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.
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
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
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 briefing note written by Evidence for Action Ethiopia provides a review of the global experience of MDSR at April 2016. It covers the history and current state of national MDSR systems and provides six lessons learnt from countries’ experiences.
E4A has been providing technical assistance for the introduction, implementation and scale-up of Ethiopia’s national Maternal Death Surveillance & Response (MDSR) system since 2012.
At national level, this has involved contributing to the development of the MDSR Guidance, data collection tools and database, and training curriculum, participating as active members of the MDSR task force, and representing the programme internationally.
The Ethiopia E4A team is based in the MNCH department of the WHO Ethiopia country office. In addition to a Programme Director, E4A is supported by five regional Technical Advisors who have been supporting the four large agrarian regions (Amhara, Oromiya, SNNPR and Tigray) as well as Harari, Dire Dawa and Addis Ababa, and a Data Manager working in the EPHI Public Health Emergency Management (PHEM) directorate. The University of Aberdeen’s Immpact programme and Options serve as the E4A Technical Support Unit, providing strategic guidance and 2 advisors based in Ethiopia.
Read our two page summary of our experiences here>
The Ministry of Health and Sanitation (MoHS) have developed national MDSR guidelines (see here) in partnership with UNFPA, the World Bank, and the WHO. The Directorate of Reproductive and Child Health are now leading on the national roll-out of these guidelines. Also, the MoHS, in partnership with UNFPA and other health development partners, has developed a three year costed plan to be implemented over the next three years.
In February 2016, the national MDSR committee was inaugurated and an orientation meeting took place in the same month. This month, an orientation meeting is planned for all MDSR focal point persons, including midwife investigators and other key staff from the districts. All districts will shortly have inaugural meetings for their MDSR committees (building on existing MDR committees).
Update from Bockarie Sesay, Monitoring & Evaluation Advisor for the Partnership Management, Evaluation and Learning (PMEL) programme, and Rosanna le Voir, Technical Assistant for PMEL
The recent report on MMR estimates for 2013 that was released by the UN agencies – Trends in Maternal Mortality: 1990 to 2013 – shows a 45% decline in global maternal deaths between 1990 and 2013. The burden and risk of maternal death remains the highest in sub-Saharan Africa and South Asia with these regions accounting for 62% and 24% of the deaths, respectively. Whilst absolute numbers show that India and Nigeria account for one third of all global maternal deaths, country level MMR estimates show that Sierra Leone records the highest (1100), and Chad and Somalia have the highest lifetime risk of maternal death. Giving birth is becoming safer, but not yet at the rate at which it should to meet the MDG targets in several countries. Continue reading →
Dr Matthews Mathai is Coordinator, Epidemiology, Monitoring and Evaluation & Focal Point, Maternal and Perinatal Health at the Department of Maternal, Newborn, Child & Adolescent Health at the World Health Organization. Continue reading →
This key document, published in October 2013, provides practical guidance to move from maternal death reviews to surveillance and response, emphasising the response component as well as focusing on quality of care improvements.
This document introduces the critical concepts of MDSR, including goals, objectives, and specific instructions for implementing each surveillance component, as well as outlining how districts can set up MDSR processes to strengthen surveillance and response.
Health-care professionals, health care planners and managers, policy makers working in maternal health, and those who measure maternal mortality will find these guidelines useful as they set up, implement and strengthen MDSR systems in their own settings.