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

WHO: World Health Organization.

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