Table 3

Lenses and levels for examining drivers of maternal and perinatal death surveillance and response (MPDSR)

Health systems drivers with a governance focusHealth system levels
MacroMesoMicro
Service delivery lens

  • Policy mandate

  • Coordination mechanisms

  • Service delivery readiness

  • User capacity

  • National MPDSR policy and guidelines

  • Death notification requirements (legal framework for notifying deaths)

  • Legal mandate to involve communities and other sectors

  • Human resources shortages across the system but particularly for maternal and child health specialists

  • Committees formed

  • Committee composition: profession, gender, seniority

  • Meeting frequency

  • Publication of proceedings

  • Strategy for staff orientation to MPDSR

  • Availability of MPDSR tools

  • Health worker workload

  • Functionality of information systems

  • Competencies of managers, supervisors, providers to analysis and interpret data and information

Society lens

  • Political prioritisation

  • Accountability dynamics

  • Interpersonal dynamics

  • National prioritisation of preventing maternal and perinatal deaths

  • Perceived preventability of deaths

  • Social implications of political party affiliation, gender, class, among committee members, etc

  • Community engagement

  • Leadership: individuals (champions) and of system (space for teamwork)

  • Moving away from blame to learning environment/ trust

  • Credibility of HMIS system

  • Visibility of effect/impact

  • Health worker responses and prioritisation

  • Confidence of and capability of health workers to complete and analyse deaths

  • Relationship between committee members

  • Mentorship, clinical outreach and supervisory activities through district engagement

Systems lens

  • Dis/equilibria

  • Feedback loops

  • Eventuality of change

  • Emergence

(Dynamics can link across micro, meso and macro levels)

  • Kenya: MPDSR process/outcomes fail to deliver on actions due to health system barriers which perpetuates a demoralising work environment and undermines commitment to attending meetings35

  • Nigeria: improved MPDSR led to increased reporting of deaths and therefore an increase in mortality further documenting poor performance. However, responses to insufficient blood supply led to community mobilisation for blood donor club formation. Inclusion of findings in State Medium Term Strategy led to the provision and maintenance of blood banks in state hospitals36

  • HMIS, health management and information systems.