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

Bull World Health Organ 2023;101:62–75G | doi: http://dx.doi.org/10.2471/BLT.22.288703 Systematic reviews 62 Introduction Many low- and middle-income countries are still far from at- taining 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 peri- natal 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 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 mi- nority used the full maternal and perinatal death surveillance and response cycle.7 Implementation of maternal and perinatal death surveil- lance 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 account- ability were disciplinary action, legal redress and social repri- sals,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 set- tings.15 None of the previous reviews systematically analysed a School of Primary Care, Population Sciences and Medical Education, University of Southampton, Aldermoor Health Centre, Aldermoor Close, Southampton SO16 5SE, England. b School of Nursing and Midwifery, Haramaya University, Harar, Ethiopia. c Department of Obstetrics and Gynaecology, Leiden University Medical Centre, Leiden, Netherlands. d National Perinatal Epidemiology Unit, University of Oxford, Oxford, England. Correspondence to Merlin L Willcox (email: m.l.willcox@ soton .ac .uk). (Submitted: 7 June 2022 – Revised version received: 2 October 2022 – Accepted: 3 October 2022 – Published online: 2 November 2022 ) Maternal and perinatal death surveillance and response: a systematic review of qualitative studies Merlin L Willcox,a Immaculate A Okello,a Alice Maidwell-Smith,a Abera K Tura,b Thomas van den Akkerc & Marian Knightd 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. 63Bull World Health Organ 2023;101:62–75G| doi: http://dx.doi.org/10.2471/BLT.22.288703 Systematic reviews Maternal and perinatal death surveillanceMerlin L Willcox et al. qualitative studies or took a realist ap- proach 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 experi- ences 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, MED- LINE®, 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, in- cluding participants who were involved in implementation of any part of the maternal and perinatal death surveil- lance 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 qual- ity 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 dis- agreements. 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 cod- ing 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 stud- ies 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 analyt- ical themes, we used a realist approach.19 We recoded the included articles specifi- cally 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 ma- Fig. 1. Maternal and perinatal death surveillance and response cycle Reporting all deaths Collecting accurate information Reviewing and analysing Recommending achievable solutions Implementing changes Evaluating and refining 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. 64 Bull World Health Organ 2023;101:62–75G| doi: http://dx.doi.org/10.2471/BLT.22.288703 Systematic reviews Maternal and perinatal death surveillance Merlin L Willcox et al. ternal 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 includ- ed 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. 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 effec - tiveness of the process was perceived as good (improved quality of care or reduced mortality) in 16 studies, inad- equate 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. Two overarching programme theo- ries 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 mortal- ity (Fig. 3 and Table 2; full table in the second data repository);79 and (ii) the vicious cycle, which explains how dys- functional 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 Action cycle Outcomes Successful outcomes of maternal and perinatal death surveillance and re- sponse 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 implemen- tation of positive change. Implementation of recommendations Formulation and implementation of ef- fective recommendations are common- ly 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 aggre- gated 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 men- tioned 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)man- aged.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 Fig. 2. Flowchart of the selection of studies in the systematic review on maternal and perinatal death surveillance and response 6972 records identified • 2669 from CINAHL • 601 from MEDLINE® • 1377 from Embase® • 725 from Web of Science™ • 772 from Global Index Medicus • 433 from ProQuest • 395 from Google Scholar 5137 records screened 1841 duplicate records removed before screening 6 studies identified from citation search 4898 records excluded 105 articles excluded: • 17 presentation abstracts • 88 articles with insufficient data or abstracts only 76 articles excluded: • 12 articles did not include people involved in implementing maternal and perinatal death surveillance and response in low- and middle- income countries • 24 articles were not about maternal and perinatal death surveillance and response • 18 articles did not use a qualitative study design • 14 articles did not analyse experiences of maternal and perinatal death surveillance and response • 8 articles did not report qualitative analyses 239 articles sought for retrieval 134 articles assessed for eligibility 58 articles included (reporting on 59 studies) 65Bull World Health Organ 2023;101:62–75G| doi: http://dx.doi.org/10.2471/BLT.22.288703 Systematic reviews Maternal and perinatal death surveillanceMerlin L Willcox et al. 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, includ- ing any mistakes in their manage- ment.47,53,56,74 Learning environments assure confidentiality, anonymity and separation from blame or any disciplin- ary process. Although several respon- dents recommended legal protection at the national level to prevent data from maternal and perinatal death surveil- lance and response being used in litiga- tion, only South Africa had enacted this protection which “has been ratified by relevant judicial bodies.”81 In the absence of such legal pro- tection, 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 discus- sion (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 hos- pital 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 com- Fig. 3. Action cycle of a functional maternal and perinatal death surveillance and response process Reporting all deaths Collecting accurate information Reviewing and analysing Recommending achievable solutions Implementing changes Evaluating and rening Outcomes Mechanisms Contexts Vigilance Direct learning Impact • Improved quality of care • Reduced mortality Learning environment • Condential • Anonymous • Blame-free • Separate from disciplinary action Resources • Funding • Sta Positive feedback Motivation Legal protection; adherence to charter Secure storage of records Training Good leadership Understanding objectives and guidance Positive feedback, motivation Other steps in the process 66 Bull World Health Organ 2023;101:62–75G| doi: http://dx.doi.org/10.2471/BLT.22.288703 Systematic reviews Maternal and perinatal death surveillance Merlin L Willcox et al. 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 (continues. . .) 67Bull World Health Organ 2023;101:62–75G| doi: http://dx.doi.org/10.2471/BLT.22.288703 Systematic reviews Maternal and perinatal death surveillanceMerlin L Willcox et al. plained 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 con- sequences such as disciplinary action or litigation) was the most pervasive mechanism. This fear inhibited learning and participation, and led to disengage- ment 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 pro- cess not being separated from disciplin- ary procedures.76 Telling participants that the process was blame-free was in- sufficient to allay fears when senior man- agers 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 ma- ternal and perinatal death surveillance and response.22 Many references were made to: inadequate or unavailable guidance; lack of training; poor leader- ship; charters not being signed;38 and maternal and perinatal death surveil- lance and response being structured as a separate vertical programme rather Key mechanisms driving good outcomes Key contexts that enable these mechanisms to operate Examples, study and countrya 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 WHO: World Health Organization. a See second data repository for full table with quotations and comments.79 (. . .continued) Fig. 4. Vicious cycle of a dysfunctional maternal and perinatal death surveillance and response process Under-reporting of deaths Inaccurate and/or incomplete information Inadequate review and/or analysis Inadequate recommendations Lack of implementation of responses No follow-up Fear of blame Blame-shifting to avoid responsability No impact or harmful impact • Repeated recommendations • Sta shortages • Inappropriate referrals Insufficient resources • Underfunding • Sta shortages No feedback, demotivation Lack of understanding of objectives and guidance Poor leadership Lack of training Death surveillance and response process stops Lack of sustainability Poor record-keeping Blame culture Other steps in the process Poor preparation Poor working relationships and communication Outcomes Mechanisms Contexts 68 Bull World Health Organ 2023;101:62–75G| doi: http://dx.doi.org/10.2471/BLT.22.288703 Systematic reviews Maternal and perinatal death surveillance Merlin L Willcox et al. 