MDSR is a component of the health information system, which permits identification, notification, quantification, and determination of causes and avoidability of maternal deaths, for a defined time period and geographic location, with the goal of orienting the measures necessary for its prevention.

1. Maternal Death Surveillance and Response
Prepared by Najibullah Hamid
October 2012

2. Why is MDSR important?
• Maternal mortality continues to be unacceptably high in
many countries
• Maternal death surveillance provides information for
taking appropriate actions to prevent deaths
• “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.” (Danel, Graham & Boerma. Bull World Health Organ Nov
2011; 89:779–779A)

3. The Need for MDSR
• Due to the lack of complete and reliable data in low
income countries, levels and trends in maternal mortality
have long been generated through modeling exercises
based on survey results
• The resulting maternal mortality ratios are generated
periodically, have very wide confidence intervals and
reflect situations five to 10 years prior to the surveys
• What is needed, is a surveillance approach that reflects
maternal deaths in real time

4. The Need for MDSR….
• Real-time monitoring provides information that can be
used in the development of programs and interventions
to improve maternal health, reduce maternal morbidity,
and improve the quality of care of women during
pregnancy, delivery, and postpartum
• MDSR involves systematic notification of pregnancy-
related deaths, continuous analysis of the causes and
geographic distribution of these deaths, and the use of
that information to inform and evaluate public health
practices

5. Introduction
• MDSR is a component of the health information system,
which permits identification, notification, quantification,
and determination of causes and avoidability of maternal
deaths, for a defined time period and geographic
location, with the goal of orienting the measures
necessary for its prevention
• It provides information that can be used in the
development of programs and interventions to improve
maternal health, reduce maternal morbidity, and
improve the quality of care of women during pregnancy,
delivery, and postpartum

6. Introduction….
Maternal death surveillance and response system: a continuous action cycle at
community, facility, regional & national level

7. Rationales
• MDSR provides information about avoidable factors that
contributed to a maternal death and guides actions that
need to be taken at the community level, within the
formal health care system, and at the intersectoral level
to prevent similar deaths in the future
• MDSR establishes the framework for an accurate
assessment of the magnitude of women's deaths related
to pregnancy
• Accurate assessment of maternal mortality, let policy
and decision makers, to give the problem the attention it
deserves. It let evaluators accurately assess the
effectiveness of interventions

8. Aim
• An MDSR system aim to identify every maternal death in order to
accurately monitor maternal mortality and the impact of
interventions to reduce it

9. MDSR System
• Set Up
• Awareness creation among health care workers and the
community
• Process of the MDSR system (Identification, reporting
and reviewing of maternal deaths)
• Analysis (aggregation of multiple case reviews) -
perspective on national, regional and provincial level
• Dissemination of results
• Response
• M&E for MDSR

10. MDSR System
• Set Up
• Awareness creation among health care workers and the
community
• Process of the MDSR system (Identification, reporting
and reviewing of maternal deaths)
• Analysis (aggregation of multiple case reviews) -
perspective on national, regional and provincial level
• Dissemination of results
• Response
• M&E for MDSR

11. Set Up
• For successful implementation of maternal death review
the following settings are needed:
– Establish National, regional and local committee
• National MDSR task force
• Regional safe motherhood technical working group/ RH task
force
• Facility based MDSR committee
– Determine roles and responsibilities of key actors
• Provincial MNCH focal person
• Director of hospital / health center
• CBHC officers
• Community Health Supervisors
• HMIS focal persons at provincial, regional and national level

12. Set Up….
– Availing tools and guidelines for MDSR
• Notification and verbal autopsy tool
• Community based maternal death review tool
• Facility based maternal death summary form
• Reporting template from Health facility to Next level
• Reporting format from province to region
• Reporting format from Region to National
• M&E of MDSR guide
– Legal and ethical considerations
• Autonomy
• Privacy
• Beneficence

13. MDSR System
• Set Up
• Awareness creation among health care workers and the
community
• Process of the MDSR system (Identification, reporting
and reviewing of maternal deaths)
• Analysis (aggregation of multiple case reviews) -
perspective on national, regional and provincial level
• Dissemination of results
• Response
• M&E for MDSR

14. Awareness Creation
• In MDSR system, health care workers will be involved in
a variety of ways such as data collection, revision or
care provision
• Orientation is needed for health care staff on objectives,
processes and principles of MDSR
• Awareness creation to community is important as
deaths occur there and for establishment of ownership
of the review process
• For community-based reviews, the support of local
village leaders and religious & cultural leaders is
essential

15. MDSR System
• Set Up
• Awareness creation among health care workers and the
community
• Process of the MDSR system (Identification, reporting
and reviewing of maternal deaths)
• Analysis (aggregation of multiple case reviews) -
perspective on national, regional and provincial level
• Dissemination of results
• Response
• M&E for MDSR

