Maternal death is one of the thorny problems of global health. Many different factors can cause a mother to lose her life – cultural attitudes about childbirth, geographical isolation, access to healthcare and the skill level of her healthcare providers. It’s difficult to save the lives of mother when you cannot identify what needs fixing.
In response to that challenge, the WHO developed a specific methodology known as Maternal Death Surveillance and Response (MDSR). Every country is now encouraged to have an MDSR system, which will “…generate data by ensuring that all deaths of women of reproductive age are notified, and that all probable maternal deaths are reviewed by experts. They promote methods that investigate all factors contributing to a mother’s death, such as verbal and social autopsy. And, crucially, they firmly couple surveillance and review to response – the process of generating evidence-based recommendations and using them to prevent similar maternal deaths.”
On Friday, WHO released the first global MDSR report. The report is not a collection of data on maternal death; it is too soon for that. Instead, it is an analysis of the current state of maternal mortality data and investigation. It outlines justification for using MDSR, paired with maternal death case descriptions that identify the kind of maternal deaths that better data can help prevent and a series of case studies of countries using MDSR. Overall, the report finds that most countries are committed to MDSR in theory but actual implementation of the system as intended to reduce maternal deaths varies greatly among countries.
According to the report, MDSR systems are essential because many maternal deaths, “…go completely unrecorded in countries that have weak systems for notifying vital events, or are misclassified under causes unrelated to motherhood. Maternal death reviews all too often focus solely on medical causes to the exclusion of other factors that may have contributed to a woman’s death, such as lack of transport or money to pay for care.” In addition, “Official reports underestimate the true magnitude by up to 30% worldwide and by 70% in some countries. This matters, because it is only by gathering and analyzing large volumes of quality data that we can identify trends in maternal mortality – including the causes of deaths and where they occur – and use the knowledge to target health programs and interventions that save women’s lives.”
The report describes the basics of an MDSR system: identification, investigation, and notification. To fulfill the requirement for identification and investigation, all deaths among women of reproductive age (15–49 years) in both health facilities and the community must be investigated to determine whether death occurred during pregnancy or the postpartum period. To fulfill the notification function, every suspected maternal death that occurs in a health facility must be notified to the MDR committee within 24 hours, and within 48 hours when a woman dies in the community.
Investigating maternal deaths contributes to both better data collection and vital statistics and the health system as a whole. Identifying health system gaps – such as poor emergency transportation – that lead to maternal death and resolving them increases quality of care for all patients.
Current Global State of MDSR
64 countries participated in the survey on maternal health data recording, and the WHO provided information on an additional 39 countries from its health system database. 86% of the countries had a requirement in place to notify all maternal deaths. 85% required that all maternal deaths be reviewed. However, only 46% of countries had maternal death review committees that met at least twice a year.
Obstacles to Collecting Better Data
The report summarizes six major obstacles to MDSR: 1) Awareness – health care providers, especially frontline workers, may not understand the importance of this kind of data collection 2) Blame culture – people involved in the process may withhold important information if they fear reprisals or disciplinary action following an MDR. 3). Staff and training – Many countries report having insufficient numbers at all levels to cover all the work needed to prepare for maternal death reviews. 4) Data collection – personnel may be unclear on the actual mechanics and timeline of data collection. 5) Follow-up and sustainability – the maternal death findings have to be acted on; the data collection and investigation must not be an end in themselves. 6) Financial resources – many countries simply don’t have the money to effectively collect this data, or act upon it.
What the Report Doesn’t Say
Access to safe abortion care is a key component of maternal health, yet it is mentioned in the briefest possible terms in this major report on maternal death. Even in the section on obstacles to improving maternal care and cultural barriers, there is no mention of abortion.
One sentence takeaway
Collecting honest data on maternal deaths gives us the information we need to save women’s lives.