The global movement for

Maternal Death Surveillance

and Response(MDSR)

Prepared by Professor Wendy J Graham

WHO, 2004

Confidential Enquiries into Maternal Deaths:United Kingdom, Malaysia, Sri Lanka, South Africa, Egypt

Maternal death reviews (MDR) have been shown to be effective in improving team work, management and quality of care.

46 AFRO countries (2011):15% have established required policies & are conducting MDR at facility and community levels.68% of countries are conducting facility-based MDR in selected districts. 17% of countries had no information available.

Why is there renewed interest in maternal death reviews?

Why a global movement?

The Millennium Development Goals (MDGs)

1990-2015

On Track for MDG 5(a) only (1)Equatorial Guinea

On track for MDGs 4 and 5a (8)Bangladesh, Cambodia, China, Egypt, Eritrea, Lao PDR, Nepal and Vietnam

On track for MDG 4 only (15)Bolivia, Brazil, Guatemala, Indonesia, Iraq, Korea DPR, Kyrgyz Republic, Liberia, Madagascar, Malawi, Mexico, Morocco, Peru, Philippines, Solomon Islands

Progress on maternal and child survival : 75 highest-burden countries (2012)

The Continuum of CareDo all women, newborns and children have access to the essential continuum of care?

Continuum of care: Ethiopia 2011

ANC

1 vi

sit

Neo

nata

l Tet

nus

2+ T

etan

us In

jecti

ons

ANC

4/4+

visi

ts

SAD

Insti

tutio

nal d

eliv

erie

s

Post

nata

l visi

t

Brea

stfe

edin

g

DPT

1 d

ose

Full

Vacc

ine

Cont

race

ptive

use

Met

nee

d

0102030405060708090

100

Poorest 2 3 4 Richest

%

Uptake

Source: Analysis of DHS data; Graham & Fitzmaurice, 2013 – most recent birth only

“Maternal mortality is much more than a medical issue”

Ban Ki-moon

United Nations Secretary General

UN General Assembly 2009

http://www.everywomaneverychild.org

Secretary-General Ban Ki-moon launches the Global Strategy for Women’s and Children’s Health (Sept 2010)

Commission’s 10 recommendations have been translated into a common strategic work plan, with priority areas including:

• birth and death registration• monitoring of results• maternal death surveillance and response• strengthening use of ICT• resource tracking• national mechanisms for review and accountability• advocacy for action

Maternal Death Surveillance & Response: a continuous action cycle at community, facility,

regional & national levels

Surveillance

Response

Identify & notify deaths

Review deaths

Respond & monitor response

Analyse & makerecommendations

Maternal Death Surveillance & Response

“A maternal death surveillance and response system that includes maternal death identification, reporting, review and response can provide the essential information to stimulate and guide actions to prevent future maternal deaths and improve the measurement of maternal mortality.”

(Bull World Health Organ Nov 2011;89:779–779A)

May 2013

What lessons were learnt from existing death review systems?

• Review-process focused• Facility deaths only• Deaths not notifiable• Physician-driven• Health sector only• Culture of blame & legal

issues ignored• Ad hoc capture of data• Limited lessons for

action at national level

• Action-focused • Facility & community deaths• Deaths are notifiable events• Multi-professional • Multi-sectoral responsibility• Culture of no-blame & legal

framework addressed• Systematic capture & use• Lessons learnt at all levels

MDSR

Why is MDSR important?

What opportunities does MDSR provide?

• Provides information for action• Connects actions to results• Makes maternal death visible at local & national levels• Sensitizes communities & facility health workers• Boosts country ownership of data• Provides data in real time• Enables progress towards capturing all deaths

What are the challenges faced in implementing MDSR?

Engaging communities

Weak data availability & quality

Human resource requirements

Need for continuous commitment at all levels

Building enabling environment of “no blame” & legal framework (protection, anonymity, confidentiality)

Common concerns with death reviews

• Patients: concern that illegal behaviour will be punished (e.g. abortion, under-age marriage)

• Families: concern for repercussions (not seeking care, being involved in illegal behaviour)

• Health workers: concern for prosecution or job loss

• Facilities: concern for lost reputation & legal costs• Committee members: concern for adverse

reactions from colleagues or management

Some consequences of concerns

• Under-reporting• Misreporting• Defensive behaviour• Diverts attention

from actions to save lives of mothers & newborns

Fostering the essential culture of “no blame”

• Acknowledgment throughout system that mistakes do happen

• Constructive approach to learning from every death• Identifying preventive measures for the future as

over-riding priority• Use of multi-professional committee to build team

solidarity• Participation of community representatives to

explain value & results to wider audience

Pearson, L. et al (2009). Maternal death reviews in Africa. International Journal of Gynecology and Obstetrics, 106, 89-94.

“The presence of a legal framework is a driving force behind MDSR systems ,and is critical to mitigating legal challenges on numerous levels including for

the patient, family, health professional and facility”

International Example:United Kingdom

• “No name, no blame” is a fundamental principle • Both women who have died AND the health

providers remain anonymous during reviews• Two government acts guarantee confidentiality• Reviews cannot be used in litigation,

management sanctions or personal blame

International experience: India

• Motherhood is the top priority of India’s Rural Health Mission• Confidential, non-threatening environment created to allow

documentation and analysis of factors leading to adverse maternal outcomes

• Informed consent and confidentiality ensured• Confidentiality protected when sharing findings• Result has been openness in reporting, trust across the system

and better data

Why is Ethiopia at the forefront of the global movement for MDSR?

• RMNCH is a top national priority• FMoH’s strong ownership of MDSR• Action-focused MDSR from outset• Strong champions• Existing expertise & experience• Community link enabled by HDA• High level commitment to maintaining momentum started today• Enabling environment being built, including legal framework