Implementation status of Surveillance and Response for Maternal - - PDF document

Implementation status of Surveillance and Response for Maternal Deaths in Nepal Sharad Kumar Sharma, Pooja Pradhan, NP KC, Meera Thapa Upadhyay Abstract: Even though Maternal Mortality Ratio (MMR) has reduced substantially during the last two decades in Nepal with improvement in availability and accessibility of services, there is a substantial gap to achieve the Sustainable Development Goal (SDG) of 70 deaths per 1,00,000 live births by 2030. Government of Nepal implemented Maternal and Perinatal Death Surveillance and Response (MPDSR) at six districts in 2016 with plan to gradually expand across the country by

• 2020. The system includes routine identification, notification, quantification and determination of

causes and avoidable factors of all maternal deaths, as well as use of this information to respond with actions that will decrease preventable maternal deaths. As this is in very initial phase, there is need to document the process of implementation to identify the issues and challenges. It is also very important to analyze the information and data received from the process to identify the socio- demographic characteristics of women who are dying, cause of death, avoidable factors, action plans identified to be implemented in different levels. This information will be vital for strengthening the program for further expansion and ultimately achieve the goal to reduce preventable maternal mortality. Background: Nepal has shown significant progress in reduction of maternal and perinatal mortality in the past with its commitment towards achieving targets set by periodic plans and global endeavors. The Maternal Mortality Ratio (MMR) in Nepal decreased substantially from 539 per 100,000 live births in 1996 (Pradhan et.al., 1997) to 258 per 100,000 live births in 2015 (World Health Organization et.al, 2015). Improvement in maternal health services has been the key factor in reducing the country's MMR and has contributed to the improvement of infant and child survival as well. Due to continued government encouragement through free delivery services and financial incentives for transportation, the percentage of births taking place in health facilities has increased by three-fold in the past ten years (from 18 percentage in 2006 to 57 percentage in 2016) (Ministry of Health and Population (MoHP) [Nepal], New ERA, and ICF International Inc., 2012; Ministry of Health and Population (MoHP) [Nepal], New ERA, and ICF International Inc., 2017). Despite its consistent and regular progress in maternal and child health indicators, maternal and child death continues to

Identify cases Collect information Analyze results Recommen- dations for actions Evaluate andrefine

Figure 1: MPDSR Cycle

be a major public health problem. Most of these deaths are preventable if timely intervention had taken place. In 2016, Government of Nepal redesigned Maternal and Perinatal Death Review (MPDR) implemented in hospitals into MPDSR to capture maternal deaths in the communities as well. National MPDSR guideline was developed based on the MDSR Technical Guidance from WHO, 2013 (World Health Organization, 2013). MPDSR is a form of continuous surveillance process that links health information system and quality improvement processes from local to national

• levels. It includes routine identification, notification, quantification and determination of causes

and avoidable factors of all maternal and perinatal deaths, as well as use of this information to respond with actions that will prevent maternal deaths in the future. MPDSR takes into consideration key components of the UN Global Strategy for Women’s and Children’s Health and The Commission on Information and Accountability (CoIA) (CoIA, 2011) One of CoIA’s key points is to get better information for producing better results. It recommends setting up a health system that efficiently combines data from facilities, administrative sources and

• surveys. The concept of CoIA has been adapted in Nepal as Country Accountability Roadmap

Nepal (CARN) (Ministry of Health and Population, 2012). MPDSR provides information about avoidable factors that contribute to maternal and perinatal deaths and uses the information to guide actions that must be taken at the community level, within the formal health-care system, and at the inter-sectorial level (i.e. in other governmental and social sectors) that are critical for preventing similar deaths in the future (Family Health Division, 2015). Community-based maternal death review system includes Verbal Autopsy (VA) to collect the information on events that occurred before death of a woman in the community. Based on the information in the VA, cause of death is assigned by a physician. The district level MPDSR committee then reviews the death to ascertain the personal, family, or community factors that may have contributed to the death and formulates action plans to prevent maternal deaths due to similar cause in the future. Objectives: The overall objective of the study is to provide brief overview of current status of MPDSR implementation in Nepal. Specific Objectives:  To describe the status of implementation of MPDSR in Nepal including issues and challenges.  To explore socio-demographic characteristics, health related factors and avoidable factors contributing to maternal deaths.  To identify causes of maternal deaths assigned from verbal autopsy based on ICD MM coding.