16. Process of MDSR System
• Sources of information
– Community
• For identification: community health workers, CHS, religious
leaders/community leaders, administrative leaders,
community members)
• For verbal autopsy: persons primarily attended the women
during illness, labour/delivery at home, person present at the
side of woman at the time of death, husband
– Health Facility
• For notifying: head of maternity/labour ward
• For facility deaths reviews: referral sheets, medical records,
log books, attending health workers, others

17. Process of MDSR System….
• Identification and reporting of maternal deaths
– In the community (identification by CHWs, reporting by CHS)
– In facility (head nurse/midwife)
• Data contents and data collection
– Demographic data
– Prenatal history
– Delivery information
– Information on death
– Potentially avoidable factors
– Info on MDR
• Reviewing of the Event
• The chairperson of the review committee at each level of the
review process will assign two reviewers for every death to be
reviewed and produce summary reports

18. MDSR System
• Set Up
• Awareness creation among health care workers and the
community
• Process of the MDSR system (Identification, reporting
and reviewing of maternal deaths)
• Analysis (aggregation of multiple case reviews) -
perspective on national, regional and provincial level
• Dissemination of results
• Response
• M&E for MDSR

19. Analysis
• Data analysis is critical to provide useful information to
guide action
• The best approach is a combination of both qualitative and
quantitative analysis
• Qualitative analysis of each case, identifies the medical and non-
medical problems that contributed to that death
• Grouping the findings, especially the problems, and looking at them
quantitatively provides information on which problems are most
common
• The use of qualitative and quantitative analysis together allows one
to both understand what the problems are and prioritize the actions
to remediate them
• Analysis needs to be done at provincial level, regional level, and
national level

20. MDSR System
• Set Up
• Awareness creation among health care workers and the
community
• Process of the MDSR system (Identification, reporting
and reviewing of maternal deaths)
• Analysis (aggregation of multiple case reviews) -
perspective on national, regional and provincial level
• Dissemination of results
• Response
• M&E for MDSR

21. Dissemination of results
• Whom to inform of the results:
– Ministry of health; local, regional, and national health care
planners, policy-makers and politicians; professional
organizations and their members; social, security and the
private sector; academic institutions; community members;
national or local advocacy groups; the media; opinion leaders
who can promote and facilitate beneficial changes in local
customs; all those who participated in the survey
• Methods for dissemination of results:
– Team meetings; thematic seminars at facilities; community
meetings; radio programmes; printed reports; training
programmes; posters; video clips
• Publish the results:
– single facility death review report; facilities-based review report;
community-based review report

22. MDSR System
• Set Up
• Awareness creation among health care workers and the
community
• Process of the MDSR system (Identification, reporting
and reviewing of maternal deaths)
• Analysis (aggregation of multiple case reviews) -
perspective on national, regional and provincial level
• Dissemination of results
• Response
• M&E for MDSR

23. Response
• Taking action to prevent maternal deaths is the primary
objective of MDSR
• In most reviews, multiple problems will be identified, and
a number of potential actions will be recommended
• Possible actions include interventions in the community,
within health services, and in the public sector

24. MDSR System
• Set Up
• Awareness creation among health care workers and the
community
• Process of the MDSR system (Identification, reporting
and reviewing of maternal deaths)
• Analysis (aggregation of multiple case reviews) -
perspective on national, regional and provincial level
• Dissemination of results
• Response
• M&E for MDSR

25. M&E for MDSR
• Indicators for monitoring of MDSR
– Overall system indicators:
• Maternal death is a notifiable event
• National maternal death review task force exists that meets
regularly
• National maternal mortality report published annually
• % of facilities with maternal death review committees
• % of provinces with someone responsible for MDSR
– Identification and reporting:
• % of maternal deaths reported within 48 hours in facilities
• % of community maternal deaths reported within 1 week

27. M&E for MDSR…
– Review
• % of facilities with a review committee
• % of facility maternal deaths are reviewed
• % of verbal autopsies conducted for pregnancy related
deaths in community
• Regional maternal mortality review committee exists and
meets regularly to review facility and community deaths
• percentage of deaths reviewed by the region among
reported ones
– Response
• % of committee recommendations that are implemented at
facility level
• % of committee recommendations that are implemented at
community level

28. M&E for MDSR…
– Reports
• National Committee produces annual report
• Regional committee produces annual report
– Impact
• Case fatality rate (facility)
• National maternal mortality ratio
• Regional maternal mortality ratio
• In addition to the monitoring indicators,
periodically a more detailed evaluation is useful
• The evaluation of MDSR system should take
efficiency and effectiveness into consideration

29. Key messages
• Avoiding maternal death and improving quality of care is
possible, even in resource constrained settings.
Obtaining the right kind of information to guide action is
critical
• Every maternal death is a tragedy and should be a
notifiable event that is reviewed, discussed and that
leads to corrective actions to address the problems
encountered
• Understanding the underlying factors leading to the
deaths is critical to prevent future mortality

30. Key messages…..
• Data collection must be linked to action. A commitment
to act upon findings is a key prerequisite for success
• As a starting point, all maternal deaths in health facilities
and communities should be identified, reported,
reviewed and responded to with measures to prevent
future deaths

31. Thank You