age . Conception rates Conception statistics include pregnancies that result in one or more live births, stillbirths or a legal abortion. They do not include miscarriages or illegal abortions . These relate to women of childbearing (age 15–44 years old), who could give birth in any year Fertility rates The General Fertility Rate (GFR) equates to ‘ . . . the number of children per 1000 women born to a population or sub-population’. For example, a GFR of 56 in 2007 for the UK means that for every 1000 women of childbearing age in the UK, 56 babies were born.

19. Vital Statistics -Situational analysis Situational analysis maternal and neonatal , infant mortality rates. Kenya current info on MMR The maternal mortality rate is 414/100,000 live births, with only 42 percent of births attended by skilled health-care personnel while 53 percent attend antenatal care at least four times Given the current annual births, this means that there are nearly 5000 women and girls dying annually due to pregnancy and childbirth complications. Current report as per region. Region Per 100,000 live births North Eastern 2000 Nyanza 546 Eastern 400 Rift valley 377 Central 287 Nairobi 212

20. Maternal Mortality Rates However, despite reports as shown in the table in addition. Mandera County has the most alarming level at about 3,800 deaths per 100,000 live births followed by Wajir (1,683), Turukana (1,594) and Marsabit (1,127). The other counties with an MMR above the national average are mainly from Coast and Nyanza regions.

21. Of the 47 counties in the country, fifteen contribute to 98 per cent of maternal mortality in the country. Among those,  Turkana County  faces challenges and barriers in reporting maternal and perinatal mortality data in the Kenya Health Information System (KHIS ). According to the just concluded Kenya demographic health survey of 2022, the report indicted that: At the county level, the proportion of live births delivered by a skilled provider is lowest in Turkana (53%), Mandera (55%), Wajir (57%), Samburu (57%), and Tana River (59%)

22. Vital Statistics in Midwifery Kenya Maternal Mortality Rate - Historical Data Year Per 100K Live Births Annual % Change 2017 342.00 -1.16% 2016 346.00 -1.98% 2015 353.00 -1.40%

23. Vital Statistics in Midwifery The top 3 contributors to maternal mortality Infections Blood pressure disorders of pregnancy, including preeclampsia and eclampsia.  Complications of labor and delivery. (Report of 14 May 2020). Causes of maternal death are classified as: Direct Indirect Maternal Deaths

24. Vital Statistics in Midwifery Causes of Direct and Indirect Maternal Deaths: Direct Deaths : Thrombosis and thromboembolism Hypertensive disease Haemorrhage Sepsis Amniotic fluid embolism Ectopic pregnancy Spontaneous miscarriage Legal termination of pregnancy Genital tract trauma Anaesthesia Fatty liver Indirect deaths : Cardiac disease Psychiatric disorder Other indirect causes Indirect malignancies

25. Vital Statistics in Midwifery Definition of other terms; Neonatal deaths - neonatal death under 28 days. Live birth refers to a baby born, showing spontaneous signs of life after birth regardless of gestational period (WHO 2013). Perinatal Mortality comprises of: Stillbirth Early neonatal death Late neonatal death

26. Vital Statistics in Midwifery Definitions Stillbirth : ( SB )any fetus born with no signs of life after 24 weeks of gestation . Of particular importance in the definition is that it is delivery of the baby which dates the stillbirth and not the point in the pregnancy at which the baby was known to die Early neonatal death (END): death in the first week after birth. END rate = death in the 1st week of life ×1000live births Perinatal death : all stillbirth plus death in the first week after birth. Perinatal mortality rate (PMR): the number of stillbirths and early neonatal deaths per 1000 live births and stillbirths.

27. Vital Statistics in Midwifery PMR = END + stillbirth ×1000 PMR is widely used as an indicator of the quality of obstetric care and enables comparisons to be made among nations, regions and indeed individual hospitals. Late fetal loss : deaths occurring between 20+0 weeks and 23 weeks+6 days. If gestation is not sure, all birth of at least 300g are reported.   Late neonatal death: (LND) death of a neonate from age 7 days to 27 completed days of life. Post neonatal death : death of a baby at age 28 days and over, but under 1 year . Infant death : death at age under 1 year but born alive . Infant deaths therefore include early and late neonatal death and post-neonatal death .