 To identify possible actions taken to prevent maternal deaths in future. Methodology: We conduct desk review of existing policy and programmatic document related to MPDSR to analyse and explore the process and key issues & challenges for implementing MPDSR. Further to this, quantitative method was used to analyse the data received from VA of maternal deaths that

• ccurred in the six MPDSR implementing districts during 2016-17 to identify socio demographic

characteristics, health related factors, utilization of health servicesas well as cause of deaths. Additionally, qualitative information based on narrative part of the VAs was further explored to identify the events preceeding the deaths including avoidable factors. The ICD MM (World Health Organization, 2012) approach was used to assign cause of death from VA to provide respective ICD codes. Results: The analyzed results and tabulated data has been presented in the tables as shown below. Furthermore, descriptive information has been provided based on the review of existing policy and programmatic document related to MPDSR implementation, issues and challenges identified during implementation of MPDSR at different levels and narrative information in verbal autopsy forms. Table 1: Socio-demographic information

Socio-demographic Information Frequency Percent District Baitadi 7 14.9 Banke 16 34.0 Dhading 7 14.9 Kailali 6 12.8 Kaski 4 8.5 Solukhumbu 7 14.9 Total 47 100 Age <20 6 12.8 20-35 36 76.6 >35 5 10.6 Total 47 100 Ethnicity Dalit 15 34.9 Janjati 12 27.9 Terai/Madhesi 7 16.3 Muslim 1 2.3

Socio-demographic Information Frequency Percent Brahmin/kshetri 8 18.6 Total 47 100 Education No Formal Education 17 36.2 Primary 15 31.9 Secondary 12 25.5 Higher Secondary 3 6.4 Total 47 100 Occupation Unemployed 3 6.4 Domestic Work & agriculture 40 85.1 Business 2 4.3 Service 2 4.3 Total 47 100

Table 1 shows the socio-demographic information of the reported maternal deaths. A total of 47 maternal deaths that occurred in the community were reported through verbal autopsy form with majority of the maternal deaths ranging from age group 20-35 years. Majority of the women, 76.6% belonged to age group 20-35years followed by 12.8% from age group below 20 years and 10.6% belonged to age group below 35 years. Majority of the maternal deaths occurred in Banke district accounting 34% followed by 14.9% in Baitadi, Dhading and Solukhumbu whereas 12.8%

• ccurred in Kailai and very least, 8.5% death occurred in Kaski. Majority of the death occurred

among Dalits accounting 34.9% followed by 27.9 % among Janajati and least occurred among Terai/ Madhesi, Muslim, Brahmin and Chhetri. Most of the cases, 36.2% did not have formal education whereas 31.9% had primary education followed by 25.5% with secondary education and very least had higher secondary education. Majority of the cases, 85.1% were involved in agriculture and domestic work, 6.4% were unemployed and very few were involved in business and service. Table 2: Health Care Utilization Status

Utilization of Health Services Frequency Percent Gravida One 11 23.4 2 to 3 19 40.4 4+ 11 23.4 Don’t Know 5 10.6 Missing 1 2.1 Total 47 100 Antenatal care No 5 10.6 Yes 42 89.4

Utilization of Health Services Frequency Percent Total 47 100 ANC Place No ANC 5 10.6 Hospital 14 29.8 HP/PHC/PHCORC 28 59.6 Total 47 100.0 Place of delivery Home 9 19.2 Facility 2 4.3 HP 5 10.6 Hospital 13 27.7 NA 18 38.3 Total 47 100 Mode of delivery Normal Vaginal 22 46.8 LSCS 7 14.9 NA 18 38.3 Total 47 100 Timing of death During Pregnancy 13 27.7 During Delivery 7 14.9 During Postpartum Period 23 48.9 Within 42 days After Termination of Pregnancy 3 6.4 54 Days After Abortion 1 2.1 Total 47 100 Place of death Home 19 40.4 the way to health facility 1 2.1 from one facility to other 2 4.3 Hospital 25 53.2 Total 47 100

