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Dear members and friends,
Welcome to the final MDSR Action Network newsletter: Celebrating 5 years of sharing the latest
innovation in MDSR!
Over the years, we have had the great privilege to share with you updates and resources on
maternal death surveillance and response (MDSR) from around the world. We are sad to say this is
the last newsletter we will be issuing, but you will still be able to access resources from the MDSR
Action Network. Also, keep an eye out for new content about maternal and perinatal death
surveillance and response (MPDSR) on the Evidence for Action (E4A)-MamaYe website.
For our last edition, we reflect on some of our publications from recent years.
We kick off with an opinion piece we put together following the 2016 release of three new tools to
count and review stillbirths, and maternal and neonatal deaths. Five experts in maternal, newborn
and child health shared their views on the opportunities and challenges of implementing perinatal
death surveillance and response, including advice on sampling perinatal deaths (click here to read).
Celebrating the MDSR Action Network
2
More recently, Dr Sarah Barnett considered the viability of scaling-up community maternal verbal
autopsies in low-resource settings to achieve the MDSR goal and objectives, and suggested
approaches to obtain community-based information (click here to read).
To better understand how clinical and non-clinical actors in the
health system can most effectively contribute to reviewing
maternal deaths worldwide, we compiled common themes
from the insights of six experts to draw out lessons learned for
the successful involvement of the multi-disciplinary health
actor in MDSR with particular emphasis on the role of midwives
(click here to read). For more about midwives and MDSR, read
a blog we posted for International Day of the Midwife about
how MPDSR in Kenya helped lift the morale of midwives
working in challenging conditions during the four-month strike
by Government doctors (click here to read).
To view and download MDSR-related resources from Ethiopia,
visit the country Resource Hub, which includes national
reports, training materials and a short film (click here to
browse).
And in case you missed our last newsletter, click here to read our post on Sierra Leone’s MDSR
Report: 2016 and here to read a blog by Dr Owen Musopole about the recent MDSR reports in
Malawi Northern Zone.
Act | Country update
Kenya | MPDSR committees across all levels jointly
tackle referral systems challenges A linked MPDSR system can have a positive impact on reducing
mortality. Find out what actions the Bungoma county-level MPDSR
committee took to address problems with its referral system. Read
more here and below.
Learn | Ethiopia resources New MDSR report and MPDSR materials In the third annual MDSR report, Ethiopia synthesised MDSR data for
1,065 maternal deaths from the Ethiopian fiscal year (EFY) 2009 (2016-
2017). The country has also released National MPDSR Technical
Guidance and an MPDSR Training Manual with accompanying
Workbook and presentation slides. Visit the Ethiopia MDSR Resource
Hub to keep up to date on Ethiopia-related resources.
New posts
3
Act | Country update Bangladesh scales up MPDSR To prevent mothers and babies from dying, Bangladesh has taken
action to scale up its MPDSR system. Dr Animesh Biswas, Senior
Scientist and Associate Director, Reproductive and Child Health
Department at the Centre for Injury Prevention and Research, gives an
account of the scale-up activities to support the expansion of the
system. Read more here and below.
Learn | Publication Legislation and policies that support MDSR We end our three-part series with an annotated bibliography of
relevant literature. Legislation mandating maternal death as a
reportable event and laws and policies supporting a “no-blame culture”
are crucial for the successful implementation of MDSR. Fear of
repercussions and restrictive laws and policies can hinder
effectiveness. Read more here and below.
Learn | Resources Seminar recordings: Maternal and perinatal survival
in crisis settings Visit here and here to watch the presentations of the seminar series
where speakers share ideas and experiences about innovations to
improve maternal and newborn death surveillance to respond to
future Ebola outbreaks and about applying MDSR to crisis settings.
RCOG World Congress 2018, 21-24 March, 2018, Singapore
Fifth Global Symposium on Health Systems Research, 8-12 October, 2018, Liverpool, UK
XXII FIGO World Congress of Gynecology and Obstetrics, 14-19 October, 2018, Rio de Janeiro,
Brazil
Fifth International Conference on Family Planning, 12-15 November, 2018, Kigali, Rwanda
Women Deliver Fifth Global Conference, 3-6 June, 2019, Vancouver, Canada
Keep up to date on upcoming events here. For more information including location and event
registration details (where applicable), view the Calendar of Events at the end of the newsletter.
