Maternal and perinatal death surveillance and response in Bangladesh: A case study on measuring impact through health information systems

Abu Sadat Mohammad Sayem; Jens Johan Kaasbøll; Abul Halim; Dr. Abu Sayeed Md. Abdullah

doi:10.12688/f1000research.142710.3

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Case Study

Revised

Maternal and perinatal death surveillance and response in Bangladesh: A case study on measuring impact through health information systems

[version 3; peer review: 1 approved, 1 approved with reservations, 1 not approved]

Abu Sadat Mohammad Sayem ¹, Jens Johan Kaasbøll¹, Abul Halim², Dr. Abu Sayeed Md. Abdullah²

PUBLISHED 18 Feb 2025

Author details Author details

¹ University of Oslo, Oslo, Norway
² Centre for Injury Prevention and Research, Bangladesh (CIPRB), Dhaka, Bangladesh

Abu Sadat Mohammad Sayem
Roles: Conceptualization, Data Curation, Formal Analysis, Investigation, Methodology, Resources, Validation, Writing – Original Draft Preparation, Writing – Review & Editing

Jens Johan Kaasbøll
Roles: Supervision, Validation, Writing – Review & Editing

Abul Halim
Roles: Writing – Review & Editing

Dr. Abu Sayeed Md. Abdullah
Roles: Conceptualization, Methodology, Writing – Review & Editing

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Abstract

The information systems for the Maternal and Perinatal Death Surveillance and Response (MPDSR) program have been digitalized in Bangladesh since 2014. This study aimed to investigate the availability of information systems for measuring the status of an MPDSR program and the planning process and actions developed based on real-time information. This study explored innovative information systems designed to easily monitor and measure the impact of health programs. The study included both the primary and secondary data. Key informant interviews were conducted to explore the enablers and strengths of information systems. Secondary data were collected from government websites and approved MPDSR action plans. This study highlights the potential and challenges of governmental health information systems in notifying maternal and neonatal deaths. The study reveals that the existing death notification rates are not up to national standards. It is encouraging to see health managers develop action plans and address this issue. The MPDSR information system serves as an essential tool for health managers, enabling them to assess variations in maternal and perinatal mortality rates while facilitating the development of interventions tailored to local needs. However, several obstacles must be addressed, such as insufficient data, lack of monitoring, and irregularities in MPDSR review meetings. By finding ways to overcome these challenges, we can unlock the full potential of MPDSR and improve maternal and neonatal health outcomes. The success of an MPDSR program relies on how the information is utilized to take action and measure the outcome. Advanced information systems, such as health dashboards, scorecards, and administrative data, can play a vital role in measuring the progress and impact of a program. The primary challenge lies in capturing all deaths, including their causes, and having the capacity to analyze the data effectively to develop action plans for health managers.

Keywords

Health information systems, dashboard, Maternal and perinatal deaths, impact measurement

Corresponding author: Abu Sadat Mohammad Sayem

Competing interests: No competing interests were disclosed.

Grant information: CIPRB will provide funding to publish this manuscript.
The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Copyright: © 2025 Sayem ASM et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

How to cite: Sayem ASM, Kaasbøll JJ, Halim A and Abdullah DASM. Maternal and perinatal death surveillance and response in Bangladesh: A case study on measuring impact through health information systems [version 3; peer review: 1 approved, 1 approved with reservations, 1 not approved]. F1000Research 2025, 13:258 (https://doi.org/10.12688/f1000research.142710.3) First published: 10 Apr 2024, 13:258 (https://doi.org/10.12688/f1000research.142710.1) Latest published: 18 Feb 2025, 13:258 (https://doi.org/10.12688/f1000research.142710.3)

Revised Amendments from Version 2

In light of your feedback, we have made several updates to the manuscript to enhance its clarity and provide a more comprehensive understanding of the information systems in Bangladesh. We have included an additional diagram to assist readers who may not be familiar with the existing MPDSR system, making it more accessible for comparisons with other countries. Furthermore, we have revised the language to eliminate any potential confusion and have elaborated on the methods employed in the study. We sincerely appreciate your comments and questions and are always open to discussing the study further on any platform.

See the authors' detailed response to the review by Tahmina Begum
See the authors' detailed response to the review by Theresa Diaz
See the authors' detailed response to the review by Christelle Boyi Hounsou

Introduction

The health information system in Bangladesh has been transformed from a paper-based and disorganized system to a web-based system called District Health Information Software (DHIS2).¹ With over 16,000 health facilities adopting DHIS2 in 2013, Bangladesh has emerged as one of the largest DHIS2 deployers in the world.² The Maternal and Perinatal Death Surveillance and Response (MPDSR) program represents a significant advancement in health initiatives, particularly in its implementation of a digital reporting system. The quality of care within the health system has improved by adopting tools like MPDSR, which the WHO recommended in 2013 through technical guidance.³ It is worth noting that Bangladesh is one of the few countries that uses real-time MPDSR data through a dashboard, which the MOH creates for real-time monitoring. The program notifies the death of the mother and newborn, followed by a death review to identify causes and develop a response to prevent future deaths.³^,⁴

The program was piloted in one district in 2007 and was gradually scaled to all 64 districts. The program reports deaths through identification and examines the causes of maternal and neonatal deaths and stillbirths, both within the community and at the facility.⁵ The data for the MPDSR were initially collected in papers. The data includes quantitative and qualitative information through a structured verbal autopsy form through interviews of the family members of the deceased person conducted by a designated health worker. A group of professionals reviewed the document to identify the cause of death and associated factors. The recommendations were then sent back to the health managers. This process usually takes more than six months to determine the cause of death and to act accordingly ( Figure 1).

Figure 1. Workflow of the existing MPDSR death notification, review and planning process.

Globally, there was a 44% reduction in maternal deaths, from 532,000 in 1990 to 303,000 in 2015.⁶ In Bangladesh, the Maternal Mortality Ratio (MMR) declined between 2001 and 2010 but has now plateaued compared to 2016. A wide range of factors influences this, but information systems are the keys to measuring and monitoring. Although progress has been impressive in the past, it is necessary to accelerate the rate of reduction of deaths to reach the Sustainable Development Goals and end preventable maternal deaths through a renewed focus on accountability and actions.⁷

One of the essential pillars of the WHO’s six building blocks is the health management information system, which is crucial for the evaluation and performance measurements of any health program. Health management information systems form the foundation of data-driven decision-making at both the national and subnational levels.⁸^,⁹ While designing a health information platform, it is crucial to understand that the need for the quantity and comprehensiveness of data at the district [or equivalent] and lower levels is generally more significant than that at the national level.¹⁰ One of the challenges of health management in developing countries is the existence of weak accountability and feedback practices.¹¹ At the national level, data is necessary for a broader scope of policymaking. At the district and sub-district levels, local data are of immense value in allocating resources and capacity-building health workers to improve existing service delivery and quality and introduce new services.¹² With data available as evidence, local health managers can formulate and justify short- and long-term planning, with the involvement of community people and stakeholders.¹²

The DHIS2 system has presented Kenya with unprecedented potential to move from the era of an unreliable and fragmented HIS system to an ideal situation of availability and use of quality health information for rational decision-making.¹³ Sri Lanka has a DHIS2 platform linked to CRVS data. This ensures that no deaths go unreported, which has compelled healthcare managers to take actions that have effectively reduced maternal deaths.¹⁴ The Commission on Information and Accountability (CoIA) in 2011 and the recent Global Strategy for Women’s, Children’s, and Adolescents’ Health (2016–2030) recommend accountability as a core principle driving progress in health outcomes.⁷

The National Core Management Information Systems (MIS) committee, chaired by the directorates, meets monthly to obtain feedback on technical issues and monitor data from all the districts.¹⁵ Within the MPDSR program, a community healthcare provider enters data related to the death of a mother or newborn (death notification) at the grassroots level into the DHIS2 within 3 days. After the notification, a health inspector, the supervisor of the catchment area, visits the deceased’s house with a structured questionnaire (death review) and conducts an awareness session using a focus group discussion method within a month. The supervisor sends the form to the district-level office. Healthcare managers at national and subnational levels can learn about an event in real-time from the same platform (DHIS2).¹⁶ The final causes of death are determined at the divisional level by Gynaecologists, Obstetricians, and Neonatologists based on death review forms, and that information is also entered into the DHIS2 within a year.¹⁷

Each year, the divisional or district authority holds an MPDSR planning workshop to create a yearly plan (response) based on death notifications and reviews.

Although MPDSR reporting has been incorporated into DHIS2 in Bangladesh, we remain unsure about its effectiveness in aiding health managers with planning for maternal and neonatal health programs. Utilizing a mixed-method approach with data from 2019 to 2021, we examined how the integration of MPDSR findings into DHIS2 was employed to report deaths, inform program reviews, create MDSPR action plans, and connect outcomes on key indicators. Furthermore, we gathered recommendations for enhancing the MDPSR program. This study presents comprehensive insights into the MPDSR dashboard’s functionality in Bangladesh and explores how the identified gaps and barriers impact evidence-based decision-making and actions.

Methods

The study used qualitative and quantitative approaches to understand the research problem. Mixed-methods research has emerged as a major methodological approach across the social sciences, often regarded as a third paradigm alongside qualitative and quantitative research.¹⁸ The study integrated qualitative and quantitative strands, collecting and analyzing data from both approaches to provide a comprehensive understanding of the research problem. We selected 27 districts in which MPDSR implementation matured in 2019. We collected secondary data on reproductive maternal, neonatal, child, and adolescent health (RMNCAH) from 27 districts in 2019 and 2021 (January–December). The quantitative data collected were based on maternal and perinatal deaths notified and reviewed using the DHIS2. The selected districts were mainly low-performing and high-priority, based on key performance indicators. Data were collected from the Government of Bangladesh website ( DGHS dashboard). The secondary data was received from the Health managers who had approved MPDSR action plans and were collected from seven districts (2019-20 plans). We conducted six key informant interviews at the national level with the National MPDSR core committee members for primary data as well. The participants were chosen based on their relevance to the program for an extended time. The qualitative data were analyzed with codes and themes relevant to the study.

The ethical clearance for the study was obtained from the Ethical Review Committee of the Centre for Injury Prevention and Research, Bangladesh (ERC review number: CIPRB/ERC/2020/08, Date of approval: 27 February 2020). A consent form was developed and used for each interview. Written informed consent was obtained from the respondents before starting the interviews. The consent form clearly stated that their participation is voluntary and can be stopped at any time for any reason and that they can answer some questions and skip others if they wish. The research was guided by ethical considerations, including child safeguarding, sensitivity, openness, confidentiality, data protection, reliability, and independence.

Primary data collection

Key Informant Interviews (KII) were conducted in 2021 using a standardized guideline as part of the primary data collection to complement the secondary data findings.²⁵ The KII guidelines were provided by the authors, experts in MPDSR implementation research (CIPRB) and had long-term experience in Bangladesh. It was pilot-tested before the interview. Two trained anthropologists collected the primary data through face-to-face interviews with key respondents. The interviewers were MBBS with MPH backgrounds. They were experts in taking KIIs of health and family planning managers at the national and district levels. First, an approval letter was circulated from the Line Director, MNC&AH, Directorate General of Health Services (DGHS), to conduct these KIIs with respondents. Then, the interviewers communicated with the respondents over the phone and booked their interview time. The research team developed a guideline for KII and a consent form in Bangla for this data collection. The respondents who were highly engaged with the MPDSR program in Bangladesh were selected purposively. The data collectors communicated with the selected key informants over the cell phone and booked their time for an interview. Then, they visited the respondents’ work and conducted the interview. Before starting the interview, consent was received for the interview and audio recording. The duration of each interview (KII) was 30-45 minutes. Audio records were included in each interview. The transcription was developed from audio recordings, and the translation was conducted from Bangla to English. After the data collection through in-depth interviews, the analysis involved thematic coding to identify key themes and patterns from the transcript. KIIs were performed to understand critical stakeholders’ beliefs about MPDSR data use and how the implementation of MPDSR could be improved by identifying barriers. Thematic analysis was employed to categorize the data into meaningful themes, then examined to understand the barriers and facilitators of MPDSR implementation. No software was used for analysis. The research team interpreted the findings to ensure consistency and validity. The respondents (Table 1) were specifically asked about the gaps in the MPDSR implementation and process and their recommendations for improving the process for a higher impact.

Table 1. List of key organizations involved in the MPDSR committee for primary data collection.

SL.	Department and organization
1.	Maternal, New-born, Child, and Adolescent Health Program Directorate General of Health (DGHS), Ministry of Health and Family Welfare (MOH&FW), Bangladesh
2.	Maternal and Child Health- Services & Maternal & Child, Reproductive and Adolescent Health Program, Directorate General of Family Planning (DGFP) Ministry of Health and Family Welfare, Bangladesh
3.	Quality Improvement Secretariat (QIS), Health Economic Unit (HEU), MOHFW, Bangladesh
4.	Maternal Health Program, Directorate General of Health (DGHS), Ministry of Health and Family Welfare (MOH&FW), Bangladesh
5.	Emergency Obstetric Care, Directorate General of Health (DGHS), Ministry of Health and Family Welfare (MOH&FW), Bangladesh
6.	United Nations Population Fund (UNFPA), Bangladesh

Secondary data collection

This study collected district MPDSR action plans developed by health managers through workshops and funded for implementation. The plans were implemented in the Sylhet, Maulvibazar, Bandarban, Cox’sbazar, Jamalpur, Netrokona, and Gazipur districts.

Secondary data were collected from public governmental health websites with seeking permission. There was a specific dashboard on the MPDSR program within the health dashboard. The MPDSR dashboard produced tables, pie charts, and trends. To provide a quick overview of the performance at the district level, a color-coded tool/table can be generated, with green indicating on track, yellow indicating progress, and red indicating not on track. Consent and permission were obtained from the Ethical Review Committee and the Government to access all data used in this study; thus, ethical clearance was ensured. Reviewing the Reproductive, Maternal, Neonatal and Child Health (RMNCH) scorecard was another method applied in this study to observe progress in the health indicators in the MPDSR data. The baseline was 2019 and compared with 2021. The RMNCH scorecard data was collected from 27 districts from the government website ( Figure 2). The data from the website was extracted in 2022.

Figure 2. 27 districts for secondary data (dark shaded).

The causes of death data were also entered into DHIS2 after an expert’s review at the district level. The districts organize a one-day-long workshop with all their sub-district health managers to develop a plan based on the available data in DHIS2. After data collection from MPDSR dashboards and health records, the data were cleaned and processed to ensure accuracy and completeness. Descriptive statistics and any trends or patterns were used to summarise the data. Frequency analysis was used for MPDSR key actions in the seven districts and presented in a tabulated form. Quantitative data on death notifications were also analyzed in a Microsoft Excel (Version 2308) spreadsheet, shown in Figures 3, 4 and 5. The analysis also helped identify gaps in the system that may hinder the effective use of MPDSR data.

Results

Performance review through routine health information system

The Ministry of Health developed a real-time MPDSR dashboard to review the MPDSR data entered from any level of health facilities. The dashboard was developed by a consortium of information technology specialists and public health professionals to systematically visualize the data available on the health ministry’s website. This visualization incorporates statistical analyses, including trends, rates, indicators, and targets. These elements were specifically designed to assist managers in interpreting the data efficiently for informed decision-making and strategic action. The users of the dashboard were from all levels of health administration. The MOH holds a monthly video call with the district managers, and the dashboard was used to show the progress and discuss the causes of deaths they reported. The study team examined data to measure performance in 27 districts (downloaded from the MPDSR dashboard). This dashboard is used for various meetings, including MPDSR committee meetings, monthly health coordination meetings, MPDSR action plan workshops, video conferences, and national MPDSR core committee meetings. WHO provides projection-based population data to estimate the number of children born in each administrative unit, which helps the manager get a proxy denominator for their districts.

In 2019, only 63% of the estimated 2056 maternal deaths were reported, and health workers reviewed only 32% of notified cases. According to the national MPDSR guidelines, the target for maternal death review was 100% of notified cases. Facility maternal deaths are notified and reviewed, with much better performance compared to community MPDSR. 76% of the cases were reviewed at the facility ( Figure 3). At the facility, the nurses are responsible for death notification, and the MPDSR focal point is responsible for reviewing the process.

Figure 3. Gaps in capturing maternal death and review.

According to the national MPDSR guidelines, 10% of neonatal deaths should be reviewed to determine the causes of death and identify social barriers. However, the performance of neonatal death surveillance in capturing community data shows that 29% of cases were recorded. Additionally, health workers reviewed 46% of the cases, even though this was not required ( Figure 4).

Figure 4. Gaps in capturing neonatal death and review.

We observed that the death notification system is unique in all 64 districts and captures data from around 5000 unions (lowest administrative units) through health assistant reports. The data show that the system captures 45% of maternal and 26% of neonatal deaths nationally ( Figure 5). This is to mention that private hospitals and urban health facilities are not fully reporting through DHIS2. In this case, the selected districts performed better than the national level regarding death notification, which was typical for all districts.

Figure 5. Percentage of maternal and neonatal death notifications by country and intervention districts 2019 (Source: MPDSR dashboard).

Qualitative information through routine data

This study found that the current information system can capture important qualitative data to aid health managers in evidence-based planning. According to the three-delay model, maternal mortality is linked to delays in three areas: (1) deciding to seek care, (2) reaching the healthcare facility, and (3) receiving care. By analyzing the MPDSR dashboard, health managers could identify the major causes of maternal and neonatal deaths at different levels, which helps planning. The MPDSR dashboard displays the percentage of other causes of maternal and neonatal deaths, which allows health managers prioritize their efforts. Figure 6 below shows that hemorrhage is the leading cause of maternal death, whereas birth asphyxia is the primary cause of neonatal death.

Figure 6. Major maternal and neonatal causes of death (Source MPDSR dashboard 2021).

MPDSR action plans

We collected detailed action plans from seven districts to determine whether the actions were linked to the information systems. Health managers developed MPDSR action plans annually through a 1-2 day-long workshop. All team members analyze the data and develop a 6-to 12-month plan for the district. The senior gynecologist and neonatologist led the technical expertise for interventions, and health managers developed key actions to reduce mortality. We observed that the key actions were being produced in different thematic groups by the cause of death for maternal and neonatal deaths. Some cross-sectoral health-system barriers have been identified. After reviewing the documents, we summarized the key actions to reduce maternal and neonatal deaths in the seven districts ( Table 2). During the workshops, health managers identified the major causes of maternal and neonatal deaths along with barriers. The experts recommended solutions to these problems and developed action plans that were costed for implementation. The actions in Table 2 were linked to the causes of death from the dashboard. The people responsible for implementing these action plans at the community level were health education officers, community healthcare providers, health inspectors, and local elite persons. At the facility level and in the MPDRS committee, the Residential Medical Officer, Medical Officer, Civil Surgeon, Upazila Health and Family Planning Officer, and Upazila Family Planning Officer were responsible for implementing actions to reduce death. The quality of MPDSR action plans varied from district to district. Significant gaps in data completeness have been addressed in the action plan by authorities to improve data entry.

Table 2. List of interventions to prevent maternal and neonatal deaths identified in plans.

Key actions for reducing maternal deaths	Key actions for reducing neonatal deaths
Ensure 24/7 availability of skilled service providers to handle complicated cases with proper logistic support at the facility level.	Provide proper counseling and health education about nutrition during ANC and PNC. Planning of birth Preparedness through ANC.
Provide emergency transport support to pregnant mothers so they can reach the facilities easily.	Labor room up gradation with life support equipment.
Ensuring availability and quality of ANC and PNC services.	Strengthen the referral system and financial support to poor mothers.
Creating awareness among the community people by showing dangerous signs of pregnancy.	Strengthen the data entry and monitoring of death notification and review.
The motivation of community people for institutional delivery and stay in hospital for more extended periods (at least 24 hours).	Ensure regular MPDSR meetings at district and sub-district levels.
Ensuring regular MPDSR meetings at district and sub-district levels.	Increase awareness among the community through courtyard sessions.
Strengthen the monitoring of death notification and review.	Make 7.1% chlorhexidine and IFA supplements to mothers available in the field.
Ensuring emergency and safe blood transfusion services to the mothers during delivery if needed.	Arrangement of emergency C-Section in the presence of an anesthetist.
Preparation of a complete list of pregnant women along with their contact numbers to track risk pregnancy.	Ensure essential care for newborns.
Providing proper training to the service providers on PPH management.	Identification and registration of mothers who are at risk of malnutrition.

