Case studies

Learning from Ireland: establishing a confidential maternal death enquiry in a low maternal mortality context

Ireland has recorded a low maternal death rate for several years now, but it was still important for the country to introduce confidential maternal death enquiry.

Edel Manning – the MDE Ireland Co-ordinator, tells us why and how they recently introduced confidential enquiries. Edel outlines the inspiration, the challenges and the results that this new system achieved for Ireland’s mothers.

In recent decades, Ireland has been credited with a low maternal death rate: 4 per 100,000 live births. This was based on data derived from the Irish civil death registration system. However, in acknowledging national and international evidence, it was considered that in the absence of active case ascertainment, under-reporting and misclassification of maternal deaths occur, even in countries with advanced civil registration systems.

The aim of establishing a confidential enquiry into maternal deaths in Ireland was not just to ascertain numbers, but principally to promote safer pregnancy by learning how such tragedies could be avoided in the future. This could make a major contribution to informing and improving standards of care in maternity services.

Establishing MDE Ireland had many challenges. First, engaging and establishing support at governance level with stakeholders in the Irish maternity service including: the national health authority, maternity service providers, multidisciplinary health professionals and academics proved more protracted than expected.

This process was driven by a dedicated Maternal Mortality in Ireland Working Group, a joint Institute of Obstetricians and Gynaecologists in Ireland/Health Service Executive initiative which helped to garner the required support. Inviting multidisciplinary representatives from relevant stakeholders to join the Working Group, in the development stage, was considered key to establishing commitment for the project.  Although support for the ethos of the project was widely considered as laudable, issues of concern related to data protection, potential adverse litigation and anticipated review of cases by agencies out with MDE Ireland.

Jeyheich, Flickr (Creative Commons license)

Jeyheich, Flickr (Creative Commons license)

The confidential Maternal Death Enquiry (MDE) Ireland was officially established in 2009, with the stated objective of linking with the UK Confidential Enquiry into Maternal Deaths (CEMD). Given the relatively small number of maternities in Ireland (70,709 in 2012) there was much to be gained from pooling Irish data with data from the UK.  Joining a larger cohort of maternal death case reviews would help to preserve confidentiality and allow for more meaningful analysis and recommendations.  The UK, our nearest neighbour, has a similar maternity service and a respected and validated methodology in the 60 year old CEMD, which could easily be adapted to the Irish context.

The UK CEMD is part of the national Maternal, Newborn and Infant Clinical Outcomes Review Programme, which was previously conducted by the Centre for Maternal and Child Enquiries (CMACE), and was transferred to Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries (MBRRACE-UK) in 2012. MBRRACE-UK has revised and streamlined the process of data collection and analysis on maternal deaths, which will result in reports being published annually.

The first MBRRACE-UK report including data on maternal deaths occurring in Ireland was published in December 2015: ‘Saving Lives, Improving Mother’s Care: Lessons learned to inform future maternity care from the UK and Ireland Confidential Enquiries into Maternal Death and Morbidity 2009 – 2012’ 1.  Surveillance data on maternal deaths occurring in Ireland is not included in the MBRRACE-UK report.  Irish maternal mortality rates (MMR) are published independently in annual data briefs and in more detailed triennial MDE Ireland reports (available on the MDE Ireland website).

Since the inception of MDE Ireland in 2009, there have been many challenges in implementing the enquiry process nationally. It was clear to us that confidence and ‘buy-in’ for the confidential enquiry process was paramount at service level as it was a ‘top down’ approach.  We attempted to build this by:

  • Raising awareness and support for the MDE through presentations at the service level, articles in multidisciplinary journals and a national workshop;
  • Establishing a national reporting network to the MDE at service level and collaboration with coroners.
  • Promoting awareness that the MDE process is independent of clinical incident reporting and local review of serious adverse incidents;
  • Alleviating concerns regarding potential litigation.  Confidentiality is assured through a process of anonymisation of data submitted prior to multidisciplinary assessment of cases. There is no disclosure of information to any outside agency.