Act | Events
4
Research article: Timing of maternal death: Levels, trends, and ecological correlates using sibling
data from 34 sub-Saharan African countries
WHO South Sudan: The Ministry of Health in partnership with WHO and partners strengthens
health information system for effective health service delivery in South Sudan
UNICEF Bangladesh: Reducing maternal and neonatal mortality and improving sexual,
reproductive health rights in the low-performing districts
Devex (Global views | Data and development): Opinion: The Achilles heel of the Sustainable
Development Goals is a lack of data
WHO Sierra Leone: Training clinicians to provide lifesaving emergency care for women and
newborns
CDC MMRIA data system: Maternal Mortality Review Information Application and user guide
Act | Country update
Kenya | MPDSR committees across all levels jointly tackle referral systems
challenges
Case study
The Lugulu hospital MPDSR committee discussed the challenges they were facing with referrals,
especially during the doctors’ strike at the turn of the year.
“A client suffering from pre-eclampsia was referred by ambulance from a Sub-County
Hospital to Lugulu Hospital in April, 2017. She was travelling alone and had not received any
treatment to stabilise her. She was dropped off at the entrance to the facility and left alone
to find her way to maternity, but collapsed in the corridor and started fitting”- Lugulu
Nursing Officer in charge.
At the sub-county MPDSR committee meetings, representatives from each of the sub-county
MPDSR facilities come together alongside sub-county staff. This forum provided an opportunity
for Lugulu Hospital to voice their concerns about the referral processes and explain how it was
contributing to maternal deaths. The referring facilities were made aware of the systemic failures
and the changes they needed to make. The sub-county District Public Health Nurse visited the
weak referring facilities to reiterate performance expectations in the referral processes and to
hold the teams to account. Lugulu Hospital has subsequently reported dramatic improvements to
the referral process and better inter-facility teamwork.
‘’the referring facilities now inform us on time, enabling us to make the necessary
preparation. There has also been a remarkable improvement in documentation on referral
notes’’ - Lugulu Nursing Officer in charge.
Act | In the news
Full-text posts
5
In 2016, nearly half of maternal deaths (48%)1 and almost a third of perinatal deaths (31%)2
occurring in health facilities in Bungoma County were referred from another facility. The facility
level maternal and perinatal death reviews in the County, supported by the Maternal and Newborn
Initiative (MANI) project highlighted multiple problems with the referral system, including:
• Delays in the decision to refer clients
• Inappropriate treatment prior to referral or lack of efforts to try to stabilise clients before
transit (e.g. Administering magnesium sulphate to clients experiencing pre-eclampsia)
• Referring facilities not calling ahead to enable referral facilities to prepare for receiving
emergency cases
• Referring facilities not sending completed referral slips or client history
• Lack of (or delays in organising) ambulances, drivers, and/or fuel, especially at night
• Lack of a nurse or clinician to accompany clients in ambulance
• Emergency clients being dropped off alone at facility entrances.
Photo caption: Benchmarking visit to Kakamega, which included the County Chief Nurse and Deputy and
two Sub-County Public Health Nurses (SCPHNs). Photo credit: Caroline Lavu
Alongside problems with blood safety and supply, MPDSR review meetings identified the weak
referral system as one of the major contributors to facility-based maternal deaths. More than one
fifth of maternal death reviews in Bungoma County in 2016 recommended actions to tackle referral
system challenges1. To address the challenges with the referral system, the county-level MPDSR
committee took the following action:
• Four Ministry of Health officials, from the County Health Management Team and Sub-
County Health Management Teams, undertook a benchmarking visit to neighbouring
Kakamega County to observe their effective inter-facility referral system.
• A Bungoma County Referral Strategy and Investment Plan (2017)3 was drafted.
• A two-day training on the Referral Strategy and emergency preparedness took place, with
60 health care workers attending from 33 facilities, to raise awareness of the referral
6
process and protocols and improve communications between the referring facilities,
including private and faith-based facilities.
The County deputy nursing officer in-charge, who oversees the ambulance services in the county,
identified the ambulance drivers and the hospital administrators (who control the resources and
influence ambulance protocols) as key stakeholders in the referral process, and organised a one-day
workshop for 37 ambulance drivers and 22 hospital administrators to orientate them on emergency
preparedness and the need to prioritise funding for fuel for ambulances.