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 in- formation 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 in- formation 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 inevita- ble consequence of inaccurate informa- tion: “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 relation- ships; or stakeholders feared blame or attempted to shift blame to others.26,36,40 Inadequate recommendations re- sult from inadequate review. Poor chair- ing, lack of focus in review meetings and blame-shifting26,36,43 also impaired the formulation of effective recommenda- tions.40 Sometimes meetings focused on accurately determining the cause of death at the expense of formulating effective recommendations.45 Non-implementation of recom- mendations 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 implementa- tion.25,36,48,72 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 (continues. . .) 69Bull World Health Organ 2023;101:62–75G| doi: http://dx.doi.org/10.2471/BLT.22.288703 Systematic reviews Maternal and perinatal death surveillanceMerlin L Willcox et al. Key mechanisms driving poor outcomes Key contexts that enable mechanisms to operate Examples, study and countrya 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 (. . .continued) 70 Bull World Health Organ 2023;101:62–75G| doi: http://dx.doi.org/10.2471/BLT.22.288703 Systematic reviews Maternal and perinatal death surveillance Merlin L Willcox et al. 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 demo- tivating.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 mecha- nisms leading to dysfunctional maternal and perinatal death surveillance and response. First, a blame culture height- ens 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 disci- plinary 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 Paradoxi- cally, 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 pre- vented: adequate preparation for ma- ternal and perinatal death surveillance and response; adequate data collection; convening of review meetings; and im- plementation of recommendations.60,63 Staff shortages meant that key stake- holders 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 compensa- tion were provided.25 Lack of any budget for maternal and perinatal death surveil- lance 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 behav- iour, 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 ma- ternal and perinatal death surveillance and response, insufficient communica- tion, poor chairing of surveillance and response meetings,52 non-implementa- tion and follow-up of recommendations, and general demotivation.42 Discussion We found 59 qualitative studies inves- tigating implementation of maternal and perinatal death surveillance and response in low- and middle-income countries. To achieve a functional ac- tion 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 stud- ies 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 re- sponse 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 infor- mation, worsened staff shortages, inap- propriate 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 disciplin- ary 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 under- standing 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 qualita- tive studies because we were interested in the subjective experiences of those participating in maternal and perinatal death surveillance and response. How- ever, 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 mater- nal 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 ma- ternal 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 recommenda- tions. In the context of a blame culture (including litigation and disciplinary procedures), poor leadership and insuf- ficient 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 impor- tant mechanism by many implementers. 71Bull World Health Organ 2023;101:62–75G| doi: http://dx.doi.org/10.2471/BLT.22.288703 Systematic reviews Maternal and perinatal death surveillanceMerlin L Willcox et al. 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 re- sponse, it is important to assess not only the level of implementation of recommendations, but also whether participants are learning from the pro- cess, 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 clas- sification may detract from the response component to improve outcomes. Fourth, an adaptable toolbox of strategies to improve implementation of maternal and perinatal death surveil- lance 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 mater- nal and perinatal death surveillance and response could be co-created with teams already conducting this process in low-income contexts, based on their ex- perience 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 differ- ent 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 op- timal balance between a blame-free anonymous process, while maintaining accountability.47 Although WHO has suggested high-level strategies to mini- mize 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 surveil- lance and response process is almost impossible, because negligence will be uncovered and will need to be tack- led.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 proce- dures and the surveillance and response process. A certain level of accountability and vigilance is one of the key mecha- nisms 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 indi- vidual health workers.70,73 In conclusion, maternal and peri- natal death surveillance and response can be an effective behaviour-change quality-improvement intervention even in low- and middle-income set- tings with limited resources, provided the process is conducted in a largely blame-free learning environment, sup- ported 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. صخلم ةيعونلا تاساردلل ةيجهنم ةعجارم :اله ةباجتسلااو ةدلاولاب ةطيحلما ةترفلا تايفوو تاهملأا تايفو ةبقارم ةبقارمب نوموقي نيذلا صاخشلأا تاروصتو براتج مهف ضرغلا ةباجتسلااو ،ةدلاولاب ةطيحلما ةترفلا تايفو وأ/و تاهملأا تايفو تايللآاو ،طسوتلما لخدلاو ضفخنلما لخدلا تاذ لودلا في اله .ةوجرلما جئاتنلا قيقتح الهلاخ نم ةيلمعلا هذله نكمي يتلا في يجهنم لكشب ثحبلاب انمق ،2022 ناريزح/وينوي في ةقيرطلا نيذلا ةحلصلما باحصلأ ةيعونلا تاساردلل تانايب دعاوق عبس ةطيحلما ةترفلا تايفو وأ/و تاهملأا تايفو ةبقارم ذيفنتب نوموقي لخدلاو ضفخنلما لخدلا تاذ لودلا في اله ةباجتسلااو ،ةدلاولاب تلااقلما صحفب لقتسم لكشب ينعجارلما نم نانثا ماق .طسوتلما قاقتشلا يعوضولما عيمجتلا انمدختسا دقو .اتهدوج مييقتو ةيللآاو قايسلا عاضوأ مهفل يعقاو بولسأو ،ةيفصو تاعوضوم .جئاتنلاو تناك .لماتشلاا يرياعم ةسارد نوسخمو عست تفوتسا جئاتنلا (تايفولا لدعم ضافخنا وأ ةياعرلا ةدوج ينستح) ةديلجا جئاتنلا ةلاعفلا ةبقارلما تايلآ تنمضت .ةيفيظو لمع ةرودب ةموعدم ،تايصوتلا ذيفنتو ةظقيلاو ملعتلا نم لك ،اله ةباجتسلااو تايفولل ينكمتل سييئرلا قايسلا ناك .ةكراشلما نم ديزم لىع عّجش ام وهو نم ةيلاخ ةيميلعت ةئيب وه اله ةباجتسلااو تايفولل ةلاعفلا ةبقارلما نستح دوجو مدع) ةيفاكلا يرغ جئاتنلا تجتن .ةديج ةدايق عم موللا نع (اله ةباجتسلااو تايفولا ةبقارم فّقوتو ،تايفولاو ،ةياعرلا في ةعجارلماو ،ةقيقدلا يرغ تانايبلاو ،غلابلإا صقن نم ةغرفم ةقلح .باحسنلااو ةملها طيبثت لىإ ىدأ ام وهو ،ةيفاكلا يرغ تايصوتلاو ،ةمئلالما يرغ تلااحلإا لثم ،ةراضلا جئاتنلا ضعب نع غلابلإا مت فولخا نع جتن يذلاو ،ينفظولما في روهدتلما صقنلا تلااحو وأ ،ةيبيدأتلا تاءارجلإا وأ ،موللا كلذ في ماب ،ةيبلسلا تاعبتلا نم .ضياقتلا تايفول ةلاعفلا ةبقارملل ةبولطلما طوشرلا لمشت جاتنتسلاا ام اله ةباجتسلااو ةدلاولاب ةطيحلما ةترفلا تايفو وأ/و تاهملأا تاداشرلإا ؛ةيبيدأتلاو ةيئاضقلا تاءارجلإا نع ةيلمعلا لصف :ليي فاشرلإاو ؛تايصوتلا ذيفنتل ةيفاكلا دراولماو ؛بيردتلاو ةلماشلا .نملآا ملعتلا ينكمتل معادلا 72 Bull World Health Organ 2023;101:62–75G| doi: http://dx.doi.org/10.2471/BLT.22.288703 Systematic reviews Maternal and perinatal death surveillance Merlin L Willcox et al. 摘要 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 目的 旨在了解中低收入国家实施孕产妇和 / 或围产期 死亡监测和响应的经验和相关人员的看法，以及该流 程实现预期结果的机制。 方法 在 2022 年 6 月，我们系统地搜索了七个定性研 究数据中关于在中低收入国家实施孕产妇和 / 或围产 期死亡监测和响应的利益相关者的数据。两名评审员 对论文进行了独立筛选并评估了论文质量。我们将各 个主题进行整合以获得描述性的主题，并使用实际可 行的方法来了解情境 - 机制 - 结果的结构关系。 结果 59 项研究符合纳入标准。周期性地采取功能性 行动带来了积极结果（提高护理质量或降低死亡率）。 有效的死亡监测和响应机制包括学习、保持警觉并执 行可促进更多人员参与的建议。实现有效死亡监测和 响应的关键条件是打造免于受责的学习环境和优秀的 领导力。不充分的结果（不能改善护理质量和降低死 亡率以及持续实施死亡监测和响应）源自漏报、数据 不准确、审查和建议不足造成的恶性循环，这导致了 消极怠工和工作疏离感。论文中报告了一些有害结果， 如不适当的转诊和人员短缺加剧，这是由于担心承担 负面后果（如指责、纪律处分或诉讼）所造成的。 结论 有效实施孕产妇和 / 或围产期死亡监测和响应所 需的条件包括：将该过程与诉讼和纪律程序独立开来； 开展全面指导和培训 ；拥有足够资源以执行建议 ；以 及提供确保安全学习的支持性监督。 