National guidelines for maternal and perinatal deaths surveillance and response in nigeria

Objectives

Nigeria’s Maternal and Perinatal Death Surveillance and Response (MPDSR) guideline establishes a national, evidence-based framework to eliminate preventable maternal, stillbirth and newborn deaths by identifying every death, understanding its causes and contributing factors, and converting findings into action that improves access to and quality of care.[1]It seeks to move beyond counting deaths towards systematic learning, accountability and prevention across communities, health facilities, states and national institutions.[2]

• Notify and document all maternal and perinatal deaths, including deaths associated with early pregnancy, ectopic pregnancy and abortion complications, to improve the completeness and credibility of mortality information.[3][4]
• Determine medical causes, contributing factors, avoidability and trends, including barriers related to care-seeking, reaching services and receiving timely, adequate care.[1][5]
• Review maternal deaths, perinatal deaths, severe acute maternal morbidity and near misses to identify substandard practices, service gaps and practical measures to prevent recurrence.[6][2]
• Improve maternal and newborn outcomes through evidence-based recommendations on community participation, referrals, emergency services, health-worker training, resource allocation, regulation, affordability and advocacy.[7]
• Strengthen public health education and health-system capacity across the three delays: deciding to seek care, accessing care and receiving quality care.[8]
• Integrate a continuum of review methods, comprising community verbal autopsy, facility maternal death review, severe acute maternal morbidity review, criterion-based clinical audit, and confidential enquiry at state, zonal or national levels.[9]
• Support the wider aspiration that every intended pregnancy results in a healthy mother and a baby able to survive and fulfil its potential.[10]

Implementation

MPDSR is designed as a routine surveillance-and-response system linking community reporting, facility case review, state synthesis and national oversight with health-information systems and continuous quality improvement.[1]Implementation uses confidential, anonymous and non-punitive review processes so that professionals and communities can identify failures and act on them without assigning individual blame.[11][9]

• Establish national leadership through a National MPDSR Steering Committee based in the office of the Minister of Health, supported by a Technical Sub-Committee for clinical analysis, training, material development and expansion planning.[12]Hold national steering meetings quarterly to consider facility reports, notifications and technical analyses.[13][14]
• Operate state committees within State Ministries of Health, led by obstetric and paediatric representatives and involving planning, primary health care, nursing, hospital, laboratory, pharmacy, local-government and civil-society members.[14]Synthesise data, prepare reports, advise government, disseminate findings and monitor the state response.[15]
• Assign facility implementation to Chief Medical Directors or equivalent officers, supported by multidisciplinary committees including clinical, nursing, records, pharmacy, laboratory, public health and client representatives.[15]Refresh relevant standards and protocols, sensitise staff, train committee members and ensure prompt death notification.[15]
• Notify relevant surveillance officers when a maternal or perinatal death occurs, retrieve the case record within 24 hours, complete review documentation within 72 hours and present the case at the next committee meeting.[16]Conduct non-threatening facility reviews every two to four weeks, ordinarily considering no more than two cases per session, and develop recommendations, action plans and follow-up arrangements.[16][17]
• Apply community-based MPDSR to deaths at home or in transit through verbal autopsy, using community committees that involve leaders, women’s groups, transport workers, providers and local health personnel.[17][18]Conduct sensitive and confidential investigations within three weeks of notification, then submit findings for compilation and review.[19]
• Review every facility maternal and perinatal death as a multidisciplinary institutional function, examining care quality, diagnoses, treatment, referrals, communication, records, equipment, family circumstances and delays in care.[9][20]
• Use standardised notification, review, recommendation, action-plan and response-tracking forms, including unique identification codes, to support consistent reporting and follow-up.[21][22]
• Submit facility and community reports through Local Government Area and state channels to the Federal or State Ministry of Health, while implementing local remedies through the responsible facility or community actors.[16][23]
• Monitor notification coverage, timeliness, data quality, reporting consistency, implementation of recommendations and the effect of interventions on maternal and perinatal mortality.[12][24]Undertake periodic evaluation where targets are missed or mortality fails to decline.[24]
• Disseminate results transparently to policy-makers, health personnel, civil society and communities to support advocacy, resource mobilisation and government accountability.[7]
• Integrate MPDSR data and tools with Health Management Information System software and share reports with the National Population Commission to strengthen Civil Registration and Vital Statistics.[24]
• Phase national expansion from federal tertiary facilities and concurrent primary-health-care audit activity, review initial schemes after one year, then extend implementation to state facilities and private providers.[25]
• Secure enabling legislation, legal protection for participants, supportive policy, adequate training, data-management capacity and a costed implementation plan to sustain the system.[13][24]Financing details and monetary allocations are not specified, although resources for meetings, report processing, dissemination and operational delivery are envisaged through Federal Ministry of Health appropriations and initial government and development-partner support.[12]

