Maternal Death Surveillance and Response Systems in driving accountability and influencing change

Abstract

Good progress has been made in reducing maternal deaths from 1990–2015 but accelerated progress is needed to achieve the Sustainable Development Goals (SDGs) in ending preventable maternal deaths through a renewed focus on accountability and actions. This paper looks at how Maternal Death Surveillance and Response (MDSR) systems are strengthening response and accountability for better health outcomes by analyzing key findings from the WHO and UNFPA Global MDSR Implementation Survey across 62 countries. It examines two concrete examples from Nigeria and Ethiopia to demonstrate how findings can influence systematic changes in policy and practice. We found that a majority of countries have policies in place for maternal death notification and review, yet a gap remains when examining the steps beyond this, including reviewing and reporting at an aggregate level, disseminating findings and recommendations, and involving civil society and communities. As more countries move toward MDSR systems, it is important to continue monitoring the opportunities and barriers to full implementation, through quantitative means such as the Global MDSR Implementation Survey to assess country progress, but also through more qualitative approaches, such as case studies, to understand how countries respond to MDSR findings.

1 Background

Globally, there has been a 44% reduction in maternal deaths and a drop in the annual number of maternal deaths from 532 000 in 1990 to 303 000 in 2015 [1]. Despite notable progress there is still wide disparity, with low- and middle-income countries making up 99% of global maternal deaths [2]. More than 80% of maternal deaths are avoidable, even in resource-constrained countries, and often minimal changes can improve maternal survival [3]. To achieve the target of decreasing the maternal mortality ratio to less than 70 per 100 000 live births under the Sustainable Development Goals (SDGs), renewed focus and accountability toward ending preventable maternal deaths are needed.

The Commission on Information and Accountability (CoIA) in 2011 and the recent Global Strategy for Women's, Children's and Adolescents’ Health (2016–2030) recommend accountability as a core principle to drive progress for health outcomes [4,5]. A continuous monitor–review–act cycle is recommended, which includes national oversight, monitoring of results, multi-stakeholder reviews, and action—all ingredients of surveillance and response systems [6,7].

In response to CoIA recommendations, the World Health Organization (WHO), the United Nations Population Fund (UNFPA), the International Federation of Gynecology and Obstetrics (FIGO), Centers for Disease Control (CDC), and the International Confederation of Midwives (ICM) released a Maternal Death Surveillance and Response (MDSR) Technical Guidance document in 2013 that builds on the continuous learning and action cycle under CoIA to bolster accountability for maternal health outcomes (Fig. 1) [8].

Figure 1

Maternal Death Surveillance and Response (MDSR) monitoring and evaluation (M&E) cycle.

MDSR is a comprehensive system building on facility-based maternal death reviews (MDRs) implemented in many countries, but focuses more explicitly on notification of maternal death, findings being acted upon, and accountability for responses undertaken [7–9]. It also provides opportunities to ensure that learning from maternal deaths influences more systemic responses to quality of care improvements from local to national levels [9].

Established MDSR systems can contribute to improved maternal mortality measurement by counting all maternal deaths, location of death, causes and contributing factors of death, and linking it to routine health information systems [1,7,10–13]. Findings from MDSR can provide powerful evidence to influence actions and advocacy among those in the health sector but also beyond including policy and decision-makers, non-governmental organizations, and communities among others [3]. Every maternal death has a story to tell and provides information to unlocking barriers to improve services [11,14], but these findings must be acted upon for real change to occur at policy, program, and facility levels as demonstrated in South Africa, Egypt, Mali, Senegal, and South-East Asia [3,8,10,12,15,16].

Since the launch of the technical guidance on MDSR, a number of countries have been working toward implementing comprehensive MDSR systems by building on their existing approaches, including MDRs, confidential enquiries, and verbal autopsies to count, review, act, account for, and reduce preventable maternal deaths. In 2015, WHO and UNFPA undertook a baseline survey that will be repeated regularly, to assess the implementation status of MDSR across low- and middle-income countries and identify where further efforts could strengthen the transition into a comprehensive MDSR system. This paper looks at how MDSRs strengthen response and accountability for better health outcomes by analyzing key findings from the WHO and UNFPA Global MDSR Implementation Survey and examining two concrete examples from Nigeria and Ethiopia on how findings have influenced systematic changes in policy or practice.

