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Year : 2018  |  Volume : 62  |  Issue : 4  |  Page : 299-301  

Moving from maternal death review to surveillance and response: A paradigm shift

1 Public Health Specialist, WHO Country Office for India, New Delhi, India
2 Director Professor and Head, Department of Community Medicine, Maulana Azad Medical College, New Delhi, India
3 Junior Resident, Department of Community Medicine, Maulana Azad Medical College, New Delhi, India

Date of Web Publication11-Dec-2018

Correspondence Address:
Dr. Amrita Kansal
WHO Country Office for India, 1st Floor, RK Khanna Stadium, Africa Avenue, New Delhi
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijph.IJPH_37_18

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In the era of the sustainable development goals, India is committed to reduce its maternal mortality ratio to less than 70 per one lakh live births by 2030. An important strategy that was adopted in the Reproductive and Child Health Programme in 2010 was maternal death review. Analysis of the progress so far has brought to light certain gaps which have prompted the paradigm shift toward Maternal Death Surveillance and Response (MDSR), which focuses on taking action on information obtained from every maternal death so as to prevent further maternal deaths. The new guidelines on MDSR were released by the Ministry of Health and Family Welfare in 2017.

Keywords: Maternal mortality, response, surveillance

How to cite this article:
Kansal A, Garg S, Sharma M. Moving from maternal death review to surveillance and response: A paradigm shift. Indian J Public Health 2018;62:299-301

How to cite this URL:
Kansal A, Garg S, Sharma M. Moving from maternal death review to surveillance and response: A paradigm shift. Indian J Public Health [serial online] 2018 [cited 2021 Sep 21];62:299-301. Available from:

   Introduction Top

Maternal death is defined as death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and the site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management but neither from accidental nor incidental causes. Maternal death is expressed as maternal mortality ratio (MMR) which indicates the quality of healthcare in a country.

India once had one of the highest MMRs in the world – in 1990, it was 437 per 100,000 live births.[1] In 2005, the government launched the National Rural Health Mission “to provide accessible, affordable, and quality health care to the rural sections, especially the vulnerable populations.” It did so by promoting institutional delivery and breastfeeding and postnatal care by integrating various conditional cash transfer schemes for pregnant and lactating women. In 2011–2013, maternal deaths reduced to 167 per one lakh live births. The decline in MMR was much faster in India (4.5%) as compared to global rate (2.6%).[2] However, as per historical trend, India is likely to miss the millennium development goal target of 109 per 100,000 live births.[1]

Need for Maternal Death Surveillance and Response

The Government of India is striving toward bringing down the MMR to <70/100,000 live births by 2030 as per the sustainable development goals (SDGs). India's commitment to reduce its MMR is reflected in the National Health Policy 2017 which envisages reducing MMR to 100 by 2020.[3]

A robust Maternal Death Surveillance and Response (MDSR) is expected to be important to eliminate preventable maternal mortality and reduce the MMR. MDSR is a form of continuous surveillance that links the health information system and quality improvement processes from local to national levels. It includes routine identification, notification, quantification, and determination of causes to avoid all maternal deaths, as well as the use of this information to respond with actions that will prevent future deaths.[4]

Maternal death review (MDR) as a strategy was mentioned in Reproductive and Child Health (RCH) Phase I (1997–2004), which resulted in some states collecting data on maternal deaths, but no action was taken on this information. MDR was subsequently included in RCH Phase II (2005–2012), which also emphasized creating demand for quality care and greater community participation.

In the last 6 years, states have instituted the MDR process with varying degree of reporting, reviewing, and action planning. An analysis of the progress till date brings forward three gaps – first, <50% of the estimated maternal deaths got reported in the health management information system. Second, while institutional mechanisms for reviews had been established, the capacity to undertake quality review at various levels was weak. Finally, translation of findings into action, i.e., the mechanism for “response,” lagged behind.[4]

Based on these learning and in line with the WHO guidelines, the Government of India revised the MDSR guidelines with a focus on surveillance (for improving reporting), response (for improving analysis and action planning), and incorporating a component of Confidential Review. Mechanisms for review of deaths in migrant population, use of ICD 10 instead of ICD 9 for classification of maternal deaths, and training of medical officers on Medical Certification of Cause of Death (MCCD) are few of the newer components in the guidelines. Most importantly, the guidelines reiterate that based on the findings of the maternal death reviews, no disciplinary action is to be initiated against any of the service providers. The review should not be a fault finding mission.

Focus on identifying actionable gaps: Three-delay model

To achieve the SDG, the need of the hour is to identify and take actions to correct the causes and determinants of maternal death to prevent future deaths. The new guidelines adopt a health systems approach and the focus is on identifying gaps in the system and responds by taking action to address those gaps. The factors leading to maternal death are identified as per the “three-delay model.”

