"Maternal Death Surveillance and Response (MDSR): Learning from Every Death"

EXECUTIVE SUMMARY

Maternal Death Surveillance and Response (MDSR) is a continuous cycle of identification, notification, review, and response for every maternal death — with the objective of learning from each death to prevent future ones. WHO, UNFPA, and partners promoted MDSR as a replacement for confidential enquiry models that were effective in high-income countries but difficult to implement in LMICs. The MDSR approach integrates with existing health information systems and CRVS, making it more feasible in resource-constrained settings.

UNFPA supports MDSR implementation in approximately 80 countries, providing technical assistance for system design, health worker training, data management, and the critical "response" component — ensuring that findings from maternal death reviews lead to concrete changes in clinical practice, referral systems, and health policy. The shift from merely counting maternal deaths to actively learning from each one represents a philosophical transformation in maternal health programming.

KEY FACTS

WHO MDSR guidance: First published 2013; updated technical guidance available; UNFPA is a co-publisher
MDSR cycle: Identification → Notification → Review → Response → Monitoring
Country adoption: Over 100 countries have MDSR policies; approximately 80 countries have functional MDSR systems with varying coverage
Maternal death review: A structured assessment of the clinical, health system, and social factors that contributed to a maternal death; conducted by a multidisciplinary team
Near-miss review: Extension of MDSR to include women who nearly died from obstetric complications but survived — provides more cases for learning
Three delays model: Framework commonly used in MDSR reviews: delay in deciding to seek care, delay in reaching a facility, delay in receiving appropriate care at the facility
Notification rates: In many LMICs, fewer than 50% of maternal deaths are captured by MDSR systems; community deaths are most likely to be missed
Response gap: The weakest link in most MDSR systems — reviews identify problems but responses (staffing changes, protocol updates, infrastructure improvements) are not consistently implemented
UNFPA support: Technical assistance, training materials, MDSR software tools, and advocacy for MDSR institutionalisation in national health systems

DETAIL

How MDSR Works

Identification: All maternal deaths — in facilities, in communities, during transport — should be identified and reported. This requires health facility reporting systems, community surveillance (community health workers reporting deaths), and CRVS linkage. In practice, facility deaths are better captured than community deaths.

Notification: Deaths are notified to the district/national MDSR coordinator within a defined timeframe (typically 24–48 hours). Rapid notification enables timely review.

Review: A maternal death review committee (comprising clinicians, midwives, administrators, and sometimes community representatives) examines the circumstances of each death using medical records, interviews with health workers, and family interviews. The review identifies contributing factors using the three delays framework.

Response: The most critical and most neglected step. Reviews should generate specific, actionable recommendations: clinical protocol updates, referral system improvements, training needs, equipment procurement, staffing adjustments. Without response, MDSR becomes an accounting exercise rather than a quality improvement tool.

UNFPA's MDSR Support

UNFPA supports MDSR through:

National MDSR system design and policy development
Training of review committee members and data managers
Development of MDSR data tools and reporting templates
Advocacy for government ownership and resource allocation to MDSR
Regional peer learning networks on MDSR
Integration of MDSR with perinatal death review and near-miss surveillance

CURRENT STATUS

MDSR is established as global best practice for maternal mortality reduction
Coverage and quality of MDSR systems vary enormously across and within countries
The response component remains the weakest link — turning review findings into action requires governance commitment and resources
Digital MDSR tools are being deployed to improve data quality and timeliness
Integration of MDSR with perinatal death surveillance is expanding
The COVID-19 pandemic disrupted MDSR systems in some countries but also highlighted the importance of death surveillance

SOURCES

WHO: "Maternal Death Surveillance and Response: Technical Guidance" (2013)
WHO, UNFPA, UNICEF, et al.: "Time to Respond: A Report on the Global Implementation of MDSR" (2016)
Smith, H. et al.: "Implementing maternal death surveillance and response: a review of lessons from country case studies" (BMC Pregnancy and Childbirth, 2017)