Similar to experience in the UK and other European countries, a key learning point was that a proactive approach to case ascertainment identified maternal deaths that were not captured by the civil death registration system.  However, achieving this has been labour intensive and, despite support letters from governing bodies, was challenging.  Participation in the Enquiry is policy but not statutory for publicly funded health care providers.  Further, the dedicated time of a national co-ordinator and the support and guidance of the Maternal Mortality in Ireland Working Group has been essential to implementing the enquiry process in Ireland.

A fundamental component of the UK CEMD process is dissemination of recommendations from enquiry reports.  Since its inception, MDE Ireland has promoted this element of the audit cycle through a series of organised educational events.

MDE Ireland’s most recent report was published in February 20152.  To improve the power of analysis and to facilitate direct comparisons with the UK, Irish MMR is presented over a rolling three year period.  Although the overall MMR identified by MDE Ireland (outlined in Table 1), compares favourably with the UK (MMR = 10.1 per 100,000 maternities for the years 2010-2012) and other developed countries, it is important to avoid complacency.  The ongoing enquiry process and collaboration with the UK CEMD will provide learning points for health professionals in advancing quality and safety within the Irish maternity services. As in the UK, our findings were that maternal deaths in Ireland during the years 2010-2012 were predominately due to indirect causes (70%) with the remainder (30%) due to direct obstetric causes.

The increasing number of pregnant women presenting in Ireland with co-morbidities has highlighted the ongoing need for appropriate assessment of women at the booking visit to a maternity unit, allocation of appropriate pathways of care and pre-conception counselling. Also, the disproportionately high representation of ethnic minorities in this cohort challenges us to address health seeking behaviours of immigrant pregnant women in a country which provides free maternity services for all pregnant women.

Table 1: Direct and Indirect Maternal Mortality rates per 100,000 maternities in Ireland: rolling three year average 2009 – 2012

Ireland_maternal death rates_tablesNB: The apparent increase in the MMR 2010 – 2012 is not statistically significant.


This case study was written by Edel Manning – a trained midwife and currently the MDE Ireland Co-ordinator who is responsible for the co-ordination of the maternal death enquiry process and dissemination of MDE recommendations. This is an updated version of a case study originally published in our May 2014 issue of the MDSR Action Network newsletter.

For further information on MDE Ireland please visit their website –


  1. Knight M, Kenyon S, Brocklehurst P, Neilson J, Shakespeare J, Kurinczuk JJ (Eds.) on behalf of MBRRACE-UK. Saving Lives, Improving Mothers’ Care – Lessons learned to inform future maternity care from the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2009–12. Oxford: National Perinatal Epidemiology Unit, University of Oxford 2014. Available at:
  2. O’Hare MF, Manning E, Greene RA on behalf of MDE Ireland. Confidential Maternal Death Enquiry in Ireland, Report for 2009 – 2012. Cork: National Perinatal Epidemiology Centre, February 2015. Available at:

Ethiopia puts ‘R’ in MDSR

In May 2013, the Federal Ministry of Health launched Ethiopia’s MDSR system. By the end of 2014, the system had been introduced in 17 zones and has been integrated into the existing surveillance system. This case study presents the findings of a preliminary audit of responses to maternal death.  The “response” arm of MDSR is recognized to be the most challenging part of MDSR with few centres managing to respond in an organised constructive manner to maternal death.

A preliminary audit of responses to maternal death from health facilities at different levels of the health system demonstrated an average of 3 responses to each maternal death.

The audit captured 211 responses to 71 maternal deaths at 33 health facilities/ communities. Of the 211 responses 39% were aimed at improving care within the hospital or health centre demonstrating a constructive approach to the MDSR process. In other words, health facility staff did not simply pass blame to the community or referring health facility for the woman’s death and say “she came too late”.