Résumé Surveillance des décès maternels et périnatals et riposte: revue systématique d'études qualitatives Objectif Comprendre les expériences et perceptions des individus chargés de mettre en œuvre la surveillance des décès maternels et périnatals et la riposte dans les pays à revenu faible et intermédiaire, ainsi que les mécanismes utilisés pour que ce processus atteigne ses objectifs. Méthodes En juin 2022, nous avons analysé systématiquement sept bases de données à la recherche d'études qualitatives sur les intervenants responsables du processus de surveillance des décès maternels et périnatals et de la riposte dans les pays à revenu faible et intermédiaire. Deux réviseurs ont passé séparément les articles en revue afin d'évaluer leur qualité. Nous avons ensuite utilisé une synthèse thématique pour extraire des thèmes descriptifs et une approche réaliste permettant d'identifier les configurations contexte–mécanisme–résultat. Résultats Nous avons inclus 59 études correspondant aux critères d'inclusion. Les résultats positifs (amélioration de la qualité des soins ou diminution de la mortalité) reposaient sur un cycle fonctionnel d'actions. Parmi les mécanismes favorisant la surveillance et la riposte contre les décès figuraient une expérience instructive, la vigilance et l'application de recommandations, ce qui motivait les acteurs à participer. Un environnement éducatif dépourvu de culpabilisation et bien dirigé offrait un contexte optimal pour garantir l'efficacité de la surveillance et de la riposte. Au contraire, les résultats insatisfaisants (absence d'amélioration des soins et de la mortalité, interruption du processus de surveillance et de riposte contre les décès) étaient liés à un cercle vicieux fait de sous-déclaration des décès, de renseignements inexacts, mais aussi d'analyses et de recommandations inadéquates, entraînant une démotivation et un manque d'engagement. Certains résultats néfastes ont également été rapportés, tels que des références inappropriées et une aggravation du manque de personnel, suscités par la crainte de conséquences négatives (blâmes, sanctions disciplinaires ou litiges). Conclusion Plusieurs conditions sont requises pour assurer une surveillance et une riposte efficaces contre les décès maternels et/ ou périnatals: séparer ce processus des procédures disciplinaires et des litiges; proposer un ensemble de formations et de lignes directrices; fournir les ressources nécessaires à la mise en œuvre des recommandations; et enfin, opter pour une supervision constructive, propice à un environnement éducatif sans danger. Резюме Эпиднадзор за материнской и перинатальной смертностью и ответные меры: систематический обзор качественных исследований Цель Понять опыт и восприятие людей, осуществляющих эпиднадзор за материнской и (или) перинатальной смертностью и ответные меры в странах с низким и средним уровнем дохода, а также механизмы, благодаря которым этот процесс может привести к намеченным результатам. Методы В июне 2022 года в семи базах данных был проведен систематический поиск качественных исследований заинтересованных сторон, осуществляющих эпиднадзор за материнской и (или) перинатальной смертностью и ответные меры в странах с низким и средним уровнем дохода. Два рецензента, независимо друг от друга, отбирали статьи и оценивали их качество. Для выявления описательных тем использовался тематический синтез и реалистичный подход для понимания структуры контекста-механизма-результата. Результаты Критериям включения соответствовали пятьдесят девять исследований. Благоприятные исходы (улучшение качества ухода или снижение смертности) подкреплялись функциональным циклом действий. В число механизмов эффективного эпиднадзора за смертностью и ответных мер входили обучение, внимательность и выполнение рекомендаций, которые мотивируют к дальнейшему участию. Ключевым контекстом для обеспечения эффективного эпиднадзора за смертностью и ответных мер являлась свободная от обвинений образовательная среда с хорошим руководством. Неудовлетворительные исходы (отсутствие улучшения ухода и снижения смертности, прекращение эпиднадзора за смертностью и ответных мер) стали результатом замкнутого круга занижения отчетных показателей, неточных данных, ненадлежащего анализа и рекомендаций, что привело к снижению мотивации и отстраненности. Сообщалось о некоторых неблагоприятных исходах, таких как ненадлежащие направления к врачам и усугубление нехватки персонала, что было вызвано страхом перед негативными последствиями, включая обвинения, дисциплинарные меры или судебные разбирательства. Вывод В число необходимых условий для эффективного эпиднадзора за материнской и (или) перинатальной смертностью 73Bull World Health Organ 2023;101:62–75G| doi: http://dx.doi.org/10.2471/BLT.22.288703 Systematic reviews Maternal and perinatal death surveillanceMerlin L Willcox et al. и ответных мер входят: отделение процесса от судебных разбирательств и дисциплинарных процедур; комплексные руководства и обучение; достаточные ресурсы для выполнения рекомендаций; поддерживающий надзор для обеспечения безопасного обучения. Resumen Vigilancia y respuesta a la mortalidad materna y perinatal: una revisión sistemática de los estudios cualitativos Objetivo Comprender las experiencias y percepciones de las personas que implementan la vigilancia y la respuesta a la mortalidad materna o perinatal en los países de ingresos bajos y medios, y los mecanismos por los que este proceso puede alcanzar los resultados previstos. Métodos En junio de 2022, se realizaron búsquedas sistemáticas en siete bases de datos para encontrar estudios cualitativos de las partes interesadas que implementan la vigilancia y la respuesta a la mortalidad materna o perinatal en países de ingresos bajos y medios. Dos revisores analizaron de forma independiente los artículos y evaluaron su calidad. Se utilizó la síntesis temática para derivar temas descriptivos y un enfoque realista para comprender las configuraciones de contexto, mecanismo y resultado. Resultados Cincuenta y nueve estudios cumplieron los criterios de inclusión. Los resultados satisfactorios (mejora de la calidad de la atención o reducción de la mortalidad) se sustentaron en un ciclo de acción funcional. Los mecanismos para una vigilancia y respuesta eficaces a la mortalidad incluyeron el aprendizaje, la vigilancia y la aplicación de recomendaciones que motivaron un mayor compromiso. El contexto clave para hacer posible una vigilancia y respuesta eficaz a la mortalidad fue un entorno de aprendizaje libre de culpa con un buen liderazgo. Los resultados insuficientes (falta de mejora en la atención y la mortalidad e interrupción de la vigilancia y la respuesta a la mortalidad) fueron el resultado de un círculo vicioso de falta de notificación, datos inexactos y revisión y recomendaciones inadecuadas, que condujeron a la desmotivación y la falta de compromiso. Se notificaron algunos desenlaces perjudiciales, como las derivaciones incorrectas y una mayor falta de personal, que se debieron al miedo a las consecuencias negativas, como la culpa, las medidas disciplinarias o los litigios. Conclusión Entre los requisitos necesarios para que la vigilancia y la respuesta a la mortalidad materna o perinatal sean eficaces se encuentran los siguientes: separación del proceso de los litigios y los procedimientos disciplinarios; directrices y formación exhaustivas; recursos adecuados para aplicar las recomendaciones; y una supervisión de apoyo que permita el aprendizaje seguro. References 1. Kruk ME, Gage AD, Joseph NT, Danaei G, García-Saisó S, Salomon JA. Mortality due to low-quality health systems in the universal health coverage era: a systematic analysis of amenable deaths in 137 countries. Lancet. 2018 Nov 17;392(10160):2203–12. doi: http:// dx .doi .org/ 10 .1016/ S0140 -6736(18)31668 -4 PMID: 30195398 2. Beyond the numbers: reviewing maternal deaths and complications to make pregnancy safer. Geneva: World Health Organization; 2004. Available from: https:// apps .who .int/ iris/ handle/ 10665/ 42984 [cited 2022 Aug 9]. 3. Maternal death surveillance and response: technical guidance. Information for action to prevent maternal death. Geneva: World Health Organization; 2013. Available from: https:// apps .who .int/ iris/ handle/ 10665/ 87340 [cited 2022 Aug 9]. 4. Making every baby count: audit and review of stillbirths and neonatal deaths. Geneva: World Health Organization; 2016. Available from: https:// apps .who .int/ iris/ handle/ 10665/ 249523 [cited 2022 Aug 9]. 5. Maternal and perinatal death and surveillance and response: materials to support implementation. Geneva: World Health Organization; 2021. Available from: https:// apps .who .int/ iris/ handle/ 10665/ 348487 [cited 2022 Aug 9]. 6. Time to respond: a report on the global implementation of maternal death surveillance and response. Geneva: World Health Organization; 2016. Available from: https:// apps .who .int/ iris/ handle/ 10665/ 249524 [cited 2022 Aug 9]. 7. Ahmed SM, Rawal LB, Chowdhury SA, Murray J, Arscott-Mills S, Jack S, et al. Cross-country analysis of strategies for achieving progress towards global goals for women’s and children’s health. Bull World Health Organ. 2016 May 1;94(5):351–61. doi: http:// dx .doi .org/ 10 .2471/ BLT .15 .168450 PMID: 27147765 8. Dumont A, Fournier P, Abrahamowicz M, Traoré M, Haddad S, Fraser WD; QUARITE research group. Quality of care, risk management, and technology in obstetrics to reduce hospital-based maternal mortality in Senegal and Mali (QUARITE): a cluster-randomised trial. Lancet. 2013 Jul 13;382(9887):146–57. doi: http:// dx .doi .org/ 10 .1016/ S0140 -6736(13)60593 -0 PMID: 23721752 9. Pattinson R, Kerber K, Waiswa P, Day LT, Mussell F, Asiruddin SK, et al. Perinatal mortality audit: counting, accountability, and overcoming challenges in scaling up in low- and middle-income countries. Int J Gynaecol Obstet. 2009 Oct;107 Suppl 1:S113–21, S121–2. doi: http:// dx .doi .org/ 10 .1016/ j .ijgo .2009 .07 .011 PMID: 19815206 10. Willcox ML, Price J, Scott S, Nicholson BD, Stuart B, Roberts NW, et al. Death audits and reviews for reducing maternal, perinatal and child mortality. Cochrane Database Syst Rev. 2020 Mar 25;3(3):CD012982. doi: http:// dx .doi .org/ 10 .1002/ 14651858 .CD012982 .pub2 PMID: 32212268 11. Pattinson R, editor. Saving babies 2008–2009: seventh report on perinatal care in South Africa. Pretoria: Tshepesa Press; 2011. 