the study revealed a dramatic drop of 52% in maternal...
TRANSCRIPT
1
International School of Public Health United Nations Population Fund
Assessment of Maternal Death Surveillance and Response System in
(EGYPT)
Final Report
Developed by
Dr. Khaled Ahmed Nasr
Maternal and child health consultant
EGYPT
Date of completion
(12 December, 2017)
2
Acknowledgment
I would like to extend my deepest gratitude for the Ministry of Health and Population for their genuine support in providing all data and for granting me their approval to utilize maternal mortality survey data.
Sincere thanks for UNFPA colleagues both in the Regional and country office, who kindly gave me a lot of their time and valuable guidance through the whole process.
I would also like to acknowledge WHO , UNICEF Egypt country offices and Medical Syndicate for their kind support in providing valuable information for this study.
I convey my special thanks to colleagues in International School of Public Health, Mohammed VI University of Health Sciences in Casablanca, Morocco, who worked so diligently to review this paper and document the surveillance system in countries of the Region.
3
Table of contents
Acronyms 4
1. Introduction 6
2. Analysis of the context of the country and maternal 8
3. Policy and strategy of the MDSR 23
4. Governance of the system of the MDSR 25
5. The MDSR implementation process 29
6. Case Study and Desk Review 45
7. Results 56
8. Conclusions and recommendations 64
9. References 67
10. Annexes 68
4
Acronyms
ANC Antennal Care.
ASRO Arab States Regional Offices.
CAPMAS Central Agency for Public Mobilization and statistics
CEMOC Comprehensive emergency obstetric Care
CPP Consultation of the Post-Partum
D.G. Director General.
DAD District Assistant Director.
DNF Death Notification form
EDHS Egypt Demographic Health Survey.
ENMMS Egypt National Maternal Mortality Study
EOC Essential obstetric Care
F.P Family Planning
GOE Government Of Egypt
IEC Information, Education, Communication
IMCI Integrated Management Of Child Illness
IP Improvement Plan
ISPH International School of public health
JSI John Snow, Inc
KAP Knowledge, attitude, practice
M & E Monitoring and Evaluation
MCH Maternal and Child Health.
MDGS Millennium Development Goals
MDSR The maternal death surveillance and response
MMR Maternal Mortality Ratio.
MMSS Maternal Mortality Surveillance System.
MMSSQ Maternal Mortality Surveillance System Questioner.
MOE Ministry Of Education
MOE Ministry of Education
MOHP Ministry of Health and population.
NGOS Non Governmental Organizations
NHIC National Health Information Center.
NMMSS National Maternal Mortality Surveillance System.
NMR Neonatal Mortality Rate
PHC Primary Health Care.
PKU Phenyle Ketunurea
PNC Pre-natal consultation
SDOS Sustainable Development Objectives
SMC Safe Motherhood Committee.
5
1. Introduction
The Safe Motherhood Initiative is a worldwide effort that aims to reduce the number of deaths and illness associated with pregnancy and childbirth. The global Initiative was launched during a conference in Nairobi, Kenya in 1987. Its aim was to draw the world's attention to the thousands of deaths and millions of serious illnesses that affect women every year.
Making motherhood safe for the world's women calls for national governments, funding agencies, and non –governmental organizations (NGOs) to make maternal health an urgent health priority and to ensure that the necessary political and financial support is dedicated to this effort.
The government of Egypt has demonstrated continued political commitment for improving maternal, neonatal and child health. Egypt was one of six countries that supported the 1990 summit conference for the protection and development of children, which strongly endorsed safe motherhood programs and strategies.
In 1994 as host nation of the International Conference on Population and Development, the Government of Egypt (GOE) endorsed a comprehensive approach to women's health, with a focus on reducing maternal mortality.
Specific projects and interventions have been implemented through the Ministry Of Health and Population (MOHP) /Maternal and Child Health (MCH) Department with support from USAID, UNICEF,UNFPA, WHO, EU, the population council, other international donors and Technical Organizations eg, JOHN SNOW, Mother Care, Pathfinder organization……)
The Egyptian Ministry of Health and Population launched the first national study of maternal mortality in 1992 in all Egyptian governorates (except for five frontier governorates). The specific objectives of the study were to:
Obtain a national and regional figure of maternal mortality in Egypt. Identify the main causes of maternal mortality. Determine the avoidable factors contributing to these maternal deaths. Provide data required to develop preventive programs to reduce maternal deaths.
In 1994, the Egypt National Maternal Mortality Study 1992/93 (ENMMS 1992/93) summarized the data collected and reported an overall maternal mortality ratio (MMR) of 174/100.000 live births. The five main causes of death at this time were postpartum
6
hemorrhage (25%). hypertensive disease (16%), ante partum hemorrhage (8%), puerperal sepsis (8%) and ruptured uterus (7%). The study showed that the two main avoidable factors of death were substandard care on the part of health care providers (59%) and delays in seeking care on the part of the woman and her family (42%).
The findings were to be used by the MOHP and senior policy makers to revise and implement effective strategies to reduce the maternal mortality.
To monitor the impact of the implemented strategies the second maternal mortality study was carried out in 2000 to monitor the progress of the maternal mortality reduction efforts and the changes in avoidable and unavoidable causes.
The study revealed a dramatic drop of 52% in maternal deaths to an MMR of 84/100,000 live birth, in Upper Egypt the ratio was reduced by 59%.
MOHP recognized the importance of collecting the maternal mortality data on a regular basis as a tool for policy makers to achieve safe motherhood strategy. Hence, in 2002, MOHP decided to plan and implement the National Maternal Mortality Surveillance System (NMMSS) which became an integral part of the national maternal mortality reduction strategy.
For the purpose of this study, the study team conducted a desk review about the national MMSS during the month of August 2017. This was done through:
a) In-depth interviews with responsible staff at MCH general directorate, medical syndicate, concerned UN agencies and relevant stakeholders.
b) Review of steps of implementation and system description c) Revision of samples of the available collected data and forms "DNF, MMSSQ,
monthly report form, quality checking actions and performance monitoring system.d) Study the available information about maternal mortality at national level during the
last years and the report of analyzed data at MCH information center. e) Revising the actions taken by national and local safe motherhood committees, activity
for improvement and constrains
2. Analysis of the context of the country and maternal
7
The population of Egypt in 2016 was reported to be 92,128,271 by Egypt's Central Agency for Public Mobilization and statistics (CAPMAS). The people of Egypt live almost exclusively in the Nile Valley, the Nile Delta, the Suez Canal region, and the northern coastal of the Sinai Peninsula. There are small communities in the oasis of the west Desert and in the oil-drilling and mining area. There is a small population of nomadic Bedouins. Egypt’s overall population density is 92.4 persons per sq km but the population density in the inhabited portions of the country, which make up less than 5 percent of its land area, is 1,162.9 persons per sq km.
The population growth rate, which was about 2.5 percent per year in the 1980s, declined steadily in the 1990s as the country's birth rate fell. In 2016 the rate of population growth was 2%. The birth rate was 30.2 per 1,000 persons, and the death rate was 6.5 per 1,000 persons. By 2016, 42, 8% of the population lived in urban areas.
Health services in Egypt is organized in three levels: primary level composed of primary health care units, family health centers, MCH centers and health offices; the secondary level includes specialized hospitals, general hospitals and district hospitals; the tertiary level is composed of university hospitals, teaching hospitals and institutions.
At the peripheral level, the MOHP of Egypt has 27 Governorates, each divided into districts (283) which in turn are divided into health bureaus (offices) or family health centers and units (5000). The number of districts per Governorate ranges from one in the Governorate of Port Said to 38 in the Governorate of Cairo.
2.1. Demographic data.
Indicator Data Source Year
Total population of the country 92,128,271
CAPMAS 2017
Percentage of urban population 42.8 % CAPMAS 2017
Average age at first marriage 21.6 CAPMAS 2017
Number and percentage of women in the Age of Reproduction (15-49 years)
24,423,533
26.5 %
CAPMAS 2017
Number and percentage of women in reproductive age who married
17,096,473
70 %
CAPMAS 2017
8
Total fertility rate 3.5 DHS 2014
Birth rate 30.2 DHS 2014
Number of births per year 2,685,276 MOHP 2015
Average annual population growth rate 23.7 CAPMAS 2017
Marriage of girls under 15 2% UNICEF 2016
Marriage of girls under 18 years old
*In DHS it’s measured from 15—19 years
3.5 % DHS 2014
First marriages between 18-25 years old NA
Adolescent fertility rate 51/ 1000 World Bank group
2015
Number and situation of migrants and refugees in the country Syrians :
Sudanese:
Somalis :
Iraqis :
Southern Sudanese:
Eritreans :
Other Nationalities :
185,149
127,914
26,488
6.878
6.854
5.227
5.128
6.660
UNHCR 2016
Enrolment rate for girls 48% MOE 2014
Drop-out rate among school girls + boys 6.5 % MOE 2014
Other relevant indicators
9
2.2. Evolution the Maternal, infant and neonatal mortality in the country since 2000
Indicator /Years
2000 2005 2010 2015 2016
Level
SourceYear
Level SourceYear
Level
SourceYear
Level SourceYear
Level SourceYear
Maternal Mortality
84
MCH/MOHP 63 MCH/MOHP 54 MCH/MOHP 49 MCH/MOHP
46 MCH/MOHP
Neo-natal Mortality
24 DHS 20 DHS 16 DHS,2008 14 DHS,2014
Infant Mortality
44 DHS 33 DHS 25 DHS,2008 22 DHS, 2014
Under 5 Mortality
54 DHS 41 DHS 28 DHS,2008 27 DHS, 2014
2.3. Maternal health indicators
Indicator Situation Source Year Number of Deliveries in the country by areas Total 2,600,173 MOHP 2016
Urban NARural NA
Percentage of deliveries attended by skilled personnel by area and by sector
Urban 96.4 % DHS 2014Rural 89.4 % DHS 2014Public 25.6 % DHS 2014Private 61.1 % DHS 2014
Prenatal consultation at least one visit by area (%)
Urban 92.8 % DHS 2014Rural 89.2 % DHS 2014
Prenatal consultation 4 or more visits by area Urban 87.8 % DHS 2014Rural 80.5 % DHS 2014
Post natal consultation by area (%) Urban 89.1 % DHS 2014Rural 78.2 % DHS 2014
Cesarien section by sector Public 45.3 % DHS 2014Private 65.7 % DHS 2014
Number of Syrian women receiving prenatal care Number of Syrian women receiving post natal care Number of Syrian children (under 5 ) receiving immunization and health care services
Total
Total
Total
804
717
15575
MCH/MOHP 2016
For all indicators, and whenever possible, integrate data on migrants and refugees.