Impact measurement and comparing performance trends

This study analyzed maternal and neonatal indicators to evaluate the impact of information systems from 2019 to 2021 ( Table 3). Based on the scorecard system developed by MOH&FW for key indicators, it was revealed that all seven districts in 2019 had inadequate coverage of specific services, including the registration of pregnant mothers, antenatal care (ANC) and postnatal care (PNC) services, and delivery by skilled birth attendants. This highlights the need to improve these areas to ensure better health care services. The RMNCAH dashboard generates a color-coded table that provides a quick overview of performance at the district level. Green indicates on track, yellow indicates progress, and red indicates not on track ( Table 3). The information system can track the progress of health indicators in a district for comparison and trend analysis among health workers. This information system can track the progress of health indicators in a district for comparison and trend analysis. Despite the COVID pandemic, the seven districts that developed MPDSR action plans could measure progress using many indicators. This is to remind you that the COVID pandemic has heavily impacted routine essential health services such as ANC, facility delivery, routine immunization services, and PNC. In 2021, many efforts have been made to restore the services to the baseline year (2019). The impact was impressive in most cases, except in a few districts, which require further investigation.

Table 3. Comparison between key indicators from 2019 and 2021 (Source: RMNCAH Scorecard- DGHS).

District	2019	2021	2019	2021	2019	2021	2019	2021	2019	2021	2019	2021	2019	2021
District	% of registered pregnant women	% of registered pregnant women	Antenatal Care 1 Coverage	Antenatal Care 1 Coverage	Antenatal Care 4 Coverage	Antenatal Care 4 Coverage	Delivery by Skilled birth attendant (SBA) (%)	Delivery by SBA (%)	Postnatal Care 1 Coverage	Postnatal Care 1 Coverage	Neonatal Mortality Rate	Neonatal Mortality Rate	Maternal Mortality Ratio (MMR)	Maternal Mortality Ratio (MMR)
Bandarban District	17.2	16.2	36.4	16.9	21.6	7.5	36.5	17.6	17.2	6.1	5.7	12.6	260.4	544.9
Coxs Bazar District	12.8	15.5	69.9	71	34.1	41.3	63.6	80.6	40.6	48	3.5	1.1	89.5	86.4
Jamalpur District	17.4	23.1	69.6	68.3	47.1	45.7	56.6	59.4	53.6	55.2	6.8	3.3	442.4	111
Maulavi Bazar District	7.4	20.2	91.2	87.2	42.8	55.2	70.5	70.6	61.6	65.2	8.4	6.5	165.6	133.9
Netrokona District	15	13.4	51.2	54.5	32.7	34.7	55.8	59.2	23.4	33.2	4.3	6.7	94	89
Sylhet District	8.8	9	74	80	37.8	44.2	75.4	76.2	65.7	70.1	2	1.4	82.7	54.5
Gazipur District	36.1	44.2	54.2	47.5	30	40.2	99	69.2	24.6	35.4	2.2	3.5	30.6	45

This study reviewed the scorecard of the MPDSR program and found that its key performance indicators were linked with maternal and neonatal mortality rates. The program’s performance dashboard can visualize its impact based on surveys and routine data. Most indicators showed positive changes, except in the Bandarban and Gazipur districts, where mortality and service coverage decreased. Pregnancy registration, delivery antenatal 4th visits coverage, and postnatal care increased in Jamalpur and Maulvibazar, where the impact of reducing MMR was the highest. The data were subject to verification but could be discussed during the MPDSR meetings.

Key recommendations for MPDSR

The interviews informed recommendations for improving MPDSR in developing countries.

Strengthening the health workforce through capacity building and incentives

MPDSR involves capacity-building opportunities, such as training and logistics, as well as motivating healthcare workers. The respondents mentioned that the training helps workers understand the importance of death reviews and enables them to use this information during planning. Engaging professional associations and providing incentives can motivate workers to ensure their success. One of the interviewees mentioned that “There was remuneration for death review before, and now there is no incentive for death review and social autopsy in the field. The staff needs to be accountable for this work.”

Linking MPDSR information systems with quality improvement programs

The respondents agreed that MPDSR plays a crucial role in enhancing the quality of healthcare services. The results derived from the facility death review process should be connected with the quality improvement cycle at the national, subnational, and facility levels through QI/MPDSR committees. Every intervention at the facility level must be linked to the Plan Do Check and Act (PDCA) cycle, ensuring continuous improvement and monitoring through information systems.

Providing a sustainable and trouble-free information system

The MOH respondents mentioned that it is essential to provide technical assistance to ensure accurate data entry at all levels, especially at the district and upazila levels. With proper guidance and support from an IT cell/department, technical issues related to data entry, data accuracy, and server issues may be minimized or resolved.

Better coordination between policymakers and field-level staff

The respondents emphasized that coordination at all levels needs to be strengthened to ensure better implementation and participation of field-level health workers and their supervisors. During the national MPDSR core committee meetings, policymakers need more involvement to change the national strategy and address the findings from lower tiers, such as incentivizing success and appreciating champions at the national level. The managers mentioned that the MPDSR initiative aims to improve maternal and perinatal health outcomes by fostering a collaborative and comprehensive approach. To achieve this, the organogram must include UNICEF, WHO, CIPRB, and the ministry for death notification, data analysis, DHIS2 updates, coordination, and collaboration. By bringing together various stakeholders, the initiative can significantly impact reducing mortality rates and improving healthcare systems, aligning with global efforts to improve maternal and perinatal health outcomes. One of the managers said that:

“The coordination needs to be improved between the Directorate General of Health Services (DGHS) and the Directorate General of Family Planning (DGFP). The staff members need to be rewarded for the work.”

Revision of National MPDSR guideline

Most key stakeholders believe that the current MPDSR guidelines, developed in 2014, need to be revised. The new guidelines should clarify certain functions and add improvements to the existing framework/process, as per the new WHO guidelines, including stillbirth.

“There is an urgent need to revise the MPDSR guideline based on the lessons learned from the experiences of implementation. We are currently revising the MPDSR guidelines, including integration of stillbirth.”

Promote standardized response processes.

The actions taken during the MPDSR workshops were mostly similar and broad. Some solutions, such as HR and funds, are not manageable by local health managers. This includes the systematic follow-up and implementation of recommendations across system levels using a tracking system. The MPDSR committee can review the actions and define a set of common actions for all districts as a recommendation.

Legal enforcement of death reporting

In many countries, death reporting is required by law, which makes it essential for healthcare providers to report all types of deaths, including maternal and neonatal deaths and stillbirths. This will further strengthen the information system for the MPDSR. One respondent stated that:

“In Bangladesh, recently, with the support of UNFPA, progress has been made by the parliament to make death reporting a legal requirement. Soon, maternal and neonatal deaths and stillbirths will be more accurately reported, which will aid in the success of MPDSR scale-up and implementation.”

Monthly district-level cause-analysis

The stakeholders recommend providing monthly cause analysis workshops at the district level instead of conducting them at a higher level. At the district level, gynaecological and pediatric consultants are present, so conducting cause analysis workshops monthly using the local information system is possible. This will improve the accuracy and speed of local action plan development.

MPDSR-monitoring cell

Policymakers suggest forming a separate MPDSR-focused cell to concentrate on the successful implementation of the program, including partners supporting it in different districts. Local health managers need to further strengthen the capacity for MPDSR data analysis. However, the performance in reviewing facility deaths was satisfactory. Identifying the right target can help health workers reduce their workload by targeting the appropriate number of cases.

Discussion

Public health surveillance is the ongoing systematic collection, analysis, and interpretation of health data. This includes disseminating the resulting information to health managers who need it to develop actions. MDSR continuously links the health information system and quality improvement processes, both locally and nationally. It includes routine identification, notification, quantification, and determination of causes and modifiable causes of all maternal deaths as well as using this information to respond to actions that will prevent future deaths.³

RMNCH scorecards and MPDSR dashboards were innovative tools for visualizing and converting data into information for use. The scorecard alerts program managers and decision-makers to be aware of areas that continuously record low performance and lack progress, as well as those needing more attention and action.¹⁹ The innovation here was the integration of scorecard and dashboard functionalities that help track progress and drive actions.

The study found that information systems could identify gaps in measuring MPDSR performance, such as coverage of maternal death notifications, pregnancy registration systems, and effective interventions to improve awareness among pregnant mothers. Moreover, based on this information, health managers have developed interventions for their districts based on context. An information system can measure the effectiveness of an intervention and determine whether it has been successful. For example, in Bandarban, a hilly terrain, the interventions listed in the plan did not work out, and as per the scorecard, the MMR went up. The managers mentioned conducting video conferences to monitor progress regularly and to improve health managers’ accountability may change the situation over time.

The Southeast Asia region WHO reports revealed that out of 10 countries, only three hold national-level meetings twice yearly on MPDSR committees.²⁰ In Bangladesh, health officials recommend that the government and relevant stakeholders collaborate effectively to implement the MPDSR system. It is also important to establish accountability and enhance coordination between the two directorates to facilitate discussions on existing data for the planning process.

In Ethiopia, the identification and detection of maternal and perinatal deaths are poor relative to the national target. However, the percentage of maternal death reviews is higher in Ethiopia than in Kenya and Guinea.²¹ In Guinea, it was found that healthcare providers underreport maternal death for fear of being accused and punished,²² which was not the case in Bangladesh. It was also revealed that out of 23 study districts in the country, three did not have any maternal death review committee, and among the reported maternal deaths, only half were reviewed.²² Poor reporting and record-keeping results in poor documentation in Nigeria.²³ Bangladesh’s robust information systems have facilitated more significant progress than those of Kenya, Ethiopia, and Guinea.

This study identified common actions to prevent maternal and perinatal deaths. Similar measures are also taken in other countries, which include proper training of health care providers for the management of complications,²⁰ motivating people for institutional delivery,²² ensuring sufficiency of medicine at the facility, ensuring the availability of transport facilities,²² making better coordination between referring and referral intuition, confirming the birth plan for every woman,²⁰ proper monitoring and evaluation, strengthening MPDSR implementation by regular meetings at the district level,²³ and ensuring adequate funding.²² Our study aligns with comparable findings from national-level interviews and discussions with health managers conducted during the formulation of action plans. Information systems at the grassroots level facilitate health managers in addressing similar challenges and formulating essential strategies.

Action plans should be taken according to the cause of death, and it should be feasible to apply them according to the country’s context.²⁴ Our study revealed that the action plans taken in our study districts are heavily data-driven. Although the number of deaths, HR, and facility readiness were not similar, most actions were similar between the districts. Moreover, there was no tracking of the actions and no information on how the action was implemented to achieve the goal. This is one of the areas in which the country needs further attention to design more effective interventions to reduce deaths. This study found that an MPDSR dashboard could be a helpful solution for health managers to easily find data for the program’s planning, monitoring, and evaluation. This must be integrated with motivational awards or incentives through events, such as the National Health Minister’s Award of Emergency Obstetric Care Awards. There is a need for capacity building for health managers to strengthen monitoring through the MPDSR dashboard, which could help field health workers work more cohesively.

The main challenges of MPDSR implementation are poor documentation, underreporting, and a lack of regular monitoring and feedback at the district level.²⁰^,²²^,²⁴ The government portal in Bangladesh explicitly compares death reviews and notifications at both the facility and community levels. Although most studies have been conducted at the facility level, it is crucial to conduct more studies at the community level to identify obstacles to implementing this approach. Examining death reviews and notification processes in different contexts and levels is essential to achieve better outcomes. The government portal in Bangladesh explicitly compares death reviews and notifications at both facility and community levels. While the majority of studies have focused on the facility level, it is essential to conduct additional research at the community level to identify the barriers to implementing this approach. Analyzing death reviews and notification processes across various contexts and levels is vital for achieving improved outcomes.

Conclusion

Bangladesh has implemented innovative methods for visualizing MPDSR information systems. This enables health managers to monitor, design action plans, and evaluate their impact in real time. Data quality plays a crucial role in decision-making at both local and policy levels. Although routine data indicated decreased maternal and neonatal mortality in most of the implemented districts, further evaluation through data triangulation and independent assessment is recommended. The existing information system allows the program to track the progress of every step of the MPDSR. However, monitoring and accountability by managers need strengthening. The availability of MPDSR information systems has fostered a culture of evidence-based planning and monitoring through visualization platforms, such as the RMNCAH scorecard and MPDSR dashboard. As a result, health managers can now make evidence-based decisions. An improved routine information system has reduced dependence on survey data. However, there is a lack of tracking interventions after the development of action plans, making it challenging to assess the effectiveness of each intervention. Nevertheless, information systems can provide insights into program impact. Enhancing the data quality of MPDSR through effective monitoring is essential for success. Real-time data from MPDSR can help identify underperforming districts. Strengthening accountability in the program could aid Bangladesh in achieving its SDG goals.

Data availability

Underlying data

The data on the website can be accessed from the government website using the following url:

- MPDSR dashboard https://dashboard.dghs.gov.bd/pages/dashboard_mpdsr_performance.php
- RMNCAH scorecard https://dashboard.dghs.gov.bd/pages/dashboard_rmnch.php

All routine data pertaining to the government can be found on the website and is accessible from anywhere. There are various dashboards available for specific programs, but for the purposes of this research, two dashboards have been utilized: the MPDSR dashboard and the RMNCAH scorecard. The MPDSR dashboard is used by program managers to monitor the progress of implementation, while the RMNCAH scorecard is employed to track coverage indicators and measure progress over time.

Figshare: MPDSR-Bangladesh data. https://doi.org/10.6084/m9.figshare.24710166.²⁵

The project contains the following underlying data:

- Paper 2 MPDSR Raw data file final.xlsx
- Interview transcript MPDSR redacted.pdf

Extended data

Figshare: MPDSR-Bangladesh data. https://doi.org/10.6084/m9.figshare.24710166.²⁵

The project contains the following extended data:

- Guideline KII_National level_MPDSR IR.pdf (Interview guides)
- MPDSR Figure 1.tiff
- MPDSR Figure 2.tiff
- MPDSR Figure 3.tiff
- MPDSR Figure 4.tiff
- MPDSR Figure 5.tiff
- MPDSR Table 1.tiff
- MPDSR Table 2.tiff
- MPDSR Table 3.tiff

Data are available under the terms of the Creative Commons Zero “No rights reserved” data waiver (CC0 1.0 Public domain dedication).

References

1. UNICEF ROSA: Health System Strengthening: Transforming the health information system in Bangladesh | UNICEF South Asia. UNICEF; 2019. Reference Source
2. Khan MAH, Cruz V de O, Azad AK: Bangladesh’s digital health journey: reflections on a decade of quiet revolution. WHO South East Asia J. Public Health 2019; 8(2): 71–76. Publisher Full Text
3. World Health Organization: Maternal and perinatal death surveillance and response: materials to support implementation. Geneva: World Health Organization; 2021. Licence: CC BY-NC-SA 3.0 IGO.
4. Kinney MV, Walugembe DR, Wanduru P, et al.: Implementation of maternal and perinatal death reviews: a scoping review protocol. BMJ Open. 2019; 9(11): e031328. PubMed Abstract | Publisher Full Text | Free Full Text
5. Biswas A: Shifting paradigm of maternal and perinatal death review system in Bangladesh: a real time approach to address sustainable developmental goal 3 by 2030. F1000Res. 2017; 6: 1120. PubMed Abstract | Publisher Full Text | Free Full Text
6. World Health Organization: Trends in maternal mortality 2000 to 2020: estimates by WHO, UNICEF, UNFPA, World Bank Group and UNDESA/Population Division. Geneva: World Health Organization; 2023. Licence: CC BY-NC-SA 3.0 IGO.
7. Bandali S, Thomas C, Hukin E, et al.: Maternal death surveillance and response systems in driving accountability and influencing change. Int. J. Gynecol. Obstet. 2016; 135(3): 365–371. PubMed Abstract | Publisher Full Text
8. Indicators, A. H. O: Monitoring the building blocks of health systems. Geneva, Switzerland: WHO Document Production Services; 2010.
9. Sandiford P, Annett H, Cibulskis R: What can information systems do for primary health care? An international perspective. Soc. Sci. Med. 1992; 34(10): 1077–1087. Publisher Full Text
10. Senyoni WF, Kimaro HC, Braa J, et al.: An institutional perspective on the adoption of open dashboard for health information systems in Tanzania. Information and Communication Technologies for Development. Strengthening Southern-Driven Cooperation as a Catalyst for ICT4D: 15th IFIP WG 9.4 International Conference on Social Implications of Computers in Developing Countries, ICT4D 2019, Dar es Salaam, Tanzania, May 1–3, 2019, Proceedings, Part I 15. Springer International Publishing. 2019; pp. 272–283.
11. Moyo CM, Frøyen MH, Sæbo JI, et al.: Using performance league tables to promote accountability and feedback in health management in Malawi. IFIP WG. 2016, December; Vol. 9.
12. Chaulagai CN, Moyo CM, Koot J, et al.: Design and implementation of a health management information system in Malawi: issues, innovations and results. Health Policy Plan. 2005; 20(6): 375–384. PubMed Abstract | Publisher Full Text
13. Karuri J, Waiganjo P, Daniel ORWA, et al.: DHIS2: the tool to improve health data demand and use in Kenya. J. Health Inform. Dev. Ctries. 2014; 8(1).
14. Hazard RH, Buddhika MP, Hart JD, et al.: Automated verbal autopsy: from research to routine use in civil registration and vital statistics systems. BMC Med. 2020; 18: 1–11. Publisher Full Text
15. Begum T, Khan SM, Adamou B, et al.: Perceptions and experiences with district health information system software to collect and utilize health data in Bangladesh: a qualitative exploratory study. BMC Health Serv. Res. 2020; 20(1): 1–13. Publisher Full Text
16. Biswas A, Ferdoush J, Abdullah ASM, et al.: Social autopsy for maternal and perinatal deaths in Bangladesh: a tool for community dialog and decision making. Public Health Rev. 2018; 39(1): 1–7. Publisher Full Text
17. Ministry of Health and Family Welfare [MoHFW]: National Guideline on MPDSR 2016.[cited 2020 July 28]. Reference Source
18. Clark VLP, Creswell JW, Green DON, et al.: Mixing quantitative and qualitative approaches. Handbook of emergent methods. Vol. 363.2008; pp. 363–387.
19. Hanifi SMA, Hossain A, Chowdhury AH, et al.: Do community scorecards improve utilisation of health services in community clinics: experience from a rural area of Bangladesh. Int. J. Equity Health. 2020; 19: 1–11. Publisher Full Text
20. WHO: Strengthening Country Capacity on Maternal and Perinatal Death Surveillance and Response: Report of a South-East Asia Regional Meeting, 16-18 February 2016.2016.
21. Ayele B, Gebretnsae H, Hadgu T, et al.: Maternal and perinatal death surveillance and response in Ethiopia: achievements, challenges and prospects. PLoS One. 2019; 14(10): e0223540. PubMed Abstract | Publisher Full Text | Free Full Text
22. Millimouno TM, Sidibé S, Delamou A, et al.: Evaluation of the maternal deaths surveillance and response system at the health district level in Guinea in 2017 through digital communication tools. Reprod. Health. 2019; 16: 1–11. Publisher Full Text
23. Sageer R, Kongnyuy E, Adebimpe WO, et al.: Causes and contributory factors of maternal mortality: evidence from maternal and perinatal death surveillance and response in Ogun state, Southwest Nigeria. BMC Pregnancy Childbirth. 2019; 19(1): 1–8. Publisher Full Text
24. Schiavone F, Leone D, Caporuscio A, et al.: Revealing the role of intellectual capital in digitalized health networks. A meso-level analysis for building and monitoring a KPI dashboard. Technol. Forecast. Soc. Chang. 2022; 175: 121325. Publisher Full Text
25. Sayem ASM: MPDSR-Bangladesh data. Dataset. figshare. 2023. Publisher Full Text

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Version 3

VERSION 3 PUBLISHED 10 Apr 2024

Author details Author details

¹ University of Oslo, Oslo, Norway
² Centre for Injury Prevention and Research, Bangladesh (CIPRB), Dhaka, Bangladesh

Jens Johan Kaasbøll
Roles: Supervision, Validation, Writing – Review & Editing

Abul Halim
Roles: Writing – Review & Editing

Dr. Abu Sayeed Md. Abdullah
Roles: Conceptualization, Methodology, Writing – Review & Editing

Competing interests

No competing interests were disclosed.