12. Pattinson R, editor. Saving babies 2010–2011: eighth report on perinatal care in South Africa. Pretoria: Tshepesa Press; 2013. 13. Martin Hilber A, Blake C, Bohle LF, Bandali S, Agbon E, Hulton L. Strengthening accountability for improved maternal and newborn health: a mapping of studies in Sub-Saharan Africa. Int J Gynaecol Obstet. 2016 Dec;135(3):345–57. doi: http:// dx .doi .org/ 10 .1016/ j .ijgo .2016 .09 .008 PMID: 27802869 14. Lusambili A, Jepkosgei J, Nzinga J, English M. What do we know about maternal and perinatal mortality and morbidity audits in sub- Saharan Africa? A scoping literature review. Int J Hum Rights Healthc. 2019;12(3):192–207. doi: http:// dx .doi .org/ 10 .1108/ IJHRH -07 -2018 -0052 15. Kinney MV, Walugembe DR, Wanduru P, Waiswa P, George A. Maternal and perinatal death surveillance and response in low- and middle-income countries: a scoping review of implementation factors. Health Policy Plan. 2021 Jun 25;36(6):955–73. doi: http:// dx .doi .org/ 10 .1093/ heapol/ czab011 PMID: 33712840 16. Willcox ML, Okello IA, Maidwell-Smith A, Tura AK, van den Akkerd T, Knighte M. Maternal and perinatal death surveillance and response in low- and middle-income countries: a systematic review of qualitative studies. Supplementary material [data repository]. London: figshare; 2022. doi: http:// dx .doi .org/ 10 .6084/ m9 .figshare .21360267 17. CASP qualitative checklists [internet]. Oxford: Critical Appraisal Skills Programme; 2018. Available from: https:// casp -uk .net/ casp -tools -checklists/ [cited 2022 May 31]. 18. Thomas J, Harden A. Methods for the thematic synthesis of qualitative research in systematic reviews. BMC Med Res Methodol. 2008 Jul 10;8(1):45. doi: http:// dx .doi .org/ 10 .1186/ 1471 -2288 -8 -45 PMID: 18616818 19. Pawson R, Greenhalgh T, Harvey G, Walshe K. Realist review – a new method of systematic review designed for complex policy interventions. J Health Serv Res Policy. 2005 Jul;10(1) Suppl 1:21–34. doi: http:// dx .doi .org/ 10 .1258/ 1355819054308530 PMID: 16053581 20. Pawson R. Evidence-based policy: the promise of “realist synthesis”. Evaluation. 2002;8(3):340–58. doi: http:// dx .doi .org/ 10 .1177/ 135638902401462448 74 Bull World Health Organ 2023;101:62–75G| doi: http://dx.doi.org/10.2471/BLT.22.288703 Systematic reviews Maternal and perinatal death surveillance Merlin L Willcox et al. 21. Abbakar NAO. Maternal death surveillance and response in Sudan: an evidence-based, context-specific optimisation to improve maternal care. Oxford: University of Oxford; 2021. 22. Abebe B, Busza J, Hadush A, Usmael A, Zeleke AB, Sita S, et al. ‘We identify, discuss, act and promise to prevent similar deaths’: a qualitative study of Ethiopia’s maternal death surveillance and response system. BMJ Glob Health. 2017 Mar 14;2(2):e000199. doi: http:// dx .doi .org/ 10 .1136/ bmjgh -2016 -000199 PMID: 28589016 23. Aborigo RA, Allotey P, Tindana P, Azongo D, Debpuur C. Cultural imperatives and the ethics of verbal autopsies in rural Ghana. Glob Health Action. 2013 Sep 19;6(1):18570. doi: http:// dx .doi .org/ 10 .3402/ gha .v6i0 .18570 PMID: 24054087 24. Afayo V. Maternal death surveillance and response: barriers and facilitators. Arua regional referral hospital. Kampala: Makerere University; 2018. 25. Agaro C, Beyeza-Kashesya J, Waiswa P, Sekandi JN, Tusiime S, Anguzu R, et al. The conduct of maternal and perinatal death reviews in Oyam District, Uganda: a descriptive cross-sectional study. BMC Womens Health. 2016 Jul 14;16(1):38. doi: http:// dx .doi .org/ 10 .1186/ s12905 -016 -0315 -5 PMID: 27418127 26. Armstrong CE, Lange IL, Magoma M, Ferla C, Filippi V, Ronsmans C. Strengths and weaknesses in the implementation of maternal and perinatal death reviews in Tanzania: perceptions, processes and practice. Trop Med Int Health. 2014 Sep;19(9):1087–95. doi: http:// dx .doi .org/ 10 .1111/ tmi .12353 PMID: 25039579 27. Ayele B, Gebretnsae H, Hadgu T, Negash D, G/silassie F, Alemu T, et al. Maternal and perinatal death surveillance and response in Ethiopia: achievements, challenges and prospects. PLoS One. 2019;14(10):e0223540. doi: http:// dx .doi .org/ 10 .1371/ journal .pone .0223540 PMID: 31603937 28. Bakker W, van den Akker T, Mwagomba B, Khukulu R, van Elteren M, van Roosmalen J. Health workers’ perceptions of obstetric critical incident audit in Thyolo District, Malawi. Trop Med Int Health. 2011 Oct;16(10):1243–50. doi: http:// dx .doi .org/ 10 .1111/ j .1365 -3156 .2011 .02832 .x PMID: 21767335 29. Balogun HA, Musoke SB. The barriers of maternal death review implementation in Sudan – a qualitative assessment. Solna: Karolinska Institutet; 2014. 30. Bandali S, Thomas C, Wamalwa P, Mahendra S, Kaimenyi P, Warfa O, et al. Strengthening the “P” in Maternal and Perinatal Death Surveillance and Response in Bungoma county, Kenya: implications for scale-up. BMC Health Serv Res. 2019 Aug 30;19(1):611. doi: http:// dx .doi .org/ 10 .1186/ s12913 -019 -4431 -4 PMID: 31470854 31. Belizán M, Bergh A-M, Cilliers C, Pattinson RC, Voce A; Synergy Group. Stages of change: a qualitative study on the implementation of a perinatal audit programme in South Africa. BMC Health Serv Res. 2011 Sep 30;11(1):243. doi: http:// dx .doi .org/ 10 .1186/ 1472 -6963 -11 -243 PMID: 21958353 32. Biswas A, Fazlur R, Abdul H, Eriksson C, Dalal K. Experiences of community verbal autopsy in maternal and newborn health of Bangladesh. Healthmed. 2015;9(8):329–38. 33. Biswas A, Rahman F, Eriksson C, Dalal K. Community notification of maternal, neonatal deaths and still births in Maternal and Neonatal Death Review (MNDR) system: experiences in Bangladesh. Health. 2014;6(16):2218–26. doi: http:// dx .doi .org/ 10 .4236/ health .2014 .616257 34. Biswas A, Rahman F, Eriksson C, Halim A, Dalal K. Facility death review of maternal and neonatal deaths in Bangladesh. PLoS One. 2015 Nov 5;10(11):e0141902. doi: http:// dx .doi .org/ 10 .1371/ journal .pone .0141902 PMID: 26540233 35. Biswas A, Rahman F, Eriksson C, Halim A, Dalal K. Social autopsy of maternal, neonatal deaths and stillbirths in rural Bangladesh: qualitative exploration of its effect and community acceptance. BMJ Open. 2016 Aug 23;6(8):e010490. doi: http:// dx .doi .org/ 10 .1136/ bmjopen -2015 -010490 PMID: 27554100 36. Cahyanti RD, Widyawati W, Hakimi M. “Sharp downward, blunt upward”: district maternal death audits’ challenges to formulate evidence-based recommendations in Indonesia – a qualitative study. BMC Pregnancy Childbirth. 2021 Oct 27;21(1):730. doi: http:// dx .doi .org/ 10 .1186/ s12884 -021 -04212 -7 PMID: 34706687 37. Combs Thorsen V, Sundby J, Meguid T, Malata A. Easier said than done!: methodological challenges with conducting maternal death review research in Malawi. BMC Med Res Methodol. 2014 Feb 21;14(1):29. doi: http:// dx .doi .org/ 10 .1186/ 1471 -2288 -14 -29 PMID: 24559148 38. Congo B, Sanon D, Millogo T, Ouedraogo CM, Yaméogo WME, Meda ZC, et al. Inadequate programming, insufficient communication and non-compliance with the basic principles of maternal death audits in health districts in Burkina Faso: a qualitative study. Reprod Health. 2017 Sep 29;14(1):121. doi: http:// dx .doi .org/ 10 .1186/ s12978 -017 -0379 -1 PMID: 28969656 39. Dartey AF. Development of an employee assistance programme (EAP) for midwives dealing with maternal death cases. The Ashanti Region, Ghana [dissertation]. Cape Town: University of the Western Cape; 2016. 40. de Kok B, Imamura M, Kanguru L, Owolabi O, Okonofua F, Hussein J. Achieving accountability through maternal death reviews in Nigeria: a process analysis. Health Policy Plan. 2017 Oct 1;32(8):1083–91. doi: http:// dx .doi .org/ 10 .1093/ heapol/ czx012 PMID: 28666342 41. Dortonne JR, Dumont A, Traore M, Perreault G, Couturier F, Kanouté K. [Maternal mortality audits in low-resource countries: analysis of 23 hospitals in Senegal and Mali (the QUARITE study)]. J Obstet Gynaecol Can. 2009 Oct;31(10):936–7. French. doi: http:// dx .doi .org/ 10 .1016/ S1701 -2163(16)34323 -7 PMID: 19941723 42. Dumont A, Tourigny C, Fournier P. Improving obstetric care in low-resource settings: implementation of facility-based maternal death reviews in five pilot hospitals in Senegal. Hum Resour Health. 2009 Jul 23;7(1):61. doi: http:// dx .doi .org/ 10 .1186/ 1478 -4491 -7 -61 PMID: 19627605 43. Gao Y, Kildea S, Barclay L, Hao M, Zeng W. Maternal mortality surveillance in an inland Chinese province. Int J Gynaecol Obstet. 2009 Feb;104(2):128–31. doi: http:// dx .doi .org/ 10 .1016/ j .ijgo .2008 .10 .004 PMID: 19022443 44. van Hamersveld KT, den Bakker E, Nyamtema AS, van den Akker T, Mfinanga EH, van Elteren M, et al. Barriers to conducting effective obstetric audit in Ifakara: a qualitative assessment in an under-resourced setting in Tanzania. Trop Med Int Health. 2012 May;17(5):652–7. doi: http:// dx .doi .org/ 10 .1111/ j .1365 -3156 .2012 .02972 .x PMID: 22469464 45. Hartsell LR. Assessing maternal mortality data: a look into the quality of maternal mortality data registration in Kilimanjaro Region, Tanzania. Dar Es Salaam: Muhimbili University of Health and Applied Sciences; 2010. 46. Hofman JJ, Mohammed H. Experiences with facility-based maternal death reviews in northern Nigeria. Int J Gynaecol Obstet. 