Legal issues in the implementation of Maternal Death Surveillance and Response: a scoping review

Health Policy and Planning, 39, 2024, 985–999 DOI: https://doi.org/10.1093/heapol/czae071 Advance access publication date: 3 August 2024 Review Legal issues in the implementation of Maternal Death Surveillance and Response: a scoping review Mulu Beyene Kidanemariam1,2,* , Ingrid Miljeteig3 , Karen Marie Moland4 and Andrea Melberg3,4 1 Faculty of Law, University of Bergen, Magnus Lagabøtes Plass 1, Bergen 5010, Norway School of Law, Mekelle University, Adi-Haqi Campus, Mekelle, Tigray, Ethiopia 3 Bergen Center for Ethics and Priority Setting in Health (BCEPS), University of Bergen, Aarstadveien 21, Bergen 5009, Norway 4 Centre for International Health, University of Bergen, Aarstadveien 21, Bergen 5009, Norway 2 Accepted on 1 August 2024 Abstract The Maternal Death Surveillance and Response (MDSR) system is designed to continuously identify and review all maternal deaths. It aims to help countries understand the scale and distribution of maternal deaths, identify their causes, and inform corrective measures to address the challenge. Despite the growing adoption of the MDSR by numerous low- or middle-income countries, its implementation faces various challenges, including legal ones. This scoping review was conducted to map legal issues and challenges that arise during the implementation of the MDSR. It adapted the Bain and Kongnyuy framework, categorizing legal issues into data, people, use of findings, and legal regulation. Literature was retrieved from seven databases, complemented by additional online searches. We included studies published in English between 2010 and November 2022 that report on legal issues arising during the implementation of MDSR. Out of 1174 studies screened, 31 were selected for review. The review highlighted the limited attention given to the legal dimension of the MDSR by the research community. It also documented the lack of adequate legal framework essential for the system’s effective implementation. Inadequate safeguards for informational privacy and the lack of confidentiality reinforce a prevalent sense of being blamed, mainly among health workers. Consequently, widespread under-reporting and intentional misattribution of causes of maternal death, defensive referrals, and disengagement from the MDSR process were reported. We recommend that implementing countries regulate the gathering and use of MDSR data through appropriate laws and legally ensure that the MDSR data are only used for the intended purpose. Appropriate complaint-handling mechanisms are needed in health systems to prevent the misuse of the MDSR. Future studies on MDSR implementation would benefit from involving legal experts, considering the multifaceted legal dimensions of the MDSR. Keywords: MDSR, maternal death, death review, legal issues, privacy, health workers, scoping review Key messages • There is a scarcity of empirical studies documenting the legal issues in Maternal Death Surveillance and Response (MDSR) implementation. • Prevalent legal issues that the MDSR faces relate to informational privacy, confidentiality, and fear of blame and litigation among health workers. Legal regulation for MDSR should aim to address these issues. • The lack of legal frameworks supporting MDSR implementation is apparent. • The ‘data, people, use of findings, and legal regulation’ framework could be utilized in future research to explore specific laws impacting the MDSR. The MDSR: an introduction Maternal mortality remains a significant global public health challenge. According to a recent report, ‘in 2020 an estimated 287000 women globally died from maternal causes, equivalent to almost 800 maternal deaths every day…’ (WHO, 2023). Historically, maternal mortality became a global issue in the mid-1980s when studies revealed that the maternal mortality rate in many African countries was much higher than previously thought (WHO, 1986; De Brouwere et al., 1998; Starrs, 2006). International initiatives for the recognition of women’s rights and reproductive health rights in the 1990s, coupled with the growing evidence that most maternal deaths are preventable, led to further recognition of maternal mortality as a human rights issue. Today, maternal mortality is used as an indicator not only of the strength of health systems and gender equity but also of compliance with certain human rights (De Brouwere et al., 1998; Cabal and Stoffregen, 2009; Aasen, 2013; Yamin, 2013). Understanding the scale, trend and distribution of maternal mortality and identifying causes and contributing factors to maternal deaths have been fundamental in efforts to address the challenge (WHO, 2015). However, many countries burdened by high maternal mortality lack functional systems to generate reliable data. This poses an obstacle to the development and monitoring of effective policies and interventions © The Author(s) 2024. Published by Oxford University Press in association with The London School of Hygiene and Tropical Medicine. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted reuse, distribution, and reproduction in any medium, provided the original work is properly cited. *Corresponding author. Faculty of Law, University of Bergen, Magnus Lagabøtes Plass 1, Bergen 5010, Norway. E-mail: 986 safeguard the data collected for this purpose and to maintain the confidentiality of the process. Despite these stipulations, inadequate legal protection and prevalent naming and blaming remain among the challenges hindering MDSR implementation (WHO, 2014; 2016a; Smith et al., 2017b; Melberg et al., 2019; Kinney et al., 2021). However, there is a dearth of research on how the legal challenges are manifested in practice (WHO, 2016a; Smith et al., 2017a; Bain and Kongnyuy, 2018). The WHO’s survey on the implementation of the MDSR in 67 countries concluded that it ‘found little literature that considers MDSR from a legal perspective’ (WHO, 2016a: p. 31). A comprehensive recent review on MDSR implementation in low- and middle-income countries, similarly, concluded that although the absence of a strong MDSR legal framework is contributing to fear among health workers, ‘explicit aspects of fear about litigation are not described or explored’ in the literature (Kinney et al., 2021: p. 966). This research aims to map the available literature on the nature and forms of legal topics and issues that arise in the implementation of the MDSR. The research question for this review is: What is known from the existing literature about legal issues that arise during the implementation of the MDSR? Conceptual framework As a central component of the research question, the expression ‘legal issues’ requires clarification. Conventionally, a legal issue is discussed in the context of court cases, where it refers to the part of a dispute that necessitates the application of a specific law for its resolu (...truncated)