Maternal and Perinatal Death Reviews (Mpdrs)

Maternal and Perinatal Death Reviews (MPDRs) -

Health WorkersTrainers Guide

March 2013

Acknowledgements

Aogu : Dr. Romano Byaruhanga, Dr. Jolly Beyeza, Dr. Imelda Namagembe, Dr. Dan Murokora

UPA: Dr. Jolly Nankunda

WHO Dr. Olive Sentumbwe

UNFPA: Ms Maria Najjemba, Dr. Yvonne Mugerwa

MOH. Dr. Jesca Nsungwa, Dr. Collins Tusingwire, Dr. Miriam Sentongo, Ms Juliet, Ms Carol Nalugya, Wilberforce Mugwanya, Sarah Nakitto, Ms Lilliane Luwaga, Rogers Kalyesubula

Save the ChildrenDr Naamala Hanifah sengendoAcronyms

ANC / Antenatal Care
CS / Caesarean Section
DHIS2 / District Health Information System 2
HC / Health Centre
HW(s) / Health Worker(s)
ICD / International Classification of Diseases
MCH / Maternal and Child Health
MDSR / Maternal Death Surveillance and Response
MPDSR / Maternal and Perinatal Death Surveillance and Response
MOH / Ministry of Health
MPDR / Maternal and Perinatal Death Review
RRH / Regional Referral Hospital

Table of contents

Acknowledgements

Acronyms

Table of contents

Glossary of Terms

Content Outline

Topic 1: Introduction

Topic 2: Quality of care

Topic 3: Preparing to conduct MPDR at the facility level

Topic 4: Forming MPDR committee

Topic 5: Conducting MPDR

Topic 6: Reporting

Topic 7: Follow – up

Glossary of Terms

Maternal Deaths:

Martenal Morbidity

Maternal Mortality Rate

Maternal Mortality ratio

Direct obstetric deaths

Indirect Obstetric deaths

Perinatal Deaths:

Perinatal Morbidity

Perinatal mortality rates

Perinatal Mortality Ratio

Newborn Deaths

Stillbirths

Early neonatal deaths

Near miss

Live births

Confidential Inquiry

Case fatality rate

GENERAL INFORMATION

Trainers:

Training is provided by persons trained in medical audit and with practical experience in Maternal Deaths Reviews and basic mentoring skills. They should be familiar withEmergency Obstetric and Newborn Care protocols, policies and guidelines.

There will be one trainer for every 5 participants.

Selection of participants

This course is designed:

For health professionals: gynaecologist-obstetricians, anaesthetists, intensive care practitioners, paediatricians and/or neonatologists, general practitioners, midwives, nurses, pharmacists/dispensers, and laboratory technicians.
For representative(s) of administration or hospital director.

The objective is to form a multidisciplinary team.

The recommended maximum number of people per session is 15 to 20 people in order to enable active participation.

Criteria for selection of participants

The main objective of thistraining is to improve maternal and newborn health, therefore It is important that persons who can are involved in the day today care of the mothers and newborns participate in the process. They should be active in service provision at the facility (administrative or otherwise)

Planning for the training

When planning to conduct National and District trainings, the facilitators, should do the following;

Notify the relevant authorities at least 2 weeks prior to the proposed dates of training
Inform the District Directors and or hospital directors/Medical superintendents about the training and request them to select and invite 3-5 participants from hospitals and Health centres. Hospitals should have a minimum of 5 participants. Ideally the incharge of martenity, obstetrician/medical officer, hospital administrator, pharmascist, Laboratory staff, Theatre, biostatistician.
Liase with the incharge of the martenity to organize files of maternal and perinatal deaths to be used during the training and make them anonymous.(Hide name of deceased and signatures of the Health worker (s)

Become familiar with the curriculum and review objectives, content outline and learning activities for the sessions.
Prepare/obtain the training materials for each session.
Plan for and provide simulated situations that offer the opportunity for trainees to practice and be assessed in relevant skills and attitudes.