2014 Aug;126(2):111–4. doi: http:// dx .doi .org/ 10 .1016/ j .ijgo .2014 .02 .014 PMID: 24834852 47. Jepkosgei J, Nzinga J, Adam MB, English M. Exploring healthcare workers’ perceptions on the use of morbidity and mortality audits as an avenue for learning and care improvement in Kenyan hospitals’ newborn units. BMC Health Serv Res. 2022 Feb 10;22(1):172. doi: http:// dx .doi .org/ 10 .1186/ s12913 -022 -07572 -8 PMID: 35144594 48. Karimi A, Sadoughi F, Majdzadeh R. Essential revisions in the maternal mortality surveillance system: lessons learned from a qualitative study. Acta Med Mediter. 2018;34(4):1111. doi: http:// dx .doi .org/ 10 .19193/ 0393 -6384 _2018 _4 _171 49. Kinney MV, Ajayi G, de Graft-Johnson J, Hill K, Khadka N, Om’Iniabohs A, et al. “It might be a statistic to me, but every death matters.”: an assessment of facility-level maternal and perinatal death surveillance and response systems in four sub-Saharan African countries. PLoS One. 2020 Dec 18;15(12):e0243722. doi: http:// dx .doi .org/ 10 .1371/ journal .pone .0243722 PMID: 33338039 50. Kongnyuy EJ, van den Broek N. The difficulties of conducting maternal death reviews in Malawi. BMC Pregnancy Childbirth. 2008 Sep 11;8(1):42. doi: http:// dx .doi .org/ 10 .1186/ 1471 -2393 -8 -42 PMID: 18786267 51. Melberg A, Mirkuzie AH, Sisay TA, Sisay MM, Moland KM. “Maternal deaths should simply be 0”: politicization of maternal death reporting and review processes in Ethiopia. Health Policy Plan. 2019 Sep 1;34(7):492–8. doi: http:// dx .doi .org/ 10 .1093/ heapol/ czz075 PMID: 31365076 52. Muffler N, Trabelssi MH, De Brouwere V. Scaling up clinical audits of obstetric cases in Morocco. Trop Med Int Health. 2007 Oct;12(10):1248–57. doi: http:// dx .doi .org/ 10 .1111/ j .1365 -3156 .2007 .01911 .x PMID: 17956508 53. Muvuka B. Uncovering the stories behind the numbers: a case study of maternal death surveillance and response in Goma, Democratic Republic of Congo [dissertation]. Louisville: University of Louisville; 2019. 54. Nyamtema AS, Urassa DP, Pembe AB, Kisanga F, van Roosmalen J. Factors for change in maternal and perinatal audit systems in Dar es Salaam hospitals, Tanzania. BMC Pregnancy Childbirth. 2010 Jun 3;10(1):29. doi: http:// dx .doi .org/ 10 .1186/ 1471 -2393 -10 -29 PMID: 20525282 55. Owolabi H, Ameh CA, Bar-Zeev S, Adaji S, Kachale F, van den Broek N. Establishing cause of maternal death in Malawi via facility-based review and application of the ICD-MM classification. BJOG. 2014 Sep;121 Suppl 4:95–101. doi: http:// dx .doi .org/ 10 .1111/ 1471 -0528 .12998 PMID: 25236641 56. Patel Z, Kumar V, Singh P, Singh V, Yadav R, Baqui AH, et al.; Saksham Study Group. Feasibility of community neonatal death audits in rural Uttar Pradesh, India. J Perinatol. 2007 Sep;27(9):556–64. doi: http:// dx .doi .org/ 10 .1038/ sj .jp .7211788 PMID: 17637788 57. Said A, Sirili N, Massawe S, Pembe AB, Hanson C, Malqvist M. Mismatched ambition, execution and outcomes: implementing maternal death surveillance and response system in Mtwara region, Tanzania. BMJ Glob Health. 2021 May;6(5):e005040. doi: http:// dx .doi .org/ 10 .1136/ bmjgh -2021 -005040 PMID: 34020994 75Bull World Health Organ 2023;101:62–75G| doi: http://dx.doi.org/10.2471/BLT.22.288703 Systematic reviews Maternal and perinatal death surveillanceMerlin L Willcox et al. 58. Tayebwa E, Sayinzoga F, Umunyana J, Thapa K, Ajayi E, Kim YM, et al. Assessing implementation of maternal and perinatal death surveillance and response in Rwanda. Int J Environ Res Public Health. 2020 Jun 18;17(12):4376. doi: http:// dx .doi .org/ 10 .3390/ ijerph17124376 PMID: 32570817 59. Upadhyaya S, Shetty S, Kumar SS, Dongre A, Deshmukh P. Institutionalizing district level infant death review: an experience from southern India. WHO South-East Asia J Public Health. 2012 Oct-Dec;1(4):446–56. doi: http:// dx .doi .org/ 10 .4103/ 2224 -3151 .207047 PMID: 28615610 60. Study on the implementation of maternal death review in five countries in the South-East Asia Region of the World Health Organization. New Delhi: World Health Organization Regional Office for South-East Asia; 2014. Available from: https:// apps .who .int/ iris/ handle/ 10665/ 205952 [cited 2022 Aug 9]. 61. Boyi Hounsou C, Agossou MCU, Bello K, Delvaux T, Benova L, Vigan Guézodjè A, et al. “So hard not to feel blamed!”: assessment of implementation of Benin’s maternal and perinatal death surveillance and response strategy from 2016–2018. Int J Gynaecol Obstet. 2022 Aug;158(S2) Suppl 2:6–14. doi: http:// dx .doi .org/ 10 .1002/ ijgo .14041 PMID: 34961924 62. Bvumbwe MM. Maternal death review practices among northern zone hospitals in Malawi. Eldoret: Moi University; 2019. 63. Chirwa MD, Nyasulu J, Modiba L, Limando MG. Challenges faced by midwives in the implementation of facility-based maternal death reviews in Malawi [preprint]. Durham: Research Square; 2022. doi: http:// dx .doi .org/ 10 .21203/ rs .3 .rs -1227560/ v1 64. Compaoré R, Kouanda S, Kuma-Aboagye P, Sagoe-Moses I, Brew G, Deganus S, et al. Transitioning to the maternal death surveillance and response system from maternal death review in Ghana: challenges and lessons learned. Int J Gynaecol Obstet. 2022 Aug;158(S2) Suppl 2:37–45. doi: http:// dx .doi .org/ 10 .1002/ ijgo .14147 PMID: 35315062 65. Compaoré R, Millogo T, Ouedraogo AM, Tougri H, Ouedraogo L, Tall F, et al. Maternal and neonatal death surveillance and response in Liberia: an assessment of the implementation process in five counties. Int J Gynaecol Obstet. 2022 Aug;158(S2) Suppl 2:46–53. doi: http:// dx .doi .org/ 10 .1002/ ijgo .14174 PMID: 35434804 66. Congo B, Méda CZ, Millogo T, Sanon/Ouédraogo D, Ouédraogo CMR, Kouanda S. Evaluation of the quality of maternal death review cycles in Burkina Faso. Int J Gynaecol Obstet. 2022;158 Suppl 2:21–8. doi: http:// dx .doi .org/ 10 .1002/ ijgo .14071 PMID: 35099071 67. Congo B, Yaméogo WME, Millogo T, Compaoré R, Tougri H, Ouédraogo CMR, et al. Barriers to the implementation of quality maternal death reviews in health districts in Burkina Faso. Int J Gynaecol Obstet. 2022 Aug;158 Suppl 2:29–36. doi: http:// dx .doi .org/ 10 .1002/ ijgo .14232 PMID: 35616151 68. Diallo I, Bationo N, Soubeiga D, et al. Midwives’ experiences in the practice of maternal death audits in Burkina Faso: a qualitative study. Int J Nurs Midwifery. 2022;14(1):10–3. doi: http:// dx .doi .org/ 10 .5897/ IJNM2021 .0488 69. Jati SP, Budiyanti RT, Dewanti NAY, Sriatmi A, Martini M. Development model of perinatal death surveillance and response (PDSR) in Semarang City, Indonesia. JMMR Jurnal Medicoeticolegal dan Manajemen Rumah Saki. 2019;8(1):1–6. doi: http:// dx .doi .org/ 10 .18196/ jmmr .8181 70. Khader Y, Al-Sheyab N, Alyahya M, Batieha A. Registration, documentation, and auditing of stillbirths and neonatal deaths in Jordan from healthcare professionals’ perspectives: reality, challenges and suggestions. J Matern Fetal Neonatal Med. 2020 Oct;33(19):3338–48. doi: http:// dx .doi .org/ 10 .1080/ 14767058 .2018 .1531120 PMID: 30348027 71. Kouanda S, Ouedraogo OMA, Busogoro JF, Conombo Kafando GS, Nkurunziza T. Maternal and neonatal death surveillance and response is implemented in Burundi but needs improvement. Int J Gynaecol Obstet. 2022 Aug;158(S2) Suppl 2:54–60. doi: http:// dx .doi .org/ 10 .1002/ ijgo .14151 PMID: 35322418 72. Kouanda S, Ouedraogo OMA, Tchonfiene PP, Lhagadang F, Ouedraogo L, Conombo Kafando GS. Analysis of the implementation of maternal death surveillance and response in Chad. Int J Gynaecol Obstet. 2022 Aug;158(S2) Suppl 2:67–73. doi: http:// dx .doi .org/ 10 .1002/ ijgo .14150 PMID: 35322874 73. Melberg A, Teklemariam L, Moland KM, Aasen HS, Sisay MM. Juridification of maternal deaths in Ethiopia: a study of the maternal and perinatal death surveillance and response (MPDSR) system. Health Policy Plan. 2020 Oct 1;35(8):900–5. doi: http:// dx .doi .org/ 10 .1093/ heapol/ czaa043 PMID: 32594165 74. Mukinda FK, George A, Van Belle S, Schneider H. Practice of death surveillance and response for maternal, newborn and child health: a framework and application to a South African health district. BMJ Open. 2021 May 6;11(5):e043783. doi: http:// dx .doi .org/ 10 .1136/ bmjopen -2020 -043783 PMID: 33958337 75. Richard F, Ouédraogo C, Zongo V, Ouattara F, Zongo S, Gruénais ME, et al. The difficulty of questioning clinical practice: experience of facility-based case reviews in Ouagadougou, Burkina Faso. BJOG. 2009 Jan;116(1):38–44. doi: http:// dx .doi .org/ 10 .1111/ j .1471 -0528 .2008 .01741 .x PMID: 18503575 76. Russell N, Tappis H, Mwanga JP, Black B, Thapa K, Handzel E, et al. Implementation of maternal and perinatal death surveillance and response (MPDSR) in humanitarian settings: insights and experiences of humanitarian health practitioners and global technical expert meeting attendees. Confl Health. 2022 May 7;16(1):23. doi: http:// dx .doi .org/ 10 .1186/ s13031 -022 -00440 -6 PMID: 35526012 77. Yameogo WME, Nadine Ghilat Paré/Belem W, Millogo T, Kouanda S, Ouédraogo CMR. Assessment of the maternal death surveillance and response implementation process in Burkina Faso. Int J Gynaecol Obstet. 2022;158 Suppl 2:15–20. doi: http:// dx .doi .org/ 10 .1002/ ijgo .14227 PMID: 35603808 78. Dartey A, Ganga-Limando M. Contributions of midwives in the implementation of facility-based maternal death review (MDR) in selected health facilities in Ashanti Region, Ghana. Int J Res Health Sci. 2014;2(2):614–20. 