2 Nigeria: Accountability influencing local action and strategic decisions

Many countries are currently implementing facility MDRs as they build up to a more comprehensive MDSR system. We looked at Nigeria as an example of how it is using lessons on actions and accountability from MDRs to evolve into a Maternal and Perinatal Death Surveillance and Response System (MPDSR).

Nigeria has 19% of the world's maternal deaths—a health challenge that urgently needs to be addressed [1]. According to the Global MDSR Implementation Survey, the country has a long way to go to strengthen notification. Only seven of 37 states are reporting maternal deaths, with zero notified to the national committee and extremely low numbers of deaths notified at facility and community levels. Despite reporting challenges, there are concrete sub-national level efforts focused on using MDR findings and accountability for those maternal deaths that are captured to drive systemic health sector changes at local and policy levels.

Evidence for Action (E4A; see acknowledgements) worked with state health officials to introduce scorecards in Northern Nigeria. It is one of the first countries to track the implementation status of MDRs across all secondary facilities in selected states using questions adapted from the Global MDSR Implementation Survey. Scorecards (Fig. 2) appear to be an effective accountability tool to improve MDRs as Nigeria transitions into the implementation of an MPDSR system with the potential to realize systematic improvements beyond the facility level. Data captured in the scorecard include maternal death notification, whether action plans are developed, and if recommendations are acted upon.

Figure 2

Jigawa Maternal Death Review (MDR) scorecard.

The scorecards as well as MDR findings have influenced health practices at local levels but also increased visibility of maternal deaths and responses at higher levels. From June to August 2015, Jigawa State reviewed only 36 of the 163 maternal deaths that occurred [17]. However, findings from even these few MDRs have inspired local action and responses in the state—a key element of the MDSR cycle. A general hospital in Jigawa state showed hemorrhage as a leading cause of maternal deaths due to insufficient blood supply and non-functional blood banks. In response, service providers sensitized the public to encourage voluntary blood donation, which led to the formation of blood donor clubs. The facility now has a directory of blood donors that includes their blood groups and phone numbers so that they can be reached any time blood is needed. Moving to policy level influence, the government in Kano state, concerned by the high number of maternal deaths—108 deaths between June and August 2015 as captured in the MDR scorecard [18]—decided for the first time to incorporate MDR findings into the State Medium Term Sector Strategy (2016–2018), including:

• Provision and maintenance of functional blood banks in all state hospitals since hemorrhage and anemia are the leading causes of maternal deaths.

• Improving knowledge and awareness of health care among communities as low uptake of prenatal care and delivery services are prevalent in Northern Nigeria and often linked to maternal mortality.

3 Ethiopia: National roll-out and focusing on the “R” of the MDSR system

Ethiopia was selected as an example as it is one of the few countries that has a framework in place to implement an MDSR system that covers both community and facility deaths. With so many maternal deaths occurring in communities, verbal autopsies are an important part of Ethiopia's MDSR system alongside facility MDRs. Since 2014, all maternal deaths are now notifiable under Ethiopia's Public Health Emergency Management (PHEM) system, equivalent to an integrated surveillance and response system in other countries, thus activating the surveillance part of the MDSR cycle. Maternal deaths in the community are notified by the Health Extension Workers. A verbal autopsy is then conducted by the health center PHEM surveillance officer to determine the circumstances leading to the death [19].

More emphasis is needed on reporting; according to the Global MDSR Implementation Survey, only 206 maternal deaths in 2015 were reported of the estimated 11 000 maternal deaths in Ethiopia [1]. Nevertheless, Ethiopia shows that actions can be implemented and important lessons learned from those maternal deaths that are captured in the system.

