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. 2022 Nov 2;101(1):62–75G. doi: 10.2471/BLT.22.288703

Maternal and perinatal death surveillance and response: a systematic review of qualitative studies

Surveillance des décès maternels et périnatals et riposte: revue systématique d'études qualitatives

Vigilancia y respuesta a la mortalidad materna y perinatal: una revisión sistemática de los estudios cualitativos

مراقبة وفيات الأمهات ووفيات الفترة المحيطة بالولادة والاستجابة لها: مراجعة منهجية للدراسات النوعية

实施孕产妇和围产期死亡监测和响应：一项对定性研究的系统评价

Эпиднадзор за материнской и перинатальной смертностью и ответные меры: систематический обзор качественных исследований

Merlin L Willcox a,✉, Immaculate A Okello a, Alice Maidwell-Smith a, Abera K Tura b, Thomas van den Akker c, Marian Knight d
PMCID: PMC9795385  PMID: 36593778

Abstract

Objective

To understand the experiences and perceptions of people implementing maternal and/or perinatal death surveillance and response in low- and middle-income countries, and the mechanisms by which this process can achieve its intended outcomes.

Methods

In June 2022, we systematically searched seven databases for qualitative studies of stakeholders implementing maternal and/or perinatal death surveillance and response in low- and middle-income countries. Two reviewers independently screened articles and assessed their quality. We used thematic synthesis to derive descriptive themes and a realist approach to understand the context–mechanism–outcome configurations.

Findings

Fifty-nine studies met the inclusion criteria. Good outcomes (improved quality of care or reduced mortality) were underpinned by a functional action cycle. Mechanisms for effective death surveillance and response included learning, vigilance and implementation of recommendations which motivated further engagement. The key context to enable effective death surveillance and response was a blame-free learning environment with good leadership. Inadequate outcomes (lack of improvement in care and mortality and discontinuation of death surveillance and response) resulted from a vicious cycle of under-reporting, inaccurate data, and inadequate review and recommendations, which led to demotivation and disengagement. Some harmful outcomes were reported, such as inappropriate referrals and worsened staff shortages, which resulted from a fear of negative consequences, including blame, disciplinary action or litigation.

Conclusion

Conditions needed for effective maternal and/or perinatal death surveillance and response include: separation of the process from litigation and disciplinary procedures; comprehensive guidelines and training; adequate resources to implement recommendations; and supportive supervision to enable safe learning.

Introduction

Many low- and middle-income countries are still far from attaining the sustainable development goals to reduce maternal and child mortality; one of the main obstacles is poor quality of health care.1 In 2004, the World Health Organization (WHO) recommended that all countries implement maternal death reviews,2 and in 2013 recommended all countries implement maternal death surveillance and response,3 to which perinatal deaths were added in 2016.4 Guidance on maternal and perinatal death surveillance and response was published in 2021.5 The existing programme theory, describing how the mortality audit cycle should function, is shown in Fig. 1 and Box 1.2–5

Fig. 1.

Fig. 1

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Maternal and perinatal death surveillance and response cycle

Box 1. Programme theory for maternal and perinatal death surveillance and response.

Identifying and reporting

All maternal and perinatal deaths should be reported to produce valid statistics on mortality.

Collecting information

A truthful and complete account of the patient’s symptoms, treatment-seeking and management before their death should be obtained from verbal and/or social autopsy interviews, medical records and reports from health workers.

Reviewing and analysing information

The committee reviewing the account should reliably identify the cause of death and avoidable factors.

Recommending solutions

The committee should make effective recommendations to avoid recurrence of the same scenario.

Implementing changes

The recommendations made by the committee should be implemented.

Evaluating and refining

The implementation of the entire audit cycle should be monitored and, if necessary, changes should be made to achieve the desired goal of reducing maternal and perinatal mortality.

In a survey of low- and middle-income countries, 85% (88/103) had a national policy to review all maternal deaths.6 Most low- and middle-income countries that succeeded in reducing maternal and child mortality used some form of death reporting system to monitor progress, but only a minority used the full maternal and perinatal death surveillance and response cycle.7

Implementation of maternal and perinatal death surveillance and response in low- and middle-income countries is challenging because resources are more constrained than in high-income settings, but the opportunities to achieve a significant impact are greater. Maternal death reviews can reduce maternal mortality by up to 35% (odds ratio; OR: 0.65; 95% confidence interval, CI: 0.55–0.77) and perinatal death reviews have been associated with a 30% reduction in perinatal mortality (OR: 0.70; 95% CI: 0.62–0.79).8–10 However, these data from health facility studies represent a best-case scenario. When scaling up to the national level, the outcomes are more heterogeneous. For example, among 35 facilities that have been part of the South African Perinatal Problem Identification Programme for at least 5 years, perinatal mortality declined in four facilities, increased in five, and did not change in the remaining 26 facilities.11,12

The reasons for this heterogeneity in effectiveness are unclear. Several scoping reviews describe different maternal and perinatal death surveillance and response processes in sub-Saharan Africa and low- and middle-income countries, some with contradictory interpretations.13–15 While one review suggested that the most important mechanisms for accountability were disciplinary action, legal redress and social reprisals,13 another review reported that fear of blame and punitive approaches undermined the process.14 These reviews highlight the need for more research on death surveillance and review processes, the context in which they are conducted,14 and the subjective experiences of individuals implementing maternal and perinatal death surveillance and response in different settings.15 None of the previous reviews systematically analysed qualitative studies or took a realist approach to understanding why maternal and perinatal death surveillance and response systems achieve positive or negative outcomes in different contexts.

Therefore, in this systematic review, we aimed to understand the experiences of people implementing maternal and perinatal death surveillance and response in low- and middle-income countries. We sought to understand the mechanisms by which this process achieves (or fails to achieve) its intended outcomes, and the contexts that trigger these mechanisms.

Methods

We conducted a systematic review of qualitative studies. The protocol was registered on PROSPERO (PROSPERO 2021 CRD42021271527).