28. Vital Statistics in Midwifery Rates of neonatal and infant death are expressed as rates per 1000 live births (while late fetal loss rate, stillbirths rate and PMR is per 1000 live and stillbirth ) Classification of Perinatal Mortality causes Fetal abnormality Preterm delivery Intrauterine growth retardation Unexplained intrauterine death Antepartum haemorrhage Maternal hypertension Intrapartum asphyxia Infection Trauma Hemolytic disease

29. Vital Statistics Infant mortality rate in Kenya The statistic shows the infant mortality rate in Kenya from 2010 to 2020. In 2020, the infant mortality rate in Kenya was at about  31.2 deaths per 1,000 live births . The infant mortality rate for Kenya in 2021 was  32.913 deaths per 1000 live births , a 3.36% decline from 2020 . The current infant mortality rate for Kenya in 2022 is 31.771 deaths per 1000 live births, a 3.47% decline from. 2021 In 2020, child mortality rate for Kenya was  41.9 deaths per 1,000 live births . Child mortality rate of Kenya fell gradually from 147.3 deaths per 1,000 live births in 1971 to 41.9 deaths per 1,000 live births in 2020. The current birth rate for Kenya in 2022 is  27.667 births per 1000 people , a 1.1% decline from 2021. The birth rate for Kenya in 2021 was 27.976 births per 1000 people, a 1.1% decline from 2020.

30. Vital Statistics Infant mortality rate in Kenya Common causes of neonatal mortality include:   pre-term birth complications, intrapartum growth restrictions, infections such as tetanus low birth weight congenital malformations and neonatal sepsis among other factors In addition, there exists a relationship between maternal health and neonatal survival Leading causes of child mortality Globally infectious diseases including pneumonia, diarrhoea and malaria, along with pre-term birth complications, birth asphyxia

31. Vital Statistics Infant mortality rate in Kenya and trauma and congenital anomalies remain the leading causes of death for children under five The first 28 days of life – the neonatal period – is the most vulnerable time for a child's survival. Children face the highest risk of dying in their first month of life at an average global rate of 17 deaths per 1,000 live births in 2020, down by 54 per cent from 37 deaths per 1,000 in 1990. Be on the look out of these dangers signs in newborns Wheezing , grunting, or whistling sounds while breathing. Odor, drainage, or bleeding from the umbilical cord. Yellow coloring of the eyes, chest, or extremities. Crying, irritability, or twitching which does not improve with cuddling and comfort.

32. Vital Statistics Infant mortality rate in Kenya How can we prevent infant mortality? Are there ways to reduce the risk of infant mortality? Preventing Birth Defects. Addressing Preterm Birth, Low Birth Weight, and Their Outcomes. Getting timely Pre-Pregnancy and Prenatal Care. Creating a Safe Infant Sleep Environment . Using Newborn Screening to Detect Hidden Conditions. Universal Immunization Programme (UIP): vaccination protects children against many life-threatening diseases such as Tuberculosis, Diphtheria, Pertussis [whooping cough], Polio, Tetanus, Hepatitis B and Measles

33. Vital Statistics Infant mortality rate in Kenya What is the difference between infant and child mortality In demography, child mortality refers to the death of children under the age of five while infant mortality refers to the death of those under the age of one year. What is it called when a baby dies in their sleep ? Sudden unexpected infant deaths include:   Sudden infant death syndrome (SIDS)- Accidental suffocation in a sleeping environment, and other deaths from unknown causes.