79. Willcox ML, Okello IA, Maidwell-Smith A, Tura AK, van den Akkerd T, Knighte M. Maternal and perinatal death surveillance and response in low- and middle-income countries: a systematic review of qualitative studies. Supplementary Tables 2&3 [data repository]. London: figshare; 2022. doi: http:// dx .doi .org/ 10 .6084/ m9 .figshare .21455760 .v1 80. Kongnyuy EJ, Leigh B, van den Broek N. Effect of audit and feedback on the availability, utilisation and quality of emergency obstetric care in three districts in Malawi. Women Birth. 2008 Dec;21(4):149–55. doi: http:// dx .doi .org/ 10 .1016/ j .wombi .2008 .08 .002 PMID: 18842471 81. Moodley J, Pattinson RC, Fawcus S, Schoon MG, Moran N, Shweni PM; National Committee on Confidential Enquiries into Maternal Deaths in South Africa. The confidential enquiry into maternal deaths in South Africa: a case study. BJOG. 2014 Sep;121 Suppl 4:53–60. doi: http:// dx .doi .org/ 10 .1111/ 1471 -0528 .12869 PMID: 25236634 82. Tura AK, Fage SG, Ibrahim AM, Mohamed A, Ahmed R, Gure T, et al. Beyond no blame: practical challenges of conducting maternal and perinatal death reviews in eastern Ethiopia. Glob Health Sci Pract. 2020 Jun 30;8(2):150–4. doi: http:// dx .doi .org/ 10 .9745/ GHSP -D -19 -00366 83. Yardley L, Ainsworth B, Arden-Close E, Muller I. The person-based approach to enhancing the acceptability and feasibility of interventions. Pilot Feasibility Stud. 2015 Oct 26;1(1):37. doi: http:// dx .doi .org/ 10 .1186/ s40814 -015 -0033 -z PMID: 27965815 84. Kinney MV, Day LT, Palestra F, Biswas A, Jackson D, Roos N, et al.; MPDSR Technical Working Group. Overcoming blame culture: key strategies to catalyse maternal and perinatal death surveillance and response. BJOG. 2022 May;129(6):839–44. doi: http:// dx .doi .org/ 10 .1111/ 1471 -0528 .16989 PMID: 34709701 Bull World Health Organ 2023;101:62–75G| doi: http://dx.doi.org/10.2471/BLT.22.288703 75A Systematic reviews Maternal and perinatal death surveillanceMerlin L Willcox et al. Ta bl e 1. St ud ie s o n m at er na l a nd p er in at al d ea th su rv ei lla nc e a nd re sp on se in clu de d in th e r ev ie w St ud y Co un tr y, co nt ex t Ty pe of d ea th Ty pe of re vi ew Pe rc ei ve d eff ec tiv en es s o f pr oc es s St ud y d es ig n Da ta co lle ct io n m et ho d No . a nd ty pe of p ar tic ip an ts Ty pe of an al ys is Ab ba ka r, 20 21 21 Su da n, n at io na l M at er na l M at er na l d ea th su rv ei lla nc e an d re sp on se In ad eq ua te Q ua lit at iv e In -d ep th in te rv ie w s 54 m at er na l d ea th su rv ei lla nc e an d re sp on se st aff , d oc to rs a nd m id w iv es Th em at ic an al ys is Ab eb e, e t a l., 20 17 22 Et hi op ia , n at io na l M at er na l M at er na l d ea th su rv ei lla nc e an d re sp on se Su cc es sf ul Q ua lit at iv e In di vi du al a nd gr ou p in te rv ie w s 69 fr on tli ne st aff re sp on sib le fo r im pl em en ta tio n of m at er na l d ea th su rv ei lla nc e an d re sp on se Th em at ic co nt en t a na ly sis Ab or ig o et a l., 20 13 23 Gh an a, c om m un ity Al l Ve rb al a ut op sy N ot sp ec ifi ed Q ua lit at iv e In -d ep th in te rv ie w s 36 b er ea ve d fa m ili es , fi el d st aff , ph ys ic ia ns a nd lo ca l l ea de rs Th em at ic an al ys is Af ay o, 2 01 82 4 U ga nd a, h ea lth fa ci lit y M at er na l M at er na l d ea th su rv ei lla nc e an d re sp on se In ad eq ua te M ix ed m et ho ds In -d ep th in te rv ie w s 11 h os pi ta l s ta ff an d m at er na l d ea th su rv ei lla nc e an d re sp on se c om m itt ee m em be rs Th em at ic co nt en t a na ly sis Ag ar o et a l., 20 16 25 U ga nd a, d ist ric t h ea lth fa ci lit y M at er na l a nd pe rin at al M at er na l a nd pe rin at al d ea th su rv ei lla nc e an d re sp on se In ad eq ua te M ix ed m et ho ds Se m i-s tru ct ur ed in te rv ie w s 76 : 6 6 he al th w or ke rs a nd 1 0 ke y in fo rm an ts Th em at ic co nt en t a na ly sis Ar m st ro ng e t a l., 20 14 26 U ni te d Re pu bl ic o f T an za ni a, m ul tip le le ve ls M at er na l a nd pe rin at al M at er na l a nd pe rin at al d ea th re vi ew In ad eq ua te Q ua lit at iv e D oc um en t r ev ie w an d in te rv ie w s 37 : 2 0 ho sp ita l s ta ff, 1 2 di st ric t o r re gi on al c oo rd in at or s, 5 na tio na l ex pe rt s Ad ap te d th em at ic an al ys is Ay el e et a l., 20 19 27 Et hi op ia , h ea lth fa ci lit y an d co m m un ity M at er na l a nd pe rin at al M at er na l a nd pe rin at al d ea th su rv ei lla nc e an d re sp on se In ad eq ua te M ix ed m et ho ds In -d ep th in te rv ie w s a nd fo cu s g ro up di sc us sio ns 25 w om en g ro up le ad er s i n 3 fo cu s gr ou ps ; 1 1 he al th m an ag er s i n in - de pt h in te rv ie w s Th em at ic co nt en t a na ly sis Ba kk er e t a l., 20 11 28 M al aw i, he al th fa ci lit y (ru ra l an d di st ric t) M at er na l M at er na l d ea th re vi ew Su cc es sf ul Q ua lit at iv e In -d ep th in te rv ie w s, fo cu s gr ou p di sc us sio ns an d ob se rv at io n 25 h ea lth w or ke rs N ot sp ec ifi ed Ba lo gu n & M us ok e, 20 14 29 Su da n, n at io na l M at er na l M at er na l d ea th re vi ew In ad eq ua te Q ua lit at iv e In -d ep th in te rv ie w s a nd fo cu s g ro up di sc us sio ns M ed ic al a nd h ea lth st ak eh ol de rs a t th e na tio na l, s ta te a nd fa ci lit y le ve l i n 12 in -d ep th in te rv ie w s a nd 1 8 fo cu s gr ou p di sc us sio ns Q ua lit at iv e co nt en t a na ly sis Ba nd al i e t a l., 20 19 30 Ke ny a, h os pi ta l a nd h ea lth ce nt re M at er na l a nd pe rin at al M at er na l a nd pe rin at al d ea th su rv ei lla nc e an d re sp on se Su cc es sf ul M ix ed m et ho ds In -d ep th in te rv ie w s a nd fo cu s g ro up di sc us sio ns 5 he al th re co rd s i nf or m at io n offi ce rs (in te rv ie w s) ; m at er na l a nd p er in at al de at h su rv ei lla nc e an d re sp on se co m m itt ee m em be rs (4 d isc us sio n gr ou ps ) Th em at ic an al ys is Be liz án e t a l., 20 11 31 So ut h Af ric a, h ea lth fa ci lit y Pe rin at al Pe rin at al P ro bl em Id en tifi ca tio n Pr og ra m m e N ot sp ec ifi ed Q ua lit at iv e Fo cu s g ro up a nd w or ks ho p 48 c lin ic ia ns a nd c oo rd in at or s i n th e Pe rin at al P ro bl em Id en tifi ca tio n Pr og ra m m e in 4 fo cu s g ro up di sc us sio ns Fr am ew or k an al ys is us in g st ag es -o f- ch an ge m od el (c on tin ue s. . . ) Bull World Health Organ 2023;101:62–75G| doi: http://dx.doi.org/10.2471/BLT.22.28870375B Systematic reviews Maternal and perinatal death surveillance Merlin L Willcox et al. St ud y Co un tr y, co nt ex t Ty pe of d ea th Ty pe of re vi ew Pe rc ei ve d eff ec tiv en es s o f pr oc es s St ud y d es ig n Da ta co lle ct io n m et ho d No . a nd ty pe of p ar tic ip an ts Ty pe of an al ys is Bo yi H ou ns ou e t al ., 2 02 26 1 Be ni n, h ea lth d ist ric t M at er na l M at er na l d ea th re vi ew In ad eq ua te M ix ed m et ho ds O nl in e gr ou p di sc us sio ns 34 d ist ric t m ed ic al o ffi ce rs in tw o on lin e gr ou p di sc us sio ns In du ct iv e th em at ic an al ys is Bi sw as e t a l., 20 14 33 Ba ng la de sh , c om m un ity M at er na l, pe rin at al a nd ne on at al M at er na l a nd pe rin at al d ea th re vi ew Su cc es sf ul M ix ed m et ho ds In -d ep th in te rv ie w s a nd fo cu s g ro up di sc us sio ns H ea lth w or ke rs a nd c om m un ity vo lu nt ee rs in 4 fo cu s g ro up di sc us sio ns a nd 4 in -d ep th in te rv ie w s Th em at ic an al ys is Bi sw as e t a l., 20 15 34 Ba ng la de sh , h ea lth fa ci lit y M at er na l, pe rin at al a nd ne on at al M at er na l a nd pe rin at al d ea th re vi ew Su cc es sf ul Q ua lit at iv e In -d ep th in te rv ie w s, fo cu s gr ou p di sc us sio ns an d do cu m en t re vi ew 46 h ea lth w or ke rs im pl em en tin g fa ci lit y de at h re vi ew : 3 5 in in -d ep th in te rv ie w s; 11 in fo cu s g ro up di sc us sio ns Th em at ic an al ys is Bi sw as e t a l., 20 15 32 Ba ng la de sh , c om m un ity M at er na l, pe rin at al a nd ne on at al Ve rb al a ut op sy Su cc es sf ul Q ua lit at iv e In -d ep th in te rv ie w s, fo cu s gr ou p di sc us sio ns an d pa rt ic ip an t ob se rv at io n H ea lth -c ar e pr ov id er s: 3 fo cu s g ro up di sc us sio ns , 6 in -d ep th in te rv ie w s, 6 pa rt ic ip an t o bs er va tio ns Th em at ic an al ys is Bi sw as e t a l., 20 16 35 Ba ng la de sh , c om m un ity M at er na l, pe rin at al a nd ne on at al So ci al a ut op sy Su cc es sf ul Q ua lit at iv e In -d ep th in te rv ie w s, fo cu s gr ou p di sc us sio ns , ob se rv at io n an d do cu m en t r ev ie w H ea lth in sp ec to rs in 9 fo cu s g ro up di sc us sio ns ; 1 8 he al th w or ke rs a nd 12 c om m un ity m em be rs in in -d ep th in te rv ie w s Co nt en t a nd th em at ic an al ys is Bv um bw e, 2 01 96 2 M al aw i, he al th fa ci lit y M at er na l M at er na l d ea th re vi ew In ad eq ua te Q ua lit at iv e In -d ep th in te rv ie w s a nd fo cu s g ro up di sc us sio ns 42 m at er na l d ea th re vi ew c om m itt ee m em be rs a nd 3 2 m id w iv es : 4 fo cu s gr ou p di sc us sio ns w ith m id w iv es ; 4 fo cu s g ro up d isc us sio ns w ith co m m itt ee m em be rs ; a nd 3 in -d ep th in te rv ie w s w ith h ea lth zo ne te ch ni ca l offi ce rs Th em at ic an al ys is Ca hy an ti et a l., 20 21 36 In do ne sia , d ist ric t h ea lth fa ci lit