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

背景：尽管联合国和世界上许多国家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地区。仅在埃塞俄比亚，同年就有大约1.4万名妇女死亡（仅次于尼日利亚、印度和刚果民主共和国），在两年的时间里，全国孕产妇死亡率甚至从每10万活产353人增加到401人。由于缺乏可靠的数据，埃塞俄比亚减少产妇死亡和残疾的努力受到阻碍。为了制定有针对性的干预措施和衡量在实现可持续发展目标方面取得的进展，迫切需要对孕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。以前发现，这种登记和查询对减少联合王国和其他高收入国家的产妇死亡率作出了重要贡献。目标：建立一个区域埃塞俄比亚产科监测系统（EthOSS）网络，以监测埃塞俄比亚东部12个产科单位的严重产妇并发症，并审查在埃塞俄比亚实施国家EthOSS网络的可行性。方法：本项目包括四项相互关联的活动：1)建立一个区域网络和EthOSS联盟；2)根据联盟定义的特定严重孕产妇结局进行病例登记；3)收集详细的管理数据，对一个选定的条件进行保密调查；4)建立一个国家EthOSS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相关者（联邦卫生部、专业协会、社区代表和参与机构）参加网络联盟。在埃塞俄比亚哈拉马亚大学卫生和医学科学学院和英国牛津大学全国围产期流行病学股的领导下，将举行一次区域启动会议，在会议期间选择死亡率和发病率的报告标准。在下一阶段（6个月），在12个参与的产科单位中，每个单位的指定临床医生将从选定的条件中报告病例（包括产妇死亡和死亡原因）到一个安全的REDCap数据库。EthOSS研究人员将通过访问报告单位来确认病例。此外，将收集与一种情况下的病例有关的更详细的管理项目（将在启动会议期间确定），通过执行保密询问来评估该情况下的病例管理质量。6个月后，该联盟将对EthOSS数据库和报告信息的质量进行评估。对优先条件下的案件进行详细审查/保密调查后，将编写关于该优先条件的区域报告。最后三个月，将评估将监测扩大到国家一级的可行性以及所面临的挑战。在可行性评估的基础上，该网络将与联邦卫生部、国家专业组织和客户代表密切合作，编写一份规模更大的赠款提案，以启动一个全国伦理道德和社会服务网络。预期结果：首次研究了在撒哈拉以南非洲的低收入和中等收入国家引入区域性、简单而有力的严重产妇并发症登记制度的可能性。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查询将产生关于产科护理质量的证据，并确定改进的机会。最后，制定了一整套国家监测的可行性标准。

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.