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Dear members and friends,

Welcome to the final MDSR Action Network newsletter: Celebrating 5 years of sharing the latest

innovation in MDSR!

Over the years, we have had the great privilege to share with you updates and resources on

maternal death surveillance and response (MDSR) from around the world. We are sad to say this is

the last newsletter we will be issuing, but you will still be able to access resources from the MDSR

Action Network. Also, keep an eye out for new content about maternal and perinatal death

surveillance and response (MPDSR) on the Evidence for Action (E4A)-MamaYe website.

For our last edition, we reflect on some of our publications from recent years.

We kick off with an opinion piece we put together following the 2016 release of three new tools to

count and review stillbirths, and maternal and neonatal deaths. Five experts in maternal, newborn

and child health shared their views on the opportunities and challenges of implementing perinatal

death surveillance and response, including advice on sampling perinatal deaths (click here to read).

Celebrating the MDSR Action Network

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More recently, Dr Sarah Barnett considered the viability of scaling-up community maternal verbal

autopsies in low-resource settings to achieve the MDSR goal and objectives, and suggested

approaches to obtain community-based information (click here to read).

To better understand how clinical and non-clinical actors in the

health system can most effectively contribute to reviewing

maternal deaths worldwide, we compiled common themes

from the insights of six experts to draw out lessons learned for

the successful involvement of the multi-disciplinary health

actor in MDSR with particular emphasis on the role of midwives

(click here to read). For more about midwives and MDSR, read

a blog we posted for International Day of the Midwife about

how MPDSR in Kenya helped lift the morale of midwives

working in challenging conditions during the four-month strike

by Government doctors (click here to read).

To view and download MDSR-related resources from Ethiopia,

visit the country Resource Hub, which includes national

reports, training materials and a short film (click here to

browse).

And in case you missed our last newsletter, click here to read our post on Sierra Leone’s MDSR

Report: 2016 and here to read a blog by Dr Owen Musopole about the recent MDSR reports in

Malawi Northern Zone.

Act | Country update

Kenya | MPDSR committees across all levels jointly

tackle referral systems challenges A linked MPDSR system can have a positive impact on reducing

mortality. Find out what actions the Bungoma county-level MPDSR

committee took to address problems with its referral system. Read

more here and below.

Learn | Ethiopia resources New MDSR report and MPDSR materials In the third annual MDSR report, Ethiopia synthesised MDSR data for

1,065 maternal deaths from the Ethiopian fiscal year (EFY) 2009 (2016-

2017). The country has also released National MPDSR Technical

Guidance and an MPDSR Training Manual with accompanying

Workbook and presentation slides. Visit the Ethiopia MDSR Resource

Hub to keep up to date on Ethiopia-related resources.

New posts

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Act | Country update Bangladesh scales up MPDSR To prevent mothers and babies from dying, Bangladesh has taken

action to scale up its MPDSR system. Dr Animesh Biswas, Senior

Scientist and Associate Director, Reproductive and Child Health

Department at the Centre for Injury Prevention and Research, gives an

account of the scale-up activities to support the expansion of the

system. Read more here and below.

Learn | Publication Legislation and policies that support MDSR We end our three-part series with an annotated bibliography of

relevant literature. Legislation mandating maternal death as a

reportable event and laws and policies supporting a “no-blame culture”

are crucial for the successful implementation of MDSR. Fear of

repercussions and restrictive laws and policies can hinder

effectiveness. Read more here and below.

Learn | Resources Seminar recordings: Maternal and perinatal survival

in crisis settings Visit here and here to watch the presentations of the seminar series

where speakers share ideas and experiences about innovations to

improve maternal and newborn death surveillance to respond to

future Ebola outbreaks and about applying MDSR to crisis settings.

RCOG World Congress 2018, 21-24 March, 2018, Singapore

Fifth Global Symposium on Health Systems Research, 8-12 October, 2018, Liverpool, UK

XXII FIGO World Congress of Gynecology and Obstetrics, 14-19 October, 2018, Rio de Janeiro,

Brazil

Fifth International Conference on Family Planning, 12-15 November, 2018, Kigali, Rwanda

Women Deliver Fifth Global Conference, 3-6 June, 2019, Vancouver, Canada

Keep up to date on upcoming events here. For more information including location and event

registration details (where applicable), view the Calendar of Events at the end of the newsletter.

