Episode 2

full
Published on:

7th Mar 2023

Improving the Quality of Care Using Maternal Perinatal Death Surveillance and Response (MPDSR) in Kenya

In this mini-series, we are shining a spotlight on the programme Improving Quality of Maternal and Newborn Health. This is a UK funded programme by the Foreign Commonwealth and Development Office (FCDO), and it is led by the Liverpool School of Tropical Medicine.

In this episode, we focus on a maternal and perinatal death surveillance and response approach.

MPDSR is an essential approach to monitoring quality improvement for mothers and babies. From the programme featured in this episode, those involved have learned that, whereas most maternal deaths are audited and there has been an improvement in the proportion perinatal deaths audited, there is a need to assess whether the audits have informed quality of care improvement for both mothers and newborns.

Acting on the recommendation agreed upon during committee meetings has been found to be an essential component of the response cycle. Having intense follow-up visits, short and focused learning meetings with targeted health care workers, are more likely to produce positive results. A strong process for auditing maternal and perinatal deaths has been established during the programme but a system to objectively assess the ‘Response’ from the MPDSR process is still required.

Dr. Serem describes the MPDSR mechanism;

“MPDSR is one of the key components on checking the quality of care for the mothers and the newborns, and in our country, for the last four years through the support of LSTM, we have done a lot of things. One is setting up the national MPDSR committee, chaired by the Director General of the Republic from the Ministry of Health, Republic of Kenya. In Kenya, we have 47 subnationals, which we are calling them counties. These are like the small governments of Kenya. We've set up, the committees in all the counties.

These committees have been very instrumental because they have been looking at the causes of death. In a nutshell, assessing, reviewing, auditing, what went wrong? What are these events?

We have therefore been in a position to give feedback, strengthen their committees. Once you strengthen the committees, they learn a lot”

More about our guests:

Lucy Nyaga - Country Director, Liverpool School of Tropical Medicine, Kenya

Lucy is the Country Director, Liverpool School of Tropical medicine, in Kenya. She has a background in Medical Anthropology and Public Health with extensive experience in promoting implementation of research results into policy and practice with a special focus on maternal and neonatal health (MNH). With twenty years’ experience working in health programming, her experience and expertise in MNH has involved managing and implementing programmes that incorporate implementation research to inform effective programming and policy influence. Working with a range of organisations ranging from governments, academic and research institutions, UN agencies, and national & INGO, Lucy has led and contributed to key MNH research that has then led to policy influence in Eastern Africa.

Dr Edward Serem MBCHB, OB/GYN (UON) - Head, Division of Reproductive and Maternal Health, Ministry of Health, Kenya

Dr Edward Serem is an obstetrician gynaecologist and Head of the Division of Reproductive and Maternal Health Services, Ministry of Health, Kenya. Dr Serem has the overall responsibility of periodic National review of policies, guidelines, standard operating procedures, protocols, data analysis, research and technical assistance and building the capacity of health care workers at the sub-national level on reproductive health service provision. The Division played key roles in setting up the National MPDSR secretariat.

Dr Pamela Godia - Lecturer, Senior Technical Officer, Department Public and Global Health, University of Nairobi, Liverpool School of Tropical Medicine

Dr Pamela Godia is a public health specialist with vast experience in managing reproductive health programmes. Over the last five years Dr. Godia has been providing technical assistance to the National Ministry of Health Kenya in setting up a system of confidential enquiry in maternal deaths in Kenya and oversaw the production of the first ever Confidential Enquiry into Maternal Death (CEMD) report (2017) for Kenya. Dr. Godia has also overseen the production of the first National Annual Maternal and Perinatal Death Surveillance and Response Report for Kenya (2021).

Ms Wabwire Scolastica - Program Officer, Division of Reproductive and Maternal Health, Ministry of Health, Kenya

Wabwire Scolastica is a Field Epidemiologist with experience in disease surveillance, monitoring and evaluation and project management. Scolastica has an MSc. Field Epidemiology and MSc. Nursing Education. She has over 15 years’ experience as a nursing professional. Scolastica plays a leading role in coordinating Maternal and Perinatal Death Surveillance and Response (MPDSR) activities at the national level and sub-national in addition to overseeing the implementation of Maternal Newborn Health Quality of Care Standards, Research and Learning through capacity building at both national and sub-national levels. Scolastica is also responsible for reproductive health data management at national and sub-National levels.

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Transcript
Kim Ozano:

Hello, and welcome to our brand new mini-series.

