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Project
Implementation of community-based maternal and perinatal death surveillance and response systems in high-burden countries
Maternal and perinatal mortality remain global public health concerns that share interconnected determinants and intervention approaches(1, 2). These outcomes serve as essential metrics for assessing population health status and healthcare quality across the pregnancy-postnatal continuum (3). Despite decades of global initiatives, the burden remains disproportionately high in specific regions, with sub-Saharan Africa accounting for approximately 70% of all maternal deaths worldwide and maintaining the highest regional maternal mortality ratio at 454 deaths per 100,000 live births (4). According to the World Health Organization (WHO)'s Trends in Maternal Mortality report, 65 countries continue to face moderate to very high maternal mortality ratios, with 55 countries recording 100-499 deaths and 10 countries exceeding 500 deaths per 100,000 live births (5). A main challenge in addressing this persistent problem is that many maternal and perinatal deaths go unreported, particularly at the community level where surveillance systems are often weakest in the highest-burden settings.
Sustainable Development Goal (SDG) Targets 3.1 and 3.2 calls for reducing the global maternal mortality ratio to less than 70 per 100,000 live births, and an end preventable deaths of newborns and children under 5 years of age by 2030 (1, 6). Achieving these targets will require countryspecific strategies tailored to local contexts (1). For maternal health programs to be effective, they must be built upon a comprehensive understanding of the evolving epidemiological landscape and the predominant causes of maternal death in each setting (7). A vital component of any maternal mortality reduction strategy is a robust surveillance system that tracks deaths and provides critical information about causes, underlying contributing factors, and potential preventive actions (8). Maternal and perinatal death surveillance and response (MPDSR) represents such a system. MPDSR involves the routine identification and timely notification of maternal and perinatal deaths to appropriate stakeholders, reviewing the causes and circumstances surrounding these deaths, and implementing actions to prevent future avoidable deaths (3). MPDSR entails thorough in-depth investigations into the causes and circumstances of maternal and perinatal deaths, serving as an integral part of quality improvement initiatives aimed at reducing maternal, stillbirth, and neonatal deaths (9). It addresses modifiable factors contributing to maternal or perinatal deaths by monitoring the implementation of recommendations and establishing accountability (10, 11). The MPDSR process comprises both quantitative (counting deaths) and qualitative (understanding the causes of death) components within a continuous action and surveillance cycle (See Figure 1) (3).
In many countries with weak health information systems, civil and vital registration systems are lacking or incomplete (12). This leads decision-makers to rely on alternative approaches to estimate maternal mortality. These approaches include population-based surveys, fertility rate calculations, and analysis of hospital records (13). Such measurement methods often produce estimates with wide confidence intervals, limiting their effectiveness in guiding specific local interventions (14). To quantify maternal mortality ratio (MMR), several specific survey methodologies are commonly employed. National Demographic Health Surveys (conducted every five years) and the Multiple Indicator Cluster Surveys both utilize the sisterhood method for maternal mortality estimation, though these approaches focus on identifying pregnancy-related deaths rather than maternal deaths specifically (13). More comprehensive methods such as national census data collection occur only once per decade, require highly trained enumerators, and involve extensive data gathering operations. Another approach, the Reproductive-Age Mortality Surveys (RAMOS), has been employed in various contexts to improve the identification of maternal deaths through multiple sources of information (15). However, RAMOS have limited utility at the population and national levels due to its complexity, time-consuming nature, and 2 relatively high cost. Additionally, RAMOS may lack accuracy in settings where a significant proportion of deliveries occur at home outside formal health facilities (16).
MPDSR contributes to the accurate documentation of maternal deaths by establishing continuous processes for identifying, notifying, reviewing, and responding to each death. Unlike periodic surveys that provide infrequent estimates or incomplete civil registration mechanisms, MPDSR promotes real-time death reporting, helping to bridge major data gaps in many low- and middleincome countries (8). While population surveys offer statistical estimates, MPDSR complements these by capturing actual deaths that might otherwise go unrecorded in formal systems (17). Importantly, MPDSR does not just document deaths but investigates their causes through thorough reviews, identifying specific clinical, facility, and system-level factors that contributed to each death. This understanding of causation directly informs targeted preventive actions. This comprehensive approach positions MPDSR as a valuable component of maternal mortality prevention strategies, particularly as countries strive to meet the SDG 3.1 target for reducing maternal mortality (8) (18).
The evolution of the MPDSR process began with the WHO’s Beyond the Numbers initiative in 2004 (19). In 2013, WHO and its partners developed technical guidelines for maternal death surveillance and response (MDSR), linking surveillance data with response efforts to strengthen accountability (20). Building on this progress, the Every New-born Action Plan (21), and Making Every Baby Count guidelines (22), became integrated into the MPDSR process in 2017 (22). Implementation of MPDSR can vary across contexts, utilizing various approaches such as maternal and/or perinatal death reviews, community-based reviews, and confidential inquiries into maternal deaths (23). There are two main types of MPDSR, distinguished by where deaths are identified and reviewed. Facility-based MPDSR focuses on deaths occurring within health facilities, where healthcare staff conduct reviews to identify medical and system-related causes, leading to action plans aimed at improving in-facility care. In contrast, community-based MPDSR (c-MPDSR) is designed to identify and review deaths that occur outside the health system, particularly in contexts where home births and unreported deaths are common. It involves community health workers and community structures to gather critical information about the circumstances of death, including socio-cultural and systemic factors (8). In areas where a high proportion of births and deaths occur outside health facilities, integrating c-MPDSR with facilitybased processes is recommended to ensure a comprehensive understanding of maternal and perinatal mortality (18, 24).