Act | Events

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Research article: Timing of maternal death: Levels, trends, and ecological correlates using sibling

data from 34 sub-Saharan African countries

WHO South Sudan: The Ministry of Health in partnership with WHO and partners strengthens

health information system for effective health service delivery in South Sudan

UNICEF Bangladesh: Reducing maternal and neonatal mortality and improving sexual,

reproductive health rights in the low-performing districts

Devex (Global views | Data and development): Opinion: The Achilles heel of the Sustainable

Development Goals is a lack of data

WHO Sierra Leone: Training clinicians to provide lifesaving emergency care for women and

newborns

CDC MMRIA data system: Maternal Mortality Review Information Application and user guide

Act | Country update

Kenya | MPDSR committees across all levels jointly tackle referral systems

challenges

Case study

The Lugulu hospital MPDSR committee discussed the challenges they were facing with referrals,

especially during the doctors’ strike at the turn of the year.

“A client suffering from pre-eclampsia was referred by ambulance from a Sub-County

Hospital to Lugulu Hospital in April, 2017. She was travelling alone and had not received any

treatment to stabilise her. She was dropped off at the entrance to the facility and left alone

to find her way to maternity, but collapsed in the corridor and started fitting”- Lugulu

Nursing Officer in charge.

At the sub-county MPDSR committee meetings, representatives from each of the sub-county

MPDSR facilities come together alongside sub-county staff. This forum provided an opportunity

for Lugulu Hospital to voice their concerns about the referral processes and explain how it was

contributing to maternal deaths. The referring facilities were made aware of the systemic failures

and the changes they needed to make. The sub-county District Public Health Nurse visited the

weak referring facilities to reiterate performance expectations in the referral processes and to

hold the teams to account. Lugulu Hospital has subsequently reported dramatic improvements to

the referral process and better inter-facility teamwork.

‘’the referring facilities now inform us on time, enabling us to make the necessary

preparation. There has also been a remarkable improvement in documentation on referral

notes’’ - Lugulu Nursing Officer in charge.

Act | In the news

Full-text posts

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In 2016, nearly half of maternal deaths (48%)1 and almost a third of perinatal deaths (31%)2

occurring in health facilities in Bungoma County were referred from another facility. The facility

level maternal and perinatal death reviews in the County, supported by the Maternal and Newborn

Initiative (MANI) project highlighted multiple problems with the referral system, including:

• Delays in the decision to refer clients

• Inappropriate treatment prior to referral or lack of efforts to try to stabilise clients before

transit (e.g. Administering magnesium sulphate to clients experiencing pre-eclampsia)

• Referring facilities not calling ahead to enable referral facilities to prepare for receiving

emergency cases

• Referring facilities not sending completed referral slips or client history

• Lack of (or delays in organising) ambulances, drivers, and/or fuel, especially at night

• Lack of a nurse or clinician to accompany clients in ambulance

• Emergency clients being dropped off alone at facility entrances.

Photo caption: Benchmarking visit to Kakamega, which included the County Chief Nurse and Deputy and

two Sub-County Public Health Nurses (SCPHNs). Photo credit: Caroline Lavu

Alongside problems with blood safety and supply, MPDSR review meetings identified the weak

referral system as one of the major contributors to facility-based maternal deaths. More than one

fifth of maternal death reviews in Bungoma County in 2016 recommended actions to tackle referral

system challenges1. To address the challenges with the referral system, the county-level MPDSR

committee took the following action:

• Four Ministry of Health officials, from the County Health Management Team and Sub-

County Health Management Teams, undertook a benchmarking visit to neighbouring

Kakamega County to observe their effective inter-facility referral system.

• A Bungoma County Referral Strategy and Investment Plan (2017)3 was drafted.

• A two-day training on the Referral Strategy and emergency preparedness took place, with

60 health care workers attending from 33 facilities, to raise awareness of the referral

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process and protocols and improve communications between the referring facilities,

including private and faith-based facilities.

The County deputy nursing officer in-charge, who oversees the ambulance services in the county,

identified the ambulance drivers and the hospital administrators (who control the resources and

influence ambulance protocols) as key stakeholders in the referral process, and organised a one-day

workshop for 37 ambulance drivers and 22 hospital administrators to orientate them on emergency

preparedness and the need to prioritise funding for fuel for ambulances.

