Synthesis of case studies from Brazil, Mexico, Jamaica, El Salvador and Colombia
According to the World Health Organisation (WHO),
“Taking a human-rights based approach to health, making maternal death a notifiable event in law, and supporting this with policies for maternal death review, analysis and follow-up action, creates the preconditions necessary for successful implementation [of maternal death surveillance and response (MDSR)]”1 (p.31).
While death review systems may draw from international guidance and be standardised to an extent across countries, legal regulations can vary and can support or hinder access to information, the conduct of an audit and the response to findings2. Fear of litigation, can prevent the objective review of maternal deaths3, so having legal protection in place and ensuring an anonymous environment can encourage the sharing of information and involvement of health care workers in the MDSR system3. Similar principles can also support the investigation of stillbirths and neonatal deaths 2.
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This report explores the legal and policy frameworks that support implementation of MDSR in Jamaica, Mexico, Brazil, Colombia and El Salvador. It presents a synthesis of findings from five case studies about MDSR released by the Regional Task Force for Maternal Mortality Reduction (GTR, acronym in Spanish) in 2015 that accompany the publication of the revised Guidelines for Maternal Death Surveillance and Response in the Americas 4 and share lessons learned.
The case studies offer a rich picture of the maternal morbidity and mortality landscape and the structure of MDSR systems in each country. In this synthesis, we focus on reviewing the legal and policy features that support the investigation of and response to maternal mortality.
The surveillance of maternal mortality
The surveillance or identification and notification of maternal deaths are established in legal and/or policy frameworks across the five countries, and identify mandatory reporting as an enabling factor for MDSR implementation.
In Jamaica, maternal mortality became a Class 1 notifiable event in 1998, and was integrated into the communicable disease surveillance system established under the 1985 Public Health Act (revised in 2004). The definition of maternal death has undergone progressive review (the latest being in 2012) to enable an active surveillance system to capture early and late maternal deaths5,6.
Reporting and notification of maternal deaths is mandatory under the routine epidemiological surveillance process in Colombia7, in El Salvador it became compulsory in 2000 under the Standards for the Registration of Vital Events – Chapter II and in Mexico, it is established under the General Health Law.
In Brazil MDSR is reported to be “a solid legal framework” (p.31) 10 and a detailed list of legal texts related to MDSR is available spanning the civil registration system and mortality surveillance (p.15) 10. In this setting, the mandatory reporting of maternal mortality enabled an increase in maternal death investigations.
Maternal mortality in policy
Technical guidelines complement legal requirements for mandatory notification and reporting of maternal deaths and support MDSR implementation by detailing institutional responsibilities for active surveillance, investigation and response to maternal deaths at various levels of the health system. In each of the five countries, policy framework for MDSRs mirror international guidelines3-4, and some have elaborated policy beyond existing technical international guidance.
El Salvador, for example, expanded the system to include maternal and infant mortality in their technical guidance in 2009. In Mexico, an active search of maternal deaths to address under-registration of maternal deaths was introduced in 20129. The guidelines describe how every death of women of child-bearing age is considered a suspected maternal death, and investigated at the jurisdictional (micro-regional) level to actively exclude factors related to pregnancy or its termination.
The MSDR guidelines in Brazil are unique in their emphasis on broader policies in the health and social sectors in relation to MDSR. The Brazilian Guidelines for the Epidemiologic Surveillance of Maternal Deaths refer to the whole continuum of care for the investigation and analysis of factors contributing to maternal deaths, for example access to family planning, antenatal care. They propose the application of criteria to determine if a death is preventable, including socio-economic factors, such as sanitation and living conditions, in addition to therapeutic measures. The Guidelines further suggest that actions beyond health care should be included in action plans to prevent similar deaths in the future. For example, in response to a maternal death case occurring in an urban dwelling of illegal occupancy where the deceased mother was found to lack basic health assistance, a family health unit was assigned to the area10.
WHO suggests that confidentiality is critical for MDSR success: having legal and regulatory protections in place can help ensure a safe and inclusive environment to investigate the death of a mother and her baby1. Ensuring confidentiality is described as a key feature of the regulatory framework in Colombia and Jamaica. In Brazil10 and Mexico9, the importance of confidentiality is mentioned in relation to the tools and processes for the investigation of maternal deaths, which occur at the local level.
