Introduction

Reducing maternal and newborn deaths is an integral part of the global agenda to achieve Millennium Development Goals (MDGs) 4 and 5 by 2015. Recent data have shown that the majority of maternal and neonatal deaths occur in developing countries: as many as 95% of total maternal and child deaths occur in 75 low- and middle-income countries [1]. Countries within Asia are at particularly high risk. Bangladesh has made encouraging progress in reducing maternal and neonatal mortality over the past two decades; since 1990, maternal mortality has fallen by two-thirds [2] and neonatal mortality has declined by over 50 per cent [3]. In 2010, Bangladesh received a United Nations award for its achievements in working towards attaining the MDGs, an acknowledgement of the great progress made in reducing maternal and neonatal mortality over the past two decades. Maternal mortality has reduced from 574 deaths per 100,000 live births in 1991 to 194 deaths in 2011. Neonatal mortality declined from 52 to 37 deaths per 1000 live births (38%) between 1989 and 2009 [4]. Recently, the Bangladesh Health and Demographic Survey showed that neonatal mortality had further reduced to 28 per 1000 live births [5]. Although the Government of Bangladesh is determined to maintain this progress, institutional delivery uptake is still poor, occurring in only 28.8% of cases [6, 7]. Recent data in Bangladesh from the maternal death review highlighted that 47.8% of maternal deaths occurred in facilities [8] and that in most cases the deaths could have been prevented.

Facility death review (FDR) is an important method for exploring gaps and delays in the system by examining the causes of death at health facilities, the aim being to improve the quality of care in hospitals [9]. In 2004, the World Health Organisation (WHO) formalized the FDR system for maternal deaths [10]. The WHO developed the Commission on Information and Accountability for Women’s and Children’s Health (COIA) Secretariat in Bangladesh to strengthen the death review system and also implement the WHO Maternal Death Surveillance and Response (MDSR) program [11].

The death audit approach is one of the most effective methods for improving health service performance to reduce maternal and perinatal deaths in healthcare facilities [12,13]. FDR is practised for maternal deaths in a number of countries [9, 14–22]. However, there is a paucity of comprehensive reviews of facility deaths in Bangladesh [20]. Bangladesh introduced a maternal and neonatal death review system for both community and facility maternal and neonatal deaths (including stillbirths) in 2010 [23]. This study explores FDRs of maternal and neonatal deaths and stillbirths and the experiences, effects, and lessons learnt to date in two districts in Bangladesh.

Methods

This was a qualitative study performed in the Thakurgaon and Jamalpur districts of Bangladesh. The FDR (maternal and neonatal death review; MNDR) was initially piloted in the Thakurgaon district of Bangladesh in 2010. The district population is around 1.4 million and is situated in the northern part of the country. After a one-year MNDR pilot study, it was extended to another three districts in Bangladesh including Narail, Jamalpur, and Moulvibazar. For the purpose of meeting the aims of this study, we chose Thakurgaon as a pilot district, and Jamalpur district was randomly selected from the other three districts; Jamalpur covers a population of around 2.2 million people. From each district, three upazilas (sub-districts) were randomly selected for study. In both districts, FDRs were examined in the district hospitals, the maternal and child welfare centers (MCWCs), and six upazila health complexes (UHCs): 16 facilities were studied in total. The MNDR system was implemented by the Directorate General of Health Services (DGHS) in collaboration with the Directorate General of Family Planning (DGFP) under the auspices of the Ministry of Health and Family Welfare in Bangladesh. The MNDR development process is described elsewhere [8, 23–24].

The FDR process and its acceptance were assessed at the end of initial piloting during January 2011 in Thakurgaon district. To explore the effect of FDR, including the lessons learnt and the challenges highlighted, data were collected from both the pilot district (Thakurgaon) and the second district (Jamalpur) in November 2011.

Focus group discussions (FGDs) and in-depth interviews (IDIs) were conducted with facility doctors and nurses. Upazila and district health managers in both districts were also interviewed. Documents related to the development of FDR were reviewed, which included meeting minutes, different reviewed national and international tools, record notes, training guidelines, and manuals. These were collected so that each document could be thoroughly reviewed to understand the FDR development process. All the different document types were useful for uncovering their meaning, developing understanding, and discovering insights with respect to the research objectives [25]. This was also used as easily available, efficient, and less obstructive supplementary data with broad coverage and precision. All documents were examined twice to help understand the development process, after which content analysis was performed using a method appropriate for text analysis [26].

