Morbidity and Performance Assessment (MAP)

Name: Morbidity and Performance Assessment (MAP)

Origin/Source: L Sibley (ACNM), L Caleb-Varkey (Intrah), J Upadhyay (Shramik Bharti), with VK Paul (All India Institute of Medical Sciences) for newborn component. USAID-funded PRIME I Community Partnership for Safe Motherhood Project.

Technical Area: Maternal and newborn health.

Part I
Part IIA
part IIB
Part III

Basic Description: A method for assessing recognition of and response to illness and death among mothers and newborns. The MAP, derived from verbal autopsy methodology, is comprised of three parts, including a household listing and screening to identify all women who delivered or experienced an abortion during a specified period of time, a semi-structured interview of the women or next of kin (in case of maternal death), followed by a clinical review by expert panel of all cases where signs of maternal and newborn life threatening complications were reported. Key portions of the interview are tape-recorded. The case review focuses on the probable problem, problem recognition, home-based first aid response, referral decision-making and health seeking. It is standardized using modified diagnostic criteria (WHO 1994) and home-based management criteria (ACNM 1999). An underlying assumption of the MAP is that illness and death are accompanied by observable signs that result in a response on the part of the patient or caregiver, and that both can be recalled during the interview.

Country Applications: India

Language Available: English and Hindi. The English version (prototype) of the questionnaire should be translated into the local language by a person who is fluent in both English and local language. The translation should be checked for cultural appropriateness and for accuracy of intended meaning. It should also be back translated to check for accuracy of intended meaning, especially of terminology for signs of life threatening complications.

Purpose: Needs assessment, evaluation, and advocacy (community mobilization).

Technical Scope/Purpose: Assessing recognition of and response to illness and death among mothers and newborns.

Design: Cross-sectional, a community-based survey combined with a clinical review of relevant cases. Descriptive, the settings in which this method can be used are varied.

Method: Qualitative and quantitative.

Key Users of Information: Policy makers and program managers for assessing need and measuring outcomes of program interventions, researchers for gaining insights into recognition and response to life-threatening complications, local NGOs and communities for advocacy in safe motherhood and child survival.

Objectives and Scope of the Tool

The specific objectives of this tool are:

  1. To provide community-based data on time and probable cause maternal and newborn illness and death, and response to illness and death, by probable cause.
  2. To assess need, plan and evaluate health interventions that aim to reduce illness and death, when these are introduced into a small geographic area on a trial basis.
  3. To facilitate research into critical areas including problem recognition, first aid response, referral decision-making and health seeking.
  4. To provide information that can be used to advocate safe motherhood and child survival

MAP Part-I is a short household listing and screening questionnaire, administered to each household in the project area. It focuses on identifying household size, composition and women who delivered or experienced an abortion during a specified time period (These women are eligible for the MAP Part II interview.).

MAP Part-II is a lengthier questionnaire consisting of open-ended questions about a woman's last childbirth, including her social and economic background, pregnancy, labor and birth, and about the postpartum and neonatal periods. It includes a series of close-ended questions that ask about symptoms and their perceived severity, followed by a series of open ended questions about first aid response, referral decision-making and health seeking in cases where symptoms reported suggest a life threatening complication was present (These cases are eligible for the MAP Part III case review). It is administered to each woman eligible for the interview or their next of kin (in case of maternal death).

MAP Part III is a case review questionnaire, which includes two sets of worksheets. One set contains pre-determined diagnostic algorithms so that standardized probable causes of complications and/or deaths can be derived. The other set contains predetermined management criteria so that response can be derived. It relies on the MAP Part-II as a data source and is completed by an expert medical panel.