Above Table2 shows the health care utilization status of the deceased. ANC utilization was 89.6% and among these 59.6 % had sought ANC from the HP/PHC/PHCORC, 29.8% from the hospital. Majority had delivered the baby from Hospital, accounting 27.7%, 19.2% from the Home, 10.6% from health post and very least from other health facility. Mode of delivery of 46.8% was normal vaginal followed by LSCS accounting 14.9%. Most of the death, 48.9% occurred during postpartum period followed by 27.7% during pregnancy, 14.9% during delivery, 6.4% within 42 days after termination of pregnancy and very least 2.1% after 54 days of abortion. Majority of the death occurred at hospital accounting 53.2% followed by 40.4% at home and least on the way to health facility and while taking from one facility to other.

Table 3: Primary Causes of maternal deaths from Verbal Autopsy

Causes of Maternal Death Frequency Percent Obstetric Hemorrhage 9 19.15 Abortion Complication 4 8.51 Other and unspecified maternal cause 4 8.51 PIH (Eclampsia) 4 8.51 Accidental Fall 3 6.38 Pregnancy Related Sepsis 3 6.38 Severe Eclampsia 3 6.38 Abruptio Placenta 2 4.26 Congenital Cyanotic Heart Disease 2 4.26 Diarrheal Diseases 2 4.26 Other and unspecified non-communicable 2 4.26 Retained Placenta 2 4.26 Acute Respiratory infection 1 2.13 Autoimmune Disease 1 2.13 Hepatitis/ Acute Liver Disease 1 2.13 Meningitis and Encephalitis 1 2.13 Other and external cause (Suicide) 1 2.13 Severe Anemia 1 2.13 Unspecified infectious diseases 1 2.13 Total 47 100 Type of death Indirect 19 40.4 Direct 28 59.6 Total 47 100

Table3 shows the primary causes of maternal deaths assigned from Verbal Autopsy. Majority of the death, 19.15% occurred due to obstetric hemorrhage followed by abortion complication,

• ther/unspecified maternal cause and PIH (Eclampsia) accounting 8.51%. Around 6.38% death
• ccurred due to accidental fall, pregnancy related sepsis and severe eclampsia. 4.26% death
• ccurred due to abruptio placenta, congenital cyanotic heart disease, diarrheal disease, other

unspecified non-communicable and retained placenta. Very least, 2.13% death occurred due to acute respiratory disease, autoimmune disease, hepatitis/acute liver disease, meningitis and encephalitis, other and external cause (suicide), severe anemia and unspecified infectious disease. Out of total cause of death 40.4% occurred due to indirect causes whereas 59.6% occurred due to direct causes.

Table 4: Primary Causes of maternal deaths by districts: from Verbal Autopsy

Causes of Maternal Death Baitadi Banke Dhading Kailali Kaski Solu Total Obstetric Hemorrhage 2 3 4 9 Abortion Complication 2 2 4 Other and unspecified maternal cause 1 2 1 4 PIH (Eclampsia) 3 1 4 Accidental Fall 2 1 3 Pregnancy Related Sepsis 2 1 3 Severe Eclampsia 1 2 3 Abruptio Placenta 1 1 2 Congenital Cyanotic Heart Disease 1 1 2 Diarrheal Diseases 1 1 2 Other and unspecified non-communicable 1 1 2 Retained Placenta 1 1 2 Acute Respiratory infection 1 1 Autoimmune Disease 1 1 Hepatitis/ Acute Liver Disease 1 1 Meningitis and Encephalitis 1 1 Other and external cause (Suicide) 1 1 Severe Anemia 1 1 Unspecified infectious diseases 1 1 Total 7 16 7 6 4 7 47

The Table4 shows the primary causes of maternal deaths by districts. Obstetric hemorrhage was the main cause of maternal death accounting 2, 3, and 4 no of deaths in Baitadi, Banke and Solukhumbu respectively whereas there was no death reported at Dhading, Kailali and Kaski.