10
2.4. Resources
Resources Urban Rural Total Year and source Number of health facilities that provide obstetric care and delivery at first level
461 4336 4797 2015Statistical B00k
MOHPNumber of health facilities that provide obstetric care and delivery at secondary level (reference hospital)
262 -------- 262 2015Statistical Book
MOHP
Number of health facilities that provide obstetric care at tertiary level
89 --------- 89 2015Statistical Book
MOHPNumber of private facilities offering Obstetric care
2081 Medical Syndicate2017
Number of obstetricians by sector
Public 6486 Curative Sector HIS;MOHP 2017
Private 1 6145 Medical Syndicate 2017
Number of anesthetic by sector
Public 1298 Curative Sector HIS;MOHP 2017
Private 6,852 Medical Syndicate 2017
Number of pediatrician by sector
Public 4185 Curative Sector HIS;MOHP 2017
Private 18,227 Medical Syndicate 2017
Number of midwives by sector
Public 3214 MCH,MOHP,2017Private
Number of midwives operating at the community
Public NAPrivate NA
Other useful information about resources
2.5. Organization
The maternal health program in Egypt is administratively under the Maternal and Child Health (MCH) Directorate which reports to the Primary Health Care Sector. Health services including maternal health, are organized in three levels:
1- Primary level composed of Primary health care units, family health centers, Maternal and child health (MCH) centers and Health offices. MCH care services are provided through a network of primary health care facilities spread in all governorates in rural and urban areas (about 5000 facility) and through mobile clinics to reach slums and needy areas. MOHP provides MCH services as a part of a comprehensive package of primary health care services
2- Secondary level includes specialized hospitals, general hospitals and district hospitals;
11
3- Tertiary level is composed of university hospitals, teaching hospitals and institutions.
At the peripheral level, the MOHP of Egypt has 27 Governorates, each divided into districts which intern are divided into health bureaus (offices) or family health centers and units (total 283 districts). The number of districts per Governorate ranges from one in the Governorate of Port Said to 38 in the Governorate of Cairo.
Since almost half of the health expenditures in Egypt are out of pocket and are directed to private physicians, the private sectors, including clinics operated by NGOs and religious entities. Usually, people of the higher wealth quantile rely on private sector for health services including maternal health. Private sector offers antenatal and postnatal care services, deliveries and family planning. Deliveries are prohibited by law in private clinics, yet widely practiced due to lack of mechanisms of monitoring their performance and enforcing laws.
As for refugees and migrants, there are no special facilities dedicated to them, they are allowed to use national health facilities, in the same manner like Egyptians. MCH general directorate offer a Basic benefit package services for MCH for all refugees and migrants in Egypt as Egyptian women. The services include ANC at PHC units through health card , examination , vaccination , investigation , supplementation with iron , folic acid , health education, and postnatal care.
2.6. Community To ensure safe-motherhood, there is a focus from MoHP, outreach workers and NGOs to increase community awareness on maternal health.
The communications strategies used focus on raising awareness targeting the most needy groups like the illiterate, poor, and in rural areas with worst indicators, targeting women and key decision-makers in the family, such as mothers-in- law and husbands.
The MoHP community awareness program is based on the gaps identified from the analysis of the maternal death surveillance. This programs covers the following areas:
- Importance of seeking timely medical care by communicating danger signs and pregnancy complications.
- Importance of antenatal and post-natal care.
- Importance of deliveries by skilled health personnel (physicians or trained nurse-midwife, not the untrained traditional birth attendant.
- Birth spacing and using family planning methods
- Timely vaccinations and supplements for mother and child
- Good nutrition
12
2.7. Financial access
Percentage of population benefiting from health coverage such as public health insurance 62%. There are also private health insurance schemes offered by the private sector.
Is there any fees waver mechanism for deliveries, caesarean sections, drugs and consumables (eg delivery kits)? NO
2.8. Place of maternal health in the priorities of the country
Maternal health is placed as one of the top priorities in the Egyptian Government. This high-level commitment was translated into allocation of financial and technical resources both by the government as well as international agencies and other stakeholders.
There were two decrees issued in this regard:
The ministerial decree No.159 of 17 July 1999 which states that it is compulsory to report all deaths occurring due pregnancy, labor and puerperium (42 days after delivery) within 15 days from the date of death. The decree also required that all death reports be sent to General Directorate of the MCH and Health information system with complete information on cause, age and residence of the deceased women.
The ministerial decree No. 197 stipulated the creation of the central safe motherhood committee headed by minister of health and population, to formulate a plan for the reduction of maternal mortality ratio in Egypt. Following the decree, safe motherhood committees were also established at the levels of governorates and districts.
National ACCELERATION PLAN for Child and Maternal Health, Egypt:
Egypt launched its maternal and child health acceleration plan for 2013–2015 on 17 February 2014. Egypt is the fifth country in the Region to have launched the plan, after, in chronological order, Sudan, Morocco, Afghanistan and Iraq.
Egypt has made remarkable progress over the past 20 years in child health, achieving so far one of the highest rates of reduction in under-5 mortality per year in the Region and recording an overall decline between 1990 and 2012 which has gone well beyond the Millennium Development Goal (MDG) 4 target. There has also been a steady and significant decline in maternal mortality and the country is on track to achieve MDG 5. These outstanding accomplishments show how a country can succeed in translating political commitment into effective actions and results. With less than 2 years left, the plan aims not only to sustain the achievements made but also to further accelerate reduction of under-5 mortality and maternal mortality.
13
The development, launching and implementation of maternal and child health acceleration plans for priority countries in the Eastern Mediterranean Region are a commitment to the Dubai Declaration of January 2013 to accelerate progress towards the Millennium Development Goals 4 and 5 on reduction of child and maternal mortality.
Main elements of the plan:-
Perinatal care: life cycle approach starting from antenatal care – child birth –
postnatal care- neonatal and childhood care.
Nutrition : It includes the following programs
o Breastfeeding – Complementary feeding – Micronutrients deficiency control – nutrition surveillance system – educational kitchen – nutrition coroner .
Maternal and perinatal mortality surveillance systems.
Save motherhood committee
Integrated management of childhood illnesses (IMCI) .
Family planning .
Raising Community awareness
Efficiently applying the above initiatives and comprehensive MCH program led to:
Increasing percentage of antenatal care coverage from 39% in 1995 to 90% in 2014.(DHS)
Increasing percentage of antenatal care (at least 4 visits) to 80%.(DHS) Increasing percentage of deliveries attended by skilled health personnel (physicians &
nurse-midwife) from 46% in 1995 to 92% in 2014.(DHS) Increasing percentage of deliveries at health facilities from 32% in 1995 to 87% in
2014.(DHS) Immunization coverage with basic vaccines increased to reach 98%.(MOHP)
As a result there was a remarkable improvement in maternal and child health indicators
Maternal mortality ratio declined from 174 per 100,000 live births in 1992 to 46 in 2016 with a percentage of decline of 73.6%.(MCH-MMSS)
Neonatal mortality rate declined from 39/1000 live birth in 1990 to 14 in 2014, with a percentage of decline of 64%.(DHS)
Infant mortality rate declined from 73/1000 live births in 1990 to 22 in 2014 with a percentage of decline of 69.9%.(DHS)
Under five mortality rate declined from 104/1000 live birth in 1990 to 27 in 2014 with a percentage of decline of 74%.(DHS).
14
Child mortality rate/1000 live births
201420082005200019951990Indicators
141620243039Neonatal Mortality Rate
222533446373Infant Mortality Rate
2728415481104Under Five Mortality Rate
1990 1995 2000 2005 2008 20140
20
40
60
80
100
120
Neonatal Mortality RateInfant Mortality RateUnder 5 Mortality Rate
Source: DHS 2014
15
Maternal Mortality Ratio /100,000 live births
Indicators 1992 2000 2005 2008 2012 2016
Maternal Mortality Ratio 174 84 63 55 50 46
1992 2000 2005 2008 2012 20160
20
40
60
80
100
120
140
160
180
200
174
84
63 55 50 46
Source: MOHP/MCH
2.9. Place of maternal health in the education of health professionals
For midwives: the curriculum focuses entirely on safe motherhood, maternal health, and vaginal deliveries. It’s composed on a practical and theoretical training for 4.5 months
MCH is an integral part in public health, OBs /GYN, and pediatrics curricula
In higher public health institute there is a special specialization on maternal and child health
On job training:
Continuous on job training is offered for physicians, nurses and outreach workers on latest protocols, standards of practice, usage of modern devices related to maternal health. They are also offered trainings on BEMOC and CEMOC.
16
2.10. Analysis of partners in the MDSR and their roles
Partner Roles
Health authorities in the country Issuing policy and strategies.
Implement, monitor and evaluation the activites of the plan.
Fund raising for support the plan.
Private sector Share in execution of SMC recommendation to reduce maternal deaths.
Other sectors Share in execution of SMC recommendation to reduce maternal deaths.
NGO Share in raising awareness of the community.
UNFPA Technical and financial support.
WHO Technical and financial support.
Other agencies of the United Nations Technical and financial support .
Other cooperation multi and bilateral agencies
Technical and financial support.
Other partners Technical and financial support.
2.11. Studies and quantitative and qualitative surveys
This type of documents generating indicators and information on maternal health including PAPFAM, DHS surveys and the Census.
Title Date
Last census in the country CAPMAS 2017
Last survey PAPFAM/DHS DHS 2014Other quantitative or qualitative surveys related to maternal healthNational Maternal Mortality Survey 1992 , 2000
1992 , 2000
First national study of maternal mortality, 1992 Pilot study about MMSS in Alexandria and Menofia, 1998
1992 – 2016 Reports
17
Evaluation of MMSS including evaluation of the health officers, physicians , health office clerks (supported by WHO) 2014Evaluation of accuracy and efficiency of MMSS (supported by UNFPA) 2016Other (specify) 2.12. Maternal mortality indicators and use of maternal health services in the national
information system
Extract the last report of the SNIS indicators related to maternal deaths and complications such as: the number of births, the number of complicated births, the percentage of Caesarean sections, the number of abortions and the number of maternal deaths
Is there any relationship between the NSIs data and MDSR system?
Indicator Most recent data Source Date Number of deliveries 1,838,772 HMIS – MOHP 2015 number of Caesarean sections
858,282 HMIS – MOHP 2015
number of maternal deaths*
350 HMIS – MOHP 2016
number of maternal deaths*
1194 MMSS (MCH - MOHP) 2016
number of deliveries by doctors in governmental health facilities
1,611,922 HMIS – MOHP 2015
number of deliveries by nurse-midwife
141,541 HMIS – MOHP 2015
% of new beneficiaries receiving ANC
53.5% at PHC units
HMIS – MOHP 2015
Average number visits for ANC follow up PHC facilities
3.7 visits at PHC units
HMIS – MOHP 2015
% of deliveries at public & private health facilities
87.5% HMIS – MOHP 2015
% of deliveries attended by public & private health personnel (physician or nurse/midwife)
95.8% HMIS – MOHP 2015
number of obstetric complications
476 MMSS 2016
number of abortions 17 MMSS 2016
18
There is an integral relationship between HMIS data and MDSR system. However, there might be discrepancies between the two systems such as the number of maternal deaths described above (*). Further integration efforts and training needs to be provided to HMIS personnel on reporting maternal cases.
2.13. Synthesis of the data, conclusions and recommendations
Egypt is highly committed to SGDs, particularly objective three:
Target 3.1
Indicator 3.1.1 Maternal mortality rate
Indicator 3.1.2 Proportion of skilled birth attendance
Target: 3.1 by 2030, to bring global maternal mortality rate under
70 to 100 000 live births.
Target 3.2
Indicator 3.2.2 Neonatal mortality rate
In the framework of Egypt's commitment to accomplish development to attain individual and family satisfaction within suitable environmental circumstances, Ministry of Health and Population (MOHP) directs its attention to provide a package of high quality health services for mothers and children, through an integrated MCH strategy. This package of services is integrated to encompass not only curative services but also preventive services and health support activities that have positive impact on improving health status and community awareness.
