This was a retrospective desk review of maternal deaths documents (narrative summaries and action plans). To do this we visited all facility that reported deaths between 1st of January to 31st of December 2018 for Mtwara and Lindi regions of Southern Tanzania and reviewed the narrative summaries and action plans. A total of 122 maternal deaths were followed up in the facilities for their summaries and action plans
The total population of Lindi and Mtwara regions is about two million people (19) . There are two regional referral hospitals, 12 district hospitals, four private/mission hospitals, 40 health centres and 399 dispensaries. In 2015, the MMR was 456 in Lindi and 579 per 100,000 live births in Mtwara (20). Facility delivery was 80.8% and 81.3%, caesarean section rate 6.0% and 10.3% respectively and family planning use was at least 50% in both regions(21). The two regions like all other regions in Tanzania have an MDSR system through which all maternal deaths occurring in health facilities are routinely reviewed. Maternal deaths occurring in each facility are reported to the district and ultimately to the region and Ministry of Health, Community, Development, Gender, Elderly and Children.
We reviewed the deaths documents following a defined set of criteria. We defined Comprehensiveness of narrative summaries as summaries that have more than 94% of the information that is recommended by Tanzania MDSR guideline of 2015. The information in the summaries was divided into four domains each with several attributes (Panel 1). The domains were 1. Demographic characteristics and Antenatal care information (12 attributes), 2. Delivery/abortion information for those who delivered/aborted before admission (six attributes) 3. Referring information (four attributes) 4. Information of events after admission (20 attributes)
Panel 1: Domains and attributes checked to assess comprehensiveness of narrative summaries
1. Demographic characteristics and Antenatal care information
- Date of review, Maternal death review number, Patient code, Age, Marital status, Gravidity, Parity, Live children, Mode of delivery of previous pregnancy, Date of last caesarean section, Number of antenatal care visits in this pregnancy, Risk factors detected during this pregnancy
2. Delivery/abortion information for those who delivered/aborted before admission
- Date of delivery/abortion, Duration of amenorrhea, Status of baby at delivery (dead/alive/abortion), Place of birth/abortion(home/facility), Assisted by who, Information on complications that occurred after delivery
3. Referring information
- Type of referring facility, Reason for referral, History of the case, How does a woman position in the community affects her referral
4. Information of events after admission
- Date of admission, Main reason for admission, Summary of history, physical examination and investigations, Initial diagnosis at admission, Summary of case evolution, Sequence of events of abortion/delivery, Indication of surgery, Diagnosis made at complications, How does a woman position in the community affects process after admission, Treatments given, Time between diagnosis of complication and treatment, Complimentary Investigation results present, Summary of case evolution (monitoring vital signs, input output, bleeding), Date of Death, Time between complications and death, cause of death, Pregnancy outcome, Other information (from community or other centres)
SMART action point means a recommended action point is Specific, Measurable, Attainable, Relevant and Time-bound. An action was considered Specific if it clearly mentioned what is to be done, how it will be done, who will do it and describes the results of the action to be done. An action point was considered Measurable if it could be evaluated against standards. Attainability meant that the action could be implemented considering the resources and available skills and capacity. A Relevant action was considered as an action that was actually needed considering the case and the dysfunction identified. An action was considered Time-bound when it had a specific time for starting or ending or both.
Data sources and measurements
A team of researchers led by the first author (AS) visited the health facilities in March and April of 2019 and requested the narrative summaries of all 122 notified maternal deaths from the facility in-charge. The first author (AS) reviewed the narrative summary using a checklist informed by recommendation in the 2015 Tanzania MDSR guideline (8).
The narrative summaries were assessed by familiarisation and checking for presence of attributes on the four different domains (Panel 1). Presence or absence of information/attributes in each domain was scored and coded as present (1), not present (2) or not applicable (3) depending on the case. The researcher read each summary repeatedly to make sure all information was available or not even if it was not explicitly mentioned. For example, the duration of amenorrhea was considered to be present if the last normal menstrual period was mentioned even if the gestation age was not mentioned explicitly. Also, marital status was considered to be present if it was mentioned that the deceased was brought to facility by husband.
After familiarisation with the action plans the first authors extracted i) the target of each action plan (community, facility or higher level) ii) specific issues it addressed in the community or facility. For community action plans, the researcher indicated whether the action was for decision making at family level, danger signs recognition or health seeking behaviour or traditional practices. Action plans in the health facility were assessed whether they addressed service delivery, human resource, equipment and supplies, referral system, accountability or facility infrastructure. The action plans were then assessed for appropriateness by checking whether they met the SMART criteria.
Quantitative data collected was entered and cleaned in SPSS version 23 for analysis. The Comprehensiveness of each narrative summary was determined by calculating individual proportion of amount of information depending on each case. We summarised the total amount of information for each summary and then the proportion of present (1) was calculated from the expected total score for that case. The proportional score of each summary was ultimately divided into be poor, average, or good/comprehensive if it had 0-74%, 75-94% or more than 94% of the required information respectively. The cut off points were decided based on having been used in a study done by Mohseni et al in Iran (15), and were used for analysis and description purposes and are not recommended as standard cut off levels. Action plans were considered to be SMART if all the criteria were met.
Descriptive analysis was done for all variables and data presented in figures and tables.