Sub-county MPDSR committees play a crucial role in enabling information to be passed from
facilities to the county level, ensuring the sub-county and county officials have a better
understanding of facility-level challenges and can take coordinated action. Linked committees also
enable feedback to be given, lessons to be shared, and create stronger inter-facility communication
and teamwork. The referral example illustrates the positive impact a linked MPDSR system,
operating at all levels, can have on reducing mortality. The county is proud of the progress made to
date in addressing the referral system challenges, but are aware that there are many referral
challenges identified by the MPDSR process still to be addressed, including ambulance
maintenance, functionality and coordination, and emergency preparedness.
This update was written by Sarah Barnett, Technical Specialist at Options and Peter Ken Kaimenyi,
Maternal and Newborn Health Technical Advisor at MANI Project funded by UK Aid.
To read more about MDSR in Kenya, click on the articles below from September 2017:
• Maternal Death Surveillance and Response: A Tall Order for Effectiveness in Resource-Poor
Settings
• Implementing Maternal Death Surveillance and Response in Kenya: Incremental Progress and
Lessons Learned
References
1 Barnett, S. & Kaimenyi, P. (2017). MDR dashboard, Bungoma County 2016. MANI project, Options
Consultancy Services Ltd.
2 Barnett, S. & Kaimenyi, P. (2017). PDR dashboard, Bungoma County 2016. MANI project, Options
Consultancy Services Ltd.
3 Ministry of Health [Kenya]. (2017). Bungoma county referral strategy and investment plan 2016/17-
2020/21. Nairobi: MoH.
Act | Country update
Bangladesh scales up MPDSR
To prevent mothers and babies from dying, Bangladesh has taken steps to scale up its maternal and
perinatal death surveillance and response (MPDSR) system nationally. The country first piloted
maternal and perinatal death review (MPDR) in 2010. By 2015, MPDR was rolled out to 12 districts.
In 2015, the estimated maternal mortality ratio was 176 per 100,000 live births and in 2016, the
estimated neonatal mortality rate was 20 per 1,000 live births. While Bangladesh has made
important gains, more needs to be done to achieve the Sustainable Development Goal 3 targets for
maternal and newborn mortality.
7
In 2016, the Ministry of Health and Family Welfare (MoH&FW) acted to roll out MPDR throughout
the country. In line with the World Health Organization (WHO) Maternal Death Surveillance and
Response (MDSR) Technical Guidance, the MPDR system was updated to ensure an increased focus
on surveillance and response.
Photo credit: Rebekah McKay-Smith/Options
Both the Health Economic Unit of the MoH&FW and the Bangladeshi government financially
supported this transition. To ensure integration and adoption across the health system, changes
were carried out in collaboration with: The Directorate General of Health Services and their
Management Information system, Directorate General of Family Planning, developmental partners
(for example, UNICEF, UNFPA, WHO), professional bodies (such as, the Obstetrical and
Gynaecological Society of Bangladesh), implementing partners (for example, non-governmental
organisations), public health experts and research organisations (such as, the Centre for Injury
Prevention and Research).
Twenty-two districts are currently implementing the new maternal and perinatal death surveillance
and response (MPDSR) system with UNICEF supporting 13 districts, UNFPA five and Save the
Children four. Scale-up activities took place at the policy and implementation levels to support the
expansion of the system, including:
• The adoption of national MPDSR guidance based on existing MPDR guidelines. New
national guidelines were approved by the MoH&FW in October 2016.
8
• The development of a national Training of Trainer’s (ToT) manual on MPDSR to use at
various levels (approved in December 2016 by the MoH&FW).
• The creation of a pocket handbook on MPDSR for on-the-ground health workers.
• The development of six additional tools, also approved in December 2016 by the MoH&FW:
The community death notification slip, the community maternal death review form, the
community neonatal death review form, the facility death notification slip, the facility-
based maternal death review form and the facility-based neonatal death review form.
• A cascade training approach comprising of a:
- National level three-day ToT for 78 health professionals from the 22 districts.
- Training of health and family planning staff on the ground, and volunteers, doctors
and nurses at the district and upazila (sub-district) levels across the 22 districts.