Actions improved feedback and training to staff, improving services available at the health facility, improving access to essential drugs and equipment and redistribution of staff to improve effectiveness. A further 35% of responses targeted community awareness of the need to access health care in pregnancy. This was done through a variety of methods including regular women’s groups, community meetings and pregnant women’s conference.

MDSR information is a powerful tool of communication between health professionals and communities. Fifteen per cent of actions involved communication with referring health facilities thereby strengthening referral pathways, whilst the remaining 10% targeted the regional or zonal offices to improve transport systems and obtain essential drugs.

It is noted that the majority of the responses taken were not expensive in terms of cash but contributed to staff professional development and raising community awareness of maternal health issues.

To read more, take a look at Ethiopia’s MDSR Newsletter here and a case study in the World Health Organization’s global MDSR report here.


Case study written by Evidence for Action in Ethiopia.

Photo credit: UNICEF Ethiopia/2010/Tuschman

Using mobile technology to support vital registration and verbal autopsy in the community: Bonsaaso Millennium Villages Project, Ghana

Prior to the inception of the Ghana Bonsaaso Millennium Villages Project in 2006,  maternal mortality was as high as 345 deaths per 100,000 live births, child mortality was 110 deaths per 1000 live births, and the institutional delivery rate was as low as 32%. The challenge of accessing healthcare was identified as the main cause of poor health indicators in the area at that time.

The Millennium Villages Project (MVP) in Ghana initiated vital registration and verbal autopsy (VRVA) in 2008 to support the improvement of maternal and child health services, and, in turn, to reduce infant, child and maternal deaths. Vital registration ensured that all community members were properly identified and included in the denominator of measures being tracked by MVP. In 2011, verbal autopsy was strengthened to ensure that any death in the village was recorded and analysed for medical and social causes so that future deaths could be prevented.

The vital registration and verbal autopsy system

At the community level, community health workers (CHWs) registered household members within their community, making sure to include pregnant women and children under five. They also collected data on the following vital statistics: birth registration (indicating date and place of birth), pregnancy outcomes, and all deaths.

Prior to 2008, a paper-based system was used to collect this data. Multiple challenges were experienced from the paper-based system, including a large volume of information being gathered making it difficult to manage and data analysis very time-consuming.

In late 2009, mobile communications were established throughout the area and, in 2010, the mobile-phone based system called ChildCount+ (CC+) was introduced by the project to address the problems of the paper-based system. The open-source system, CC+, enabled CHWs to send data via SMS text messages to a central server, collecting data in real-time. This system was later migrated to a smartphone-based system called CommCare for general home visits.

A verbal autopsy specialist assists CHWs in conducting in-depth verbal investigations into the causes of each death in the community.  This investigation gathers information from the household and the health facilities of the catchment area where the death occurred to understand the circumstances behind the death.

This more extensive data collection by the verbal autopsy specialists required the use of a complementary electronic system known as Open Data Kit (ODK), where verbal autopsy data is inputted into smartphones using mobile forms.  Specialists visit homes, record the data on the phones and later return to an area with good coverage to send data to a central electronic medical record system – OpenMRS. The OpenMRS system then automatically uses this verbal autopsy data to generate reports on the social and medical causes of each death, which were reported back to local and remote teams. The mobile phone-based system integrated with Open MRS was also eventually migrated to run on the CommCare system in 2014.

How the data is used

The data is discussed during weekly MVP health team meetings comprising selected senior doctors, nurses and heads of public health programmes in the district. During these weekly meetings, vital statistics and verbal autopsy data is reviewed and analysed in order to identify solutions to the circumstances that led to the death and/or morbidity, and to prevent future occurrences.

On a monthly basis, a meeting with a larger stakeholder group takes place where issues on all deaths and morbidity trends are discussed. During these larger stakeholder meetings the verbal autopsy specialist presents on all cases of deaths that have been investigated. Participants of this monthly meeting comprise the MVP health team and multiple representatives from where the death occurred, including from the district referral hospital, from local facilities, from communities, and CHWs.  The meeting discusses the issues presented, finds solutions, and sets timelines for their implementation.