y M at er na l M at er na l d ea th re vi ew In ad eq ua te Q ua lit at iv e Fo cu s g ro up di sc us sio ns 29 d ist ric t a ud it co m m itt ee m em be rs in 4 fo cu s g ro up d isc us sio ns Th em at ic an al ys is Ch irw a et a l., 20 22 63 M al aw i, di st ric t h os pi ta l M at er na l M at er na l d ea th re vi ew In ad eq ua te Q ua lit at iv e In -d ep th in te rv ie w s a nd fo cu s g ro up di sc us sio ns 40 n ur se m id w iv es Th em at ic co nt en t a na ly sis Co m bs T ho rs en e t al ., 2 01 43 7 M al aw i, ur ba n he al th fa ci lit y M at er na l M at er na l d ea th re vi ew N ot sp ec ifi ed M ix ed m et ho ds O bs er va tio n of pa rt ic ip an ts o f de at h re vi ew pr oc es s O bs er ve d da ta c ol le ct io n fro m be re av ed fa m ily , h ea lth w or ke rs a nd m ed ic al re co rd s Co nt en t an al ys is (. . . co nt in ue d) (c on tin ue s. . . ) Bull World Health Organ 2023;101:62–75G| doi: http://dx.doi.org/10.2471/BLT.22.288703 75C Systematic reviews Maternal and perinatal death surveillanceMerlin L Willcox et al. St ud y Co un tr y, co nt ex t Ty pe of d ea th Ty pe of re vi ew Pe rc ei ve d eff ec tiv en es s o f pr oc es s St ud y d es ig n Da ta co lle ct io n m et ho d No . a nd ty pe of p ar tic ip an ts Ty pe of an al ys is Co m pa or é et a l., 20 22 64 Gh an a, h ea lth fa ci lit y M at er na l M at er na l d ea th re vi ew In ad eq ua te M ix ed m et ho ds In -d ep th in te rv ie w s H ea lth w or ke rs a nd m an ag er s N ot sp ec ifi ed Co m pa or é et a l., 20 22 65 Li be ria , c ou nt y, he al th fa ci lit y an d co m m un ity M at er na l a nd pe rin at al M at er na l a nd pe rin at al d ea th su rv ei lla nc e an d re sp on se In ad eq ua te M ix ed m et ho ds In -d ep th in te rv ie w s Co un ty -le ve l h ea lth p er so nn el , h ea lth fa ci lit y st aff , c om m un ity h ea lth w or ke rs N ot sp ec ifi ed Co ng o et a l., 20 17 38 , 2 02 26 6, 67 Bu rk in a Fa so , r eg io na l a nd di st ric t h os pi ta l M at er na l M at er na l d ea th re vi ew In ad eq ua te Q ua lit at iv e In -d ep th in te rv ie w s a nd do cu m en t r ev ie w 73 h ea lth w or ke rs in m at er ni ty , ph ar m ac y an d la bo ra to ry u ni ts , an d st aff in a dm in ist ra tio n an d m an ag em en t Fr am ew or k an al ys is D ar te y & G an ga - Li m an do , 2 01 47 8 Gh an a, d ist ric t h os pi ta l, re gi on al re fe rra l h os pi ta l a nd te ac hi ng h os pi ta l M at er na l M at er na l d ea th re vi ew Su cc es sf ul Q ua lit at iv e In -d ep th in te rv ie w s 20 m id w iv es in vo lv ed in m at er na l de at h re vi ew s Th em at ic co nt en t a na ly sis D ar te y, 20 16 39 Gh an a, h ea lth c en tre , d ist ric t ho sp ita l, r eg io na l r ef er ra l ho sp ita l a nd te ac hi ng ho sp ita l M at er na l M at er na l d ea th re vi ew Su cc es sf ul M ix ed m et ho ds In -d ep th in te rv ie w s a nd fo cu s g ro up di sc us sio ns 39 m id w iv es in vo lv ed in m at er na l de at h re vi ew : 1 8 in -d ep th in te rv ie w s an d 8 fo cu s g ro up d isc us sio ns Th em at ic co nt en t a na ly sis de K ok e t a l., 20 17 40 N ig er ia , h ea lth fa ci lit y M at er na l M at er na l d ea th re vi ew N ot sp ec ifi ed Q ua lit at iv e O bs er va tio n of re vi ew m ee tin gs Au di t r ev ie w te am Co nv er sa tio n an d di sc ou rs e an al ys is D ia llo e t a l., 20 22 68 Bu rk in a Fa so , d ist ric t ho sp ita l M at er na l M at er na l d ea th re vi ew In ad eq ua te Q ua lit at iv e In -d ep th in te rv ie w s 9 m id w iv es In du ct iv e th em at ic an al ys is D or to nn e et a l., 20 09 41 Se ne ga l a nd M al i, ho sp ita ls M at er na l M at er na l d ea th re vi ew Su cc es sf ul M ix ed m et ho ds Q ue st io nn ai re s, ch ec kl ist , in te rv ie w s a nd do cu m en t an al ys es 39 : 2 3 m at er na l d ea th a ud it co m m itt ee m em be rs a nd 1 6 na tio na l- le ve l l ea de rs N ot sp ec ifi ed D um on t e t a l., 20 09 42 Se ne ga l, h ea lth fa ci lit y M at er na l M at er na l d ea th re vi ew Su cc es sf ul M ix ed m et ho ds In -d ep th in te rv ie w s, fo cu s gr ou p di sc us sio ns , pa rt ic ip an t ob se rv at io n an d do cu m en t r ev ie w s H ea lth w or ke rs (m at er na l h ea lth ) i n 3 fo cu s g ro up d isc us sio ns a nd 9 in - de pt h in te rv ie w s Th em at ic an al ys is G ao e t a l., 20 09 43 Ch in a, h ea lth fa ci lit y, co m m un ity M at er na l M at er na l d ea th su rv ei lla nc e an d re sp on se In ad eq ua te M ix ed m et ho ds In te rv ie w s, fie ld ob se rv at io ns a nd re vi ew o f r ep or ts an d au di ts 18 : 1 2 ho sp ita l l ea de rs , 6 m at er na l an d ch ild h ea lth w or ke rs N ot sp ec ifi ed (. . . co nt in ue d) (c on tin ue s. . . ) Bull World Health Organ 2023;101:62–75G| doi: http://dx.doi.org/10.2471/BLT.22.28870375D Systematic reviews Maternal and perinatal death surveillance Merlin L Willcox et al. St ud y Co un tr y, co nt ex t Ty pe of d ea th Ty pe of re vi ew Pe rc ei ve d eff ec tiv en es s o f pr oc es s St ud y d es ig n Da ta co lle ct io n m et ho d No . a nd ty pe of p ar tic ip an ts Ty pe of an al ys is H ar ts el l, 2 01 04 5 U ni te d Re pu bl ic o f T an za ni a, al l l ev el s ( na tio na l, r eg io na l, di st ric t a nd h ea lth fa ci lit y) in cl ud in g pr iv at e an d pu bl ic fa ci lit ie s M at er na l M at er na l d ea th re vi ew N ot sp ec ifi ed D es cr ip tiv e qu al ita tiv e ca se st ud y In -d ep th in te rv ie w s, ob se rv at io n an d do cu m en t r ev ie w s 15 h ea lth w or ke rs in vo lv ed in d at a m an ag em en t o f m at er na l d ea th s a nd de liv er ie s N ot sp ec ifi ed H of m an e t a l., 20 14 46 N ig er ia , h os pi ta l M at er na l M at er na l d ea th re vi ew N ot sp ec ifi ed M ix ed m et ho ds In -d ep th in te rv ie w s M em be rs o f t he m at er na l d ea th re vi ew c om m itt ee o f 1 1 ho sp ita ls (n um be r n ot sp ec ifi ed ) Th em at ic fra m ew or k Ja ti et a l., 20 19 69 In do ne sia , u rb an h ea lth fa ci lit ie s a nd lo ca l go ve rn m en t i n Se m ar an g Pe rin at al Pe rin at al d ea th su rv ei lla nc e an d re sp on se N ot sp ec ifi ed Q ua lit at iv e Fo cu s g ro up di sc us sio ns 20 lo ca l g ov er nm en t o ffi ci al s a nd re pr es en ta tiv es o f h ea lth fa ci lit ie s Je pk os ge i e t a l., 20 22 47 Ke ny a, h os pi ta l N eo na ta l N eo na ta l d ea th re vi ew N ot sp ec ifi ed Ex pl or at or y qu al ita tiv e st ud y In -d ep th in te rv ie w s, no n- pa rt ic ip an t ob se rv at io n of m or bi di ty a nd m or ta lit y m ee tin gs N ur se s a nd d oc to rs : 1 7 in -d ep th in te rv ie w s a nd 1 2 m or bi di ty a nd m or ta lit y m ee tin gs Th em at ic co nt en t a na ly sis Ka rim i e t a l., 20 18 48 Ira n (Is la m ic R ep ub lic of ), na tio na l, i ns tit ut io na l (te ac hi ng u ni ve rs iti es ) a nd he al th fa ci lit y M at er na l M at er na l d ea th su rv ei lla nc e an d re sp on se Su cc es sf ul Q ua lit at iv e Re vi ew o f do cu m en ts a nd ke y in fo rm an t in te rv ie w s 15 : 3 h ea lth m in ist ry d ep ut ie s, 10 m ed ic al u ni ve rs ity st aff , 2 st aff in o bs te tri cs u ni ts o f s pe ci al ize d ho sp ita ls Th em at ic Kh ad er e t a l., 20 20 70 Jo rd an , h ea lth fa ci lit y Pe rin at al Pe rin at al d ea th au di ts N ot sp ec ifi ed Q ua lit at iv e Fo cu s g ro up di sc us sio ns Pa ed ia tri ci an s, ob st et ric ia ns , nu rs es , m id w iv es in 1 6 fo cu s g ro up di sc us sio ns Th em at ic co nt en t a na ly sis Ki nn ey e t a l., 20 20 49 N ig er ia , U ni te d Re pu bl ic o f Ta nz an ia , Z im ba bw e, h ea lth fa ci lit y M at er na l a nd pe rin at al M at er na l a nd pe rin at al d ea th su rv ei lla nc e an d re sp on se M ix ed M ix ed m et ho ds In te rv ie w s a nd ob se rv at io n 41 : 4 n at io na l s ta ke ho ld er s a nd 3 7 re gi on al a nd d ist ric t g ov er nm en t he al th o ffi ci al s s up po rt in g m at er na l an d pe rin at al d ea th su rv ei lla nc e an d re sp on se Th em at ic co nt en t a na ly sis Ko ng ny uy e t a l., 20 08 50 M al aw i, he al th fa ci lit y M at er na l M at er na l d ea th re vi ew Su cc es sf ul M ix ed m et ho ds Fo cu s g ro up di sc us sio ns 60 : m at er na l a nd n eo na ta l h ea lth w or ke rs im pl em en tin g th e fa ci lit y m at er na l d ea th re vi ew a nd q ua lit y im pr ov em en t t ea m m em be rs SW O T an al ys is Ko ua nd a et a l., 20 22 71 Bu ru nd i, ho sp ita l M at er na l a nd pe rin at al M at er na l a nd pe rin at al d ea th su rv ei lla nc e an d re sp on se M ix ed Q ua lit at iv e In -d ep th in te rv ie w s 26 o ffi ci al s o f t he h ea lth m in ist ry , ho sp ita l o ffi ce rs , o ffi ce rs o f he al th re gi on s a nd d ist ric ts , a nd ob st et ric ia ns a nd g yn ae co lo gi st s a nd m id w iv es Th em at ic an al ys is (. . . co nt in ue d) (c on tin ue s. . . ) Bull World Health Organ 2023;101:62–75G| doi: http://dx.doi.org/10.2471/BLT.22.288703 75E Systematic reviews Maternal and perinatal death surveillanceMerlin L Willcox et al. St ud y Co un tr y, co nt ex t Ty pe of d ea th Ty pe of re vi ew Pe rc ei ve d eff ec tiv en es s o f pr oc es s St ud y d es ig n Da ta co lle ct io n m et ho d No . a nd ty pe of p ar tic ip an ts Ty pe of an al ys is Ko ua nd a et a l., 20 22 72 Ch ad , h os pi ta l ( na tio na l, a nd di st ric t) M at er na l M at er na l d ea th su rv ei lla nc e an d re sp on se In ad eq ua te