• The identification of MPDSR focal persons at the upazila, district and national levels.
• Establishment of MPDSR sub-committees in facilities at upazila and district levels. Facility
death findings will be periodically discussed in hospital-based MPDSR sub-committees and
necessary steps taken to improve facility services.
• The newly created national MPDSR committee will sit twice a year to discuss progress
towards achieving targets for maternal and neonatal mortality, and improvements in the
health system.
• Capacity development on the national level assignment of causes of death from community
maternal and neonatal verbal autopsy forms - based on the International Classification of
Diseases 10 (ICD-10) - were conducted for clinicians, including gynaecologists, obstetricians,
neonatologists and paediatricians, from seven tertiary medical college hospitals.
Photo caption: Workshop on “Sharing MPDSR Guidelines, Training Module and Strategic Implementation
Plan” for Universal Health Coverage, 2 October 2016. Photo credit: Dr Animesh Biswas
A key element of the revised system is to improve the quantity and quality of the collection of data.
To ensure the notification and reporting of every community- and facility-based maternal and
neonatal deaths and stillbirths, notification is now mandatory. The review of every maternal and
neonatal death will be conducted at the facility level and a verbal autopsy will be carried out for all
maternal and neonatal deaths at the community level. Moreover, for community sensitisation and
9
awareness building, social autopsies for maternal and neonatal deaths will be conducted in
communities.
Data is now viewable via a dashboard linked to the online management information system
database, the District Health Information Software (DHIS-2). In addition to being shared and
discussed at MDPSR sub-committee meetings, review findings will be fed into Quality
Improvement Committee (QIC) meetings at the upazila and district levels. The QICs will be tasked
with monitoring follow-up actions. Additional system improvements to support collection,
management and review of data included:
• Trainings to support health-care providers in community clinics to report community deaths
to the DHIS-2, the smallest health system unit covering approximately 6,000 persons.
• Trainings to upload causes of death from verbal autopsies to the DHIS-2 at the divisional
level.
• Meetings with MPDSR facility-level sub-committees to discuss findings from facility death
reviews to improve the quality of maternal and newborn care.
The DHIS-2 presents data on maternal and neonatal mortality by time period and geographic
location. Improvements in data availability, accessibility and quality are supporting improved
decision making by health managers, planners and policy makers at various levels of the health
system. Another notable achievement has been the integration of MPDSR into the fourth Health
Population Nutrition Sector Development Plan (2017-2021). The MoH&FW plans to achieve
countrywide scale up of the MPDSR system by 2021.
This country update was written by Dr Animesh Biswas, PhD, Senior Scientist and Associate Director,
Reproductive and Child Health Department at the Centre for Injury Prevention and Research (CIPRB) in
Dhaka, Bangladesh.
To read some publications by Dr Biswas, please click the titles below:
• Shifting paradigm of maternal and perinatal death review system in Bangladesh: A real time
approach to address sustainable developmental goal 3 by 2030
• Doctoral thesis: Maternal and neonatal death review system to improve maternal and
neonatal health care services in Bangladesh
• Maternal and Perinatal Death Review (MPDR): Experiences in Bangladesh
• Social Autopsy of maternal, neonatal deaths and stillbirths in rural Bangladesh: qualitative
exploration of its effect and community acceptance
• Exploration of social factors associated to maternal deaths due to haemorrhage and
convulsions: Analysis of 28 social autopsies in rural Bangladesh
10
Learn | Annotated Bibliography Legislation and policies that support MDSR
As we continue our research looking at how
laws and policies support maternal death
surveillance and response (MDSR), we follow
the release of two case studies - an in-depth
account in Jamaica and a synthesis comparing
legal and policy frameworks across five
countries with MDSR systems in South America
and the Caribbean - to end our three-part
series with an annotated bibliography of
relevant literature.
This annotated bibliography presents recent
literature discussing the importance of legal
and policy frameworks in relation to successful
implementation of MDSR and perinatal audit.
This resource intends to orient policy makers,
managers and practitioners, on relevant
publications, but is not an exhaustive review
on the topic. See endnotes for the search
strategy used, which included looking at
literature around maternal death reviews
(MDRs) and perinatal audits. We provide an
overview of the main findings relevant to the
implementation of MDSR and then present
key publications individually and in
chronological order. For these publications
that met the search criteria, we outline the aim
and methods, key findings and authors’
interpretations relevant to the topic of the
bibliography.