Grant information

CIPRB will provide funding to publish this manuscript.
The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Article Versions (3)

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Sayem ASM, Kaasbøll JJ, Halim A and Abdullah DASM. Maternal and perinatal death surveillance and response in Bangladesh: A case study on measuring impact through health information systems [version 3; peer review: 1 approved, 1 approved with reservations, 1 not approved]. F1000Research 2025, 13:258 (https://doi.org/10.12688/f1000research.142710.3)

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Christelle Boyi Hounsou, Centre de Recherche en Reproduction Humaine et en Démographie,, Cotonou, Benin; Institute of Tropical Medicine, Antwerp, Belgium

Approved with Reservations

https://doi.org/10.5256/f1000research.174178.r342075

ABSTRACT
1- “The health sector in Bangladesh is thriving, and the Maternal and Perinatal Death Surveillance and Response (MPDSR) program has been in place to investigate the causes of maternal and perinatal death. This study aimed to investigate the availability of information systems for measuring the status of an MPDSR program and the planning process and actions developed based on real-time information”

The first sentence show no link with health information system. Please review it accordingly to make it easy to understand the link with the second one.

2-"This study delved into innovative information systems that can be used to monitor and measure the impact of health programs"

Ok. But the link with the previous sentences still is missing.

INTRODUCTION
3-“ As a result, the health system’s quality of care has been enhanced by adopting tools such as Maternal and Perinatal Death Surveillance and Response (MPDSR), which the WHO and UNICEF recommend. “

Please, provide a reference “

4"The adoption of DHIS2 has indeed been transformative for health information systems, as demonstrated by the example of Bangladesh. However, it is important to clarify that the adoption of DHIS2 in itself does not directly explain the adoption of MPDSR. While DHIS2 provides a robust platform for data management and analysis, MPDSR is a distinct initiative aimed at generating actionable information to improve the quality of care and strengthen the health system."

The justification provided, linking DHIS2 adoption to MPDSR adoption, may not fully capture the complexities and specific requirements of implementing MPDSR. Beyond the technical infrastructure, MPDSR requires a strong commitment to using the information generated to drive systemic improvements, which involves leadership, capacity building, and stakeholder engagement.
It would be more accurate to highlight how DHIS2 can serve as a supportive tool for MPDSR by facilitating the integration of MPDSR data into its platform. This integration can enhance the accessibility, analysis, and use of MPDSR data within broader health information systems, creating opportunities for more efficient monitoring and decision-making. Strengthening the justification in this way will better reflect the nuanced relationship between these two initiatives and the potential for synergy when MPDSR data is effectively integrated into DHIS2.

5-“The program notifies the death of the mother and newborn, followed by a death review to identify causes and develop a response to prevent future deaths.³”

I suggest to use the original reference of MPDSR:
- World Health Organization. Maternal Death Surveillance and Response: Technical Guidance Information for Action to Prevent Maternal Death. WHO; 2013.

- World Health Organization, Maternal and perinatal death surveillance and response: materials to support implementation. Geneva: World Health Organisation; 2021. Licence: CC BY-NC-SA 3.0 IGO.

6-"The data for the MPDSR were initially collected in papers—a group of professionals reviewed the document to identify the cause of death and associated factors."

Please, explain the type of data

7-"Globally, there was a 44% reduction in maternal deaths, from 532,000 in 1990 to 303,000 in 2015.⁵ In Bangladesh, the Maternal Mortality Ratio (MMR) declined between 2001 and 2010, but has now plateaued compared to 2016. Although progress has been impressive in the past, it is necessary to achieve Sustainable Development Goals in ending preventable maternal deaths through a renewed focus on accountability and actions.^6"
Reference: WHO, UNICEF, UNFPA, World Bank Group, United Nations Population Division: Trends in Maternal Mortality: 1990 to 2015. Geneva: WHO; 2015.

7a- Please, use more acurate reference in addition:
Suggestion: World Health Organization,Trends in maternal mortality 2000 to 2020: estimates by WHO, UNICEF, UNFPA, World Bank Group and UNDESA/Population Division. Geneva: World Health Organszation; 2023. Licence: CC BY-NC-SA 3.0 IGO.

7b- This passage does not integrate well with the preceding sections. Firstly, it is not automatic to attribute (even partly) the reduction or plateau in maternal mortality to the implementation of MPDSR or the health information system. While these initiatives may contribute to improvements, such trends are influenced by a wide range of factors, including broader health system reforms, socio-economic changes, and other interventions.
To ensure coherence and accuracy, it would be beneficial to clarify the multifactorial nature of maternal mortality trends and avoid implying a direct causal link between these specific initiatives and the observed changes. This would better align the passage with the broader context and provide a more balanced perspective.

8-The National Core Management Information Systems (MIS) committee, chaired by the directorates, meets monthly to obtain feedback on technical issues and monitor data from all the districts.¹⁴ The platform has helped reduce the administrative burden on the health system, reducing silos, and streamlining processes within a national data warehouse. Within the MPDSR program, a community healthcare provider enters data related to the death of a mother or newborn at the grassroots level into the DHIS2. By contrast, healthcare managers at national and subnational levels can learn about an event in real time from the same platform.¹⁵ The final causes of death are determined at the divisional level by Gynecologists, Obstetricians, and Neonatologists based on death review forms, and that information is also entered into the DHIS2.¹⁶

The section provides a valuable overview of the MPDSR program and its integration with DHIS2. However, it would be helpful to elaborate further on how each component of the MPDSR—notification, review, and response—is operationalised within the specific context. For example:

Notification: Who is responsible for initiating the data entry at the grassroots level? What is the process for ensuring timely and accurate reporting?
Review: At what intervals are death review meetings conducted, and who participates in these discussions? How is the validation of data handled to ensure consistency and reliability?
Response: What mechanisms are in place to ensure that healthcare managers and other stakeholders at the national and subnational levels can access and act on the data? Are there specific timelines for integrating and disseminating data after entry into DHIS2?

Providing this additional detail will clarify how the MPDSR program functions within the system and enhance understanding of the roles, responsibilities, and workflows involved. This will also help illustrate how the program supports timely decision-making and accountability.

9- "This study thoroughly analyzed the current information systems utilized in the MPDSR program to understand how they help health managers plan maternal and neonatal health. The study offers comprehensive insights into the functionality of the MPDSR dashboard in Bangladesh, along with a comparative analysis of the MPDSR information systems utilized in other countries for the purposes of effective planning. The qualitative interviews revealed significant gaps and barriers impeding evidence-based planning and action"

The justification for this study is valuable, as it highlights the importance of understanding how MPDSR information systems support maternal and neonatal health planning. However, to strengthen the rationale, it may be helpful to explicitly address the specific problem or gap that the study seeks to resolve. For instance:

What are the critical challenges in using MPDSR information systems for planning?
How do the identified gaps and barriers affect evidence-based decision-making and actions?
Why is it important to compare the MPDSR systems in Bangladesh with those in other countries, and how will this comparison contribute to addressing the challenges identified?

Clarifying these aspects will provide a stronger foundation for the study and better communicate its relevance and potential impact.

METHODS
10- Overall comments
The explanation of the study’s methodology is clear, but the terminology could be refined to better reflect standard practices in mixed-methods research. Specifically, it may be more accurate to refer to the qualitative and quantitative strands or data rather than describing them as primary and secondary data. This distinction is important because mixed-methods research typically involves integrating qualitative and quantitative approaches, each of which may include both primary and secondary data sources.
Here are some ideas:
"The study used a mixed-methods approach to understand the given research problem. Mixed-methods research has emerged as a major methodological approach across the social sciences, often regarded as a third paradigm alongside qualitative and quantitative research.17 The study integrated qualitative and quantitative strands, collecting and analysing data from both approaches to provide a comprehensive understanding of the research problem."
This revision ensures clarity and aligns with widely accepted terminology in mixed-methods research.

11- "Key Informant Interviews (KII) were conducted in 2021 using a standardized guideline as part of the primary data collection to complement the findings of the secondary data.²⁵ The KII guidelines were provided by the author. It was pilot-tested before the interview."

11a- Please, describe a little bit the guideline.
Specify which author in this section.

11b- Your explanation of the study's mixed-methods approach is clear, but the structure could be improved by grouping all information related to the qualitative and quantitative strands. Additionally, it would be helpful to specify, for each type of data collected, the tools used, who collected the data, and how it was collected.
For instance:

For the qualitative strand, you could detail the use of in-depth interviews, specify the target participants (e.g., healthcare providers, health managers, policymakers), describe the interview guide, and mention how the interviews were conducted and analysed.
For the quantitative strand, you could explain the data sources (e.g., MPDSR dashboards), the type of data extracted, the tools or protocols used for data collection, and the personnel responsible for this process.

12- Data analysis
12a- Quantitative data on death notifications were also analyzed in a Microsoft Excel (Version 2308) spreadsheet, shown in the Figures 2,3 and 4.

The figures should be in the result section.

12b- It is not entirely clear from the document how the data analysis was conducted. To improve clarity, it would be helpful to provide more specific information on the analysis process for each strand of data, immediately following the data collection description. For example:

For the qualitative strand, after the data collection through in-depth interviews, the analysis involved thematic coding to identify key themes and patterns. The data were transcribed verbatim and then coded manually or using qualitative data analysis software (e.g., NVivo). Thematic analysis was employed to categorize the data into meaningful themes, which were then examined to understand the barriers and facilitators of MPDSR implementation. The findings were interpreted by the research team to ensure consistency and validity.
For the quantitative strand, after data collection from MPDSR dashboards and health records, the data were cleaned and processed to ensure accuracy and completeness. Descriptive statistics were used to summarise the data, and any trends or patterns were identified through statistical tests (e.g., chi-square, regression analysis). The data were analysed using statistical software (e.g., SPSS, STATA) to determine the frequency, timeliness, and completeness of data entry and reporting. The analysis also helped identify gaps in the system that may hinder effective use of MPDSR data.

RESULTS
13- It would be helpful to provide a more detailed explanation of how the MPDSR dashboard works, especially in terms of its real-time functionality and its role in monitoring. Maybe in the method sections, It could also be in the result section. For example, you could clarify the following points:

How is the data from the MPDSR system integrated into the dashboard in real-time?
What types of data are displayed on the dashboard (e.g., maternal deaths, causes of death, response actions)?
How are the data updated and verified to ensure their accuracy and timeliness?
Who is responsible for monitoring the dashboard and how do they use the information to drive decision-making at the national and district levels?
How does the Ministry of Health (MOH) use the dashboard for monthly monitoring? Are there specific performance indicators or thresholds that are tracked?

14-Some result parts sound like discussion , not result. Please check and adress in the whole document.
Examples
“This indicates the need for health workers to visit the deceased mother’s home to increase notifications and review the cause of death”
"According to the national MPDSR guidelines, it is recommended that 10% of neonatal deaths be reviewed to determine the causes of death and to identify social barriers. However, the performance of neonatal death surveillance in capture
We attempted to examine how the performance of MPDSR could be evaluated using data from the dashboard"

15- " Facility maternal deaths are notified and reviewed, with much better performance compared to community MPDSR. 76% of the cases were reviewed at the facility"
It would be beneficial to provide a more detailed explanation of how MPDSR functions in the context of both facility and community maternal deaths. Specifically, it would be helpful to clarify the following points:

Identification and Notification: Who is responsible for identifying and notifying maternal deaths at the community level? Are community health workers or other local healthcare providers responsible for this task? How are these deaths reported, and what is the process for ensuring timely notification?
Review Process: How are community maternal deaths reviewed, and who participates in these reviews? Are there specific teams or committees involved, and what is their role in the process? How does the review process differ between facility and community deaths?

16- It seems that the three-delay model is introduced in the results section without prior mention or explanation in the methodology or background sections. To ensure clarity and coherence, it would be helpful to briefly introduce the model earlier in the paper, ideally in the background or theoretical framework section. This would provide the reader with context before it is referenced in the results.

17 - It would be beneficial to incorporate a theoretical framework to guide the study. This framework would provide a clear line of connection between the research questions, the tools used for data collection and analysis, and the structuring of the results. A well-defined framework helps to ensure that the study remains focused and coherent, linking the theoretical concepts with the empirical findings.
In this case, integrating a relevant framework could help in aligning the study’s objectives with the data analysis process and in structuring the results in a way that directly addresses the research questions. This would also strengthen the overall validity of the study by providing a consistent lens through which the findings are interpreted and discussed.

18- It would be helpful to avoid using acronyms such as DGHS and DGFP without first providing their full names. While acronyms are commonly used in technical documents, they can create confusion for readers who may not be familiar with them. To ensure clarity, I recommend spelling out the full names of these organizations at their first mention, followed by the acronym in parentheses

19- It seems that the connection between the recommendations (in the result sections—Key recommendations for MPDSR ) and the research question could be made clearer. To strengthen this link, I suggest explicitly relating each recommendation to the specific aspects of the research question it addresses. This will help readers understand how the findings directly inform the recommendations and how they contribute to answering the research question.
Additionally, it would be useful to briefly describe the tools used for data collection and explain how they were chosen to address the research question. For example, were the in-depth interviews, surveys, or data from the MPDSR dashboard selected because they directly relate to specific components of the research question? This will provide more context for the recommendations and show how the data collection methods align with the study’s objectives.
It would be helpful to clarify that the recommendation for revising the National MPDSR guidelines was not previously identified as part of the gaps in the health system information. For instance, the suggestion to revise the guidelines to include stillbirth and align with new WHO standards seems crucial, but it wasn’t explicitly mentioned earlier in the paper as a gap in the MPDSR framework or health information system.
To strengthen the connection between the findings and the recommendations, I suggest explicitly linking this revision to the main objective of the paper, which is focused on maternal and perinatal death surveillance and response in Bangladesh. Highlighting that the absence of stillbirth inclusion in the MPDSR guidelines limits the effectiveness of maternal and perinatal death surveillance would provide more context for the need for revision.

DISCUSSION
20- Restructuring the results section using the previous comments would significantly enhance the overall structure of the discussion.

21- It seems that some of the results discussed in the paper, such as the identification of common actions to prevent maternal and perinatal deaths, may not be fully aligned with the overall objective of the study. The focus of the paper is on measuring impact through health information systems, specifically the maternal and perinatal death surveillance and response (MPDSR) system in Bangladesh.
While preventing maternal and perinatal deaths is certainly a key goal, it would be helpful to more explicitly connect these identified actions to how they relate to or are facilitated by the health information systems in place. For example, how do the actions to prevent deaths link to the effectiveness of the MPDSR system or the use of data from the system.

Is the background of the case’s history and progression described in sufficient detail?

Partly
Is the work clearly and accurately presented and does it cite the current literature?

Partly
If applicable, is the statistical analysis and its interpretation appropriate?

Partly
Are all the source data underlying the results available to ensure full reproducibility?

Yes
Are the conclusions drawn adequately supported by the results?

Partly
Is the case presented with sufficient detail to be useful for teaching or other practitioners?

Partly

Competing Interests: No competing interests were disclosed.

Reviewer Expertise: Materna, perinatal and neoanatl health, complexity, realist evaluation, quality improvment strategies

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above.

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Author Response 18 Feb 2025

Abu Sadat Mohammad Sayem, University of Oslo, Oslo, Norway

18 Feb 2025

Author Response
ABSTRACT
1- “The health sector in Bangladesh is thriving, and the Maternal and Perinatal Death Surveillance and Response (MPDSR) program has been in place to investigate the causes of maternal ... Continue reading
ABSTRACT
1- “The health sector in Bangladesh is thriving, and the Maternal and Perinatal Death Surveillance and Response (MPDSR) program has been in place to investigate the causes of maternal and perinatal death. This study aimed to investigate the availability of information systems for measuring the status of an MPDSR program and the planning process and actions developed based on real-time information”

The first sentence show no link with health information system. Please review it accordingly to make it easy to understand the link with the second one.

Response: Thanks for this very important note. I have now changed to create a link with the information systems and MPDSR in the revised one. I have tried to remove unnecessary lines and focused more on the linkage between the information systems and programs.

2-"This study delved into innovative information systems that can be used to monitor and measure the impact of health programs"

Ok. But the link with the previous sentences still is missing.

Response: This study also revealed an innovative system to publishing MPDSR data in the website through a dashboard for health managers. I have revised the text to make a link.

INTRODUCTION
3-“ As a result, the health system’s quality of care has been enhanced by adopting tools such as Maternal and Perinatal Death Surveillance and Response (MPDSR), which the WHO and UNICEF recommend. “

Please, provide a reference “

Response: Sorry, we missed the reference, but it has now been provided. The reference was actually given in the later part and also was in the list of references at number 18. Thanks for this advice.

4"The adoption of DHIS2 has indeed been transformative for health information systems, as demonstrated by the example of Bangladesh. However, it is important to clarify that the adoption of DHIS2 in itself does not directly explain the adoption of MPDSR. While DHIS2 provides a robust platform for data management and analysis, MPDSR is a distinct initiative aimed at generating actionable information to improve the quality of care and strengthen the health system."

The justification provided, linking DHIS2 adoption to MPDSR adoption, may not fully capture the complexities and specific requirements of implementing MPDSR. Beyond the technical infrastructure, MPDSR requires a strong commitment to using the information generated to drive systemic improvements, which involves leadership, capacity building, and stakeholder engagement.
It would be more accurate to highlight how DHIS2 can serve as a supportive tool for MPDSR by facilitating the integration of MPDSR data into its platform. This integration can enhance the accessibility, analysis, and use of MPDSR data within broader health information systems, creating opportunities for more efficient monitoring and decision-making. Strengthening the justification in this way will better reflect the nuanced relationship between these two initiatives and the potential for synergy when MPDSR data is effectively integrated into DHIS2.

Response: I completely agree, and we tried to explore these facts through the qualitative part of the study. We examined how information systems, as a tool, helped the managers conduct meetings and planning workshops using the existing information. The text has been revised as well.

5-“The program notifies the death of the mother and newborn, followed by a death review to identify causes and develop a response to prevent future deaths.³”

I suggest to use the original reference of MPDSR:
- World Health Organization. Maternal Death Surveillance and Response: Technical Guidance Information for Action to Prevent Maternal Death. WHO; 2013.

- World Health Organization, Maternal and perinatal death surveillance and response: materials to support implementation. Geneva: World Health Organisation; 2021. Licence: CC BY-NC-SA 3.0 IGO.

Response: Corrected

6-"The data for the MPDSR were initially collected in papers—a group of professionals reviewed the document to identify the cause of death and associated factors."

Please, explain the type of data
Response: The data was both quantitative and qualitative. Designated field workers completed a questionnaire through interviews with the deceased family members, and a specialist in gynecology and pediatrics analyzed this data. I have also added this in that section. Its really good to explain.

7-"Globally, there was a 44% reduction in maternal deaths, from 532,000 in 1990 to 303,000 in 2015.⁵ In Bangladesh, the Maternal Mortality Ratio (MMR) declined between 2001 and 2010, but has now plateaued compared to 2016. Although progress has been impressive in the past, it is necessary to achieve Sustainable Development Goals in ending preventable maternal deaths through a renewed focus on accountability and actions.⁶^"
Reference: WHO, UNICEF, UNFPA, World Bank Group, United Nations Population Division: Trends in Maternal Mortality: 1990 to 2015. Geneva: WHO; 2015.

7a- Please, use more acurate reference in addition:

Suggestion: World Health Organization,Trends in maternal mortality 2000 to 2020: estimates by WHO, UNICEF, UNFPA, World Bank Group and UNDESA/Population Division. Geneva: World Health Organszation; 2023. Licence: CC BY-NC-SA 3.0 IGO.

Response: Revised accordingly with the reference.

7b- This passage does not integrate well with the preceding sections. Firstly, it is not automatic to attribute (even partly) the reduction or plateau in maternal mortality to the implementation of MPDSR or the health information system. While these initiatives may contribute to improvements, such trends are influenced by a wide range of factors, including broader health system reforms, socio-economic changes, and other interventions.
To ensure coherence and accuracy, it would be beneficial to clarify the multifactorial nature of maternal mortality trends and avoid implying a direct causal link between these specific initiatives and the observed changes. This would better align the passage with the broader context and provide a more balanced perspective.

Response: I agree entirely and appreciate this. I have added more words to explain the facts.