Elements of the MCH Strategy
Established Essential Package of maternal, neonatal and child health standards of services.
Improved and Strengthened Role and Competency of all Health Personnel through Competency – Based Training
Improving Household Behaviours and Preventive actions:
Integrated MCH Basic Benefits package with reproductive health Services especially family planning / pregnancy spacing.
Increased District Capacity in planning, management and monitoring of MCH services.
Maternal and child health care services are provided through a network of primary health care facilities spread in all governorates in rural and urban areas (about 5000 facilities) and through mobile clinics to reach slums and needy areas. MOHP provides MCH services as a part of a comprehensive package of primary health care services through family medicine program to achieve SDGs as follows:
19
1. Antenatal care services for at least 5 times to include providing clinical and laboratory investigations, anemia treatment and prophylaxis by iron and folic acid supplementation, providing adequate care for high risk pregnancies, health education on nutrition, family planning, early marriage and pregnancy before 20 years and female genital mutilation. These services are provided also in slum and needy areas by mobile clinics.
2. Safe and clean delivery that includes designing unified competency based protocols to train the health team and activating the role of hospital safe motherhood committees, renovation and equipping gynecology and obstetric wards at general and district hospitals, training of nurses on normal labor to replace traditional birth attendants.
3. Post partum care through home visits by nurses to follow up on the mother and the newborn and encouraging breast feeding and give the mothers vitamin A capsules and give the new-born zero dose of polio vaccine
4. Apply maternal mortality surveillance system at the national level through death notification and field investigation to identify the direct and indirect causes of maternal deaths and necessary action to avoid similar cases.
5. Supporting referral system between different levels of health services.
6. Family planning services and child spacing aiming to reach 3-5 years
7. Increase community awareness of women's health problems and available health programs
8. Applying preconception care program.
9. Follow up child growth and development; record immunization and nutritional status and record child's medical history through the health card.
10. Neonatal care program which includes neonatal resuscitation and intensive care for risky neonates to reduce neonatal mortality
11. Immunization coverage with basic childhood vaccines that include vaccination against ( 11) targeted diseases
12. Neonatal screening program for early detection of congenital hypo-thyroidism and (PKU) to reduce mental retardation, 2.6 million newborn are covered by this service every year.
13. Expand in applying IMCI program to cover all primary health care units at 283 health districts in 27 governorates to reduce under 5 mortality.
14. Encourage and support breastfeeding and Mother/Baby Friendly Hospital initiative and control of artificial feeding.
15. Elimination of micronutrients deficiency disorders program (Iodine-Iron-Vitamin A) through iodization of food salt, iron, folic acid and vitamin A.
20
16. Abandoned children and children with special needs care program that includes furnishing their centers and providing them with their daily needs.
17. Upgrade and support maternal and child health information system at every governorate (27) and health districts (283) to follow up health indicators at all levels.
Maternal mortality Surveillance System
A national maternal mortality Surveillance System was designed and implemented. The purpose of MMSS is to provide the needed data about maternal deaths in all governorates and accordingly to identify the possible preventive causes or factors of the maternal deaths in order to develop and implement actions to prevent the occurrence of future cases.
Training programmes were developed for management and technical personnel to equip them with planning, monitoring and evaluation skills, effective techniques for collecting data, particularly for MMSS, and data analysis.
MOHP has adopted the WHO definition of maternal mortality which defines a maternal death as "the death of a woman while pregnant or within 42 days of termination of pregnancy irrespective of the duration and the site of pregnancy, from any cause related to or aggravated by the pregnancy or its management but not from accidental or incidental causes (ICD-10, WHO1994)”
ICD-10 further divides causes of maternal deaths into:
Direct obstetric causes: Are maternal deaths resulting from obstetric complications of pregnancy, labor and puerperium in addition to deaths due to interventions, omissions, incorrect treatment or from a chain of events resulting from any of the above.
Indirect obstetric causes: Are maternal deaths resulting from previous existing disease or from a disease that developed during the pregnancy and which was not due to direct obstetric causes but was aggravated by the physiologic effects of pregnancy
In order to obtain data on a regular basis, the MOHP decided to plan and implement nationwide Maternal Mortality Surveillance System (MMSS).
This was done in four stages:
Stage 1 (1998): A pilot study took place in two districts in Alexandria and Menofia.
Stage 2 (1999): The results of the pilot study were evaluated. The design of the MMSS was formulated based on the results of the evaluation.
(Jan. Dec. 2000): All activities related to the MMSS were put on hold so as to avoid conflicting with or biasing the ENMMS 2000, which was in progress.
Stage 3 (2001): Beginning in January 2001, the MMSS was designed and implemented to include the following:
1- Designing the Death Notification Form (DNF) and death registration log book. The DNF includes information about the deceased female "sex, age, place of death, nationality, religion, marital status, occupation, address and cause of death".
21
Four new questions were added to the DNF to be answered if the death is of a woman 15-49 years of age:-
Did the death occur during pregnancy? Did the death occur during labor / delivery? Did the death occur during the six weeks after delivery? Did the woman have an abortion during the six weeks prior to death?
In addition to:
‐ Place of delivery or abortion.‐ Date of delivery or abortion.‐ Who attend the delivery or abortion?‐ Outcome of delivery.The latest modified version of the DNF includes questions about accidental or incidental causes of death (e.g., accidental death, presence of tumor, smoking). Most important, the DNF allows one to differentiate between a female and a maternal death.
2- Designing the MMSS questionnaire (MMSSQ).3- Training of trainers on all MMSS activities in all governorates of Egypt. 4- Establishing the various levels and timing of the data flow.5- Writing, publishing and distributing teaching materials.
Stage 4 (2002): The MMSS was implemented nationwide.
22
3. Policy and strategy of the MDSR
P0licy and strategy
MDSR national plan is developed (1) Yes
Leadership is the health Ministry or other institution? Ministry of Health and P0pulation
If Yes to what date the plan carry? 1999
What is the national policy requires that all deaths be reviewed? Political support
If so on what date this policy is adopted and what is the reference?
1999 –Ministerial decree No.159/1999
If your country has implemented the MDSR, since when it is implemented?
Pilot.1998
National.2002
The MDSR is implemented at the national level? Yes
If MDSR is implemented at the regional level, in how many administrative entities (the lowest) is it implemented?
5000 PHCunits,283 districts,27 governorates
What are the objectives defined in the country the MDSR • Identification of maternal deaths.
• Determination of maternal mortality ratio at the national and governorate level.
• Determination of causes and avoidable factors of maternal deaths.
• Development of Improvement Plans and taking action to avoid future maternal deaths.
What are the success factors that positively influence this policy? • A ministerial decree no (159) / 1999 was issued to notify all maternal deaths to MCH department and National Health Information Center (NHIC) .
• Wide spread of health offices (5000).
• Accurate registration of births and deaths.
Health Information centers at all governorates and health districts.
What are the factors of constraint to this policy? • Turnover of doctors and clerk at health offices
• Lack of assistant directors for MCH at some health districts
• lack of financial support for follow up the MMSS activities
• lack of transportation means
23
for investigation Difficulties face the
investigator to obtain reports of cases from some hospitals specially at private sector
What level of priority(*) granted to the MDSR (4: High; 3: medium; 1: low; 0: None)
High
24
4. Governance of the system of the MDSR
In 2002, MOHP decided to plan and implement the National Maternal Mortality Surveillance System (NMMSS) utilizing the following supportive potentials:
The ministerial decree No.159 on 17 July 1999 was issued stipulating that it is compulsory to report all deaths occurring during pregnancy, labor and puerperium (42 days after delivery) within 15 days from the date of death. The decree also stated that all death reports be sent to General Directorate of the MCH and Health information system with complete information on cause, age and residence of the deceased women.
Obligatory registration of births and deaths. Wide distribution of Health offices (5000) for registration of births and deaths. Health information centers at all governorates and health districts. On July 4, 2002, the Ministerial Decree No. 197 stipulated the creation of the central
safe motherhood committee headed by the Minister of Health and Population, to formulate a plan for the reduction of maternal mortality ratio in Egypt. Following the decree, safe motherhood committees were also established at the levels of governorates and districts.
Purpose and objectives of the MMSS in Egypt:
Identification of maternal deaths. Identification of causes and avoidable factors of maternal deaths. Developing improvement plans and timely action for prevention of maternal deaths.
As affirmed during the in depth interviews conducted with senior MoH officials, there is strong political support from His Excellency Minister of health and population to maternal mortality reduction, leading to increased interest from the Primary Health Care Sector and the Maternal and Child Health directorate to focus on gathering quality data, and thus enhancing the MMSS.
Is there a law or regulation on the MDSR (especially for the notification of deaths...): If Yes, Cite the texts relating
• A ministerial decree no (159) / 1999 was issued to notify all maternal deaths to MCH department and National Health Information Center (NHIC) .
What are the guides and manuals of the MDSR: Dates, edition, target audience...
Guideline for implementing MMSS
Is there a unit MDSR at central level (focal point) and what it’s role?
Yes
Is there a unit MDSR at regional level (focal point) and what it’s role?
YesCo ordinate, implement and follow up the activities of MMSS
List of stakeholders involved in the MDSR - Head of PHC sector.- Head of preventive sector.- Head of curative sector.- Undersecretary of integrated health care.- General director (GD) of MCH.- Head of population and FP sector.
25
- Undersecretary of intensive and emergency care.- GD of blood and its products affairs.- GD of health information centers. - Head of nursing sector.- Representative of medical syndicate.- GD of nongovernmental health facilities and license.
What training institutions (University hospital, medical schools, schools of nursing...) are involved in the MDSR?
Yes, as members of safe motherhood committee
As technical advisory committee.
Describe the process of the MDSR at national level: national Committee, membership, and roles
The MMSSQ is used to investigate maternal deaths by collecting information about the deceased women from family members at home and health care providers at health facility (public or private).
The interview is carried by district assistant director for MCH covering information not provided by DNF, such as information about demographic, obstetric history, prenatal care, current pregnancy, labor and delivery (place, attendant, time, duration, method, complications, referral, transportation, management, medications, blood transfusion, etc….) place, date, time of death, immediate cause of death and other contributing factors.
There is a narrative description of the circumstances of the maternal death to allow the assistant district director for MCH to include additional information not included in the MMSS, and identify three types of delays:
‐ Delay in making a decision to seek care.
‐ Delay in arriving to the facility once the decision to seek care has been made.
‐ Delay in getting proper quality care after arriving to the facility.
Another form used in the MMSS is the Safe Motherhood Committee Decision Form and
26
the improvement plan for proper management of each case. Those forms are used by the SMC to record avoidable factors which contributed to the death and the interventions that need to be implemented to avoid future deaths.
Membership:- Head of PHC sector.- Head of preventive sector.- Head of curative sector.- Undersecretary of integrated health care.- GD of MCH.- Head of population and FP sector. - Undersecretary of intensive and emergency care.- Undersecretary of research and health development.- Undersecretary of pharmaceutical affairs.- GD of health education.- GD of blood and its products affairs.- GD of health information centers. - Head of nursing sector.- Representative of medical schools.- Two professors of OB/GYN.- Two professors of neonatology.- Representative of medical syndicate.Roles - Set up the suitable plan for reducing maternal deaths and co ordinate between different related sectors.- Follow up the implementation of the plan and provide the necessary resources. - Follow up the local SMC at the governorate and districts .