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Abortion complication was responsible for 2 deaths at Dhading and Banke. Other and unspecified maternal causes was responsible for 1 death in Baitadi and Kaski each followed by 2 deaths at

• Banke. PIH (eclampsia) was responsible for 3 deaths at Banke and 1 death at Dhading. Similarly

accidental fall was responsible for 2 deaths at Baitadi and one death at Kailali. Pregnancy related sepsis was responsible for 2 deaths at Dhading and one death at Kaski. Severe eclampsia was responsible for 1 and 2 deaths at Baitadi and Kaski respectively. Abruptio placenta and diarrheal disease was responsible for one maternal death each at Banke and Solukhumbu

• respectively. Congenital cyanotic heart disease was responsible for one death at Banke and

Dhading respectively. Other and unspecified non- communicable disease was responsible for one death each at Kaski and Kailali. One death occurred at Dhading and Solukhumbu each due to due to retained placenta. Acute respiratory disease, autoimmune disease, hepatitis/ acute liver disease, meningitis and encephalitis, other and external cause (suicide), severe anemia and unspecified infectious disease was responsible for one death each at Kailali, Baitadi, Banke, Kaski, Kailali and Banke respectively. Table 5: Primary Cause of Death by Time of Death

Primary Cause of Death Timing of Death Total During Pregnancy During Delivery During Postpartum Period After Abortion Abortion Complication 1 3 4 Abruptio Placenta 2 2 Accidental Fall 2 1 3 Acute Respiratory infection 1 1 Autoimmune Disease 1 1 Congenital Cyanotic H 2 2 Dirrhoeal Diseases 1 1 2 Hepatitis/ Acute Live 1 1 Meningitis and Encephalitis 1 1 Obstetric Hemorrhage 4 5 9 Other and external cause 1 1 Other and unspecified 3 1 4 Other and unspecified 1 1 2 PIH (Eclampsia) 4 4 Retained Placenta 2 2 Pregnancy Related Sepsis 3 3 Severe Eclampsia 1 2 3 Severe Anemia 1 1 Unspecified infections 1 1 Total 13 7 23 4 47

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Table5 shows the primary cause of death by the time of death. One death occurred during pregnancy and 3 deaths after abortion due to abortion complication. Two deaths occurred during delivery and during pregnancy due to abruption placenta and accidental fall respectively. 1 death

• ccurred during pregnancy due to auto immune disease and 2 deaths during postpartum period

due to congenital cyanotic H. Similarly one death occurred during pregnancy and during postpartum due to diarrheal disease and one death due to hepatitis/ acute Liver disease and meningitis during postpartum period and during pregnancy respectively. Obstetric hemorrhage was responsible for 4 deaths during delivery and 5 deaths during postpartum. Only one death

• ccurred due to other and external cause during pregnancy. 4 deaths occurred during pregnancy

and one death occurred during postpartum and during delivery each was due to other and unspecified causes. PIH (eclampsia was responsible for 4 deaths during postpartum period. 2 deaths occurred during postpartum due to retained placenta and 3 deaths due to pregnancy related sepsis. 1 death occurred during pregnancy and 2 deaths during postpartum due to severe

• eclampisa. Similarly one death that occurred during postpartum and during pregnancy was due to

severe anemia and unspecified infectious disease. Overall, majority of the deaths occurred during postpartum period (49%) followed by 28% during pregnancy, 15% during delivery and 9% after abortion. The Table6 below shows the primary cause of death by the type of death. Direct cause was responsible for 28 deaths (60%) and remaining death was responsible due to indirect cause (40%). Table 6: Primary Cause of Death by Type of Death

Primary Cause of Death Type of Death Total Indirect Direct Abortion Complication 4 4 Abruptio Placenta 2 2 Accidental Fall 3 3 Acute Respiratory infection 1 1 Autoimmune Disease 1 1 Congenital Cyanotic H 2 2 Dirrhoeal Diseases 2 2 Hepatitis/ Acute Live 1 1 Meningitis and Encephalitis 1 1 Obstetric Hemorrhage 9 9 Other and external cause 1 1 Other and unspecified 4 4 Other and unspecified 2 2 PIH (Eclampsia) 4 4 Retained Placenta 2 2 pregnancy Related Sepsis 3 3 Severe Eclampsia 3 3 Severe Anemia 1 1 Unspecified infectious disease 1 1 Total 19 28 47