8-The National Core Management Information Systems (MIS) committee, chaired by the directorates, meets monthly to obtain feedback on technical issues and monitor data from all the districts.¹⁴ The platform has helped reduce the administrative burden on the health system, reducing silos, and streamlining processes within a national data warehouse. Within the MPDSR program, a community healthcare provider enters data related to the death of a mother or newborn at the grassroots level into the DHIS2. By contrast, healthcare managers at national and subnational levels can learn about an event in real time from the same platform.¹⁵ The final causes of death are determined at the divisional level by Gynecologists, Obstetricians, and Neonatologists based on death review forms, and that information is also entered into the DHIS2.¹⁶

The section provides a valuable overview of the MPDSR program and its integration with DHIS2. However, it would be helpful to elaborate further on how each component of the MPDSR—notification, review, and response—is operationalised within the specific context. For example:

Notification: Who is responsible for initiating the data entry at the grassroots level? What is the process for ensuring timely and accurate reporting?

Review: At what intervals are death review meetings conducted, and who participates in these discussions? How is the validation of data handled to ensure consistency and reliability?

Response: What mechanisms are in place to ensure that healthcare managers and other stakeholders at the national and subnational levels can access and act on the data? Are there specific timelines for integrating and disseminating data after entry into DHIS2?

Providing this additional detail will clarify how the MPDSR program functions within the system and enhance understanding of the roles, responsibilities, and workflows involved. This will also help illustrate how the program supports timely decision-making and accountability.

Response: I agree with this point, and I have revised the section to be more detailed on the three processes mentioned. This also came up in the other findings section.

9- "This study thoroughly analyzed the current information systems utilized in the MPDSR program to understand how they help health managers plan maternal and neonatal health. The study offers comprehensive insights into the functionality of the MPDSR dashboard in Bangladesh, along with a comparative analysis of the MPDSR information systems utilized in other countries for the purposes of effective planning. The qualitative interviews revealed significant gaps and barriers impeding evidence-based planning and action"

The justification for this study is valuable, as it highlights the importance of understanding how MPDSR information systems support maternal and neonatal health planning. However, to strengthen the rationale, it may be helpful to explicitly address the specific problem or gap that the study seeks to resolve. For instance:

What are the critical challenges in using MPDSR information systems for planning?

How do the identified gaps and barriers affect evidence-based decision-making and actions?

Why is it important to compare the MPDSR systems in Bangladesh with those in other countries, and how will this comparison contribute to addressing the challenges identified?

Clarifying these aspects will provide a stronger foundation for the study and better communicate its relevance and potential impact.

Response: This is a great comment, and I have organized the content in a more systematic way. I revised it while considering the word limit. Some sentences were moved to other sections to incorporate all points clearly.

METHODS
10- Overall comments
The explanation of the study’s methodology is clear, but the terminology could be refined to better reflect standard practices in mixed-methods research. Specifically, it may be more accurate to refer to the qualitative and quantitative strands or data rather than describing them as primary and secondary data. This distinction is important because mixed-methods research typically involves integrating qualitative and quantitative approaches, each of which may include both primary and secondary data sources.
Here are some ideas:
"The study used a mixed-methods approach to understand the given research problem. Mixed-methods research has emerged as a major methodological approach across the social sciences, often regarded as a third paradigm alongside qualitative and quantitative research.17 The study integrated qualitative and quantitative strands, collecting and analysing data from both approaches to provide a comprehensive understanding of the research problem."
This revision ensures clarity and aligns with widely accepted terminology in mixed-methods research.

Response: Corrected accordingly. The method here was a bit different, as the study mainly captured the evolving transformation of information systems and how this helped the managers efficiently plan based on the information system.

11- "Key Informant Interviews (KII) were conducted in 2021 using a standardized guideline as part of the primary data collection to complement the findings of the secondary data.²⁵ The KII guidelines were provided by the author. It was pilot-tested before the interview."

11a- Please, describe a little bit the guideline.
Specify which author in this section.

Response: Provided

11b- Your explanation of the study's mixed-methods approach is clear, but the structure could be improved by grouping all information related to the qualitative and quantitative strands. Additionally, it would be helpful to specify, for each type of data collected, the tools used, who collected the data, and how it was collected.
For instance:

For the qualitative strand, you could detail the use of in-depth interviews, specify the target participants (e.g., healthcare providers, health managers, policymakers), describe the interview guide, and mention how the interviews were conducted and analysed.

For the quantitative strand, you could explain the data sources (e.g., MPDSR dashboards), the type of data extracted, the tools or protocols used for data collection, and the personnel responsible for this process.

Response: Done

12- Data analysis
12a- Quantitative data on death notifications were also analyzed in a Microsoft Excel (Version 2308) spreadsheet, shown in the Figures 2,3 and 4.

The figures should be in the result section.

Response: Agreed and revised accordingly.

12b- It is not entirely clear from the document how the data analysis was conducted. To improve clarity, it would be helpful to provide more specific information on the analysis process for each strand of data, immediately following the data collection description. For example:

For the qualitative strand, after the data collection through in-depth interviews, the analysis involved thematic coding to identify key themes and patterns. The data were transcribed verbatim and then coded manually or using qualitative data analysis software (e.g., NVivo). Thematic analysis was employed to categorize the data into meaningful themes, which were then examined to understand the barriers and facilitators of MPDSR implementation. The findings were interpreted by the research team to ensure consistency and validity.

For the quantitative strand, after data collection from MPDSR dashboards and health records, the data were cleaned and processed to ensure accuracy and completeness. Descriptive statistics were used to summarise the data, and any trends or patterns were identified through statistical tests (e.g., chi-square, regression analysis). The data were analysed using statistical software (e.g., SPSS, STATA) to determine the frequency, timeliness, and completeness of data entry and reporting. The analysis also helped identify gaps in the system that may hinder effective use of MPDSR data.

Response: Thanks for detailing this section. I have included your recommendations and revised it accordingly to enhance it reader-friendly.

RESULTS
13- It would be helpful to provide a more detailed explanation of how the MPDSR dashboard works, especially in terms of its real-time functionality and its role in monitoring. Maybe in the method sections, It could also be in the result section. For example, you could clarify the following points:

How is the data from the MPDSR system integrated into the dashboard in real-time?

What types of data are displayed on the dashboard (e.g., maternal deaths, causes of death, response actions)?

How are the data updated and verified to ensure their accuracy and timeliness?

Who is responsible for monitoring the dashboard and how do they use the information to drive decision-making at the national and district levels?

How does the Ministry of Health (MOH) use the dashboard for monthly monitoring? Are there specific performance indicators or thresholds that are tracked?

Response: All points above are integrated. Thanks for this very comprehensive feedback. This section was removed due to word limitations.

14-Some result parts sound like discussion, not result. Please check and address in the whole document.
Examples
“This indicates the need for health workers to visit the deceased mother’s home to increase notifications and review the cause of death”
"According to the national MPDSR guidelines, it is recommended that 10% of neonatal deaths be reviewed to determine the causes of death and to identify social barriers. However, the performance of neonatal death surveillance in capture
We attempted to examine how the performance of MPDSR could be evaluated using data from the dashboard"

Response: Agreed. Corrected accordingly.

15- " Facility maternal deaths are notified and reviewed, with much better performance compared to community MPDSR. 76% of the cases were reviewed at the facility"
It would be beneficial to provide a more detailed explanation of how MPDSR functions in the context of both facility and community maternal deaths. Specifically, it would be helpful to clarify the following points:

Identification and Notification: Who is responsible for identifying and notifying maternal deaths at the community level? Are community health workers or other local healthcare providers responsible for this task? How are these deaths reported, and what is the process for ensuring timely notification?

Review Process: How are community maternal deaths reviewed, and who participates in these reviews? Are there specific teams or committees involved, and what is their role in the process? How does the review process differ between facility and community deaths?

Response: Described in that section to further clarify.

16- It seems that the three-delay model is introduced in the results section without prior mention or explanation in the methodology or background sections. To ensure clarity and coherence, it would be helpful to briefly introduce the model earlier in the paper, ideally in the background or theoretical framework section. This would provide the reader with context before it is referenced in the results.

Response: This has been removed as this is not related to the findings to Corelate. It has created a confusion as it was not described before.

17 - It would be beneficial to incorporate a theoretical framework to guide the study. This framework would provide a clear line of connection between the research questions, the tools used for data collection and analysis, and the structuring of the results. A well-defined framework helps to ensure that the study remains focused and coherent, linking the theoretical concepts with the empirical findings.
In this case, integrating a relevant framework could help in aligning the study’s objectives with the data analysis process and in structuring the results in a way that directly addresses the research questions. This would also strengthen the study's overall validity by providing a consistent lens through which the findings are interpreted and discussed.

Response: Thanks for these excellent comments. This study was part of my PhD, which has a theoretical framework. It fully aligns with the overall objective of my PhD. However, due to limitations, we kept it to using information to measure the impact for MPDSR.

18- It would be helpful to avoid using acronyms such as DGHS and DGFP without first providing their full names. While acronyms are commonly used in technical documents, they can create confusion for readers who may not be familiar with them. To ensure clarity, I recommend spelling out the full names of these organizations at their first mention, followed by the acronym in parentheses

Response: Corrected.

19- It seems that the connection between the recommendations (in the result sections—Key recommendations for MPDSR ) and the research question could be made clearer. To strengthen this link, I suggest explicitly relating each recommendation to the specific aspects of the research question it addresses. This will help readers understand how the findings directly inform the recommendations and how they contribute to answering the research question.
Additionally, it would be useful to briefly describe the tools used for data collection and explain how they were chosen to address the research question. For example, were the in-depth interviews, surveys, or data from the MPDSR dashboard selected because they directly relate to specific components of the research question? This will provide more context for the recommendations and show how the data collection methods align with the study’s objectives.
It would be helpful to clarify that the recommendation for revising the National MPDSR guidelines was not previously identified as part of the gaps in the health system information. For instance, the suggestion to revise the guidelines to include stillbirth and align with new WHO standards seems crucial, but it wasn’t explicitly mentioned earlier in the paper as a gap in the MPDSR framework or health information system.
To strengthen the connection between the findings and the recommendations, I suggest explicitly linking this revision to the main objective of the paper, which is focused on maternal and perinatal death surveillance and response in Bangladesh. Highlighting that the absence of stillbirth inclusion in the MPDSR guidelines limits the effectiveness of maternal and perinatal death surveillance would provide more context for the need for revision.

Response: I appreciate your concerns, and I've taken your recommendations into account in this response. It's important to note that the revision of the MPDSR guideline was not identified as a gap since our focus was primarily on addressing the existing program's gaps through the current information systems that are in use. During discussions with health managers, they expressed that the outdated guideline is contributing to operational challenges within the program. This guideline was established when the country had not yet fully digitized its information systems.
The primary aim of this paper is to explore how information systems can assist managers in evidence-based planning using routine data. We chose to evaluate the MPDSR specifically in this context. However, it's worth mentioning that the health managers we interviewed provided recommendations that were quite comprehensive and aimed at improving the program more broadly. Thank you for your understanding.

DISCUSSION
20- Restructuring the results section using the previous comments would significantly enhance the overall structure of the discussion.

Response: Revised and adjusted as much as possible.

21- It seems that some of the results discussed in the paper, such as the identification of common actions to prevent maternal and perinatal deaths, may not be fully aligned with the overall objective of the study. The focus of the paper is on measuring impact through health information systems, specifically the maternal and perinatal death surveillance and response (MPDSR) system in Bangladesh.
While preventing maternal and perinatal deaths is certainly a key goal, it would be helpful to more explicitly connect these identified actions to how they relate to or are facilitated by the health information systems in place. For example, how do the actions to prevent deaths link to the effectiveness of the MPDSR system or the use of data from the system.

Response: The purpose of this study is to thoroughly investigate the role of information systems and their potential to improve the planning processes utilized by health managers. I have significantly revised the text to enhance its structure and clarity, ensuring that it effectively conveys the key concepts and findings. I greatly appreciate the detailed feedback provided, which has been instrumental in improving not only this paper but also future research projects in this field. This revision aims to provide deeper insights into how information systems can be leveraged for more efficient health management planning, ultimately contributing to better health outcomes. Thank you once again for your valuable input.
ABSTRACT
1- “The health sector in Bangladesh is thriving, and the Maternal and Perinatal Death Surveillance and Response (MPDSR) program has been in place to investigate the causes of maternal and perinatal death. This study aimed to investigate the availability of information systems for measuring the status of an MPDSR program and the planning process and actions developed based on real-time information”

The first sentence show no link with health information system. Please review it accordingly to make it easy to understand the link with the second one.

Response: Thanks for this very important note. I have now changed to create a link with the information systems and MPDSR in the revised one. I have tried to remove unnecessary lines and focused more on the linkage between the information systems and programs.

2-"This study delved into innovative information systems that can be used to monitor and measure the impact of health programs"

Ok. But the link with the previous sentences still is missing.

Response: This study also revealed an innovative system to publishing MPDSR data in the website through a dashboard for health managers. I have revised the text to make a link.

INTRODUCTION
3-“ As a result, the health system’s quality of care has been enhanced by adopting tools such as Maternal and Perinatal Death Surveillance and Response (MPDSR), which the WHO and UNICEF recommend. “

Please, provide a reference “

Response: Sorry, we missed the reference, but it has now been provided. The reference was actually given in the later part and also was in the list of references at number 18. Thanks for this advice.

4"The adoption of DHIS2 has indeed been transformative for health information systems, as demonstrated by the example of Bangladesh. However, it is important to clarify that the adoption of DHIS2 in itself does not directly explain the adoption of MPDSR. While DHIS2 provides a robust platform for data management and analysis, MPDSR is a distinct initiative aimed at generating actionable information to improve the quality of care and strengthen the health system."

The justification provided, linking DHIS2 adoption to MPDSR adoption, may not fully capture the complexities and specific requirements of implementing MPDSR. Beyond the technical infrastructure, MPDSR requires a strong commitment to using the information generated to drive systemic improvements, which involves leadership, capacity building, and stakeholder engagement.
It would be more accurate to highlight how DHIS2 can serve as a supportive tool for MPDSR by facilitating the integration of MPDSR data into its platform. This integration can enhance the accessibility, analysis, and use of MPDSR data within broader health information systems, creating opportunities for more efficient monitoring and decision-making. Strengthening the justification in this way will better reflect the nuanced relationship between these two initiatives and the potential for synergy when MPDSR data is effectively integrated into DHIS2.

Response: I completely agree, and we tried to explore these facts through the qualitative part of the study. We examined how information systems, as a tool, helped the managers conduct meetings and planning workshops using the existing information. The text has been revised as well.

5-“The program notifies the death of the mother and newborn, followed by a death review to identify causes and develop a response to prevent future deaths.³”

I suggest to use the original reference of MPDSR:
- World Health Organization. Maternal Death Surveillance and Response: Technical Guidance Information for Action to Prevent Maternal Death. WHO; 2013.

- World Health Organization, Maternal and perinatal death surveillance and response: materials to support implementation. Geneva: World Health Organisation; 2021. Licence: CC BY-NC-SA 3.0 IGO.

Response: Corrected

6-"The data for the MPDSR were initially collected in papers—a group of professionals reviewed the document to identify the cause of death and associated factors."

Please, explain the type of data
Response: The data was both quantitative and qualitative. Designated field workers completed a questionnaire through interviews with the deceased family members, and a specialist in gynecology and pediatrics analyzed this data. I have also added this in that section. Its really good to explain.

7-"Globally, there was a 44% reduction in maternal deaths, from 532,000 in 1990 to 303,000 in 2015.⁵ In Bangladesh, the Maternal Mortality Ratio (MMR) declined between 2001 and 2010, but has now plateaued compared to 2016. Although progress has been impressive in the past, it is necessary to achieve Sustainable Development Goals in ending preventable maternal deaths through a renewed focus on accountability and actions.⁶^"
Reference: WHO, UNICEF, UNFPA, World Bank Group, United Nations Population Division: Trends in Maternal Mortality: 1990 to 2015. Geneva: WHO; 2015.

7a- Please, use more acurate reference in addition:

Suggestion: World Health Organization,Trends in maternal mortality 2000 to 2020: estimates by WHO, UNICEF, UNFPA, World Bank Group and UNDESA/Population Division. Geneva: World Health Organszation; 2023. Licence: CC BY-NC-SA 3.0 IGO.

Response: Revised accordingly with the reference.

7b- This passage does not integrate well with the preceding sections. Firstly, it is not automatic to attribute (even partly) the reduction or plateau in maternal mortality to the implementation of MPDSR or the health information system. While these initiatives may contribute to improvements, such trends are influenced by a wide range of factors, including broader health system reforms, socio-economic changes, and other interventions.
To ensure coherence and accuracy, it would be beneficial to clarify the multifactorial nature of maternal mortality trends and avoid implying a direct causal link between these specific initiatives and the observed changes. This would better align the passage with the broader context and provide a more balanced perspective.

Response: I agree entirely and appreciate this. I have added more words to explain the facts.

8-The National Core Management Information Systems (MIS) committee, chaired by the directorates, meets monthly to obtain feedback on technical issues and monitor data from all the districts.¹⁴ The platform has helped reduce the administrative burden on the health system, reducing silos, and streamlining processes within a national data warehouse. Within the MPDSR program, a community healthcare provider enters data related to the death of a mother or newborn at the grassroots level into the DHIS2. By contrast, healthcare managers at national and subnational levels can learn about an event in real time from the same platform.¹⁵ The final causes of death are determined at the divisional level by Gynecologists, Obstetricians, and Neonatologists based on death review forms, and that information is also entered into the DHIS2.¹⁶

The section provides a valuable overview of the MPDSR program and its integration with DHIS2. However, it would be helpful to elaborate further on how each component of the MPDSR—notification, review, and response—is operationalised within the specific context. For example:

Notification: Who is responsible for initiating the data entry at the grassroots level? What is the process for ensuring timely and accurate reporting?

Review: At what intervals are death review meetings conducted, and who participates in these discussions? How is the validation of data handled to ensure consistency and reliability?

Response: What mechanisms are in place to ensure that healthcare managers and other stakeholders at the national and subnational levels can access and act on the data? Are there specific timelines for integrating and disseminating data after entry into DHIS2?

Providing this additional detail will clarify how the MPDSR program functions within the system and enhance understanding of the roles, responsibilities, and workflows involved. This will also help illustrate how the program supports timely decision-making and accountability.

Response: I agree with this point, and I have revised the section to be more detailed on the three processes mentioned. This also came up in the other findings section.

9- "This study thoroughly analyzed the current information systems utilized in the MPDSR program to understand how they help health managers plan maternal and neonatal health. The study offers comprehensive insights into the functionality of the MPDSR dashboard in Bangladesh, along with a comparative analysis of the MPDSR information systems utilized in other countries for the purposes of effective planning. The qualitative interviews revealed significant gaps and barriers impeding evidence-based planning and action"

The justification for this study is valuable, as it highlights the importance of understanding how MPDSR information systems support maternal and neonatal health planning. However, to strengthen the rationale, it may be helpful to explicitly address the specific problem or gap that the study seeks to resolve. For instance:

What are the critical challenges in using MPDSR information systems for planning?

How do the identified gaps and barriers affect evidence-based decision-making and actions?

Why is it important to compare the MPDSR systems in Bangladesh with those in other countries, and how will this comparison contribute to addressing the challenges identified?

Clarifying these aspects will provide a stronger foundation for the study and better communicate its relevance and potential impact.

Response: This is a great comment, and I have organized the content in a more systematic way. I revised it while considering the word limit. Some sentences were moved to other sections to incorporate all points clearly.

METHODS
10- Overall comments
The explanation of the study’s methodology is clear, but the terminology could be refined to better reflect standard practices in mixed-methods research. Specifically, it may be more accurate to refer to the qualitative and quantitative strands or data rather than describing them as primary and secondary data. This distinction is important because mixed-methods research typically involves integrating qualitative and quantitative approaches, each of which may include both primary and secondary data sources.
Here are some ideas:
"The study used a mixed-methods approach to understand the given research problem. Mixed-methods research has emerged as a major methodological approach across the social sciences, often regarded as a third paradigm alongside qualitative and quantitative research.17 The study integrated qualitative and quantitative strands, collecting and analysing data from both approaches to provide a comprehensive understanding of the research problem."
This revision ensures clarity and aligns with widely accepted terminology in mixed-methods research.

Response: Corrected accordingly. The method here was a bit different, as the study mainly captured the evolving transformation of information systems and how this helped the managers efficiently plan based on the information system.

11- "Key Informant Interviews (KII) were conducted in 2021 using a standardized guideline as part of the primary data collection to complement the findings of the secondary data.²⁵ The KII guidelines were provided by the author. It was pilot-tested before the interview."