34. Vital Statistics neonatal mortality rate in Kenya Neonatal mortality rate Def : Neonatal mortality rate is the number of neonates dying before reaching 28 days of age, per 1,000 live births in a given population. In 2020, neonatal mortality rate for Kenya was 20.5 deaths per 1,000 live births. Neonatal mortality rate of Kenya fell gradually from 38.6 deaths per 1,000 live births in 1971 to 20.5 deaths per 1,000 live births in 2020. Causes Preterm birth  has been reported to be the leading cause of neonatal death [1,2,3,4,5]. Infants born preterm are four times more likely than term infants to die during the neonatal period (first 28 days) and infancy (first year The Pie chart next slide shows the Causes of preterm and low birth weight neonatal mortality in Kenya Published: 29 July 2021

35. Vital Statistics neonatal mortality rate in Kenya The World Health Organization (WHO) estimates that 15 million babies are born preterm annually and approximately one million succumb to death in their first 4 weeks of life due to complications of prematurity

36. Vital Statistics neonatal mortality rate in Kenya   Mortality rates increase proportionally with decreasing gestational age or birth weight. Preterm babies born in developed countries have almost ten times better survival rates compared to those born in low-resource settings Common causes of neonatal mortality include: Pre-term birth complications, Intrapartum growth restrictions Infections such as tetanus Low birth weight Congenital malformations Neonatal sepsis among other factors.

37. Vital Statistics neonatal mortality rate in Kenya However, reports indicate that the three main causes of neonatal mortality are: Preterm birth Intrapartum-related complications (birth asphyxia or inability to breathe at birth) Infections and birth defects 

38. Maternal and Perinatal Death Surveillance and Review Introduction: In 2015, the Ministry of Health and Sanitation with the support of the World Health Organization and other partners developed  national Maternal Death Surveillance and Response  (MDSR) guidelines that led to the establishment of national and district level MDSR committees nationwide Maternal and Neonatal Death Review (MNDR) is an evidence-based in- tervention that first examines causal factors, either medical or social, and follows up with appropriate actions to reduce maternal and neonatal deaths. Surveillance of maternal deaths involves the : Systematic collection Collation Analysis , interpretation

39. Maternal and Perinatal Death Surveillance and Review and dissemination of all information related to maternal deaths Maternal and Perinatal Death Surveillance and Response (MPDSR) MPDSR systems provide information on the magnitude of and factors leading to these deaths, with the aim of identifying preventable actions to avoid further mortalities It constitutes a quality improvement approach to identify how many maternal deaths occur , what are the underlying causes of death and associated factors how to implement actions to reduce the number of preventable stillbirths and maternal and neonatal deaths.

40. Maternal and Perinatal Death Surveillance and Review This requires a coordinated approach, ensuring both national- and co-level stakeholders are enabled and supported and can implement MDSR in a “no name, no blame” environment . Brief report on experiences and challenges faced by maternal death assessors and Ministry of Health representatives in implementing MDSR. Challenges encountered included : Underreporting of data Difficulties with reviewing the data Suboptimal aggregation of data on cause of death To ensure progress toward a full national enquiry of all maternal deaths , recommendations were made as follows

41. Maternal and Perinatal Death Surveillance and Review Improving the notification of maternal deaths Ensuring regular audits and feedback at referral hospitals Strengthening community linkages with health facilities to expedite maternal death reporting  Ultimately, both a top-down and bottom-up approach is needed to ensure success of an MDSR system Maternal Death Verbal Autopsy and Audit Verbal autopsy (VA) is  a method of determining individuals' causes of death and cause-specific mortality fractions in populations without a complete vital registration system . Functions of VA Is a practical method for determining probable causes of death at the population level in places where systems for medical certification of cause of death are weak.

