Maternal Death Audit (MDA) in Rwanda 2009-2013: Findings from a Nationwide Facility-Based Retrospective Cohort Study

Over the past 10 years and since the inclusion of the Millennium Development Goals (MDGs), Rwanda has experienced significant improvements across its health sector. Amongst these improvements maternal health has become a reference point as, currently, Rwanda is one of 11 countries that are ‘on track’ to meeting MDG 5. An example is the fact that today, more than 90% of all deliveries in Rwanda occur in health facilities and have the assistance of trained health workers. However, despite unprecedented improvements, Rwanda needs to do more for its mothers and children.

Rwanda’s experience of Maternal Death: The Ministry of Health has introduced Maternal Death Audits (MDAs), which have been proven to be effective in improving the quality of obstetric care in other African nations such as Ethiopia, Nigeria and Senegal.

At its simplest level, a MDA seeks to reduce maternal and neonatal mortality. MDAs, which are compiled and executed by local audit committees, “contain information on women’s individual characteristics, the place of delivery and death, the reported causes of death, any substandard factors detected and the recommendations made by the respective hospital MDA committees” (Sayinzoga et al, 2016). In Rwanda, since 2008, MDA committees have been put in place at all government-, private- and church-owned hospitals and health centers. The presence of MDA committees in health centers around the country have resulted in 987 cases audited, which represent 93.1% of all maternal deaths reported through the national health management information system for the period of 2009-2013.

The Rwandan’s experience shows that MDA can be implemented routinely and nationwide even in low-income countries. Nationwide initiative to conduct clinical audits of all cases of maternal death that occur in health facilities is a demonstration of strong political will to improve maternal and newborn health. There do not seem to be major barriers among clinicians and other health workers to conduct audits and investigate the possible role of systemic or incidental flaws in service delivery.

A district hospital committee during an audit session (Photo credit: Sayinzoga FA)

Causes and factors surrounding maternal deaths: MDAs have shed light onto the major causes of maternal and neonatal health. As a matter of fact, approximately “70% of deaths were due to direct causes, with post-partum hemorrhage as the leading cause (22.7%), followed by obstructed labor (12.3%)” (Sayinzoga et al, 2016). Differently, indirect causes accounted for 25.7% of deaths, with malaria being the most prominent. Finally, MDAs revealed that 61.1% of maternal deaths resulted from the provision of substandard care by health facilities and centers, while 30.3% accounted for patient and community related contributory factors.

The audits have helped to classify and identify the causes and factors surrounding of maternal deaths. Direct obstetric causes were found to be the under- lying cause in the majority of cases of maternal death reviewed during the 5-year period and post partum hemorrhage is the leading cause. Various aspects of substandard care were identified as contributing to the majority of deaths and many of which are avoidable

Recommendations made by the committees: The last step taken by MDAs is that of providing recommendations so that health facilities and workers can avoid similar maternal deaths in the future. Recommendations by the MDAs can be split into four categories. First, management of obstetric complications, which brings about issues of reinforcing hygienic measures and postoperative follow-ups. Second, population sensitization, of mothers especially, suggests things like consulting health facilities on time and complying with medical advice and treatment. Third, recommendations on human resources such as increasing the number of health providers and training on emergency obstetric and neonatal care, especially on surgery. Fourth, recommendations on improving communication so that communication among staff and between departments within the hospital or between health providers and patients is no longer an issue that increase the risk of mortality during, throughout, and after the delivery.

The audits have helped to make recommendation for changes in professional care and behavior in the community and their implementation is likely to have contributed to the reduction of maternal deaths in the past few years. Implementation of the recommendations highlighted should be prioritized in order to further improve the quality of maternal and obstetric services.

In conclusion, There is scope for inclusion of information from verbal autopsy in order to complete the facility-based approach by assessing community factors contributing to maternal death. A national maternal death surveillance committee would need to be put in place so as to regularly inform policymakers. Since maternal death can be seen as the tip of an iceberg of wider problems in maternal and obstetric care, near-miss audits could be considered so as to better understand the processes leading to poor maternal outcomes. The experience gained from facility- based approaches provides a good opportunity to introduce both confidential enquiry and near-miss audit as complementary methods to address maternal morbidity and mortality.

References

Sayinzoga, F., Bijlmakers, L., van Dillen, J., Mivumbi, V., Ngabo, F., and van der Velden,

K. (2016). Maternal death audit in Rwanda 2009-2013: a nationwide facility-based

retrospective cohort study. BMJ Open, 6(1).