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Table 7: Primary Cause of Death by Place of Death

Primary Cause of Death Place of Death Total Home/ Community On the way to health facility On the way from one facility to

• ther

Hospital /Other Health Facility Abortion Complication 2 1 1 4 Abruptio Placenta 2 2 Accidental Fall 2 1 3 Acute Respiratory infection 1 1 Autoimmune Disease 1 1 Congenital Cyanotic Heart disease 1 1 2 Dirrhoeal Diseases 2 2 Hepatitis/ Acute Live 1 1 Meningitis and Encephalitis 1 1 Obstetric Hemorrhage 5 1 3 9 Other and external cause 1 1 Other and unspecified 2 2 4 Other and unspecified 2 2 PIH (Eclampsia) 1 3 4 Retained Placenta 1 1 2 pregnancy Related Sepsis 1 2 3 Severe Eclampsia 2 1 3 Severe Anemia 1 1 Unspecified infectious 1 1 Total 19 1 2 25 47

The Table7 above shows the primary cause of death by the place of death. Among all the deaths 2 deaths occurred at home/ community and one death on the way from one facility to other and hospital/other health facility each due to abortion complication. 2 deaths occurred at home/ community and one death on the way to health facility due to accidental fall. One death occurred at hospital/ other health facility due to acute respiratory infection. Similarly one death that occurred at home/ community and hospital/ other facility was due to autoimmune disease and congenital cyanotic heart disease. 2, 1, 1, deaths that occurred at hospital/ other health facility was due to diarrheal disease, hepatitis/ acute liver, meningitis/encephalitis respectively. 5,1 and 3 deaths that

• ccurred at home/community, on the way from one facility to other and hospital/ other health

facility respectively was due to obstetric hemorrhage. 1 and 2 deaths that occurred due to other/ external cause and other and unspecified cause was at home/ community and hospital/other health facility respectively. 1 and 3 deaths occurred at home/ community and hospital/ other health facility due to PIH (eclampsia). One death at home/ community and 2 death at hospital/ other health facility was due to retained placenta and pregnancy related sepsis respectively. 2 and 1 deaths that occurred at home/ community and hospital/ other health facility was due to pregnancy related sepsis and severe eclampsia. One death that occurred each at hospital/Other health facility

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was due to severe anemia and unspecified infectious disease. Overall, 53% of the deaths occurred at health facility, followed by 40% at home and rest 7% on transit to health facility. Table 8: Primary Cause of Death by Mode of Delivery

Primary Cause of Death Vaginal Caesarean Section NA Total Abortion Complication 4 4 Abruptio Placenta 1 1 2 Accidental Fall 3 3 Acute Respiratory infection 1 1 Autoimmune Disease 1 1 Congenital Cyanotic H 1 1 2 Dirrhoeal Diseases 1 1 2 Hepatitis/ Acute Live 1 1 Meningitis and Encephalitis 1 1 Obstetric Hemorrhage 8 1 9 Other and external cause 1 1 Other and unspecified 1 3 4 Other and unspecified 1 1 2 PIH (Eclampsia) 2 2 4 Retained Placenta 2 2 pregnancy Related Sepsis 3 3 Severe Eclampsia 2 1 3 Severe Anemia 1 1 Unspecified infectious disease 1 1 Total 22 7 18 47

The Table8 shows the primary cause of death by mode of delivery. Out of the total death 22 death (47%) occurred during vaginal delivery and 7 deaths (15%) occurred during caesarean section whereas 18 deaths (38%) was occurred during pregnancy. Four deaths was caused by abortion complication, one death by auto immune disease, meningitis/encephalitis, other/external causes and specified causes whose mode of delivery was unavailable. 1 death was caused during vaginal delivery due to abruptio placenta. 3 death that were caused by accidental fall whose mode of delivery was not available. One death was caused by acute respiratory infection was during vaginal delivery. One death was caused due to congenital cyanotic H during vaginal delivery and caesarean section. One death was caused by diarrheal disease due to vaginal

• delivery. 8 deaths occurred during vaginal delivery and one death during caesarean section

during obstetric hemorrhage. 1 death occurred during caesarean section was due to other unspecified cause. 2 deaths that occurred during vaginal delivery and caesarean section each was

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due to PIH (eclampsia). 2, 3 and 2 deaths that occurred during vaginal delivery was due to retained placenta, pregnancy related sepsis and severe eclampsia respectively. One death

• ccurred during caesarean section was due to severe anemia.

