Facilitating «real life» implementation of MDSR

Background

Globally the story of maternal deaths is one of staggering inequity. An overwhelming majority of maternal deaths occur among poor, uneducated women living in the rural areas of sub-Saharan Africa and South Asia.

In 2013, WHO initiated the Maternal Death Surveillance and Response System (MDSR). The MDSR is designed to identify, report, and review all maternal deaths globally at all levels (inside and outside of the health system). The system should also involve a continuous cycle of feedback / response to these deaths by interpreting the review results.

Comparing the Maternal Mortality Ratio (MMR) between Norway and the two countries involved in MATRISET, per 100 000 births, 2 women in Norway die (2017), whereas 420 and 556 (2016) die in Ethiopia and Tanzania, respectively, adding up to around 11 000 and 7 200 women dying from pregnancy and birth in Ethiopia and Tanzania, respectively, every year.

MMR is given substantial attention, particularly by aid and funding organisations as being an indicator and therefore a way of assessing how a country / region / community is doing in terms of development, health systems functioning, women’s position, and equity. However, closer examination reveals that the estimates are surrounded by substantial uncertainty and error, which is not taken into account.

MDSR-related reporting challenges

There are a number of challenges to obtaining high levels of quality assurance to maternal death data. To begin with, compared to birth survival rates, the number of maternal deaths (relatively speaking) are not numerous anywhere, even in low-income settings. More of a challenge is the lack of a well-functioning vital registration system. Of even greater concern, is the lack of high-quality surveillance sites / systems reviewing the data collected. Another complicating factor is the high number of homebirths (approx. 65-80% in Ethiopia, approx. 40-50% in other East African countries). Many of these are inaccurately or simply not reported in the health system.

Maternal death rate data has become highly politicised. Health workers are acutely aware of the importance of reporting low death rate data to ensure external funding. All the way up the reporting hierarchy, health-system leaders know the rewards for reporting low death rate data. This results in a “shaming and blaming” culture, exacerbating the challenge of obtaining high-quality data reports. In addition, in most low-income countries there are no health worker protection systems. Ultimately, this results in significant knowledge gaps.

Project objectives

MATRISET’s primary objective is: “to improve the quality of maternal mortality reporting to strengthen the knowledge on which to base remedial action to reduce maternal deaths.”

There are a number of secondary objectives including:

1.  Investigate systematic differences between how clinical care is delivered and how it is reported in the MDSR registries and reviews at health facility level (WP Ia)
2. Investigate community involvement in review processes of maternal death (WP Ib)
3. Uncover how reported maternal mortality data is reviewed and managed within the health bureaucracy, and how / to what extent feedback mechanisms work to identify remedial action (WP II)   
4. Investigate legal frameworks surrounding the maternal surveillance and reporting systems (WP III)
5. Develop measures to improve maternal mortality reporting, including measures to enhance the balance between professional accountability and legal protection of health professionals (WP IV)

Participants and partners

Social science

• CIH (Astrid Blystad, Karen Marie Moland, Ana Lorena Ruano)              
• HEMIL (Haldis Haukanes, Siri Lange)
• Addis Ababa University, Dep of Sociology  (Getnet Tadele)
• University of Dar es Salaam, Dep of Anthropology and Sociology (Richard Sambaiga)
• University of Sussex: Maya Unnithan

Nursing / public health / medicine

• CIH/IGS (Andrea Melberg, Ingvild Sandøy,  Ingrid Miljeteig)
• Addis Ababa University (Mitike Molla, Damen Haile Mariam, Mahlet Gebremariam)
• Ethiopian Public Health Institute (Abduilhafiz Hassan, Alemnesh Mirkuzie)
• MUHAS (Ali Saidi, Andrea Pembe)
• Ministry of Health Tanzania (Ahmad Makuwani)

Law

• UIB (Henriette Sinding Aasen, Mulu Beyene Kidanemariam)
• Addis Ababa University (Tsehai Wada)
• University of Dar es Salaam (Dora Mwenegoha)

User organizations: 

• Ethiopian Institute of Public Health; Ethiopian Society of Obstetrician and Gynaecologists;  Women’s Health Association in Ethiopia; Ministry of Health,  Tanzania; Tanzania Midwives Association; Tanzania Gender Networking Programme