Maternal Death Review Research Articles

A 3 YEARS REVIEW OF MATERNAL DEATH AND ASSOCIATED FACTORS AT AYDER COMPREHENSIVE SPCIALIZED HOSPITAL, NORTHERN ETHIOPIA

ABSTRACT BACKGROUND: Maternal mortality ratio in Ethiopia is one of the highest in the world. Despite measures to alleviate it and showing a promising declining trend, it still remains one of the highest at 412 maternal deaths per 100,000 live births. To our knowledge there is no accessible published study on maternal mortality at Ayder Comprehensive Specialized Hospital (ACSH). OBJECTIVE The aim of this study is to systematically analyze causes of maternal deaths and contributing factors at (ACSH).METHODS This was a descriptive, retrospective chart review of institutional maternal deaths using a 3-years record from July 1, 2014 – June 30, 2017 at ACSH.RESULTS There were 52 maternal deaths from July 1, 2014 – June 30, 2017 at ACSH. The main causes of these deaths were related to obstetric hemorrhage (n=11, 21.2 %), hypertensive disorders of pregnancy (n=10, 19.2%) and sepsis (n=7, 13.5%). About 86.5% (n=45) of the mothers were referral cases of whom 24 (53.33%) of them travelled more than 100 kilometers to reach ACSH. The furthest referral site was 498 kilometers from ACSH. Most common reasons for referral include for admission to intensive care unit, for further workup and management, for blood transfusion and for high risk admission. Most of the maternal deaths occurred in the postpartum period.CONCLUSIONThere is an urgent need for expansion of intensive care unit (ICU) and availing blood transfusion services in all the general and regional hospitals with close monitoring of mothers in the postpartum period. The referral system needs coordinnation from the lower level to the teritirary care centers. KEY WORDS: Maternal death, cause of maternal death, factors for maternal death, Ayder Comprehensive Specialized Hospital, Mekelle, Tigray, Ethiopia (Ethiopian Journal of Reproductive Health 2018; 10; 3: 38-45)

A 36-year review of maternal deaths in a low-resource country

A 36-year review of maternal deaths in a low-resource country

Alerts for managing postpartum haemorrhage

A review of maternal deaths from postpartum haemorrhage (PPH) in 2014 - 2016 raises concern at the slow rate of reduction of mortality. Folder review showed that 87.8% of deaths were avoidable and identified ‘red flags’: common omissions (poor problem recognition), commissions (incorrect treatment) and areas of substandard care (inadequate monitoring and/or management). The lessons learnt have led to key practice points for managing PPH, which are presented in this article. These include: referral to an appropriate level of care for delivery, medications for prevention of PPH, and how facilities can be prepared for PPH to detect it timeously – before the onset of coagulopathy. Emergency management of severe obstetric haemorrhage includes resuscitation, identifying the cause/s of the bleeding, medical treatment of PPH, non-medical interventions for PPH in the labour ward, early recourse to theatre with ongoing bleeding and a description of effective surgical interventions. The problems associated with referral of patients with PPH are discussed. Updated management algorithms for PPH in South Africa are presented.

326. Confidential review of maternal deaths in the Community Level Interventions for Pre-eclampsia (CLIP) Mozambique Trial