Examples of solutions implemented as a result of the verbal autopsy data include community health information sharing sessions and staff in-service training. These would be based on recommendations from the larger, monthly stakeholder meeting.


The transition towards using these electronic data collection systems saw a greater volume of data reporting (see tables 1 and 2), which was in real-time and more accurate. This data collection has become an important monitoring and managerial tool, providing vital information in real-time, so that resources and staff performance gaps can be quickly identified and action taken immediately.  The programme has seen improvements in health staff performance, logistics provision and management. This implies that an effective data collection system provides the edge to improve performance for better results.

Table 1 and table 2Challenges and lessons learned

MVP has been successful in using effective data systems to improve performance and health outcomes. However, this was not achieved without challenges. Key challenges and lessons learned include:

  • Although the paper-based system cost less compared to the CommCare system, it was not cost-effective due to the limitations faced in using it:  time consuming to collect, numerous errors, risk of data loss, large costs for data entry, and lack of real-time data collection limiting rapid decision-making. Key costs to consider for the CommCare system include the smartphone and data bundle.
  • While the CC+ mobile phone-based system introduced in 2010 reduced data bulkiness, there were a number of challenges in using it, including CHWs having to type a lot of information into basic-feature phones, which led to significant errors, and CC+ requiring mobile service at the point of sending SMS text messages. Transferring to the CommCare system using smart phones in 2012 helped to address these problems. CommCare enabled CHWs to enter data on the smart phone anytime, anywhere with or without a mobile network service since data can be synchronized as soon as the CHW enters a network zone.  Also, CommCare can be designed to limit the amount of typing, and therefore reducing errors, by using drop down selection boxes and multiple choice selection options.
  • Training on using the technology takes time. It takes about three days to train someone in the technology and one to two months to become skilful in using it. Allocating time for this is important.
  • There will always be the challenge of the equipment, namely the phones getting lost, broken, or faulty. To address this challenge, the programme provides supervisors with back-up phones ready to be used until a permanent replacement is found.
  • We have not experienced families being concerned about using the mobile phones to collect the verbal autopsy data. Nevertheless, it is important to be culturally sensitive on when you conduct the interview (e.g. in our case, conduct the interview one week after the death) and explain to the family how the data is to be collected before the interview and that it will not be used for any wrong motive.

Future plans and the way forward

The success of the system has meant that the Ministry of Health and the Ghana Health Service have expressed interest in scaling up. MVP is currently working with the Ghana Government to look for both domestic and foreign support to scale-up the interventions.


This case study was written by Eric Akosah and Seth Ohemeng Dapaah from Millennium Villages Project, Bonsaaso-Ghana and reviewed by Dr Andrew S. Kanter, Columbia University.

Further information

Read more about this mHealth solution in the article ‘Combining vital events registration, verbal autopsy and electronic medical records in rural Ghana for improved health services delivery’ published by Studies in health technology and informatics and written by contributors to this case study and their colleagues – S., Ohemeng-Dapaah,  P., Pronyk, Akosa, E., Nemser, B., & Kanter, A.

Photo Credit: Danielle Goldman

Using eHealth to support MPDR: Early experiences from Bangladesh

This case study presents some of the early experiences of the Maternal and Perinatal Death Review programme in incorporating maternal and neonatal death notification data into the District Health Information System (DHIS2). We hope to provide more insights as the programme progresses

Over the past five years, the Ministry of Health and Family Welfare in Bangladesh has set as its priority the introduction of a web-based Health Management Information System (HMIS). In 2009, the HMIS was first transferred online under the coordination of the Directorate General of Health Services (DGHS). The web-based HMIS is seen as an opportunity to provide easy public access to data on key health indicators, including registration of pregnant women and coverage of antenatal and postnatal care.