MDSR at the decentralized level process: regional Committee, membership, and roles
As the national committee.
What are the partners involved in advocacy for the MDSR at the decentralized levels?
Media, UN agencies, community leaders, National Council for childhood and Motherhood, population councils and related NGOs
Who are the partners who provide technical support for the implementation of the MDSR?
MOHP - WHO - UNFPA - USAID - UNICEF – universities
What are the partners involved in support for the MDSR training?
MOHP - WHO - UNFPA - USAID – UNICEF
What are those who are involved in the implementation of the MDSR at the lowest administrative level?
Health officers and health clerks at health office (health bureau)
Who are the partners involved in the fundraising efforts of MDSR?
MCH General Directorate and under secretary of integrated health care
27
Were NGOs involved in the implementation of the plan?
Raising community awareness and advocacy.
Does a mortality review committee or its equivalent exist?
Yes
How often the national maternal mortality Review Committee?
According to the decree 197/2002 every three months for national committee and every month for local committee but actually the national committee maybe meet every year.
What administrative level is low or a maternal mortality Review Committee exists?
District and hospital level (some times)
How many of these lower levels have a Review Committee?
25-50 %
How many review committees are functional? 50 %
How often the Committee of review cases at the level the lowest meeting?
According to MD cases, maybe every 1- 3 months.
What is referred to a special agent? Who is this person?
Yes - DR AMAL ABD ALHY(obstetrician at maternal unit at MCH GD)
What the Committee included representatives of:
Technical staff Yes
Private sector When needed.
Administrative Yes
Representatives of the NGO community When needed.
Representatives of registration of civil status When needed.
Representatives from other sectors Yes (related MOHP sectors, e.g. curative, preventive, family planning sectors)
Other describe Yes (health providers related to MD cases)
What are the mechanisms of coordination between the partners involved in the MDSR at central level (strategic)
Feedback mechanism Periodic meetings
What are the mechanisms of coordination between operational and decentralized level technical partners (responsible for the declaration, notification, review, analysis, dissemination, response...?)
Feedback mechanism Periodic meetingsWorkshop, Training Courses
28
5. The MDSR implementation process
The MDSR is used to investigate maternal deaths by collecting information about the deceased women from family members at home and health care providers at health facility (public or private).
The interview is carried by district assistant director (DAD) for MCH. The MMSSQ covers information not provided by DNF, it gives detailed information about, demographic, obstetric history, prenatal care, current pregnancy, labor and delivery (place, attendant, time, duration, method, complications, referral, transportation, management, medications, blood transfusion, etc….) place, date, time of death, immediate cause of death and other contributing factors. In addition a section of MMSSQ for inclusion of a narrative description of the circumstances of the maternal death to allow the assistant district director for MCH to include additional information not included in the MMSSQ. Questions have been added to the questionnaire to collect detailed information about three types of delays:
‐ Delay in making a decision to seek care.‐ Delay in arriving to the facility once the decision to seek care has been made.‐ Delay in getting proper quality care after arriving to the facility. Another form used in the MMSS is the Safe Motherhood Committee Decision Form
and the improvement plan for proper management of each case. Those forms are used by the SMC to record avoidable factors which contributed to the death and the interventions that need to be implemented to avoid future deaths.
The existing infrastructure for reporting death is being used to identify maternal deaths. Health officers are requested to give special attention to every death of a female in reproductive age, ensure that the four pregnancy related questions are answered & ensure that an accurate cause of death is identified.
5.1. Declaration of the death of the WRA1
All deaths of women in reproductive age (15-49 years) are reported to the district assistant director for MCH within 7 days. In case of maternal mortality; the clerk of the health office should report (within 24 hours) to the district assistant director for MCH to complete the investigation. In turn he visits the families and hospitals to complete the MMSSQ for all cases where the answer to any of the four pregnancies related questions is (yes). He also visits or call the relatives of the case of 50% sample of non-maternal female deaths to investigate and determine any association with pregnancy to be sure that reported female deaths do not include missed maternal mortalities.
To ensure accurate registration of maternal deaths and avoid missing maternal deaths the training of clerks and health officers has been developed to focus on case definition, not excluding unmarried women, in depth discussion of the DNF pregnancy related questions and the importance of completing the forms correctly.
1
29
The DNF filled by the health officers and clerks of health office is the main source of data for civil registration authorities and health authorities.
Declaration of the death Situation of registration of deaths in the country (civil status): More than 95%, it is
compulsory.
Briefly describe the system of registration of deaths by marital status: who? How? What support? What channels?... (Support in annex)
As the following
(annex)Are all deaths reported in the country at the urban and rural level? YesWhat is the percentage of declaration of death in the country More than 95%Is that what all deaths of women of reproductive age are reported? YesDid the deaths of adolescents (under 18 years old are reported) YesWhat is the system of transmission of the deaths of the WAR (model sheet)? As the following
(annex)Is there a system of transmission by telephone, internet or other technology? No Is there a mechanism of coordination between the civil State services and the Department of health?
Yes
Is there a system of declaration of migrants and refugees? Yes
Description of Maternal Death Registration systemIn EGYPT
Definition
The Tenth Revision of the International Classification of Diseases (ICD-10) defines a maternal death as: the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management but not from accidental or incidental causes.
Steps of Implementation
• Design data collection tools ( death notification form ,registers and Maternal Mortality Surveillance System Questionnaire
• Design software to collect and analyze data• Train appropriate staff at the three levels.• A Ministerial Decree No. 197/2002, was issued to form a National Safe Motherhood
Committee headed by His Excellency Minister of Health and Population and encompassing head of all related health sectors.
• Form local Safe Motherhood Committees at governorate level
30
5.2. Notification of maternal deaths
The health officers and clerk is responsible for forwarding the DNF to the district on weekly basis. The district assistant director for MCH meets with the health information system officer and the preventive care inspector to correlate the number of female and maternal deaths. The DAD for MCH conducts interviews with the family members and health providers to fill the MMSS questionnaire within 15 days from death. The DNF and MMSSQ are sent to governorate health directorate within 15 days from death. All collected forms are revised to insure completeness and accuracy to be sent as hard copies to the health information center at MCH central level.
Notification of maternal deaths
Is the maternal death a reportable event? Yes
If so, from what date this policy adopted? 1999
What the statement '' case zero " is adopted by the country? (3) Yes
How is the notification of maternal deaths? (4) Mentioned at data flow diagram
What is the proportion of deaths having been notified by the administrations of the first level?
More than 95%
What is the total number of maternal deaths reported during the last year? Quote the period please.
1194 (Jan – Dec – 2016)
How often the most decentralized units report deaths to the national Committee?
1-2 months
What is maternal in 42 days and late deaths (more than 42 days are declared)?
In post partum (42 days) only.
What is the approximate time between death and the declaration? 24 hour
Number of facilities based maternal deaths notified, during the last calendar year (please state the period) (6)
575 health bureau(office)
Number of maternal deaths notified within 24 hours during the past year? 1194
Number of maternal deaths in the community during the year increased please specify the period
1194
number of live births reported in each lowest administrative level the previous year
2.600.173
Detailed description of the mechanisms and procedures of data collection Mentioned at data flow diagram
How is the notification of the death of WAR 15-49 years Mentioned at data flow diagram
How the investigation of pregnancy-related deaths? By using MMSSQ (Annex)
What are maternal deaths well reported? Yes
31
NHIS and MDSR: what is the relationship between the death of the reported pregnancies and the NHIS? What integration?
The number of MD at MMSS is more than at HMIS
What is the circuit of the declaration of the WAR? As the previous annex
Deaths in the private sector are reported and how? Yes as any case at public facility or at community.
The death of pregnancies occurred among migrants and refugees are reported? If Yes, give an example.
Yes, the same measurement taken for Egyptian women.
NB: (MD case) A Syrian women 37 years old died on 22/6/2017 during transportation to the hospital suffering from severe chest pain.
She had delivered at private hospital on 6/6/2017 by caesarean section.
32
5.3 Maternal Deaths Review
The safe motherhood committees "SMC" at governorate level meets every month to review all forms. The committee also determines the avoidable factors in each maternal death and reviews / confirms the cause of death. In addition the SMC formulates an improvement plan.
The DNF, MMSSQ and SMC reports are sent as hard copies to the MCH general directorate on monthly basis with the monthly report. Data are checked at central MCH department and forms are sent back for completion if necessary. Quality control should be done on a sample of MMSSQ in selected governorates by MCH staff at central level.
Maternal Deaths Review
Who does the review? MCH assistant at DistrictsMCH director at Governorate MCH team at the central level
What is the frequency of MDR? Monthly
Does the Committee discuss maternal deaths cases Yes
If yes what is the discussion about all cases or only a portion? (% of reviewed death cases)
During SMC meeting - presentation of cases to determined the cause of death and avoidable factors according to the number of cases, may be all cases or 50%
Are the family members invited to participate to the review? NO
Among administrative units at the lowest level reporting maternal deaths, how many of them conduct MDRs?
All of them
Total number of maternal deaths reviewed by the Committee at the lowest level in the past year
About 50 % of case
Total number of verbal autopsies conducted for doubtful deaths cases in a year? (8)
50%
Describe the way MDR is conducted ? Mention before
What are the tools used for the MDRs (list and brief description)?
DNF - MMSSQ - SMC form - IP form - Performance evaluation form at ( health office - district- governorate -health information centers)
(Annex)
Is confidentiality respected and how? Yes
What is the coverage of the maternal deaths? 100 %
33
5.4. Analysis & interpretation of the aggregated data
Data Analysis and interpretation
How are the analysis and data processing ? Microsoft Access
Are maternal deaths records properly informed? Yes
Results from the latest national report (year) 2016
How many national reports have been developed since the adoption of the MDSR (with dates)
Every year
Since 2002
How many regional reports have been developed since the adoption of the MDSR (with dates)
Every year
Since 2002
What are the tools used for the analysis? Performance evaluation tools
What are the levels of analysis (Central, regional, district,...)? All levels
Brief description of the MDSR reports available :
What is the number and the percentage of maternal deaths reviewed?
50% of 1194
What is the place (% death at home, on the road or in a health institution: primary, secondary, tertiary, public or private)? Areas Urban, Rural...
At home 24%
At health facility 76% 2016
For facility-base deaths, what percentage of deaths by service (emergency, maternity, reanimation...)
NA
What are the percentages of deaths compared with the pregnancy period: Ante partum, per partum, postpartum or post abortion?
During pregnancy 24.1%During Delivery 32.1%Postpartum 43.8%
What is the status of the newborn at birth? S.B 18.3%Live 63.8%Referred to ICU 12.9%Died during delivery 5%
What is the geographical distribution of the deaths? National 46 Urban 63Lower Egypt 39Upper Egypt 47
What are the socio demographic characteristics of death cases ? Represent all categories of the community.
What are the main causes of death? Postpartum Hge. Hypertensive disease
What are the causes of death by group of causes: direct obstetrical Causes, and indirect obstetric causes, not determined causes?
Direct Causes 65.9%Indirect Causes 34.1%
What are the percentages of death by: hemorrhage (including Hemorrhage 24.5%
34
Uterus Rupture), pre-eclampsia and eclampsia, Infections and complications of abortion.
pre-eclampsia and eclampsia 16.1%Infections 3.5%Abortion 1.4%
What is the percentage of late maternal deaths cause?