11a- Please, describe a little bit the guideline.
Specify which author in this section.

Response: Provided

11b- Your explanation of the study's mixed-methods approach is clear, but the structure could be improved by grouping all information related to the qualitative and quantitative strands. Additionally, it would be helpful to specify, for each type of data collected, the tools used, who collected the data, and how it was collected.
For instance:

For the qualitative strand, you could detail the use of in-depth interviews, specify the target participants (e.g., healthcare providers, health managers, policymakers), describe the interview guide, and mention how the interviews were conducted and analysed.

For the quantitative strand, you could explain the data sources (e.g., MPDSR dashboards), the type of data extracted, the tools or protocols used for data collection, and the personnel responsible for this process.

Response: Done

12- Data analysis
12a- Quantitative data on death notifications were also analyzed in a Microsoft Excel (Version 2308) spreadsheet, shown in the Figures 2,3 and 4.

The figures should be in the result section.

Response: Agreed and revised accordingly.

12b- It is not entirely clear from the document how the data analysis was conducted. To improve clarity, it would be helpful to provide more specific information on the analysis process for each strand of data, immediately following the data collection description. For example:

For the qualitative strand, after the data collection through in-depth interviews, the analysis involved thematic coding to identify key themes and patterns. The data were transcribed verbatim and then coded manually or using qualitative data analysis software (e.g., NVivo). Thematic analysis was employed to categorize the data into meaningful themes, which were then examined to understand the barriers and facilitators of MPDSR implementation. The findings were interpreted by the research team to ensure consistency and validity.

For the quantitative strand, after data collection from MPDSR dashboards and health records, the data were cleaned and processed to ensure accuracy and completeness. Descriptive statistics were used to summarise the data, and any trends or patterns were identified through statistical tests (e.g., chi-square, regression analysis). The data were analysed using statistical software (e.g., SPSS, STATA) to determine the frequency, timeliness, and completeness of data entry and reporting. The analysis also helped identify gaps in the system that may hinder effective use of MPDSR data.

Response: Thanks for detailing this section. I have included your recommendations and revised it accordingly to enhance it reader-friendly.

RESULTS
13- It would be helpful to provide a more detailed explanation of how the MPDSR dashboard works, especially in terms of its real-time functionality and its role in monitoring. Maybe in the method sections, It could also be in the result section. For example, you could clarify the following points:

How is the data from the MPDSR system integrated into the dashboard in real-time?

What types of data are displayed on the dashboard (e.g., maternal deaths, causes of death, response actions)?

How are the data updated and verified to ensure their accuracy and timeliness?

Who is responsible for monitoring the dashboard and how do they use the information to drive decision-making at the national and district levels?

How does the Ministry of Health (MOH) use the dashboard for monthly monitoring? Are there specific performance indicators or thresholds that are tracked?

Response: All points above are integrated. Thanks for this very comprehensive feedback. This section was removed due to word limitations.

14-Some result parts sound like discussion, not result. Please check and address in the whole document.
Examples
“This indicates the need for health workers to visit the deceased mother’s home to increase notifications and review the cause of death”
"According to the national MPDSR guidelines, it is recommended that 10% of neonatal deaths be reviewed to determine the causes of death and to identify social barriers. However, the performance of neonatal death surveillance in capture
We attempted to examine how the performance of MPDSR could be evaluated using data from the dashboard"

Response: Agreed. Corrected accordingly.

15- " Facility maternal deaths are notified and reviewed, with much better performance compared to community MPDSR. 76% of the cases were reviewed at the facility"
It would be beneficial to provide a more detailed explanation of how MPDSR functions in the context of both facility and community maternal deaths. Specifically, it would be helpful to clarify the following points:

Identification and Notification: Who is responsible for identifying and notifying maternal deaths at the community level? Are community health workers or other local healthcare providers responsible for this task? How are these deaths reported, and what is the process for ensuring timely notification?

Review Process: How are community maternal deaths reviewed, and who participates in these reviews? Are there specific teams or committees involved, and what is their role in the process? How does the review process differ between facility and community deaths?

Response: Described in that section to further clarify.

16- It seems that the three-delay model is introduced in the results section without prior mention or explanation in the methodology or background sections. To ensure clarity and coherence, it would be helpful to briefly introduce the model earlier in the paper, ideally in the background or theoretical framework section. This would provide the reader with context before it is referenced in the results.

Response: This has been removed as this is not related to the findings to Corelate. It has created a confusion as it was not described before.

17 - It would be beneficial to incorporate a theoretical framework to guide the study. This framework would provide a clear line of connection between the research questions, the tools used for data collection and analysis, and the structuring of the results. A well-defined framework helps to ensure that the study remains focused and coherent, linking the theoretical concepts with the empirical findings.
In this case, integrating a relevant framework could help in aligning the study’s objectives with the data analysis process and in structuring the results in a way that directly addresses the research questions. This would also strengthen the study's overall validity by providing a consistent lens through which the findings are interpreted and discussed.

Response: Thanks for these excellent comments. This study was part of my PhD, which has a theoretical framework. It fully aligns with the overall objective of my PhD. However, due to limitations, we kept it to using information to measure the impact for MPDSR.

18- It would be helpful to avoid using acronyms such as DGHS and DGFP without first providing their full names. While acronyms are commonly used in technical documents, they can create confusion for readers who may not be familiar with them. To ensure clarity, I recommend spelling out the full names of these organizations at their first mention, followed by the acronym in parentheses

Response: Corrected.

19- It seems that the connection between the recommendations (in the result sections—Key recommendations for MPDSR ) and the research question could be made clearer. To strengthen this link, I suggest explicitly relating each recommendation to the specific aspects of the research question it addresses. This will help readers understand how the findings directly inform the recommendations and how they contribute to answering the research question.
Additionally, it would be useful to briefly describe the tools used for data collection and explain how they were chosen to address the research question. For example, were the in-depth interviews, surveys, or data from the MPDSR dashboard selected because they directly relate to specific components of the research question? This will provide more context for the recommendations and show how the data collection methods align with the study’s objectives.
It would be helpful to clarify that the recommendation for revising the National MPDSR guidelines was not previously identified as part of the gaps in the health system information. For instance, the suggestion to revise the guidelines to include stillbirth and align with new WHO standards seems crucial, but it wasn’t explicitly mentioned earlier in the paper as a gap in the MPDSR framework or health information system.
To strengthen the connection between the findings and the recommendations, I suggest explicitly linking this revision to the main objective of the paper, which is focused on maternal and perinatal death surveillance and response in Bangladesh. Highlighting that the absence of stillbirth inclusion in the MPDSR guidelines limits the effectiveness of maternal and perinatal death surveillance would provide more context for the need for revision.

Response: I appreciate your concerns, and I've taken your recommendations into account in this response. It's important to note that the revision of the MPDSR guideline was not identified as a gap since our focus was primarily on addressing the existing program's gaps through the current information systems that are in use. During discussions with health managers, they expressed that the outdated guideline is contributing to operational challenges within the program. This guideline was established when the country had not yet fully digitized its information systems.
The primary aim of this paper is to explore how information systems can assist managers in evidence-based planning using routine data. We chose to evaluate the MPDSR specifically in this context. However, it's worth mentioning that the health managers we interviewed provided recommendations that were quite comprehensive and aimed at improving the program more broadly. Thank you for your understanding.

DISCUSSION
20- Restructuring the results section using the previous comments would significantly enhance the overall structure of the discussion.

Response: Revised and adjusted as much as possible.

21- It seems that some of the results discussed in the paper, such as the identification of common actions to prevent maternal and perinatal deaths, may not be fully aligned with the overall objective of the study. The focus of the paper is on measuring impact through health information systems, specifically the maternal and perinatal death surveillance and response (MPDSR) system in Bangladesh.
While preventing maternal and perinatal deaths is certainly a key goal, it would be helpful to more explicitly connect these identified actions to how they relate to or are facilitated by the health information systems in place. For example, how do the actions to prevent deaths link to the effectiveness of the MPDSR system or the use of data from the system.

Response: The purpose of this study is to thoroughly investigate the role of information systems and their potential to improve the planning processes utilized by health managers. I have significantly revised the text to enhance its structure and clarity, ensuring that it effectively conveys the key concepts and findings. I greatly appreciate the detailed feedback provided, which has been instrumental in improving not only this paper but also future research projects in this field. This revision aims to provide deeper insights into how information systems can be leveraged for more efficient health management planning, ultimately contributing to better health outcomes. Thank you once again for your valuable input.
Competing Interests: No competing interests were disclosed. Close
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COMMENTS ON THIS REPORT

Author Response 18 Feb 2025

Abu Sadat Mohammad Sayem, University of Oslo, Oslo, Norway

18 Feb 2025

Author Response
ABSTRACT
1- “The health sector in Bangladesh is thriving, and the Maternal and Perinatal Death Surveillance and Response (MPDSR) program has been in place to investigate the causes of maternal ... Continue reading
ABSTRACT
1- “The health sector in Bangladesh is thriving, and the Maternal and Perinatal Death Surveillance and Response (MPDSR) program has been in place to investigate the causes of maternal and perinatal death. This study aimed to investigate the availability of information systems for measuring the status of an MPDSR program and the planning process and actions developed based on real-time information”

The first sentence show no link with health information system. Please review it accordingly to make it easy to understand the link with the second one.

Response: Thanks for this very important note. I have now changed to create a link with the information systems and MPDSR in the revised one. I have tried to remove unnecessary lines and focused more on the linkage between the information systems and programs.

2-"This study delved into innovative information systems that can be used to monitor and measure the impact of health programs"

Ok. But the link with the previous sentences still is missing.

Response: This study also revealed an innovative system to publishing MPDSR data in the website through a dashboard for health managers. I have revised the text to make a link.

INTRODUCTION
3-“ As a result, the health system’s quality of care has been enhanced by adopting tools such as Maternal and Perinatal Death Surveillance and Response (MPDSR), which the WHO and UNICEF recommend. “

Please, provide a reference “

Response: Sorry, we missed the reference, but it has now been provided. The reference was actually given in the later part and also was in the list of references at number 18. Thanks for this advice.

4"The adoption of DHIS2 has indeed been transformative for health information systems, as demonstrated by the example of Bangladesh. However, it is important to clarify that the adoption of DHIS2 in itself does not directly explain the adoption of MPDSR. While DHIS2 provides a robust platform for data management and analysis, MPDSR is a distinct initiative aimed at generating actionable information to improve the quality of care and strengthen the health system."

The justification provided, linking DHIS2 adoption to MPDSR adoption, may not fully capture the complexities and specific requirements of implementing MPDSR. Beyond the technical infrastructure, MPDSR requires a strong commitment to using the information generated to drive systemic improvements, which involves leadership, capacity building, and stakeholder engagement.
It would be more accurate to highlight how DHIS2 can serve as a supportive tool for MPDSR by facilitating the integration of MPDSR data into its platform. This integration can enhance the accessibility, analysis, and use of MPDSR data within broader health information systems, creating opportunities for more efficient monitoring and decision-making. Strengthening the justification in this way will better reflect the nuanced relationship between these two initiatives and the potential for synergy when MPDSR data is effectively integrated into DHIS2.

Response: I completely agree, and we tried to explore these facts through the qualitative part of the study. We examined how information systems, as a tool, helped the managers conduct meetings and planning workshops using the existing information. The text has been revised as well.

5-“The program notifies the death of the mother and newborn, followed by a death review to identify causes and develop a response to prevent future deaths.³”

I suggest to use the original reference of MPDSR:
- World Health Organization. Maternal Death Surveillance and Response: Technical Guidance Information for Action to Prevent Maternal Death. WHO; 2013.

- World Health Organization, Maternal and perinatal death surveillance and response: materials to support implementation. Geneva: World Health Organisation; 2021. Licence: CC BY-NC-SA 3.0 IGO.

Response: Corrected

6-"The data for the MPDSR were initially collected in papers—a group of professionals reviewed the document to identify the cause of death and associated factors."

Please, explain the type of data
Response: The data was both quantitative and qualitative. Designated field workers completed a questionnaire through interviews with the deceased family members, and a specialist in gynecology and pediatrics analyzed this data. I have also added this in that section. Its really good to explain.

7-"Globally, there was a 44% reduction in maternal deaths, from 532,000 in 1990 to 303,000 in 2015.⁵ In Bangladesh, the Maternal Mortality Ratio (MMR) declined between 2001 and 2010, but has now plateaued compared to 2016. Although progress has been impressive in the past, it is necessary to achieve Sustainable Development Goals in ending preventable maternal deaths through a renewed focus on accountability and actions.⁶^"
Reference: WHO, UNICEF, UNFPA, World Bank Group, United Nations Population Division: Trends in Maternal Mortality: 1990 to 2015. Geneva: WHO; 2015.

7a- Please, use more acurate reference in addition:

Suggestion: World Health Organization,Trends in maternal mortality 2000 to 2020: estimates by WHO, UNICEF, UNFPA, World Bank Group and UNDESA/Population Division. Geneva: World Health Organszation; 2023. Licence: CC BY-NC-SA 3.0 IGO.

Response: Revised accordingly with the reference.

7b- This passage does not integrate well with the preceding sections. Firstly, it is not automatic to attribute (even partly) the reduction or plateau in maternal mortality to the implementation of MPDSR or the health information system. While these initiatives may contribute to improvements, such trends are influenced by a wide range of factors, including broader health system reforms, socio-economic changes, and other interventions.
To ensure coherence and accuracy, it would be beneficial to clarify the multifactorial nature of maternal mortality trends and avoid implying a direct causal link between these specific initiatives and the observed changes. This would better align the passage with the broader context and provide a more balanced perspective.

Response: I agree entirely and appreciate this. I have added more words to explain the facts.

8-The National Core Management Information Systems (MIS) committee, chaired by the directorates, meets monthly to obtain feedback on technical issues and monitor data from all the districts.¹⁴ The platform has helped reduce the administrative burden on the health system, reducing silos, and streamlining processes within a national data warehouse. Within the MPDSR program, a community healthcare provider enters data related to the death of a mother or newborn at the grassroots level into the DHIS2. By contrast, healthcare managers at national and subnational levels can learn about an event in real time from the same platform.¹⁵ The final causes of death are determined at the divisional level by Gynecologists, Obstetricians, and Neonatologists based on death review forms, and that information is also entered into the DHIS2.¹⁶

The section provides a valuable overview of the MPDSR program and its integration with DHIS2. However, it would be helpful to elaborate further on how each component of the MPDSR—notification, review, and response—is operationalised within the specific context. For example:

Notification: Who is responsible for initiating the data entry at the grassroots level? What is the process for ensuring timely and accurate reporting?

Review: At what intervals are death review meetings conducted, and who participates in these discussions? How is the validation of data handled to ensure consistency and reliability?

Response: What mechanisms are in place to ensure that healthcare managers and other stakeholders at the national and subnational levels can access and act on the data? Are there specific timelines for integrating and disseminating data after entry into DHIS2?

Providing this additional detail will clarify how the MPDSR program functions within the system and enhance understanding of the roles, responsibilities, and workflows involved. This will also help illustrate how the program supports timely decision-making and accountability.

Response: I agree with this point, and I have revised the section to be more detailed on the three processes mentioned. This also came up in the other findings section.

9- "This study thoroughly analyzed the current information systems utilized in the MPDSR program to understand how they help health managers plan maternal and neonatal health. The study offers comprehensive insights into the functionality of the MPDSR dashboard in Bangladesh, along with a comparative analysis of the MPDSR information systems utilized in other countries for the purposes of effective planning. The qualitative interviews revealed significant gaps and barriers impeding evidence-based planning and action"

The justification for this study is valuable, as it highlights the importance of understanding how MPDSR information systems support maternal and neonatal health planning. However, to strengthen the rationale, it may be helpful to explicitly address the specific problem or gap that the study seeks to resolve. For instance:

What are the critical challenges in using MPDSR information systems for planning?

How do the identified gaps and barriers affect evidence-based decision-making and actions?

Why is it important to compare the MPDSR systems in Bangladesh with those in other countries, and how will this comparison contribute to addressing the challenges identified?

Clarifying these aspects will provide a stronger foundation for the study and better communicate its relevance and potential impact.

Response: This is a great comment, and I have organized the content in a more systematic way. I revised it while considering the word limit. Some sentences were moved to other sections to incorporate all points clearly.

METHODS
10- Overall comments
The explanation of the study’s methodology is clear, but the terminology could be refined to better reflect standard practices in mixed-methods research. Specifically, it may be more accurate to refer to the qualitative and quantitative strands or data rather than describing them as primary and secondary data. This distinction is important because mixed-methods research typically involves integrating qualitative and quantitative approaches, each of which may include both primary and secondary data sources.
Here are some ideas:
"The study used a mixed-methods approach to understand the given research problem. Mixed-methods research has emerged as a major methodological approach across the social sciences, often regarded as a third paradigm alongside qualitative and quantitative research.17 The study integrated qualitative and quantitative strands, collecting and analysing data from both approaches to provide a comprehensive understanding of the research problem."
This revision ensures clarity and aligns with widely accepted terminology in mixed-methods research.

Response: Corrected accordingly. The method here was a bit different, as the study mainly captured the evolving transformation of information systems and how this helped the managers efficiently plan based on the information system.

11- "Key Informant Interviews (KII) were conducted in 2021 using a standardized guideline as part of the primary data collection to complement the findings of the secondary data.²⁵ The KII guidelines were provided by the author. It was pilot-tested before the interview."

11a- Please, describe a little bit the guideline.
Specify which author in this section.

Response: Provided

11b- Your explanation of the study's mixed-methods approach is clear, but the structure could be improved by grouping all information related to the qualitative and quantitative strands. Additionally, it would be helpful to specify, for each type of data collected, the tools used, who collected the data, and how it was collected.
For instance:

For the qualitative strand, you could detail the use of in-depth interviews, specify the target participants (e.g., healthcare providers, health managers, policymakers), describe the interview guide, and mention how the interviews were conducted and analysed.

For the quantitative strand, you could explain the data sources (e.g., MPDSR dashboards), the type of data extracted, the tools or protocols used for data collection, and the personnel responsible for this process.

Response: Done

12- Data analysis
12a- Quantitative data on death notifications were also analyzed in a Microsoft Excel (Version 2308) spreadsheet, shown in the Figures 2,3 and 4.

The figures should be in the result section.

Response: Agreed and revised accordingly.

12b- It is not entirely clear from the document how the data analysis was conducted. To improve clarity, it would be helpful to provide more specific information on the analysis process for each strand of data, immediately following the data collection description. For example:

For the qualitative strand, after the data collection through in-depth interviews, the analysis involved thematic coding to identify key themes and patterns. The data were transcribed verbatim and then coded manually or using qualitative data analysis software (e.g., NVivo). Thematic analysis was employed to categorize the data into meaningful themes, which were then examined to understand the barriers and facilitators of MPDSR implementation. The findings were interpreted by the research team to ensure consistency and validity.

For the quantitative strand, after data collection from MPDSR dashboards and health records, the data were cleaned and processed to ensure accuracy and completeness. Descriptive statistics were used to summarise the data, and any trends or patterns were identified through statistical tests (e.g., chi-square, regression analysis). The data were analysed using statistical software (e.g., SPSS, STATA) to determine the frequency, timeliness, and completeness of data entry and reporting. The analysis also helped identify gaps in the system that may hinder effective use of MPDSR data.

Response: Thanks for detailing this section. I have included your recommendations and revised it accordingly to enhance it reader-friendly.

RESULTS
13- It would be helpful to provide a more detailed explanation of how the MPDSR dashboard works, especially in terms of its real-time functionality and its role in monitoring. Maybe in the method sections, It could also be in the result section. For example, you could clarify the following points:

How is the data from the MPDSR system integrated into the dashboard in real-time?

What types of data are displayed on the dashboard (e.g., maternal deaths, causes of death, response actions)?

How are the data updated and verified to ensure their accuracy and timeliness?

Who is responsible for monitoring the dashboard and how do they use the information to drive decision-making at the national and district levels?

How does the Ministry of Health (MOH) use the dashboard for monthly monitoring? Are there specific performance indicators or thresholds that are tracked?

Response: All points above are integrated. Thanks for this very comprehensive feedback. This section was removed due to word limitations.