The c-MPDSR process begins with the identification and notification of deaths at the community level, followed by verbal and social autopsies. These reviews generate context-specific recommendations, which require coordinated action. Broad stakeholder involvement is essential for effective implementation. Community members play a key role by contributing local knowledge on social norms, delays in care-seeking, traditional practices, and quality of care challenges (8, 25). Their engagement throughout the process supports local ownership. Additionally, they can engage in advocacy with healthcare providers and policymakers to promote the adoption and implementation of recommendations that emerge from the review process (26).
Sustainable Development Goal (SDG) Targets 3.1 and 3.2 calls for reducing the global maternal mortality ratio to less than 70 per 100,000 live births, and an end preventable deaths of newborns and children under 5 years of age by 2030 (1, 6). Achieving these targets will require countryspecific strategies tailored to local contexts (1). For maternal health programs to be effective, they must be built upon a comprehensive understanding of the evolving epidemiological landscape and the predominant causes of maternal death in each setting (7). A vital component of any maternal mortality reduction strategy is a robust surveillance system that tracks deaths and provides critical information about causes, underlying contributing factors, and potential preventive actions (8). Maternal and perinatal death surveillance and response (MPDSR) represents such a system. MPDSR involves the routine identification and timely notification of maternal and perinatal deaths to appropriate stakeholders, reviewing the causes and circumstances surrounding these deaths, and implementing actions to prevent future avoidable deaths (3). MPDSR entails thorough in-depth investigations into the causes and circumstances of maternal and perinatal deaths, serving as an integral part of quality improvement initiatives aimed at reducing maternal, stillbirth, and neonatal deaths (9). It addresses modifiable factors contributing to maternal or perinatal deaths by monitoring the implementation of recommendations and establishing accountability (10, 11). The MPDSR process comprises both quantitative (counting deaths) and qualitative (understanding the causes of death) components within a continuous action and surveillance cycle (See Figure 1) (3).
In many countries with weak health information systems, civil and vital registration systems are lacking or incomplete (12). This leads decision-makers to rely on alternative approaches to estimate maternal mortality. These approaches include population-based surveys, fertility rate calculations, and analysis of hospital records (13). Such measurement methods often produce estimates with wide confidence intervals, limiting their effectiveness in guiding specific local interventions (14). To quantify maternal mortality ratio (MMR), several specific survey methodologies are commonly employed. National Demographic Health Surveys (conducted every five years) and the Multiple Indicator Cluster Surveys both utilize the sisterhood method for maternal mortality estimation, though these approaches focus on identifying pregnancy-related deaths rather than maternal deaths specifically (13). More comprehensive methods such as national census data collection occur only once per decade, require highly trained enumerators, and involve extensive data gathering operations. Another approach, the Reproductive-Age Mortality Surveys (RAMOS), has been employed in various contexts to improve the identification of maternal deaths through multiple sources of information (15). However, RAMOS have limited utility at the population and national levels due to its complexity, time-consuming nature, and 2 relatively high cost. Additionally, RAMOS may lack accuracy in settings where a significant proportion of deliveries occur at home outside formal health facilities (16).
MPDSR contributes to the accurate documentation of maternal deaths by establishing continuous processes for identifying, notifying, reviewing, and responding to each death. Unlike periodic surveys that provide infrequent estimates or incomplete civil registration mechanisms, MPDSR promotes real-time death reporting, helping to bridge major data gaps in many low- and middleincome countries (8). While population surveys offer statistical estimates, MPDSR complements these by capturing actual deaths that might otherwise go unrecorded in formal systems (17). Importantly, MPDSR does not just document deaths but investigates their causes through thorough reviews, identifying specific clinical, facility, and system-level factors that contributed to each death. This understanding of causation directly informs targeted preventive actions. This comprehensive approach positions MPDSR as a valuable component of maternal mortality prevention strategies, particularly as countries strive to meet the SDG 3.1 target for reducing maternal mortality (8) (18).
The evolution of the MPDSR process began with the WHO’s Beyond the Numbers initiative in 2004 (19). In 2013, WHO and its partners developed technical guidelines for maternal death surveillance and response (MDSR), linking surveillance data with response efforts to strengthen accountability (20). Building on this progress, the Every New-born Action Plan (21), and Making Every Baby Count guidelines (22), became integrated into the MPDSR process in 2017 (22). Implementation of MPDSR can vary across contexts, utilizing various approaches such as maternal and/or perinatal death reviews, community-based reviews, and confidential inquiries into maternal deaths (23). There are two main types of MPDSR, distinguished by where deaths are identified and reviewed. Facility-based MPDSR focuses on deaths occurring within health facilities, where healthcare staff conduct reviews to identify medical and system-related causes, leading to action plans aimed at improving in-facility care. In contrast, community-based MPDSR (c-MPDSR) is designed to identify and review deaths that occur outside the health system, particularly in contexts where home births and unreported deaths are common. It involves community health workers and community structures to gather critical information about the circumstances of death, including socio-cultural and systemic factors (8). In areas where a high proportion of births and deaths occur outside health facilities, integrating c-MPDSR with facilitybased processes is recommended to ensure a comprehensive understanding of maternal and perinatal mortality (18, 24).
The c-MPDSR process begins with the identification and notification of deaths at the community level, followed by verbal and social autopsies. These reviews generate context-specific recommendations, which require coordinated action. Broad stakeholder involvement is essential for effective implementation. Community members play a key role by contributing local knowledge on social norms, delays in care-seeking, traditional practices, and quality of care challenges (8, 25). Their engagement throughout the process supports local ownership. Additionally, they can engage in advocacy with healthcare providers and policymakers to promote the adoption and implementation of recommendations that emerge from the review process (26).
Date:15 Oct 2025 → Today
Disciplines:Gynaecology and obstetrics not elsewhere classified
Project type:PhD project