Highlights from the literature
The evidence suggests that legislation
mandating maternal death as a reportable
event is critical for supporting MDSR
implementation and has been linked to
improved reporting. This raises questions
about whether making perinatal deaths a
reportable event would have a similar impact.
Given that this would add a considerable strain
on health systems, an assessment of capacity
to implement and enforce such legislation
should be done before the introduction of any
such laws.
Key findings from the bibliography on how legislative and policy frameworks can support or hinder
effective implementation of MDSR and perinatal audit:
• There is a paucity of evidence on the effectiveness of legal and policy frameworks.
• Fear of blame and legal repercussions are key barriers to effective MDSR and perinatal audit.
• Whilst policy and training documents can emphasise “avoiding blame”, a lack of legal protection
in practice jeopardises sustainability of MDSR systems.
• Legal frameworks can mandate notification, support enforcement of reporting and ensure
confidentiality, guaranteeing information is not used for medico-legal or disciplinary purposes.
• Adequate legislation and supportive policy frameworks are key drivers of success, but alone are
not sufficient for effective implementation.
• Policy can promote a no-blame, no-shame culture, mandate professionals to participate, define
institutional responsibilities and ensure resource allocation.
• Political commitment and strong leadership that champion personal and institutional
accountability are essential components of successful implementation of MDSR and perinatal
audit.
• Integrating MDSR within an existing surveillance system supports effective implementation.
• Malpractice liability is a barrier to reporting on deaths.
• There is a lack of information on the on lessons learned about improving the response
component of MDSRs.
11
The evidence also points to the critical role of
legislative and policy frameworks in
supporting a “no-blame culture”, which is
essential for success. Legislation to ensure
inquiries are confidential and anonymous and
to safeguard health workers against litigation
could provide a solution. However, studies
reveal that, even in the presence of such
conducive frameworks, fear of repercussions
may persist among health workers and at the
community level, underscoring the
importance of leaders and champions at all
levels to foster an enabling environment.
The importance of broader legal and policy
frameworks surrounding the provision of
maternal and newborn health services is also
evident as well as potential tensions
originating from restrictive laws and policies
that have a bearing on the reporting of
maternal deaths and the opportunities for
open dialogue on theirs causes, for example in
settings were pregnancy termination is illegal.
Adopting a human-right based approach and
examining the broader legal and policy
framework can maximise the effectiveness of
MDSR implementation.
Peer-reviewed articles
1. Implementing maternal death surveillance
and response: a review of lessons from country
case studies, by Smith, H., Ameh, C., Roos, N.,
Mathai, M., Broek, N.V.D. (2017) in BMC
Pregnancy and Childbirth BMC series, 17(233).
The study aimed to identify the extent to
which countries implement the essential
components of MDSR and lessons learned for
improving implementation by examining ten
case studies including countries with
established systems and where MDSR had
recently been introduced. The authors use a
policy triangle framework to illustrate how
actors, context, processes and
implementation lessons in relation to
maternal death review policies interact to
create an enabling environment for MDSR.
The authors found that legislation and
supportive policy frameworks are key drivers
of success. Legal frameworks can mandate
notification, support enforcement of reporting
and ensure confidentiality, guaranteeing
information is not used for litigation.
However, the study notes little evidence on
What is MDSR?
MDSR is a continuous cycle of identifying,
reporting and investigating deaths, and using
the findings from the reviews of deaths to
identify what actions need to be taken to
prevent other deaths happening in similar
circumstances. Importantly, the cycle should
include ensuring recommendations are
responded to and tracking these responses.
Source: WHO, 2013
Why is MDSR important?
Most maternal and newborn deaths and the
majority of stillbirths are preventable.
Understanding the circumstances around each
death can help identify contributing factors,
and enable recommendations to be made and
actions to be taken to prevent future deaths
from similar reasons.
To do this, each death must to be counted
through surveillance systems and investigated
(reviewed) by clinicians with the help of family
or community members of the deceased.
MDSR and perinatal audit can provide the
essential information to stimulate and guide
actions to prevent future events and improve
the measurement of maternal and perinatal
mortality.