Introduction Computer based algorithms, such as the WHO’s verbal autopsy tool (InterVA), are often used to attribute cause of death (COD) in low-resource settings despite their variable agreement with physician review. After a large scale community-level intervention trial for pre-eclampsia in Mozambique, maternal deaths were assessed in order to identify COD and barriers to care. Objective To compare COD for women who died in the Community Level Interventions in Pre-eclampsia (CLIP) Mozambique Trial (NCT01911494), 2015–2017, by physician review vs. the InterVA output. Methods Two physicians independently reviewed maternal mortality data from the trial (i.e., verbal autopsy [2012 WHO Instrument], baseline data and outcomes, and in the intervention arm, data from a mobile health application that included blood pressure readings), and assigned COD (by International Classification of Disease-Maternal Mortality). Disagreement was resolved by a third reviewer. Assigned COD was compared between physician review and InterVA output (set for high prevalence of malaria and HIV) using Cohen’s Kappa. Results Of the twenty-one (0.14%) maternal deaths reported, most were postpartum (14/21, 66.7%), and due to indirect causes (12, 57.1%). Malaria during or prior to pregnancy (14/21, 66.7%) and HIV/AIDs (11/21 reported, 52.3%) were found to significantly affect pregnancy. The three most common causes of death were 1) non-obstetric complications, 2) obstetric hemorrhage and 3) pregnancy-induced hypertension. Agreement between physicians and InterVA was fair, K = 0.40 [0.10–0.69]). Compared with InterVA, physicians were more likely to assign COD due to non-obstetric complications, specifically infectious diseases (9/21, 42.9%), including malaria and HIV/AIDS. Discussion Addressing infectious diseases, such as malaria and HIV/AIDs, obstetric hemorrhage and pregnancy-induced hypertension as most important causes of death is important to reduce maternal mortality in Mozambique. We found a fair level of agreement between COD assigned by InterVA and physician review at an individual case level, particularly for indirect causes of death.

How does social accountability contribute to better maternal health outcomes? A qualitative study on perceived changes with government and civil society actors in Gujarat, India

BackgroundSocial accountability mechanisms have been highlighted as making a contribution to improving maternal health outcomes and reducing inequities. But there is a lack of evidence on how they contribute to such improvements. This study aims to explore social accountability mechanisms in selected districts of the Indian state of Gujarat in relation to maternal health, the factors they address and how the results of these mechanisms are perceived.MethodsWe conducted qualitative research through in-depth interviews and focus group discussions with actors of civil society and government health system. Data were analyzed using a framework of social determinants of maternal health in terms of structural and intermediary determinants.ResultsThere are social accountability mechanisms in the government and civil society in terms of structure and activities. But those that were perceived to influence maternal health were mainly from civil society, particularly women’s groups, community monitoring and a maternal death review. The social accountability mechanisms influenced structural determinants – governance, policy, health beliefs, women’s status, and intermediary determinants – social capital, maternal healthcare behavior, and availability, accessibility and the quality of the health service delivery system. These further positively influenced the increased use of maternal health services. The social accountability mechanisms, through the process of information, dialogue and negotiation, particularly empowered women to make collective demands of the health system and brought about changed perceptions of women among actors in the system. It ultimately improved relations between women and the health system in terms of trust and collaboration, and generated appropriate responses from the health system to meeting women’s groups’ demands.ConclusionSocial accountability mechanisms in Gujarat were perceived to improve interaction between communities and the health system and contribute to improvements in access to and use of maternal health services. The influence of social accountability appeared to be limited to the local/district level and there was lack of capacity and ownership of the government structures.

State-based Review of Maternal Deaths: The Ohio Experience.

Ohio established a Pregnancy-Associated Mortality Review system in 2010 to ensure that all maternal deaths are identified and preventive actions developed. The need for detailed and reliable information to supplement vital statistics data has led to the development of state-based and urban-based maternal death reviews. Although processes vary from state to state, in general, an expert panel is convened to review individual cases and make recommendations for systems change. This article describes the development and operation of Ohio's state-based maternal death review including interventions developed and actions taken based on review data.

Analyzing the etiology behind mortality associated with antepartum, intrapartum, and post-partum cases in a tertiary care teaching hospital of West Bengal

Objective:The study was undertaken to understand the causes and circumstances of maternal deaths in West Bengal.Material and Methods:One hundred ten maternal deaths were reported during the period December 2010 through June 2012 in the Maternity Ward of Medical College and Hospitals, West Bengal. These deaths were reviewed using a facility-based Maternal Death Review protocol. The number and percentages were calculated and binary logistic regression analysis was performed.Results:The majority of the deaths occurred in the 20-24 years’ age group, those with Hindu religion, in the first and second gravida, and the postpartum period. One third of mothers had cesarean sections. The majority (78.2%) of deaths were among referred cases. Eclampsia was the leading cause of maternal death (29.1%). Approximately half of the deceased women sought care after 10 hours of developing complications. More than one-third of maternal deaths were registered with type 1 delays.Conclusion:Our study demonstrates that maternal deaths occurred among young women, referred cases, with cesarean sections and type 1 delays. We recommend that imparting basic skills and improving awareness to the community about the danger signs of pregnancy could be an effective measure to detect maternal complications at an earlier stage.