Literature search

We searched seven databases from their inception to June 2022: CINAHL, MEDLINE®, Embase®, ProQuest Dissertations and Theses, Global Index Medicus, Web of Science and Google Scholar. We used a pre-planned strategy including terms for maternal or perinatal death reviews from a Cochrane review10 and a search filter for qualitative studies (see strategy in first data repository).16

Study selection

Two reviewers independently screened titles and abstracts against the inclusion criteria: studies using qualitative data collection and analysis methods, including participants who were involved in implementation of any part of the maternal and perinatal death surveillance and response process in low- and middle-income countries – including verbal and/or social autopsy when these involved investigation of maternal or perinatal deaths. We had no language restrictions. The reviewers then assessed the full text of the selected studies. We resolved disagreements by discussion with a third reviewer.

Critical appraisal

One of the reviewers evaluated the quality of the included full-text articles using the Critical Appraisal Skills Programme tool for qualitative studies.17 The second reviewer independently evaluated a randomly selected 10% of the included articles; we found no significant disagreements.

Data extraction and analysis

We imported studies into NVivo, version 12 (QSR International Inc., Burlington, MA, United States of America). We used a thematic synthesis approach:18 two authors developed a preliminary coding frame based on a sample of studies and refined this further by discussion. Higher-order categories of codes were deductive (barriers and enablers) but lower-order categories were developed inductively and iteratively from the data in the texts. We coded subsequent studies line by line, focusing on the results and discussion sections, and created new codes when considered necessary. We used the codes to develop descriptive themes. To develop higher-order analytical themes, we used a realist approach.19 We recoded the included articles specifically looking for contexts, mechanisms, outcomes and context–mechanism–outcome configurations.19,20 We used these configurations to construct flow diagrams showing causal links and to refine the programme theory for maternal and perinatal death surveillance and response.

Results

Studies included

The initial searches yielded a total of 5137 articles after removal of duplicates. After screening, we finally included 58 publications, reporting on 59 different studies (Fig. 2).21–78 These studies included over 1891 participants from 30 low- and middle-income countries, ranging from community members to health workers and national-level stakeholders involved in implementation of maternal death reviews or maternal and perinatal death surveillance and response.

Fig. 2.

Fig. 2

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Flowchart of the selection of studies in the systematic review on maternal and perinatal death surveillance and response

Most studies (34/59) focused on maternal deaths (25 on maternal death reviews and nine on maternal death surveillance and response), 19 included both maternal and perinatal deaths, and six studies considered only perinatal or neonatal deaths (Table 1; available at: https://www.who.int/publications/journals/bulletin/). The overall effectiveness of the process was perceived as good (improved quality of care or reduced mortality) in 16 studies, inadequate in 21 studies and mixed in five studies; the perceived effectiveness was not reported in 17 studies. All studies were of sufficient quality (see details in the first data repository),16 although most did not adequately consider the relationship between the researcher and the participants.

Table 1. Studies on maternal and perinatal death surveillance and response included in the review.

