Maternal Death Surveillance and Response: Looking Backward, Going Forward

ADAPTING OBSTETRIC SURVEILLANCE SYSTEMS FOR LMIC SETTINGS

In this issue of GHSP, Tura and colleagues⁶ report on a hospital-based obstetric surveillance system in eastern Ethiopia. Adapted for the Ethiopian context from obstetric surveillance systems used in high-income countries (HICs), the system collects information from 13 participating health care facilities in the region on selected maternal morbidities (hemorrhage, eclampsia, uterine rupture, sepsis, and severe anemia) and maternal deaths. Ten maternal deaths and 904 women with the morbidities of interest were reported among 17,317 live births in these facilities in the first 6 months. Staff were also trained to conduct confidential enquiries into maternal deaths (CEMD).

While this externally funded hospital-based surveillance project has worked well in the short term in 1 region, it is unclear how this approach will, in the longer term, contribute to improved maternal survival across Ethiopia. Considerable financial support would be needed to run another surveillance system in parallel to an existing national system. Long-term sustainability will require buy-in from the government and closer integration with national surveillance systems.

Tura et al. report that the existing national MDSR system reportedly captures less than 10% of maternal deaths. Underreporting of maternal deaths, albeit at lesser levels, occurs even in HICs.⁷ However, ensuring corrective actions (the “response”) are taken after reviewing even a small proportion of deaths could contribute to improvement to maternal health and survival.

The authors’ statement that “…while the MDSR is a facility-based review of maternal death by a multidisciplinary committee to identify the cause of the death and design an appropriate response for preventing similar deaths at that facility in the future, CEMD focuses on more general recommendations that extend beyond the review of a single case at a specific facility” misinterprets WHO guidance on MDSR.⁸ Well-functioning MDSR systems also include maternal deaths outside health facilities and corrective actions to recommend that go beyond the health care facility. Unlike HICs, where most births take place in hospitals and maternal deaths are rare, half of births in Ethiopia are still at home.⁹ The CEMD process, as reported by Tura et al., focuses only on maternal deaths in hospitals.

ESTABLISHING MDSR TAKES TIME

MDSR systems take time to establish and will encounter challenges in early implementation. WHO guidance on MDSR recommends a phased approach to implementation.⁸ The importance to “think big but to start small and grow gradually” cannot be overemphasized. Many LMICs have aspired to implement CEMD at the national level without first establishing good confidential (“no name”) and nonpunitive (“no blame”) audit practices at the facility and community levels. The first maternal death reviews in the United Kingdom were initiated by health care workers in Rochdale in northwestern England who were concerned with having the highest rate of maternal mortality in the country.¹⁰ This local practice was adopted in other jurisdictions over the following 2 decades leading to the establishment of the first national CEMD in 1952. Obstetric surveillance of maternal morbidities was established several decades later, only after maternal deaths had become uncommon.

Successful MDSR implementation can be expected to lead to improved quality of care and reduced maternal mortality. As noted by Willcox and colleagues¹¹ “the key context to enable effective death surveillance and response was a blame-free learning environment with good leadership.” The politicization of maternal death reviews and the fear of punitive actions and litigations, as reported from Ethiopia,^4,5 can be demotivating and lead to “a vicious cycle of under-reporting, inaccurate data, and inadequate review and recommendations, which lead to demotivation and disengagement.”¹¹ Lessons from this project and from global experiences on the facilitators and barriers to successful implementation should inform efforts to make the Ethiopian national MDSR system more effective.