14-Some result parts sound like discussion, not result. Please check and address in the whole document.
Examples
“This indicates the need for health workers to visit the deceased mother’s home to increase notifications and review the cause of death”
"According to the national MPDSR guidelines, it is recommended that 10% of neonatal deaths be reviewed to determine the causes of death and to identify social barriers. However, the performance of neonatal death surveillance in capture
We attempted to examine how the performance of MPDSR could be evaluated using data from the dashboard"

Response: Agreed. Corrected accordingly.

15- " Facility maternal deaths are notified and reviewed, with much better performance compared to community MPDSR. 76% of the cases were reviewed at the facility"
It would be beneficial to provide a more detailed explanation of how MPDSR functions in the context of both facility and community maternal deaths. Specifically, it would be helpful to clarify the following points:

Identification and Notification: Who is responsible for identifying and notifying maternal deaths at the community level? Are community health workers or other local healthcare providers responsible for this task? How are these deaths reported, and what is the process for ensuring timely notification?

Review Process: How are community maternal deaths reviewed, and who participates in these reviews? Are there specific teams or committees involved, and what is their role in the process? How does the review process differ between facility and community deaths?

Response: Described in that section to further clarify.

16- It seems that the three-delay model is introduced in the results section without prior mention or explanation in the methodology or background sections. To ensure clarity and coherence, it would be helpful to briefly introduce the model earlier in the paper, ideally in the background or theoretical framework section. This would provide the reader with context before it is referenced in the results.

Response: This has been removed as this is not related to the findings to Corelate. It has created a confusion as it was not described before.

17 - It would be beneficial to incorporate a theoretical framework to guide the study. This framework would provide a clear line of connection between the research questions, the tools used for data collection and analysis, and the structuring of the results. A well-defined framework helps to ensure that the study remains focused and coherent, linking the theoretical concepts with the empirical findings.
In this case, integrating a relevant framework could help in aligning the study’s objectives with the data analysis process and in structuring the results in a way that directly addresses the research questions. This would also strengthen the study's overall validity by providing a consistent lens through which the findings are interpreted and discussed.

Response: Thanks for these excellent comments. This study was part of my PhD, which has a theoretical framework. It fully aligns with the overall objective of my PhD. However, due to limitations, we kept it to using information to measure the impact for MPDSR.

18- It would be helpful to avoid using acronyms such as DGHS and DGFP without first providing their full names. While acronyms are commonly used in technical documents, they can create confusion for readers who may not be familiar with them. To ensure clarity, I recommend spelling out the full names of these organizations at their first mention, followed by the acronym in parentheses

Response: Corrected.

19- It seems that the connection between the recommendations (in the result sections—Key recommendations for MPDSR ) and the research question could be made clearer. To strengthen this link, I suggest explicitly relating each recommendation to the specific aspects of the research question it addresses. This will help readers understand how the findings directly inform the recommendations and how they contribute to answering the research question.
Additionally, it would be useful to briefly describe the tools used for data collection and explain how they were chosen to address the research question. For example, were the in-depth interviews, surveys, or data from the MPDSR dashboard selected because they directly relate to specific components of the research question? This will provide more context for the recommendations and show how the data collection methods align with the study’s objectives.
It would be helpful to clarify that the recommendation for revising the National MPDSR guidelines was not previously identified as part of the gaps in the health system information. For instance, the suggestion to revise the guidelines to include stillbirth and align with new WHO standards seems crucial, but it wasn’t explicitly mentioned earlier in the paper as a gap in the MPDSR framework or health information system.
To strengthen the connection between the findings and the recommendations, I suggest explicitly linking this revision to the main objective of the paper, which is focused on maternal and perinatal death surveillance and response in Bangladesh. Highlighting that the absence of stillbirth inclusion in the MPDSR guidelines limits the effectiveness of maternal and perinatal death surveillance would provide more context for the need for revision.

Response: I appreciate your concerns, and I've taken your recommendations into account in this response. It's important to note that the revision of the MPDSR guideline was not identified as a gap since our focus was primarily on addressing the existing program's gaps through the current information systems that are in use. During discussions with health managers, they expressed that the outdated guideline is contributing to operational challenges within the program. This guideline was established when the country had not yet fully digitized its information systems.
The primary aim of this paper is to explore how information systems can assist managers in evidence-based planning using routine data. We chose to evaluate the MPDSR specifically in this context. However, it's worth mentioning that the health managers we interviewed provided recommendations that were quite comprehensive and aimed at improving the program more broadly. Thank you for your understanding.

DISCUSSION
20- Restructuring the results section using the previous comments would significantly enhance the overall structure of the discussion.

Response: Revised and adjusted as much as possible.

21- It seems that some of the results discussed in the paper, such as the identification of common actions to prevent maternal and perinatal deaths, may not be fully aligned with the overall objective of the study. The focus of the paper is on measuring impact through health information systems, specifically the maternal and perinatal death surveillance and response (MPDSR) system in Bangladesh.
While preventing maternal and perinatal deaths is certainly a key goal, it would be helpful to more explicitly connect these identified actions to how they relate to or are facilitated by the health information systems in place. For example, how do the actions to prevent deaths link to the effectiveness of the MPDSR system or the use of data from the system.

Response: The purpose of this study is to thoroughly investigate the role of information systems and their potential to improve the planning processes utilized by health managers. I have significantly revised the text to enhance its structure and clarity, ensuring that it effectively conveys the key concepts and findings. I greatly appreciate the detailed feedback provided, which has been instrumental in improving not only this paper but also future research projects in this field. This revision aims to provide deeper insights into how information systems can be leveraged for more efficient health management planning, ultimately contributing to better health outcomes. Thank you once again for your valuable input.
ABSTRACT
1- “The health sector in Bangladesh is thriving, and the Maternal and Perinatal Death Surveillance and Response (MPDSR) program has been in place to investigate the causes of maternal and perinatal death. This study aimed to investigate the availability of information systems for measuring the status of an MPDSR program and the planning process and actions developed based on real-time information”

The first sentence show no link with health information system. Please review it accordingly to make it easy to understand the link with the second one.

Response: Thanks for this very important note. I have now changed to create a link with the information systems and MPDSR in the revised one. I have tried to remove unnecessary lines and focused more on the linkage between the information systems and programs.

2-"This study delved into innovative information systems that can be used to monitor and measure the impact of health programs"

Ok. But the link with the previous sentences still is missing.

Response: This study also revealed an innovative system to publishing MPDSR data in the website through a dashboard for health managers. I have revised the text to make a link.

INTRODUCTION
3-“ As a result, the health system’s quality of care has been enhanced by adopting tools such as Maternal and Perinatal Death Surveillance and Response (MPDSR), which the WHO and UNICEF recommend. “

Please, provide a reference “

Response: Sorry, we missed the reference, but it has now been provided. The reference was actually given in the later part and also was in the list of references at number 18. Thanks for this advice.

4"The adoption of DHIS2 has indeed been transformative for health information systems, as demonstrated by the example of Bangladesh. However, it is important to clarify that the adoption of DHIS2 in itself does not directly explain the adoption of MPDSR. While DHIS2 provides a robust platform for data management and analysis, MPDSR is a distinct initiative aimed at generating actionable information to improve the quality of care and strengthen the health system."

The justification provided, linking DHIS2 adoption to MPDSR adoption, may not fully capture the complexities and specific requirements of implementing MPDSR. Beyond the technical infrastructure, MPDSR requires a strong commitment to using the information generated to drive systemic improvements, which involves leadership, capacity building, and stakeholder engagement.
It would be more accurate to highlight how DHIS2 can serve as a supportive tool for MPDSR by facilitating the integration of MPDSR data into its platform. This integration can enhance the accessibility, analysis, and use of MPDSR data within broader health information systems, creating opportunities for more efficient monitoring and decision-making. Strengthening the justification in this way will better reflect the nuanced relationship between these two initiatives and the potential for synergy when MPDSR data is effectively integrated into DHIS2.

Response: I completely agree, and we tried to explore these facts through the qualitative part of the study. We examined how information systems, as a tool, helped the managers conduct meetings and planning workshops using the existing information. The text has been revised as well.

5-“The program notifies the death of the mother and newborn, followed by a death review to identify causes and develop a response to prevent future deaths.³”

I suggest to use the original reference of MPDSR:
- World Health Organization. Maternal Death Surveillance and Response: Technical Guidance Information for Action to Prevent Maternal Death. WHO; 2013.

- World Health Organization, Maternal and perinatal death surveillance and response: materials to support implementation. Geneva: World Health Organisation; 2021. Licence: CC BY-NC-SA 3.0 IGO.

Response: Corrected

6-"The data for the MPDSR were initially collected in papers—a group of professionals reviewed the document to identify the cause of death and associated factors."

Please, explain the type of data
Response: The data was both quantitative and qualitative. Designated field workers completed a questionnaire through interviews with the deceased family members, and a specialist in gynecology and pediatrics analyzed this data. I have also added this in that section. Its really good to explain.

7-"Globally, there was a 44% reduction in maternal deaths, from 532,000 in 1990 to 303,000 in 2015.⁵ In Bangladesh, the Maternal Mortality Ratio (MMR) declined between 2001 and 2010, but has now plateaued compared to 2016. Although progress has been impressive in the past, it is necessary to achieve Sustainable Development Goals in ending preventable maternal deaths through a renewed focus on accountability and actions.⁶^"
Reference: WHO, UNICEF, UNFPA, World Bank Group, United Nations Population Division: Trends in Maternal Mortality: 1990 to 2015. Geneva: WHO; 2015.

7a- Please, use more acurate reference in addition:

Suggestion: World Health Organization,Trends in maternal mortality 2000 to 2020: estimates by WHO, UNICEF, UNFPA, World Bank Group and UNDESA/Population Division. Geneva: World Health Organszation; 2023. Licence: CC BY-NC-SA 3.0 IGO.

Response: Revised accordingly with the reference.

7b- This passage does not integrate well with the preceding sections. Firstly, it is not automatic to attribute (even partly) the reduction or plateau in maternal mortality to the implementation of MPDSR or the health information system. While these initiatives may contribute to improvements, such trends are influenced by a wide range of factors, including broader health system reforms, socio-economic changes, and other interventions.
To ensure coherence and accuracy, it would be beneficial to clarify the multifactorial nature of maternal mortality trends and avoid implying a direct causal link between these specific initiatives and the observed changes. This would better align the passage with the broader context and provide a more balanced perspective.

Response: I agree entirely and appreciate this. I have added more words to explain the facts.

8-The National Core Management Information Systems (MIS) committee, chaired by the directorates, meets monthly to obtain feedback on technical issues and monitor data from all the districts.¹⁴ The platform has helped reduce the administrative burden on the health system, reducing silos, and streamlining processes within a national data warehouse. Within the MPDSR program, a community healthcare provider enters data related to the death of a mother or newborn at the grassroots level into the DHIS2. By contrast, healthcare managers at national and subnational levels can learn about an event in real time from the same platform.¹⁵ The final causes of death are determined at the divisional level by Gynecologists, Obstetricians, and Neonatologists based on death review forms, and that information is also entered into the DHIS2.¹⁶

The section provides a valuable overview of the MPDSR program and its integration with DHIS2. However, it would be helpful to elaborate further on how each component of the MPDSR—notification, review, and response—is operationalised within the specific context. For example:

Notification: Who is responsible for initiating the data entry at the grassroots level? What is the process for ensuring timely and accurate reporting?

Review: At what intervals are death review meetings conducted, and who participates in these discussions? How is the validation of data handled to ensure consistency and reliability?

Response: What mechanisms are in place to ensure that healthcare managers and other stakeholders at the national and subnational levels can access and act on the data? Are there specific timelines for integrating and disseminating data after entry into DHIS2?

Providing this additional detail will clarify how the MPDSR program functions within the system and enhance understanding of the roles, responsibilities, and workflows involved. This will also help illustrate how the program supports timely decision-making and accountability.

Response: I agree with this point, and I have revised the section to be more detailed on the three processes mentioned. This also came up in the other findings section.

9- "This study thoroughly analyzed the current information systems utilized in the MPDSR program to understand how they help health managers plan maternal and neonatal health. The study offers comprehensive insights into the functionality of the MPDSR dashboard in Bangladesh, along with a comparative analysis of the MPDSR information systems utilized in other countries for the purposes of effective planning. The qualitative interviews revealed significant gaps and barriers impeding evidence-based planning and action"

The justification for this study is valuable, as it highlights the importance of understanding how MPDSR information systems support maternal and neonatal health planning. However, to strengthen the rationale, it may be helpful to explicitly address the specific problem or gap that the study seeks to resolve. For instance:

What are the critical challenges in using MPDSR information systems for planning?

How do the identified gaps and barriers affect evidence-based decision-making and actions?

Why is it important to compare the MPDSR systems in Bangladesh with those in other countries, and how will this comparison contribute to addressing the challenges identified?

Clarifying these aspects will provide a stronger foundation for the study and better communicate its relevance and potential impact.

Response: This is a great comment, and I have organized the content in a more systematic way. I revised it while considering the word limit. Some sentences were moved to other sections to incorporate all points clearly.

METHODS
10- Overall comments
The explanation of the study’s methodology is clear, but the terminology could be refined to better reflect standard practices in mixed-methods research. Specifically, it may be more accurate to refer to the qualitative and quantitative strands or data rather than describing them as primary and secondary data. This distinction is important because mixed-methods research typically involves integrating qualitative and quantitative approaches, each of which may include both primary and secondary data sources.
Here are some ideas:
"The study used a mixed-methods approach to understand the given research problem. Mixed-methods research has emerged as a major methodological approach across the social sciences, often regarded as a third paradigm alongside qualitative and quantitative research.17 The study integrated qualitative and quantitative strands, collecting and analysing data from both approaches to provide a comprehensive understanding of the research problem."
This revision ensures clarity and aligns with widely accepted terminology in mixed-methods research.

Response: Corrected accordingly. The method here was a bit different, as the study mainly captured the evolving transformation of information systems and how this helped the managers efficiently plan based on the information system.

11- "Key Informant Interviews (KII) were conducted in 2021 using a standardized guideline as part of the primary data collection to complement the findings of the secondary data.²⁵ The KII guidelines were provided by the author. It was pilot-tested before the interview."

11a- Please, describe a little bit the guideline.
Specify which author in this section.

Response: Provided

11b- Your explanation of the study's mixed-methods approach is clear, but the structure could be improved by grouping all information related to the qualitative and quantitative strands. Additionally, it would be helpful to specify, for each type of data collected, the tools used, who collected the data, and how it was collected.
For instance:

For the qualitative strand, you could detail the use of in-depth interviews, specify the target participants (e.g., healthcare providers, health managers, policymakers), describe the interview guide, and mention how the interviews were conducted and analysed.

For the quantitative strand, you could explain the data sources (e.g., MPDSR dashboards), the type of data extracted, the tools or protocols used for data collection, and the personnel responsible for this process.

Response: Done

12- Data analysis
12a- Quantitative data on death notifications were also analyzed in a Microsoft Excel (Version 2308) spreadsheet, shown in the Figures 2,3 and 4.

The figures should be in the result section.

Response: Agreed and revised accordingly.

12b- It is not entirely clear from the document how the data analysis was conducted. To improve clarity, it would be helpful to provide more specific information on the analysis process for each strand of data, immediately following the data collection description. For example:

For the qualitative strand, after the data collection through in-depth interviews, the analysis involved thematic coding to identify key themes and patterns. The data were transcribed verbatim and then coded manually or using qualitative data analysis software (e.g., NVivo). Thematic analysis was employed to categorize the data into meaningful themes, which were then examined to understand the barriers and facilitators of MPDSR implementation. The findings were interpreted by the research team to ensure consistency and validity.

For the quantitative strand, after data collection from MPDSR dashboards and health records, the data were cleaned and processed to ensure accuracy and completeness. Descriptive statistics were used to summarise the data, and any trends or patterns were identified through statistical tests (e.g., chi-square, regression analysis). The data were analysed using statistical software (e.g., SPSS, STATA) to determine the frequency, timeliness, and completeness of data entry and reporting. The analysis also helped identify gaps in the system that may hinder effective use of MPDSR data.

Response: Thanks for detailing this section. I have included your recommendations and revised it accordingly to enhance it reader-friendly.

RESULTS
13- It would be helpful to provide a more detailed explanation of how the MPDSR dashboard works, especially in terms of its real-time functionality and its role in monitoring. Maybe in the method sections, It could also be in the result section. For example, you could clarify the following points:

How is the data from the MPDSR system integrated into the dashboard in real-time?

What types of data are displayed on the dashboard (e.g., maternal deaths, causes of death, response actions)?

How are the data updated and verified to ensure their accuracy and timeliness?

Who is responsible for monitoring the dashboard and how do they use the information to drive decision-making at the national and district levels?

How does the Ministry of Health (MOH) use the dashboard for monthly monitoring? Are there specific performance indicators or thresholds that are tracked?

Response: All points above are integrated. Thanks for this very comprehensive feedback. This section was removed due to word limitations.

14-Some result parts sound like discussion, not result. Please check and address in the whole document.
Examples
“This indicates the need for health workers to visit the deceased mother’s home to increase notifications and review the cause of death”
"According to the national MPDSR guidelines, it is recommended that 10% of neonatal deaths be reviewed to determine the causes of death and to identify social barriers. However, the performance of neonatal death surveillance in capture
We attempted to examine how the performance of MPDSR could be evaluated using data from the dashboard"

Response: Agreed. Corrected accordingly.

15- " Facility maternal deaths are notified and reviewed, with much better performance compared to community MPDSR. 76% of the cases were reviewed at the facility"
It would be beneficial to provide a more detailed explanation of how MPDSR functions in the context of both facility and community maternal deaths. Specifically, it would be helpful to clarify the following points:

Identification and Notification: Who is responsible for identifying and notifying maternal deaths at the community level? Are community health workers or other local healthcare providers responsible for this task? How are these deaths reported, and what is the process for ensuring timely notification?

Review Process: How are community maternal deaths reviewed, and who participates in these reviews? Are there specific teams or committees involved, and what is their role in the process? How does the review process differ between facility and community deaths?

Response: Described in that section to further clarify.

16- It seems that the three-delay model is introduced in the results section without prior mention or explanation in the methodology or background sections. To ensure clarity and coherence, it would be helpful to briefly introduce the model earlier in the paper, ideally in the background or theoretical framework section. This would provide the reader with context before it is referenced in the results.

Response: This has been removed as this is not related to the findings to Corelate. It has created a confusion as it was not described before.

17 - It would be beneficial to incorporate a theoretical framework to guide the study. This framework would provide a clear line of connection between the research questions, the tools used for data collection and analysis, and the structuring of the results. A well-defined framework helps to ensure that the study remains focused and coherent, linking the theoretical concepts with the empirical findings.
In this case, integrating a relevant framework could help in aligning the study’s objectives with the data analysis process and in structuring the results in a way that directly addresses the research questions. This would also strengthen the study's overall validity by providing a consistent lens through which the findings are interpreted and discussed.

Response: Thanks for these excellent comments. This study was part of my PhD, which has a theoretical framework. It fully aligns with the overall objective of my PhD. However, due to limitations, we kept it to using information to measure the impact for MPDSR.

18- It would be helpful to avoid using acronyms such as DGHS and DGFP without first providing their full names. While acronyms are commonly used in technical documents, they can create confusion for readers who may not be familiar with them. To ensure clarity, I recommend spelling out the full names of these organizations at their first mention, followed by the acronym in parentheses

Response: Corrected.

19- It seems that the connection between the recommendations (in the result sections—Key recommendations for MPDSR ) and the research question could be made clearer. To strengthen this link, I suggest explicitly relating each recommendation to the specific aspects of the research question it addresses. This will help readers understand how the findings directly inform the recommendations and how they contribute to answering the research question.
Additionally, it would be useful to briefly describe the tools used for data collection and explain how they were chosen to address the research question. For example, were the in-depth interviews, surveys, or data from the MPDSR dashboard selected because they directly relate to specific components of the research question? This will provide more context for the recommendations and show how the data collection methods align with the study’s objectives.
It would be helpful to clarify that the recommendation for revising the National MPDSR guidelines was not previously identified as part of the gaps in the health system information. For instance, the suggestion to revise the guidelines to include stillbirth and align with new WHO standards seems crucial, but it wasn’t explicitly mentioned earlier in the paper as a gap in the MPDSR framework or health information system.
To strengthen the connection between the findings and the recommendations, I suggest explicitly linking this revision to the main objective of the paper, which is focused on maternal and perinatal death surveillance and response in Bangladesh. Highlighting that the absence of stillbirth inclusion in the MPDSR guidelines limits the effectiveness of maternal and perinatal death surveillance would provide more context for the need for revision.