Sub-county MPDSR committees play a crucial role in enabling information to be passed from

facilities to the county level, ensuring the sub-county and county officials have a better

understanding of facility-level challenges and can take coordinated action. Linked committees also

enable feedback to be given, lessons to be shared, and create stronger inter-facility communication

and teamwork. The referral example illustrates the positive impact a linked MPDSR system,

operating at all levels, can have on reducing mortality. The county is proud of the progress made to

date in addressing the referral system challenges, but are aware that there are many referral

challenges identified by the MPDSR process still to be addressed, including ambulance

maintenance, functionality and coordination, and emergency preparedness.

This update was written by Sarah Barnett, Technical Specialist at Options and Peter Ken Kaimenyi,

Maternal and Newborn Health Technical Advisor at MANI Project funded by UK Aid.

To read more about MDSR in Kenya, click on the articles below from September 2017:

• Maternal Death Surveillance and Response: A Tall Order for Effectiveness in Resource-Poor

Settings

• Implementing Maternal Death Surveillance and Response in Kenya: Incremental Progress and

Lessons Learned

References

1 Barnett, S. & Kaimenyi, P. (2017). MDR dashboard, Bungoma County 2016. MANI project, Options

Consultancy Services Ltd.

2 Barnett, S. & Kaimenyi, P. (2017). PDR dashboard, Bungoma County 2016. MANI project, Options

Consultancy Services Ltd.

3 Ministry of Health [Kenya]. (2017). Bungoma county referral strategy and investment plan 2016/17-

2020/21. Nairobi: MoH.

Act | Country update

Bangladesh scales up MPDSR

To prevent mothers and babies from dying, Bangladesh has taken steps to scale up its maternal and

perinatal death surveillance and response (MPDSR) system nationally. The country first piloted

maternal and perinatal death review (MPDR) in 2010. By 2015, MPDR was rolled out to 12 districts.

In 2015, the estimated maternal mortality ratio was 176 per 100,000 live births and in 2016, the

estimated neonatal mortality rate was 20 per 1,000 live births. While Bangladesh has made

important gains, more needs to be done to achieve the Sustainable Development Goal 3 targets for

maternal and newborn mortality.

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In 2016, the Ministry of Health and Family Welfare (MoH&FW) acted to roll out MPDR throughout

the country. In line with the World Health Organization (WHO) Maternal Death Surveillance and

Response (MDSR) Technical Guidance, the MPDR system was updated to ensure an increased focus

on surveillance and response.

Photo credit: Rebekah McKay-Smith/Options

Both the Health Economic Unit of the MoH&FW and the Bangladeshi government financially

supported this transition. To ensure integration and adoption across the health system, changes

were carried out in collaboration with: The Directorate General of Health Services and their

Management Information system, Directorate General of Family Planning, developmental partners

(for example, UNICEF, UNFPA, WHO), professional bodies (such as, the Obstetrical and

Gynaecological Society of Bangladesh), implementing partners (for example, non-governmental

organisations), public health experts and research organisations (such as, the Centre for Injury

Prevention and Research).

Twenty-two districts are currently implementing the new maternal and perinatal death surveillance

and response (MPDSR) system with UNICEF supporting 13 districts, UNFPA five and Save the

Children four. Scale-up activities took place at the policy and implementation levels to support the

expansion of the system, including:

• The adoption of national MPDSR guidance based on existing MPDR guidelines. New

national guidelines were approved by the MoH&FW in October 2016.

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• The development of a national Training of Trainer’s (ToT) manual on MPDSR to use at

various levels (approved in December 2016 by the MoH&FW).

• The creation of a pocket handbook on MPDSR for on-the-ground health workers.

• The development of six additional tools, also approved in December 2016 by the MoH&FW:

The community death notification slip, the community maternal death review form, the

community neonatal death review form, the facility death notification slip, the facility-

based maternal death review form and the facility-based neonatal death review form.

• A cascade training approach comprising of a:

- National level three-day ToT for 78 health professionals from the 22 districts.

- Training of health and family planning staff on the ground, and volunteers, doctors

and nurses at the district and upazila (sub-district) levels across the 22 districts.