Training

The day before training

On arrival in the district, the team of trainers/facilitators should;

Meet with the DHO and DHMT and Maternal Death surveillance team if it exists.
Request to be taken to LC5 and the RDC, Secretary for Health. Pay courtesy call explaining why the MPDR process in the country and inform the District leadership of their own roles and responsibilities in the MPDR activities. (The magnitude of martenal and perinatal deaths in Uganda MPDR Policy their role and responsibilities including establishing committees at district level. Also explain the training and what it will entail)

Request for a representative of the DHO, who is attached to Reproductive Health or the DHO himself to participate in the training in the hospital.
Check the training venue. Agree on the set timetable and arrange for how meals of participants will be availed.
Ensure that all the participants from within the hospital and those from other health facilities have been invited
Agree on the coordination for the activity

In the hospital

Trainers should introduce themselves to the Medical Director and explain the process.

Request the participation of the following departmental heads who are also members of the MPDR Committee (potential or ready formed)

Hospital Director or Medical Superintendent
Principal Nursing Officer
Medical Officer/Specialist in charge of maternity unit
Sister in charge of Maternity
Chief Lab Technician
Blood Bank Representative
Pharmacy
Representative of midwives
Hospital Secretary
Biostatistician
Anaesthest

Training Materials and methods

This training in MPDR focuses on competency-based learning and is intended to be as interactive as possible. Much time will be dedicated to practical exercises. The practice will be based on “real” maternal, perinatal and neonatal death cases (previously rendered anonymous) that occurred in any health facility where the training takes place.

Different learning methods will be used:

Interactive presentations:

Practical exercises (individual and by group) on conducting all steps of MPDR based on “real” but anonymized cases records. The last exercises will use patient files (near miss case or death) from the hospital where the training takes place. Role plays are essential activities for the participants to acquire the attitudes needed to conduct a review session and to adopt a systematic approach to address each stage of MPDR.

The training materials include:

The MPDR guidelines
WHO guidance on maternal and perinatal death surveillance and response
Additional resources:

5-6 anonymized maternal/perinatal death files prepared by the training team

Prepared PowerPoint presentations (PP) for interactive presentations

Emergency obstetric care protocols and treatment guidelines
Standard operating procedures for maternity.
Training Evaluation form

Duration of Training:

The course will last 3 days

How to use this Training Guide:

Trainers must read and familiarize themselves with the content of all modules and how they relate to each other as well as the MPDR guidelines.

Trainers should use pre- prepared newsprint/powerpoint,.
Use the trainee handout as much as possible to guide the participants through various sessions.

HOW THE TRAINING GUIDE IS ORGANISED

Following the introduction, the training guide is arranged in … topics. which are in turn divided into sessions. These topics are organized in such a way that they flow sequentially.

The information for each topic is organized as follows:

i)The topic and session Title

ii)Duration – This is the suggested time that each session should take. Depending on the level of skills trainees already have, the sessions may take a longer or a shorter time.

iii) Methods and training materials

iv)Objectives: These are the expected outcomes of the training activity. They have been presented as specifically as possible for easy understanding

v)Procedure or Learning experience indicating the training techniques used

TRAINING GOAL

The training goal is:

To equip health workers with knowledge and skills on maternal and perinatal death review (MPDR) in order to improve quality of Health care delivery thus reducing maternal, perinatal and newborn mortality and morbidity.

General training Objectives:

By the end of the training trainees will be able to:

Acquire knowledge and skills to enable them to conduct MPDR in their health facilities
Identify avoidable factors and develop recommendations for quality improvement To improve the quality of documentation and management of information regarding clients
To reflect on individual or team attitude performance for and contribution to the improvement of quality of care.
To develop plans to address avoidable factors and monitor the progress of the implementation of the recommendations (MPDR cycle).
To advocate for MPDR in their workplace
To compile reports for dissemination to relevant audiences.