Response: I appreciate your concerns, and I've taken your recommendations into account in this response. It's important to note that the revision of the MPDSR guideline was not identified as a gap since our focus was primarily on addressing the existing program's gaps through the current information systems that are in use. During discussions with health managers, they expressed that the outdated guideline is contributing to operational challenges within the program. This guideline was established when the country had not yet fully digitized its information systems.
The primary aim of this paper is to explore how information systems can assist managers in evidence-based planning using routine data. We chose to evaluate the MPDSR specifically in this context. However, it's worth mentioning that the health managers we interviewed provided recommendations that were quite comprehensive and aimed at improving the program more broadly. Thank you for your understanding.

DISCUSSION
20- Restructuring the results section using the previous comments would significantly enhance the overall structure of the discussion.

Response: Revised and adjusted as much as possible.

21- It seems that some of the results discussed in the paper, such as the identification of common actions to prevent maternal and perinatal deaths, may not be fully aligned with the overall objective of the study. The focus of the paper is on measuring impact through health information systems, specifically the maternal and perinatal death surveillance and response (MPDSR) system in Bangladesh.
While preventing maternal and perinatal deaths is certainly a key goal, it would be helpful to more explicitly connect these identified actions to how they relate to or are facilitated by the health information systems in place. For example, how do the actions to prevent deaths link to the effectiveness of the MPDSR system or the use of data from the system.

Response: The purpose of this study is to thoroughly investigate the role of information systems and their potential to improve the planning processes utilized by health managers. I have significantly revised the text to enhance its structure and clarity, ensuring that it effectively conveys the key concepts and findings. I greatly appreciate the detailed feedback provided, which has been instrumental in improving not only this paper but also future research projects in this field. This revision aims to provide deeper insights into how information systems can be leveraged for more efficient health management planning, ultimately contributing to better health outcomes. Thank you once again for your valuable input.
Competing Interests: No competing interests were disclosed. Close
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Reviewer Report 21 Nov 2024

Theresa Diaz, Department of Maternal, Newborn, Child, Adolescent Health and Ageing,, World Health Organization, Geneva, Switzerland

Not Approved

https://doi.org/10.5256/f1000research.174178.r338439

This is an extremely important topic, however, as written is quite confusing without an overall diagram explaining how the entire system is supposed to work, it is difficult to understand this paper. I know MDPSR well but as written I could not understand how it is supposed to function in Bangladesh. I found the order of paragraphs could be changed and that there are some mixings of methods in results, results in methods and discussion in results and these should be fixed. There should be a separate section on analysis to understand how all these mixed methods are brought together.

Additionally, I have highlighted issues and provided some possible solutions

Although all the information is in the introduction I find the order and presentation a bit confusing.

I would first start with maternal death data and please update it with the latest estimates from 2020
Then I would explain what MPDSR is and how it is suppose to work in Bangladesh
Finally I would explain DHIS2 followed by the current information system in Bangladesh
Then the specific objectives of the study

Is the background of the case’s history and progression described in sufficient detail?

No
Is the work clearly and accurately presented and does it cite the current literature?

Partly
If applicable, is the statistical analysis and its interpretation appropriate?

Partly
Are all the source data underlying the results available to ensure full reproducibility?

Partly
Are the conclusions drawn adequately supported by the results?

Partly
Is the case presented with sufficient detail to be useful for teaching or other practitioners?

Partly

Competing Interests: No competing interests were disclosed.

Reviewer Expertise: Epidemiology and Monitoring and Evaluation

I confirm that I have read this submission and believe that I have an appropriate level of expertise to state that I do not consider it to be of an acceptable scientific standard, for reasons outlined above.

CITE

Report a concern

Author Response 18 Feb 2025

Abu Sadat Mohammad Sayem, University of Oslo, Oslo, Norway

18 Feb 2025

Author Response
Reviewer Comments:
This is an extremely important topic, however, as written is quite confusing without an overall diagram explaining how the entire system is supposed to work, it is difficult ... Continue reading
Reviewer Comments:
This is an extremely important topic, however, as written is quite confusing without an overall diagram explaining how the entire system is supposed to work, it is difficult to understand this paper. I know MDPSR well but as written I could not understand how it is supposed to function in Bangladesh. I found the order of paragraphs could be changed and that there are some mixings of methods in results, results in methods and discussion in results and these should be fixed. There should be a separate section on analysis to understand how all these mixed methods are brought together.

Response: Thanks for the suggestion. I am adding an diagram in the introduction section

Reviewer Comments:
Additionally, I have highlighted issues and provided some possible solutions

Although all the information is in the introduction I find the order and presentation a bit confusing.

I would first start with maternal death data and please update it with the latest estimates from 2020

Then I would explain what MPDSR is and how it is suppose to work in Bangladesh

Finally I would explain DHIS2 followed by the current information system in Bangladesh

Then the specific objectives of the study

The objectives of the study listed in the last paragraph are vague. It is unclear as to why you need this study and what are the specific objectives.
You wrote page 3 para 7
“This study thoroughly analyzed the current information systems utilized in the MPDSR program to understand how they help. The study offers comprehensive insights into the functionality of the MPDSR dashboard in Bangladesh, along with a comparative analysis of the MPDSR information systems utilized in other countries for the purposes of effective planning. The qualitative interviews revealed significant gaps and barriers impeding evidence-based planning and action”

I think something like this instead might be helpful
Although MPDSR reporting has been incorporated into DHIS2 in Bangladesh we do not know how effective this has been to assist health managers plan for maternal and neonatal health programs. Using a mix method approach of data from 2019 to 2021 we examined the how this inclusion of MPDSR findings into DHIS2 was used to report deaths, inform program reviews, create MDSPR action plans and link to outcomes on key indicators. Additionally, we collected recommendations for improving the MDPSR program.

Response: This is great feedback, and I have tried to incorporate all of it in my way to keep the objective aligned with the research question.

Reviewer Comments:
Methods
The research question is not clear, please see my suggestion to refine the research question but you also need to state the specific objectives in the first paragraph. Not just say to “understand the given research problem”.

The methods or introduction should include a diagram as to who the current system works is supposed to work so we can better understand the results.

Response: I have revised it accordingly.

Reviewer Comments:
Page 4 para 3
A thematic analysis is not part of primary data collection but rather analysis. Please mention any software that might have been used to do this analysis. Please create a separate section in methods that is just analysis and how the mixed methods were brought together.

Response: I have not used software like NVIVO for thematic analysis. This was done based on the interviews and the emerging discussion points to organize it into different themes. I am added few lines in the method section.

Reviewer Comments:
Page 4 para 2
Similarly in Secondary data collection you mix the data collection with the analysis and it becomes confusing for example for public health websites you discuss using baseline 2019 data compared with 2021 from the score card but exactly what was compared and how statistically?
But I don’t understand what were the analysis methods used?

Response: The MPDSR dashboard includes various indicators, such as ANC and PNC coverage, which were compared between 2019 and 2021. This was a descriptive statistical analysis of the dashboard findings on MPDSR.

Reviewer Comments:
Page 4, para 3
Similarly, this belongs in an analysis section of methods
“Frequency analysis was used for MPDSR key actions in the seven districts and presented in a tabulated form. Quantitative data on death notifications were also analyzed in a Microsoft Excel (Version 2308) spreadsheet, shown in the Figures 2,3 and 4”

Response: We listed the interventions planned in the MPDSR action plans and analyzed the frequency of activities that were planned in most of the districts, highlighting the common actions based on the information available in the DHIS2. This analysis provides an impression of whether the information was used for planning, as the actions are linked to the reported number of deaths and causes of death.

Reviewer Comments:
Results
Overall, it is hard to understand what data sources were used for each research question and how each finding links to your original research questions. Also this section includes only results but some of the aspects written in this section should be in methods or introduction or discussion.
For example, suddenly you mention that Bangladesh is one of the few countries uses real time MPSDR data through a dashboard. That should have been mentioned in the introduction.

Then you add a method “The study team examined data to measure performance in 27 districts
and identify gaps in information system” These methods. Also the statement is vague, examine what data? To measure what performance, based on what measure?

Response: While inquiring about the data, the MOH directed us to the available dashboard where we could download the information. The team accessed the MPDSR dashboard to retrieve performance indicators such as death notification rates, death review rates, and other metrics like ANC and PNC coverage to evaluate district performance. This exercise was conducted for 27 districts.

Reviewer Comments:
Page 8 para 2
You don’t describe in methods how you would statistically determine an association.
“This study reviewed the scorecard of the MPDSR program and found that its key performance indicators were linked with maternal and neonatal mortality rates. The program’s performance dashboard can visualize its impact based on surveys and routine data. Most indicators showed positive changes, except in the Bandarban and Gazipur districts, where mortality and service coverage decreased. Pregnancy registration, delivery antenatal 4th visits coverage, and postnatal care increased in Jamalpur and Maulvibazar, where the impact of reducing MMR was the highest. The data were subject to verification but could be discussed during the MPDSR meetings”
Table 3 shows you results by district with no information as to what was happening with the MDSPR during these years, but to link the two you need to include this in the table how many MSDPR reviews occurred in each district in which years and what actions were actually taken up. All you are showing it the dashboard, the changes overtime could have occurred for many reasons other than MPDSR.

Response: Thank you again for critically examining this data. We had several discussions with the team on this topic, and we ultimately agreed to document our findings from the study. I understand that some of the findings were vague, but it is true that there was no further information on those issues, and the study faced limitations in further investigating the districts with higher mortality rates. However, we provided an analysis of the overall reporting performance of the MPDSR at the start, including the rate of death notifications and a review of those districts. Then, we attempted to review the MPDSR action plans to understand their strategies and their connection to the existing information. I acknowledge that many factors impacted the MMR and NMR, but the aim of the study was to determine whether the information was being utilized and to assess the dashboard's effectiveness in measuring what is happening.

Reviewer Comments:
Key recommendations
These findings are from the qualitative component key informant interviews, correct? Or are you putting some conclusions here?
Again it is confusing

Response: The recommendation came from the interview and I just mentioned what they mentioned during the interview. We are not trying any conclusion. But based on your advice, we are revising the language, which has created confusion.

Reviewer Comments:
Discussion
I could better understand the dashboards if I had a better explanation on how the overall system works. I am finding it confusing to know when the dashboards come into the process. Perhaps a diagram earlier on in methods would have helped.

Para 1 page 12
“The Southeast Asia region WHO report revealed that out of 10 countries, only three hold national-level meetings twice early on MPDSR committees. In Bangladesh, health managers recommend that the government and partners collaborate to implement the MPDSR and establish accountability and laws for death notification”
Without a explanation or diagram on how the system should work in Bangladesh, including frequency of meetings, this recommendation from Bangladesh is very vague. What is even the point of this paragraph if you do not mention the frequency in Bangladesh.

For example Page 11 para 8
In Bandarban, a hilly terrain, the interventions listed in the plan did not work out, and as per the scorecard, the MMR went up. The managers mentioned conducting video conferences to monitor progress regularly and to improve health managers’ accountability”
Was this ever mentioned in the results?
Not sure that the poor documentation mentioned in the discussion was highlighted in the results section

Response: I completely agree, but there were few papers on the MPDSR information system, including a dashboard. We tried to link other papers related to this study. There is definitely future scope to have more papers on MPDSR information systems and their impact. We have revised the points that you mentioned above.

Reviewer Comments:
Conclusion
Until the specific objectives and methods and results are re written it is hard to tell if these conclusions are linked to the findings.

Response: We have revised it completely.
Reviewer Comments:
This is an extremely important topic, however, as written is quite confusing without an overall diagram explaining how the entire system is supposed to work, it is difficult to understand this paper. I know MDPSR well but as written I could not understand how it is supposed to function in Bangladesh. I found the order of paragraphs could be changed and that there are some mixings of methods in results, results in methods and discussion in results and these should be fixed. There should be a separate section on analysis to understand how all these mixed methods are brought together.

Response: Thanks for the suggestion. I am adding an diagram in the introduction section

Reviewer Comments:
Additionally, I have highlighted issues and provided some possible solutions

Although all the information is in the introduction I find the order and presentation a bit confusing.

I would first start with maternal death data and please update it with the latest estimates from 2020

Then I would explain what MPDSR is and how it is suppose to work in Bangladesh

Finally I would explain DHIS2 followed by the current information system in Bangladesh

Then the specific objectives of the study

The objectives of the study listed in the last paragraph are vague. It is unclear as to why you need this study and what are the specific objectives.
You wrote page 3 para 7
“This study thoroughly analyzed the current information systems utilized in the MPDSR program to understand how they help. The study offers comprehensive insights into the functionality of the MPDSR dashboard in Bangladesh, along with a comparative analysis of the MPDSR information systems utilized in other countries for the purposes of effective planning. The qualitative interviews revealed significant gaps and barriers impeding evidence-based planning and action”

I think something like this instead might be helpful
Although MPDSR reporting has been incorporated into DHIS2 in Bangladesh we do not know how effective this has been to assist health managers plan for maternal and neonatal health programs. Using a mix method approach of data from 2019 to 2021 we examined the how this inclusion of MPDSR findings into DHIS2 was used to report deaths, inform program reviews, create MDSPR action plans and link to outcomes on key indicators. Additionally, we collected recommendations for improving the MDPSR program.

Response: This is great feedback, and I have tried to incorporate all of it in my way to keep the objective aligned with the research question.

Reviewer Comments:
Methods
The research question is not clear, please see my suggestion to refine the research question but you also need to state the specific objectives in the first paragraph. Not just say to “understand the given research problem”.

The methods or introduction should include a diagram as to who the current system works is supposed to work so we can better understand the results.

Response: I have revised it accordingly.

Reviewer Comments:
Page 4 para 3
A thematic analysis is not part of primary data collection but rather analysis. Please mention any software that might have been used to do this analysis. Please create a separate section in methods that is just analysis and how the mixed methods were brought together.

Response: I have not used software like NVIVO for thematic analysis. This was done based on the interviews and the emerging discussion points to organize it into different themes. I am added few lines in the method section.

Reviewer Comments:
Page 4 para 2
Similarly in Secondary data collection you mix the data collection with the analysis and it becomes confusing for example for public health websites you discuss using baseline 2019 data compared with 2021 from the score card but exactly what was compared and how statistically?
But I don’t understand what were the analysis methods used?

Response: The MPDSR dashboard includes various indicators, such as ANC and PNC coverage, which were compared between 2019 and 2021. This was a descriptive statistical analysis of the dashboard findings on MPDSR.

Reviewer Comments:
Page 4, para 3
Similarly, this belongs in an analysis section of methods
“Frequency analysis was used for MPDSR key actions in the seven districts and presented in a tabulated form. Quantitative data on death notifications were also analyzed in a Microsoft Excel (Version 2308) spreadsheet, shown in the Figures 2,3 and 4”

Response: We listed the interventions planned in the MPDSR action plans and analyzed the frequency of activities that were planned in most of the districts, highlighting the common actions based on the information available in the DHIS2. This analysis provides an impression of whether the information was used for planning, as the actions are linked to the reported number of deaths and causes of death.

Reviewer Comments:
Results
Overall, it is hard to understand what data sources were used for each research question and how each finding links to your original research questions. Also this section includes only results but some of the aspects written in this section should be in methods or introduction or discussion.
For example, suddenly you mention that Bangladesh is one of the few countries uses real time MPSDR data through a dashboard. That should have been mentioned in the introduction.

Then you add a method “The study team examined data to measure performance in 27 districts
and identify gaps in information system” These methods. Also the statement is vague, examine what data? To measure what performance, based on what measure?

Response: While inquiring about the data, the MOH directed us to the available dashboard where we could download the information. The team accessed the MPDSR dashboard to retrieve performance indicators such as death notification rates, death review rates, and other metrics like ANC and PNC coverage to evaluate district performance. This exercise was conducted for 27 districts.

Reviewer Comments:
Page 8 para 2
You don’t describe in methods how you would statistically determine an association.
“This study reviewed the scorecard of the MPDSR program and found that its key performance indicators were linked with maternal and neonatal mortality rates. The program’s performance dashboard can visualize its impact based on surveys and routine data. Most indicators showed positive changes, except in the Bandarban and Gazipur districts, where mortality and service coverage decreased. Pregnancy registration, delivery antenatal 4th visits coverage, and postnatal care increased in Jamalpur and Maulvibazar, where the impact of reducing MMR was the highest. The data were subject to verification but could be discussed during the MPDSR meetings”
Table 3 shows you results by district with no information as to what was happening with the MDSPR during these years, but to link the two you need to include this in the table how many MSDPR reviews occurred in each district in which years and what actions were actually taken up. All you are showing it the dashboard, the changes overtime could have occurred for many reasons other than MPDSR.

Response: Thank you again for critically examining this data. We had several discussions with the team on this topic, and we ultimately agreed to document our findings from the study. I understand that some of the findings were vague, but it is true that there was no further information on those issues, and the study faced limitations in further investigating the districts with higher mortality rates. However, we provided an analysis of the overall reporting performance of the MPDSR at the start, including the rate of death notifications and a review of those districts. Then, we attempted to review the MPDSR action plans to understand their strategies and their connection to the existing information. I acknowledge that many factors impacted the MMR and NMR, but the aim of the study was to determine whether the information was being utilized and to assess the dashboard's effectiveness in measuring what is happening.

Reviewer Comments:
Key recommendations
These findings are from the qualitative component key informant interviews, correct? Or are you putting some conclusions here?
Again it is confusing

Response: The recommendation came from the interview and I just mentioned what they mentioned during the interview. We are not trying any conclusion. But based on your advice, we are revising the language, which has created confusion.

Reviewer Comments:
Discussion
I could better understand the dashboards if I had a better explanation on how the overall system works. I am finding it confusing to know when the dashboards come into the process. Perhaps a diagram earlier on in methods would have helped.

Para 1 page 12
“The Southeast Asia region WHO report revealed that out of 10 countries, only three hold national-level meetings twice early on MPDSR committees. In Bangladesh, health managers recommend that the government and partners collaborate to implement the MPDSR and establish accountability and laws for death notification”
Without a explanation or diagram on how the system should work in Bangladesh, including frequency of meetings, this recommendation from Bangladesh is very vague. What is even the point of this paragraph if you do not mention the frequency in Bangladesh.

For example Page 11 para 8
In Bandarban, a hilly terrain, the interventions listed in the plan did not work out, and as per the scorecard, the MMR went up. The managers mentioned conducting video conferences to monitor progress regularly and to improve health managers’ accountability”
Was this ever mentioned in the results?
Not sure that the poor documentation mentioned in the discussion was highlighted in the results section

Response: I completely agree, but there were few papers on the MPDSR information system, including a dashboard. We tried to link other papers related to this study. There is definitely future scope to have more papers on MPDSR information systems and their impact. We have revised the points that you mentioned above.

Reviewer Comments:
Conclusion
Until the specific objectives and methods and results are re written it is hard to tell if these conclusions are linked to the findings.

Response: We have revised it completely.
Competing Interests: No competing interests were disclosed. Close
Report a concern
Respond or Comment

COMMENTS ON THIS REPORT

Author Response 18 Feb 2025

Abu Sadat Mohammad Sayem, University of Oslo, Oslo, Norway

18 Feb 2025

Author Response
Reviewer Comments:
This is an extremely important topic, however, as written is quite confusing without an overall diagram explaining how the entire system is supposed to work, it is difficult ... Continue reading
Reviewer Comments:
This is an extremely important topic, however, as written is quite confusing without an overall diagram explaining how the entire system is supposed to work, it is difficult to understand this paper. I know MDPSR well but as written I could not understand how it is supposed to function in Bangladesh. I found the order of paragraphs could be changed and that there are some mixings of methods in results, results in methods and discussion in results and these should be fixed. There should be a separate section on analysis to understand how all these mixed methods are brought together.

Response: Thanks for the suggestion. I am adding an diagram in the introduction section

Reviewer Comments:
Additionally, I have highlighted issues and provided some possible solutions

Although all the information is in the introduction I find the order and presentation a bit confusing.