Access factors linked to maternal deaths in Lundazi district, Eastern Province of Zambia: a case control study analysing maternal death reviews

BackgroundAccess factors associated with maternal death are important to understand because they are considered to be an essential measure of women’s health and indicative of the performance of health care systems in any community globally. This study aimed to analyse the access risk factors linked to maternal deaths in Lundazi district of the Eastern Province of Zambia using secondary data obtained from maternal death reviews and delivery registers.MethodsThis was a case-control study with cases being recorded maternal deaths for Lundazi district (n = 100) while controls were randomly selected Lundazi District Hospital deliveries (n = 300) for the period 2010 to 2015. STATA™ (Stata Corporation, Texas, TX, USA) version 12.0 was used to analyse data. Odds ratio and 95% confidence intervals with associated p-values were used to analyse disparities between cases and controls while bivariate and multivariate regression analyses were done to show associations.ResultsThe likelihood of experiencing maternal death was 94% less among women who completed their scheduled antenatal care visits than those who did not (OR 0.06, 95% CI = 0.01–0.27, p = < 0.001). Delayed referral associated with maternal deaths and complications were 30% (30) for cases, 12% (37) for controls and 17% (67) for both cases and controls. Long distances, unskilled deliveries were 3%, (15) for both cases and controls with 13% (13) for cases and 1% (2) for controls only.ConclusionAntenatal care is important in screening for pre-existing risk conditions as well as complications in early stages of pregnancy that could impact adversely during pregnancy and childbirth. Delay in seeking health care during pregnancy could be minimised if health services are brought closer to the communities to reduce on distances covered by pregnant women in Lundazi. Maternal education appears to influence antenatal health care utilisation because greater knowledge and understanding of the importance of antenatal care might increase the ability to select most appropriate service. Therefore, there is need for Lundazi District Health Office to scale up interventions that motivate women to make at least four scheduled antenatal care visits during pregnancy as recommended by the World Health Organization.

Maternal death and delays in accessing emergency obstetric care in Mozambique

BackgroundDespite declining trends maternal mortality remains an important public health issue in Mozambique. The delays to reach an appropriate health facility and receive care faced by woman with pregnancy related complications play an important role in the occurrence of these deaths. This study aims to examine the contribution of the delays in relation to the causes of maternal death in facilities in Mozambique.MethodsSecondary analysis was performed on data from a national assessment on maternal and neonatal health that included in-depth maternal death reviews, using patient files and facility records with the most comprehensive information available. Statistical models were used to assess the association between delay to reach the health facility that provides emergency obstetric care (delay type II) and delay in receiving appropriate care once reaching the health facility providing emergency obstetric care (delay type III) and the cause of maternal death within the health facility.ResultsData were available for 712 of 2,198 maternal deaths. Delay type II was observed in 40.4% of maternal deaths and delay type III in 14.2%.and 13.9% had both delays. Women who died of a direct obstetric complication were more likely to have experienced a delay type III than women who died due to indirect causes. Women who experienced delay type II were less likely to have also delay type III and vice versa.ConclusionsThe delays in reaching and receiving appropriate facility-based care for women facing pregnancy related complications in Mozambique contribute significantly to maternal mortality. Securing referral linkages and health facility readiness for rapid and correct patient management are needed to reduce the impact of these delays within the health system.

Journey to Death: Are Health Systems Failing Mothers?