• The identification of MPDSR focal persons at the upazila, district and national levels.

• Establishment of MPDSR sub-committees in facilities at upazila and district levels. Facility

death findings will be periodically discussed in hospital-based MPDSR sub-committees and

necessary steps taken to improve facility services.

• The newly created national MPDSR committee will sit twice a year to discuss progress

towards achieving targets for maternal and neonatal mortality, and improvements in the

health system.

• Capacity development on the national level assignment of causes of death from community

maternal and neonatal verbal autopsy forms - based on the International Classification of

Diseases 10 (ICD-10) - were conducted for clinicians, including gynaecologists, obstetricians,

neonatologists and paediatricians, from seven tertiary medical college hospitals.

Photo caption: Workshop on “Sharing MPDSR Guidelines, Training Module and Strategic Implementation

Plan” for Universal Health Coverage, 2 October 2016. Photo credit: Dr Animesh Biswas

A key element of the revised system is to improve the quantity and quality of the collection of data.

To ensure the notification and reporting of every community- and facility-based maternal and

neonatal deaths and stillbirths, notification is now mandatory. The review of every maternal and

neonatal death will be conducted at the facility level and a verbal autopsy will be carried out for all

maternal and neonatal deaths at the community level. Moreover, for community sensitisation and

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awareness building, social autopsies for maternal and neonatal deaths will be conducted in

communities.

Data is now viewable via a dashboard linked to the online management information system

database, the District Health Information Software (DHIS-2). In addition to being shared and

discussed at MDPSR sub-committee meetings, review findings will be fed into Quality

Improvement Committee (QIC) meetings at the upazila and district levels. The QICs will be tasked

with monitoring follow-up actions. Additional system improvements to support collection,

management and review of data included:

• Trainings to support health-care providers in community clinics to report community deaths

to the DHIS-2, the smallest health system unit covering approximately 6,000 persons.

• Trainings to upload causes of death from verbal autopsies to the DHIS-2 at the divisional

level.

• Meetings with MPDSR facility-level sub-committees to discuss findings from facility death

reviews to improve the quality of maternal and newborn care.

The DHIS-2 presents data on maternal and neonatal mortality by time period and geographic

location. Improvements in data availability, accessibility and quality are supporting improved

decision making by health managers, planners and policy makers at various levels of the health

system. Another notable achievement has been the integration of MPDSR into the fourth Health

Population Nutrition Sector Development Plan (2017-2021). The MoH&FW plans to achieve

countrywide scale up of the MPDSR system by 2021.

This country update was written by Dr Animesh Biswas, PhD, Senior Scientist and Associate Director,

Reproductive and Child Health Department at the Centre for Injury Prevention and Research (CIPRB) in

Dhaka, Bangladesh.

To read some publications by Dr Biswas, please click the titles below:

• Shifting paradigm of maternal and perinatal death review system in Bangladesh: A real time

approach to address sustainable developmental goal 3 by 2030

• Doctoral thesis: Maternal and neonatal death review system to improve maternal and

neonatal health care services in Bangladesh

• Maternal and Perinatal Death Review (MPDR): Experiences in Bangladesh

• Social Autopsy of maternal, neonatal deaths and stillbirths in rural Bangladesh: qualitative

exploration of its effect and community acceptance

• Exploration of social factors associated to maternal deaths due to haemorrhage and

convulsions: Analysis of 28 social autopsies in rural Bangladesh

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Learn | Annotated Bibliography Legislation and policies that support MDSR

As we continue our research looking at how

laws and policies support maternal death

surveillance and response (MDSR), we follow

the release of two case studies - an in-depth

account in Jamaica and a synthesis comparing

legal and policy frameworks across five

countries with MDSR systems in South America

and the Caribbean - to end our three-part

series with an annotated bibliography of

relevant literature.

This annotated bibliography presents recent

literature discussing the importance of legal

and policy frameworks in relation to successful

implementation of MDSR and perinatal audit.

This resource intends to orient policy makers,

managers and practitioners, on relevant

publications, but is not an exhaustive review

on the topic. See endnotes for the search

strategy used, which included looking at

literature around maternal death reviews

(MDRs) and perinatal audits. We provide an

overview of the main findings relevant to the

implementation of MDSR and then present

key publications individually and in

chronological order. For these publications

that met the search criteria, we outline the aim

and methods, key findings and authors’

interpretations relevant to the topic of the

bibliography.