In October 2013, the DGHS incorporated the web-based data collection software – District Health Information System (DHIS2) – into the HMIS.  This software is an open source tool which enables users to collect, validate, analyse and present aggregated data related to HMIS activities[1]. DHIS2 enabled routine data to be inputted directly into the HMIS at the district level from the government health facilities, rather than at the national level from paper- based reporting sent through email.  As such, this functionality provided the scope for each maternal and neonatal death captured from each district to be inputted directly into the central HMIS system.

In light of this functionality, in October 2014, the Maternal and Perinatal Death Review (MPDR) programme undertook a pilot of incorporating maternal and neonatal death notification data into the DHIS2 in Netrokona district with support from UNICEF and the Centre for Injury Prevention and Research, Bangladesh (CIPRB). Before this pilot, death notification was inputted into the  HMIS  on a monthly basis from the district. This made it difficult to review progress from the national level.

The pilot began in Purbadhala Upazila[2] in Netrokona District with maternal death data being entered each month into DHIS2 by sub-district statisticians from the Upazila Health Complex (Primary Health Care Centre). The statistician  received notification of the deaths from field level health workers (e.g. Community Health Care Providers (CHCP)). The deaths were uploaded for each community clinic catchment area.


  • The pilot set an example of how to incorporate MPDR into the existing HMIS system using the web-based DHIS2 system. Following the pilot, maternal and neonatal death data from the MPDR programme were uploaded into DHIS2 from three hard-to-reach districts of Bangladesh (Bandarban, Cox’s Bazar and Netrokona).
  • The death registration data inputted into DHIS2 enabled, for the first time, district level maternal mortality ratios and neonatal mortality rates to be generated.
  • Inputting maternal deaths into DHIS2 acted as a monitoring tool of the HMIS system. For example, the fact that not all maternal deaths reported into DHIS2 showed up as registered as pregnant demonstrated that not all pregnant women were being recorded in HMIS and that not all maternal care was being provided to women who needed it.

Key challenges and lessons learned:

The pilot has demonstrated that online notification of maternal and neonatal deaths is possible at the Upazila level. Nevertheless, there were challenges in implementing the pilot. For example, a lack of trained health care providers to enter data into the HMIS and DHIS2, and poor internet connection and limited electricity at hard to reach community clinics, which meant that deaths could not be inputted into the DHIS2 system by CHCPs.

These challenges were addressed by ensuring the training of CHCPs in MPDR and data entry, and having statisticians enter the deaths into the system at the Upazila Health Complex, rather than by the CHCPs at the community clinics. Moreover, having the statisticians enter the data into the system meant that any death that occurred outside the coverage area of the community clinic, which the CHCPs are responsible for, would still be entered into the system.

Way forward:

In light of the feasibility of the pilot, it is expected that by the end of 2015, DHIS2 will be used to collect data on maternal deaths in 10 MPDR-focused districts. It is hoped that linking MPDR and DHIS2 will ensure improved measurement and standardization of the health services through evidence-based quality data. This data will enable better support for decision making by local level managers and in developing evidence based plans at sub-district level.


The case study was written by Dr Animesh Biswas, Senior Scientist at the Reproductive and Child Health (RCH) unit of CIPRB with support and review by Dr Shukhrat Rakhimdjanov, Heath Manager (HSS), Dr Riad Mahmud, Health Specialist, UNICEF Bangladesh and Prof Abdul Halim, Director, RCH unit of CIPRB. Email:,

Photo credit: Todd Post


[2] Upazilas are sub-districts in Bangladesh



Maternal and Perinatal Death Reviews in Bangladesh

Read more about the Maternal and Perinatal Death Review system in Bangladesh highlighted in this case study:

1)      Biswas, A., Rahman, F., Halim, A., Eriksson, C. and Dalal, K. (2014) Maternal and Neonatal Death Review (MNDR): A Useful Approach to Identifying Appropriate and Effective Maternal and Neonatal Health Initiatives in BangladeshHealth, 6, 1669-1679.