Background:Annually, about 44,000 maternal deaths occur in India, which is 20% of the global burden. Despite persistent efforts, India failed to meet the fifth millennium development goal by 2015. Lack of reliable data on maternal mortality demands utilization of tools for counting maternal deaths which is vital to implement preventative actions.Objectives:Our study aims to determine health system-related issues of maternal mortality using the WHO validated tool – Maternal Death Review and demonstrates usefulness of maternal death surveillance and review as a monitoring tool.Methods:Fourteen maternal deaths were evaluated through community based and facility-based audits from July 2013 to June 2014 in three districts of Gujarat. Pathways to death were traced through Global Positioning System (GPS). Factors contributing to the three delays were analyzed.Results:Type III delay, that is, delay in receiving adequate care was frequently observed in our review including weak referral linkages, lack of blood banking services, inadequate surgical facilities. and staff shortages. Mothers succumbed, not because they did not seek treatment or reach facilities in time but because facilities were incapable of providing appropriate medical care.Conclusion:Scaling up of maternal death audits and subsequent use of these findings will help to reduce maternal mortality in India. As we continue to push for institutional deliveries, we need to reevaluate if our health system is prepared to manage an increasing number of facility births and obstetric complications.

Investigating institutional maternal deaths in Ogun State, Nigeria: analysis of 2016 maternal and perinatal deaths surveillance data

Introduction: globally over 600,000 women die annually from complications of pregnancy. Nigeria ranks second globally in the number of maternal deaths. Ogun State has maternal mortality rate (MMR) of 179 per 100000 live births, with 5728 women dying of pregnancy related complications annually. Ogun State has a total fertility rate of 5.4 and contraceptive prevalence rate of 26%. Maternal and Perinatal Deaths Surveillance and Response (MPDSR) started as Maternal Death Review (MDR) in Ogun State in year 2009. The initiative was geared towards conducting qualitative assessment of the causes of maternal and perinatal deaths for evidence-based decisions to prevent reoccurrences of such preventable deaths. This study describes the outcome of maternal death review conducted in selected health facilities in Ogun State to give insight to why women die from pregnancy and related events.

Moving from maternal death review to surveillance and response: A paradigm shift.

In the era of the sustainable development goals, India is committed to reduce its maternal mortality ratio to less than 70 per one lakh live births by 2030. An important strategy that was adopted in the Reproductive and Child Health Programme in 2010 was maternal death review. Analysis of the progress so far has brought to light certain gaps which have prompted the paradigm shift toward Maternal Death Surveillance and Response (MDSR), which focuses on taking action on information obtained from every maternal death so as to prevent further maternal deaths. The new guidelines on MDSR were released by the Ministry of Health and Family Welfare in 2017.

Maternal death review and outcomes: An assessment in Lagos State, Nigeria.

The objective of the study was to investigate the results of Maternal and Perinatal Death Surveillance and Response (MPDSR) conducted in three referral hospitals in Lagos State, Nigeria over a two-year period and to report the outcomes and the lessons learned. MPDRS panels were constituted in the three hospitals, and beginning from January 2015, we conducted monthly MPDSR in the three hospitals using a nationally approved protocol. Data on births and deaths and causes of deaths as identified by the MPDSR panels were collated in the hospitals. The results show that over a 21-month period (January 1, 2015 –September 30, 2016), maternal mortality ratio (MMR) remained high in the hospitals. Although there was a trend towards an increase in MMR in Lagos Island Maternity Hospital and Gbagada General Hospital, and a trend towards a decline in Ajeromi Hospital, none of these trends were statistically significant. Eclampsia, primary post-partum haemorrhage, obstructed labour and puerperal sepsis were the leading obstetric causes of death. By contrast, delay in arrival in hospital, the lack of antenatal care and patients’ refusal to receive recommended treatment were the patients’ associated causes of death, while delay in treatment, poor use of treatment protocols, lack of equipment and lack of skills by providers to use available equipment were the identified facility-related causes of death. Failure to address the patients and facility-related causes of maternal mortality possibly accounted for the persistently high maternal mortality ratio in the hospitals. We conclude that interventions aimed at redressing all causes of maternal deaths identified in the reviews will likely reduce the maternal mortality ratios in the hospitals.

