Over 5 million perinatal deaths are estimated to occur annually in low-income and middle-income countries. Most of these deaths are not registered, reported or investigated by the health systems in these countries.
The 10th revision of the International Statistical Classification of Diseases and Related Health Problems (ICD-10) is a document that contains different codes for diseases, signs and symptoms. It is used globally by doctors and systems recording deaths to give a standardised code to different causes of adult and child deaths. In 2012, the WHO wrote ICD-MM: guidance on how to apply ICD-10 to deaths of women during pregnancy, childbirth and the puerperium (the period after delivery). However there was no single globally-recognised guidance on how to code the causes of the deaths of stillbirths and neonatal deaths, meaning that countries could not compare their estimates.
The World Health Organization has launched two important documents to address this problem: the WHO Application of ICD-10 to deaths during the perinatal period (ICD-PM) and the Making Every Baby Count: Audit and Review of Stillbirths and Neonatal Deaths. Continue reading
While many countries have been implementing maternal death surveillance and response (a mortality audit cycle to address the contributing factors of maternal deaths from local to national levels and ultimately improve quality of care), less attention has been given to stillbirths and neonatal deaths despite babies sharing the same periods of risk as their mothers. This publication by the World Health Organizatio (WHO) gives guidance on conducting a mortality audit system to investigate the modifiable factors in perinatal deaths and prevent similar causes of events. Continue reading
Maternal death surveillance and response (MDSR) is a continuous cycle of notification, review, analysis and response. It builds on the concept of maternal death reviews (MDRs) by focusing on the response and follow-up to ensure recommendations are acted on.
MDSR is a relatively new concept and there is limited systematic data on its implementation. Therefore, in 2015, the World Health Organization (WHO), in collaboration with the United Nations Population Fund (UNFPA) conducted a global survey of national MDSR systems to provide baseline data on the status of implementation.
This report presents the findings of this survey, including additional information from the WHO-MNCAH policy indicator database. It details key aspects of the MDSR system, and discusses the importance of MDSR and its role in reducing preventable maternal death by 2030.
- A 46 question survey questionnaire was developed based on the indicators of MDSR implementation
- The questionnaire was circulated through WHO and UNFPA regional offices in April 2015 and responses were received between May-September 2015
- 67 countries responded, 64 of which were low- and middle-income countries (LMIC)
- Information from the WHO-MNCAH policy indicator database was used to supplement survey responses and build of picture of the current status of MDSR implementation in LMICs
- There has been widespread adoption of the important elements of the MDSR system globally, yet, there remains a gap between policy and practice and there is a lack of progress towards full implementation in many countries
- Most countries have national policies to notify all maternal deaths (86%) and review all maternal deaths (85%)
- Only a small proportion of countries have a national MDR committee that meets at least biannually (46%)
- Only 60% of countries have both a national and subnational MDR committee
- Frequent review meetings at all levels are important for successful surveillance and response. Therefore the functioning of the MDSR system may be sub-optimal in countries whose committees meet less than biannually
Case study insights
Member states were also invited to share case studies describing successful implementation. 18 countries contributed at least one case-study, describing how barriers were overcome and highlighting innovative approaches. Some of the challenges and barriers to implementation include:
- Limited political buy-in and long-term vision
- Under reporting of suspected maternal deaths due to inefficient/incomplete notification systems
- Blame culture
- Incomplete/inadequate legal frameworks
- Inadequate staff, resources, and budget
- Cultural norms and practices that limit MDSR operation
- Problems of geography and infrastructure that inhibit MDSR operation
Conclusions and next steps
- There is a gap between MDSR policy and practice in many countries, with the “response” component lagging the furthest behind
- Countries should be supported to focus on improving levels of maternal death notification and on strengthening mechanisms for response at all levels
- To support countries in their implementation effort, the MDSR Working Group will work with partners to develop flexible MDSR training packages that can be adapted to countries priorities
- The next global MDSR implementation survey is scheduled for 2017 and will be repeated every two years thereafter
To download the report for free, click here.
To read the WHO’s MDSR technical guidance, which describes the measures required to establish an effective MDSR system, click here.
Reference: World Health Organization. (2016). Time to respond: a report on the global implementation of maternal death surveillance and response. Geneva: WHO.
This article by Kate Kerber and colleagues in BMC Pregnancy & Childbirth presents the findings of a review and assessment of evidence for facility-based perinatal mortality audit in low- and middle- income countries, including their policy and implementation status on maternal and perinatal mortality audits.
The authors found that only 17 countries have a policy on reporting and reviewing stillbirths and neonatal deaths despite evidence suggesting that birth outcomes can be improved if the audit cycle is completed. Key challenges in completing the audit cycle and where improvements are needed were identified in the health system building blocks of “leadership” and “health information systems”. Evidence based solutions and experiences from high-income countries are provided to help address these challenges.
The authors conclude that the system needs data mechanisms (e.g. standardised classification for cause of death and best practice guidelines to track performance) as well as leaders to champion the process (e.g. bring about a no-blame culture) and access decision-makers at other levels to address ongoing challenges.