Tag Archives: Near miss

Bangladesh | the roll out of MPDSR

Maternal and perinatal death surveillance and response in Bangladesh was initiated by the Ministry of Health and Family Welfare (MOH&FW) to monitor the overall improvement of maternal and neonatal health. Since its inception, the MoH&FW has been implementing MPDSR in 17 districts across Bangladesh following the pilot programme in Thakurgaon district in 2010. The approval of the national MPDSR guideline has paved the way to scale up MPDSR. From July to September 2016, a number of initiatives have taken place to further MPDSR implementation across the country.


  • The national guidelines for MPDSR have been approved by the MOH&FW. Printing is underway and the dissemination workshop will take place in October 2016.
  • Plans to scale up MPDSR countrywide by 2021 have been drafted in the results framework of the Health, Population and Nutrition Sector Development Program 2011-2016
  • The MPDSR Training of Trainers manual is under development and will be implemented to train sub-national level facilitators who in-turn will train healthcare providers from multiple disciplines at the district and upazila levels. The upazila team will then train the field-level health care providers on death notification, verbal autopsy (VA), social autopsy and facility death review. Participants will also be trained in data collection and analysis
  • A booklet on MDPSR for health and family planning workers in the field is also being developed in the local Bengali language. A draft will be complete by September 2016. The booklet is expected to be distributed to field-level health workers (health assistants, family welfare assistants, health inspectors, assistant health inspectors, family planning inspectors and sanitary inspectors) by November 2016
  • Simplified tools of MPDSR to help facilitate death notification, VA and facility death reviews, to name a few, are being prepared for dissemination to all 17 districts. Selected variables of VA have been incorporated in the District Health Information System-2 (DHIS-2)
  • A national-level meeting – led by the Director, Primary Health Care and Line Director of Maternal, Neonatal, Child and Adolescent Health of the Directorate General of Health Services – was planned in September 2016 to share experiences in maternal and perinatal death review across 14 districts
  • The national MPDSR guidelines will be shared at six divisional workshops once finalised (expected date: December 2016).
  • The UNICEF South Asian Regional Office has organised a South-to-South exchange visit for the MOH&FW Obstetric and Gynaecological Society of Bangladesh to travel to China in November 2016 to share experiences about auditing maternal near misses

To learn more about Bangladesh’s implementation of MPDSR or components of it, please read the country update from July 2016.

Browse this case study to read about how social autopsy is used as an intervention tool to prevent maternal and neonatal deaths in communities in Bangladesh. The WHO has also published a case study about social autopsy in Bangladesh.

Acknowledgements: This country update was prepared and reviewed by Dr Riad Mahmud, Health Specialist (Maternal and Neonatal Health), Health Section, UNICEF Bangladesh and Dr Animesh Biswas, National Consultant (MPDSR), Health Section, UNICEF, Bangladesh.

Maternal death audit in Rwanda 2009–2013: a nationwide facility-based retrospective cohort study

This article by Felix Sayinzoga and colleagues, published by BMJ Open in January 2016, presents the findings of a review of all health facility-based maternal death audits in Rwanda between January 2009 and December 2013.  Based on this review, the authors found that the facility-based maternal death audit approach has helped facility teams to identity causes of death and contributing factors, as well as make recommendations for action to prevent future deaths. They recommend that Rwanda better inform corrective actions by complementing these audits with other strategies, such as confidential enquiries and near-miss audits

Ethiopia: Obstetricians plan for the future with CME module in MDSR

MDSR now has its own ESOG (Ethiopian Society of Obstetrics and Gynecologists) continuing  medical education (CME) module, which will be used across the country to educate obstetricians and other senior clinicians about  the process of  MDSR.

The module was launched at the ESOG Annual Conference with 68 participants. These  included senior gynaecologists,  who graduated well before the development of the MDSR system, alongside Obstetric and Gynecologist residents who will be leading the system in the future.

The seminar included the latest maternal death data from the national database, the global context of MDSR, an overview of the surveillance system, as well as practical exercises that guide SMART (Specific, Measurable, Achievable, Relevant, and Time-bound) responses.

Ethiopia_CME training

Eighty-five per cent of  the delegates rated the workshop as excellent or above average and ninety-four per cent rated the module as relevant to their practice. Similar numbers said they would modify their practice as a result of the workshop with improvement in documentation being the most popular improvement.

There are plans to take the seminars to the Regions in the near future.

To read more, take a look at Ethiopia’s February 2016 MDSR Newsletter here. You’ll find updates on the role of the Ethiopian Public Health Institute in managing national MDSR data, inspiring stories of good practice, and two case studies: 1) the death of a pregnant adolescent girl from sepsis and 2) a near miss of a pregnant woman with a scarred uterus who received delayed management.

Please also read a presentation on strengthening the MDSR system in Ethiopia delivered at the Global Maternal Newborn Health Conference in Mexico in October 2015 by Professor Wendy Graham, University of Aberdeen, Scotland, and Dr Ephrem Teckle Lemango, Federal Ministry of Health, Ethiopia.

Update from Dr Ruth Lawley, Clinical Technical Adviser, E4A-Ethiopia


MDSR in Malaysia is in its fourth year of inception. It complements the Confidential Enquiry into Maternal Deaths that has been in existence since 1991. As part of MDSR feedback, we have weekly updates on the most recent data on maternal deaths for the week and compare this data to the same week the previous year. Based on the findings of the MDSR committee (which meets at least four times a year) a near miss registry is being formed and the ground work is completed. As we leave the Millennium Development Goals and move on to the Sustainable Development Goals we see a greater role for MDSR.

Update from Dr Ravichandran Jeganathan, National Head of Obstetrics and Gynaecological Services at the Ministry of Health.