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Cited by 107Global Maternal and Child HealthHealth Policy Implementation ScienceMaternal and fetal healthcare

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

Open access
Smith, Helen, Ameh, Charles, Roos, Natalie, Mathai, Matthews, Broek, Nynke van den·2017·BMC Pregnancy and Childbirth
DOI 10.1186/s12884-017-1405-6PMC PMC5513145
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Abstract

BACKGROUND: Maternal 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. METHODS: A 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. RESULTS: MDR 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. CONCLUSIONS: Case 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.

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  • The incompleteness of some audits could be related to late reporting of deaths, a lack of MDSR institutionalization including reluctance of health providers to engage in audits, incomplete clinical record-keeping, or lack of community involvement.

    “The incompleteness of some audits could be related to late reporting of deaths, a lack of MDSR institutionalization including reluctance of health providers to engage in audits, incomplete clinical record‐keeping, or lack of community involvement. 5 , 7 , 8 , 17”

    From Review of maternal death audits in refugee camps in <scp>UNHCR</scp> East and Horn of Africa and Great Lakes Region, 2017–2019 (2023) · cites this paper as [7]

    The Results (Maternal death review; no page available) link incomplete reporting and missing case records to staff unfamiliarity with reporting, and describe delays, record-quality problems, and barriers to staff participation. The Results (Identification and notification of maternal deaths; no page available) also say community information is critical to identifying deaths. The paper does not clearly establish late reporting or lack of community involvement as causes of incomplete audits specifically. (LLM, conf=0.82)

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  • In low resource settings, significant challenges have been identified in the MPDSR process, including the quality of mortality reviews and linkage to concrete actions.

    “In low resource settings where the numbers of maternal and perinatal deaths are the highest, significant challenges have been identified in the MPDSR process, including the quality of mortality reviews and linkage to concrete actions [23, 24].”

    From Implementation of maternal and perinatal death surveillance and response (MPDSR) in humanitarian settings: insights and experiences of humanitarian health practitioners and global technical expert meeting attendees (2022) · cites this paper as [23]

    The Results (Maternal death review) describe shortcomings in reporting and review quality, while the Discussion and conclusion (Study limitations) identify implementing recommendations as a weak point. These findings support the claim for maternal death surveillance and response, but the paper does not establish the same challenges for the perinatal component of MPDSR. (LLM, conf=0.84)

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Research works printed but not linked: 1

  1. [9]BJOG: an International Journal of Obstetrics & Gynaecology. Special issue: International Reviews: Quality of Care. 2014; 121 (s4):1–171. http://onlinelibrary.wiley.com/doi/10.1111/bjo.2014.121.issue-s4/issuetoc · DOI

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Authors
Smith, H., Ameh, C., Roos, N., Mathai, M., & Broek, N. V. D.
Affiliations
  • Liverpool School of Tropical Medicine (GB)
  • World Health Organization (CH)
Corresponding author
Smith, Helen
ORCID
Venue
BMC Pregnancy and Childbirth
Publisher
Springer Science and Business Media LLC
Published
2017-07-17
Volume
17
Issue
1
Pages
233-233
ISSN
1471-2393 (ISSN-L)
DOI
10.1186/s12884-017-1405-6
PMC
PMC5513145
OpenAlex
W2734843257
Cited by
107
References
27
Citations by year
2026: 10 · 2025: 13 · 2024: 14 · 2023: 10 · 2022: 26 · 2021: 11 · 2020: 12 · 2019: 9 · 2018: 2
FWCI
6.87
Type
journal article
Language
en
Open access
Licence
cc-by
Locations
  • BMC Pregnancy and Childbirth (publishedVersion, cc-by)
  • PubMed Central (publishedVersion, cc-by)
  • PubMed (publishedVersion)
  • LSTM Online Archive (Liverpool School of Tropical Medicine) (acceptedVersion)
  • DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion, cc-by-sa)
Funders
World Health Organization (2015/563656-0)
Topics
  • Health Sciences › Medicine › Pediatrics, Perinatology and Child Health › Global Maternal and Child Health
  • Health Sciences › Health Professions › General Health Professions › Health Policy Implementation Science
  • Health Sciences › Medicine › Pediatrics, Perinatology and Child Health › Maternal and fetal healthcare
Keywords
maternal death surveillance and response, maternal death review, implementation barriers and facilitators, health information systems, no-blame culture, health system strengthening, scale-up, policy analysis
MeSH terms
Female, Health Plan Implementation, Humans, Maternal Mortality, Pregnancy, Public Health Surveillance, Maternal Death

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