Table 9: Type of delays related to deaths

Delays Number Delay1 Delay in recognizing problem during pregnancy 24 Delay in decision to seek appropriate care 10 Sought care from traditional healers (Dhami/Jhankri) 6 Delay to arrange money for treatment 4 Did not receive delivery care from health facility 3 Sought care from local medicine shop 2 Did not tell anyone at home about problem 2 Did not share about her pregnancy to any body 1 Became pregnant against getting medical advice 1 Did not take oral misoprostol at home 1 Lack of money to take the patient to ho 1 Did not seek care due to shortage of money 1 Delay2 Delay in reaching health facility 2 Late referral from Dadeldhura to Kailali 1 Referred without examining from HP 1 Delay in getting referral from medical shop 1 Lack of proper communication between facility 1 Used public vehicle 1 Delay3 Delay in receiving appropriate care at health facility 5 Substandard care received from hospital 2 Could not undergo surgery suggested at hospital 1 Delay in getting admission at health facility 1 Unable to get admission at ICU in hospital 1

Table9 shows the type of delay related to deaths. In delay one, the majority of the death was due to delay in recognizing problem during pregnancy accounting 24 in number. Ten deaths were caused due to dearly in decision to seek appropriate care, six deaths were caused due to sought care form traditional healers (Dhami/ Jhankri), four deaths were due to Delay in arranging money for treatment, three deaths were due to not receiving delivery care from health facility, two deaths were caused due to seeking care from local medicine shop and not telling anyone at home about the problem. One death was caused because of not sharing about pregnancy to anybody, for becoming pregnant against getting medical advice, not taking oral misoprostol at home, due to lack of money to take the patient to hospital and for not seeking care due to the shortage of money. In second delay, two deaths occurred due to delay in reaching health facility. One death occurred due to the late referral from Dadeldhura to Kailai, referred without examining from HP, delay in

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getting referral from medical shop, lack of proper communication between facility and because of using public vehicle. In the third delay, five deaths occurred due to delay in receiving appropriate care at health

• facility. two deaths occurred due to Substandard care received from hospital and one death
• ccurred due to not being able to undergo surgery suggested at hospital, delay in getting

admission at health facility and Unable to get admission at ICU in hospital. Table 10: Avoidable factors based on three delay model Delays Avoidable factors First delay

• Sought care from traditional healer (Dhami-Jhankri) (6)
• Home delivery (4)
• Lack of knowledge of danger sign (10)
• Did not share problem with family (3)
• Taking medicine from local medical shop (2)
• Delay in decision to seek care (10)
• Did not take proper nutrition during pregnancy (2)
• Did not seek care from facility for swelling (1)
• Unwanted pregnancy (1)
• Did not take misoprostol at home to manage

haemorrhage (1)

• No antenatal care (1)
• Did not take medical advice (1)

Second delay

• Delay in arranging money (7)
• Delay in reaching facility due to public transport (2)
• Delay in getting referred from medical shop (1)
• No proper communication between facility (1)

Third delay  No proper primary management at HP (1)  Delay in receiving care in hospital (3)  Delay in admission at hospital (1)  Doctor did not arrive on time (1)  Long time waiting at hospital before taking care (1)

 Substandard care received at hospital (1)

Table10 represents the avoidable factors based on three delay model. Out of total deaths

• ccurred due to first delay, the highest number of deaths reported was ten which were caused due

to lack of knowledge of danger sign and delay in seeking medical care. Six were due to seeking health care from traditional healer. Four reported deaths were due to home delivery. Three deaths