MDSR in Ethiopia started with strong political commitment and the subsequent roll-out across the country with technical support from WHO and E4A. MDSR training programs were provided in seven of the eleven regions, which are now reporting an increasing number of deaths to the national database with actions implemented in response to problems identified [17]. Ethiopia has a National MDSR task force that had met twice in 2016 at the time of writing and is in the process of finalizing a National report. Posts have been created at the Ethiopian Public Health Institute to support the MDSR national database.

With the expansion of the MDSR system in Ethiopia, many examples of responses are emerging from facility level to more widespread changes in the health system. Regional Health Bureau (RHB) MDSR Committees are in the process of developing responses to the very high incidence of hemorrhage deaths. In Amhara region where monthly reviews of maternal deaths take place, findings are analyzed at facility level by the MDSR committee, which is comprised of a multiprofessional team according to the MDSR national guidelines. Responses to findings led to recommendations for focused postpartum hemorrhage training for facility personnel, availability of hemorrhage guidelines, and job aids at all health facilities among other actions. In one facility an additional operating space was also established with appropriate anesthesia support to reduce waiting times for emergency procedures. However, findings have also influenced more widespread changes across facilities and within the region. There is improved communication within the hospital and among different professional groups including midwives, anesthetists, obstetricians, managers, and laboratory staff. At regional level, findings have informed planning at Regional Bureau level and feedback on bottlenecks is regularly communicated to referring district hospitals, health centers, and communities.

4 Analysis of key findings from the Global MDSR Implementation Survey

The examples from Nigeria and Ethiopia provide contextual insight into how findings from maternal deaths can influence accountability, actions, and responses at multiple levels. We now turn to the implementation status of MDSR across 62 countries based on data gathered from the WHO and UNFPA Global MDSR Implementation Survey completed in 2015. A total of 67 countries responded to the survey. We included the 62 countries with WHO profiles prior to a cut-off point of April 2016 [20]. The data analyzed are based on responses received until the end of September 2015 only. Summary statistics provide a status update on MDSR implementation. A thematic analysis of open responses was conducted, where we compared countries’ responses and identified recurring patterns using themes. We used these themes to develop categories for each open response question, with a view to benchmarking countries against recommendations in the MDSR Technical Guidance [8] where possible. For this analysis, countries were stratified according to the Strategies toward Ending Preventable Maternal Mortality categories [13], which are based on maternal mortality ratios (MMR) in 2010: low burden MMR < 70 (n = 13), medium burden MMR < 420 (n = 25), and high burden MMR > 420 (n = 24). This analysis focusses on the reporting and response components of the MDSR cycle.

An overview of the MDSR program framework including notification, reviews, reporting, and stakeholder involvement is provided. Fig. 3 shows that more progress has been made on early phases of the MDSR action cycle with notification and policy in place than implementation of later stages of the cycle such as having review committees and reports with recommendations at different levels. Minimal progress has been made on dissemination of findings and involving stakeholders outside the health system.

Figure 3

Maternal Death Surveillance and Response (MDSR) implementation progress (n = 62).

The MDSR Technical Guidance emphasizes that regular and transparent dissemination of results is crucial for ensuring government accountability for improving maternal health. It provides a list of groups, including civil society, health professionals, planners, policy makers, and media to consider when disseminating findings at the community, facility, sub-national, and national level. Of 62 countries, only 26 made annual MDSR reports available to any stakeholders at national, sub-national, community, or facility level (Fig. 4). This was least common in high burden countries.

Figure 4

Countries making annual MDSR reports available annually to stakeholders (n = 62).

Laos, Malaysia, Maldives, Sri Lanka, and Senegal (low burden countries except Senegal and Laos, which are medium burden countries) follow good practice in disseminating information to a range of stakeholders using multiple channels. For example, Senegal disseminates reports to communities as well as within the health system.

The MDSR Technical Guidance recommends that findings are “disseminated using a variety of channels to enable a wide range of people to access it and ensure that the information gets to those who can act on it” [8]. Low and medium burden countries disseminate findings more than high burden countries (Table 1). Contrary to WHO recommendations to always feedback to communities and hospitals that provided data, there appears to be minimal dissemination at facility or community levels.

