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      Analysis of the Iranian maternal mortality surveillance system and providing system improvement strategies: study protocol for strategy formulation

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          Abstract

          Background

          The implementation of the maternal mortality surveillance system in Iran has significantly reduced the incidence of maternal mortality. However, the pattern of the causes of the mortalities, which has remained constant over the years, are still concerning. This study aimed to explain the experiences of the actors of the Iranian maternal mortality surveillance and provide strategies for improving this system.

          Methods

          This research is a qualitative study to develop strategies, that will be conducted in two phases. In the first phase, purposive sampling will be performed, and the data will be collected based on the experiences of the Iranian maternal mortality surveillance system actors in Iran’s Ministry of Health and the selected universities (Shiraz, Isfahan, Tehran, Zahedan, Alborz, Shahrekord) through semi-structured interviews. Moreover, during this phase, some part of the data will be collected through random participation of the researcher in some maternal mortality committees of the selected universities. In order to carry out the second phase, a panel of experts will be set up to discuss the best strategies for improving the Iranian maternal mortality surveillance by considering the above results.

          Discussion

          The analysis of maternal mortality surveillance system needs to evaluate the experiences of the actors who are the policymakers of this system and can be effective in identifying its challenges. This analysis and formulation of the subsequent strategies can lead to maternal health indicators remaining within the range of international standards or even beyond those standards in Iranian universities and countries with similar surveillance system.

          Résumé en français (French abstract)

          Contexte de recherché

          La mise en œuvre du système de surveillance de la mortalité maternelle en Iran a considérablement réduit les taux de mortalité maternelle. Cependant, le schéma des causes de mortalité qui est. resté stable pendant plusieurs années est. toujours préoccupant. Le but de cette étude est. d’expliquer les expériences des agents iraniens de surveillance de la mortalité maternelle et de proposer des stratégies pour améliorer ce système.

          Méthodes

          Cette recherche est. une étude qualitative et a été effectuée pour développer des stratégies qui se feront en deux phases. Dans la première phase, un échantillonnage ciblé est. effectué et les données sont utilisées par le biais d’entretiens semi-structurés basés sur les expériences des agents iraniens du système de surveillance de la mortalité maternelle au ministère de la Santé et dans certaines universités iraniennes (à Shiraz, Isfahan, Téhéran, Zahedan, Alborz, Shahrekord) seront collectées. De plus, au cours de cette phase, certaines parties des données seront collectées grâce à la participation aléatoire de chercheurs aux comités de mortalité maternelle dans certaines universités. Afin de réaliser la deuxième phase, selon les résultats ci-dessus, un groupe d’experts est. considéré pour discuter des meilleures stratégies pour améliorer la surveillance de la mortalité des mères iraniennes.

          Discussion

          L’analyse des systèmes de surveillance de la mortalité maternelle nécessite d’évaluer les expériences des agents qui sont les décideurs de ce système et peuvent être efficaces pour identifier ses défis. Cette analyse et le développement de stratégies ultérieures peuvent garantir que les indicateurs de santé maternelle restent dans la portée des normes internationales ou même au-delà de ces normes dans les universités de l’Iran et des pays avec des systèmes de surveillance similaires.

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          Most cited references10

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          Maternal mortality ratios in 2852 Chinese counties, 1996–2015, and achievement of Millennium Development Goal 5 in China: a subnational analysis of the Global Burden of Disease Study 2016

