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Achievements and lessons learnt from facility‐based maternal death reviews in C ameroon

2014; Wiley; Volume: 121; Issue: s4 Linguagem: Inglês

10.1111/1471-0528.12902

1471-0528

Vincent De Brouwere, Thérèse Delvaux, RJ Leke,

Global Health Care Issues

Recent estimates from the World Health Organization (WHO), United Nations Population Fund (UNFPA), United Nations Children's Fund (UNICEF) and the World Bank showed that the maternal mortality ratio in Cameroon increased slightly between 1990 and 2010 from 670 to 690 maternal deaths per 100 000 live births and the estimate obtained in the last Demographic Health Survey (DHS 2011) was 782 per 100 000 births.1, 2 Skilled birth attendance also stagnated at 64% between 1991 and 2011 although attendance for at least one antenatal care visit was already high in 1991 at 79% and reached 85% in 2011.2, 3 In 2010, Cameroon adopted the Campaign on the Accelerated, the Reduction of Maternal Mortality in Africa (CARMMA) as its strategic plan. This guided the actions for the 2011–13 period among which 'audits of maternal deaths' both at facility level and in the community were mentioned as a means to assess and improve case management. The International Federation of Gynecology and Obstetrics (FIGO) works with national Membership Associations to improve policies and practices in reproductive, maternal and neonatal health. One of its projects, called LOGIC (Leadership in Obstetrics and Gynaecology for Impact and Change), focuses on strengthening the capacity of Membership Associations to conduct maternal death reviews (MDR). Cameroon is one of the eight focus countries benefiting from FIGO support. The Society of Gynecologists and Obstetricians of Cameroon (SOGOC) leads the implementation in Cameroon. The LOGIC project was initiated in 2009. A memorandum of understanding was signed between SOGOC and the Ministry of Public Health, a process that took approximately 9 months. A national SOGOC team was trained by international experts, and subsequently, in 2010/11 MDR training sessions took place in three hospitals in Yaoundé (Central Hospital Yaoundé [CHY], Gynaecology, Obstetric and Paediatric Hospital of Yaoundé [HGOPY], University Hospital of Yaoundé [CHUY]), and one regional hospital (Bertoua). In 2012, two other hospital teams were trained (Lacquintinie Hospital in Douala and Biyem Assi District Hospital close to Yaoundé) to reach a total of 88 health personnel who had been trained in conducting MDRs. Following the training sessions, MDR committees were created in each of the hospitals and the SOGOC monitored the MDR meeting reports sent by the MDR committees, compiled these reports and sent them to the Ministry of Public Health. It also contributed to ensure MDR was introduced as part of the midwifery schools training programmes in Cameroon. The 2011 and early 2012 MDR training programme lasted 3 days with most of the time devoted to theoretical presentations inspired by the Beyond the Numbers manual.4 The presentations included maternal mortality in Cameroon, the audit process and the different types of audit including MDR. Half a day was devoted to practical exercises (analysis of a maternal death case, of a near-miss case, and of a verbal autopsy); one day was spent on review of the tools for MDR and adaptation of these, and to the setting up of an MDR committee. A review of the implementation process was organised with SOGOC in January 2012 and the main suggestion regarding training was to transform the 3-day training session into a more competency-based learning programme. A more objective-based approach meant that at the end of the training session, every trainee would be able to prepare the summary of a case, present a case, chair a session, write an MDR session report and fill in the follow-up form containing recommendations. In 2011–13, 60 maternal deaths were reviewed by the trained teams. The most frequent causes of death were haemorrhage (40%), hypertensive disorders (20.5%) and infections (20%, among which 50% were associated with HIV). The contributing factors identified by the hospital teams were the lack of emergency drugs, the lack of blood, delays in case management, poverty and poor antenatal care attendance. Built on research experience and inspired by observations made in Cameroon, a new training programme was developed along with tools and guidelines on how to conduct MDR.5, 6 Both the training programme and the tools were then tested in Cameroon in August 2012 and modified using the inputs of both the trainees and the trainers. Since August 2012, and following the development of adapted guidelines and training curriculum, no further training sessions have taken place in Cameroon. The SOGOC was approached by the Ministry of Public Health to lead the scaling up of the process of MDR in Cameroon but the agreement has not yet been signed. Meanwhile, the FIGO-LOGIC project stopped in October 2013 and, without funds, no supervision and follow-up have been conducted. We identified three main challenges to implementing and scaling up MDR: finding