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the effectiveness of such frameworks and how
they are maintained.
Policy can promote a no-blame, no-shame
culture, mandate professionals to participate,
define institutional responsibilities and ensure
resource allocation. A key study limitation is
that case studies did not offer specific lessons
on how to improve the response component
of MDSR.
2.‘We identify, discuss, act and promise to
prevent similar deaths’: a qualitative study of
Ethiopia's Maternal Death Surveillance and
Response system, by Abebe, B., Busza, J.,
Hadush, A., Usmael, A., Belew Zeleke, A., Sita,
S., Hailu, S., Graham, W.J. (2017) in BMJ Global
Health, 2 (2) e000199.
Focusing on the first two years of MDSR
implementation in Ethiopia from 2013-15, this
study aimed to identify facilitators and
barriers to implementation and assess
outcomes through a qualitative policy
assessment with data collected via interviews.
The findings stress the importance of political
commitment and benefit of integrating MDSR
within an existing surveillance system.
The authors emphasise the importance of
maternal mortality being a reportable event.
They found however, widespread fear about
reporting deaths at the community level and
among health providers concerned about
potential legal repercussions or disciplinary
actions. While policy and training documents
emphasise “avoiding blame”, respondents
reported a lack of legal protection in practice
jeopardising the sustainability of the system.
3. Drivers of maternity care in high-income
countries: can health systems support
woman-centred care? By Shaw, D., Guise,
J.M., Shah, N., Gemzell-Danielsson, K.,
Joseph, K.S., Levy, B., Wong, F., Woodd, S.,
Main, E.K. (2016) in the Lancet, published
online.
This paper from the Lancet Maternal Health
Series presents the main delivery care models
in high-income countries (HICs), and examines
the main drivers of these models. Of relevance
to the topic of this bibliography, the study
underscores the role of confidential enquiries
into maternal deaths to improve care quality
and safety, and notes that most HICs lack
robust surveillance systems for ascertainment
of maternal deaths, and for accurate
identification of the underlying causes of
death and preventable cases. The authors
argue that a policy change should enable
institutionalisation of national- or sub-
national-level audits of maternal deaths,
which include the collation and dissemination
of results on social circumstances and clinical
contexts alongside recommendations for
prevention of future deaths. Furthermore, the
authors identify malpractice liability as a
barrier to optimal care in several high-income
settings, and provide examples of state
support provision and insurance regulatory
frameworks to minimise such a barrier.
4. Counting every stillbirth and neonatal death
through mortality audit to improve quality of
care for every pregnant woman and her baby,
by Kerber, K. J., Mathai, M., Lewis, G.,
Flenady, V., Erwich, J. J. H. M., Segun, T.,
Aliganyira, P., Abdelmegeid, A., Allanson, E.,
Roos, N., Rhoda, N., Lawn, J. E., Pattinson, R.
(2015) in BMC Pregnancy and Childbirth BMC
series, 15(Suppl 2):S9.
This study investigates progress
institutionalising facility-based maternal and
perinatal death audits, synthesises the main
challenges using the World Health
13
Organization (WHO) health system building
blocks, and proposes solutions for scaling up
audits for stillbirths and neonatal deaths.
Methods include a review of literature on
facility-based perinatal and maternal
mortality audits with a focus on high-burden
countries.
Seventeen countries out of 71 were identified
with policies providing a national mandate for
perinatal death reviews and only51 for
maternal deaths. Key challenges were found
in the leadership domain. The authors identify
that a policy framework is a necessary
condition to commence implementation but
policy alone is not sufficient for effective
implementation. Fear of blame and legal
repercussions are cited as key barriers, which
can be potentially overcome by the
development of an ethos of safety through a
supportive, non-punitive policy and legal
environment at national level, and having
leaders champion personal and institutional
accountability.
5. The cultural environment behind successful
maternal death and morbidity reviews, by
Lewis, G. (2014) in BJOG: An International
Journal of Obstetrics & Gynaecology, 121
(Suppl. 4): 24–31.