          Summary Background As one of only a handful of countries that have achieved both Millennium Development Goals (MDGs) 4 and 5, China has substantially lowered maternal mortality in the past two decades. Little is known, however, about the levels and trends of maternal mortality at the county level in China. Methods Using a national registration system of maternal mortality at the county level, we estimated the maternal mortality ratios for 2852 counties in China between 1996 and 2015. We used a state-of-the-art Bayesian small-area estimation hierarchical model with latent Gaussian layers to account for space and time correlations among neighbouring counties. Estimates at the county level were then scaled to be consistent with country-level estimates of maternal mortality for China, which were separately estimated from multiple data sources. We also assessed maternal mortality ratios among ethnic minorities in China and computed Gini coefficients of inequality of maternal mortality ratios at the country and provincial levels. Findings China as a country has experienced fast decline in maternal mortality ratios, from 108·7 per 100 000 livebirths in 1996 to 21·8 per 100 000 livebirths in 2015, with an annualised rate of decline of 8·5% per year, which is much faster than the target pace in MDG 5. However, we found substantial heterogeneity in levels and trends at the county level. In 1996, the range of maternal mortality ratios by county was 16·8 per 100 000 livebirths in Shantou, Guangdong, to 3510·3 per 100 000 livebirths in Zanda County, Tibet. Almost all counties showed remarkable decline in maternal mortality ratios in the two decades regardless of those in 1996. The annualised rate of decline across counties from 1996 to 2015 ranges from 4·4% to 12·9%, and 2838 (99·5%) of the 2852 counties had achieved the MDG 5 pace of decline. Decline accelerated between 2005 and 2015 compared with between 1996 and 2005. In 2015, the lowest county-level maternal mortality ratio was 3·4 per 100 000 livebirths in Nanhu District, Zhejiang Province. The highest was still in Zanda County, Tibet, but the fall to 830·5 per 100 000 livebirths was only 76·3%. 26 ethnic groups had population majorities in at least one county in China, and all had achieved declines in maternal mortality ratios in line with the pace of MDG 5. Intercounty Gini coefficients for maternal mortality ratio have declined at the national level in China, indicating improved equality, whereas trends in inequality at the provincial level varied. Interpretation In the past two decades, maternal mortality ratios have reduced rapidly and universally across China at the county level. Fast improvement in maternal mortality ratios is possible even in less economically developed places with resource constraints. This finding has important implications for improving maternal mortality ratios in developing countries in the Sustainable Development Goal era. Funding National Health and Family Planning Commission of the People's Republic of China, China Medical Board, WHO, University of Washington Center for Demography and Economics of Aging, Bill & Melinda Gates Foundation.
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            Determinants and causes of maternal mortality in Iran based on ICD-MM: a systematic review

            Background No systematic review has explored the causes of and factors associated with maternal mortality in the context of Iran. This study reviewed determinants and causes of maternal mortalities during pregnancy, delivery and the puerperium using the International Classification of Diseases-Maternal Mortality (ICD-MM), introduced by the World Health Organization. Methods A systematic electronic search of all the studies that identified causes and/or determinants of maternal deaths in any part of Iran or in the whole country were included, without any restriction of time or language of studies. To identify the studies to include in this study, a combination of hand searching and bibliographies was also conducted. These sources and citations yielded a total of 653 articles; nevertheless, only 29 articles met the inclusion criteria, hence, required data were extracted, summarized, and grouped together from these papers and are reported in the tables. Results Amongst the 29 studies published between 2003 and 2017 in Iran, 24 studies were cross-sectional. Overall, 4633 deaths were reviewed, and 2655 (58%) of the cases included the data on the causes of death generally. According to the ICD-MM, a total of 69.9, 20.6, and 5.2% of the mortalities were due to direct, indirect and unspecified causes respectively and 4.3% of the causes were not clear in several studies. The leading direct and indirect causes of death were identified as hemorrhage (30.7%) and hypertensive disorders (17.1%) and circulatory system diseases (8.1%) respectively. Several factors including gravidity, type of delivery, socio-economic status of mothers, locations of birth, death and maternity care venues were found in the original studies as the most important determinant of maternal mortalities in Iran. Conclusions This study, provided an updated summary of evidences on the causes and determinants of maternal death in Iran, which is critically important for the development of interventions and reduction of the burden of maternal mortality and morbidities.
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              Evaluation of the maternal deaths surveillance and response system at the health district level in Guinea in 2017 through digital communication tools

