AMBIENTAL BANANERO

The District Health Officer (DHO) for Mangochi District Hospital provided office space at the district hospital. This office acted as central point for coordinating all research activities during the study period. The office had a locked cupboard for data storage and a working telephone for communication.

4.6.1 Development of data collection tools

Five separate data collection tools were used to collect data about deaths of WRA and MDs from both facility and community levels. Details of all the tools on how they were developed, who used them and when they were used are listed in Table 4.4.

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Table 4.4: Tools used to collect data Name of the tool Existing,

adapted or adopted

Who used it When Appendix

Facility death identification form adapted PI, DCs, HSAs, Cluster Supervisors and health workers Identification phase 4a Community death identification form adapted PI, DCs, HSAs, Cluster Supervisors Identification phase 4b Facility record

review form adapted

PI, Panel of Experts

Assigning cause of death and factors associated to MDs

4c Maternal death

review form existing

Health workers, DCs and PI

Assigning cause of death and factors associated to MDs 1 Verbal autopsy form adopted DCs, PI, Panel of Experts Assigning cause of death and factors associated to MDs

5

4.6.2 Tools for identifying death of WRA

Health facility and community data extraction forms

Two separate forms were used to identify deaths of WRA at health facility and community level, [Appendices 4a and 4b]. The health facility data extraction form was used to identify deaths of WRA which occurred at facility level while the community data extraction forms for the community. Both forms were adapted from the free online toolkit guide developed by the

Initiative for Maternal Mortality Programme Assessment (IMMPACT)

(IMMPACT/Population Reference Bureau 2007). IMMPACT is a global research initiative for the evaluation of safe motherhood intervention strategies based at the University of Aberdeen. IMMPACT has developed a range of tools for maternal health programme evaluation. These include ways to measure maternal and perinatal mortality and morbidity, quality of maternal health care, economic outcomes and health systems factors. The tools have been tested in countries such as Ghana and Burkina-Faso. Modifications were made to suit the Malawian context.

Both forms had detailed information on the socio demographic information of the deceased, details to identify the pregnancy status of the deceased woman and cause of death [see

appendices 4a and 4b]. The health facility data extraction form had additional information on the code level of facility where the woman died, date and time of admission and diagnosis.

4.6.3 Facility Record Review Form

This was a validated form adapted from the IMMPACT tool kit. The form was used to extract information from the individual case notes of women classified as MD. This form had information on the clinical management or procedures done on the deceased women. The information was collected to assist in identification cause of MD, [Appendix 4c]. This information was extracted by the PI who is a nurse/midwife with more than seven years of experience working in maternity and general wards within developing countries which facilitated collection of appropriate data. However to avoid observer bias which may have risen out of unconscious assumptions or preconceptions by the PI, patient case files and health passport books where information was gathered were photocopied and analysed by expert panel.

4.6.4 Maternal death review Form

The MDR2 is one of the existing tools in Malawi developed by MOH and is used during MD audit meetings. Details of the form are described in section 2.4.7 in Chapter 2 (See sample of MDA 2 in Appendix 1). The completed forms for the deceased were photocopied and used for

cause classification. This form had the following details:

a) Social demographic data the deceased

b) Location where of death occurred (level of facility and ownership of facility e.g. public or private)

c) Admission date and time.

d) Reason for admission

e) Condition at admission

f) ANC, delivery and postpartum details

g) Cause of death

h) Associated factors that contributed to death (facility and community)

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4.6.5 Verbal Autopsy form

In order to achieve a high degree of consistency and ensure comparability with other data sets, a validated verbal autopsy (VA) questionnaire, developed by a WHO led expert group of researchers, data users, and other stakeholders, with sponsorship from the Health Metrics Network (HMN) in 2007, was used to collect data (WHO 2007d) [Appendix 5]. The tool was developed based on widely used validated VA questionnaires and procedures (Abou Zahr 2007). Standard VA questionnaires for three age groups were available: questionnaires for the under four weeks; four weeks to 14 years and 15 years and above. This study used the 15 years and above questionnaire for women. This study used the 2007, WHO standard VA tool, as it was the only validated tool available when this study commenced in 2010. However, the WHO revised the 2007 VA tool and published a new version in 2012 (World Health Organization 2012 ). In comparison with the 2007 version, the questions in the 2012 VA tool were the same but numbers of conditions and questions have been reduced. This implies the 2007 tool used in this study captured more data.

The VA questionnaire elicited information on signs, symptoms, medical history and circumstances preceding death. The tool comprised of six main sections as follows:

1) Background information on the deceased

2) Brief obstetric history of the deceased woman.

3) General information was collected about events preceding the death.

4) Information regarding general illness leading to death

5) Questions on symptoms and signs of the last illness

6) Information on MDs during pregnancy, delivery, abortion, and within six weeks after

delivery or abortion.

7) Information regarding treatment and care-seeking behaviour of the deceased woman.

This questionnaire was translated in Yao language, the common language for the district, by an expert in Yao language. The Yao questionnaire was back-translated into English again to ensure accurate translation.

In this study, VAs were conducted by the Principal Investigator (PI) and the Data collectors (DCs) on all identified MDs, which occurred at both a health facility and at community level.