On 16 August, 2016 the World Health Organization (WHO) launched three new tools to count and review stillbirths, and maternal and neonatal deaths!
Browse the standardised system to capture and classify stillbirths and neonatal deaths in the WHO Application of the International Classification of Disease-10 to deaths during the perinatal period (ICD-PM).
Read the guide and toolkit, Making every baby count: audit and review of stillbirths and neonatal deaths. This publication assists countries to conduct audits and reviews to recommend and put into action solutions to prevent future stillbirths and neonatal deaths.
Explore Time to respond: a report on the global implementation of maternal death surveillance and response to review the findings of the WHO & UNFPA global survey of national MDSR systems in 2015.
Browse the press release and WHO website to learn more about these three tools, including related papers by the BJOG.
Read this Lancet commentary about all three publications.
Explore this photo story to learn more about MDSR implementation in ten countries around the world.
View this infographic about improving data to learn about what the WHO is doing to help countries save mothers’ and babies’ lives.
Do you know how many women each day experience a stillbirth worldwide? Browse this infographic on the tragedy of stillbirths to find out how many, and more!
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 report was published in May 2016 and is based on information collected of perinatal deaths in the UK for births from January to December 2014. The document focuses on deaths reported through the secure online reporting system, which include all late foetal losses (22nd to 23rd weeks of gestational age), stillbirths (a baby delivered at or after 24 weeks of gestational age with no signs of life) and neonatal deaths (a liveborn baby delivered at 20 weeks of gestational age or later, or weighing 400g or more when gestation is unavailable) who died within 28 days of being born. The findings are displayed in mortality rates for stillbirths, neonatal deaths and extended perinatal deaths (both stillbirths and neonatal deaths). The report offers key findings and recommendations, as well as describing causes of death and factors that influence rates of perinatal death.
Scale of the problem
In South Africa, perinatal deaths are defined as all stillbirths and early neonatal deaths (from live birth to seven full days after birth). While the country has accepted the definition* of reporting and recording all deaths (foetal and neonatal) weighing more than 500 grams, it is uncertain if all hospitals where deliveries take place are correctly reporting all deaths weighing less than 1000 grams, especially stillbirths. This may be influenced by a South African law that requires all defined stillbirths to have a burial and notification of death. In rural areas and busy hospitals, this may be seen as labour intensive for already overworked staff. Continue reading
This case study is the first of two. The second part will be published in 2017 and will report on progress toward scaling up perinatal and neonatal death surveillance and response (PNDSR) across the country.
In December 2015, Ethiopia began piloting a perinatal and neonatal death surveillance and response system in Tigray region in response to national commitments to improve newborn survival. The perinatal mortality rate in Ethiopia is high, estimated 46 per 1,000 births in 2011). The Tigray Regional Health Bureau (RHB) initiated the implementation of PNDSR after learning the importance of maternal death surveillance and response to generate evidence to save pregnant women’s lives following the scale up and national launch of maternal death surveillance and response (MDSR) in May 2013. The World Health Organization (WHO) has been supporting the region following its good performance during the initial phase of MDSR implementation.
This article by Animesh Biswas and colleagues, published by Health in September 2014, presents findings from a mixed-method study examining the process, feasibility, and acceptance of community death notification in Thakurgaon district, Bangladesh. The study found that community death notification was achievable and acceptable at the district level.
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.
This article by Animesh Biswas and colleagues in PLoS ONE presents findings of a qualitative study with healthcare providers involved in Facility Maternal and Newborn Death Reviews (FDRs) in two districts in Bangladesh: Thakurgaon and Jamalpur. The study aimed to explore healthcare providers’ experiences, acceptance, and effects of carrying out FDRs.
The study found that there was a high level of acceptance of FDRs by healthcare providers and there were examples of FDRs leading to improvements in quality of care at facilities, such as the use of FDR findings in Thakurgaon district hospital which ensured that adequate blood supplies were available, which saved the life of a mother who had severe post-partum bleeding. The article also identified gaps and challenges in carrying-out FDRs to consider for future efforts, including ensuring incomplete patient records and inadequately skilled human resources to carry out FDRs.
The authors conclude that FDRs are a simple and non-blaming mechanism to improving outcomes for mothers and newborns in health facilities.
To read more about maternal and newborn death reviews in Bangladesh, take a look at several case studies: two from the MDSR Action Network website: “Mapping for Action” and “eHealth to support MPDRs”; and another in the WHO’s global MDSR report here.