2)      Biswas, A., Rahman, F., Eriksson, C., & Dalal, K. (2014). Community Notification of Maternal, Neonatal Deaths and Still Births in Maternal and Neonatal Death Review (MNDR) System: Experiences in Bangladesh. Health, 6(16), 2218.

Acting on findings from a Maternal Death Review at the facility level

Maternal death reviews (MDR) in Nigeria are not new, as some states have been conducting them over the years. However the methods used were developed locally and unique to each state. Aminu Magashi Garba – Evidence Advisor with the Evidence for Action programme in Nigeria presents the case of a secondary level facility that has been able to make small but important changes after having adopted MDRs.  Continue reading

From Maternal Death Reporting and Review to Maternal Death Surveillance and Response: the Philippines Experience

The Philippines has introduced a new system to analyse maternal mortality, one which emphasises action and response. 

Zenaida Dy-Recidoro, Chief Health Programme Officer at the Department of Health, tells us what changes it has brought, the importance of community engagement and how it has stimulated improvements in quality of care.

Continue reading

Malaysia’s Experience with Maternal Deaths

Dr. Ravichandran Jeganathan, National Head of Obstetrics and Gynaecological Services at the Ministry of Health in Malaysia, shares the inspirational story of Malaysia’s efforts to make every death count.

Find out more about some of the specific actions and responses that were introduced as a result of the Malaysia Confidential Enquiry System.

Continue reading

A Maternal Survival Action Network for Sierra Leone

This case study outlines how Sierra Leone introduced a Maternal Survival Action Network to support the implementation of maternal death reviews across the country. Read more about their inclusive approach.

In Sierra Leone, implementation of maternal death reviews (MDRs) is making gradual progress. Sierra Leone’s national MDR framework focuses on facility-based MDRs. The Ministry of Health and Sanitation (MoHS) consolidated results from MDR implementation in thirteen district hospitals in 2011.

There is widespread agreement by experts and activists that the use of findings for service delivery improvements in the current model of implementing MDRs could be significantly strengthened. In response to this the MoHS has recently finalised new MDR guidelines and tools, and is planning to scale up MDR coverage to all primary health facilities (notification of deaths) and some non-public sector facilities in 2012-2013. A review of current processes and challenges is underway to identify opportunities to strengthen MDRS and make better use findings at facility level. The intention is to strengthen the system so by identifying context-specific barriers and enablers to the use of MDR findings for quality of care improvements.

A Maternal Survival Action Network for Sierra Leone

In an exciting new development Sierra Leone have established an Action Networkdeveloped and hosted by the CARMMA Initiative under the office of the First Lady with backend coordination and technical support provided by Evidence for Action.

This is championed by the First Lady. The network convenes policy makers, managers, clinicians and civil society committed to helping to ensure maternal death reviews make a difference.

The network, a sub-network of the Global Network, facilitates the sharing of national evidence; enable quality of care improvement by advocating for resource mobilisation, mentorship, training and other relevant high impact interventions from MDR recommendations are realised.

Most importantly the Network tracks progress on actions from MDR recommendations and motivates, connects and advocates so that responses happen. They set targets based on priority MDR recommendations set by National MDR Committee and Reproductive Health and Family Planning.

They act as a catalyst for facilitating change around releasing bottle necks in areas where inadequate progress on actions on MDR recommendations are being made. They bring partners together to identify areas of input and synergies. The network engages non-state actors like media, CSO, community, traditional or religious leaders and others to raise profile of need to prioritise action on MDR recommendations and generate positive survival messaging and advocate for partners to take action on MDR recommendations.

The Action Network, like this Global Network, showcases examples of learning and action and it provides a forum within which national members can problem solve and share experience.

Membership and composition

Membership is by invitation and not representation, and is open to any group or individual with an interest in increasing maternal survival through quality of care improvement methods especially taking forward MDR recommendations.

SL Action Network

Members are selected based on the capacity as change agents, influencers and/or opinion leaders and expertise and knowledge on specific issues central to implementing MDR recommendations.

See an update of this case study in April 2016 here.