Table 1. Dissemination of information and recommendations (n = 62).

Only Malaysia produces an annual report and disseminates recommendations at all levels. Malaysia and Sri Lanka were the only countries where MDSR recommendations include timelines, which is considered good practice according to the MDSR Technical Guidance [8]. In Malaysia, recommendations are prioritized based on the scale, resources required for, and feasibility of implementation. Morocco was explicit about recommendations being prioritized depending on their importance and impact, which are in turn included in the Action Plan of Maternal Mortality Reduction.

Monitoring systems are important for determining if and how MDSR findings and recommendations have been implemented to track actions and outcomes [8]. However, less than half of countries assessed have a monitoring system in place (Fig. 5). In Sri Lanka and Rwanda, timelines and responsibilities are set for each recommendation. In Burkina Faso actions plans are costed. In Nigeria, there are annual monitoring visits to focal sites. Kenya, Cambodia, and Nepal characterized their monitoring systems as very weak or nonexistent, but are in the process of strengthening these systems. Nepal is also reviewing its MPDSR guidelines, which will include monitoring of recommendations.

Figure 5

Countries with monitoring systems in place (n = 62).

5 Conclusion

Countries with higher numbers of maternal deaths generally face greater challenges in setting up a system that captures all maternal deaths. While notification of all maternal deaths is ideal and key to accountability in terms of measuring progress toward reduction, there are life-saving actions already taken by countries in response to findings from maternal deaths without full implementation. Systems should be set up in a way that ensures all maternal deaths are reviewed, or at the very least, analyze a sufficient number of cases to avoid biases and promote system-wide learning.

The MDSR Technical Guidance is relatively new and countries have made early progress in implementing recommendations. A majority of countries have policies in place for maternal death notification and review, yet a gap remains when examining the steps beyond this, including reviewing and reporting at an aggregate level, disseminating findings and recommendations, and involving civil society and communities. Compared with low and medium burden countries, fewer high burden countries are making reports available to stakeholders, disseminating at multiple levels, and have monitoring systems in place to track recommendations.

As MDSR uptake increases globally, several factors should be considered to increase its effectiveness and sustainability including:

• a supportive institutional culture at all levels fostering a learning rather than a punitive environment [21];

• multidisciplinary teams that review and communicate findings at different levels of the health system [11] and availability to those in a position to act on the evidence;

• leadership and commitment of government and healthcare staff to the system [10];

• aggregating data from facility and community level to higher levels to gain deeper insight into quality of care gaps and address wider systemic barriers[21]; and

• recognition that local and less resource-intensive solutions can save lives [21].

Wider scale-up of MDSR can help achieve SDG goals in ending preventable maternal mortality and improving quality of both maternal and newborn care [7,13]. It is thus important to continue monitoring the status of MDSR and identify the opportunities and barriers to full implementation, through quantitative means such as the Global MDSR Implementation Survey to assess country progress, but also through more qualitative approaches such as case studies to delve into how countries respond to MDSR findings. Such resources are hosted on the MDSR Action Network [22], convened by E4A on behalf of the Global MDSR Technical Working Group led by WHO, and provides a platform for virtual learning and sharing of best practice.

Acknowledgments

The Evidence for Action (E4A) program is funded by the UK Government's Department for International Development (DFID). It aims to improve maternal and newborn survival in six Sub-Saharan countries (Ethiopia, Ghana, Malawi, Nigeria, Sierra Leone, and Tanzania) and at regional level, using a strategic combination of evidence, advocacy, and accountability interventions.

Conflict of interest

The following authors work for Evidence for Action, managed by Options Consultancy Services: Louise Hulton is the Strategic Advisor; Sarah Bandali is the Nigeria and Regional Technical Lead; Zoë Matthews is the former Evidence lead; Eleanor Hukin is the Evidence Lead; Ruth Lawley is Ethiopia Strategic Advisor; Oko Igado is Nigeria National Technical Advisor; and Camille Thomas provides Technical Input for the program.