Burn Injury of a Pregnant Mother in Rural Bangladesh: A Case Report

Introduction: This paper describes a case of pregnant mother who died of burn injury in order to understand the societal factors related to the event. We reviewed the case in the rural community. Initially, the case was reported as a maternal death to maternal and neonatal death review (MNDR) system being conducted in Bangladesh within exiting health system to explore the medical and social causes of maternal and newborn deaths. However, during the verbal autopsy, it was found that the mother died of bun injury. Therefore, we performed detailed case study. Case Presentation: A woman aged 18 years was nine months pregnant in a rural community in Moheskhali upazila of Cox’s Bazar district. During the wintertime, the mother feels cold and goes near to the oven in the yard to be warm. Suddenly, part of her clothing (Anchal of Sari) catches fire; she does not recognized and starts to walk towards her room. A neighbor notices and starts to shout. The woman scars and tries to run. The neighbors come with a bucket of water. By this time, the fire spreads over whole body and cloths. Immediately after the event, she is transferred to a medical college hospital. Conclusions: Doctors tried to do immediate cesarean section; however, they could not save the life of the baby inside. The mother who was severely burnt also died after 10 days. Rural community in Bangladesh still does not have adequate awareness and knowledge about risk of burn. The scarce knowledge of appropriate steps immediately after burn was explored. Moreover, delays in decision-making and transferring the patient to the facility were identified. Specific interventions need to be taken to increase knowledge and awareness in the community, which could save thousands of lives.

Trends in maternal deaths in HIV-infected women, on a background of changing HIV management guidelines in South Africa: 1997 to 2015.

IntroductionAs work begins towards the Sustainable Development Goal target of reducing the global maternal mortality ratio (MMR) to less than 70 deaths per 100,000 live births by 2030, much needs to be done in ending preventable maternal deaths. After 1990, South Africa experienced a reversal of gains in decreasing maternal mortality, with an increase in HIV‐related maternal deaths. In this study, we assessed trends in maternal mortality in HIV‐infected women, on a background of an evolving HIV care programme.MethodsThis was a cross‐sectional, retrospective record review of maternal deaths in the obstetrics unit at Chris Hani Baragwanath Academic Hospital, in Johannesburg, South Africa, a referral hospital in a high HIV prevalence setting where the prevalence among pregnant women has plateaued around 29.0% for the past decade. Trends in HIV diagnosis and management in pregnancy, and causes of maternal deaths in HIV‐infected women were analysed over different time periods (1997 to 2003, 2004 to 2009, 2010 to 2012, and 2013 to 2015) reflecting major guideline changes.ResultsFrom January 1997 to December 2015, there were 692 maternal deaths in the obstetrics unit. Of the 490 (70.8%) maternal deaths with a documented HIV status, 335 (68.4%) were HIV‐infected. A Chi‐squared test for trends showed that the institutional MMR (iMMR) in women known to be HIV‐infected peaked in the period 2004 to 2009 at 380 (95% CI 319 to 446) per 100,000 live births, with a decline to 267 (95% CI 198 to 353) in 2013 to 2015, p = 0.049. This decrease coincided with changes in the South African HIV management guidelines, mainly increased availability of antiretroviral therapy (ART). Non‐pregnancy related infections were the leading cause of death throughout the review period, accounting for 61.5% (206/335) of deaths. Only 23.3% (78/335) of the women who died were on ART at the time of death, this in the context of advanced immune suppression and an overall median CD4 count of 136 cells/μl (interquartile ranges (IQR) 45 to 301).ConclusionIn this 19‐year review of maternal deaths in Johannesburg, South Africa, there was evidence of a decrease in the iMMR among HIV‐infected women, but it remains unacceptably high. Efforts to address drivers of mortality and barriers to accessing ART need to be accelerated if we are to see substantial decreases in maternal mortality.