42. Vital Statistics in Midwifery VAs are written records of the events leading up to a person's death, collected by interviewing the family of the deceased , In situations where there was no physical autopsy and the cause of death was not determined by a physician . Purpose The purpose of an autopsy is two-fold: 1)  T o thoroughly evaluate the presence and extent of human disease in patients  and 2 ) T o evaluate the effectiveness of therapeutic procedures for the benefit of patient families , staff , and the future practice of medicine

43. Vital Statistics in Midwifery Interactive Autopsy Introduction. ... Step 1 - External Examination Step 2 - Internal Examination Step 3 - Viewing the internal organs Step 4 - Removal of the organs Step 5 - Removing the brain Step 6 - Examining the organs Importance Autopsies are diagnostic by nature, and  can help a family learn more information about the disease processes that caused a patient's demise . For example, an autopsy could identify an unknown primary cancer, or it can allow doctors to perform examinations that were not feasible when the patient was alive.

44. Vital Statistics in Maternal Death A maternal death review  provides an opportunity for health staff, family and communities to learn from a tragic – and often preventable - event . Maternal death reviews should be conducted as learning exercises that do not include blaming, finger-pointing or punishment For effective review of maternal death, there is guideline in existence which outlines the following: A) The process of reviewing a maternal death B) The requirements for reporting a maternal death

45. Process of Reviewing Maternal Death A) The process of reviewing a maternal death As seen earlier, maternal death is death of a woman while pregnant or within 42 days of the end of pregnancy, irrespective of the duration and the site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management, but not from accidental or incidental causes . Should each maternal death be reviewed ? Yes. Every maternal death that occurs within a refugee camp (of a refugee or a national), at home or at a referral health facility should be systematically reviewed What is the purpose of reviewing a maternal death? provides a rare opportunity for a group of health staff and community members to learn from a tragic – and often preventable - event. Is conducted as learning exercises that do not include finger-pointing or punishment

46. Process of Reviewing Maternal Death To improve the quality of safe motherhood programming to prevent future maternal and neonatal morbidity and mortality. What process should be used to review a maternal death? There are 2 main methodologies for reviewing maternal deaths that are relevant to a refugee setting: Community-Based Maternal Death Review / Verbal Autopsy Facility-Based Maternal Death Review Community-Based Maternal Death Review / Verbal Autopsy Definition : A method of finding out the medical causes of death and ascertaining the personal, family or community factors that may have contributed to the death of a woman who died outside of a medical facility

47. Process of Reviewing Maternal Death Requirements Cooperation from the family of the woman who died and sensitivity is needed in discussing the circumstances of the death Advantages: Provides means to arrive at medical cause of death when a woman dies at home Allows both medical and non-medical factors to be explored Provides the opportunity to include the family’s perspective on health services Disadvantages: Different assessors may arrive at different causes of death D eaths from indirect causes may be overlooked / underreported

48. Process of Reviewing Maternal Death Facility-Based Maternal Death Review Definition: A qualitative, in-depth investigation of the causes of and circumstances surrounding a maternal death at a health facility; the death is initially identified at the facility level but such reviews are also concerned with identifying the combination of factors at the facility and in the community that contributed to the death, and which ones were avoidable Requirements: Cooperation from those who provided care to the woman who died, and their willingness to report accurately on the management of the case Advantages : Is a well-understood process in some settings Allows for complete review of medical aspects

49. Process of Reviewing Maternal Death Provides a learning opportunity for all staff, and can stimulate improvements to medical care Disadvantages: Requires committed leadership at the facility level Does not provide information about deaths occurring in the community A 3rd, additional methodology for improving safe motherhood programs is optional for country programs with the necessary capacity: “ Near Miss” Review Definition: The identification and assessment of cases in which a pregnant woman survives an obstetric complication; there is no universally acceptable definition for such cases and it is important that the definition used be appropriate to local circumstances to enable local improvements in maternal care

50. Process of Reviewing Maternal Death Requirements : Good-quality medical record system Management culture where life- threatening events can be discussed freely without fear of blame Commitment from management and clinical staff to act upon findings Advantages: A “near-miss” may occur more frequently than a maternal death it is possible to interview the woman herself during the review process , C an reduce the likelihood of future maternal deaths through quality improvement Disadvantages: Requires clear definition of severe maternal morbidity Selection criteria are required for settings with a high volume of life-threatening events

51. Process of Reviewing Maternal Death B) The Process of Reporting a Maternal Death Should each maternal death be reported? Yes. The accompanying report form (or a substitute format available in your location) should be completed electronically for each maternal death review and e-mailed (at minimum) to: The Sub-County Health Coordinator and The County Reproductive Health Officer, and Other relevant staff (e.g. IP Health Coordinator, other partner agencies, etc.) How do I complete the REVIEWERS section of the form? It is important to include multiple people in the process of reviewing a maternal death, regardless of whether the death occurred in the community or in a health facility.

