Decision support system tool of the “Electronic-Implementation of Maternal Death/Mortality Review (E-MPATHY)” for formulating evidence-based recommendations with the learning environment at the district level: Development, Validation, Reliability, and Acceptability

Abstract

Background: Maternal Death Review (MDR), the cornerstone of Maternal Death Surveillance and Response (MDSR), provides evidence-based recommendations for reducing maternal death. A key difficulty in conducting MDR is the existence of a blaming culture leading to inaccuracy of maternal death classification and delays for policy-making. To support the conducive learning environment at local levels, scientific evidence and clinical standards as the main structure in MDR are required. However, an integrated decision support system tool is absent. This study reports the development, validation, reliability, and acceptability of a decision support system tool to formulate evidence-based recommendations for a supportive learning environment of MDR at district levels. Methods: Tool development comprised four steps: needs assessment, face and content validity, reliability, and acceptability assessment. The kappa (κ) value was calculated to assess inter-observer reliability in examining 113 maternal mortalities by the district and province review teams in Central Java, Indonesia. Reviewers’ acceptability was identified with observations during the review and analysis applying the Theoretical Framework of Acceptability. Results: The needs assessment resulted in: 1) naming the tool as the “Electronic Implementation of Maternal Death/Mortality Review” (E-MPATHY) reflecting a supportive learning environment; 2) a conceptual structure of a solution-based approach in each pregnancy period with integrated scientific evidence and the 3-delays model as a flow framework to assign the underlying cause based on the International Classification of Diseases-Maternal Mortality (ICD-MM), the contributing events, and recommendations. The E-MPATHY was found to be valid (CVI=1) and readable. An almost perfect agreement was found between the causes of maternal death assigned by the district and province reviewers using the ICD-MM, κ=0.86 (95%CI:0.76-0.96); p<0.001. In the 3-delays assessment, the highest agreement was found in the postpartum period (κ=0.58, 95%CI:0.42-0.74; p<0.001) with a substantial value (κ=0.61, 95%CI:0.46-0.75; p<0.001) in the third phase delay. The reviewer’s acceptability highlighted the benefits of reviewing using scientific evidence and providing encouragement for positive attitudes toward learning in their daily practices. Conclusion: The E-MPATHY performs as a useful tool to guide formulating evidence-based recommendations in a standardized way. The tool can support direct learning and be potentially applied to institutionalizedworkable district MDR.