The death of a mother during pregnancy, childbirth or six weeks after that is medically known as maternal death. It has widespread implications; the family loses a mother, the surviving children live for shorter periods than if the mother was alive, the community and the nation lose a productive person in the peak of life.

A Malaysia-learnt lesson in lowering maternal mortality using an anonymous and non-punitive system of clinical audit has inspired other nations to emulate it. This health-based system known as the Confidential Enquiries into Maternal Deaths (CEMD) classifies every maternal death using a scientific system known as the ICD classification of deaths. Thus, data is comparable between countries.

Malaysia successfully reduced maternal mortality, through several efforts which in the broad sense include:

(i) the overall socio-economic development of the country;

(ii) the provision of health services focusing specifically on the issue of access to maternal health clinics; and

(iii) the specific efforts and initiatives for the reduction of maternal mortality, the overarching one being the CEMD.

The reduction of maternal mortality can be traced in three distinct phases. There was a strong political commitment to the reduction of maternal mortality from the founding fathers and the Government of Malaya, which was above 500 deaths per 100,000 live births at the time of independence. The foundations were laid for the development of maternal and child health services. The professionalisation of midwifery had its foundations in the passing of the Midwives Ordinance in 1954 and its subsequent revisions. Continuity in the roles of the care providers in remote areas was ensured by the professional status provided to the midwives, unlike in many other countries where such staff went missing from their posts.

The second phase was from 1958 to 1975. The maternal mortality ratio was moderately high but was rapidly declining. The free health system for pregnancy care was strengthened by improving better access to the disadvantaged. Partnerships with traditional birth attendants were strengthened while adequate numbers of skilled birth attendants (community nurses and midwives) were being trained. This effort was a particularly important innovation in integrating a traditional birth attendant into mainstream services. Also, this effort was to ensure that they provided services that were not harmful under supervision (such as postnatal services) while ensuring she did not conduct deliveries, which could be detrimental (as she was not adequately trained).

The third phase can be traced from 1976 till presently. The relatively low MMR underwent further decline but showed plateauing. This phase saw further capacity strengthening and the introduction of several specific initiatives such as the meticulous auditing of maternal deaths using confidential enquiry into maternal deaths (CEMD) which began in 1991. The plateau indicated that more emphasis was required in improving the quality and speed of care to pregnant mothers.

The benefits

There has been an improvement in the reporting systems of maternal deaths. This improvement was in contrast to 1991, when the introduction of the CEMD system showed a doubling of the maternal mortality ratio as compared to that reported by the Department of Statistics, Malaysia.

Efforts were made to overcome the disparity in reported rates by encouraging the active capture of maternal deaths.

The CEMD reports provided evidence-based information to support budget requests for pregnancy care in the Ministry of Health. Home-based, patient-carried maternal records provided for better continuity of care by the health and hospital sectors (both public and private). These cards also encouraged responsibility and ownership by the mothers for their health and provided health education as these records carried important health messages on nutrition, frequency of antenatal visits and warning signs of obstetric emergencies.

Training modules were developed for the major causes of maternal mortality: postpartum haemorrhage, hypertensive disease of pregnancy, heart disease in pregnancy, and management of blood clots in the veins which could be dislodged causing severe effects, known as venous thromboembolism. Obstetric life-saving skills courses were introduced to improve the competency of caregivers.

The CEMD allowed for improvement in work processes based on the remedial factors in care identified in the audit. Examples of these include:

• in the hospital setting: the use of the partogram (a graph that plots the progress of the labour process and provides an early warning system)
• at home: protocol development (such as for anaemia)
• conduct of combined inter-disciplinary clinics for medical disorders in pregnancy
• the creation of the red alert system in hospitals, which allowed for rapid mobilisation of specialists in O&G as well as anaesthesia and support staff for obstetric emergencies such as postpartum haemorrhage (bleeding after delivery), eclampsia (fits in pregnancy) and maternal collapse.

We are now witnessing a changing trend in maternal deaths from direct obstetric causes (due entirely to pregnancy) to indirect maternal deaths (such as conditions that are aggravated by pregnancy) and fortuitous deaths (deaths that would happen irrespective of the pregnant state).

Empowerment of midwives was a vital component of the CEMD activities. This empowerment included the colour coding system used in Malaysian antenatal care which was designed to streamline referrals by midwives to the hospitals. A woman given a red code by a midwife could be admitted to a specialist hospital immediately without any hindrance and irrespective of cost considerations.

What would be needed to replicate the system?

There is a need for political will that women form an essential part of society and that they deserve better care during the most vulnerable period in their lives, i.e. the reproductive age.

It is vital that the system assures anonymity and be a non-punitive system to ensure that it is sustainable. It is tempting to mete out administrative admonishment in various forms, but doing so would mean that the persons reporting the event would not be entirely honest in revealing the chain of events that happened. A complete root cause analysis to remedy deficiencies should be performed. A problem with the system demands a solution that ensures the system is corrected, not individual actions.

The system should blend well with the health administrative system in any country. The CEMD system is found at the health district, state and national levels in Malaysia as the health district headed by a Health Officer is the key to the implementation of any health-related activity. The CEMD system is not anonymised at the health district or state level. However, the report is anonymised when it is sent to the national level. This critical distinction ensures that remedial actions are taken speedily at the ground level, but system-wide improvement occurs after national-level investigations. This measure ensures prioritising scant health resources according to areas of need.

One should be prepared to witness a rise in the maternal mortality ratio when the system is first introduced as cases not previously captured under any audit system will be included. Malaysia saw a paradoxical increase in the maternal mortality ratio at the initiation of the system.

However, deaths will reduce over time, as there will be a focus on remedial measures to correct any identified weaknesses in the system. Success will be the tonic that will sustain the system, and more importantly, ensure the patients benefit from the audit system. The CEMD has now been incorporated into hospital accreditation systems.

Conclusion

There is no shortcut to success (avoid shortcuts - A). There must be system changes for sustainable progress. The CEMD system was benchmarked (B) against other established systems internationally. Competency (C) was emphasised to ensure skilled care at delivery. There was documentation (D) of every step of the progress made. All interventions were evidenced-based (E). Frank explanations (F) were provided to top management when things did not go well, e.g. a paradoxical rise in maternal death ratios. Widely disseminated guidelines (G) serve to spread the message. There is an A-G for converting maternal deaths into maternal health, and this is sustainable as well as replicable in any country! Malaysia has been consistently spreading this message in the scientific and world community.

-- BERNAMA

Professor Datuk Dr Ravindran Jegasothy is the Dean of the Faculty of Medicine, MAHSA University, Kuala Lumpur.