In Colombia, ensuring a confidential environment is a “basic tenet of the surveillance system” (p.35)7. Operating in a “mostly anonymous and secure” (p.35)7 environment is essential for health professionals and communities to frankly disclose facts related to the circumstances of a maternal death, and promote dialogue and learning. Their rights of health are further protected in Colombia where it is stated that “the review [of a maternal death] will not be used to initiate lawsuits or administrative punishments, nor to seek guilty parties” (p.35)7.
In Jamaica, death cases are reviewed as confidential enquiries where the names of the attending physicians are removed from the case-investigations and documentation process5. MDSR experts in Jamaica report that since maternal mortality was classified as a notifiable event, “MDSR records have never been used for litigation against a health worker or facility”5.
In Jamaica, amending the existing Class I disease surveillance system to include maternal mortality enabled the surveillance of maternal deaths without having to develop separate legislation, which can be a lengthy process5.
Immediate notification of maternal deaths within 24 hours is reported among the best practices of the MDSR system in Mexico, enabled by the presence of “obligatory regulatory documents” (p.31) 9.
In Colombia and El Salvador, important improvements in coverage and completeness have been achieved, resulting in the correct identification of a growing number of maternal deaths7-8. The case study of Brazil also reports a strong and credible surveillance and investigation system, noting that WHO uses data from Brazil’s Mortality Information System “without applying any correction factor” (p.18) 10.
In Jamaica, the confidentiality of the MDSR system was seen a major success, promoting learning and action in response to deaths. Similarly, in Brazil, the importance of open dissemination of reports to communities and health professionals – underpinned by a confidential enquiry system – is regarded as important for the social control of the health system. The case study mentions further best practices such as the creation of forums to debate quality of maternal health care, which includes members of the medical and nursing councils, the public prosecutor office, non-governmental organisations, and health professionals10.
Challenges and lessons learned
Weak institutional linkages and coordination across sectors are a key challenge. In Jamaica, agreements are being put in place to share data between the Ministry of Health and the Ministry of Justice to address the difficulties in the routine reporting of maternal deaths that have become medico-legal cases5-6. Colombia experienced similar challenges in coordinating with forensic medicine and other social sectors, thus hindering responses to maternal death review findings that focus on social determinants7.
In Mexico and El Salvador, limited institutional accountability mechanisms are a challenge for the operationalisation of MDSR policy guidelines8-9.
In Brazil, resistance to a critical analysis of health care persists, despite the Guidelines’ emphasis on non-punitive action, confidentiality and open discussion10. Defensive attitudes are also reported as a challenge in El Salvador8.
1 World Health Organization. (2016). Time to respond: a report on the global implementation of maternal death surveillance and response. Geneva: WHO.
2 World Health Organization (WHO). (2016). Making every baby count: audit and review of stillbirths and neonatal deaths. Geneva: WHO
3 World Health Organization. (2013). Maternal death surveillance and response: technical guidance. Information for action to prevent maternal death. Geneva: WHO.
4 GTR, UNFPA, Pan American Health Organization, WHO, USAID and Family Care International. (2015). Guidelines for Maternal Death Surveillance and Response (MDSR): Region of the Americas. Panama City: UNFPA.
5 McCaw-Binns, A. & Spence, S. (2017). How legal and policy frameworks support MDSR in Jamaica.
6 Grupo de Trabajo Regional para la Reducción de la Mortalidad Materna (GTR). (n.d.). Epidemiological Surveillance of Maternal Mortality (1982-2012): Country: Jamaica.*
7 GTR. (n.d.). Case study on maternal death surveillance and response: Country: Colombia.*
8 GTR. (2014). Case Study on Maternal Death Surveillance and Response: Country: El Salvador.*
9 GTR. (2014). Case Study on Maternal Death Surveillance and Response: Country: Mexico.*
10 GTR. (2014). Case Study on Maternal Death Surveillance and Response: Country: Brazil. *
* Items 6-10 retrieved in January 2017 from URL: http://www.familycareintl.org/en/resources/publications/123