sustainable resources; stimulating and maintaining the motivation of MDR hospital teams to organise MDR meetings; and implementing the recommendations of the MDR meetings. Table 1 summarises the main achievements and challenges in Cameroon. There are almost 150 health districts in Cameroon in which every hospital team will have to be trained in conducting MDR. This will only be possible if there is some decentralisation (regionalisation) in the organisation of the training. SOGOC may focus on training the nine regional teams who would, in turn, be in charge of training their district teams (cascade training). However, this would mean about four full-time equivalent months taking into account the 3-day training and at least two successive coaching visits to each regional hospital. Funding for this primary training and coaching has not yet been identified. The government is engaged in the maternal mortality reduction strategy and intends to scale up MDR to all regional hospitals in 2012 and then to extend to district hospitals (US$ 100,000 have been earmarked). The investment in training of all ten regional teams was estimated at US$ 1.5 million and the running cost for ten MDR committees (one per region) at US$ 800 per year. Nevertheless, in 2013, there was no move to scale up although UNFPA had included training for MDR teams from the North and Adamaoua regions in the 2012 budget. More difficult than the identification of funding is the problem of a shortage of human resources. Indeed, available experienced trainers in MDR are scarce in Cameroon. The SOGOC has a small team ready to train and follow-up regional teams but trainers are not always available to go into the field. Going further in scaling up requires careful coordination especially in a big country such as Cameroon. This represents a real challenge in itself. Obstacles to implementing MDRs or clinical audit are well known.7, 8 In Cameroon, assuming the training will be adequate, two main obstacles remain: the lack of local resources to correct the problems identified through MDRs and the perceived lack of potential benefit for the healthcare providers in implementing MDRs (increased workload, relationship problems). This is not a problem only observed in Cameroon. In research conditions (randomised control trial on effectiveness of clinical audits in Benin, Burkina Faso and Niger), where the hospital teams received financial incentives to attend audit meetings, the proportion of actual meetings reported against the number agreed on varied from 33% in Niger to 53% in Benin for standards-based audit and from 25% to 85% for case reviews.9 Other examples from countries where MDR was implemented at a national level as a strategy to address and decrease maternal mortality show that conducting MDRs was very difficult to sustain.10-12 However, when strong leadership and a dedicated coordinator exist at hospital level and when hospital teams are regularly coached, the process has been shown to be sustainable.13, 14 Finally, implementing the recommendations of the MDR meetings and follow-up with the solutions adopted by the team is indeed a major step towards improving obstetric care and maternal and newborn health. This step has been shown to be difficult in research settings as well as in regular working conditions.15, 16 In addition, the context in which MDRs are implemented is a key factor allowing (or not) agreed solutions to be effectively put in place, including a number of actions to facilitate a timely delivery of quality obstetric care in case of complications. In Cameroon, contrary to many countries in the region, no structural intervention to decrease financial barriers to obstetric care has been implemented at national level. The cost of care for families is a major factor contributing to delay both at household level, when a decision is to be made to go to hospital, and at hospital level where patients will receive drugs, consumables or a caesarean section kit only when they have paid for it. This problem cannot be solved at hospital-team level without structural change and represents an impediment for implementation of actions formulated and recommended as a result of MDRs. Although these challenges may appear difficult to overcome today, a feasible strategy was designed by the SOGOC which can rapidly be implemented as soon as the political commitment and allocation of the requested resources can be secured. VDB and TD declare that they have no competing interest. RJL is president of the SOGOC. All the authors participated in the observations that led to the writing of this case study. RJL summarised the main achievements and lessons from facility-based reviews in Cameroon; VDB wrote the first draft of the case study. TD significantly contributed to the manuscript. All authors read and approved the final manuscript. Implementation of MDR in Cameroon is part of the FIGO-LOGIC project financed by the Bill and Melinda Gates Foundation. The authors would like to thank the hospital teams, especially Dr Philip Njotang Nana, who kindly agreed to being observed during MDRs and shared their experience.