Thakurgaon district hospital, MCWC, and three UHCs were selected to identify the acceptability of FDRs. IDIs were conducted with doctors and nurses, one from each of the UHCs. Moreover, upazila health and family planning officers of those upazilas were also interviewed. In total, 13 IDIs were performed. Moreover, an FDG was conducted with the district hospital facility death review team, which consisted of doctors and nurses working in obstetrics and gynecology and pediatrics departments in Thakurgaon. There was a total of 11 participants: five doctors and six nurses (Table 1).

Download:

• PPT
  PowerPoint slide
• PNG
  larger image
• TIFF
  original image

Table 1. Qualitative methods used in January 2011 in Thakurgaon district.

https://doi.org/10.1371/journal.pone.0141902.t001

To identify the effects of FDR, including lessons learnt and challenges discovered, three UHCs from Jamalpur district and in Thakurgaon were randomly selected; data were collected from the same three upazilas where acceptability data collection was performed. In addition to the UHCs, information was also collected from Thakurgaon and Jamalpur district hospitals.

A total of 12 IDIs were conducted with doctors and nurses primarily and actively involved in the facility death review process in both districts. In addition, IDIs were conducted with upazila health and family planning officers (Table 2).

Download:

• PPT
  PowerPoint slide
• PNG
  larger image
• TIFF
  original image

Table 2. Qualitative methods used in November 2011 at Thakurgaon and Jamalpur district.

https://doi.org/10.1371/journal.pone.0141902.t002

Each IDI was carried out with the doctors and nurses in their working facilities and took 20–30 minutes. Civil surgeons were interviewed at the district hospital, and deputy directors of family planning were interviewed at the district maternal and child welfare centers.

The anthropologists designated as research officers were formally trained prior to conducting the interviews. Pre-testing was performed before the study to finalize the guidelines. FDG and IDI participants provided informed verbal consent before the discussions and interviews. Informed consent was taken from each respondent before start of interviews, with tape recording only used after prior permission from respondents. Research officers made formal appointments with district and upazila health managers before the interviews. Since it was difficult to obtain written consent from each participant (doctors and nurses) during hospital working hours, both the investigators and participants were comfortable providing verbal consent before initiation of interviews in this setting. The ethics committee approved the taking of verbal consent.

Transcripts were prepared from audio records and handwritten notes in the local Bengali language and then translated to English. The research investigator was responsible for observing and monitoring the interviews in the field and also participated in the FGD sessions. Based on the findings, the investigator provided feedback to ensure data quality. Ten percent of transcripts were reviewed and checked for the quality of transcription from recorders; all transcripts were in the acceptable range for analysis. Data were first examined superficially to review its content, prior to thorough reading, examination, and interpretation. Open coding followed by selective coding was performed systematically by constantly moving backwards and forwards in the entire dataset and collecting relevant codes. Codes were then organized into different potential themes. The analysis was completed using a manual thematic approach, which is a flexible method for qualitative data analysis.

Results

Reviewed Documents

The facility death review instrument was initially developed prior to piloting in 2010 by reviewing the death review forms used in tertiary medical college hospitals and district hospitals and some other tools used by the Obstetrical and Gynecological Society of Bangladesh, Lamb Hospital. The WHO death audit form was also reviewed [10]. The DGHS and DGFP jointly organized a number of technical workshops and meetings in the presence of different government stakeholders and professional experts including obstetricians and gynecologists, neonatologists, and public health specialists. Developmental partners developed a simpler version of FDR that was effective for collecting data from district and lesser facilities.

FDR involved a participatory and non-blaming process of reviewing any maternal deaths, neonatal deaths, and stillbirths in each facility. In the MNDR system, FDRs took place in the district hospital, maternal and child welfare centers, and UHCs. Senior staff nurses were assigned to perform facility death notifications of maternal and neonatal deaths and stillbirths in the district hospitals and UHCs, while family welfare visitors conducted FDRs in the district maternal and child welfare centers. This was followed by reviewing the deaths using existing records and recall by visiting the health care providers in the facility who treated or managed the patient prior to death. Nurses sought support from consultants or trainee doctors to assign causes of death if not recorded. Facilities planned to conduct each FDR immediately after the death was reported at the facilities. Review meetings for analyzing the causes of deaths to prepare corrective action plans took place quarterly in the district and in upazilas (Fig 1).

Download:

• PPT
  PowerPoint slide
• PNG
  larger image
• TIFF
  original image

Fig 1. Facility death review in MNDR.

https://doi.org/10.1371/journal.pone.0141902.g001

Hospital administrators or managers, consultants in obstetrics and gynecology, pediatrics, and anesthesia, and nurses involved in the FDR process participated in death review meetings. In each facility, a death review committee was formed to review the deaths as per national agreed guidelines.