What is the percentage of fortuitous cause of maternal deaths?
0.15%
5.8%
What is the percentage of avoidable deaths? 77.9%
Which are the independent factors related to the avoidability of the deaths ? (Factors related to the woman /family, factors related to the community,factors related to human resources, factorsrelated to transport, factors related to the lack of means such as the transfusion… and other factors)
Factors related to woman and family: 56 cases
community,factors :88 cases
factors related to the lack of transfusion , blood and other :36 cases
Which are the principal recommendations agreed upon? - Allocate adequate resources to provide transportation facilities for central, governorate and districts levels to support supervision, MMSS and other MCH activities.- Support and strength the established Technical Advisory Committee (TAC) at (MCH) center level to review all the investigated maternal mortality cases to identify the main causes of deaths, the contributing avoidable factors and recommends actions to prevent similar cases.- Involve the medical syndicates in governorate safe motherhood committee to take recommended action towards the unsatisfactory performance of public and private specialists during management of cases. - Ongoing training activities should be done for the health officers and clerks at the level of health unit to overcome the high turnover of them.
Up to what point were the recommendations implemented? - Technical advisor
35
committee was establishing at MCH central level in 2017.
- Two cycle of midwifery training.
one implemented at Sohag in upper Egypt and the other at M.Matroh 2017.
- Training of obstetrician at general and district hospital on CEMOC (22 doctor at Sohag and 22 at Alex) 2017.
- Dedicate team of obstetrician at MCH at central level to be in charge for MMSS activates.
Why the recommendations are not implemented? Inadequate financial support for transportation at central, governorate and district level.
Insufficient coordination and cooperation between different sectors at MOHP.
Annex: notification sheet and maternal deaths summary case note
5.5. Dissemination of results
Data from DNF and MMSS are entered and processed using a special computer program at central level. Findings are shared with SMC at central level to discuss the recommended action or interventions, feed back to MOHP officials at all levels through reports and seminars.
Dissemination of results
Describe the mechanisms whereby the information and recommendations from the national Committee are disseminated to health structures, to the lowest level and to communities
Feedback mechanism
Periodic meeting
Press conference
The national committee produces an annual report and recommendations? Yes
the regional Committee produces an annual report and recommendations Yes
How can stakeholders access to the reports Through meeting of SMC Committee
Who should receive the reports (health, NGOs, other sectors, media...) All of them
Apart from the detailed report, is there is a summary of the report that is disseminated?
Yes
Is there a mechanism for dissemination of certain recommendations in the community?
Yes
Raising awareness
Among the following dissemination mechanisms which ones are available in the country
Team meetings Yes
Thematic seminars in healthcare facilities Yes
Community meetings Yes
Broadcasting Yes
Printed reports Yes
Training programs Yes
printed Reports for decision-makers Yes
Statistical publications Yes
Scientific papers Yes
Professional conferences Yes
Press releases Yes
Internet sites Yes
Letters and newsletters Yes
Information sheets Yes
36
Posters NO
Video clips NO
5.6. Response
Response
What is the number of recommendations in the final report? 24
Extent to which the recommendations have been implemented and what is the scope of application? give some examples of recommendations implemented and not implemented.
Establish of Technically advisory Committee at the central level
Prepare and printing 6000 copy of MMSS guidelines in 2016.
Prepare and print 5000 posters of case definition of maternal death.
18 SMC Meeting at governorate level.
Allocated resources for transportation of central investigators and supervisory team
The recommendations are translated into strategies and action plans? Provide few examples.
Yes, established central technical advisory committee
Tools and The data flow of the MMSS are outlined in the following figure:
Tools of Data collection
1. Death Notification Form (DNF) Annex2. Maternal Mortality Surveillance System Questionnaire (MMSSQ) Annex
37
38
Hospital Home
Health Offices Health
Officer/Clerk
District Health Offices District Assistant Director for MCH
Governorate Health Directorate Safe Motherhood Committee
Central MCH Department Safe Motherhood Committee
InterviewDNF
MMSQ
Interview
Avoidable factors And causes of deathImprovement Plan
DNFMMSQ
Flow of data in MMSS
Quality Control:-
• Field visits to health offices to supervise the programme implementation • Review all investigated case reports and feed back comments to the governorates.• Reinvestigate 5 % of all maternal mortality cases. • Attendance of local safe-motherhood committee. • Follow up actions taken by safe-motherhood committee to prevent future deaths.
39
5.7 Resources
While the maternal mortality surveillance process requires a lot of technical and financial resources, there is no specific budget line in the ministry for this. The budget comes as a part of the total amount allocated for the maternal and child health directorate.
Partners: UNICEF, UNFPA and WHO also provide financial and technical support to the program in general and not specific to the surveillance. Also there are funding gaps which they cannot sponsor and have no allocations in MoH such as travel allowances of surveillance clerks. This poses a challenge on the sustainability and accuracy of the system.
Technological resources are available and well functioning where data entry and data processing software are in place. There are also sufficient and comprehensive guidelines and resources available to ensure that staff are well performing according to standardized procedures, where there is a detailed guideline for MMSS.
ResourcesTotal budget for the implementation of MDSR? NAsource of funds allocated by the partners:
‐ Ministry of health NA‐ UNFPA 2.500.496 LE for all maternal
health activities including MDSR
‐ WHO 78,224 L.E for all activity of MCH
‐ UNICEF NA‐ Other (define) NA
Availability and use of appropriate technology: data entry and data processing software
Available
Human resources: staff training guides have been developed. If so, please list all
Guideline for MMSS Midwifery training Training of obstetrician at hospital on CEMOC MCH training guideline
Is in-service training planned and implemented. If so, briefly describe.
OJT for health officer and clerk at health office
What logistics and financial resources are available for travel within the community?
Lake of means and fees for transportation of investigators and supervisory team
40
5.8. Monitoring and evaluation (M&E) of MDSR system The MMSS has incorporated an element allowing the on-going internal evaluation of
the system. It is based on a system of three specifically designed Performance Score Checklists addressing the tasks performed at the levels of the health office, the health district and the health directorate at the governorate level. The staff for which the checklists are designed at each level are comprised of the following:
Health office: health office and heath clerk. Health District: district assistant director for MCH: director of the HIS; and
preventive care inspectors. Health Directorate: MCH director: director of the HIS: and director of
preventive care.The checklists and performance scores allow the MoHP to monitor the level of
acceptance of the system, the sensitivity, specificity, and timeliness of reporting. Although it is primarily designed to support the function of the system as designed, it can also be used as a tool for improving the MMSS. An external evaluation of the system must also be conducted on a regular basis against the criteria stated in the SIPs.
Explore… ResultsIs there an M&E mechanism for MDSR in place? If Yes, please describe the mechanism?
Yes, using performance evaluation form for all levels of MMSS
Describe the established M&E system to check whether the recommendations are being monitored?
What are the M&E indicators used - Availability and completeness of MDRS tools.
- Knowledge of health team to define MD.
- Review and active surveillance for female death at reproductive age 15 – 49 years.
What are the country perspectives to improve and extend MDSR?
Taking action to improve quality of services to reduce maternal deaths
Has the country introduced newborn deaths surveillance? Yes, as a pilot study at assuit governorate.
If Yes, what are the measures adopted? Hospital based and verbal autopsy at the community (Annex)
Do decision Makers think that MDSR is a relevant approach for maternal mortality reduction?
Yes
Do decision Makers think that MDSR is a heavy and expensive approach?
Yes
Do decision Makers think that MDSR is a a sustainable approach? If not, why?
Yes
41
M&E Indicators
Among the indicators listed below, what are the ones adopted in the country and what is their assessment. Is there other indicator for M&E? , If so, list them.
Indicator
Indicators of MDSR System
1. Maternal death is a reportable event Yes
2. There is a National Maternal Death Review Committee that meets regularly
Yes
3. Percentage of regions with an MDR committee 100 %
4. Percentage of regions with a person responsible for the MDSR
80 %
Notification Indicators :
5. Number of maternal deaths reported in the year (the most recent year specified)
1194 (2016).
6. Number of maternal deaths reviewed in the same year: (Institutional and in the community )
About 50%
7. Percentage of death cases reviewed 50 %
Analysis:
8. Percentage of hospitals with a maternal death review committee
20-50% active
9. Number of institutional deaths and percentage cases reviewed
908 MD, About 50% reviewed
10.Number of deaths reported by the community that were subject of a verbal autopsy
1194 all cases are subjected to verbal autopsy.
11.The death causes are well defined In most cases as groups of causes
Quality 12.The regional Committee compile all deaths of women in
reproductive ageAbout 50%
13.The Committee defines and ensures pregnancy-related deaths
Yes
14.The notification forms are properly completed 60 %
15.All forms are submitted to the Maternal Death Review Committee
About 50%
Response 16. MDR Committee has an action plan with well-defined
activitiesYes
17.Number and percentage of recommended activities and implemented during the year
Establish a technical advisory committee at the center level to review the MD cases and set up recommendation.
18. MDR Committee holds regular meetings (at least quarterly)
Yes
19. The focal point is regularly notified on maternal deaths Yes
42
20.All reported maternal deaths are reviewed within 48 hours Within 15 days the assistant director of MCH do the interview with the relative and with the health providers and the staff attended the delivery, then he sent the MMSSQ to the MCH director at the governorate level to review and discuss the cases at the Safe Motherhood Committee (SMC)meeting
21. Health providers use the recommendations to improve the quality of services
Some times
43
6. Case Study and Desk Review
For the purpose of the study, the study team conducted a desk review about the national MMSS during the month of August 2017. This was done through:
f) In-depth interviews with responsible staff at MCH general directorate, medical syndicate, concerned UN agencies and relevant stakeholders.
g) Review of steps of implementation and system description h) Revision of samples of the available collected data and forms "DNF, MMSSQ,
monthly report form, quality checking actions and performance monitoring system.i) Study the available information about maternal mortality at national level during the
last years and the report of analyzed data at MCH information center. j) Revising the actions taken by national and local safe motherhood committees, activity
for improvement and constrains
In-depth interviews:
Interviews were held with the following MOHP officials:
- Dr. Mona Hafez, Head of Primary Health Care sector. - Dr. Nahla Roshdy, Undersecretary of Integrated Health Care. - Dr. Khaled Otafy, General Directorate of Maternal and child Health - Miss Ibtessam Mostafa, General Directorate of National Health Information Center
MOHP- Dr. Soad Abdel Megeed, Head of Population and Family Planning Sector. - Dr. Aly Mahroos under secretary of Nongovernmental Health Facilities and License. - Dr. Essam Haroon ,General Director of Nongovernmental Health Facilities and
License. - Dr.Yasser Salah Eldeen, Director of Maternal Health Unit at Maternal and Child
Health Directorate. - Dr. Amal Abd ElHay and her team, Office in charge of MDRS activities maternal
health unit at (MCH GD). - Dr. Nanees Abdelmohsen, director of Perinatal care program at MCH GD- Dr.Fawzee Fathee ,coordinator of MCH care program for Syrians Refugees .- Mr.Ahmed Hussein,Mr Mohamed Abdeltawab and their team at MCH health
information center.General Directors and Undersecretary at governorate level:
- Dr. Kawther Ahmed Imam, Director of MCH (EL Fayum). - Dr. Amal Mohamed Hashem, Undersecretary (EL Fayum). - Dr. Waffa Ismaeel,Director of MCH (Cairo). - Dr. Alae Osman, Undersecretary (Behara). - Dr. Medhat Nawar,Director of MCH (Behara).