Kim Ozano:

In this mini-series, we are shining a spotlight on the programme Improving Quality of Maternal and Newborn Health.

Kim Ozano:

This is a UK funded programme by the Foreign Commonwealth and Development Office (FCDO), and it is led by the Liverpool School of Tropical Medicine.

Kim Ozano:

In each episode, we discuss the different ways that the programme has strengthened the capacities of health practitioners to deliver high

Kim Ozano:

This episode is the second of four episodes, and today we will be focusing on a maternal and perinatal death surveillance and response approach.

Kim Ozano:

We have three great guests with us today, Dr.

Kim Ozano:

Pamela Godia, who is a senior technical officer with the Liverpool School of Tropical Medicine and is also a lecturer at the University of Nairobi.

Kim Ozano:

We have Dr.

Kim Ozano:

Edward Serem, who is the head of the division of Reproductive and Maternal Health Services at the Ministry of Health, and we also have Wabwire Scolastica, who is a field epidemiologist and

Kim Ozano:

So before we go on to hear more from our guests, let's say hello to our co-host Lucy, who is going to help us through the questions and the learning from the programme.

Kim Ozano:

She is the country director of the Liverpool School of Tropical Medicine in Kenya and is a medical anthropologist by background, with over 20 years of experience in maternal and child health.

Kim Ozano:

Lucy, I understand the Ministry of Health in Kenya has developed national guidelines on how to conduct reviews of maternal and newborn deaths and stillbirths, as well as near misses.

Kim Ozano:

We'll look forward to you explaining to us what near misses means at the facility and the community level, but I understand that the guidelines outline the reporting pathways and the documentation

Kim Ozano:

So if you could help us understand some of these concepts and what the approach is, that would be really useful.

Kim Ozano:

Thanks, Lucy.

Lucy Nyaga:

Thank you very much, Kim.

Lucy Nyaga:

Welcome our wonderful guests from the Ministry of Health and, uh, from Liverpool School of Tropical Medicine.

Lucy Nyaga:

I'm glad to be here, Kim, to record this episode, which is really going to give us great insights into what we have been doing at Liverpool School of Tropical Medicine and together

Lucy Nyaga:

The maternal, perinatal death, surveillance and response normally referred to as MPDSR, normally involves systematic analysis of trends in deaths as well as

Lucy Nyaga:

This is important because it can identify health systems barriers and inspire local solutions to prevent such deaths in the future and this is really a role of the government.

Lucy Nyaga:

You did also mention about near miss, when we talk of near miss we are basically referring to a very ill pregnant or a woman that has recently delivered and

Lucy Nyaga:

So this is near miss.

Kim Ozano:

Thanks very much, Lucy.

Kim Ozano:

That certainly helps me understand.

Kim Ozano:

I will hand over to you and the guest to tell us a little bit more detail about the programme.

Lucy Nyaga:

Thank you very much, Kim.

Lucy Nyaga:

We are going to be looking at three key issues that helps us understand what is it that, uh, the interventions that the Liverpool School of Tropical Medicine in collaboration

Lucy Nyaga:

Dr.

Lucy Nyaga:

Serem, could you please give us a brief overview of the Maternal Perinatal Death Surveillance and Response programme and the scope of the support that

Dr Edward Serem:

We started MPDSR programme in the country around 2016.

Dr Edward Serem:

It's one of the key components on checking the quality of care for the mothers and the newborns, and in our country therefore, for the last

Dr Edward Serem:

One is setting up the national MPDSR committee, chaired by the Director General of the Republic from the Ministery of Health, Republic of Kenya and this one cuts across the committee.

Dr Edward Serem:

In Kenya, we have 47 subnationals, which we are calling them counties.

Dr Edward Serem:

And these ones are like the small governments of Kenya.

Dr Edward Serem:

We've set up, the committees in all the counties.

Dr Edward Serem:

These committees have been very instrumental because they have been looking at the causes of death.

Dr Edward Serem:

In a nutshell, assessing, reviewing, auditing, what went wrong?

Dr Edward Serem:

What are these events?

Dr Edward Serem:

And all this information covered that we've come up with reports.

Dr Edward Serem:

We had the first report, I think somewhere 2017, and I think this one informed most of the top management leadership to, in some form of advocacy, and also making

Dr Edward Serem:

We have therefore been in a position to give feedback, strengthen their committees.

Dr Edward Serem:

Once you strengthen the committees, they learn a lot of issues because if a mother dies of lack of blood this time round, so definitely something will

Dr Edward Serem:

If it's an issue of referral delays, then those things, once documented, then people will look at those missing gaps and address them and improve on them.

