Mulu Beyene Kidanemariam
Introduction
Initiated by the WHO and its partners in 2013, the Maternal and Perinatal Death Surveillance and Response (MPDSR) is a routine surveillance program designed to track, report, review, and respond to all maternal and perinatal deaths. The program consists of four components: maternal death identification & notification, death review, analysis & recommendations, and response & monitoring. Its primary objective is to assess the extent of maternal mortality, understand its causes, and inform policies aimed at preventing avoidable maternal deaths.
In this blog post, I outline the major governance structures and issues related to the MPDSR in Ethiopia. The post aims to provide essential information about the health program and draw attention to key regulatory challenges that need addressing for more effective implementation.
1. The Introduction of MPDSR: Drivers and development
- Formally introduced in May 2013.
- High maternal mortality, the absence of a functioning civil registration system, and political commitment to reducing maternal mortality were the main drivers.
- Implementation process: Initially piloted in 4 regions, it was rolled out throughout the country in late 2015.
- Before 2014, MDSR was run under the Maternal and Child Health (MCH) divisions, located under all tiers of government structure – at wereda, zone, region, and federal ministry levels.
- Since 2014, maternal death has become a reportable condition, subject to the integrated reporting system (PHEM).
- In 2017, perinatal death was added to the same structure, thus renamed as MPDSR.
2. MDSR structures and institutions involved
- Community members (relatives, elders, community leaders, Women Development Army): report suspected community maternal death to Health Extension Workers (HEW) by phone, text, or in person.
- HEW: establish probable maternal death by conducting a verbal autopsy and notify findings to the Surveillance Focal Person (SFP) at the respective health center- through a notification form.
- SFP: helps HEWs in verifying community maternal deaths, draws up reports and recommendations; actively looks for facility maternal deaths from medical records, prepares files for death review, and follows up on the implementation of recommendations.
- Maternal ward health providers: notify suspected facility maternal death to the SFP and participate in death reviews.
- Facility review committee: reviews each facility death, based on medical records and abstraction forms; draws up recommendations, and disseminates them to the health system and relevant administrative structures.
- Wereda and zonal PHEM offices: report compiled reports to regional and national MDSR coordination offices.
- Ethiopian Public Health Institute: issues technical guidance, training manuals, and MDSR formats, establishes a national working committee, conducts bi-annual meetings to draw up national reports: disseminates reports to relevant state organs and external stakeholders (civil societies, media)
3. Legal authority to undertake MPDSR
- All technical guidance do not provide the basis under which they were issued.
- The Ethiopian Public Health Institute, which is a technical wing and accountable to the Ministry of Health, coordinates the overall MDSR system.
- Its mandate is outlined in Regulation No. 301/2013. In Article 6, it is empowered to “undertake national surveys and surveillance… on diseases and other health-related conditions.”
4. Status of the Technical Guidance
- The governance and operational guide of the MDSR is outlined in the Technical Guidance. Three versions have been released thus far: September 2013, May 2014, and 2017.
- Although these guidance contain important clauses of a legal nature (such as mandatory notification, privacy rights, confidentiality protection, and protection from legal liability …), their legal status under Ethiopian law is questionable. They are unpublished to provide legal notice, fail to cite the legal authority under which they are issued, and lack essential characteristics required to qualify as formal laws.
- The MDSR largely functions under inadequate legal regulation.
5. MDSR in the federal system
- Under the FDRE Constitution, conducting public health surveillance is arguably a shared mandate between the federal and regional states.
- Some of the regions have their own technical guidelines.
- Without a clear division of mandate, disagreements may arise in the future.
6. MPDSR Outputs, implementation challenges
- So far six annual reports have been prepared: 2014/15; 2015/16; 2016/17; 2017/18: 2019/20, and 2020/2021.
- By 2022, the MDSR could only capture around 8% of estimated maternal deaths in Ethiopia (2022 report).
- Lack of resources, training, and motivation, along with fear of blame and punitive consequences, remain among the major challenges, according to a recent MPDSR assessment report (2022, on file with the author).