The global
movement for
Maternal Death
Surveillance
and Response
(MDSR)
Prepared by Professor Wendy J Graham
Confidential Enquiries
into Maternal Deaths:
United Kingdom,
Malaysia, Sri Lanka,
South Africa, Egypt
WHO, 2004
Maternal death reviews (MDR)
have been shown to be effective
in improving team work,
management and quality of care.
46 AFRO countries (2011):
15% have established required policies & are conducting MDR at
facility and community levels.
68% of countries are conducting facility-based MDR in selected
districts. 17% of countries had no information available.
Why is there renewed interest in
maternal death reviews?
Why a global movement?
The Millennium
Development
Goals (MDGs)
1990-2015
Progress on maternal and child survival :
75 highest-burden countries (2012)
On track for MDGs 4
and 5a (8)
Bangladesh, Cambodia,
China, Egypt, Eritrea, Lao
PDR, Nepal and Vietnam
On track for MDG 4 only (15)
Bolivia, Brazil, Guatemala, Indonesia,
Iraq, Korea DPR, Kyrgyz Republic,
Liberia, Madagascar, Malawi, Mexico,
Morocco, Peru, Philippines,
Solomon Islands
On Track for MDG
5(a) only (1)
Equatorial Guinea
Do all women, newborns and children have access to the
The
Continuum
of
Care
essential continuum of care?
0
Source: Analysis of DHS data; Graham & Fitzmaurice, 2013 – most
recent birth only
Poorest
2
3
4
Met need
Contraceptive use
Full Vaccine
DPT 1 dose
Breast
feeding
Postnatal visit
Institutional deliveries
SAD
ANC 4/4+ visits
2+ Tetanus Injections
U
p
t
a
k
e
Neonatal Tetnus
%
ANC 1 visit
Continuum of care: Ethiopia 2011
100
90
80
70
60
50
40
30
20
10
Richest
“Maternal mortality is much more
than a medical issue”
Ban Ki-moon
United Nations Secretary General
UN General Assembly 2009
Secretary-General Ban Ki-moon launches the
Global Strategy for Women’s and Children’s Health
(Sept 2010)
http://www.everywomaneverychild.org
Commission’s 10
recommendations have been
translated into a common
strategic work plan, with
priority areas including:
• birth and death registration
• monitoring of results
• maternal death
surveillance and response
• strengthening use of ICT
• resource tracking
• national mechanisms for
review and accountability
• advocacy for action
Maternal Death Surveillance & Response:
a continuous action cycle at community, facility,
regional & national levels
Surveillance
Respond &
monitor response
Identify &
notify deaths
Analyse & make
recommendations
Review deaths
Response
Maternal Death Surveillance & Response
“A maternal death surveillance and
response system that includes
maternal death identification,
reporting, review and response
can provide the essential
information to stimulate and guide
actions to prevent future maternal
deaths and improve the
measurement of maternal
mortality.”
(Bull World Health Organ Nov 2011;89:779–
779A)
May 2013
What lessons were learnt from
existing death review systems?
MDSR
•
•
•
•
•
•
Review-process focused
Facility deaths only
Deaths not notifiable
Physician-driven
Health sector only
Culture of blame & legal
issues ignored
• Ad hoc capture of data
• Limited lessons for
action at national level
•
•
•
•
•
•
Action-focused
Facility & community deaths
Deaths are notifiable events
Multi-professional
Multi-sectoral responsibility
Culture of no-blame & legal
framework addressed
• Systematic capture & use
• Lessons learnt at all levels
Why is MDSR important?
What opportunities does MDSR provide?
•
•
•
•
•
•
•
Provides information for action
Connects actions to results
Makes maternal death visible at local & national levels
Sensitizes communities & facility health workers
Boosts country ownership of data
Provides data in real time
Enables progress towards capturing all deaths
What are the challenges faced in implementing MDSR?
Engaging communities
Weak data availability & quality
Human resource requirements
Need for continuous commitment at all
levels
Building enabling environment of “no
blame” & legal framework (protection,
anonymity, confidentiality)
Common concerns with death reviews
• Patients: concern that illegal behaviour will be
punished (e.g. abortion, under-age marriage)
• Families: concern for repercussions (not seeking
care, being involved in illegal behaviour)
• Health workers: concern for prosecution or job
loss
• Facilities: concern for lost reputation & legal costs
• Committee members: concern for adverse
reactions from colleagues or management
Some consequences of concerns
•
•
•
•
Under-reporting
Misreporting
Defensive behaviour
Diverts attention
from actions to save
lives of mothers &
newborns
Fostering the essential culture of “no blame”
• Acknowledgment throughout system that mistakes
do happen
• Constructive approach to learning from every death
• Identifying preventive measures for the future as
over-riding priority
• Use of multi-professional committee to build team
solidarity
• Participation of community representatives to
explain value & results to wider audience
“The presence of a legal framework is a driving force
behind MDSR systems ,and is critical to mitigating
legal challenges on numerous levels including for
the patient, family, health professional and
facility”
Pearson, L. et al (2009).
Maternal death reviews in
Africa. International Journal of
Gynecology and Obstetrics, 106,
89-94.
International Example:
United Kingdom
• “No name, no blame” is a fundamental principle
• Both women who have died AND the health
providers remain anonymous during reviews
• Two government acts guarantee confidentiality
• Reviews cannot be used in litigation,
management sanctions or personal blame
International experience:
India
• Motherhood is the top priority of India’s Rural Health Mission
• Confidential, non-threatening environment created to allow
documentation and analysis of factors leading to adverse
maternal outcomes
• Informed consent and confidentiality ensured
• Confidentiality protected when sharing findings
• Result has been openness in reporting, trust across the system
and better data
Why is Ethiopia at the forefront of the
global movement for MDSR?
• RMNCH is a top national priority
• FMoH’s strong ownership of MDSR
• Action-focused MDSR from outset
• Strong champions
• Existing expertise & experience
• Community link enabled by HDA
• High level commitment to
maintaining momentum started
today
• Enabling environment being built,
including legal framework