Highlights from the literature

The evidence suggests that legislation

mandating maternal death as a reportable

event is critical for supporting MDSR

implementation and has been linked to

improved reporting. This raises questions

about whether making perinatal deaths a

reportable event would have a similar impact.

Given that this would add a considerable strain

on health systems, an assessment of capacity

to implement and enforce such legislation

should be done before the introduction of any

such laws.

Key findings from the bibliography on how legislative and policy frameworks can support or hinder

effective implementation of MDSR and perinatal audit:

• There is a paucity of evidence on the effectiveness of legal and policy frameworks.

• Fear of blame and legal repercussions are key barriers to effective MDSR and perinatal audit.

• Whilst policy and training documents can emphasise “avoiding blame”, a lack of legal protection

in practice jeopardises sustainability of MDSR systems.

• Legal frameworks can mandate notification, support enforcement of reporting and ensure

confidentiality, guaranteeing information is not used for medico-legal or disciplinary purposes.

• Adequate legislation and supportive policy frameworks are key drivers of success, but alone are

not sufficient for effective implementation.

• Policy can promote a no-blame, no-shame culture, mandate professionals to participate, define

institutional responsibilities and ensure resource allocation.

• Political commitment and strong leadership that champion personal and institutional

accountability are essential components of successful implementation of MDSR and perinatal

audit.

• Integrating MDSR within an existing surveillance system supports effective implementation.

• Malpractice liability is a barrier to reporting on deaths.

• There is a lack of information on the on lessons learned about improving the response

component of MDSRs.

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The evidence also points to the critical role of

legislative and policy frameworks in

supporting a “no-blame culture”, which is

essential for success. Legislation to ensure

inquiries are confidential and anonymous and

to safeguard health workers against litigation

could provide a solution. However, studies

reveal that, even in the presence of such

conducive frameworks, fear of repercussions

may persist among health workers and at the

community level, underscoring the

importance of leaders and champions at all

levels to foster an enabling environment.

The importance of broader legal and policy

frameworks surrounding the provision of

maternal and newborn health services is also

evident as well as potential tensions

originating from restrictive laws and policies

that have a bearing on the reporting of

maternal deaths and the opportunities for

open dialogue on theirs causes, for example in

settings were pregnancy termination is illegal.

Adopting a human-right based approach and

examining the broader legal and policy

framework can maximise the effectiveness of

MDSR implementation.

Peer-reviewed articles

1. Implementing maternal death surveillance

and response: a review of lessons from country

case studies, by Smith, H., Ameh, C., Roos, N.,

Mathai, M., Broek, N.V.D. (2017) in BMC

Pregnancy and Childbirth BMC series, 17(233).

The study aimed to identify the extent to

which countries implement the essential

components of MDSR and lessons learned for

improving implementation by examining ten

case studies including countries with

established systems and where MDSR had

recently been introduced. The authors use a

policy triangle framework to illustrate how

actors, context, processes and

implementation lessons in relation to

maternal death review policies interact to

create an enabling environment for MDSR.

The authors found that legislation and

supportive policy frameworks are key drivers

of success. Legal frameworks can mandate

notification, support enforcement of reporting

and ensure confidentiality, guaranteeing

information is not used for litigation.

However, the study notes little evidence on

What is MDSR?

MDSR is a continuous cycle of identifying,

reporting and investigating deaths, and using

the findings from the reviews of deaths to

identify what actions need to be taken to

prevent other deaths happening in similar

circumstances. Importantly, the cycle should

include ensuring recommendations are

responded to and tracking these responses.

Source: WHO, 2013

Why is MDSR important?

Most maternal and newborn deaths and the

majority of stillbirths are preventable.

Understanding the circumstances around each

death can help identify contributing factors,

and enable recommendations to be made and

actions to be taken to prevent future deaths

from similar reasons.

To do this, each death must to be counted

through surveillance systems and investigated

(reviewed) by clinicians with the help of family

or community members of the deceased.

MDSR and perinatal audit can provide the

essential information to stimulate and guide

actions to prevent future events and improve

the measurement of maternal and perinatal

mortality.