Study Country, context Type of death Type of review Perceived effectiveness of process Study design Data collection method No. and type of participants Type of analysis
Abbakar, 202121 Sudan, national Maternal Maternal death surveillance and response Inadequate Qualitative  In-depth interviews 54 maternal death surveillance and response staff, doctors and midwives Thematic analysis
Abebe, et al., 201722 Ethiopia, national Maternal Maternal death surveillance and response Successful Qualitative Individual and group interviews 69 frontline staff responsible for implementation of maternal death surveillance and response Thematic content analysis
Aborigo et al., 201323 Ghana, community All Verbal autopsy Not specified Qualitative In-depth interviews 36 bereaved families, field staff, physicians and local leaders Thematic analysis
Afayo, 201824 Uganda, health facility Maternal Maternal death surveillance and response Inadequate Mixed methods  In-depth interviews 11 hospital staff and maternal death surveillance and response committee members Thematic content analysis
Agaro et al., 201625 Uganda, district health facility Maternal and perinatal Maternal and perinatal death surveillance and response Inadequate Mixed methods Semi-structured interviews 76: 66 health workers and 10 key informants Thematic content analysis
Armstrong et al., 201426 United Republic of Tanzania, multiple levels Maternal and perinatal Maternal and perinatal death review Inadequate Qualitative Document review and interviews 37: 20 hospital staff, 12 district or regional coordinators, 5 national experts Adapted thematic analysis
Ayele et al., 201927 Ethiopia, health facility and community Maternal and perinatal Maternal and perinatal death surveillance and response Inadequate Mixed methods In-depth interviews and focus group discussions 25 women group leaders in 3 focus groups; 11 health managers in in-depth interviews Thematic content analysis
Bakker et al., 201128 Malawi, health facility (rural and district) Maternal Maternal death review Successful Qualitative In-depth interviews, focus group discussions and observation 25 health workers Not specified
Balogun & Musoke, 201429 Sudan, national Maternal Maternal death review Inadequate Qualitative In-depth interviews and focus group discussions Medical and health stakeholders at the national, state and facility level in 12 in-depth interviews and 18 focus group discussions Qualitative content analysis
Bandali et al., 201930 Kenya, hospital and health centre Maternal and perinatal Maternal and perinatal death surveillance and response Successful Mixed methods In-depth interviews and focus group discussions 5 health records information officers (interviews); maternal and perinatal death surveillance and response committee members (4 discussion groups) Thematic analysis
Belizán et al., 201131 South Africa, health facility Perinatal Perinatal Problem Identification Programme Not specified Qualitative Focus group and workshop 48 clinicians and coordinators in the Perinatal Problem Identification Programme in 4 focus group discussions Framework analysis using stages-of-change model
Boyi Hounsou et al., 202261 Benin, health district Maternal Maternal death review Inadequate Mixed methods Online group discussions 34 district medical officers in two online group discussions Inductive thematic analysis
Biswas et al., 201433 Bangladesh, community Maternal, perinatal and neonatal Maternal and perinatal death review Successful Mixed methods In-depth interviews and focus group discussions Health workers and community volunteers in 4 focus group discussions and 4 in-depth interviews Thematic analysis
Biswas et al., 201534 Bangladesh, health facility Maternal, perinatal and neonatal Maternal and perinatal death review Successful Qualitative In-depth interviews, focus group discussions and document review 46 health workers implementing facility death review: 35 in in-depth interviews; 11 in focus group discussions Thematic analysis
Biswas et al., 201532 Bangladesh, community Maternal, perinatal and neonatal Verbal autopsy Successful Qualitative In-depth interviews, focus group discussions and participant observation Health-care providers: 3 focus group discussions, 6 in-depth interviews, 6 participant observations Thematic analysis
Biswas et al., 201635 Bangladesh, community Maternal, perinatal and neonatal Social autopsy Successful Qualitative In-depth interviews, focus group discussions, observation and document review Health inspectors in 9 focus group discussions; 18 health workers and 12 community members in in-depth interviews Content and thematic analysis
Bvumbwe, 201962 Malawi, health facility Maternal Maternal death review Inadequate Qualitative In-depth interviews and focus group discussions 42 maternal death review committee members and 32 midwives: 4 focus group discussions with midwives; 4 focus group discussions with committee members; and 3 in-depth interviews with health zone technical officers Thematic analysis
Cahyanti et al., 202136 Indonesia, district health facility Maternal Maternal death review Inadequate Qualitative Focus group discussions 29 district audit committee members in 4 focus group discussions Thematic analysis
Chirwa et al., 202263 Malawi, district hospital Maternal Maternal death review Inadequate Qualitative In-depth interviews and focus group discussions 40 nurse midwives Thematic content analysis
Combs Thorsen et al., 201437 Malawi, urban health facility Maternal Maternal death review Not specified Mixed methods Observation of participants of death review process Observed data collection from bereaved family, health workers and medical records Content analysis
Compaoré et al., 202264 Ghana, health facility Maternal Maternal death review Inadequate Mixed methods In-depth interviews Health workers and managers Not specified
Compaoré et al., 202265 Liberia, county, health facility and community Maternal and perinatal Maternal and perinatal death surveillance and response Inadequate Mixed methods In-depth interviews County-level health personnel, health facility staff, community health workers Not specified
Congo et al., 201738, 202266,67 Burkina Faso, regional and district hospital Maternal Maternal death review Inadequate Qualitative In-depth interviews and document review 73 health workers in maternity, pharmacy and laboratory units, and staff in administration and management Framework analysis
Dartey & Ganga-Limando, 201478 Ghana, district hospital, regional referral hospital and teaching hospital Maternal Maternal death review Successful Qualitative In-depth interviews 20 midwives involved in maternal death reviews Thematic content analysis
Dartey, 2016 39 Ghana, health centre, district hospital, regional referral hospital and teaching hospital Maternal Maternal death review Successful Mixed methods In-depth interviews and focus group discussions 39 midwives involved in maternal death review: 18 in-depth interviews and 8 focus group discussions Thematic content analysis
de Kok et al., 201740 Nigeria, health facility Maternal Maternal death review Not specified Qualitative Observation of review meetings Audit review team Conversation and discourse analysis
Diallo et al., 202268 Burkina Faso, district hospital Maternal Maternal death review Inadequate Qualitative In-depth interviews 9 midwives Inductive thematic analysis
Dortonne et al., 200941 Senegal and Mali, hospitals Maternal Maternal death review Successful Mixed methods Questionnaires, checklist, interviews and document analyses 39: 23 maternal death audit committee members and 16 national-level leaders Not specified
Dumont et al., 200942 Senegal, health facility Maternal Maternal death review Successful Mixed methods In-depth interviews, focus group discussions, participant observation and document reviews Health workers (maternal health) in 3 focus group discussions and 9 in-depth interviews Thematic analysis
Gao et al., 200943 China, health facility, community Maternal Maternal death surveillance and response Inadequate Mixed methods Interviews, field observations and review of reports and audits 18: 12 hospital leaders, 6 maternal and child health workers Not specified
Hartsell, 201045 United Republic of Tanzania, all levels (national, regional, district and health facility) including private and public facilities Maternal Maternal death review Not specified Descriptive qualitative case study In-depth interviews, observation and document reviews 15 health workers involved in data management of maternal deaths and deliveries Not specified
Hofman et al., 201446 Nigeria, hospital Maternal Maternal death review Not specified Mixed methods In-depth interviews Members of the maternal death review committee of 11 hospitals (number not specified) Thematic framework