This expert piece, based on experience of
instituting reviews of maternal deaths and
near misses worldwide, suggests that a
positive and enabling environment for
successful maternal death reviews results
from: A culture of individual responsibility, a
proactive institutional ethos, and a supportive
political and policy environment at national
and/or local level. The authors outline that
providing legal protection for those
participating in maternal death reviews can
remove fear of participation. In contrast,
linking maternal death notification with police
reporting has led to the stalling of the process
in a few countries. The article also notes that a
requirement for anonymising reviews can
ensure that any cases of malpractice continue
to be dealt with using existing legal
procedures.
6. The confidential enquiry into maternal
deaths in South Africa: a case study, by
Moodley, J., Pattinson, R.C., Fawcus, S.,
Schoon, M.G., Moran, N., Shweni, P.M. (2014)
in BJOG: An International Journal of Obstetrics
& Gynaecology, 121 (Suppl. 4): 53–60.
This article presents the process, findings and
impact of the Confidential Enquiry into
Maternal Deaths (CEMD) in South Africa
which has been operational since 1998. The
article places the CEMD process in the context
of enabling legislation specifically mandatory
notification of maternal death but also, more
broadly, legislation granting free health care
to pregnant women and children, and
enabling elective pregnancy terminations. It
also provides a rare example in the literature
of how the principles of confidentiality and
anonymity are applied in the CEMD system in
practice so that findings from the CEMD
process cannot be used for medico-legal or
disciplinary purposes. It further points to the
fact that medico-legal processes do continue
to occur, protecting patients from clinical
malpractice, but they are separate and parallel
processes, which has been ratified by relevant
judicial bodies.
7. Easier said than done!: methodological
challenges with conducting maternal death
review research in Malawi, by Thorsen, V. C.,
14
Sundby, J., Meguid, T., Malata, A. (2014) in
BMC Medical Research Methodology, 14:29.
This article describes the methodological
challenges experienced when conducting
maternal death review research. It draws
observations from a study using facility-based
maternal death review to assess cause of
death. Study methods include review of case
audits and participant interviews. Fear of
blame and potential repercussions are cited as
barriers affecting the completeness and
accuracy of data recorded. To ensure
participation in reviews, the authors needed to
reassure participants that their contributions
would not be used for litigation. The study
underscores the importance of ensuring
anonymity and confidentiality during reviews
and demonstrates the complexity involved in
conducting facility-based audits.
Reports: Global and regional
1. Time to respond: a report on the global
implementation of maternal death
surveillance and response (MDSR), WHO,
2016.
This report presents the findings of a global
survey conducted by the WHO and UNFPA to
determine the status of MDSR
implementation in countries where there is a
national system, and provides overall
implementation insights and case studies.
Individual MDSR country profiles are available
in the report with information about national
policies for maternal death notification and
review.
In relation to policy frameworks, the report
suggests a gap between policy and practice.
Most participating countries (86%) reported
having a national policy to notify and review all
maternal deaths, but only 46% reported that a
National Maternal Death Review Committee
meets biannually (twice a year). In relation to
legal frameworks, the study identified little in
the literature that considers MDSR from a
legal perspective, suggesting more research is
required. It also suggests that the legal
environment within which MDSR is
implemented, such as country laws for the
rights of women and by extension for their
reproductive rights, can either assist or hinder
the effectiveness of MDSR as a tool for
reducing maternal mortality. For example, the
existence of an efficiently run MDSR system
cannot fully mitigate the risks to girls who
marry and conceive at a young age, or to
women who seek to terminate a pregnancy in
a country where abortion is illegal. Conversely,
taking a human-rights-based approach to
health, making maternal death a notifiable
event in law and supporting this legislation
with policies for maternal death review,
analysis and follow-up action, creates the
preconditions necessary for successful
implementation of MDSR.
2. Making every baby count: audit and review of
stillbirths and neonatal deaths, WHO, 2016
This guide discusses the role of perinatal
mortality audit as a quality improvement
strategy. It makes the case for introducing a
system to capture the number and causes of
all stillbirths and neonatal deaths, and
reviewing a selection of individual cases for
more in-depth, systematic and critical analysis
of the quality of care received, and provides
detailed guidance for it. It notes that in many
settings established MDSR systems may
present an opportunity to integrate perinatal
audits effectively and efficiently, however this
is not a precondition. It refers to how the law
can contribute to the creation of an enabling
15
environment, particularly when this ensures
protection of staff and patients throughout
the process. The report recognises that in
settings with high malpractice litigation, the
fear of law suits can hamper data collection
and the use of findings from death audits and
thus the importance of separate processes for
handling legal misconduct to mitigate this is
noted. It also provides a sample code of
conduct to be adhered to by all stakeholders,
and discusses policy and ethical issues in
relation to access to information and use of
results.
