Establishing the Ethiopian Obstetric Surveillance System (EthOSS): building a regional network to monitor severe outcomes of pregnancy

背景：尽管联合国和世界各国政府努力减少怀孕期间和分娩前后死亡的妇女人数，但2017年仍有29.5万名妇女在怀孕和分娩期间死亡，其中99%在低收入和中等收入国家，特别是撒哈拉以南非洲。仅在埃塞俄比亚，同年就有大约14 000名妇女死亡(死亡人数仅次于尼日利亚、印度和刚果民主共和国)，全国孕产妇死亡率似乎在两年内从每10万名活产中死亡353人增加到401人。埃塞俄比亚减少产妇死亡和残疾的努力因缺乏可靠数据而受到阻碍。为了制定有针对性的干预措施并衡量在实现可持续发展目标方面取得的进展，迫切需要对产妇死亡率和发病率进行强有力的登记，并收集相关数据以评估护理质量。这种登记和查询以前被发现对减少英国和其他高收入国家的孕产妇死亡起到了重要作用。目标：建立埃塞俄比亚地区产科监测系统网络，以监测埃塞俄比亚东部12个产科病房的严重产妇并发症，并研究在埃塞俄比亚实施国家产科监测系统网络的可行性。方法：该项目涉及四个相互关联的活动：1)建立一个区域网络和埃塞俄比亚产科监测系统联盟，2)根据该联盟的定义，对特定的严重孕产妇后果进行病例登记，3)收集详细的管理数据，以便对选定的情况进行保密调查，以及4)建立国家产科监测系统联盟和网络的可行性标准。在第一阶段(2-3个月)，我们邀请所有潜在的利益攸关方(联邦卫生部、专业协会、社区代表和参与设施)参加网络联盟。在埃塞俄比亚哈拉玛亚大学健康与医学学院和英国牛津大学国家围产期流行病学股的领导下，将举行一次区域启动会议，会上将选择死亡率和发病率的报告标准。在下一阶段(6个月)，12个参与的产科病房的指定临床医生将向安全的RedCap数据库报告选定条件下的病例(包括产妇死亡和死亡原因)。国家开放源码软件研究人员将通过走访报告单位确认病例。此外，还将收集与一种情况(将在启动会议上确定)有关的更详细的管理项目，以通过进行保密询问来评估该情况的情况管理质量。在六个月结束时，该联盟将对国家开放源码软件数据库的质量和报告的信息进行评估。对优先情况下的案件进行详细审查/保密询问将形成关于该情况的区域报告。在最后三个月，将评估将监测扩大到国家一级的可行性和感知到的挑战。在这一可行性评估的基础上，该网络将编写一份更大的赠款提案，以便与联邦卫生部、国家专业组织和客户代表密切合作，启动一个全国性的ethOSS网络。预期的结果：首次研究了在撒哈拉以南非洲的LMIC中引入一个区域、简单但强有力的严重孕产妇并发症登记的可能性。这将有助于确定该区域产妇死亡率和其他严重并发症的负担。使用详细的管理数据和保密的查询将产生产科护理质量的证据，并确定改进的机会。最后，制定了一套国家监控的可行性标准。

Background: Despite efforts by the United Nations and many governments around the world to reduce the number of women who die during pregnancy and around childbirth, 295 000 women still died during pregnancy and childbirth in 2017, 99% of whom in low- and middle- income countries (LMIC), particularly sub-Saharan Africa. In Ethiopia alone, around 14 000 women died the same year (highest number following Nigeria, India and DR Congo) and it appeared that the national maternal mortality ratio had even increased from 353 to 401 per 100 000 live births in the course of two years. Efforts to reduce maternal deaths and disability in Ethiopia are hampered by lack of reliable data. In order to develop targeted interventions and measure progress towards achieving the sustainable development goals, there is an urgent need to institute robust registration of maternal mortality and morbidity, and collect associated data to assess quality of care. Such registrations and enquiries were previously found to contribute importantly to the reduction of maternal deaths in the UK and other high-income countries. Objectives: establish a regional Ethiopian Obstetric Surveillance System (EthOSS) network to monitor severe maternal complications in twelve maternity units in Eastern Ethiopia and examine feasibility to implement a national EthOSS network in Ethiopia.Methods: This project involves four inter-related activities: 1) establishing a regional network and EthOSS consortium, 2) case registration on specific severe maternal outcomes, as defined by the consortium, 3) collection of detailed management data for confidential enquiry into one selected condition, and 4) establishing criteria for feasibility of a national EthOSS consortium and network.In the first phase (2-3 months), we invite all potential stakeholders (federal ministry of health, professional societies, community representatives and participating facilities) to take part in the network consortium. Under the leadership of College of Health and Medical Sciences, Haramaya University, Ethiopia, and the National Perinatal Epidemiology Unit (NPEU), University of Oxford, UK, a regional start-up meeting will be held, during which reporting criteria for mortality and morbidity are chosen. In the next phase (6 months), nominated clinicians at each of the twelve participating maternity units will report cases (including maternal deaths and cause of death) from selected conditions into a secure REDCap database. EthOSS researchers will confirm cases by visiting reporting units. Additionally, more detailed management items pertaining to cases from one condition (to be determined during the start-up meeting) will be collected to assess quality of case management for that condition by performing confidential enquiry. At the end of six months, quality of the EthOSS database and reported information will be evaluated by the consortium. A detailed review/confidential enquiry of cases from the priority condition will lead into a regional report on that condition. The final three months, feasibility of scaling up surveillance to national level and perceived challenges will be evaluated. Based on this evaluation of feasibility, the network will write a larger grant proposal in order to initiate a national EthOSS network, in close collaboration with the federal ministry of health, national professional organizations and client representatives.Expected outcomes: The possibility to introduce a regional, simple but robust registry of severe maternal complications in an LMIC in sub-Saharan Africa is examined for the first time. This will help to determine the burden of maternal mortality and other severe complications in the region. Use of detailed management data and confidential enquiry will generate evidence on quality of obstetric care and identify opportunities for improvement. Finally, a package of feasibility criteria for national surveillance is created.