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the effectiveness of such frameworks and how

they are maintained.

Policy can promote a no-blame, no-shame

culture, mandate professionals to participate,

define institutional responsibilities and ensure

resource allocation. A key study limitation is

that case studies did not offer specific lessons

on how to improve the response component

of MDSR.

2.‘We identify, discuss, act and promise to

prevent similar deaths’: a qualitative study of

Ethiopia's Maternal Death Surveillance and

Response system, by Abebe, B., Busza, J.,

Hadush, A., Usmael, A., Belew Zeleke, A., Sita,

S., Hailu, S., Graham, W.J. (2017) in BMJ Global

Health, 2 (2) e000199.

Focusing on the first two years of MDSR

implementation in Ethiopia from 2013-15, this

study aimed to identify facilitators and

barriers to implementation and assess

outcomes through a qualitative policy

assessment with data collected via interviews.

The findings stress the importance of political

commitment and benefit of integrating MDSR

within an existing surveillance system.

The authors emphasise the importance of

maternal mortality being a reportable event.

They found however, widespread fear about

reporting deaths at the community level and

among health providers concerned about

potential legal repercussions or disciplinary

actions. While policy and training documents

emphasise “avoiding blame”, respondents

reported a lack of legal protection in practice

jeopardising the sustainability of the system.

3. Drivers of maternity care in high-income

countries: can health systems support

woman-centred care? By Shaw, D., Guise,

J.M., Shah, N., Gemzell-Danielsson, K.,

Joseph, K.S., Levy, B., Wong, F., Woodd, S.,

Main, E.K. (2016) in the Lancet, published

online.

This paper from the Lancet Maternal Health

Series presents the main delivery care models

in high-income countries (HICs), and examines

the main drivers of these models. Of relevance

to the topic of this bibliography, the study

underscores the role of confidential enquiries

into maternal deaths to improve care quality

and safety, and notes that most HICs lack

robust surveillance systems for ascertainment

of maternal deaths, and for accurate

identification of the underlying causes of

death and preventable cases. The authors

argue that a policy change should enable

institutionalisation of national- or sub-

national-level audits of maternal deaths,

which include the collation and dissemination

of results on social circumstances and clinical

contexts alongside recommendations for

prevention of future deaths. Furthermore, the

authors identify malpractice liability as a

barrier to optimal care in several high-income

settings, and provide examples of state

support provision and insurance regulatory

frameworks to minimise such a barrier.

4. Counting every stillbirth and neonatal death

through mortality audit to improve quality of

care for every pregnant woman and her baby,

by Kerber, K. J., Mathai, M., Lewis, G.,

Flenady, V., Erwich, J. J. H. M., Segun, T.,

Aliganyira, P., Abdelmegeid, A., Allanson, E.,

Roos, N., Rhoda, N., Lawn, J. E., Pattinson, R.

(2015) in BMC Pregnancy and Childbirth BMC

series, 15(Suppl 2):S9.

This study investigates progress

institutionalising facility-based maternal and

perinatal death audits, synthesises the main

challenges using the World Health

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Organization (WHO) health system building

blocks, and proposes solutions for scaling up

audits for stillbirths and neonatal deaths.

Methods include a review of literature on

facility-based perinatal and maternal

mortality audits with a focus on high-burden

countries.

Seventeen countries out of 71 were identified

with policies providing a national mandate for

perinatal death reviews and only51 for

maternal deaths. Key challenges were found

in the leadership domain. The authors identify

that a policy framework is a necessary

condition to commence implementation but

policy alone is not sufficient for effective

implementation. Fear of blame and legal

repercussions are cited as key barriers, which

can be potentially overcome by the

development of an ethos of safety through a

supportive, non-punitive policy and legal

environment at national level, and having

leaders champion personal and institutional

accountability.

5. The cultural environment behind successful

maternal death and morbidity reviews, by

Lewis, G. (2014) in BJOG: An International

Journal of Obstetrics & Gynaecology, 121

(Suppl. 4): 24–31.