The review meetings analyzed relevant events, factors, and delays that occurred in relation to service provision at the facility. The process aimed to identify all remediable factors to prevent recurrence of these types of deaths. The FDRs maintained the highest possible level of confidentiality and ethics. All information and data remained confidential, and anonymous records were preserved at the focal point in UHCs or district hospitals. The information was not publicly published or used to punish or appraise anybody.

Discussion

Here we show that FDR has been introduced in district hospitals, maternal and child welfare centers, and UHCs in Bangladesh for the review of maternal and neonatal deaths including stillbirths. A vigorous process has been undertaken to adopt the tools and guidelines from existing instruments in overseas countries to prepare a practical and achievable death review system for primary and secondary health care centers. The government has approved the FDR instruments, including the facility death notification form and the death review form for maternal and neonatal deaths and stillbirths and guidelines used in districts to review facility deaths. The government health system has clearly played a key role in the implementation of death review. FDR for each maternal and neonatal death is practicable and functional, even considering the present health infrastructure including human resources and available facilities.

FDR of maternal deaths has previously been undertaken in Ethiopia with a system engaging healthcare providers in ten district hospitals, where it was found to be a powerful tool to maintain accountability [27]. Another study in northern Nigeria analyzed the experiences of maternal death review in 18 facilities and explored the existing maternal death review system and its challenges [9]. A study in Senegal demonstrated that maternal death review at facilities was feasible, especially in low resources settings [21]. FIGO LOGIC initiatives have shown that FDR resulted in significant health improvements at the local level [22]. Maternal and perinatal death reviews have been conducted in Tanzanian facilities since 2006 and have identified avoidable factors and opportunities for improvement via confidential multidisciplinary team discussions led by healthcare providers and by reviewing patient records [28]. A Lebanese study mentioned that the FDR approach helped professionals to understand the causes and determinants of maternal mortality [29]. In Asia, the WHO initiated maternal and perinatal death review at facilities in Bangladesh, Sri Lanka, India, Nepal, Myanmar, Bhutan, the Maldives, Indonesia, Thailand, and Korea [30]. In Bangladesh, one study on FDR reported that death review at a medical college hospital and district hospital provided the opportunity to identify substandard care at these facilities [20].

Here we examined beyond death review numbers and explored gaps and challenges [10]. FDR meetings were used as a platform for in-depth discussion of deaths and to identify service gaps behind the deaths that had occurred in the facility. A study on FDR reported that discussions with the healthcare providers at the facilities identified lessons and steps to further improve service [31].

There is some evidence to demonstrate examples of good practice to improve quality of care at facilities using the FDR system. The FDR system is simple and easy to implement; this is particularly evident when examining a case study of a woman where blood was managed using a donor network established through a vigorous review of maternal deaths during 2010 in Thakurgaon district hospital. Similar successes were found in Orissa, India, where FDR findings that post-partum haemorrhage was a major cause of maternal death were used to good effect: eight districts set up blood banks and a blood storage unit to improve patient survival. In Rajasthan, India, an obstetrics helpline and referral transport system was established for mothers [32].

A number of challenges were identified during FDR implementation, the most notable being inadequate patient information being documented in hospital records. This made it difficult to assess the real causes and gaps or challenges. There was also a major obstacle in the lack of space or time for healthcare providers to perform FDR. Delays in completing the FDR resulted in the loss of some data due to the prolonged recall period, sometimes over a month, even though the national agreed level to complete an FDR is within 15 days of a death occurring. In many cases, the transfer of trained healthcare providers (nurses and doctors) from the hospital decreased the facility’s ability to conduct FDR. One study on maternal death review in Africa also reported that frequent turnover of programme managers and staff caused difficulty in maternal death review [14].

Other countries have reported similar findings, with FDR found to be challenging due to deficiencies in basic patient registration details, record keeping, and skilled human resources to conduct the death review [9, 16, 20–21, 25–26, 33–35].

Conclusions

The lack of information in patient records and human resource constraints are key challenges to ensuring quality FDR. However, the successes noted are also evidence to suggest improvement in the quality of care at health facilities due to FDR. Our study shows that facility-based case reviews are simple, non-blaming, and can easily be performed within the existing health system. Although FDRs require intensive supervision, monitoring, and support to overcome obstacles, they also provide the opportunity to improve outcomes for mothers and newborns at health facilities in Bangladesh.

Acknowledgments

We thank the Directorate General of Health Services (DGHS) and Directorate General of Family Planning (DGFP), Ministry of Health and Family Welfare (MOHFW) of the Government of the People’s Republic of Bangladesh for implementing Maternal and Neonatal Death Review under a joint GoB-UN Maternal Neonatal Health Initiative. We are also grateful to UNICEF, Bangladesh for providing technical and financial support through Canadian CIDA (DFATD) and Department for International Development (DFID) & European Commission (EC) to initiate the piloting.