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The global movement for
Maternal Death Surveillance
and Response(MDSR)
Prepared by Professor Wendy J Graham
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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.
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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.
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Why is there renewed interest in maternal death reviews?
Why a global movement?
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The Millennium Development Goals (MDGs)
1990-2015
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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)
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The Continuum of CareDo all women, newborns and children have access to the essential continuum of care?
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Continuum of care: Ethiopia 2011
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Source: Analysis of DHS data; Graham & Fitzmaurice, 2013 – most recent birth only
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“Maternal mortality is much more than a medical issue”
Ban Ki-moon
United Nations Secretary General
UN General Assembly 2009
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http://www.everywomaneverychild.org
Secretary-General Ban Ki-moon launches the Global Strategy for Women’s and Children’s Health (Sept 2010)
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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
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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
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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
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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
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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
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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)
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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
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Some consequences of concerns
• Under-reporting• Misreporting• Defensive behaviour• Diverts attention
from actions to save lives of mothers & newborns
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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
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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”
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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
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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
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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