Jati et al., 201969 Indonesia, urban health facilities and local government in Semarang Perinatal Perinatal death surveillance and response Not specified Qualitative Focus group discussions 20 local government officials and representatives of health facilities  
Jepkosgei et al., 202247 Kenya, hospital Neonatal Neonatal death review Not specified Exploratory qualitative study In-depth interviews, non-participant observation of morbidity and mortality meetings Nurses and doctors: 17 in-depth interviews and 12 morbidity and mortality meetings Thematic content analysis
Karimi et al., 201848 Iran (Islamic Republic of), national, institutional (teaching universities) and health facility Maternal Maternal death surveillance and response Successful Qualitative Review of documents and key informant interviews 15: 3 health ministry deputies, 10 medical university staff, 2 staff in obstetrics units of specialized hospitals Thematic
Khader et al., 202070 Jordan, health facility Perinatal Perinatal death audits Not specified Qualitative Focus group discussions Paediatricians, obstetricians, nurses, midwives in 16 focus group discussions Thematic content analysis
Kinney et al., 202049 Nigeria, United Republic of Tanzania, Zimbabwe, health facility Maternal and perinatal Maternal and perinatal death surveillance and response Mixed Mixed methods Interviews and observation 41: 4 national stakeholders and 37 regional and district government health officials supporting maternal and perinatal death surveillance and response Thematic content analysis
Kongnyuy et al., 200850 Malawi, health facility Maternal Maternal death review Successful Mixed methods Focus group discussions 60: maternal and neonatal health workers implementing the facility maternal death review and quality improvement team members SWOT analysis
Kouanda et al., 202271 Burundi, hospital Maternal and perinatal Maternal and perinatal death surveillance and response Mixed Qualitative In-depth interviews 26 officials of the health ministry, hospital officers, officers of health regions and districts, and obstetricians and gynaecologists and midwives Thematic analysis
Kouanda et al., 202272 Chad, hospital (national, and district) Maternal Maternal death surveillance and response Inadequate Qualitative In-depth interviews 25 officials at the central level, staff of technical and financial partners (WHO, UNFPA, UNICEF) and obstetricians and gynaecologists Thematic analysis
Melberg et al., 201951 and 202073 Ethiopia, public health facility Maternal Maternal and perinatal death surveillance and response Inadequate Qualitative In-depth interviews and observation 46: 11 primary caregivers who had experienced perinatal deaths, 5 men who had lost their partner to a maternal death, 4 health extension workers, 7 health workers in general and referral hospitals, 13 health workers in health centres, 6 health administrators responsible for implementation of maternal and perinatal death surveillance and response Thematic content analysis
Muffler et al., 200752 Morocco, health facility Maternal Maternal death review Not specified Mixed methods In-depth interviews 56 implementers in the audit process Systematic content analysis
Mukinda et al., 202174 South Africa, health district and subdistrict Maternal and perinatal Maternal and perinatal death surveillance and response Mixed Descriptive qualitative case study In-depth interviews and observation 45 frontline health managers and providers involved with maternal, perinatal, neonatal and child death surveillance and response Thematic analysis
Muvuka, 201953 Democratic Republic of the Congo, hospital and health facility Maternal Maternal death surveillance and response Mixed Qualitative In-depth interviews, document review and observation of one maternal death review session 15 maternal death surveillance and response focal persons and members of maternal death review teams Inductive thematic analysis
Nyamtema et al., 201054 United Republic of Tanzania, hospital and health facility Maternal and perinatal Maternal and perinatal death review Inadequate Mixed methods In-depth interviews and semi-structured questionnaire 59: 29 health managers and 30 health-care providers Qualitative content analysis
Owolabi et al., 201455 Malawi, health facility Maternal Maternal death review Not specified Mixed methods In-depth interviews 8 individuals involved in implementing maternal death review Thematic analysis
Patel et al., 200756 India, community Neonatal Community neonatal death audits Not specified Qualitative In-depth interviews and focus group discussions Community members and family of the deceased in 3 in-depth interviews and 6 focus group discussions. Also included field staff from a subsequent study Deductive thematic analysis
Richard, 200975 Burkina Faso, urban district hospital Maternal and perinatal Maternal and perinatal death review Not specified Mixed methods In-depth interviews 35 members of staff from maternity and surgical departments Thematic analysis
Russell, 202276 International, international expert consultation meeting Maternal and perinatal Maternal and perinatal death surveillance and response Not specified Qualitative In-depth interviews and group interviews 55 health workers with experience in maternal and/or newborn health in humanitarian settings, and/or programmatic or research experience in maternal and perinatal death surveillance and response Thematic analysis
Said et al., 202157 United Republic of Tanzania, health facility Maternal Maternal death surveillance and response Inadequate Qualitative In-depth interviews 60 involved in maternal death surveillance and response activities: 30 health providers in focus group discussions; 30 health managers in in-depth interviews Inductive thematic analysis
Tayebwa et al., 202058 Rwanda, health facility Maternal and perinatal Maternal and perinatal death surveillance and response Not specified Mixed methods Desk reviews,in-depth interviews and observations 23: type not stated Not specified
Upadhyaya et al., 201259 India, district and peripheral health facility, community and/or village Infant Infant death review Successful Mixed methods In-depth interviews and review of documents 38 health-care providers involved in programme activities Content analysis
van Hamersveld et al., 201244 United Republic of Tanzania, district hospital Maternal and perinatal Maternal and perinatal death review Inadequate Qualitative Participant observation and  in-depth interviews 23 health workers and managers Inductive thematic analysis
WHO 201460 India, all levels (national, regional, facility and community) Maternal Maternal death review Successful Mixed methods Review of documents and reports, interviews and observations Stakeholders at national, state and district levels Not specified
Indonesia, all levels (national, regional, facility and community) Maternal Maternal death review Mixed Mixed methods Review of documents and reports, and interviews Informants from the health ministry, district health office, hospitals and health centres Not specified
Sri Lanka, national Maternal Maternal death review Successful Mixed methods Stakeholder workshop and  in-depth interviews 20 former secretaries of health, former directors of the Family Health Bureau, provincial administrators, clinicians, representatives of professional colleges, national programme managers and representatives from international NGOs Not specified
Nepal, national Maternal Maternal death review Not specified Mixed methods Document review, in-depth interviews and stakeholder workshop 27: 16 doctors, 4 staff nurses, 5 medical recorders and 2 programme managers from 10 hospitals Not specified
Myanmar, national Maternal Maternal death review Not specified Mixed methods In-depth interviews 10–12 participants from 10 townships including township medical officer, obstetricians, township health nurse, station medical officers, focal persons of a rural health centre, and midwives Not specified
Yameogo et al., 202277 Burkina Faso, health district (urban and rural) Maternal Maternal death surveillance and response Inadequate Qualitative In-depth interviews 23: 3 technical and financial partners, 2 central level managers, 2 regional health directors, 4 district management team members, 8 health-care providers and 4 community health workers Thematic analysis
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NGO: nongovernmental organization; SWOT: strengths, weaknesses, opportunities and threats; UNFPA: United Nations Population Fund; UNICEF: United Nations Children’s Fund; WHO: World Health Organization.