44
- Dr. Abdelnaser Hemeda, Undersecretary (Benisuef). - Dr. Shereen Salah Eldeen, Director of MCH (Benisuef). - Dr. Naglae Morshedy, Director of MCH (Giza).
Interviews were also held with MCH experts:
- Dr. Essmat Mansour ,Former Head of PHC and Nursing sector and consultant of PHC ( MOHP).
- Dr. Alaa Sultan, Consultant of Obs/Gyn , Former Director of maternal health unite at MCH GD.
Professors of obs/ Gyn and Paediatrics at Medical School:
- Dr. Emad Darweesh: Alexandria Medical School. - Dr. Ehab Abd ElFattah: Ain shams Medical School- Dr. Ayman AbuAlnour: Ain shams Medical School. - Dr. Yasser AbuTaleb: Ain shams Medical School. - Dr. Monera Gad: Alazhar Medical School. - Dr. Nahed Fahmy: Cairo Medical School and member at national Safe Motherhood
Committee. Medical Syndicate:
- Dr.Mohamed Almenes, Head of medical syndicate at Behera governorate. UN Agencies:
- UNFPA: DR Maha Wanis, Reproductive Health Programme Officer - UNICEF: Dr. Essam Allam, Health Officer. - WHO: Dr Hala ElHennawy, National Professional Officer
The interviewees affirmed the following issues:
- There is strong a political support from His Excellence Minister of health and population.
- Turnover of health officers and clerks at health bureau (office) hampered the accuracy and completeness of data of death notification form and death register so they need more training and orientation.
- At Upper Egypt and Frontier governorate, there is a shortage of doctor to be in charge of MMSS at the level of districts, this lead to use the chief nurse to conduct the surveillance
- MMSS is a tool to determine MMR at national and governorate level with accuracy more than 95%,due to good notification and registration. But investigation is not accurate in some cases due to hidden information by health providers especially at private sector.
- Insufficient documentation of the process and interventions at some hospitals (private and public). In case of availability of these documents, it was uncompleted.
45
- The causes of maternal deaths are not specific, not accurate and are in grouping, as: Hemorrhage, Hypertension, Anaemea, Sepsis.
- Due to lack of transportation and financial support, some investigations are completed through telephone.
- Training of obstetricians should be according to specific causes of death and malpractices
- Don’t blame the health providers but try to inquires about the process and the possible causes of deaths, and mentoring them about the risk of some intervention.
- In case of repeated caesarean sections and placenta previa acreta, the lady should stay at hospital under close observation of vital signs and vaginal bleeding for about 3 days.
- Activate the high risk pregnancy clinic at all hospitals and the availability of woman health card to record in it all the available information.
- Ensure the availability of blood and blood products, and call (Hot line137). - The data of MD at private sector is not accurate (it is more than registered), because
they allow to the family of the deceased case to take her to their home, so it is calculated that it died at home.
- There are no protocols of services in most of hospitals (private and public). - There is a mortality and morbidity committee at all public hospitals but it needs to be
activated. - At SMC meeting, representative of hospital that have maternal deaths should attend
the discussion of case study from medical aspect. - The coordination between MCH and Curative Sector is very important to improve the
performance, availability of guidelines and raising capabilities of obstetricians at public and private hospitals.
- Apply performance standards of obstetric services at public and private hospitals for achieving the integration in provision of emergency obstetric care.
- The Central and Local Administration of Non Governmental Facilities at MOHP should collaborate with Medical Syndicate to monitor performance at private sector facilities, and take the appropriate corrective actions.
- Change of risk factors where other factors were not considered at the time of establishment of the system, such as (A) increasing the rate of cesarean section up to 52% (DHS2014) while it is 18% at the rest of the world, which leads to complications and problems, one of these problems related to the procedure of the operation (due to abdominal surgical incision and the consequent complications from inflammation and Medications resistant), and the other is the surgical operation itself (anesthesia and the doctor's skills). (B) Increase in stunting rate in Egypt, reached to 29% from 21%, which affects the girl's pelvic size in and leads to increased risk to the mother during childbirth. (C) Increase the age of marriage at educated woman in urban area and decrease age of marriage at rural area both of them consider risk factor not taken in consideration in a policy development and recommendations.
46
- The system has no feedback that allows decision makers to avoid death-related errors such as: A. Circumstances surrounding the provision of service from (referral system, availability of ambulances and blood banks) to respond quickly when complications occur. B. Medical errors that occur during the process.
A. Interviews with UN agencies Interview with UNFPA
Dr. Maha Abdelwanis, Reproductive Health Program Officer at UNFPA explained that since the signature of Dubai declaration in January 2013, UNFPA has extensively collaborated with the Ministry of Health to accelerate the reduction of maternal mortality in Egypt and to support the country in meeting MDG5.
UNFPA is a partner with the ministry of health to assist in developing and executing the national plan for maternal and child health; through strengthening the national health system to enable it respond to the need for reduction of maternal mortality. UNFPA is directly contributing to strengthening the maternal deaths surveillance system through technically and financially supporting regular review of the system, to identify and address gaps and challenges.
UNFPA is also supporting regular meetings conducted by the central administration in the Ministry of Health, MCH to all governorates, known as safe motherhood committees, which examines the results of the maternal mortality surveillance system, and conducting an in-depth review of MD cases. This committee gives recommendations about case surveillance that might lead to partial or total re-investigation. Feedback is given to relevant authorities at the governorate level for appropriate response.
UNFPA also supports the analysis of data gathered from the system at national and governorate levels to enable specifying MMR, causes of death and highlights correlations between different variables.
The RH officer explained that the Egyptian maternal mortality surveillance system is one of the most successful and comprehensive systems in the region, which has a remarkable ability to specify MMR at national and governorate levels, as well as direct and indirect causes of death. Yet it’s believed that the accuracy and quality of data collection needs enhancement at governorate level, specifically when it comes to detailed causes and circumstances of death.
On the other hand, the response part needs strengthening. Corrective measures need to be identified and enforced. Also more control on private sector practices should be enforced. The coordination mechanism between different entities providing maternal services but not under direct authority of MoHP, such as military hospitals, educational hospitals, etc., needs evaluation and review.
UNFPA recommends enhancing the capacity of surveillance at governorates where gaps are identified, continuing detailed examination of individual cases and system supervision, capacitating health personnel on identified areas of weaknesses, exercising more
47
control on private sector practices, enhancing the communication skills of the surveillance team to be able to communicate with immediate family members of the deceased, and improving in-depth and secondary analysis of collected data. Moreover, it is recommended that a higher committee coordinates with different entities, investigate cases, and supports response and corrective measures where applicable.
Interview with WHO
Dr Hala ElHennawy, National Program Officer, WHO/Egypt acknowledged that Egypt has a success story for reducing its maternal death in a relatively short time. These achievements came as a result of concerted efforts led by the Ministry of Health and Population, and supported by different stakeholders
WHO supported the formulation of a central technical committee, for in depth review and expert analytical rereading of cases of maternal deaths, resulting in recognition of an emerged new pattern of maternal deaths that needs prompt response & action in the form of “ Refining the process of filling out the maternal mortality surveillance system questionnaire to ensure performing thorough verbal autopsy to help accurate recognition of the maternal killers and the main contributing players of the scene”.
Consequently, technical capacity building of the team of MCH director assistants was supported. Also, the surveillance system was used to develop a national action plan for the prevention of maternal deaths.
WHO also supported the MMSS review in 2014. Accordingly WHO believes that there are challenges facing the system like:
- Missed opportunities, if properly utilized, could help to refine the MMSS in Egypt
- Inadequate human resources capacities due to high turnover
- Under-utilization of available data.- The need for more frequent reviews, by senior obstetric consultants
On the other hand, the system has many opportunities:
- Functioning heath offices (5000)
- Functioning MMSS
- Registration system of births & deaths
- IT canters for health information covering all governorates & health districts
- Clear Strict policy for notification of all maternal deaths to the MCH department at
the district & governorate levels (the ministerial decree No.159 in 1999)
48
Interview with UNICEF:
Dr Essam Allam discussed the Perinatal and Neonatal Mortality Surveillance System (PNMSS). It was implemented by MCH-GD of PHC sector of the MOHP with the technical and funding support from UNICEF and USAID. It began in Assiut governorate of Upper Egypt in 2010, which has high perinatal mortality rates, and was since expanded to include Minya, Sohag and Qena governorates. The PNMSS has been shown to be an effective method to obtain data on perinatal and neonatal deaths, many of which would have been missed by the vital registration system. The PNMSS had two main components: a hospital component and a community component.
B. Review of samples of available data and forms: The collected data forms during last 6 months of 2017 were reviewed. It included the
monthly report forms coming from the governorates "DNF, MMSSQ, SMC reports and the summary report of cases" In addition to the evaluation form of visited health offices.
The IT responsible staff receives all the filled forms from all governorates. They check the completeness of data and the correct filling of forms. All the checked data forms are to be entered and processed at MCH central information office, the designed computer program was used for data analysis to produce monthly report and feed back for dissemination to involved staff at central and governorates levels.
Study of available reports, provided during the interview with health information center at MCH, during the last years showed continuous decrease of national maternal mortality ratio as a following:
- The maternal mortality ratio declined from 84 per 100.000 live births in 2000 to 46 in 2016 with 45.2 % decrease.
- Proportion of female deaths represented by maternal deaths (% MD/FD = 5.02%) is lower than the figure reported in 2000 (6.9%).
- According to time of MD compared to MMSS 2000, Deaths in 2016 were more likely to occur during postpartum period (43.8% compared to 26% in 2000)
- 39% of referred cases to high level were from the private sector.- 86.4% of cases had ANC follow up; about 91% of them were at private sector.- Direct causes of death (65.9%) and indirect causes (34.1%).- According of the direct causes of death, hemorrhage, especially postpartum is the
leading cause of deaths (18.1%) followed by hypertensive diseases (16.1%). - In MMSS 2000, sepsis was the fourth cause of death (8%) whereas in 2016, sepsis
was the fifth cause of death (3.5%)- In 2000 pulmonary embolism was the eighth cause of death (4%) whereas in 2016
it was the fourth cause of death (6.8%).
49
- According to indirect causes of deaths, cardiovascular diseases of pregnancy (9%) and respiratory tract diseases (7.7%) were the most frequent indirect cause of deaths.
- According to outcome for the fetus or infant, in 2016:o Stillbirths 18.3% o Died during delivery 5%o Alive and referred to ICU 12.9%o Alive and normal 63.8%
- According to avoidable factors:o Delay in recognize problem 56 cases o Seeking medical care 52 caseso Lake of transportation 13 caseso Lake of drugs, supplies and equipment in health facilities 8 cases o Lake of health providers 8 cases o Lake of blood 4 cases
- 76% of the cases occur at hospital "public or private" with increase of deaths in private sector from 36.1% (2013) to 39.1 (2016).
- About 85% of deliveries of deceased women at hospitals were attended by consultant and specialist.
Study of actions taken by local SMC at governorate level revealed inadequate recommended action and unsatisfactory implementation of activities to improve the situation due to shortage of resources and disturbed working environment.