• ccurred due to not sharing problems with family members. Two deaths were caused due to

taking medicine from local medicine shop and not taking proper nutrition during pregnancy. One death was reported each from not seeking care from facility for swelling, unwanted pregnancy, not taking misoprostol at home to manage haemorrhage and not taking medical advice. In second delay, the highest reported deaths were Seven, which were caused by delay in arranging money. Two deaths were caused due to delay in reaching health facility by using

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public transport. One death was reported due to delay in getting referred from medical shop and no proper communication between facilities. The total deaths due to avoidable factors in third delay, three deaths were caused by delay in receiving care in hospital. One death was reported each from no proper primary management at HP, delay in admission at hospital, doctor did not arrive on time, long time waiting at hospital before taking care and due to substandard care received at hospital. Discussion and conclusion In this current study 76.6% belonged to age group 20-35 years followed by 12.8% from age group below 20 years and 10.6% belonged to age group below 35 years. This result is similar to the results shown by Ramos and others in Argentina. This current study showed that 27.7% death

• ccurred during pregnancy, 14.9% death occurred during delivery, 48.9% of the death occurred

during postpartum and 6.4% death occurred within 42 days after termination of pregnancy which was different than the study conducted by Ramos and other in Argentina as 26% of deaths occurred during pregnancy, 25% within 7 days after delivery and 22% were late maternal deaths (Ramos et al., 2007). Our result is also different than the result shown by Sloan and others as 30% of deaths

• ccurred before delivery, 25.2% during delivery, 24.5% within 24 hours after delivery and 21.0%

within 40 days after delivery (Sloan et al., 2001). In the present study death rate was high among those without formal education which is similar to the study of Ethiopia. In the current study it was found that 85.1% were involved in domestic and household work, 77% received ANC during pregnancy. In the present study 10 number of death occurred due to delay in decision to seek appropriate care and 2 deaths occurred due to delay in reaching facility due to public transport. Similarly, 59.6% death occurred due to direct cause and the major cause associated with death was obstetric hemorrhage accounting 19.15%, PHI (eclampsia) 8.51% and severe eclampsia and sepsis 6.38%. These results are supported by the results of Bangladesh, Ethiopia and Bashour and others in Syria as direct maternal causes were ascribed to 88% pregnancy-related deaths, also the main direct cause of death was hemorrhage accounting 65%, followed by hypertensive disorders of pregnancy (11%) and deaths associated with sepsis (5%) (Bashour et al., 2009). In the present study 40.4% death occurred at home, 53.2% in hospital and remaining on the way to health facility and while taking from one health facility to other. This finding is supported by the findings of Sloan and others in Mexico as according to the verbal autopsies, 55.9% died at hospital, 39.3% died at home and 4.8% died elsewhere (Sloan et al., 2001) and also the findings as shown in Bangladesh where 47.8% died in a health facility, 17.0% died during transfer and 35.2% occurred at home. In the present study type one delay was the major cause of maternal death which is contradictory to the finding of Bangladesh as type third delay was the most responsible cause of maternal death. Similarly, delay one was reported as the major cause of maternal death followed by delay third and delay second. The study is quite similar to the scenario of Ethiopia. In the present study delay in reaching facility due to public transport, delay in arranging money, delay in receiving care in hospital were some of the delays which were responsible for the maternal

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death which is supported by the study conducted by Osoro and others in Kisii as delayed access to transport, lack of money for user fees, and hospital distance were challenges that led to delay in accessing care. Hospital experiences included; delay in service provision by staff, delayed quality emergency obstetric care and delayed care while at the hospital, unavailability of blood for transfusion, and lack of money for drugs, were reported as major challenges which attributed to maternal death.(Osoro et al., 2014) After reviewing the deaths notified in the MPDSR implementing districts, various response activities have been implemented in the community as well as in the facilities. Some key response activities include;

• Awareness raising:
• Awareness program on Sickle Cell Anemia among Tharu community.
• Mobilize local leaders to ensure institutional delivery.
• Mobilize mothers’ group to create environment where pregnant women are

comfortable for antenatal care and share their problems.

• Coordination:
• Advocate on need of road construction with local development offices for raising

accessibility to health services.

• Advocate of Calcium tablets distribution for pregnant women
• Quality improvement of service
• Blood test for anemia among adolescents and newly married women in Tharu

community with necessary referral.