Partnering of Public, Academic, and Private Entities to Reestablish Maternal Mortality Review in Georgia.

The pregnancy-related mortality ratio in the United States has increased over the past 25 years. Georgia's pregnancy-related mortality ratio is among the highest in the United States. Confronted with this harsh reality, Georgia reestablished maternal mortality review as one strategy to address its high maternal mortality. To achieve a comprehensive process for review of maternal deaths involved securing the knowledge, resources, and support of physician experts, public health agencies and professional organizations as well as representatives in the state legislature. The six key steps in successfully reinstating maternal mortality review were 1) establishing a maternal mortality advisory committee, 2) developing a defined methodology for comprehensive case identification, 3) convening an introductory maternal mortality review committee meeting, 4) securing legislative protection for the committee, 5) conducting a mock mortality review, and 6) completing a formal first-year case review and producing a summary report of initial findings. This first case review revealed the leading causes of pregnancy-related deaths in Georgia as hemorrhage, hypertension, cardiac disease, embolism, and seizures. Our objective in this commentary is to share our experiences and advocate for engaging public, private, and academic partners in working on complex and multifactorial public health issues such as high maternal mortality.

Maternal mortality audit in Suriname between 2010 and 2014, a reproductive age mortality survey

BackgroundThe fifth Millennium Development Goal (MDG-5) aimed to improve maternal health, targeting a maternal mortality ratio (MMR) reduction of 75% between 1990 and 2015. The objective of this study was to identify all maternal deaths in Suriname, determine the extent of underreporting, estimate the reduction, audit the maternal deaths and assess underlying causes and substandard care factors.MethodsA reproductive age mortality survey was conducted in Suriname (South-American upper-middle income country) between 2010 and 2014 to identify all maternal deaths in the country. MMR was compared to vital statistics and a previous confidential enquiry from 1991 to 1993 with a MMR 226. A maternal mortality committee audited the maternal deaths and identified underlying causes and substandard care factors.ResultsIn the study period 65 maternal deaths were identified in 50,051 live births, indicating a MMR of 130 per 100.000 live births and implicating a 42% reduction of maternal deaths in the past 25 years. Vital registration indicated a MMR of 96, which marks underreporting of 26%. Maternal deaths mostly occurred in the urban hospitals (84%) and the causes were classified as direct (63%), indirect (32%) or unspecified (5%). Major underlying causes were obstetric and non-obstetric sepsis (27%) and haemorrhage (20%). Substandard care factors (95%) were mostly health professional related (80%) due to delay in diagnosis (59%), delay or wrong treatment (78%) or inadequate monitoring (59%). Substandard care factors most likely led to death in 47% of the cases.ConclusionDespite the reduction in maternal mortality, Suriname did not reach MDG-5 in 2015. Steps to reach the Sustainable Development Goal in 2030 (MMR ≤ 70 per 100.000 live births) and eliminate preventable deaths include improving data surveillance, installing a maternal death review committee, and implementing national guidelines for prevention and management of major complications of pregnancy, childbirth and puerperium.

Addressing maternal deaths due to violence: the Illinois experience

Homicide, suicide, and substance abuse accounted for nearly one fourth of all pregnancy-associated deaths in Illinois from 2002 through 2013. Maternal mortality review in Illinois has been primarily focused on obstetric and medical causes and little is known about the circumstances surrounding deaths due to homicide, suicide, and substance abuse, if they are pregnancy related, and if the deaths are potentially preventable. To address this issue, we implemented a process to form a second statewide maternal mortality review committee for deaths due to violence in late 2014. We convened a stakeholder group to accomplish 3 tasks: (1) identify appropriate committee members; (2) identify potential types and sources of information that would be required for a meaningful review of violent maternal deaths; and (3) revise the Maternal Mortality Review Form. Because homicide, suicide, and substance abuse are closely linked to the social determinants of health, the review committee needed to have a broad membership with expertise in areas not required for obstetric maternal mortality review, including social service and community organizations. Identifying additional sources of information is critical; the state Violent Death Reporting System, case management data, and police and autopsy reports provide contextual information that cannot be found in medical records. The stakeholder group revised the Maternal Mortality Review Form to collect information relevant to violent maternal deaths, including screening history and psychosocial history. The form guides the maternal mortality review committee for deaths due to violence to identify potentially preventable factors relating to the woman, her family, systems of care, the community, the legal system, and the institutional environment. The committee has identified potential opportunities to decrease preventable death requiring cooperation with social service agencies and the criminal justice system in addition to the physical and mental health care systems. Illinois has demonstrated that by engaging appropriate members and expanding the information used, it is possible to conduct meaningful reviews of these deaths and make recommendations to prevent future deaths.