The first delay is described as the delay in deciding to seek care. The reasons behind this delay may be social, cultural, or economic. They may stem from lack of woman empowerment to make decisions regarding health, beliefs, and cultural practices of the family or financial constraints. Lack of awareness regarding danger signs in pregnancy is also an important factor contributing to the first delay and indicates a deficiency in adequate antenatal care and advice. This delay is probably the most difficult to address as it requires long-term action for improving socioeconomic status of women in society. A short-term solution would be to ensure that the existing primary-level functionaries provide good-quality antenatal services by periodic monitoring and supportive supervision.

The second delay is the delay in reaching care. Once the decision has been made to seek care, delay may be encountered on the way to the facility. Common reasons for this delay include long distances to hospitals, difficult terrain, and unavailable ambulance services. This delay needs coordination and partnership with other organizations working outside the health sector such as the Ministry of Road Transport and Highways.

The third delay is described as the delay in receiving care. This occurs when the mother reaches the facility, but there is a delay due to lack of quality care at the facility level. Facility readiness is crucial to address this delay. This includes availability of services and supplies as per the norms and adherence to the standard operating procedures.

The MDSR guidelines provide various tools to identify the delays that lead to maternal death. Community-based MDSR incorporates a verbal autopsy format that can be effectively utilized to identify the causes and determinants of maternal death. Community-based review is especially useful to identify the first and second delays. The third delay can be identified by facility-based MDSR which provides details of the patient management at the facility. Data collected during the process are envisaged to be reviewed at district level by the District MDSR Committee, and a few selected cases, identified by the CMO, are to be reviewed by the district collector. The meetings with the district collector would include close relatives of the deceased as well as the service providers who had tended to the deceased. This would ensure direct interaction of the bereaved relatives with the district administration in the presence of healthcare providers. This mechanism provides an accountability which will prevent maternal deaths from the delays identified.[4]

Following the experience from the state of Kerala, Confidential Review of maternal deaths has been introduced for the first time in these guidelines with the objective of checking adherence to protocols and line of management adopted in particular cases. Kerala, which enjoys better health indices than many other states, started Confidential Reviews in 2010. The experience was that facts regarding the cause and circumstances of death come out only if there is anonymity for the treating team and immunity from punishment. The principle of “No names, no blame” was adopted to find the reasons and learning from maternal deaths.

As per the new guidelines, Confidential Review is envisaged as a multidisciplinary investigation into a sample of maternal deaths to identify avoidable and remediable causes and take action to address them. A Committee for Confidential Reviews of Maternal Deaths is to be set up at state level comprising subject experts, which would meet quarterly. The committee will review anonymized case sheets and other relevant documents and records. It is recommended that all states institute mechanisms for such reviews, however, it is essential for states with low MMR as maternal deaths in these cases are usually due to indirect causes, including systemic illnesses.[4]

For a diverse country such as India, it is not appropriate to adopt a “one size fits all” approach. MMR in India varies greatly within and among different states. In line with the principle of “Obstetric Transition,” Indian states can be classified into three categories, viz., states with high MMR, states with moderately high MMR (which are likely to achieve MMR target in the next 5 years), and states with low MMR (below national average). The focus of MDSR should also vary accordingly. In states with high MMR, MDSR process should reveal gaps such as lack of availability of emergency obstetric care in facilities and gaps in timely referral. States with moderately high MMR must deliberate on the identification of indirect causes of maternal deaths and addressing them appropriately. For states with low MMR, focus should be on institutionalizing robust mechanism of Confidential Reviews of Maternal Deaths. Such states should also implement maternal near miss reviews and perinatal death reviews.[4]

It is important to reiterate that data by itself are useless, and data are useful only when it is applied. Commitment to respond, i.e., to act on findings of the deaths reviewed, is essential for success. Taking action upon data to reduce maternal deaths is the reason for conducting MDSR.

   Conclusion Top

MDSR is an important strategy adopted by the Government of India to reduce maternal mortality and morbidity. It identifies the determinants of maternal deaths as per the “three-delay model” and analysis on these factors can identify the delays that contribute to maternal deaths at various levels. This information can be used to adopt measures to fill the gaps in service delivery. The importance of MDSR lies in the fact that it provides detailed analysis on various factors at community, facility, regional, and national level which need to be addressed to reduce maternal deaths.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

   References Top

Millennium Development Goals India Country Report. Ministry of Statistics and Programme Implementation. Government of India; 2015.  Back to cited text no. 1
Press Information Bureau, Government of India. Improving Health Indicators in India; 25 November, 2016. Available from: [Last accessed on 2017 Dec 08].  Back to cited text no. 2
Government of India. National Health Policy; 2017. Available from: [Last accessed on 2018 Jan 12].  Back to cited text no. 3
Government of India. Guidelines for Maternal Death Surveillance and Response Available from: [Last accessed on 2018 Jan 12].  Back to cited text no. 4

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