Improvement of District-Level Maternal Mortality Reporting with - PDF document

Improvement of District-Level Maternal Mortality Reporting with Reproductive Age Mortality Survey (RAMOS) Joseph Adamako, Anthony Ofosu, Gloria Asare, Tiffany Anthony, Judy Idrovo, Bradley Iott, Andrea Momoh, Rachael Ward, Elisa Warner and Frank Anderson Abstract Objective :. To develop a process for community based maternal mortality surveillance in low resource settings. Methods : District health workers adapted the reproductive age mortality survey (RAMOS) to conduct maternal mortality surveillance among women of reproductive age (WRA) who died between June 2008 and June 2013. The survey was comprised of four simple yes or no questions with two follow up questions. A trained community health nurse conducted verbal autopsy to those women who answered positively to one of four questions. Maternal mortality review committees established the cause of death and contributing factors. Findings: 359 WRA died in the district during the specified time period. A “yes” answer to any of the 4 RAMOS questions identified 132 women who experienced either a maternal death, late maternal death or who died while pregnant or within one year of termination of pregnancy. In the resultant 108 available verbal autopsies, 59 died a maternal or late maternal deaths and 49 died a non-maternal death. The most common causes of maternal death, were hemorrhage (24%) and abortion (17%). Conclusions : The 4+2 RAMOS is a practical method for improving maternal mortality surveillance at the community level, increasing the maternal mortality ratio 158% (from 128 to 359). This study demonstrates that community based surveillance for maternal mortality amongst deaths to WRA is feasible in low resource settings. Increased ascertainment can uncover critical areas for intervention. Scale up to national community health training programs will provide accurate information for national efforts to reduce preventable maternal mortality.

Introduction: Accurate ascertainment of cases of maternal mortality is dependent on a health information system that accurately identifies and records cause of death. Because these systems are not available in some low income countries, estimates of maternal mortality based on survey methods, hospital records and fertility rates provide the data for decision making() The reproductive age mortality survey (RAMOS) has been used in a number of settings to increase ascertainment of maternal mortality (2,3). The RAMOS survey contains 39 questions and spans the many possible causes of mortality to women of reproductive age, some of which pertain to maternal death (4 who ramos instrument). The Ghana Maternal Mortality Survey, which utilized a RAMOS methodology in Accra at health facilities and morgues, found 44% under-reporting of maternal mortality ( 5 ). Community based surveillance for maternal mortality using a modified RAMOS survey was conducted in the Sene district of Ghana in 2010 (6). Ten questions were chosen from the RAMOS survey that were most likely related to maternal mortality and could be asked by community health workers to a family member where a woman of reproductive age (WRA) had died. A maternal mortality review committee investigated all cases with a positive answer to one of the 10 questions, and using the committee's determination of maternal death as the gold standard, 4 questions emerged as the most predictive: was she pregnant when she died?; was she recently pregnant?; did she have a child less than one year old when she died?; and did she die from miscarriage or abortion? (6) These 4 simple questions were found to have a high predictive value for detecting a maternal mortality. Additionally, in the year that community based surveillance for maternal mortality occurred, the number of maternal deaths almost doubled. A similar study in Eritrea showed similar results (3 ). Methods: This observational study was approved by the Ghana Health Service Ethical Review board and was reviewed by the University of Michigan Institutional Review Board and found to be exempt. Community-based health volunteers and sub-district nursing staff were trained by the Kuntanase Government Health Department in the RAMOS protocol and survey administration. The review of data took place between May 2013-August 2014. In May of 2013, trainers and community health workers discussed the most effective ways to ask the four central questions: if the deceased was pregnant at the time of death, if she was recently pregnant when she died, if she had a child less than one year of age, and if she had a miscarriage

or abortion. District staff also added 2 additional questions: did she die in a healthcare facility or at home, and do you know why she died? (RAMOS 4+2). Between May and August 2013, the community based surveillance volunteers and health nurses conducted the interviews in the local language, Twi, and elaborated on any questions that needed further explanations to get the final answer. The community health workers, also called Community Based Surveillance (CBS) workers, assisted in surveillance by identifying all WRA who died in the last five years. Small incentives were given for identifying the women’s families and debriefing them ahead of time as to the details of the RAMOS 4+2 methodology. In addition, the CBS workers attended a training meeting at the Kuntenase District Hospital for a full debriefing of the survey, project training, and a chance to pose questions regarding the material. Permission was asked of each family member whether or not they would participate, and no incentive was given to any interviewee. RAMOS results were available for 357 WRA who died during the period of review. 225 WRA were confirmed as non-maternal deaths as determined by RAMOS. 132 WRA were confirmed as possible maternal deaths by answering one of the first four questions positively. These deaths include maternal deaths, late maternal deaths, pregnancy- associated deaths up to one year. (Table 1) Thirteen families of WRA could not be located for interview or declined interview. Verbal Autopsy Following the administration of RAMOS surveys, community health nurses and midwives conducted verbal autopsies at households where positive answers to one of four indicative questions of the RAMOS survey was found. The verbal autopsy reviews the deceased woman’s regional demographics, obstetric history, hospital attendance, pregnancy preparedness, socio- cultural factors and a written conclusion (7). Upon completion of verbal autopsies, two maternal mortality review committees (MMRC) took place to evaluate and discuss the factors contributing to each death and to determine if the death was the result of a pregnancy complication, or issues that pertained to the pregnancy (maternal deaths or late maternal deaths). MMRCs are group of health professionals that come together and examine medical and technical aspects of care for women who have died. They then identified patterns of adverse outcomes related to non-medical and system related factors. MMRCs consisted of 10-11 participants; an OB/GYN, a pharmacist, midwives, and senior and entry level community health nurses. During the meeting, the RAMOS survey results and verbal autopsy interviews for each woman were analyzed. Definitions of maternal death, pregnancy related death, and late maternal death provided by the World Health Organization and the International Statistical Classification of Diseases and Related Health Problems, 10th revision (ICD-10) were utilized in determining whether the WRA’s death was of maternal causes (Table