Q ua lit at iv e In -d ep th in te rv ie w s 25 o ffi ci al s a t t he c en tra l l ev el , st aff o f t ec hn ic al a nd fi na nc ia l pa rt ne rs (W H O, U N FP A, U N IC EF ) a nd ob st et ric ia ns a nd g yn ae co lo gi st s Th em at ic an al ys is M el be rg e t a l., 20 19 51 a nd 2 02 07 3 Et hi op ia , p ub lic h ea lth fa ci lit y M at er na l M at er na l a nd pe rin at al d ea th su rv ei lla nc e an d re sp on se In ad eq ua te Q ua lit at iv e In -d ep th in te rv ie w s a nd ob se rv at io n 46 : 1 1 pr im ar y ca re gi ve rs w ho h ad ex pe rie nc ed p er in at al d ea th s, 5 m en w ho h ad lo st th ei r p ar tn er to a m at er na l d ea th , 4 h ea lth e xt en sio n w or ke rs , 7 h ea lth w or ke rs in g en er al an d re fe rra l h os pi ta ls, 1 3 he al th w or ke rs in h ea lth c en tre s, 6 he al th ad m in ist ra to rs re sp on sib le fo r im pl em en ta tio n of m at er na l a nd pe rin at al d ea th su rv ei lla nc e an d re sp on se Th em at ic co nt en t a na ly sis M uffl er e t a l., 20 07 52 M or oc co , h ea lth fa ci lit y M at er na l M at er na l d ea th re vi ew N ot sp ec ifi ed M ix ed m et ho ds In -d ep th in te rv ie w s 56 im pl em en te rs in th e au di t p ro ce ss Sy st em at ic co nt en t a na ly sis M uk in da e t a l., 20 21 74 So ut h Af ric a, h ea lth d ist ric t an d su bd ist ric t M at er na l a nd pe rin at al M at er na l a nd pe rin at al d ea th su rv ei lla nc e an d re sp on se M ix ed D es cr ip tiv e qu al ita tiv e ca se st ud y In -d ep th in te rv ie w s a nd ob se rv at io n 45 fr on tli ne h ea lth m an ag er s a nd pr ov id er s i nv ol ve d w ith m at er na l, pe rin at al , n eo na ta l a nd c hi ld d ea th su rv ei lla nc e an d re sp on se Th em at ic an al ys is M uv uk a, 2 01 95 3 D em oc ra tic R ep ub lic o f t he Co ng o, h os pi ta l a nd h ea lth fa ci lit y M at er na l M at er na l d ea th su rv ei lla nc e an d re sp on se M ix ed Q ua lit at iv e In -d ep th in te rv ie w s, do cu m en t r ev ie w an d ob se rv at io n of o ne m at er na l de at h re vi ew se ss io n 15 m at er na l d ea th su rv ei lla nc e an d re sp on se fo ca l p er so ns a nd m em be rs of m at er na l d ea th re vi ew te am s In du ct iv e th em at ic an al ys is N ya m te m a et a l., 20 10 54 U ni te d Re pu bl ic o f T an za ni a, ho sp ita l a nd h ea lth fa ci lit y M at er na l a nd pe rin at al M at er na l a nd pe rin at al d ea th re vi ew In ad eq ua te M ix ed m et ho ds In -d ep th in te rv ie w s a nd se m i-s tru ct ur ed qu es tio nn ai re 59 : 2 9 he al th m an ag er s a nd 3 0 he al th -c ar e pr ov id er s Q ua lit at iv e co nt en t a na ly sis O w ol ab i e t a l., 20 14 55 M al aw i, he al th fa ci lit y M at er na l M at er na l d ea th re vi ew N ot sp ec ifi ed M ix ed m et ho ds In -d ep th in te rv ie w s 8 in di vi du al s i nv ol ve d in im pl em en tin g m at er na l d ea th re vi ew Th em at ic an al ys is Pa te l e t a l., 20 07 56 In di a, c om m un ity N eo na ta l Co m m un ity ne on at al d ea th au di ts N ot sp ec ifi ed Q ua lit at iv e In -d ep th in te rv ie w s a nd fo cu s g ro up di sc us sio ns Co m m un ity m em be rs a nd fa m ily o f th e de ce as ed in 3 in -d ep th in te rv ie w s an d 6 fo cu s g ro up d isc us sio ns . A lso in cl ud ed fi el d st aff fr om a su bs eq ue nt st ud y D ed uc tiv e th em at ic an al ys is (. . . co nt in ue d) (c on tin ue s. . . ) Bull World Health Organ 2023;101:62–75G| doi: http://dx.doi.org/10.2471/BLT.22.28870375F Systematic reviews Maternal and perinatal death surveillance Merlin L Willcox et al. St ud y Co un tr y, co nt ex t Ty pe of d ea th Ty pe of re vi ew Pe rc ei ve d eff ec tiv en es s o f pr oc es s St ud y d es ig n Da ta co lle ct io n m et ho d No . a nd ty pe of p ar tic ip an ts Ty pe of an al ys is Ri ch ar d, 2 00 97 5 Bu rk in a Fa so , u rb an d ist ric t ho sp ita l M at er na l a nd pe rin at al M at er na l a nd pe rin at al d ea th re vi ew N ot sp ec ifi ed M ix ed m et ho ds In -d ep th in te rv ie w s 35 m em be rs o f s ta ff fro m m at er ni ty an d su rg ic al d ep ar tm en ts Th em at ic an al ys is Ru ss el l, 2 02 27 6 In te rn at io na l, i nt er na tio na l ex pe rt c on su lta tio n m ee tin g M at er na l a nd pe rin at al M at er na l a nd pe rin at al d ea th su rv ei lla nc e an d re sp on se N ot sp ec ifi ed Q ua lit at iv e In -d ep th in te rv ie w s a nd gr ou p in te rv ie w s 55 h ea lth w or ke rs w ith e xp er ie nc e in m at er na l a nd /o r n ew bo rn h ea lth in h um an ita ria n se tt in gs , a nd /o r pr og ra m m at ic o r r es ea rc h ex pe rie nc e in m at er na l a nd p er in at al d ea th su rv ei lla nc e an d re sp on se Th em at ic an al ys is Sa id e t a l., 20 21 57 U ni te d Re pu bl ic o f T an za ni a, he al th fa ci lit y M at er na l M at er na l d ea th su rv ei lla nc e an d re sp on se In ad eq ua te Q ua lit at iv e In -d ep th in te rv ie w s 60 in vo lv ed in m at er na l d ea th su rv ei lla nc e an d re sp on se a ct iv iti es : 30 h ea lth p ro vi de rs in fo cu s g ro up di sc us sio ns ; 3 0 he al th m an ag er s i n in -d ep th in te rv ie w s In du ct iv e th em at ic an al ys is Ta ye bw a et a l., 20 20 58 Rw an da , h ea lth fa ci lit y M at er na l a nd pe rin at al M at er na l a nd pe rin at al d ea th su rv ei lla nc e an d re sp on se N ot sp ec ifi ed M ix ed m et ho ds D es k re vi ew s,i n- de pt h in te rv ie w s an d ob se rv at io ns 23 : t yp e no t s ta te d N ot sp ec ifi ed U pa dh ya ya e t a l., 20 12 59 In di a, d ist ric t a nd p er ip he ra l he al th fa ci lit y, co m m un ity an d/ or v ill ag e In fa nt In fa nt d ea th re vi ew Su cc es sf ul M ix ed m et ho ds In -d ep th in te rv ie w s an d re vi ew o f do cu m en ts 38 h ea lth -c ar e pr ov id er s i nv ol ve d in pr og ra m m e ac tiv iti es Co nt en t an al ys is va n H am er sv el d et al ., 2 01 24 4 U ni te d Re pu bl ic o f T an za ni a, di st ric t h os pi ta l M at er na l a nd pe rin at al M at er na l a nd pe rin at al d ea th re vi ew In ad eq ua te Q ua lit at iv e Pa rt ic ip an t ob se rv at io n an d in -d ep th in te rv ie w s 23 h ea lth w or ke rs a nd m an ag er s In du ct iv e th em at ic an al ys is (. . . co nt in ue d) (c on tin ue s. . . ) Bull World Health Organ 2023;101:62–75G| doi: http://dx.doi.org/10.2471/BLT.22.288703 75G Systematic reviews Maternal and perinatal death surveillanceMerlin L Willcox et al. St ud y Co un tr y, co nt ex t Ty pe of d ea th Ty pe of re vi ew Pe rc ei ve d eff ec tiv en es s o f pr oc es s St ud y d es ig n Da ta co lle ct io n m et ho d No . a nd ty pe of p ar tic ip an ts Ty pe of an al ys is W H O 2 01 46 0 In di a, a ll le ve ls (n at io na l, re gi on al , f ac ili ty a nd co m m un ity ) M at er na l M at er na l d ea th re vi ew Su cc es sf ul M ix ed m et ho ds Re vi ew o f do cu m en ts a nd re po rt s, in te rv ie w s an d ob se rv at io ns St ak eh ol de rs a t n at io na l, s ta te a nd di st ric t l ev el s N ot sp ec ifi ed In do ne sia , a ll le ve ls (n at io na l, r eg io na l, f ac ili ty an d co m m un ity ) M at er na l M at er na l d ea th re vi ew M ix ed M ix ed m et ho ds Re vi ew o f do cu m en ts a nd re po rt s, an d in te rv ie w s In fo rm an ts fr om th e he al th m in ist ry , di st ric t h ea lth o ffi ce , h os pi ta ls an d he al th c en tre s N ot sp ec ifi ed Sr i L an ka , n at io na l M at er na l M at er na l d ea th re vi ew Su cc es sf ul M ix ed m et ho ds St ak eh ol de r w or ks ho p an d in - de pt h in te rv ie w s 20 fo rm er se cr et ar ie s o f h ea lth , f or m er di re ct or s o f t he F am ily H ea lth B ur ea u, pr ov in ci al a dm in ist ra to rs , c lin ic ia ns , re pr es en ta tiv es o f p ro fe ss io na l co lle ge s, na tio na l p ro gr am m e m an ag er s a nd re pr es en ta tiv es fr om in te rn at io na l N GO s N ot sp ec ifi ed N ep al , n at io na l M at er na l M at er na l d ea th re vi ew N ot sp ec ifi ed M ix ed m et ho ds D oc um en t re vi ew , in -d ep th in te rv ie w s a nd st ak eh ol de r w or ks ho p 27 : 1 6 do ct or s, 4 st aff n ur se s, 5 m ed ic al re co rd er s a nd 2 p ro gr am m e m an ag er s f ro m 1 0 ho sp ita ls N ot sp ec ifi ed M ya nm ar , n at io na l M at er na l M at er na l d ea th re vi ew N ot sp ec ifi ed M ix ed m et ho ds In -d ep th in te rv ie w s 10 –1 2 pa rt ic ip an ts fr om 1 0 to w ns hi ps in cl ud in g to w ns hi p m ed ic al o ffi ce r, ob st et ric ia ns , t ow ns hi p he al th n ur se , st at io n m ed ic al o ffi ce rs , f oc al p er so ns of a ru ra l h ea lth c en tre , a nd m id w iv es N ot sp ec ifi ed Ya m eo go e t a l., 20 22 77 Bu rk in a Fa so , h ea lth d ist ric t (u rb an a nd ru ra l) M at er na l M at er na l d ea th su rv ei lla nc e an d re sp on se In ad eq ua te Q ua lit at iv e In -d ep th in te rv ie w s 23 : 3 te ch ni ca l a nd fi na nc ia l pa rt ne rs , 2 c en tra l l ev el m an ag er s, 2 re gi on al h ea lth d ire ct or s, 4 di st ric t m an ag em en t t ea m m em be rs , 8 he al th -c ar e pr ov id er s a nd 4 co m m un ity h ea lth w or ke rs Th em at ic an al ys is N GO : n on go ve rn m en ta l o rg an iza tio n; S W OT : s tre ng th s, w ea kn es se s, op po rtu ni tie s a nd th re at s; UN FP A: U ni te d N at io ns P op ul at io n Fu nd ; U N IC EF : U ni te d N at io ns C hi ld re n’s F un d; W HO : W or ld H ea lth O rg an iza tio n. (. . . co nt in ue d)