Dr Edward Serem:

So over time, therefore we've seen sustained improvement in the quality of care.

Dr Edward Serem:

We've seen improvements of the structures; we are talking about the commodities, like drugs, about resuscitative equipment, about referral systems.

Dr Edward Serem:

We've been doing a lot of, um, trainings on emergency obstetric care and neonatal care, and I think some has immensely contributed into the quality of care, because

Lucy Nyaga:

Thank you very much, Dr.Serem, really interesting.

Lucy Nyaga:

Dr.

Lucy Nyaga:

Pamela do you want to just mention how this has affected the women in terms of the community committees?

Pamela Godia:

The issue of establishing committees at the county level and also ensuring that those committees are officially appointed by the chief executive or the county leadership

Pamela Godia:

How long should this review take?

Pamela Godia:

How often should these reviews take?

Pamela Godia:

Then, if they're conducting reviews on a monthly basis the LSTM team, uh, followed up these review meetings at the facility levels to find out, okay, are the health workers at

Pamela Godia:

If they have an action that they feel that if a certain item would have been available or a certain intervention would have been available, this mother would have been saved.

Pamela Godia:

Then those are the things that are put in place.

Pamela Godia:

The idea is to take action to prevent future deaths.

Pamela Godia:

That's the essence of the maternal and prenatal death, surveillance and response.

Pamela Godia:

Working with all the stakeholders at the facility level, and just making them feel that whatever they're doing, is important and it has a major contribution to the overall

Lucy Nyaga:

Thank you very much.

Lucy Nyaga:

Scholastica, could you kindly give us an overview, very brief, of the committees and their membership so that people understand of who we are talking about in a broad scope.

Wabwire Scolastica:

We have four levels of committees.

Wabwire Scolastica:

At the national level, we have the Director General who is the chair of that committee supported by the secretary, who is the head of Department of Family Health in which the division lies.

Wabwire Scolastica:

At the county level, we have the County Director of Health, who is the chair and then is supported by the secretary, who is the reproductive health coordinator at that county level.

Wabwire Scolastica:

Then at the subcounty level we have the Medical Officer of Health in charge of that sub county, is the chair and is supported by the secretary, who is the subcounty reproductive health coordinator.

Wabwire Scolastica:

And then at the facility level, we have the medical superintendent, who chairs it and then supported by the one who is in charge of, maternal

Wabwire Scolastica:

For each level there are different memberships, directed by what they can bring at the table or what their responsibilities are related to that level of committee that they belong to.

Pamela Godia:

If a maternal death occurs in that community, the community health committee rally the members of that family and the other members of the community.

Pamela Godia:

The health workers, who are within the neighbouring facility would still come and be part of that community health committee and they would discuss issues

Pamela Godia:

The common term that they're referred to when they're doing a maternal death is the verbal autopsy.

Pamela Godia:

You are talking to each other and trying to do a post-mortem of why a woman died at that level.

Lucy Nyaga:

Pamela it was very interesting what you said about the community.

Lucy Nyaga:

How about neonatal, perinatal deaths?

Lucy Nyaga:

What would you say, about the way it is handled at community level, especially with our African concepts, a neonatal death may not necessarily be considered as seriously as a mother.

Pamela Godia:

The value the society puts onto an a, unborn child who has died, either prematurely or if you had a still birth, it's a bit lower.

Pamela Godia:

So currently the reviews that are done at the community level with regards to the perinatal, I would say it's minimal, it's still a big gap that needs to be done.

Pamela Godia:

That also goes with the culture that we have in our setup that some communities will not even discuss such a death and they will not count that to be a child.

Wabwire Scolastica:

This is work in progress even for Kenya because we have strengthened the areas that we have been able to, with the support of the

Wabwire Scolastica:

This is where we have not put enough structures for the community level audits or notification of perinatal and maternal death.

Wabwire Scolastica:

We have at least a defined structure for maternal death audits at the community level, but we have not given a structure or clearly identified pathway for the audits of

Lucy Nyaga:

Thank you very much for that overview.

Lucy Nyaga:

Maybe Schola, you can continue to just tell us the key achievement lessons learned and how the programme has impacted on the lives of mothers and children.

Wabwire Scolastica:

Looking at the key achievements for MPDSR, we have achieved much as a country.

