THE REPUBLIC OF UGANDA Ministry of Health “Why did they die?” Reviewing the evidence to save tomorrow's mothers and babies REPORT Maternal and Perinatal Death Review Uganda 2012/13 By the National MPDR Committee i Acknowledgements No mother should die while giving birth. Therefore, we commend the work of health workers especially midwives, doctors and anesthetists who safely delivered close to 800,000 mothers in our health facilities this year despite the odds. We are truly proud of you for bringing smiles to many Ugandans. And to those who lost their loved ones, we convey our sincere condolences. This 2nd National Maternal and Perinatal death review (MPDR) report is a result of efforts of health workers that have been keen on analyzing deaths, the Resource centre and the National MPDR committee. The Ministry of Health recognizes the efforts of health facilities in conducting death reviews and forwarding findings to the centre. Special appreciation goes to the following people who contributed tremendously to the production of this report: Ms. Emily Atuheire, Dr. Sarah Byakika, Dr. Frank Kaharuza, Ms Carol Kyozira, Dr. Anthony Mugasa. Dr. Yvonne Mugerwa, Ms Maria Najjemba, Dr. Victoria Nakibuuka, Dr. Joseph Ngonzi, Dr. Hanifah Sengendo, Dr. Miriam Sentongo and Dr. Olive Sentumbwe Mugisa. The entire National MPDR committee is also commended for their noble guidance and deliberations. The Ministry applauds the collaboration, support and technical input of the development partners, institutions and organizations that have supported the process of institutionalizing MPDR. Specifically the Ministry appreciates the financial and technical support provided by UNFPA, CDC, USAID, WHO, Save The Children, World Bank, AOGU and Mbarara University of Science and technology. Lastly, MPDR is a process that must be fully institutionalized in order to improve the survival of mothers and babies. The facility teams must discuss why they lost a mother and /or baby; what could have been done differently to save life; and put in place remedial measures to avoid similar deaths. Communities shall be encouraged, also, to review deaths in their areas so they can act quickly to save mothers and newborns. HMIS reporting including on MPDR is requisite if we are to address bottlenecks in providing quality Emergency Obstetric and Newborn care in the country. Thank You Chairperson National MPDR committee ii Contents Acknowledgements .................................................................................................................... ii Contents ................................................................................................................................... iii Acronyms ................................................................................................................................... v Glossary of terms ..................................................................................................................... vii Executive summary ................................................................................................................... ix 1.0 Introduction and Back ground ............................................................................................. 1 2.0 Methods: .............................................................................................................................. 3 3.0 Results ................................................................................................................................. 4 3.1 Routine reporting and notification of maternal deaths ..................................................... 4 3.2 Maternal Death notification ............................................................................................. 5 3.3 Maternal Death reviews ................................................................................................... 7 3.3.1 Epidemiological description of the deceased mothers .............................................. 9 3.3.2 Cause of death ............................................................................................................. 14 3.3.3 Avoidable factors ........................................................................................................ 17 3.4 Other Maternal death notification and review initiatives .......................................... 17 3.4.1 Integration of MDSR into IDSR .............................................................................. 18 3.4.2 MPDR efforts by Save the Children in Uganda program ........................................ 18 3.4.3 MPDR in Mbarara Regional Referral Hospital ....................................................... 21 3.4.4 Maternal Mortality reviews by AOUGU and UPA ................................................. 23 4. Perinatal death reporting and review ................................................................................... 24 4.1 Routine reporting of Perinatal deaths ............................................................................. 24 4.2 Health Facilities Conducting Perinatal Death Reviews ................................................. 25 4.3 Maternal Characteristics and interventions for the Perinatal Deaths ............................. 26 4.4 Baby Characteristics of the Perinatal Deaths ................................................................. 28 4.5 Avoidable factors for perinatal deaths ........................................................................... 31 iii 4.6 Nsambya Hospital Perinatal Audit ................................................................................. 32 5.0 Discussion .......................................................................................................................... 35 6.0 Conclusions and Recommendations .................................................................................. 37 Appendices ............................................................................................................................... 38 Appendix 1: Members of the National Maternal-Perinatal Death Review committee .......... 38 Appendix 2: Districts from where deceased mothers originated ............................................. 39 Appendix 3: Typical Case Summaries ..................................................................................... 41 References ................................................................................................................................ 43 iv Acronyms AIDS Acquired Immuno-Deficiency Syndrome ANC Antenatal Care APH Antepartum Haemorrhage ART Anti-retroviral Therapy ARVs Anti-retroviral BBA Born Before Arrival BEMOC Basic Emergency Obstetric Care C/S Caesarean Section CDC Communicable Diseases Control CMR Child Mortality Rate EMOC Emergency Obstetric Care GoU Government of Uganda HC Health Centre HMIS Health Management Information System HRH Human Resource for Health HSD Health Sub-District HSSIP Health Sector Strategic and Investment Plan IDSR Infectious Disease Surveillance and Response IEC Information Education and Communication IMR Infant Mortality Rate IPT Intermittent Preventive Treatment ITN Insecticide Treated Nets MD Maternal Death MDGs Millennium Development Goals v MDSR Maternal Death Surveillance and Response MLG Ministry of Local Government MMR Maternal Mortality Ratio MOH Ministry of Health MPDR Maternal Perinatal Death Reviews NGO Non-Governmental Organization NHP National Health Policy NMR Neonatal Mortality Rate NMS National Medical Stores NRH National Referral Hospitals PFP Private for Profit PHC Primary Health Care PHP Private Health Practitioners PNFP Private Not for Profit RRH Regional Referral Hospitals STI Sexually Transmitted Infection vi Glossary of terms Maternal death 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 the site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management but not from accidental or incidental causes” A woman must therefore be pregnant or recently pregnant, and have experienced some complication, before her death can be defined as a maternal death. This definition may seem clear but numerous studies have found misclassification of causes and underreporting of maternal deaths in official statistics1. Maternal deaths are subdivided into two groups Direct obstetric deaths: Direct obstetrics deaths are those resulting from obstetric complications of the pregnancy state (pregnancy, labour and puerperium), from interventions, omissions, incorrect treatment, or from a chain of events resulting from any of the above Indirect obstetric deaths: Indirect obstetric deaths are those resulting from previous existing disease or disease that developed during pregnancy and which was not due to direct obstetric causes, but which was aggravated by physiologic effects of pregnancy What is the definition of a perinatal death? Perinatal death: A death that occurred around the time of birth. Includes both still births and early neonatal deaths. The perinatal period: This commences at 28 completed weeks of gestation and ends seven completed days after birth. Early neonatal deaths: These are deaths occurring during the first seven days of life Stillbirth: This is death prior to the complete expulsion or extraction from its mother of a fetus/baby of 1000 grams or 28 weeks gestation; the death is indicated by the fact that after such separation