3. Guidelines for Maternal Death Surveillance
and Response (MDSR): Region of the
Americas, Regional Task Force for Maternal
Mortality Reduction, 2015
This guide contextualises WHO MDSR
guidelines in the Latin American and
Caribbean context, includes a situation
assessment of the maternal mortality context,
detailed guidance on each MDSR component,
and analysis and recommendations on context
specific barriers and solutions for optimal
implementation. The report stresses the
importance of an enabling legal and policy
framework in relation to mandatory reporting
of maternal deaths, anonymisation of data,
and sharing information on suspected
maternal deaths across sectors. It also
recommends integrating MDSR into sexual
and reproductive health, and general health
policy.
The guidelines are accompanied by five case
studies on MDSR implementation in Jamaica,
Mexico, Brazil, Colombia and El Salvador.
Making maternal deaths notifiable by law,
enshrining in law rights to quality care,
particularly for women, and adopting a policy
framework that clearly identifies institutional
responsibilities were reported as enabling
factors for successful implementation. More
detail on case study country experiences can
be found in this synthesis. The case studies
from Jamaica and Brazil offer particularly
valuable detail on conducive legal
frameworks.
4. Maternal death surveillance and response:
technical guidance, WHO, 2013
WHO technical guidance on MDSR introduces
the concept of MDSR as a continuous action
cycle building on established maternal death
review systems. It represents a pivotal
resource with detailed guidance to implement
each surveillance component. In relation to
legal frameworks, it stresses that
identification and development of regulations
and legal protections are crucial pre-requisites
to implementation. Notification of a maternal
death should be mandatory. A ministerial
decree is usually needed to establish the
MDSR system. Developing a policy or a code
of conduct and standards for conducting
maternal death reviews, and orienting all
stakeholders on these is essential to create a
collaborative rather than blame environment.
A legal framework on confidentiality and
medical liability should be in place to prevent
the use of review findings in litigation, thus
aiding the development and dissemination of
findings and recommendations.
It also highlights that other legal provisions
may have a bearing on MDSR implementation
and should be assessed and considered at the
start. For example, reviewing patient health
records, speaking with family members or
friends, and interviewing health-care workers
may require the adoption of regulations.
Furthermore, dissemination of findings may
be affected by legal frameworks surrounding
pregnancy terminations.
5. Study on the implementation of maternal
death review in five countries in the South-
East Asia region of the World Health
Organization, WHO, 2014
This report presents the findings of a study on
the implementation of maternal death
reviews in five countries in South-East Asia,
namely India, Indonesia, Myanmar, Nepal, and
Sri Lanka, including individual country reports
16
and a regional overview. The studies all used
largely qualitative methods. Of relevant to the
bibliography topic, the report discusses
government policies and directives which
provide clear institutional and managerial
arrangements in each country. It also
identifies fear of possible punitive action
among the critical challenges for the conduct
of maternal death reviews in the region.
Recommendations include improved
communication to promote a no-blame
culture in implementation.
Endnotes: Search strategy and criteria
The search strategy was not intended to be
systematic or exhaustive, but to identify key
recent publications on the issue of legal and
policy frameworks for MDSR.
The Open University database, subscribed to
over 150,000 journals including the British
Medical Journal, BioMed Central and the
Lancet, was searched for published literature,
using the search terms “MDSR”, “MDR”,
“maternal death review”, “maternal death
surveillance” and “perinatal death
surveillance”.
References of relevant articles were hand-
searched and key stakeholder websites,
including WHO and UNFPA, were searched to
identify additional publications. Inclusion
criteria: Research studies, editorials and
reports; English only; published in the last 15
years; specifically discussing legislation and
policy frameworks in relation to MDSR
implementation. The search was not
restricted to specific settings.
Suggested citation
MDSR Action Network. (2018). Annotated
bibliography: Legislation and policies that
support MDSR. London: Evidence for Action.
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