              Background Reducing maternal mortality still remains a major challenge in low-income countries. This study aims to explore how digital communication tools can be used to evaluate the maternal deaths surveillance and response (MDSR) system at the health district level in Guinea. Methods A descriptive cross-sectional study was conducted, using an innovative digital approach called District.Team, from April to September 2017. This study targeted all 38 district medical officers in Guinea. In addition to district medical officers, the participation of health actors from regional and central levels were also expected in the online discussion forum. Data collected through the questionnaire were mixed and those from the online discussion forum were entirely qualitative. Results In total, 23 (61%) district medical officers (DMOs) participated in the study. Out of health districts (87%) which had updated guidelines and standards for the MDSR, 4 (20%) did not apply the content. In two health districts (8.7%), not all health facilities had maternal deaths notification forms. Three districts (13%) did not have maternal death review committees. In 2016, only half (50.2%) of reported maternal deaths were reviewed. The main recommendation formulated was related to quality of care. Other needs were also highlighted including continuous training of health care providers on emergency obstetric and neonatal care. Less than half (45%) of the review committee’s recommendations were implemented. Six health districts (26.1%) did not have a response plan to reported maternal deaths and no district annual report on the MDSR was published in 2016. The weaknesses identified were, among others, insufficiency of human resources and lack of financial resources. Fifty-eight messages related to MDSR weaknesses and improvement solutions were posted in the online discussion forum by 28 participants (23 DMOs and 5 health actors from regional and central levels). Conclusion Digital tools can be used to assess the functioning of a system like maternal deaths surveillance and response. Moreover, the findings of the evaluation conducted will help stakeholders (starting from the health districts themselves) to design strategies and interventions for an effective MDSR.
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                Author and article information

                Contributors
                marjan.beigi@modares.ac.ir
                shahideh.jahanian@modares.ac.ir
                Nasrin_g2000@yahoo.com
                mohamade@modares.ac.ir
                Kazemi@nm.mui.ac.ir
                Journal
                Reprod Health
                Reprod Health
                Reproductive Health
                BioMed Central (London )
                1742-4755
                23 July 2020
                23 July 2020
                2020
                : 17
                : 111
                Affiliations
                [1 ]GRID grid.412266.5, ISNI 0000 0001 1781 3962, Department of Midwifery and Reproductive Health, Faculty of Medical Sciences, , Tarbiat Modares University, ; Tehran, Iran
                [2 ]GRID grid.415814.d, ISNI 0000 0004 0612 272X, Ministry of Health and Medical education, ; Tehran, Iran
                [3 ]GRID grid.412266.5, ISNI 0000 0001 1781 3962, Department of Nursing, Faculty of Medical Sciences, , Tarbiat Modares University, ; Tehran, Iran
                [4 ]GRID grid.411036.1, ISNI 0000 0001 1498 685X, Nursing and Midwifery Care Research Center, Department of Midwifery and Reproductive Health, Faculty of Nursing and Midwifery, , Isfahan University of Medical Sciences, ; Isfahan, Iran
                Author information
                https://orcid.org/0000-0003-2675-8402
                http://orcid.org/0000-0002-7006-8487
                Article
                963
                10.1186/s12978-020-00963-2
                7376841
                4d41c874-9fc6-4baf-a84a-a3bc48bdaf91
                © The Author(s) 2020

                Open AccessThis article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

                History
                : 16 June 2020
                : 13 July 2020
                Funding
                Funded by: FundRef http://dx.doi.org/10.13039/501100008257, Tarbiat Modares University;
                Award ID: 64000000 IRR
                Award Recipient :
                Categories
                Study Protocol
                Custom metadata
                © The Author(s) 2020

                Obstetrics & Gynecology
                mortalité maternelle,etude de la mortalité maternelle,système de surveillance de la mortalité des mères iraniennes,surveillance et réponse de la mortalité maternelle,stratégie,maternal mortality,maternal death review,iranian maternal mortality surveillance system,maternal death surveillance and response,strategy

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