Towards elimination of maternal deaths: maternal deaths surveillance and response

Reproductive Health Towards elimination of maternal deaths: maternal deaths surveillance and response Sennen Hounton 2 Luc De Bernis 2 Julia Hussein 1 Wendy J Graham 1 Isabella Danel 0 Peter Byass 4 Elizabeth M Mason 3 0 US Centers for Disease Control and Prevention , Atlanta , USA 1 Aberdeen University , Aberdeen , UK 2 UNFPA Technical Division , New York , USA 3 WHO , Geneva , Switzerland 4 Umea University , Umea , Sweden Current methods for estimating maternal mortality lack precision, and are not suitable for monitoring progress in the short run. In addition, national maternal mortality ratios (MMRs) alone do not provide useful information on where the greatest burden of mortality is located, who is concerned, what are the causes, and more importantly what sub-national variations occur. This paper discusses a maternal death surveillance and response (MDSR) system. MDSR systems are not yet established in most countries and have potential added value for policy making and accountability and can build on existing efforts to conduct maternal death reviews, verbal autopsies and confidential enquiries. Accountability at national and sub-national levels cannot rely on global, regional and national retrospective estimates periodically generated from academia or United Nations organizations but on routine counting, investigation, sub national data analysis, long term investments in vital registration and national health information systems. Establishing effective maternal death surveillance and response will help achieve MDG 5, improve quality of maternity care and eliminate maternal mortality (MMR 30 per 100,000 by 2030). - Introduction Of all Millennium Development Goals (MDGs), improving maternal health (MDG 5) is the least likely to be achieved. Despite knowledge on determinants and causes, and effective clinical and public health strategies [1], the goal of reducing, the maternal mortality ratio (MMR) between 1990 and 2015 by three quarters is unlikely to be met. More than ever before, maternal and newborn health has received heightened attention from the United Nations, governments, non-governmental organizations, and civil society [2]. The Commission on Information and Accountability of the Global Strategy for Womens and Childrens Health recommended the implementation of an accountability framework that in countries is based on national oversight, accurate and comprehensive monitoring of results, regular multi-stakeholder review of data and responses, all key features of traditional surveillance and response systems. Significant reduction of maternal mortality in countries will require counting every case and collection of information to permit an effective response that prevents future deaths [3]. Thus a maternal * Correspondence: 1UNFPA Technical Division, New York, USA Full list of author information is available at the end of the article death surveillance and response (MDSR) Technical Working Group (TWG) has been established and chaired by the World Health Organization. The overall objectives of the MDSR are: 1) To provide information that effectively guides actions to eliminate preventable maternal mortality at health facilities and in the community; and 2) To count every maternal death, permitting an assessment of the true magnitude of maternal mortality and the impact of actions taken to reduce it [4]. The upcoming technical guidance of MDSR by the World Health Organization will provide comprehensive concepts of MDSR. This paper describes why MDSR is needed and what would be entailed, builds on lessons from communicable disease surveillance, and considers the pre-requisites for widespread implementation. Eliminating maternal mortality The vision no woman should lose her life when giving birth reflects the human rights perspective on maternal mortality and would require that 90% of maternal deaths (when diagnosed and treated in a timely manner) [5], be avoided, making maternal mortality a potential target for an elimination strategy. The term elimination in this paper refers to a significantly lowered level to the point at which maternal mortality ceases to be a major public health burden in countries (for example a goal of a MMR 30 per 100,000 by 2030 [5] although other target dates such as 2035 or much closer 2025 are being considered). Although pregnancy is not a disease and maternal death is non-communicable, the good and bad outcomes (births, deaths, complications for mothers and newborns and subsequent disabilities) are all relevant to public health. All issues carrying the burdens of mortality and morbidity warrant public health surveillance systems, and although most have been established for communicable diseases, similar principles could be applied to maternal events [6-8]. Paradigm shift: why MDSR and what is its added value? Rationale for MDSR Tracking progress on maternal mortality ratios or rates is notoriously difficult given the lack of reliable vital registration in developing countries and problems in the ascertainment of pregnancy status especially in its early stages. Current national MMR estimates are generated by United Nations agencies and academia despite the absence of civil vital registration and the difficulties in capturing maternal deaths [9-11]. These estimates use aggregated national figures, which lack precision; are not timely, referring to the past; and are often not readily available in formats like simple maps or trend diagrams. Current methods in many developing countries use largescale periodic surveys (national censuses, Demographic and Health Surveys, Multiple Indicator Cluster Surveys, etc.), which are expensive and data are retrospective and not released in a timely manner. These estimates carry wide confidence intervals and often provide no clues for action. Such estimates are often disputed by countries, and not acted upon. Efforts to generate national estimates have usually ignored the equity dimension of maternal mortality within countries, mainly because of large sample size errors that are associated with survey methodologies for relatively rare events [12]. MDSR would assist in computing national, country-owned maternal mortality data, as well as provide more reliable MMR at sub national levels, thereby showing where the greatest burden of mortality is located, who is concerned and what the causes are. MDSR can inform the actions needed to prevent maternal deaths both in the community and in health facilities. MDSR can improve the quality of care provided to pregnant women by identifying gaps in health services that contributed to a maternal death. Data are needed to enable short term progress tracking, intervention evaluation, timely actions and increased accountability of civil society, policy makers, managers and donors at national and sub-national levels. These data must be locally relevant, fit for purpose, inform an immediate response system and be presented in simple table and graphic formats (...truncated)