Maternal Death Surveillance and Response in Sudan: an evidence-based, context-specific optimisation to improve maternal care

Background: Maternal Death Review [MDR] and Maternal Death Surveillance and Response [MDSR] are a compilation of approaches such as verbal autopsy and confidential enquiries. They aim to identify, investigate, and derive lessons from cases of maternal deaths to help prevent future deaths. Prevention efforts or responses can take the form of targeted programmes or policies. In Sudan, MDR/MDSR have been in place for over a decade. However, capturing maternal deaths in the community, which is the first step in reviewing deaths, has consistently been reported as a major challenge. Without including these deaths, efforts to substantially reduce maternal mortality may remain futile because, in Sudan, most births occur at home.
Objectives: The thesis aims to identify means to improve the MDSR in Sudan and include the perspective of midwives. To achieve this, the following objectives were developed: to review the literature on MDR and identify reviews that could be modelled to optimise reviews in Sudan; to examine trends in the utilisation of skilled birth attendants to identify key providers that should be included in MDSR; to examine the correlation between maternal mortality ratio [MMR] and birth attendants and other indicators to aid prioritisation of providers to include in MDSR; to describe the organisation of community providers to help understand the maternal health care context; to describe and evaluate the current MDSR; to identify barriers to the inclusion of community providers using an interprofessional collaborative framework for MDSR; and to make recommendations for improvements of MDSR and inclusion of midwives.
Methods: Four separate studies were carried out. A comprehensive systematic review of published and grey literature was carried out where a qualitative narrative was reported; a trend analysis using three consecutive Sudan household surveys [SHHS] with multivariable logistic regression used for analysis; an ecological study that used non-parametric rank correlation measures to investigate the relationship between health and other indicators with MMR using state-level indicators; and a qualitative study using semi-structured interviews with 54 maternal health providers and other officials and analysed using thematic content analysis.
Findings: The systematic review identified that MDRs were implemented worldwide, but no suitable MDR was identified for use in Sudan. Therefore, a logic model was developed to guide the optimisation of MDSR. Analysis of the latest SHHS showed that village and community midwives [trained birth attendants] attended nearly half of all births [55.5%], followed by doctors, health visitors, and nurse-midwives [skilled birth attendants] [22.8%], and the remainder [21.7%] were not attended by a health provider. Between 2006 and 2014, a downward trend was observed in the presence of a skilled birth attendance [Odds ratio 0.46, p=<0.0001] while an upward trend was observed for trained birth attendance [Odds ratio 2.2, p= <0.0001]. The ecological analysis showed that, at state-level, higher levels of facility birth [rho -0.49, p=0.04] and of skilled birth attendance [rho -0.57, p=0.01] were correlated with lower MMR but not for births attended by trained providers [rho 0.16 p=0.51]. The semi-structured interviews revealed that there are eight types of midwives in Sudan. The structure of MDSR facilitated its activities at health facilities but not in the community. Several barriers to the inclusion of midwives into MDSR were identified: the current state of midwifery, such as lack of harmonisation and standardisation of the profession and midwives’ negative interactions with the medical system; structural barriers relating to the organisation and conduct of MDSR, such as reliance on individual doctors; and inter-professional barriers such as lack of collaboration between midwives and doctors.
Conclusion: Four interlinked recommendations are made to improve MDSR and to include midwives: [1] to invest in the development of an autonomous midwifery profession; [2] to promote early inter-professional learning and collaborative practice between maternal health providers; [3] to strengthen midwifery and other MDSR inputs, and [4] to review maternal health care provided by all practitioners in cases of deaths using provider-based reviews.

Keywords: Sudan
MDR
Midwifery education
MMR
Maternal Death Review
Maternal Mortality Ratio
SBA
Facility births
Inter-professional collaboration
Maternal Death Surveillance and Response
Trends analysis
Skilled Birth Attendance
Midwifery
Advisor: Knight, M
Nair, M
Hinton, L
Khogali, M