Date Published: November 5, 2015
Publisher: Public Library of Science
Author(s): Animesh Biswas, Fazlur Rahman, Charli Eriksson, Abdul Halim, Koustuv Dalal, Mahfuzar Rahman.
To explore the experiences, acceptance, and effects of conducting facility death review (FDR) of maternal and neonatal deaths and stillbirths at or below the district level in Bangladesh.
This was a qualitative study with healthcare providers involved in FDRs. Two districts were studied: Thakurgaon district (a pilot district) and Jamalpur district (randomly selected from three follow-on study districts). Data were collected between January and November 2011. Data were collected from focus group discussions, in-depth interviews, and document review. Hospital administrators, obstetrics and gynecology consultants, and pediatric consultants and nurses employed in the same departments of the respective facilities participated in the study. Content and thematic analyses were performed.
FDR for maternal and neonatal deaths and stillbirths can be performed in upazila health complexes at sub-district and district hospital levels. Senior staff nurses took responsibility for notifying each death and conducting death reviews with the support of doctors. Doctors reviewed the FDRs to assign causes of death. Review meetings with doctors, nurses, and health managers at the upazila and district levels supported the preparation of remedial action plans based on FDR findings, and interventions were planned accordingly. There were excellent examples of improved quality of care at facilities as a result of FDR. FDR also identified gaps and challenges to overcome in the near future to improve maternal and newborn health.
FDR of maternal and neonatal deaths is feasible in district and upazila health facilities. FDR not only identifies the medical causes of a maternal or neonatal death but also explores remediable gaps and challenges in the facility. FDR creates an enabled environment in the facility to explore medical causes of deaths, including the gaps and challenges that influence mortality. FDRs mobilize health managers at upazila and district levels to forward plan and improve healthcare delivery.
Reducing maternal and newborn deaths is an integral part of the global agenda to achieve Millennium Development Goals (MDGs) 4 and 5 by 2015. Recent data have shown that the majority of maternal and neonatal deaths occur in developing countries: as many as 95% of total maternal and child deaths occur in 75 low- and middle-income countries . Countries within Asia are at particularly high risk. Bangladesh has made encouraging progress in reducing maternal and neonatal mortality over the past two decades; since 1990, maternal mortality has fallen by two-thirds  and neonatal mortality has declined by over 50 per cent . In 2010, Bangladesh received a United Nations award for its achievements in working towards attaining the MDGs, an acknowledgement of the great progress made in reducing maternal and neonatal mortality over the past two decades. Maternal mortality has reduced from 574 deaths per 100,000 live births in 1991 to 194 deaths in 2011. Neonatal mortality declined from 52 to 37 deaths per 1000 live births (38%) between 1989 and 2009 . Recently, the Bangladesh Health and Demographic Survey showed that neonatal mortality had further reduced to 28 per 1000 live births . Although the Government of Bangladesh is determined to maintain this progress, institutional delivery uptake is still poor, occurring in only 28.8% of cases [6, 7]. Recent data in Bangladesh from the maternal death review highlighted that 47.8% of maternal deaths occurred in facilities  and that in most cases the deaths could have been prevented.
This was a qualitative study performed in the Thakurgaon and Jamalpur districts of Bangladesh. The FDR (maternal and neonatal death review; MNDR) was initially piloted in the Thakurgaon district of Bangladesh in 2010. The district population is around 1.4 million and is situated in the northern part of the country. After a one-year MNDR pilot study, it was extended to another three districts in Bangladesh including Narail, Jamalpur, and Moulvibazar. For the purpose of meeting the aims of this study, we chose Thakurgaon as a pilot district, and Jamalpur district was randomly selected from the other three districts; Jamalpur covers a population of around 2.2 million people. From each district, three upazilas (sub-districts) were randomly selected for study. In both districts, FDRs were examined in the district hospitals, the maternal and child welfare centers (MCWCs), and six upazila health complexes (UHCs): 16 facilities were studied in total. The MNDR system was implemented by the Directorate General of Health Services (DGHS) in collaboration with the Directorate General of Family Planning (DGFP) under the auspices of the Ministry of Health and Family Welfare in Bangladesh. The MNDR development process is described elsewhere [8, 23–24].
Here we show that FDR has been introduced in district hospitals, maternal and child welfare centers, and UHCs in Bangladesh for the review of maternal and neonatal deaths including stillbirths. A vigorous process has been undertaken to adopt the tools and guidelines from existing instruments in overseas countries to prepare a practical and achievable death review system for primary and secondary health care centers. The government has approved the FDR instruments, including the facility death notification form and the death review form for maternal and neonatal deaths and stillbirths and guidelines used in districts to review facility deaths. The government health system has clearly played a key role in the implementation of death review. FDR for each maternal and neonatal death is practicable and functional, even considering the present health infrastructure including human resources and available facilities.
The lack of information in patient records and human resource constraints are key challenges to ensuring quality FDR. However, the successes noted are also evidence to suggest improvement in the quality of care at health facilities due to FDR. Our study shows that facility-based case reviews are simple, non-blaming, and can easily be performed within the existing health system. Although FDRs require intensive supervision, monitoring, and support to overcome obstacles, they also provide the opportunity to improve outcomes for mothers and newborns at health facilities in Bangladesh.