Key indicators:

The key indicators attempt to track the 'pathway to survival' and include:

  1. Probable time and cause of maternal illness or death, including obstructed labor, abortion, antepartum and postpartum hemorrhage, sepsis and hypertensive disorders of pregnancy.
  2. Probable time, causes of newborn illness or death, including birth trauma, birth asphyxia, low birth weight, tetanus, pneumonia and other sepsis.
  3. Knowledge of maternal and newborn danger signs.
  4. Presence of an emergency care plan (e.g., knew to whom or where and how to go in the event of a life threatening complication).
  5. Recognition of signs of life threatening complication (e.g., agreement between respondents and expert panel on the severity of signs reported)
  6. Adequacy of home based management to life threatening complications (e.g., correct/did the right thing, complete/did everything possible in home setting, safe/did nothing to cause harm or delay according to pre-determined management criteria)
  7. Appropriateness of referral decision making (e.g., needed/sought or not needed/not sought according to pre-determined management criteria)
  8. Appropriateness of the referral process (e.g., direct to facility capable of emergency care, accompanied by adult family member or friend according to pre-determined management criteria)

Implementation and Training:

The MAP Part-I and Part-II implementation requires a team consisting of supervisor(s), field editor(s), interviewer(s), a data manager and statistician or data analyst. After local adaptation and translation/back translation of the tool, the team should agree on the final drafts of the questionnaires. The MAP team should then pre-test by interviewing women who have given birth within the specified time period, coding and editing the completed questionnaire against an editors checklist and cross-checking the key portions of the coded responses against the tape. The MAP data manager should double-enter the data into an electronic database. Any problems with the questionnaire, field or office operations should be resolved before taking the questionnaire into the field. Training for implementation involves an orientation to the purpose and objectives of the MAP, jobs and tasks of the various team members, dissection of the questionnaire (e.g., structure, content, logic and skip patterns), training in interviewing techniques and in field editing, data flow, quality controls and management, and finally logistics.

The MAP Part-III implementation requires an expert panel consisting of medically qualified persons (e.g., obstetrician, nurse-midwife, pediatrician etc.). The panel should pre-test the questionnaire by reviewing at least five cases. Any problems should be resolved before reviewing further cases.

Lessons from Experience:

  1. A clear understanding of the purpose of the MAP and confidence in the interviewer increases the willingness of respondents to participate in the interview.
  2. A respondent's ability to recall and describe symptoms of a life threatening complication is influenced by, among other things, her understanding of causes of illness and death, as well as her concept of what are 'normal' and 'abnormal' symptoms (e.g., symptoms of excessive maternal bleeding in the immediate postpartum period or general newborn sepsis are challenging). The diagnostic algorithm terminology for each life threatening complication needs to be modified to include locally understood symptoms to the extent possible.
  3. The MAP interview is designed to be flexible, allowing the interviewer to follow the woman's (or neonate's) history sequentially as it unfolds. Interviewing techniques and working with the many skip patterns must be mastered so that the interview flows in the sense of an illness narrative. Adequate training in all phases of implementation and field supervision are essential.

 

Contact person:

Lynn Sibley, E-Mail: antls@learnlink.emory.edu
American College of Nurse-Midwives
818 Connecticut Ave. N.W. Suite 900
Washington, D.C. 20006
USA
Tel: 202-728-9864
Fax: 202-728-9897

Comments from the author:

Some cautions regarding the MAP tool. At the level of the household screening (MAP Part-I), abortions may be under-reported. At the level of the cross-sectional survey (MAP Part-II), stillbirths and early neonatal deaths may be under-reported. Finally, symptoms of life threatening

complications may not be reported because the respondents do not recognize or recall symptoms. Misclassification exists if a life threatening complication that was in present but not reported, or if a life-threatening complication was not present but was reported. Misclassification is a common difficulty when validation of complications is not possible. Establishing prevalence for biomedically confirmed life threatening complications is not the purpose of the MAP tool. However, misclassification may affect the overall number of cases to be assessed. Improved recognition and response to life threatening complications as a result of interventions is expected. Whether the number of cases eligible to be assessed will increase or decrease is post-intervention, however, is not known.