This expert piece, based on experience of

instituting reviews of maternal deaths and

near misses worldwide, suggests that a

positive and enabling environment for

successful maternal death reviews results

from: A culture of individual responsibility, a

proactive institutional ethos, and a supportive

political and policy environment at national

and/or local level. The authors outline that

providing legal protection for those

participating in maternal death reviews can

remove fear of participation. In contrast,

linking maternal death notification with police

reporting has led to the stalling of the process

in a few countries. The article also notes that a

requirement for anonymising reviews can

ensure that any cases of malpractice continue

to be dealt with using existing legal

procedures.

6. The confidential enquiry into maternal

deaths in South Africa: a case study, by

Moodley, J., Pattinson, R.C., Fawcus, S.,

Schoon, M.G., Moran, N., Shweni, P.M. (2014)

in BJOG: An International Journal of Obstetrics

& Gynaecology, 121 (Suppl. 4): 53–60.

This article presents the process, findings and

impact of the Confidential Enquiry into

Maternal Deaths (CEMD) in South Africa

which has been operational since 1998. The

article places the CEMD process in the context

of enabling legislation specifically mandatory

notification of maternal death but also, more

broadly, legislation granting free health care

to pregnant women and children, and

enabling elective pregnancy terminations. It

also provides a rare example in the literature

of how the principles of confidentiality and

anonymity are applied in the CEMD system in

practice so that findings from the CEMD

process cannot be used for medico-legal or

disciplinary purposes. It further points to the

fact that medico-legal processes do continue

to occur, protecting patients from clinical

malpractice, but they are separate and parallel

processes, which has been ratified by relevant

judicial bodies.

7. Easier said than done!: methodological

challenges with conducting maternal death

review research in Malawi, by Thorsen, V. C.,

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Sundby, J., Meguid, T., Malata, A. (2014) in

BMC Medical Research Methodology, 14:29.

This article describes the methodological

challenges experienced when conducting

maternal death review research. It draws

observations from a study using facility-based

maternal death review to assess cause of

death. Study methods include review of case

audits and participant interviews. Fear of

blame and potential repercussions are cited as

barriers affecting the completeness and

accuracy of data recorded. To ensure

participation in reviews, the authors needed to

reassure participants that their contributions

would not be used for litigation. The study

underscores the importance of ensuring

anonymity and confidentiality during reviews

and demonstrates the complexity involved in

conducting facility-based audits.

Reports: Global and regional

1. Time to respond: a report on the global

implementation of maternal death

surveillance and response (MDSR), WHO,

2016.

This report presents the findings of a global

survey conducted by the WHO and UNFPA to

determine the status of MDSR

implementation in countries where there is a

national system, and provides overall

implementation insights and case studies.

Individual MDSR country profiles are available

in the report with information about national

policies for maternal death notification and

review.

In relation to policy frameworks, the report

suggests a gap between policy and practice.

Most participating countries (86%) reported

having a national policy to notify and review all

maternal deaths, but only 46% reported that a

National Maternal Death Review Committee

meets biannually (twice a year). In relation to

legal frameworks, the study identified little in

the literature that considers MDSR from a

legal perspective, suggesting more research is

required. It also suggests that the legal

environment within which MDSR is

implemented, such as country laws for the

rights of women and by extension for their

reproductive rights, can either assist or hinder

the effectiveness of MDSR as a tool for

reducing maternal mortality. For example, the

existence of an efficiently run MDSR system

cannot fully mitigate the risks to girls who

marry and conceive at a young age, or to

women who seek to terminate a pregnancy in

a country where abortion is illegal. Conversely,

taking a human-rights-based approach to

health, making maternal death a notifiable

event in law and supporting this legislation

with policies for maternal death review,

analysis and follow-up action, creates the

preconditions necessary for successful

implementation of MDSR.

2. Making every baby count: audit and review of

stillbirths and neonatal deaths, WHO, 2016

This guide discusses the role of perinatal

mortality audit as a quality improvement

strategy. It makes the case for introducing a

system to capture the number and causes of

all stillbirths and neonatal deaths, and

reviewing a selection of individual cases for

more in-depth, systematic and critical analysis

of the quality of care received, and provides

detailed guidance for it. It notes that in many

settings established MDSR systems may

present an opportunity to integrate perinatal

audits effectively and efficiently, however this

is not a precondition. It refers to how the law

can contribute to the creation of an enabling

15

environment, particularly when this ensures

protection of staff and patients throughout

the process. The report recognises that in

settings with high malpractice litigation, the

fear of law suits can hamper data collection

and the use of findings from death audits and

thus the importance of separate processes for

handling legal misconduct to mitigate this is

noted. It also provides a sample code of

conduct to be adhered to by all stakeholders,

and discusses policy and ethical issues in

relation to access to information and use of

results.