Two overarching programme theories emerged from our review of the studies: (i) a refined version of the classic action cycle, which explains how functional maternal and perinatal death surveillance and response systems reduce maternal and perinatal mortality (Fig. 3 and Table 2; full table in the second data repository);79 and (ii) the vicious cycle, which explains how dysfunctional systems can fail to achieve their intended objectives, or worse, lead to unintended harmful outcomes (Fig. 4 and Table 3; full table in the second data repository).79

Fig. 3.

Fig. 3

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Action cycle of a functional maternal and perinatal death surveillance and response process

Table 2. Mechanisms and contexts underlying functional maternal and perinatal death surveillance and response systems.

Key mechanisms driving good outcomes Key contexts that enable these mechanisms to operate Examples, study and countrya
Preparing for implementation Supportive national policy Biswas et al., Bangladesh33
Clear guidelines Biswas et al., Bangladesh35
Comprehensive training of all stakeholders Agaro et al., Uganda25
Bandali et al., Kenya30
Good, committed and supportive leadership and drivers at all levels Belizán et al., South Africa31
Dortonne et al., Senegal and Mali41
Blame-free learning environment Jepkosgei et al., Kenya47
Implementing comprehensive death reporting Clear responsibilities Biswas et al., Bangladesh34
Clear lines of communication Said et al., United Republic of Tanzania57
Collecting accurate information Clear, accurate documentation Biswas et al., Bangladesh34
Secure storage of records Muvuka, Democratic Republic of the Congo53
User-friendly forms WHO, Nepal60
Appropriate timing to interview families Aborigo et al., Ghana23
Appropriate person to interview families Biswas et al., Bangladesh33
Dumont et al., Senegal42
Validation of data Aborigo et al., Ghana23
Biswas et al., Bangladesh32
Learning through participation in reflective review and analysis Inclusive multidisciplinary review committee with key stakeholders, working as a team Bandali et al., Kenya30
Muvuka, Democratic Republic of the Congo53
Clear communication about meetings Congo et al., Burkina Faso38
Meetings embedded into routine work responsibilities Belizán et al., South Africa31
Muvuka, Democratic Republic of the Congo53
Good attendance at review meetings Bakker et al., Malawi28
Refreshments for staff at meetings Jepkosgei et al., Kenya47
Skilled chairing to ensure the discussion is confidential, anonymous, blame-free (but with accountability), participatory, focused and time-efficient, and a useful learning experience for all involved Armstrong et al., United Republic of Tanzania26
de Kok et al., Nigeria40
Jepkosgei et al., Kenya47
Structured discussion Jepkosgei et al., Kenya47
Evaluation of care against accepted standards Cahyanti et al., Indonesia36
Kongnyuy et al., Malawi50
Recommending achievable solutions Focus on achievable goals Bandali et al., Kenya30
Involvement of the people who will need to implement the solutions Bandali et al., Kenya30
Biswas et al., Bangladesh35
Kinney et al., Zimbabwe49
Clear assignment of responsibility for each recommendation Belizán et al., South Africa31
van Hamersveld et al., United Republic of Tanzania44
Documentation of the recommendations and dissemination to all relevant stakeholders Bandali et al., Kenya30
Muvuka, Democratic Republic of the Congo53
Implementing changes Changes that can be incorporated within existing budget and workplan; sufficient resources to implement them Abebe et al., Ethiopia22
Agaro et al., Uganda25
Direct learning from the review Biswas et al., Bangladesh35
Said et al., United Republic of Tanzania57
Emotional impact of the review Dartey, Ghana39
Richard et al., Burkina Faso75
Vigilance because of the review process van Hamersveld et al., United Republic of Tanzania44
Muvuka, Democratic Republic of the Congo53
Communities motivated to raise funds Hofman & Mohammed, Nigeria46
WHO, Myanmar60
Recommendations transmitted and implemented at national level Abbakar, Sudan21
Follow-up of implementation Armstrong et al., United Republic of Tanzania26
Bandali et al., Kenya30
Mukinda et al., South Africa74
Evaluating and refining Positive feedback Bandali et al., Kenya30
Muffler et al., Morocco52
WHO, South-East Asia60
Supervision and mentoring, external champions and facilitators Belizán et al., South Africa31
Bandali et al., Kenya30
Dortonne et al., Mali and Senegal41
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WHO: World Health Organization.

a See second data repository for full table with quotations and comments.79

Fig. 4.

Fig. 4

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Vicious cycle of a dysfunctional maternal and perinatal death surveillance and response process

Table 3. Contexts and mechanisms underlying dysfunctional maternal and perinatal death surveillance and response systems.

