Study design and period
Cross sectional study design was conducted from January1-30/ 2018 in Dewachefa district, North- East of Ethiopia.
Study setting
Dewachefa district is located about 325 Kilometers from Addis Ababa (the capital city of Ethiopia) and 555 Kilometers from Bahir Dar (the capital city of Amhara region) at an altitude of 1623 meter to 2570 meter above sea level. The district is bordered by Majetie district in the South, South Wello in the West, Dewi Harewa in the Northwest, Artuma fursi district in the Northeast and the East. The area of the district is 782.22 square kilometer with the total population 151645. The district is governmentally alienated into 26 kebeles. There are 7 health centers (health center is the primary health care unit that provides preventive and curative health services) and 26 health posts (health post is the subset of health centers that provides preventive health care service at the community level) in the district (21).
Source population
The source population for this study were all governmental health facilities, and health extension workers (who are certified by government and working at community levels or health post) and health professionals (public health officers, nurses and midwifes) who have been working in governmental health facilities in Dewachefa district.
Study population
Dewachefa health office, Dulcha and Weldi health centers, and Teref, Tochie, Weldi, Gerbi and Kelo health posts, and health extension workers and health professions in this health facilities were study population. Maternal, youth and Public health emergency officers who are responsible for MDSR data collection from lower levels and they compile, analyze and propose response plan. Health officers, nurses and midwives who are responsible for identification, notification, reviewing health center maternal deaths and developing action plan. Health extension workers who are responsible for identification, notification and conducting verbal autopsy for community maternal deaths were included in the study. All (26 weekly reports) for 2017 were also reviewed by 3 field Epidemiology residents in all health facilities. Those health extension workers and health professionals who were not present during data collection due to annual leave, medical and social problem were excluded.
Sample size determination and sampling technique
We assumed that 79.7% of health workers used the data that were generated by the surveillance system (5). We have used the single population formula to calculate the sample size.
n=(Z1/2)2P(1-P)/d2= (1.96)2x (0.797x (1-0.797)/ (0.05)2=249
Where:
n= Sample size [where population> 10,000]
Z= Normal deviation at the desired confidence interval. In this case it was taken at 95%, Z value at 95% is 1.96
P= Proportion of the population with the desired characteristic (p=79.7%)
d= Degree of precision; was taken to be 5%. Since the proportion of the population with the characteristic is not known, then 50% was used
We have used Population Correction formula because the total number of study population was 32.
nf=n/1+n/N =249/1+249/32=29
Where:
nf= The desired sample size for population <10,000
n= the calculated sample size
N= the total population (N= 32. The total calculated sample size was 29 but the total study population was 32 so, no need of sampling from 32. Therefore, the total sample size that was included in this study was 32.
Dewachefa district was purposively selected because the surveillance evaluation was not conducted before and more than half of Zonal maternal death was occurred in this district. Among the total health centers in this district, 2(25%) of the district health centers were included in the study. These health centers were selected by lottery method of simple random sampling. From these health centers; all health posts were involved in this evaluation. Equally, all health professionals in the health centers and all health extension workers in the health posts were invited to be included in the study.
Data collection tools
Standard data collection tools were prepared from US Centers for Disease Control and Prevention guidelines for surveillance system evaluation in 2013 (1) and National guideline for MDSR (9, 11). The tool consisted of two separated Questionnaires (i.e. for health extension workers and health professionals) and checklists for woreda (Woreda is middle administrative structure that owned its budget) health office, health centers and health posts.
Both questionnaires of health extension workers and health professionals consisted of sociodemographic, knowledge and attitude related questions toward MDSR.
Pre-testing of data collection tools
Collection tools were checked in Artuma Fursi district, because the district provided a similar setting with the area under study. The orders of the questions in the questionnaire was changed so that the questions followed a logical sequence that made meaning to the participants.
Data collection techniques
Structured self-administered technique was used to collect data from health workers and health extension workers to assess their sociodemographic, knowledge and attitude towards the surveillance attributes and operations of the MDSR system (1, 9).. A checklist, using MDSR guidelines on surveillance system evaluation was used to assess the stability of the system and completeness retrospective record review of the report of 31weeks (9, 11). MDSR identification, notification and weekly and case-based report formats were reviewed to check for data quality, completeness (If all components of the report and notification form were filled then we assigned 1 point and, for incomplete variable, we gave 0 point.) and timeliness of the system. In addition to these, identification, notification, reviewing and response plan for maternal death were assessed.
Data analysis
Epidata versions 3.1 was used to enter collected data. Entered data were exported into statistical package for social science (SPSS) version 20 for data clearness and analysis. The knowledge related questions were coded on a true/false basis. A correct answer was assigned 1 point and an incorrect/unknown answer was assigned 0 point. The total knowledge was computed in SPSS. The median of knowledge was determined. Then variable was categorized as knowledgeable and non-knowledgeable based on the median. Frequency mean, median and proportion were computed. The findings of this evaluation were stated in the form of text and tables.
Attributes of the surveillance system
Simplicity is an easiness of a surveillance system as both its structure and implementation while quiet meeting their aims. This attribute was evaluated by assessing the training status of the implementers and determining the experience of the implementers of ever filling MDSR form.
Acceptability is the preparedness of persons and organizations to take part in a surveillance system. Health care workers were asked whether they were ready to remain participating in the MDSR. As well as completeness and timeliness were also be assessed as a substitution of acceptability.
Usefulness is ability to use maternal mortality data to implement changes that leads to maternal care and mortality reduction
Sensitivity; The sensitivity of a surveillance system can be evaluated by the percentage of cases identified by the surveillance system. This attribute was considered by asking main respondents the number of maternal deaths that were picked by the MDSR system, through verifying whether maternal deaths were correctly classified
Flexibility is the ease with which system can integrate another disease or event with little or no additional resources
Stability is the consistency and availability of the system. Consistency is the capability to collect, manage and provide data properly without failure. Availability is the capacity of a surveillance system to be functional when it is required. Stability of the MDSR was evaluated by examining for consistency in reporting, availability of communication apparatus and other material resources needed for the surveillance system.
Data quality The quality of data is prejudiced by the clearness of surveillance forms, the quality of training and the observation of persons who complete the maternal death notification forms and the amount of care that is practiced in handling the surveillance data. A review of these structures of a surveillance system provided an unintended measure of the quality of data. Maternal death notification form ( MDNF) were revised to check for completeness of the notification forms.
Timeliness states as the speed at which data is communicated between different levels in the surveillance system. It was measured by checking whether MDNF are completed within seven days of a maternal death and are then sent to the district health office within 14 days of the maternal days as restricted.
Operational definitions
Satisfactory Knowledge: Those respondents who score median or above median score of MDSR related knowledge questions
Positive attitude: Those respondents who score above median score of attitude assessing questions toward MDSR.