Review of the organization structure of MMSS at MCH General Directorate
It was explained by Dr. Khaled Otafy General director of MCH that:
During the year 2017, a full time an obstetrician was chosen to be in charge of managing the MMSS in addition to two assisting obstetricians (all are full time for MMSS activities), reporting to the director of maternal units at MCH GD. Another team of 9 part-time physicians who work in MCH general directorate assist in supervision of MMSS (part time).
There is a team of statistical specialists and administrators at the MCH health information center responsible for data entry and clerical tasks.
All the resources and means of communication needed for data entry, review and developing reports are available for the team managing the information center.
Recently a technical advisory committee was formed at the central level to review MMSS and review the diagnosis of the cases, causes and avoidable factors. The member of the committee are Professors of obstetric and gynaecolyg at medical school of Cairo, Ain shams, Al Azhar, Banha University and Teaching hospitals. In addition to, specialist from MCH /MOHP
50
Gaps identified when reviewing the data collection tools during the year 2017 we found the following:
1. Inaccuracy, incompleteness of DNF filling for some personal data about deceased woman and cause of death according to ICD- 10 of maternal causes of death.
2. Incompleteness in the sector concerned with female death at reproductive age (15-49 years).
3. Incomplete information about the personal data in case investigation sheet "MMSSQ" specially place of birth, referral to hospital and time of death.
4. Before data entry at central level there is review for completeness of system tools where incomplete reports return to director of MCH at health governorate to be filled properly.
5. Incomplete safe motherhood committee report, indefinite cause of death and precautions to avoid similar cases.
6. Regulations of system implementation states the necessity of active surveillance to 50% of female death at the age (15-49 years) to make sure that there is no undiscovered cases of maternal mortality, yet we found that it is either not followed at the health district or not documented.
7. Inadequate quality control for the investigation of 5% of discovered maternal mortality cases at central and governorate level in addition to active surveillance to female death to test sensitivity of surveillance system.
8. All discovered maternal mortality cases were investigated but quality control on investigation is insufficient.
9. There is delay in the flow of data and monthly reports that may reach up to two months from date of death in addition to incompliance with MMSS guidelines in some of governorates.
10. Although there is a system for data entry and a program for analysis at MCH general directorate, yet they are not distributing or giving regular feedback to governorates through definite feedback tools.
11. By reviewing the actions taken during the last years, it found that at the central level there are efforts to improve the quality of the system performance through limited training in some governorates, inadequate quality control of investigated cases and limited efforts for dissemination of information through the periodical meetings and seminars.
12. Governorate Safe motherhood committee is not held on monthly basis, sometimes it is delayed to two or three months with irregular attendance of university staff and consultants of obstetrics and neonatologist as recommended.
13. Recommendations of safe motherhood committee are not strictly followed due to lack of resources and weak input from the medical syndicate towards the uncommitted private obstetricians.
14. The results of performance assessment of health offices were as the following: The range of performance assessment score was from 36% to 96%. The score of 37.5% of health offices was less than 60%.
51
The score of 19% of health offices was 60-- < 75%. The score of 22.5% of health offices was 75--< 85%. The score of 21%of health offices was 85% +.
To have a practical insight about the MMSS, the researcher attended 4 safe motherhood committee meetings held at Fayom and Banisuef in upper Egypt, Behera in lower Egypt and Cairo. Two meetings were held at the hospital, one meeting was held at medical syndicate and the other held at meeting room of health directorate. These meeting were attended by Professors of Ob/ Gyn at medical school and representative of medical syndicate. Detailed description and evaluation of discussed cases is outlined in Annex 1.
Also workshops to strengthen the MMSS team at governorate level were attended during the months of August and September 2017 with the following objectives:
- Unify of information about definition of maternal mortality and MMSS.- Importance of flow of data between the three levels ( health office, district and
governorate)- Importance of feedback mechanism between the three levels These workshops were attended by:
- Director of MCH at governorate level.- Assistant director of MCH at district level.- Director of HIS at governorate and district level.- Health officers and health clerks of health offices.It is worth mentioning that This system has been subjected to 2 reviews and
evaluations by international expert (Dr Hani K.Atrash ,WHO Consultant, CDC Atlanta, USA, Oct.,1998 and Feb.,2004 ). His comments were: “I was impressed by the amount of data being collected. It appears that Egypt has excellent vital statistics system. Vital statistics are the backbone of any maternal and child surveillance”. About the pilot study of MMSS in 1998. “The surveillance system has been refined to more simple, efficient, useful to health care managers and providers, and acceptable to its participants”. “I am highly impressed by the progress that has been made in implementing the MMSS at all levels and congratulate staff at the MOHP, USAID, and JSI for the excellent work”. Feb, 2004.
Also a review of implementation steps by local experts (Dr. Esmat Mansour and Dr. Khaled Nasr ) in 2012 and 2016, to follow up the accuracy of implementation, results, and information from the data collection, as well as reviewing procedures that have been implemented based on the results of the surveillance system to improve the implemented plan or modification of implementation follow up methods or availability of resources to improve clinical capacity of the medical and administrative team at the three levels (central, governorates, and districts).
52
Cases discussed during the attended SMC meetings
The following cases are real cases which were investigated by the MCH District assistants in the mentioned governorates.
Case 1
37 years old female ,multigravida , went to the primary health care unit for only one antenatal care visit in the 9th month of her pregnancy and mentioned in the laboratory results the presence of anemia . On Thursday 5/15 she went to outpatient clinic in general hospital ,the obstetrician described her vaginal tablets for stimulation of uterine contraction to take it at home.
She returned home but her relatives wanted to speed up delivery as she ended the 9 th
month of her pregnancy , they call up daya (TBA) to the house, she gave her large doses of uterine stimulants vaginally and parentally that did not induce labor ,the next morning they transferred her to the hospital where she arrived in cardiac arrest ,CPR was done and she respond and diagnosed as rupture uterus and IUFD after trial of vaginal delivery outside hospital, anti shock measures and hysterectomy was done but the case deteriorated and died in ICU immediately after operation on 16/5/2017.
Case 2
17 years old female, primigravida, she was known to be a cardiac patient suffering from mitral valve prolapse .before pregnancy, She asked the cardiologist if it will be safe for her and he told her that there was no risk of pregnancy with continue cardiac treatment and good follow-up .She was also having regular antenatal care visits with specialist of obstetrics and gynecologyThe doctor gave her the date of Caesarean delivery on 16/4/2017 .The C.S operation was done at her private clinic around 11 am. The woman returned to her home in the same day after operation. At about 3:00 PM, she complained of chest pain and shortness of breath and died immediately on the same day.
Case 3
18 years old pregnant woman, primigravida, trying to get pregnant for 3 years. She attended 10 antenatal visits with an obstetrician in his private clinic. No health problems were detected. The obstetrician started to induce labor at 9 months gestation because she was ‘Post-date’. He gave her half a tablet of misoprostol followed by another half, but still no labor pain. She was given 2 ampoules of oxytocin. Suddenly after 2 hours, she had severe bleeding and became unconscious. The obstetrician transferred her to the public hospital where she died on arrival.
Case 4
A 23 primigravida female, who passed her Ante-natal period smoothly except for normal habitual pregnancy complaints. On onset of delivery she went to her doctor in private clinic to manage her case. More than 8 hours passed without significant progress. Her doctor applied (oxytocin in high dose) till fetal distress happened. An
53
emergency caesarean section was done. Intra-operative, her doctor diagnosed rupture uterus and intrapartum fetal death. He failed to resuscitate her due to unavailable blood products or surgical experience for management of these cases.Response:
- MCH general directorate reported to the medical syndicate and to the central administration of nongovernmental facilities (MOHP) to take actions against the malpractice.
- The MCH reports include names of the health providers, addresses of their clinics and a summary of the case , however no effective actions were taken (just the clinic may be closed for 30 days and then it is reopened and the physician repractises his job).
- To solve the problem of malpractice in private clinics many actions may be taken such as:-
1. Cancellation of the license of the physician.2. Enacting the law of dealing with faulty killing.3. Develop a law to prevent deliveries outside the governmental hospitals 4. review the existing regulations of the private facilities and issue new ones5. Reevaluate and relicense the physicians every 3 years
- This is the role of the ministry of health, the medical syndicate, the governors and the parliament
54
7. Results
MDSR results at national level
The MMSS enables the government to have accurate figures and data about number of maternal deaths, MMR, their distribution by region, timing and place of death, age group, direct and indirect causes and a list of avoidable factors.