Key mechanisms driving poor outcomes Key contexts that enable mechanisms to operate Examples, study and countrya
Fear of blame (at all levels) Political pressure to reduce maternal deaths Melberg et al., Ethiopia51
Punitive environment Abbakar, Sudan21
Abebe et al., Ethiopia22
Combs Thorsen et al., Malawi37
Melberg et al., Ethiopia73
Increasing litigation against health workers Gao et al., China43
Melberg et al., Ethiopia73
Blame culture: maternal and perinatal death surveillance and response process is not separated from litigation and disciplinary process Cahyanti et al., Indonesia36
Karimi et al., Iran (Islamic Republic of)48
Muvuka, Democratic Republic of the Congo53
Inadequate preparation Guidelines insufficient or non-existent Abebe et al., Ethiopia22
Muvuka, Democratic Republic of the Congo53
Staff unaware of guidelines Cahyanti et al., Indonesia36
Said et al., United Republic of Tanzania57
Lack of training Abebe et al., Ethiopia22
Congo et al., Burkina Faso38
Said et al., United Republic of Tanzania57
Poor leadership: no support for staff Afayo, Uganda24
Muffler et al., Morocco52
Vertical process, not integrated Balogun & Musoke, Sudan29
Hartsell, United Republic of Tanzania45
Under-reporting of deaths Fear of blame Abbakar, Sudan21
Melberg et al., Ethiopia51
Muvuka, Democratic Republic of the Congo53
Political pressure Khader et al., Jordan70, Melberg et al., Ethiopia51
Social stigma and cultural beliefs Biswas et al., Bangladesh33
Muvuka, Democratic Republic of the Congo53
No mandatory reporting for out-of-hospital deaths Dumont et al., Senegal42
Muvuka, Democratic Republic of the Congo53
Inaccurate or incomplete information Fear of blame: concealing or falsifying information Agaro et al., Uganda25
Muvuka, Democratic Republic of the Congo53
Said et al., United Republic of Tanzania57
Staff lack of understanding of purpose Kinney et al., Nigeria49
Poor record-keeping Dumont et al., Senegal42
Muvuka, Democratic Republic of the Congo53
Resource shortages: insufficient time to collect data Hartsell, United Republic of Tanzania45
Data collection forms too long and/or complex and/or unavailable WHO, Myanmar60
Inadequate review Inaccurate and/or insufficient information impeding review process Gao et al., China43
Owolabi et al., Malawi55
Key stakeholders not involved or invited Abbakar, Sudan21
Dumont et al., Senegal42
Gao et al., China43
Jepkosgei et al., Kenya47
Non-attendance of review committee members because of staff shortages, workload, competing priorities, poor communication or demotivation Afayo, Uganda24
Kinney et al., United Republic of Tanzania49
Muvuka, Democratic Republic of the Congo53
Congo et al., Burkina Faso67 ,van Hamersveld et al., United Republic of Tanzania44
Lack of incentives to participate Afayo, Uganda24
Agaro et al., Uganda25
Ineffective participation of members because of demotivation and/or hierarchy Armstrong et al., United Republic of Tanzania26
Cahyanti et al., Indonesia36
de Kok et al., Nigeria40
Richard et al., Burkina Faso75
Lack of confidentiality Muvuka, Democratic Republic of the Congo53
Congo et al., Burkina Faso67
Fear of blame Jepkosgei et al., Kenya47
Muffler et al., Morocco52
Blame-shifting and/or avoiding responsibility Jepkosgei et al., Kenya47
Melberg et al., Ethiopia51
Inadequate recommendations Poor chairing Jepkosgei et al., Kenya47
Lack of focus during meetings de Kok et al., Nigeria40
Hartsell, United Republic of Tanzania45
WHO, Indonesia60
Blame-shifting and/or avoiding responsibility Armstrong et al., United Republic of Tanzania26
Cahyanti et al., Indonesia36
Gao et al., China43
Inadequate implementation Recommendations not actionable Muvuka, Democratic Republic of the Congo53
Key stakeholders (responsible for implementation) absent from meetings Nyamtema et al., United Republic of Tanzania54
WHO, India60
Unclear responsibility and/or accountability Armstrong et al., United Republic of Tanzania26
Avoidance of responsibility Balogun & Musoke, Sudan29
Cahyanti et al., Indonesia36
Insufficient resources to allow implementation Agaro et al., Uganda25
Cahyanti et al., Indonesia36
Karimi et al., Iran (Islamic Republic of)48
Lack of feedback and/or dissemination of recommendations Kouanda et al., Chad72
Lack of follow-up; no feedback or incentive to implement Jepkosgei et al., Kenya47
Demotivation, disengagement, discontinuation Demotivation of participants because of lack of implementation or positive feedback Agaro et al., Uganda25
Muffler et al., Morocco52
Nyamtema et al., United Republic of Tanzania54
Lack of supportive supervision Agaro et al., Uganda25
Muvuka, Democratic Republic of the Congo53
Unintended harmful consequences Exacerbation of staff shortages Bakker et al., Malawi28
Kinney et al., United Republic of Tanzania49
Defensive practice, inappropriate referrals Melberg et al., Ethiopia51
Unsustainable process Over-dependence on foreign aid Congo et al., Burkina Faso38
Hofman & Mohammed, Nigeria46
Said et al., United Republic of Tanzania57
Kouanda et al., Chad72
Frequent staff turnover and lack of handover and training Abebe et al., Ethiopia22
Hofman & Mohammed, Nigeria46
Over-dependence on one person Abbakar, Sudan21
van Hamersveld et al., United Republic of Tanzania44
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WHO: World Health Organization.

a See second data repository for full table with quotations and comments.79

Action cycle

Outcomes

Successful outcomes of maternal and perinatal death surveillance and response included implementation of positive changes, especially at the facility level, such as improvements in quality of care, behavioural changes and targeted actions to address specific issues. Two studies41,50 were linked to quantitative studies8,80 demonstrating reductions in mortality.

Mechanisms

Three key mechanisms led to implementation of positive change.

Implementation of recommendations

Formulation and implementation of effective recommendations are commonly assumed to be the only mechanism of action for maternal and perinatal death surveillance and response.4 They are underpinned by a relatively complicated chain of events (Fig. 3 and Table 2). Most examples of effective responses were targeted actions implemented in individual facilities.25 Although WHO guidelines recommend that aggregated data be analysed at district and national levels to identify, recommend and implement higher-level solutions,6 documented examples of these actions were rare.21

Learning from case discussions

Learning from mistakes was a powerful behaviour-change mechanism mentioned by several respondents and was facilitated by a learning environment in the facility47 and community-based review meetings.35 Behaviour change was also motivated by the emotional experience of hearing the stories about the maternal and perinatal deaths and how these cases had been (mis)managed.39,62,75

Increased vigilance

This learning, and the review process itself, were reported to make health workers more vigilant in their daily practice, because they knew that if a patient died, their actions and records would be reviewed.44,53,75

Contexts

Underpinning these mechanisms is a learning environment (Fig. 3), where people feel safe to honestly report deaths, disclose accurate information and openly discuss the cases, including any mistakes in their management.47,53,56,74 Learning environments assure confidentiality, anonymity and separation from blame or any disciplinary process. Although several respondents recommended legal protection at the national level to prevent data from maternal and perinatal death surveillance and response being used in litigation, only South Africa had enacted this protection which “has been ratified by relevant judicial bodies.”81

In the absence of such legal protection, the next best context was an audit charter; members of the maternal and perinatal death surveillance and response committee were required to sign this charter to indicate their commitment to the principles of good conduct of clinical audit, including confidentiality, before participating in any session.38,75 Good leadership and chairing of meetings at the facility level also create a safe space for open discussion (Fig. 3 and Table 2).40 Adequate resources enable implementation of the process and of recommendations.

