1. The global movement for Maternal Death Surveillance and Response
(MDSR)
Prepared by Professor Wendy J Graham

2. 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.

3. 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.

4. Why is there renewed interest in maternal death reviews
Why is there renewed interest in maternal death reviews? Why a global movement?

5. The Millennium Development Goals (MDGs)

6. 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 5(a) only (1)
Equatorial Guinea
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

7. Do all women, newborns and children have access to the essential continuum of care?
The Continuum of Care

8. Continuum of care: Ethiopia 2011

10. “Maternal mortality is much more than a medical issue”
Ban Ki-moon
United Nations Secretary General
UN General Assembly 2009

11. Secretary-General Ban Ki-moon launches the Global Strategy for Women’s and Children’s Health
(Sept 2010) 11 11

12. 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

13. Maternal Death Surveillance & Response:
a continuous action cycle at community, facility, regional & national levels
Surveillance
Respond &
monitor response
Analyse & make
recommendations
Identify & notify deaths
Review deaths
Response

14. Maternal Death Surveillance & Response
May 2013
“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)

15. What lessons were learnt from existing death review systems?
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
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

16. 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

17. 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)

18. 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

19. Some consequences of concerns
Under-reporting
Misreporting
Defensive behaviour
Diverts attention from actions to save lives of mothers & newborns

20. 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

21. “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,

22. 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

23. 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

24. 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