Maternal, perinatal and neonatal mortality case review tool

Tool Name: Maternal, perinatal and neonatal mortality case review tool

Purpose: A mortality case review is a method of identifying the principle causes contributing to a death through an in-depth review of the events preceding the death. MotherCare developed a standardised case review tool for examining causes of maternal, perinatal and neonatal deaths in communities in Bolivia and Bangladesh.

Type of Design: Retrospective, community-based survey of the persons involved in the events preceding the death of a "case."

Where Used: Bolivia and Bangladesh

Tool 14

BASIC INFORMATION

Name: Maternal, perinatal and neonatal mortality case review tool

Origin /Source: MotherCare Project

Technical Area: Maternal and newborn health

Basic Description: The tool is a structured questionnaire administered to family members of mothers or infants who have died. Questions are asked to determine the cause of death as well as on other variables such as socioeconomic status, number of previous births, education level nutritional status and the process of care seeking and decision making before death.

These questions are divided into 3 sections:

• History Section: This section seeks to capture basic socio-economic and demographic information.
• Verbal Autopsy Section: This section involves a review of the circumstances surrounding the death of a woman of reproductive age or the death of a child in the peri/neonatal period, in order to determine the precise cause of that death. (See A Standard Verbal Autopsy Method for Investigating Causes of Death in Infants and Children (Including Neonates))

• Process Diagnostic Section: This section reviews a basic model of decision-making and health care seeking behaviour to identify gaps and strengths in problem recognition, decision-making, logistics and service delivery, which surrounded the maternal or peri/neonatal death.

Country Applications: Bangladesh and Bolivia

Language(s) available: English

Note that this questionnaire was developed specifically for use in Bolivia and Bangladesh. but could be adapted to other settings. As with all surveys concerned with local understanding of illness and care seeking behaviour, the standard questionnaire should be adapted to the local setting. Ideally the questionnaire should be translated into the local language by someone who is fluent both in English and in the local language, and who is familiar with the local lay medical terminology. A local anthropologist or a demographer should check the translation for accuracy of intended meaning. Back translation should also be done and compared to the original questionnaire to make sure that the intent of each question reflects the original medical meaning.

Alternative local terms for medical conditions, symptoms and signs of illness should be considered both during the translation phase and also during the interviewing training. Local terms can be printed directly on the questionnaire or inserted by the interviewer.

Purpose: needs assessment, evaluation

Technical Scope: See "Objectives and Scope of the Tool" below.

Method: Qualitative and quantitative

Design: Retrospective cross sectional, community-based survey.

Key Users of Information: Researchers, policy-makers and programme planner and managers for assessing the need for and impact of programme interventions.

Objectives and Scope of the Tool:

The tool was designed to

• identify characteristics associated with maternal and peri/neonatal death and stillbirths

• identify the relationship between care seeking behaviours, health care and deaths
• to identify gaps in current services provision and ways to reduce unnecessary deaths.

Tool Design:

The questionnaire was designed to be administered to family members of deaths identified within a specific population. The tool was originally adapted for use in Bolivia and Bangladesh, although it may be applicable to other settings. Identifying all deaths is important, but may be difficult as many deaths, particularly those that occur in early pregnancy or in utero, are often not reported and more accurate information about numbers of deaths may be ascertained by using multiple sources such as community informants, facility records, etc.

[Ed note: As far as we are aware validation of the diagnosis derived from the verbal autopsy component with a proven medical diagnosis was not carried out as the main focus of both the studies that subsequently used the tool (see below) was originally to identify factors predisposing to death ( i.e. improve risk screening), rather than to establish an accurate medical diagnosis].

Tool Applications:

In Nasirnagar, district of Brahmanbaria, the verbal autopsy and the process diagnosis sections of the questionnaire were applied to all cases of stillbirth and neonatal mortality that occurred in 1989 and 1990.

In Inquisivi, Bolivia, a two-year retrospective case-control study was conducted using the short version of the tool. Cases were identified as stillbirths, maternal and peri/neonatal deaths in the project areas of Inquisivi, Circuata and Licoma within the previous 2 years. Controls were selected randomly from the population from a project community database. Two controls were selected for each case to increases the statistical power of the study given the small number of cases.

Lessons learned:

• MotherCare experience with the case-control study in Bolivia indicated that the type of risk factors identified in case-control study, for instance, pregnancy at a very young age, were not necessarily those that could be addressed programmatically in countries with scarce health care resources.

• The sensitivity and specificity of the tool were low, ie too may women were identified as being at risk but did not subsequently have a bad pregnancy outcome. Other studies have know shown that most women who develop life-threatening complications are not those women initially identified "at risk".

• The MotherCare project in Bangladesh decided to seek out those factors that contributed most immediately to intra- and postpartum deaths through a review of individual cases. This was done using the verbal autopsy and process diagnosis methodologies as a case review technique. This methodology was found to be more time efficient, less costly and as useful as the case control study to determine specific project interventions.

Contact:

Measure Evaluation (measure@unc.edu)