Monitoring & Evaluation

Maternal and Perinatal Death Surveillance and Response (MPDSR) is designed as a continuous surveillance, review and action system: every maternal and perinatal death should be identified, notified, counted, investigated for causes and avoidable factors, reviewed, and followed by recommendations whose implementation and impact are monitored.[1]The approach links routine health-information processes with clinical and community quality improvement, using findings to reduce preventable deaths, improve care, strengthen accountability and inform public-health action.[9][7]

• Notify maternal and perinatal deaths promptly through standardised forms and reporting routes. A maternal death notification should be completed immediately after death and transmitted to local, state or federal health authorities within 24 hours.[4]Facility processes include retrieving case records within 24 hours, completing MPDSR forms within 72 hours, and presenting cases at the next committee meeting.[16]
• Review deaths at facility, community, state and national levels. Facility committees should review every maternal and perinatal death in a multidisciplinary, confidential and non-punitive process, while community verbal autopsies investigate deaths at home or in transit and identify barriers to care.[9][17]
• Analyse direct and underlying causes, contributing factors, avoidability, trends, geographical and demographic patterns, health-seeking behaviour, and barriers in access and quality of care.[1]Reviews specifically consider delays in deciding to seek care, reaching a facility and receiving adequate treatment, alongside deficiencies in staff skills, equipment, consumables, records, referral, communication and transport.[5][26]
• Use structured instruments to support consistent reporting and case analysis, including maternal and perinatal notification forms, facility review forms, recommendation and action-plan forms, response-tracking reports, coding instructions, case-analysis grids and committee terms of reference.[21]The forms capture clinical, demographic, service-use, treatment, pregnancy, delivery, neonatal outcome and cause-of-death information, supporting classification and review of deaths.[27][28]
• Conduct facility committee reviews at intervals of two to four weeks, normally examining no more than two cases per session to allow meaningful deliberation.[16][29]Community investigations should be completed within three weeks of notification, and relevant notification forms submitted monthly.[19]
• Apply defined reporting timeframes for perinatal review: complete the facility form within 48 hours, complete the facility review within one month, and follow up the action plan within three months.[23]At facility level, completed forms and session reports should be submitted through the facility head to the relevant Federal or State Ministry of Health.[16][29]
• Track recommendations, assign actions to responsible recipients, follow up non-reporting facilities, collate notifications and reports, and issue annual reports with findings and recommendations for dissemination and action.[12]State committees are expected to synthesise and interpret results, advise government, monitor implementation of recommendations and monitor the state response to maternal and perinatal deaths.[15]
• Maintain governance and accountability through quarterly National MPDSR Steering Committee meetings, technical analysis of accumulated reports, recorded meeting minutes, review of previous recommendations and transparent dissemination of results to stakeholders, including civil society.[12][14][7]The committee structure includes performance-based renewal provisions for members and office holders.[12]
• Evaluate pilot implementation after one year in federal tertiary facilities and concurrent primary-health-care audit activities before expansion to state facilities and the private sector.[25]Periodic evaluation is also envisaged where MPDSR steps miss expected targets or maternal and perinatal mortality does not decline.[24]
• Strengthen data quality, timeliness, coverage and system acceptability, and integrate MPDSR information with the Health Management Information System, District Health Information System and Civil Registration and Vital Statistics development.[24][30]The Monitoring and Evaluation Sub-Committee is tasked with assessing data accuracy, quality assurance, analysis, dissemination and institutional capacity, and reporting on quality of care to managers and policy-makers.[30]

Costing & Financing

The framework recognises that sustained MPDSR requires adequate operational resources, training, data-management capacity and a costed implementation plan, but the supplied material provides no monetary budget, allocation, cost estimate, financing formula, funding-gap estimate or economic assumption.[13][12]

• Finance national committee meetings, report processing, report generation and dissemination through Federal Ministry of Health budgets and appropriations.[12]Initial government and development-partner support was envisaged because the scheme was new and had not yet been included in the ministry’s operational plan.[12]
• Provide facility-level operational resources through the Chief Medical Director or equivalent office.[15]Implementation conditions also include resources, supportive policy, staff training and retraining, and capacity for data collection, collation and transmission.[15]
• Develop a costed implementation plan spanning all levels of health care to support comprehensive and sustainable national implementation.[13]
• Use MPDSR evidence to inform more efficient resource allocation and recommendations concerning emergency services, the cost of care and billing.[7]Institutionalised review is also expected to support better resource allocation and cost-effectiveness, although no quantified economic analysis is supplied.[9]
• Mobilise resources through advocacy based on MPDSR evidence and accounts of deaths, with transparent dissemination intended to encourage government accountability and stakeholder support.[7]Development partners are identified as potential sources of technical assistance and implementation support, without quantified financial commitments.[31][30]
• Recognise financial constraints as possible contributory factors in individual maternal and perinatal deaths, particularly where they affect care-seeking, referral or access to services.[20]The source does not specify mechanisms for subsidising care or addressing household financial barriers.[20]