Time to Respond: A Report on the Global Implementation of Maternal Death Surveillance and Response

Trying to understand why a mother died during pregnancy or childbirth, or even weeks later, can be incredibly frustrating. The medical causes may be known, but the full explanation for death from a treatable condition such as eclampsia remains unclear. Care may have been available in the woman’s community or in a nearby health facility, but still she died.

This report on maternal death surveillance and response (MDSR) quotes harrowing examples of death from preventable maternal causes such as the story of Assetou, who died while being taken to hospital on the back of a motorcycle. Or of Dhani, who died before her family could call an ambulance to their isolated village at night. The physical suffering of these women and the panic and misery felt by them and their families are almost impossible to imagine.

MDSR is a relatively new approach to investigating maternal deaths and taking action based on the findings, which has evolved from the established system of maternal death review (MDR). It builds on MDR by stressing the importance of follow-up action (response) and of continual monitoring to ensure that recommendations are acted on. As a result, MDSR has been described as a “continuous action cycle for monitoring of maternal deaths”. The approach is new but the elements of MDSR have developed over several decades.