Wabwire Scolastica:

Basically what informed our achievement is the findings that we get from the audits and also the confidential enquiry on maternal deaths findings have given us the focus

Wabwire Scolastica:

One of key achievements is we have, uh, been able to set up a satelilte for blood, to avail blood to women who are in need of blood during that critical

Wabwire Scolastica:

So the findings were able to help the countries come up with these satellite places where blood can be accessed and also, most of the counties have taken it as their responsibility

Wabwire Scolastica:

Most of these implementations or the findings, gears towards quality of care.

Wabwire Scolastica:

Quality of care is what we are grappling with, uh, at the moment.

Wabwire Scolastica:

And we have come up with, um, uh, standards that really define what quality of care is required for these women and to have an, uh, favourable outcome for the women and children or the newborns.

Wabwire Scolastica:

We also have ways of assessing this quality of care, and now, come up with interventions to improve the quality of care in the counties and we make use of the quality improvement

Wabwire Scolastica:

I think it's really great because we can really see a clear link between, the national level actions, policies, guidelines, and actual impact on the mother.

Lucy Nyaga:

Pamela, do you have anything that you'd want to add in terms of the impact and lessons learned, uh, from implementing the MPDSR programme?

Pamela Godia:

I would say that the focal programme counties have responded to the identified gaps that are identified during the maternal death audits.

Pamela Godia:

For example, in one of the counties where we worked, after the reviews, they realised that the hospital had one operating theatre, but after the reviews, they realised that

Pamela Godia:

So the management of the county identified a room where they could convert that room into a maternity theatre, a maternity theatre that is specific for maternity cases and

Pamela Godia:

For example, if it is realised that a newborn died because of the lack of proper neonatal resuscitation, then the facilities would organise for mentorship

Pamela Godia:

Yeah, so those are some of the critical examples that I would say have made a significant contribution, uh, to the health of the mothers and babies.

Lucy Nyaga:

Thank you very much, Dr.

Lucy Nyaga:

Pamela Godia for that.

Lucy Nyaga:

Now I will go to Dr.

Lucy Nyaga:

Serem.

Lucy Nyaga:

We published the first report and looking at the recommendation of that report, the first confidential enquiry into maternal deaths, how

Dr Edward Serem:

We had the first report and of course once you have the report as usual, when we do audits for maternal deaths, of course, um, it's not punitive.

Dr Edward Serem:

The top leadership has the responsibility making sure that the response part of it is acted upon in a continuous manner because issues of

Dr Edward Serem:

Of course right now, we had another administration, it is imperative that they need to be sensitised on this because MPDSR actually checks on the quality of the care to the women.

Dr Edward Serem:

Moving forward therefore is to look at those leadership.

Dr Edward Serem:

I would also want to add is the findings from this projects also has contributed to change of studies because we are now looking from the division

Dr Edward Serem:

The other thing, of course, is on mentorship.

Dr Edward Serem:

We form a programme where we no longer take health healthcare workers on issues of MPDSR, the trainings into the classrooms.

Dr Edward Serem:

Mentorship, we go facility to facility.

Dr Edward Serem:

As we look at their reports, we go there and mentor them.

Lucy Nyaga:

I'm really encouraged to note that Dr.

Lucy Nyaga:

Serem's focus is so much in enthusiastic and internal looking and that confidence that the government can do it.

Lucy Nyaga:

This is really, uh, encouraging.

Lucy Nyaga:

I would like to hand over back to Kim

Kim Ozano:

Thanks very much, Lucy.

Kim Ozano:

This has been a really good conversation.

Kim Ozano:

We hear a lot about community engagement, but this is engaging communities in a different way where you capture their real life experiences, immediately learn from

Pamela Godia:

When it comes to community participation, we want communities to be aware of what a maternal death is.

Pamela Godia:

We want community members to be aware of what are the danger signs are, what are the signs and symptoms of a mother who is, uh, pregnant and is in danger and is anticipating a complication.

Pamela Godia:

So are they able to identify early enough the signs and symptoms of a complication that is arising?

Pamela Godia:

If I see a mother with a swollen leg?

Pamela Godia:

Is that a sign?

Pamela Godia:

Are they able to elicit that as a sign that they need to seek care?

Pamela Godia:

So it comes to communities being aware of that and also communities participating in designing the healthcare services that they would want to see.

Pamela Godia:

For example, if you have a health centre at a community level, are community members aware of the range of services that are available in that health centre?

Pamela Godia:

And then they can go there and seek care in case of an emergency.

Pamela Godia:

If a woman is pregnant that is not feeling that her baby is kicking or her baby is moving, does she know that she's able to go to the nearest facility and seek advice and seek care so that if

Pamela Godia:

Then also communities also participating in the referral mechanism.