3. Guidelines for Maternal Death Surveillance

and Response (MDSR): Region of the

Americas, Regional Task Force for Maternal

Mortality Reduction, 2015

This guide contextualises WHO MDSR

guidelines in the Latin American and

Caribbean context, includes a situation

assessment of the maternal mortality context,

detailed guidance on each MDSR component,

and analysis and recommendations on context

specific barriers and solutions for optimal

implementation. The report stresses the

importance of an enabling legal and policy

framework in relation to mandatory reporting

of maternal deaths, anonymisation of data,

and sharing information on suspected

maternal deaths across sectors. It also

recommends integrating MDSR into sexual

and reproductive health, and general health

policy.

The guidelines are accompanied by five case

studies on MDSR implementation in Jamaica,

Mexico, Brazil, Colombia and El Salvador.

Making maternal deaths notifiable by law,

enshrining in law rights to quality care,

particularly for women, and adopting a policy

framework that clearly identifies institutional

responsibilities were reported as enabling

factors for successful implementation. More

detail on case study country experiences can

be found in this synthesis. The case studies

from Jamaica and Brazil offer particularly

valuable detail on conducive legal

frameworks.

4. Maternal death surveillance and response:

technical guidance, WHO, 2013

WHO technical guidance on MDSR introduces

the concept of MDSR as a continuous action

cycle building on established maternal death

review systems. It represents a pivotal

resource with detailed guidance to implement

each surveillance component. In relation to

legal frameworks, it stresses that

identification and development of regulations

and legal protections are crucial pre-requisites

to implementation. Notification of a maternal

death should be mandatory. A ministerial

decree is usually needed to establish the

MDSR system. Developing a policy or a code

of conduct and standards for conducting

maternal death reviews, and orienting all

stakeholders on these is essential to create a

collaborative rather than blame environment.

A legal framework on confidentiality and

medical liability should be in place to prevent

the use of review findings in litigation, thus

aiding the development and dissemination of

findings and recommendations.

It also highlights that other legal provisions

may have a bearing on MDSR implementation

and should be assessed and considered at the

start. For example, reviewing patient health

records, speaking with family members or

friends, and interviewing health-care workers

may require the adoption of regulations.

Furthermore, dissemination of findings may

be affected by legal frameworks surrounding

pregnancy terminations.

5. Study on the implementation of maternal

death review in five countries in the South-

East Asia region of the World Health

Organization, WHO, 2014

This report presents the findings of a study on

the implementation of maternal death

reviews in five countries in South-East Asia,

namely India, Indonesia, Myanmar, Nepal, and

Sri Lanka, including individual country reports

16

and a regional overview. The studies all used

largely qualitative methods. Of relevant to the

bibliography topic, the report discusses

government policies and directives which

provide clear institutional and managerial

arrangements in each country. It also

identifies fear of possible punitive action

among the critical challenges for the conduct

of maternal death reviews in the region.

Recommendations include improved

communication to promote a no-blame

culture in implementation.

Endnotes: Search strategy and criteria

The search strategy was not intended to be

systematic or exhaustive, but to identify key

recent publications on the issue of legal and

policy frameworks for MDSR.

The Open University database, subscribed to

over 150,000 journals including the British

Medical Journal, BioMed Central and the

Lancet, was searched for published literature,

using the search terms “MDSR”, “MDR”,

“maternal death review”, “maternal death

surveillance” and “perinatal death

surveillance”.

References of relevant articles were hand-

searched and key stakeholder websites,

including WHO and UNFPA, were searched to

identify additional publications. Inclusion

criteria: Research studies, editorials and

reports; English only; published in the last 15

years; specifically discussing legislation and

policy frameworks in relation to MDSR

implementation. The search was not

restricted to specific settings.

Suggested citation

MDSR Action Network. (2018). Annotated

bibliography: Legislation and policies that

support MDSR. London: Evidence for Action.

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