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• Re:RE: Community-Linked Maternal Death Review (CLMDR) to measure and prevent maternal mortality: a pilot study in rural Malawi
  Tim Colbourn
  Published on: 1 June 2016
• RE: Community-Linked Maternal Death Review (CLMDR) to measure and prevent maternal mortality: a pilot study in rural Malawi
  Levis K. Nyavanda
  Published on: 13 May 2016

• Published on: 1 June 2016

  Re:RE: Community-Linked Maternal Death Review (CLMDR) to measure and prevent maternal mortality: a pilot study in rural Malawi

  • Tim Colbourn, Lecturer in Global Health Epidemiology and Evaluation
  • Other Contributors:
    • Hilda Chapota, Tambosi Phiri, Olivia Bayley, Carina King, Bejoy Nambiar, Mikey Rosato, Peter Kazembe

  We thank Levis K. Nyavanda for his interest in our work and his letter in response to our article. We agree that Health and Demographic Surveillance Systems (HDSS) can provide accurate data on births and deaths in settings such as Mchinji, Malawi where our study was set. Our community-linked maternal death review (CLMDR) intervention however did not rely on such a complex and expensive system to identify deaths. In our stud...

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  We thank Levis K. Nyavanda for his interest in our work and his letter in response to our article. We agree that Health and Demographic Surveillance Systems (HDSS) can provide accurate data on births and deaths in settings such as Mchinji, Malawi where our study was set. Our community-linked maternal death review (CLMDR) intervention however did not rely on such a complex and expensive system to identify deaths. In our study we compared the maternal mortality ratio estimated from the number of maternal deaths identified by the community and facility maternal death review teams and the total population size of the district and estimated crude birth rate, to that observed from a cluster randomised trial in the same site that did involve a HDSS. We do not propose that our CLMDR system could act as a replacement for a HDSS, but rather we aimed to highlight its comparable robustness. We are unsure what Nyavanda means when he states "the Community-Linked Maternal Death Review (CLMDR) on its own could not predict accurate verbal autopsy information through a prospective cohort study without case controls and multinomial regression models". Who would the "case controls" be? And would the multinomial regression models be used to predict different causes of maternal deaths (these being the multinomial outcomes?) using information from the verbal autopsy? Our CLMDR system is intended to identify individual deaths and investigate and respond to the social, as well as clinical and health systems factors that contribute to these deaths so as to prevent future deaths from occurring. Aggregating the verbal autopsy data could be done to useful effect at macro-level, as it has been done in previous work [1]. However rapid analysis tools for verbal autopsy tend to be optimized for population-level reporting and would not necessarily be an appropriate approach in the immediate local situations CLMDR seeks to improve. Aggregation could also be done without the use of multinomial regression models - indeed with relatively few deaths from each cause such models would likely be underpowered as well as be unnecessarily complex and incomplete given likely lack of data on all important social and system factors for each case.

  We agree that the CLMDR process requires local adaptation in each new context in which it is introduced, and encourage such adaptation. We also thank Nyavanda for his suggestions for "additional stages" - we kindly note however that the community training stage is already an integral part of the CLMDR intervention - indeed the volunteer community teams require training in the process before it can start in their community - and the community are already encouraged to be a focal point for providing reliable information about the context of the maternal deaths. As we state in our paper the community CLMDR teams identified 43 (83%) of the maternal deaths, including 4 that happened at the district hospital but were overlooked by the pre-existing facility-based system. CLMDR also encourages integration of community and facility data.

  Reference

  1. Fottrell E, Osrin D, Alcock G, Azad K, Bapat U, et al. Cause-specific neonatal mortality: analysis of 3772 neonatal deaths in Nepal, Bangladesh, Malawi and India. Arch Dis Child Fetal Neonatal Ed, 2015; 100(5):F439-47.

  Conflict of Interest:

  None declared

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  Conflict of Interest:
  None declared.

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• Published on: 13 May 2016

  RE: Community-Linked Maternal Death Review (CLMDR) to measure and prevent maternal mortality: a pilot study in rural Malawi

  • Levis K. Nyavanda, Lecturer
  • Other Contributors:
    • Consultant

  As the author stated, maternal mortality remains high and existing maternal death reviews fail to adequately review most deaths, or capture those that occur outside the health system, particularly in the sub-Saharan region. Health and Demographic Surveillance System (HDSS) sites provide data on vital events and a sampling frame and base population for community-based research in countries where vital registration systems...

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  As the author stated, maternal mortality remains high and existing maternal death reviews fail to adequately review most deaths, or capture those that occur outside the health system, particularly in the sub-Saharan region. Health and Demographic Surveillance System (HDSS) sites provide data on vital events and a sampling frame and base population for community-based research in countries where vital registration systems are non-existent or weak (UNFPA, 2014). An HDSS collects and monitors the demographic and health characteristics of a population living in a well-defined geographic area. The process starts with a baseline census followed by regular update of key demographic events (birth, death, and migration) and health events through systematic data collection. The author shows advantages of Health System Survey sites as a platform for research and research capacity building and in providing evidence- based interventions for health development. However, the Community-Linked Maternal Death Review (CLMDR) on its own could not predict accurate verbal autopsy information through a prospective cohort study without case controls and multinomial regression models. The design of the CLMDR which partnered with the community and health facility stakeholders to identify and review maternal deaths and to generate actions to prevent future deaths is a crucial strategy to mould the bottom-up-approach in strengthening health systems. The author has presented the CLMDR process involving four stages: community verbal autopsy, community and facility review meetings, a public meeting and bimonthly reviews and involving both community and facility representatives.

  I propose that this process should be tailored to each context and should target men, women, youth and influential decision- makers. I further propose the inclusion of two additional stages consisting of training of community members and integration of the community as the focal point (CFP) in providing reliable information. These two stages are appropriate approaches for use in rural areas, where due to lack of health education, not all information related to pregnancy risk factors are recorded.

  References

  * UNFPA. The State of the World's Midwifery 2014. A Universal Pathway. A Woman's Right to Health. New York: UNFPA, 2014.

  * UNDESA. World Population Prospects: The 2012 Revision. 2012. Available online at: http://esa.un.org/wpp/ unpp/panel_indicators.htm

  * Saving Mothers, Giving Life. Making Pregnancy and Childbirth Safer in Uganda and Zambia. Annual Report. Washington DC: US?AID, 2013.

  * Jacob Annamma, text book of midwifery and gynecological nursing, 5rd, Jaypee, DELHI, 2012.

  Conflict of Interest:

  None declared

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  Conflict of Interest:
  None declared.

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