Pamela Godia:

A facility may not have a vehicle or an ambulance to take the woman from, or a patient from one level to the next level, which might be, uh, a few kilometers away.

Pamela Godia:

But sometimes communities come together and say, okay, in case we have an emergency in this area, there's one person who has a vehicle, so we need to

Pamela Godia:

Communities have their own structures in terms of leadership, so engaging communities through their own leadership and participating actively in decision

Kim Ozano:

Thank you very much.

Kim Ozano:

We like to end our episodes by asking our guests for one piece of advice that they would give to anyone who's trying to implement something

Kim Ozano:

So let's start with Dr.

Kim Ozano:

Serem.

Kim Ozano:

Would you like to tell us, what advice would you give to others who want to implement something like this?

Dr Edward Serem:

Implementation of MPDSR, we are all looking at sustainable development call number three, where are every country is committed to eliminating, maternal and neonatal deaths.

Dr Edward Serem:

On that note therefore, ending maternal mortality becomes an advocacy tool that we bring everybody on board to talk about how do we end,

Dr Edward Serem:

It has not been going down the way we would have wished.

Dr Edward Serem:

Thank you.

Kim Ozano:

Thank you very much.

Kim Ozano:

So I think a clear message there; we need advocacy to restart the conversation to end mortality in the future.

Kim Ozano:

Thank you very much.

Kim Ozano:

Pamela, a piece of advice please.

Pamela Godia:

I would say that implementing the maternal and perinatal death surveillance and response programme has been an exciting experience and also a challenging experience.

Pamela Godia:

So one needs to be very patient in implementing these activities, especially when it comes to conducting maternal death reviews.

Pamela Godia:

It is a vigorous exercise, and it is a draining exercise, having to review one death after another, after another.

Pamela Godia:

So one has to be patient and also has to be resilient and most importantly, engage the stakeholders or the communities of practice around you,

Pamela Godia:

It is a great strategy, especially for checking and monitoring quality of care.

Kim Ozano:

Thank you very much for bringing that human element where you require patience, endurance, and I can imagine it's very

Kim Ozano:

Thank you for highlighting that.

Kim Ozano:

Scholastica, would you like to give your piece of advice please?

Wabwire Scolastica:

MPDSR is about checking out what has failed the woman in the system but it's not something that you use to find faults on the ones who took care of the

Wabwire Scolastica:

So it is basically looking at where the system will fail and making remedial measures to improve so that you prevent any other death that might occur because of something that the system was not able

Kim Ozano:

Lucy, take us home with a message for our listeners on this topic, please.

Lucy Nyaga:

For me, having engaged with it, I would say partnership is key.

Lucy Nyaga:

This is not, you know, a one system, a one man or a one institution show.

Lucy Nyaga:

You have to engage a number of stakeholders from across the government, from across implementing partners from across professional bodies.

Lucy Nyaga:

They all have their role in ensuring that the quality of care provided to mothers.

Lucy Nyaga:

Their babies while pregnant is, um, is really engaged.

Lucy Nyaga:

So I would say partnership in ensuring successful maternal and perinatal death is key.

Lucy Nyaga:

Thank you, Kim.

Kim Ozano:

Wonderful take home message there.

Kim Ozano:

Thank you very much.

Kim Ozano:

So thank you, Lucy, for being a wonderful co-host again, it's nice to see you and thank you for our guests for the wonderful explanation of this very

Kim Ozano:

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About the Podcast

Improving the Quality of Maternal and Newborn Health in Kenya
Maternal and Newborn Health in Kenya
Welcome to our brand new mini-series. In this mini-series, we are shining a spotlight on the programme, Improving Quality of Maternal and Newborn Health. This is a UK funded programme by the Foreign Commonwealth and Development Office, and is led by the Liverpool School of Tropical Medicine.

In each of the four episodes that we will be delivering to you, we will be discussing different ways that the programme has strengthened the capacities of health practitioners to deliver high quality care, to reduce maternal and newborn morbidity and mortality.

About your host

Profile picture for Kim Ozano

Kim Ozano

Research and Development Director at SCL and co-founder and host of the ‘Connecting Citizens to Science’ (CCS) podcast. Kim is a health policy and systems researcher with over 15 years’ experience of designing, delivering and evaluating health and development projects in the Global South and UK. She is an implementation health research specialist, as can be seen from her publications and work at the Liverpool School of Tropical Medicine, where she remains an Honorary lecturer.
Kim creates space in Connecting Citizens to Science for researchers and communities to share their experience of co-production to shape policy and lasting positive change.