52. Process of Reviewing Maternal Death Some examples of people you might want to include are : Relevant family members (sister, husband, boyfriend, parent(s), friend(s), etc.) Relevant health staff (TBAs, midwives, doctors, managers, coordinators, etc.) Relevant community leaders (religious, elders, women’s association, youth, etc.) How do I complete the INFORMATION sections of the form ? Fill in three sections (summary information, information on pregnancy, information on death) This allows the service provider to document basic information pertaining to the woman who died. additional factors specific to location of discussion during the review (e.g. the woman’s address, her religion, etc.) that do not need to be documented in the summary report.

53. Process of Reviewing Maternal Death How do I complete the SUMMARIZED HISTORY section of the form? This section summarizes the story of what happened It is intentionally open-ended so that one can include the immediate events surrounding different types of maternal deaths Some elements one might want to include (in both the review process and the report) are Timeline of relevant events that have not already been documented Summary of the interventions treatment provided prior to the death Relevant patient history not already documented

54. Process of Reviewing Maternal Death How do I complete the RELEVANT DELAY FACTORS section of the form? This section encourages one to review and document the relevant delay factors by using the Three Delay Model for maternal mortality. Remember that there may be important community-level factors related to a death in a health facility , factors related to a death just as there may be important facility-level in the community.

55. Process of Reviewing Maternal Death Some examples of direct causes of maternal death are : Ectopic pregnancy Eclampsia Sepsis Obstructed labour Antepartum hemorrhage Post-partum hemorrhage Abortion complications Anaesthetic complications Embolism

56. Process of Reviewing Maternal Death Some examples of indirect causes of maternal death are: : Anaemia Malaria HIV/AIDS Heart disease Substance abuse Substance abuse

57. Vital Statistics in Midwifery How do I complete the LESSONS LEARNED & ACTION TO BE TAKEN section of the form? This will likely be the most important component of maternal death review. After analyzing all of the relevant information, individuals involved need to agree on key lessons learned from the process and commit to action that will improve these areas in the future. It is important to consider lessons and action related to both the community and to the health facility.

58. Example of Formulation of Maternal Death Review Committees

59. Three Delays Model and our Integrated Approach The Three Delays Model and our Integrated Approach Maternity Worldwide uses an integrated approach to address each of the issues women face when trying to access safe childbirth. This is based on the Three Delays Model* which identifies three groups of factors which may stop women and girls accessing the maternal health care they need:

60. Three Delays Model and our Integrated Approach The "Three Delays" model proposes that pregnancy-related mortality is overwhelmingly due to delays in:  ( 1) deciding to seek appropriate medical help for an obstetric emergency ( 2) reaching an appropriate obstetric facility (3) receiving adequate care when a facility is reached .

61. Three Delays Model and our Integrated Approach 1: Delay in decision to seek care due to; The low status of women Poor understanding of complications and risk factors in pregnancy and when to seek medical help Previous poor experience of health care Acceptance of maternal death Financial implications 2. Delay in reaching care due to; Distance to health centres and hospitals Availability of and cost of transportation Poor roads and infrastructure Geography e.g. mountainous terrain, rivers

62. Three Delays Model and our Integrated Approach 2.   Delay in receiving adequate health care due to; Poor facilities and lack of medical supplies Inadequately trained and poorly motivated medical staff Inadequate referral systems END END Thank you for your participation END