Implementing maternal death surveillance and response: a review of lessons from country case studies

Abstract

BackgroundMaternal Death Surveillance and Response (MDSR) implementation is monitored globally, but not much is known about what works well, where and why in scaling up. We reviewed a series of country case studies in order to determine whether and to what extent these countries have implemented the four essential components of MDSR and identify lessons for improving implementation.MethodsA secondary analysis of ten case studies from countries at different stages of MDSR implementation, using a policy analysis framework to draw out lessons learnt and opportunities for improvement. We identify the consistent drivers of success in countries with well-established systems for MDSR, and common barriers in countries were Maternal Death Review (MDR) systems have been less successful.ResultsMDR is accepted and ongoing at subnational level in many countries, but it is not adequately institutionalised and the shift from facility based MDR to continuous MDSR that informs the wider health system still needs to be made. Our secondary analysis of country experiences highlights the need for a) social and team processes at facility level, for example the existence of a ‘no shame, no blame’ culture, and the ability to reflect on practice and manage change as a team for recommendations to be acted upon, b) health system inputs including adequate funding and reliable health information systems to enable identification and analysis of cases c) national level coordination of dissemination, and monitoring implementation of recommendations at all levels and d) mandatory notification of maternal deaths (and enforcement of this) and a professional requirement to participate in MDRs.ConclusionsCase studies from countries with established MDSR systems can provide valuable guidance on ways to set up the processes and overcome some of the barriers; but the challenge, as with many health system interventions, is to find a way to provide catalytic assistance and strengthen capacity for MDSR such that this becomes embedded in the health system.

Triangulating data sources for further learning from and about the MDSR in Ethiopia: a cross-sectional review of facility based maternal death data from EmONC assessment and MDSR system

“…Furthermore, the number of facilities whose reports were captured at national level was less than half of the number of facilities reporting to the next level. Other studies revealed that poor data flow from the facility to the central level was a challenge in both MDR and MDSR systems, and stemmed from a lack of knowledge and confusion among facility staff on the reporting process, high staff turnover and fear of legal repercussions [6,7,24].…”

“…Multiple factors can affect the implementation of MDSR. Lack of awareness of the purpose and principles of MDSR among stakeholders, the existence of a blame culture, insufficient number of trained staff to implement MDSR, the unavailability of guidelines and tools, lack of commitment and financial resources all contribute to the implementation of MDSR [4][5][6][7][8][9][10][11][12][13]. These barriers may prevent compliance with national and global targets for MDSR and delay the establishment of functioning MDSR committees at all health facilities [14].…”

From Passive Surveillance to Response: Suriname's Steady Efforts to Implement Maternal Death Surveillance and Response (MDSR)

“…Subsequently, the evaluation of the previous guidelines and the development of guidelines on postnatal and antenatal care, sepsis, sickle cell anemia, emergency obstetrics, and early warning scores followed in April 2019. Facility-based trainings, guided by BOG and PAHO and the recently installed maternal health quality of care committee, were conducted to enhance guideline implementation and adherence, as advised in earlier studies [6,7]. In addition to quality of care improvement projects, committee MaMS was involved in conducting nationwide studies on maternal morbidity and near-miss (2017-2019), childbirth outcomes, and ethnic disparities in maternal health care and stillbirths [33,34].…”

“…Several barriers are yet to overcome to incorporate MDSR in the health system in Suriname fully. To progress from insu cient surveillance, incidental facilitybased audits, and voluntary-based national audits to a well-established MDSR, strong government commitment, professionals' involvement, and external support of organizations like PAHO are essential [7,36]. Successful and sustained implementation now requires delineation of roles for surveillance and audit, responsibilities for action, and monitoring to track implementation progress.…”

“…By performing audits, an attempt is made to understand the "how and why" of the death, analyze substandard care, and formulate "lessons learned" to initiate steps for improvement. Combining audits with national guideline development, training, and monitoring of implementation could improve guidelines adherence [6,7]. The different types of medical audits are verbal autopsy (at community level), clinical audit (at facility level, by involved healthcare workers), and con dential enquiry (at national level, by an independent committee) [5].…”