Vicious cycle

In contrast, many studies reported elements of a vicious cycle resulting in dysfunctional death surveillance and response (Fig. 4 and Table 3).

Outcomes

The commonest negative outcome was simply the lack of any change.49,77 In some cases, the maternal and perinatal death surveillance and response process stopped.72 Two studies reported on the maternal and perinatal death review process in the same urban district hospital in Burkina Faso in 2004–200575 and 2015–2016.77 Although this was one of the pioneer hospitals, in the second study an informant from the district level reported, “I know the team is there, but I don’t believe that this committee ever has a session.”77

More worryingly, a few studies reported harmful outcomes. First, staff shortages could be worsened as staff became afraid to work on the labour ward,28,62 some took several weeks off work after an upsetting review73 and junior doctors were deterred from choosing obstetrics as a career.73 Second, some staff practised defensive medicine such as inappropriate referral of unstable patients at high risk of death.51,73 Third, an extreme example given was refusal of admission to referral facilities of women who seemed likely to die, possibly to avoid damaging mortality statistics.76 Fourth, serious repercussions were reported for a woman who had complained that a midwife had treated her harshly; the midwife recognized herself in the audit session and complained to the woman’s parents.75

Mechanisms

Fear of blame (and of negative consequences such as disciplinary action or litigation) was the most pervasive mechanism. This fear inhibited learning and participation, and led to disengagement from the maternal and perinatal death surveillance and response process at all stages, which resulted in under-reporting, inaccurate data, inadequate participation in reviews, inadequate formulation of solutions and avoidance of responsibility. Fear of blame usually resulted from insufficient confidentiality or anonymity, and the death review process not being separated from disciplinary procedures.76 Telling participants that the process was blame-free was insufficient to allay fears when senior managers were present who would also be in charge of disciplinary procedures53,76 or when litigation against health workers was increasing.73

Inadequate preparation enabled the blame culture to persist as staff were unsure how to implement maternal and perinatal death surveillance and response.22 Many references were made to: inadequate or unavailable guidance; lack of training; poor leadership; charters not being signed;38 and maternal and perinatal death surveillance and response being structured as a separate vertical programme rather than being integrated with other public health systems.29,45

Under-reporting of deaths was often due to fear of blame or other negative consequences, such as reduced funding,21,53,73,76 but also resulted from social stigma,33 cultural beliefs, non-mandatory reporting53 and political pressure.51,72,73

Inaccurate and/or incomplete information undermines the review process. Although poor record-keeping was common,42,53 several reports noted deliberate falsification of records25,57,70,73 or misclassification of deaths70,76 to avoid blame or reputational damage. Sometimes staff did not collect the information because they simply did not have time45 or the correct forms,60 or did not understand the purpose of maternal and perinatal death surveillance and response.49

Inadequate review was the inevitable consequence of inaccurate information: “it is essentially garbage in, garbage out.”55 Reviews could also fail if: the committee did not include all necessary stakeholders; some key stakeholders did not attend; stakeholders attended but felt unable to participate because of disengagement or hierarchical relationships; or stakeholders feared blame or attempted to shift blame to others.26,36,40

Inadequate recommendations result from inadequate review. Poor chairing, lack of focus in review meetings and blame-shifting26,36,43 also impaired the formulation of effective recommendations.40 Sometimes meetings focused on accurately determining the cause of death at the expense of formulating effective recommendations.45

Non-implementation of recommendations was inevitable if they were unachievable. Furthermore, implementation rarely happened if: responsibility for implementation was unclear;44 the individuals responsible for implementation were not involved in the review;21,38,54,60 recommendations were not fed back to those responsible for implementation;30,44 implementers avoided taking responsibility;40,43 or no mechanism was in place to follow up on implementation.76,77 Insufficient resources also prevented implementation.25,36,48,72

Demotivation and disengagement resulted from non-implementation and the perception that the process was not achieving its intended aim.25,52,54 The lack of any incentives was also demotivating.24,25,76

Lack of sustainability resulted from over-dependence on foreign aid,38,46,72 or on a small number of staff.21 If no team or mechanism existed for training new staff, the process would stop when key staff were absent or left, which was common given high staff turnover in many settings.

Contexts

Three key contexts triggered the mechanisms leading to dysfunctional maternal and perinatal death surveillance and response. First, a blame culture heightens fear of blame, which was widely reported in health workers and families being questioned about a death. This problem was exacerbated in countries under an authoritarian system, where confidentiality was not guaranteed75 and the maternal and perinatal death surveillance and response process was not separated from litigation or disciplinary procedures,51 where families had no avenues for complaining apart from litigation,73 and where health workers could be detained by the police after maternal or child deaths.22,73,82 Paradoxically, high-level political commitment to reducing maternal mortality sometimes resulted in pressure on health workers not to report deaths.51,72,73

Second, insufficient resources prevented: adequate preparation for maternal and perinatal death surveillance and response; adequate data collection; convening of review meetings; and implementation of recommendations.60,63 Staff shortages meant that key stakeholders could not leave clinical duties to complete investigations or attend meetings34,44,50,53 and also that anonymity was not possible in review meetings.67 In some cases, sufficient forms were not available.60 Staff were often expected to attend meetings during lunch breaks or after work, but were reluctant to do so if no refreshments or financial compensation were provided.25 Lack of any budget for maternal and perinatal death surveillance and response also made it difficult to implement many recommendations;44 for example buying new equipment or holding community meetings.