The MMSS Results for 2016 are outlined hereunder:
Maternal deaths/ Female deaths and Maternal Mortality Ratio (’1992 – ’2016)
Years MMR% Maternal Death / Female Death
NMMS 92 174 10.3%
NMMS 2000 84 6.9%
NMMSS 2005 63 5.4%
NMMSS 2011 57 5.9%
NMMSS 2016 46 5.02%
NMMS : National Maternal Mortality survey
NMMSS: National Maternal Mortality surveillance system
Maternal Mortality Ratios by regions 1992 - 2016
NMMS 92
NMMS 2000
NMMSS 2007
NMMSS 2011
NMMSS 2016
Urban 233 48 65 63 63
Lower Egypt
132 93 46 51 39
Upper Egypt
217 89 60 62 47
Total 174 84 57 57 46
55
% Time Of Maternal Death 1992-2016
During Pregnancy
During Delivery
Postpartum
NMMS 92 26 39 35
NMMS 2000 25 49 26
NMMSS 2005 22.7 45.2 32.1
NMMSS 2011 22.4 39.2 38.4
NMMSS 2016 24.1 32.1 43.8
% Place of Maternal Mortality 1992-2016
HomeHealth Facility
NMMS 92 36 64
NMMS 2000 38 62
NMMSS 2005 30 70
NMMSS 2011 25 75
NMMSS 2012 22 78
NMMSS 2016 24 76
% Maternal Mortality by number of previous births
PrimigravidaLess than 3 births
3+
NMMSS 2005 28.2 37.7 34.1
NMMSS 2011 31.3 37.7 31
NMMSS 2016 30.6 40.7 28.7
56
% Maternal Mortality by type of hospitals (In patient)
University hospital
Teaching hospital
General hospital
District Hospital
Health insurance
Private hospital
Other
NMMSS 2005 26.5 7.5 20.9 25.7 1.5 12.5 2.4
NMMSS 2011 32.4 9.2 25.8 13.4 1.4 15 2.8
NMMSS 2016 34 6 23.5 12.4 1.2 19.2 3.7
% Distribution of maternal deaths according to sites that referred the cases
HomePrivate Clinic
PHCGeneral Hospital
NMMSS 2005 52 34.5 4.7 5.8
NMMSS 2011 47.2 38.5 1.5 12.8
NMMSS 2016 48.1 39.1 0.5 12.3
% Maternal Mortality by type of Age group
< 20 20-35 > 35 NA
NMMSS 2005 5.2 84 10.6 0.2
NMMSS 2011 4.9 89 5.9 0.4
NMMSS 2016 5.8 88 6.3 0
57
% Distribution of Maternal Mortality according to ANC Follow up
With ANC Follow-Up
Without NA
NMMSS 2005 78.7 14.1 7.2
NMMSS 2011 84.2 9 6.8
NMMSS 2016 86.4 6.4 7.3
% Distribution of ANC follow up according to health provider
Private doctor
PHC NA
NMMSS 2005 71.3 26.3 2.4
NMMSS 2011 85 14 1
NMMSS 2016 90.9 8.7 0.4
% Distribution of maternal mortality according to transportation means
Private car
Taxi Ambulance Other NA
NMMSS 2005 24.7 42.2 24.8 2.5 5.9
NMMSS 2011 34.1 35 22.7 1.6 6.5
NMMSS 2016 37.6 30.9 25.2 1.2 5.1
58
% of Direct and Indirect causes of death
Direct Causes
Indirect Causes
NMMS 92 65 35
NMMS 2000 77 23
NMMSS 2005 71 29
NMMSS 2011 65.1 34.9
NMMSS 2016 65.9 34.1
59
% of Direct Causes of Maternal Death 92-2016
NMMS 92 NMMS 2000 NMMSS 2007 NMMSS 2011 NMMSS 2016
Postpartum Hemorrhage 24.8 34 25.4 23.4 18.1
Antepartum Hemorrhage 8.1 9 3.2 2.6 3.4
Hypertensive disease 19.9 22 17.7 14.2 16.1
Ectopic pregnancy 0.6 1 0.5 0,5 0.9
Abortion 4.4 4 2.3 1.6 1.4
Ruptured uterus 3.1 5 3.9 3.7 3
Sepsis 8.4 8 3 4.2 3.5
complication of surgery 6.1 7 2.3 6.7 11.5
pulmonary embolism 1 4 10.9 11.3 6.8
60
% Indirect Cause of Maternal Death 92-2012
NMMS 92 NMMS 2000 NMMSS 2007 NMMSS 2011 NMMSS 2016
Cardiovascular 12.8 13 14.2 15.6 9
respiratory tract diseases - - 3.9 7 7.7
digestive disease 1.3 5 2.8 2.9 2.9
Neurological disease 2.4 2 1.5 2.3 3.1
Urological disease 0.3 4 0.7 1.6 1.2
Infectious and Parasitic 3.6 4 0,4 0,6 0.8
Neoplasm 1.7 2 0.9 1.7 0.2
blood and immunty disease 0.6 11 2.6 3.5 3.1
Diabetes 0.8 2 2 2.2 2.5
Other 3.5 7 0.2 0.4 5.9
61
% Distribution of relationship between births and maternal mortality
StillbirthDied during delivery
Live and referred to ICU
Live and normal
NMMSS 2005 19.9 8.8 8.7 59.3
NMMSS 2011 17 6.8 12.7 63.5
NMMSS 2016 18.3 5 12.9 63.8
No of maternal mortality cases attributed to various avoidable factors
NMMSS 2005 NMMSS 2011 NMMSS 2016
Delay in recognizing problem / seeking medical care
43 69 56
Lack of health providers 10 8 8
Lack of drug's, supplies, and equipment in health facilities
4 8 8
Lack of blood 18 28 4
Lack of transportation 7 13 13
Length of distance 41 69 52
62
8. Conclusions and recommendations
Conclusion
The maternal and child health general directorate in the ministry of health and population is implementing the maternal mortality surveillance system since 2002. It is implemented as a component of MCH program supported by the two ministerial decrees No. 159 for the year 1999 and No. 197 for the year 2002 for obligatory notification of all maternal deaths and establishment of national safe motherhood committee headed by the minister of health and local committee at each governorate.
The system is operational in 27 governorates, 283 districts and about 5000 health facilities which reflect the huge effort in implementation and expansion on the national level during the period from 2002 up till now.
Review of the "MMSS" revealed that the system is functioning at the three levels and used as an effective tool to monitor the impact of maternal mortality reduction efforts. The results of implementing the system meets the objectives of its establishment as the system is giving the needed information about maternal mortality ratio at the national and governorate levels with a high level of confidence. The analysis of collected data in 2016 showed reduction of maternal mortality by 73.5% between 1992 and 2016 and by 45.2% between 2000 and 2016.
The MMSS is defining and collecting information about nearly all maternal deaths, causes of death, place and time in addition to contributing factors of maternal death. Meanwhile the system needs strengthening of quality in its implementation especially case investigation, active surveillance of female deaths in reproductive age and performance assessment at reporting sites.
Adequate resources should be provided at central level to support the established technical advisory committee, revitalize national safe motherhood committee, in addition to provide the transportation facilities and technical support to central and governorate levels.
Recommendations:
1. Political commitment should continue as it is a fundamental element for achieving targets.2. Enforce implementation of the ministerial decree "No 197 – 2002" to revitalize the
national safe motherhood committee and to accelerate the maternal mortality reduction strategy.
3. Ensure abiding with the ministerial decree "No159-1999" to report all maternal deaths to the General Directorate of MCH in order to investigate all cases and to ensure the quality of surveillance and identify the avoidable causes of maternal mortality.
4. Allocate adequate resources to provide transportation facilities for central, governorate and districts levels to support supervision, MMSS and other MCH activities.
5. Support and strength the established Technical Advisory Committee (TAC) at (MCH) center level to review all the investigated maternal mortality cases to identify the main
63
causes of deaths, the contributing avoidable factors and recommends actions to prevent similar cases.
6. Involve the medical syndicates in governorate safe motherhood committee to take recommended action towards the unsatisfactory performance of public and private specialists during management of cases.
7. Ongoing training activities should be done for the health officers and clerks at the level of health unit to overcome the high turnover.
8. Utilize the available supervision on Primary health care (PHC) units system to include performance assessment of MMSS at reporting sites "health offices+ PHC unit" and the needed on job training to the responsible staff.
9. Improve quality control of case investigation through continuous supervision from governorate and central MCH staff to apply the 5 % quality control on investigated maternal mortality cases.
10. Enforce the active surveillance of 50 % of female deaths in reproductive age (15-49) and document its implementation using the available forms to improve the sensitivity of the system and to avoid missing maternal mortality cases.
11. Improve capacity of information centers’ staff to revise and enter the collected data at governorate level under supervision of MCH director.
12. Periodical feedback reports should be distributed to all governorates, districts and reporting sites using the different affordable methods e.g. periodical meetings, follow up visits, bulletins, circulars and newsletters.
13. Participation of representative from university, teaching , health insurance and MOHP hospitals in these Periodic meeting to discuss the results of MMSS and propose the appropriate action to reduce maternal deaths.
14. Wide distribution of MMSS results to involved partners "Universities" teaching hospitals, general hospitals, interested councils and safe motherhood committee members…..etc
15. A website could be established at central MCH directorate for dissemination of information electronically to all the other national and international sectors.
16. Establishment and activate the clinics for risk pregnancy at hospitals and provided it with guidelines and protocols for the management of attendant cases.
17. The MOHP and the medical schools should conduct a comprehensive review of post graduate training programs. The Egyptian Medical Syndicate and Ministry of Higher Education should link continuing medical education with CBT program for re-licensing.
18. Efforts to revise the obstetric and nurse training curricula in medical and nursing schools should be continued in collaboration with MOHP, Medical schools, Ministry of Higher Education and the Private Sector.
19. Strategies for working with private providers, clinics, and hospitals, and efforts to collaborate with Egyptian Medical Syndicate need to be strengthened. Strategies to accredit private clinics and hospitals against service standards should be considered.
20. Additional efforts should be made to ensure and to maintain the availability of an adequate supply of blood and blood products for use in emergency obstetric and neonatal complications in district and general hospitals.
64
21. Reduce the Caesarean delivery rates to accordingly reduce associate mortalities and morbidities
22. Repeated cesarean sections and placenta previa acreta are referred to university hospitals and conducted by skilled consultants with follow-up the cases after birth and allowed to leave after at least three days.
23. Nurse midwifery Training Program should continue to achieve the national replacing policy of Dayas as it proved to be effective especially in ruler and slum areas. For insuring the sustainability of this training it should be under the umbrella of financial support of MOHP training sector.
24. Increase community awareness (including men, women, youth, community leaders, etc) about the importance of
a. family planning / child spacing for saving mothers b. safe deliveries and safe motherhood including suitable antenatal care and
delivery sitesc. importance of reporting maternal deaths and accurate responses to surveillanced. patient maternal health rights and appropriate channels for reporting gaps in
services and mal practices.
65
9. References
1. Report Review of Egyptian MMSS at MCH-MOHP, 2016, Dr.Esmat Mansour, Dr. Khaled
Nasr.,(UNFPA and MCH-MOPH, short term consultant).
2. Time to respond, a report on the global implementation of Maternal Death Surveillance
and Response ( MDSR), WHO, 2016.
3. Annual Statistics Book, 2016. Central Agency for Public Mobilization and Statistics.
4. Egypt Demographic and Health Survey (EDHS, 2014).
5. Maternal Mortality bulletin, Maternal and child health directorate, MOHP, dr.mohamed
nour el-din, September 2014.
6. MMSS, Guideline in Egypt, Esmat Mansour, Khaled Nasr,M.Nour, Abdelatef Gaber, MCH,
MOHP-UNFPA, 2014.
7. Maternal Death Surveillance and Response, WHO, UNFPA, 2013.
8. Achievement of MDGs 4 and 5, in Egypt (A case study), Dr.Maha Wanis, 2013.
9. Report, Review of MMSS, Egypt 2012, Dr. Esmat mansour, Dr. Khaled Nasr,( WHO, Short
Term Consultants) .
10. Standards of Practice for Integrated Maternal and Child Health and Reproductive Healths
Services, 2nd Edition,2008, MOHP,Egypt
11. Hani.K.Atrash, M.D.,M.P.H.,Associate director for program development, National center
on birth defect and developmental disabilities, Assignment Report, Egypt, Feb. 2004 to
assess Maternal Mortality Surveillance System (MMSS) .
12. The Guideline for registration of death certificates and medical reports, MOHP-WHO,
2002.
13. Second National Maternal Mortality Study in Egypt, 2000.
14. Reduction of Maternal Mortality. A Joint WHO/UNICEF/World Bank, Statement, 1999.
15. International Statistical Classification of Diseases and Related Health Problems, Tenth
Revision. Geneva, WHO (ICD-10) 1993. 48
16. First National Maternal Mortality Study in Egypt, 1992-1993.
17. Safe Motherhood and the Millennium successful strategies in Egypt, Dr.Esmat Mansour,
P.H.D,Public Health, MCH, MOHP.
18. .Maternal and Child Health General Directorat,MOHP,Documents.
66
10. Annexes
A. Tools of MMSS
1-Death Notification Form (DNF).
2- Death Register.
3- Maternal Mortality Surveillance System Questionnaire (MMSSQ).
4- Safe Motherhood Committee Decision Form (SMCDF).
5- Improvement Plan (IP).
6- Investigation Form of Female Deaths during Reproductive Age (15- 49 years).
7- Result of Investigating 50% of Female Deaths.
8- Monthly Report for Maternal and Female (15-49 years) Deaths.
B. Ministerial Decree
1- Ministerial Decree No.159 on July 17, 1999.2- Ministerial Decree No.197 on July 4, 2002.3- Ministerial Decree No.236 on September 16, 2004.4- Letter from Undersecretary of Non-governmental (Private) Health Facilities and Licenses,
to all directors of health directorats, about Disallow to do delivery at private clinics.
C. Performance Monitoring and Evaluation Forms For:
1- Health Office.2- Health District.3- Health Directorate.4- Health Information Center at Health District.5- Health Information Center at Health Directorate.
D. Guideline for Maternal Mortality Surveillance System in Egypt
E. Perinatal and Neonatal Mortality Surveillance System (Newsletter)
67