Content Outline

Topic 1:Introduction

Session 1: Climate setting and orientation to training

Session 2: Overview of maternal and perinatal death reviews

-Magnitude of maternal and perinatal deaths

-Trends in the Reproductive Health Indicators

-Policy on Maternal/Perinatal Death Review

- Maternal and Perinatal death Review

Introduction to the MPDR Cycle

Topic 2:Quality of care

-Definition

-Principles of quality of care

-Protocols

Topic 3: Preparing to conduct MPDR

Topic 4: Forming MPDR committees

Topic 5: Conducting the MPDR Review

Session 1: The MPDR cycle

Session 2: Filing forms and summarizing cases

Session 3: Conducting Maternal and Perinatal death review meetings

Topic 6: Reporting & feedback

Topic 7: Follow – up, monitoring and evaluation

Orientation to the training

Description of the Topic

This topic seeks to create a conducive climate among trainers and trainees that will enhance effective learning.

The roles of trainers and trainees will be identified and agreed on through sharing expectations and Training objectives.

This topic will also give an overview of maternal and perinatal death reviews in Uganda and help participants to appreciate it in the context of improving the Quality of care.

SESSION 1.1:Climate Setting and Orientation to training

DURATION:30 MINS

Materials

News print/PowerPoint slides with Workshop Goal and Objectives

Workshop schedule

PROCEDURE

Facilitator:

Welcomes trainees.

Introduces the trainers/facilitators and

Asks participants to introduce themselves and mention their expectations for the workshop

Ask trainees to register themselves if they have not already done so

Explains briefly the workshop goals and objectives

Explain the workshop schedule noting the starting and ending time; breaks,

Allow questions and make necessary clarifications

Explain workshop logistics i.e. accommodation, meals, allowances, transport refund, any other issues

Ask trainees if they have any problems with the schedule and /or logistics and make modifications if possible

Allow and answer questions

Trainer:

Highlight major issues covered during the session

Wrap up and introduce the next session.

SESSION 1.2:Overview ofMaternal and Perinatal death Review in Uganda

Duration: 1 hour

Session outline

-Magnitude of maternal and perinatal deaths

-Trends in the Reproductive Health Indicators

-Policy on Maternal/Perinatal Death Review (when & who)

-Why Maternal and Perinatal death Review (pg 12 of guidelines)

The MPDR Cycle

SESSION OBJECTIVES

By the end of the session participants will be able to:

Discuss the rationale/justification for conducting MPDR
Explain the MPDR policy
outline the MPDR cycle

Methods:Lecturette, Large group discussion

Materials:Handouts/PowerPoint slides on the MPDR cycle, newsprints, markers, masking tape

Preparations: Slides/flipchart

Procedure:

Trainer:

Asks participants to mention some of the RH indicators they know
Acknowledge response
Put up newsprint/slide and discuss one by one (MMR, PMR, NMR, Still birth, CPR, Facility deliveries, causes of MPD (obstetric causes and Contributing factors), Case Fatality Rate)

Trainer:

Asks participants to share what they know or hear about MPDR Policy in Uganda
Acknowledge response
Explain the MPDR Policy in Uganda
Allow discussion and clarify where necessary
Emphasize that there are many factors that contribute to a maternal and or Newborn death, so MPDR is a process to analyze and find Solutions to prevent another death but not a blame game for the Health workers thus not a finger pointing process.

Trainer:

Leads a discussion on why Maternal Perinatal Deaths should be reviewed (refer to the MPDR guideline)
Allows questions and answers
Clarifies as necessary

Trainer:

Displays newsprint/power point slide of the MPDR Cycle
Explains the different steps of the cycle
Allows questions and clarifies as necessary

Summarizes and closes session

Topic 2: Quality of care / quality improvement (Ms. Najjemba & Dr. Olive)

Topic Description

The major purpose of this topic is to make participants appreciate MPDR as one of the ways to improve the Quality of care in maternal and new born care.

It will discuss the principles and steps to be followed in quality improvement.

Topic Outline

Definition of Quality of care and Quality improvement
Principles of Quality of care improvement
Steps in Quality improvement.