Third, poor leadership at facility, district or national levels perpetuated unfavourable environments and behaviour, including: the blame culture,63 a general lack of commitment to maternal and perinatal death surveillance and response,54,72 under-resourcing, frequent staff turnover, poor preparation for maternal and perinatal death surveillance and response, insufficient communication, poor chairing of surveillance and response meetings,52 non-implementation and follow-up of recommendations, and general demotivation.42

Discussion

We found 59 qualitative studies investigating implementation of maternal and perinatal death surveillance and response in low- and middle-income countries. To achieve a functional action cycle with positive outcomes, such as reduced mortality and improved quality of care, a blame-free learning environment needs to be nurtured, clearly separated from litigation and disciplinary processes. Although WHO guidelines state that a mortality audit “is not a solution in itself,”4 several studies found that a learning environment enables not only the formulation of achievable recommendations, but also direct learning from the process and a healthy vigilance regarding quality of care. Good outcomes motivate staff to remain engaged, making the process sustainable.

In stark contrast, maternal and perinatal death surveillance and response often became a dysfunctional vicious cycle in the context of a blame culture, poor leadership and insufficient resources. Fear of blame inhibits all steps of the surveillance and response cycle. This fear not only inhibits intended outcomes but can also provoke harmful outcomes such as falsification of information, worsened staff shortages, inappropriate referrals or even the refusal to accept referrals, with the intention of avoiding responsibility. Our findings contradict the conclusions of the 2016 study that reported disciplinary action, legal redress and social reprisals were the most important mechanisms for accountability:13 we found that disciplinary action, litigation and social reprisals were likely to result in disengagement, lack of learning and negative outcomes.

While the literature search was comprehensive and the realist approach provided a useful framework for understanding causal pathways, the maternal and perinatal death surveillance and response process is cyclical rather than linear and a particular issue could be a context, a mechanism or an outcome at different points in the cycle. While other study types may also contain useful information, we only included qualitative studies because we were interested in the subjective experiences of those participating in maternal and perinatal death surveillance and response. However, social desirability bias is likely to be an important weakness of any research in contexts where freedom of speech is limited and a fear of blame exists, both of which may prevent participants from being completely open and honest about their experiences.51 Nevertheless, our review included several articles giving candid accounts of dysfunctional maternal and perinatal death surveillance and response processes in several settings. As the bias is likely to favour positive accounts, the reality could be worse than has been reported.

Most studies did not adequately consider the relationship between researchers and interviewees, and it is likely that this relationship influenced reported perceptions of the success, or failure, of the maternal and perinatal death surveillance and response process. Furthermore, implementation of maternal and perinatal death surveillance and response may have both positive and negative aspects in a single country or study.

Our results have implications for policy and practice. First, it is imperative to ensure that necessary preparations have been made before attempting to implement a maternal and perinatal death surveillance and response process. The essential conditions to ensure an effective process are good leadership, willingness and ability to provide a safe, blame-free learning environment and sufficient resources to support the surveillance and response process and implementation of its recommendations. In the context of a blame culture (including litigation and disciplinary procedures), poor leadership and insufficient resources, the process could do more harm than good. Turning a vicious cycle into an action cycle can be more difficult than starting the whole process from scratch, because fear of blame can persist for a long time.53

Second, direct learning from review meetings has been ignored as an important mechanism by many implementers. Thus, participatory review meetings on site and involving as many relevant staff as possible are likely to be more effective at promoting positive behaviour change than remote committee meetings with only a small number of participants.

Third, to evaluate maternal and perinatal death surveillance and response, it is important to assess not only the level of implementation of recommendations, but also whether participants are learning from the process, changing their own practice and seeing positive changes. Monitoring for possible adverse events of the process is also important, such as inappropriate referrals or worsening staff shortages. Monitoring and evaluation focusing on death reporting and cause of death classification may detract from the response component to improve outcomes.

Fourth, an adaptable toolbox of strategies to improve implementation of maternal and perinatal death surveillance and response would be valuable, based on experiences identified through this review as well as behaviour-change theory.

Our findings revealed priorities for future research. First, an intervention to improve implementation of maternal and perinatal death surveillance and response could be co-created with teams already conducting this process in low-income contexts, based on their experience and findings from this review. Scarce resources should not be a barrier to implementation, as several examples of effective review processes in low- and middle-income countries exist.8–10 A behavioural science approach should be taken to planning and optimizing the intervention, for example using the person-based approach,83 with members of death review committees in different settings. Of particular importance would be to evaluate whether such an intervention can shift a vicious cycle into a positive action cycle.

Second, more research is needed to understand how to achieve the optimal balance between a blame-free anonymous process, while maintaining accountability.47 Although WHO has suggested high-level strategies to minimize the blame culture,5,84 challenges exist because a completely blame-free, anonymous process may also remove accountability and responsibility for implementing actions,73 while a focus on accountability may instil fear of blame.73 Completely removing blame from the maternal and perinatal death surveillance and response process is almost impossible, because negligence will be uncovered and will need to be tackled.57 Although disciplinary procedures should be kept separate from maternal and perinatal death surveillance and response, in practice this separation may be impossible to achieve in district hospitals and communities where the head of the maternity unit is probably responsible for both disciplinary procedures and the surveillance and response process. A certain level of accountability and vigilance is one of the key mechanisms for a maternal and perinatal death surveillance and response system to achieve its objectives. A sensitive, inclusive death review process could provide a way to address concerns of bereaved families and sensitively inform them about their loss; this approach is important to explore, as it could reduce conflict and unjustified blame of individual health workers.70,73

In conclusion, maternal and perinatal death surveillance and response can be an effective behaviour-change quality-improvement intervention even in low- and middle-income settings with limited resources, provided the process is conducted in a largely blame-free learning environment, supported by good leadership and sufficient resources.

Funding:

MW’s salary is partly funded by the National Institute for Health and Care Research (NIHR 302412).

Competing interests:

MW is a member of the WHO technical working group on maternal and perinatal death surveillance and response. Other authors declare no competing interests.

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