Implementing maternal death surveillance and response: a review of lessons from country case studies

BackgroundMaternal Death Surveillance and Response (MDSR) implementation is monitored globally, but not much is known about what works well, where and why in scaling up. We reviewed a series of country case studies in order to determine whether and to what extent these countries have implemented the four essential components of MDSR and identify lessons for improving implementation.MethodsA secondary analysis of ten case studies from countries at different stages of MDSR implementation, using a policy analysis framework to draw out lessons learnt and opportunities for improvement. We identify the consistent drivers of success in countries with well-established systems for MDSR, and common barriers in countries were Maternal Death Review (MDR) systems have been less successful.ResultsMDR is accepted and ongoing at subnational level in many countries, but it is not adequately institutionalised and the shift from facility based MDR to continuous MDSR that informs the wider health system still needs to be made. Our secondary analysis of country experiences highlights the need for a) social and team processes at facility level, for example the existence of a ‘no shame, no blame’ culture, and the ability to reflect on practice and manage change as a team for recommendations to be acted upon, b) health system inputs including adequate funding and reliable health information systems to enable identification and analysis of cases c) national level coordination of dissemination, and monitoring implementation of recommendations at all levels and d) mandatory notification of maternal deaths (and enforcement of this) and a professional requirement to participate in MDRs.ConclusionsCase studies from countries with established MDSR systems can provide valuable guidance on ways to set up the processes and overcome some of the barriers; but the challenge, as with many health system interventions, is to find a way to provide catalytic assistance and strengthen capacity for MDSR such that this becomes embedded in the health system.

Shifting paradigm of maternal and perinatal death review system in Bangladesh: A real time approach to address sustainable developmental goal 3 by 2030.

Recently, Bangladesh has made remarkable progress in reducing maternal and neonatal morality, even though the millennium developmental goal to reduce maternal and neonatal mortality was not achieved. Sustainable Developmental Goal (SDG) 3 has already been set for a new target to reduce maternal and neonatal deaths by 2030. The country takes this timely initiative to introduce a maternal and perinatal death review system. This review will discuss the shifting paradigm of the maternal and perinatal death review system in Bangladesh and its challenges in reaching the SDG on time. This review uses existing literature on the maternal and perinatal death review system in Bangladesh, and other systems in similar settings, as well as reports, case studies, news, government letters and meeting minutes. Bangladesh introduced the maternal and perinatal death review system in 2010. Prior to this there was no such comprehensive death review system practiced in Bangladesh. The system was established within the government health system and has brought about positive effects and outcomes. Therefore, the Ministry of Health and Family Welfare of Bangladesh gradually scaled up the maternal and perinatal death review system nationwide in 2016 within the government health system. The present death review system highlighted real-time data use, using the district health information software(DHIS-2). Health mangers are able to take remedial action plans and implement strategies based on findings in DHIS-2. Therefore, effective utilization of data can play a pivotal role in the reduction of maternal and perinatal deaths in Bangladesh. Overall, the maternal and perinatal death review system provides a great opportunity to achieve the SDG 3 on time. However, the system needs continuous monitoring at different levels to ensure its quality and validity of information, as well as effective utilization of findings for planning and implementation under a measureable accountability framework.