• Ensure antenatal services in all primary health care outreach clinics.
• Proper recording of all cases in health facilities.
• Ensure presence of health workers during service hours at health facilities for antenatal

check-up.

• Health facilities to take each case sensitively and give equal importance for proper

management and referral.

• Orient health workers and female community health volunteers on referral mechanism

with communication between health facilities. Despite various response activities identified and implemented after the review of MPDSR in six districts in Nepal, many challenges have also been faced during various stages of implementation. Few challenges reported from the MPDSR implementing districts include;

• Under reporting of suspected maternal deaths
• Blame culture at some places that inhibits health professionals and others from

participating fully in the MPDSR process

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• Incomplete or inadequate legal frameworks
• Inadequate staff numbers, resources and budget
• Cultural norms and practices that inhibit the operation of MDSR
• Problems of geography and infrastructure that inhibit the operation of MDSR.
• Delay/Incomplete notification, screening, VA, review, response & use of web-based

MPDSR system In the very short period of implementing community-level MPDSR we have been able to identify different levels of factors associated with the pregnancy-related deaths and implemented various community- as well as facility-level quality improvement activities. Therefore, if we continue implementing community- as well as facility-level maternal death notification, review and responses by removing the challenges identified above, MPDSR has great potentiality to attain sustainable development goal of reducing maternal mortality by reducing it to less than 70 per 100000 live birth by the end of 2030 in Nepal. References:  Bashour, Hyam, Abdulsalam, Asmaa, Jabr, Aisha, Cheikha, Salah, Tabbaa, Mohammed, Lahham, Moataz, . . . Campbell, Oona MR. (2009). Maternal mortality in Syria: causes, contributing factors and preventability. Tropical medicine & international health, 14(9), 1122- 1127.  Commission on Information and Accountability for Women’s and Children’s Health: keeping promises, measuring results. Geneva, World Health Organization, 2011. Available from:http://www.who.int/topics/millennium_development_goals/accountability_commission/ Commission_Report_advance_copy.pdf.  Family Health Division, (2015). Maternal and Perinatal Death Surveillance and Response, Guideline 2015. Kathmandu, Nepal.  Ministry of Health and Population (MoHP) [Nepal], New ERA, and ICF International Inc., (2012). Nepal Demographic and Health Survey 2011. Kathmandu, Nepal: Ministry of Health and Population, New ERA, and ICF International, Calverton, Maryland.  Ministry of Health and Population, (2012). Country Accountability Roadmap-Nepal 2012-15. MoHP, Kathmandu.  Osoro, AA, Ng’ang’a, Z, Mutugi, M, & Wanzala, P. (2014). Maternal Mortality among Women Seeking Health Care Services in Kisii Level 5 Hospital. American Journal of Public Health Research, 2(5), 182-187.  Pradhan, A., Aryal, R.H., Regmi, G., Ban, B. and Govindaswamy, P., (1997). Nepal Family Health Survey 1996. Kathmandu, Nepal ad Calverton, Maryland: Ministry of Health [Nepal], New ERA, and Macro International Inc.  Ramos, Silvina, Karolinski, Ariel, Romero, Mariana, & Mercer, Raúl. (2007). A comprehensive assessment of maternal deaths in Argentina: translating multicentre collaborative research into action. Bulletin of the World Health Organization, 85(8), 615-622.

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 Sloan, Nancy L, Langer, Ana, Hernandez, Bernardo, Romero, M, & Winikoff, B. (2001). The etiology of maternal mortality in developing countries: what do verbal autopsies tell us? Bulletin of the World Health Organization, 79(9), 805-810.  World Health Organization, (2012). The WHO Application of ICD-10 to Deaths During Pregnancy, Childbirth and the Puerperium: ICD-MM, Geneva, Switzerland.  World Health Organization, (2013). Maternal Death Surveillance and Response, Technical Guidance, Information for action to prevent maternal death. Geneva, Switzerland.  WHO/UNICEF/UNFPA and the World Bank. Trends in maternal mortality; 1990-2015: Estimates developed by WHO, UNICEF, UNFPA and the World Bank. Geneva, World Health Organization, 2015.