Duration: 11/2 hrs

Session 1 Definition of Quality of care and Quality improvement

-SESSION OBJECTIVES

By the end of the session participants will be able to:

Define the terms quality, quality of care and quality improvement
Discuss the principles of quality of care/improvement
Explain the steps in quality improvement

Methods:Lecturette, Brain storming, large group discussion

Materials:Handouts newsprints/PowerPoint slides, markers, masking tape

INTRODUCTION

Trainer :

Asks participants to imagine that they are clients.

Asks What they would expect of a service, What they would like to have available at the facility and how would they would want to be treated if they went to a health facility for health care?

Acknowledges response and introduces the topic

Appreciate the relationship between death reviews and quality improvement

PROCEDURE

Trainer:

Asks participants to mention what they understand by the term quality

Acknowledges responses

Asks participants the meaning of quality of care and what they understand by the term quality improvement

Ackonwledges responses

Displays newsprint with the meaning of quality of care and quality improvement

Quality

Quality” has many definitions – according to context of use

•Performance according to standards

•Conformance to requirements/specifications

•Doing the right thing, the right way and at the right time

Quality of care

All actions taken to ensure that standards and procedures are adhered to and that delivered products or services meet performance requirements

Quality Improvement –

Applying appropriate methods to close the gap between current and expected level of quality/performance as defined by standards

Trainer;

Asks participants to mention the principles ofquality of care/improvement

Acknowledges responses

Displays newsprint/gives handouts with principles of quality of care/improvement and explains one by one

Principles of quality of care/improvement

Focus on the client

Clients are a focus of any quality activity
Services that do not meet client needs fail
Satisfied clients comply better with advice / treatment given. And, they will often return to the facility and / or recommend it to others
Satisfied internal clients will work with the system better



Focus on systems and processes

Analysis of service delivery system prevents problems before they occur. A system is made up of inputs, processes, outputs and outcomes

Use of data

Quality is a measure of how good something is. Measurement is important in improving quality
Collect data about the activities that one want to improve – collect only the data one needs
Compare analysed data with standard set – reveals gap
Analysed data is information and must be used to improve quality e.g. planning, monitoring (correcting gaps), evaluating etc. It must be used at point of collection
Data may be presented as bar graphs, pie charts etc.

A teamwork/collaboration

Team work is at the heart of methods to improve quality
All team members are important- including the smallest member. One big tree does not make a forest!
In an effective team, the humble contribution of each team member should be appreciated
When discussed in a team, problems become opportunities
Team members should support each other’s efforts.

Allows questions and craifies as necessary

Trainer:

Asks participants to outline the steps of qulity improvement

Acknowledges responses

Displays newsprint/gives handout with the steps of quality improvement and explains one by one

Steps of quality improvement

•Step one: Identify the problem

Quality Improvement starts by asking questions:
What is the problem?
How do you know that it is a problem?
How frequently does it occur, or how long has it existed?
What are the effects of this problem?
Identify the gap - Difference between actual and desired performance
Ways of identifying the problem - Use data from surveys, review records, observation, feedback from clients

•Step two: Analyze the problem

The purpose is to measure performance of the process or system that produces the effect.
Techniques include flow charts, cause-effect (fish bone) diagrams, review of existing data etc.
Analysis involves answering the following questions; Who is involved or affected? Why, when, where does the problem occur, What happens when the problem occurs?

•Step three: Develop possible solutions to the problem (improvement changes)

Changes are possible solutions to problems identified during process of quality improvement.
Developed on basis of knowledge and beliefs about likely causes and solutions to the problem
QI teams should ask themselves the question: What changes can we make that will lead to improvement?
Possible solutions (proposed changes) are then developed based on the hypothesis
Determine possible changes (interventions) we believe may yield improvement
Organize changes according to importance and practicality
Test changes (if possible, one change at a time )
Improvement usually requireschangebut not allchange is anImprovement!

•

•Step four: Test /implement the possible solutions