I would first start with maternal death data and please update it with the latest estimates from 2020

Then I would explain what MPDSR is and how it is suppose to work in Bangladesh

Finally I would explain DHIS2 followed by the current information system in Bangladesh

Then the specific objectives of the study

The objectives of the study listed in the last paragraph are vague. It is unclear as to why you need this study and what are the specific objectives.
You wrote page 3 para 7
“This study thoroughly analyzed the current information systems utilized in the MPDSR program to understand how they help. The study offers comprehensive insights into the functionality of the MPDSR dashboard in Bangladesh, along with a comparative analysis of the MPDSR information systems utilized in other countries for the purposes of effective planning. The qualitative interviews revealed significant gaps and barriers impeding evidence-based planning and action”

I think something like this instead might be helpful
Although MPDSR reporting has been incorporated into DHIS2 in Bangladesh we do not know how effective this has been to assist health managers plan for maternal and neonatal health programs. Using a mix method approach of data from 2019 to 2021 we examined the how this inclusion of MPDSR findings into DHIS2 was used to report deaths, inform program reviews, create MDSPR action plans and link to outcomes on key indicators. Additionally, we collected recommendations for improving the MDPSR program.

Response: This is great feedback, and I have tried to incorporate all of it in my way to keep the objective aligned with the research question.

Reviewer Comments:
Methods
The research question is not clear, please see my suggestion to refine the research question but you also need to state the specific objectives in the first paragraph. Not just say to “understand the given research problem”.

The methods or introduction should include a diagram as to who the current system works is supposed to work so we can better understand the results.

Response: I have revised it accordingly.

Reviewer Comments:
Page 4 para 3
A thematic analysis is not part of primary data collection but rather analysis. Please mention any software that might have been used to do this analysis. Please create a separate section in methods that is just analysis and how the mixed methods were brought together.

Response: I have not used software like NVIVO for thematic analysis. This was done based on the interviews and the emerging discussion points to organize it into different themes. I am added few lines in the method section.

Reviewer Comments:
Page 4 para 2
Similarly in Secondary data collection you mix the data collection with the analysis and it becomes confusing for example for public health websites you discuss using baseline 2019 data compared with 2021 from the score card but exactly what was compared and how statistically?
But I don’t understand what were the analysis methods used?

Response: The MPDSR dashboard includes various indicators, such as ANC and PNC coverage, which were compared between 2019 and 2021. This was a descriptive statistical analysis of the dashboard findings on MPDSR.

Reviewer Comments:
Page 4, para 3
Similarly, this belongs in an analysis section of methods
“Frequency analysis was used for MPDSR key actions in the seven districts and presented in a tabulated form. Quantitative data on death notifications were also analyzed in a Microsoft Excel (Version 2308) spreadsheet, shown in the Figures 2,3 and 4”

Response: We listed the interventions planned in the MPDSR action plans and analyzed the frequency of activities that were planned in most of the districts, highlighting the common actions based on the information available in the DHIS2. This analysis provides an impression of whether the information was used for planning, as the actions are linked to the reported number of deaths and causes of death.

Reviewer Comments:
Results
Overall, it is hard to understand what data sources were used for each research question and how each finding links to your original research questions. Also this section includes only results but some of the aspects written in this section should be in methods or introduction or discussion.
For example, suddenly you mention that Bangladesh is one of the few countries uses real time MPSDR data through a dashboard. That should have been mentioned in the introduction.

Then you add a method “The study team examined data to measure performance in 27 districts
and identify gaps in information system” These methods. Also the statement is vague, examine what data? To measure what performance, based on what measure?

Response: While inquiring about the data, the MOH directed us to the available dashboard where we could download the information. The team accessed the MPDSR dashboard to retrieve performance indicators such as death notification rates, death review rates, and other metrics like ANC and PNC coverage to evaluate district performance. This exercise was conducted for 27 districts.

Reviewer Comments:
Page 8 para 2
You don’t describe in methods how you would statistically determine an association.
“This study reviewed the scorecard of the MPDSR program and found that its key performance indicators were linked with maternal and neonatal mortality rates. The program’s performance dashboard can visualize its impact based on surveys and routine data. Most indicators showed positive changes, except in the Bandarban and Gazipur districts, where mortality and service coverage decreased. Pregnancy registration, delivery antenatal 4th visits coverage, and postnatal care increased in Jamalpur and Maulvibazar, where the impact of reducing MMR was the highest. The data were subject to verification but could be discussed during the MPDSR meetings”
Table 3 shows you results by district with no information as to what was happening with the MDSPR during these years, but to link the two you need to include this in the table how many MSDPR reviews occurred in each district in which years and what actions were actually taken up. All you are showing it the dashboard, the changes overtime could have occurred for many reasons other than MPDSR.

Response: Thank you again for critically examining this data. We had several discussions with the team on this topic, and we ultimately agreed to document our findings from the study. I understand that some of the findings were vague, but it is true that there was no further information on those issues, and the study faced limitations in further investigating the districts with higher mortality rates. However, we provided an analysis of the overall reporting performance of the MPDSR at the start, including the rate of death notifications and a review of those districts. Then, we attempted to review the MPDSR action plans to understand their strategies and their connection to the existing information. I acknowledge that many factors impacted the MMR and NMR, but the aim of the study was to determine whether the information was being utilized and to assess the dashboard's effectiveness in measuring what is happening.

Reviewer Comments:
Key recommendations
These findings are from the qualitative component key informant interviews, correct? Or are you putting some conclusions here?
Again it is confusing

Response: The recommendation came from the interview and I just mentioned what they mentioned during the interview. We are not trying any conclusion. But based on your advice, we are revising the language, which has created confusion.

Reviewer Comments:
Discussion
I could better understand the dashboards if I had a better explanation on how the overall system works. I am finding it confusing to know when the dashboards come into the process. Perhaps a diagram earlier on in methods would have helped.

Para 1 page 12
“The Southeast Asia region WHO report revealed that out of 10 countries, only three hold national-level meetings twice early on MPDSR committees. In Bangladesh, health managers recommend that the government and partners collaborate to implement the MPDSR and establish accountability and laws for death notification”
Without a explanation or diagram on how the system should work in Bangladesh, including frequency of meetings, this recommendation from Bangladesh is very vague. What is even the point of this paragraph if you do not mention the frequency in Bangladesh.

For example Page 11 para 8
In Bandarban, a hilly terrain, the interventions listed in the plan did not work out, and as per the scorecard, the MMR went up. The managers mentioned conducting video conferences to monitor progress regularly and to improve health managers’ accountability”
Was this ever mentioned in the results?
Not sure that the poor documentation mentioned in the discussion was highlighted in the results section

Response: I completely agree, but there were few papers on the MPDSR information system, including a dashboard. We tried to link other papers related to this study. There is definitely future scope to have more papers on MPDSR information systems and their impact. We have revised the points that you mentioned above.

Reviewer Comments:
Conclusion
Until the specific objectives and methods and results are re written it is hard to tell if these conclusions are linked to the findings.

Response: We have revised it completely.
Reviewer Comments:
This is an extremely important topic, however, as written is quite confusing without an overall diagram explaining how the entire system is supposed to work, it is difficult to understand this paper. I know MDPSR well but as written I could not understand how it is supposed to function in Bangladesh. I found the order of paragraphs could be changed and that there are some mixings of methods in results, results in methods and discussion in results and these should be fixed. There should be a separate section on analysis to understand how all these mixed methods are brought together.

Response: Thanks for the suggestion. I am adding an diagram in the introduction section

Reviewer Comments:
Additionally, I have highlighted issues and provided some possible solutions

Although all the information is in the introduction I find the order and presentation a bit confusing.

I would first start with maternal death data and please update it with the latest estimates from 2020

Then I would explain what MPDSR is and how it is suppose to work in Bangladesh

Finally I would explain DHIS2 followed by the current information system in Bangladesh

Then the specific objectives of the study

The objectives of the study listed in the last paragraph are vague. It is unclear as to why you need this study and what are the specific objectives.
You wrote page 3 para 7
“This study thoroughly analyzed the current information systems utilized in the MPDSR program to understand how they help. The study offers comprehensive insights into the functionality of the MPDSR dashboard in Bangladesh, along with a comparative analysis of the MPDSR information systems utilized in other countries for the purposes of effective planning. The qualitative interviews revealed significant gaps and barriers impeding evidence-based planning and action”

I think something like this instead might be helpful
Although MPDSR reporting has been incorporated into DHIS2 in Bangladesh we do not know how effective this has been to assist health managers plan for maternal and neonatal health programs. Using a mix method approach of data from 2019 to 2021 we examined the how this inclusion of MPDSR findings into DHIS2 was used to report deaths, inform program reviews, create MDSPR action plans and link to outcomes on key indicators. Additionally, we collected recommendations for improving the MDPSR program.

Response: This is great feedback, and I have tried to incorporate all of it in my way to keep the objective aligned with the research question.

Reviewer Comments:
Methods
The research question is not clear, please see my suggestion to refine the research question but you also need to state the specific objectives in the first paragraph. Not just say to “understand the given research problem”.

The methods or introduction should include a diagram as to who the current system works is supposed to work so we can better understand the results.

Response: I have revised it accordingly.

Reviewer Comments:
Page 4 para 3
A thematic analysis is not part of primary data collection but rather analysis. Please mention any software that might have been used to do this analysis. Please create a separate section in methods that is just analysis and how the mixed methods were brought together.

Response: I have not used software like NVIVO for thematic analysis. This was done based on the interviews and the emerging discussion points to organize it into different themes. I am added few lines in the method section.

Reviewer Comments:
Page 4 para 2
Similarly in Secondary data collection you mix the data collection with the analysis and it becomes confusing for example for public health websites you discuss using baseline 2019 data compared with 2021 from the score card but exactly what was compared and how statistically?
But I don’t understand what were the analysis methods used?

Response: The MPDSR dashboard includes various indicators, such as ANC and PNC coverage, which were compared between 2019 and 2021. This was a descriptive statistical analysis of the dashboard findings on MPDSR.

Reviewer Comments:
Page 4, para 3
Similarly, this belongs in an analysis section of methods
“Frequency analysis was used for MPDSR key actions in the seven districts and presented in a tabulated form. Quantitative data on death notifications were also analyzed in a Microsoft Excel (Version 2308) spreadsheet, shown in the Figures 2,3 and 4”

Response: We listed the interventions planned in the MPDSR action plans and analyzed the frequency of activities that were planned in most of the districts, highlighting the common actions based on the information available in the DHIS2. This analysis provides an impression of whether the information was used for planning, as the actions are linked to the reported number of deaths and causes of death.

Reviewer Comments:
Results
Overall, it is hard to understand what data sources were used for each research question and how each finding links to your original research questions. Also this section includes only results but some of the aspects written in this section should be in methods or introduction or discussion.
For example, suddenly you mention that Bangladesh is one of the few countries uses real time MPSDR data through a dashboard. That should have been mentioned in the introduction.

Then you add a method “The study team examined data to measure performance in 27 districts
and identify gaps in information system” These methods. Also the statement is vague, examine what data? To measure what performance, based on what measure?

Response: While inquiring about the data, the MOH directed us to the available dashboard where we could download the information. The team accessed the MPDSR dashboard to retrieve performance indicators such as death notification rates, death review rates, and other metrics like ANC and PNC coverage to evaluate district performance. This exercise was conducted for 27 districts.

Reviewer Comments:
Page 8 para 2
You don’t describe in methods how you would statistically determine an association.
“This study reviewed the scorecard of the MPDSR program and found that its key performance indicators were linked with maternal and neonatal mortality rates. The program’s performance dashboard can visualize its impact based on surveys and routine data. Most indicators showed positive changes, except in the Bandarban and Gazipur districts, where mortality and service coverage decreased. Pregnancy registration, delivery antenatal 4th visits coverage, and postnatal care increased in Jamalpur and Maulvibazar, where the impact of reducing MMR was the highest. The data were subject to verification but could be discussed during the MPDSR meetings”
Table 3 shows you results by district with no information as to what was happening with the MDSPR during these years, but to link the two you need to include this in the table how many MSDPR reviews occurred in each district in which years and what actions were actually taken up. All you are showing it the dashboard, the changes overtime could have occurred for many reasons other than MPDSR.

Response: Thank you again for critically examining this data. We had several discussions with the team on this topic, and we ultimately agreed to document our findings from the study. I understand that some of the findings were vague, but it is true that there was no further information on those issues, and the study faced limitations in further investigating the districts with higher mortality rates. However, we provided an analysis of the overall reporting performance of the MPDSR at the start, including the rate of death notifications and a review of those districts. Then, we attempted to review the MPDSR action plans to understand their strategies and their connection to the existing information. I acknowledge that many factors impacted the MMR and NMR, but the aim of the study was to determine whether the information was being utilized and to assess the dashboard's effectiveness in measuring what is happening.

Reviewer Comments:
Key recommendations
These findings are from the qualitative component key informant interviews, correct? Or are you putting some conclusions here?
Again it is confusing

Response: The recommendation came from the interview and I just mentioned what they mentioned during the interview. We are not trying any conclusion. But based on your advice, we are revising the language, which has created confusion.

Reviewer Comments:
Discussion
I could better understand the dashboards if I had a better explanation on how the overall system works. I am finding it confusing to know when the dashboards come into the process. Perhaps a diagram earlier on in methods would have helped.

Para 1 page 12
“The Southeast Asia region WHO report revealed that out of 10 countries, only three hold national-level meetings twice early on MPDSR committees. In Bangladesh, health managers recommend that the government and partners collaborate to implement the MPDSR and establish accountability and laws for death notification”
Without a explanation or diagram on how the system should work in Bangladesh, including frequency of meetings, this recommendation from Bangladesh is very vague. What is even the point of this paragraph if you do not mention the frequency in Bangladesh.

For example Page 11 para 8
In Bandarban, a hilly terrain, the interventions listed in the plan did not work out, and as per the scorecard, the MMR went up. The managers mentioned conducting video conferences to monitor progress regularly and to improve health managers’ accountability”
Was this ever mentioned in the results?
Not sure that the poor documentation mentioned in the discussion was highlighted in the results section

Response: I completely agree, but there were few papers on the MPDSR information system, including a dashboard. We tried to link other papers related to this study. There is definitely future scope to have more papers on MPDSR information systems and their impact. We have revised the points that you mentioned above.

Reviewer Comments:
Conclusion
Until the specific objectives and methods and results are re written it is hard to tell if these conclusions are linked to the findings.

Response: We have revised it completely.
Competing Interests: No competing interests were disclosed. Close
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Version 1

VERSION 1

PUBLISHED 10 Apr 2024

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Reviewer Report 25 Jun 2024

Tahmina Begum, Poche Centre for Indigenous Health, The University of Queensland, Saint Lucia, Queensland, Australia

Approved with Reservations

https://doi.org/10.5256/f1000research.156288.r280803

This is a very informative article and has all the merits of indexing. However, to make the study reproducible by other researchers, it requires more detail.
I have added some points for consideration for the next round of revision.
Data flow in the introduction should support the rationale of conducting this study in the context of MPDSR.; what has been done so far, what new things are we proposing, and is there any successful evidence from other LMICs using our proposed approach/ has the new approach been successful in other MNH health service delivery?
Methods:

Ethics would come next after describing the study design and setting.
This is not justified to explain mixed method as 3^rd, it is better to drop this line, at best author can say qual findings were used to explain the data gap……….. observed in quantitative findings.
Be specific about what you mean by primary and secondary data. Publicly available data from the DGHS dashboard is your secondary data source here. Did the patients provide consent to use their data for research? The research is focused on MPDSR, but the justification of analysis RMNCAH data is not clear from the methods section.
Though the author specifies the primary data source in 3^rd paragraph, different terminology “Document review was used to explain the quantitative data source. What documents did the author review as part of the Quan data source has not been specified before.
Nothing was mentioned about the analysis plan for the qualitative data. How did they divide data under the theme, what themes were used, how did you code, a-priori/reflexive /inductive …… manual /software?
What is the RMCH scorecard, and what are the components? How did u analyze them?
Figure 1.27 The study site seems clustered on the south side of the map, which means the rest of the sites are well-performing. Did the author use convenient sampling, if so, how it is going to affect the generalizability of your findings?

Result:

The result section is only to present findings, we can not add any argument or justification, For example, the below 2 lines do not fit in the result section. “It is also important to mention that the WHO provides projection-based population data to estimate the number of children born to each administrative unit”.
For all the figures Axis titles are not unique and check for spelling mistakes. Does not make sense to specify that Bangladesh and the intervention district are in the same graph with different bars.
Please explain how the estimated maternal and neonatal death numbers were calculated/projected in your method section.

Discussion:

Please add an opening paragraph with key findings from your paper.

Is the background of the case’s history and progression described in sufficient detail?

Partly
Is the work clearly and accurately presented and does it cite the current literature?

Partly
If applicable, is the statistical analysis and its interpretation appropriate?

Not applicable
Are all the source data underlying the results available to ensure full reproducibility?

Partly
Are the conclusions drawn adequately supported by the results?

Partly
Is the case presented with sufficient detail to be useful for teaching or other practitioners?

Partly

Competing Interests: No competing interests were disclosed.

Reviewer Expertise: To make this article reproducible by other researchers, a detailed description of the study methodology, data source, analysis plan needs to be well described

CITE

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Author Response 05 Nov 2024

Abu Sadat Mohammad Sayem, University of Oslo, Oslo, Norway

05 Nov 2024

Author Response

Dear Reviewer,
Thanks for your comprehensive feedback on the article, and much appreciated. I have corrected those in my new version and added more facts to boost further understanding of ... Continue reading Dear Reviewer,
Thanks for your comprehensive feedback on the article, and much appreciated. I have corrected those in my new version and added more facts to boost further understanding of the manuscript.

I have added more information in the introduction based on your comments.

Methods:
The ethics section has been relocated to a more appropriate position within the document to enhance clarity and coherence. In addition, the methods section has been thoroughly revised to improve its overall readability, and we have incorporated additional details to address your inquiries regarding both primary and secondary data collection methods.

I included qualitative analysis techniques, although I faced some constraints due to word limitations that prevented me from elaborating further on this aspect.

In the results section, I provided a comprehensive explanation of the RMNCAH (Reproductive, Maternal, Newborn, Child, and Adolescent Health) dashboard. This dashboard serves as an integrated data system that consolidates all relevant maternal and neonatal health information, enabling a better understanding of the outcome and impact-level indicators for Bangladesh.

Furthermore, the selection of districts for this study was based on specific criteria, which have been elaborated upon in the methods section to provide greater transparency regarding our approach.

Results:
The language and writing style of the results section have undergone a thorough revision to enhance clarity and precision. However, it was not possible to modify the Axis title, as it was sourced directly from the MPDSR dashboard, which has been cited in our reference materials.

Additionally, the explanation regarding the estimated population figures draws upon an Excel file that was provided by the World Health Organization (WHO) to the government. This Excel file contains comprehensive district-wise data, including detailed calculations that utilize the growth rate projections for each year. This meticulous methodology ensures accuracy and reliability in the population estimates presented.

Discussion:
It has been improved further.
Dear Reviewer,
Thanks for your comprehensive feedback on the article, and much appreciated. I have corrected those in my new version and added more facts to boost further understanding of the manuscript.

I have added more information in the introduction based on your comments.

Methods:
The ethics section has been relocated to a more appropriate position within the document to enhance clarity and coherence. In addition, the methods section has been thoroughly revised to improve its overall readability, and we have incorporated additional details to address your inquiries regarding both primary and secondary data collection methods.

I included qualitative analysis techniques, although I faced some constraints due to word limitations that prevented me from elaborating further on this aspect.

In the results section, I provided a comprehensive explanation of the RMNCAH (Reproductive, Maternal, Newborn, Child, and Adolescent Health) dashboard. This dashboard serves as an integrated data system that consolidates all relevant maternal and neonatal health information, enabling a better understanding of the outcome and impact-level indicators for Bangladesh.

Furthermore, the selection of districts for this study was based on specific criteria, which have been elaborated upon in the methods section to provide greater transparency regarding our approach.

Results:
The language and writing style of the results section have undergone a thorough revision to enhance clarity and precision. However, it was not possible to modify the Axis title, as it was sourced directly from the MPDSR dashboard, which has been cited in our reference materials.

Additionally, the explanation regarding the estimated population figures draws upon an Excel file that was provided by the World Health Organization (WHO) to the government. This Excel file contains comprehensive district-wise data, including detailed calculations that utilize the growth rate projections for each year. This meticulous methodology ensures accuracy and reliability in the population estimates presented.

Discussion:
It has been improved further.
Competing Interests: No competing interests were disclosed. Close
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COMMENTS ON THIS REPORT

Author Response 05 Nov 2024

Abu Sadat Mohammad Sayem, University of Oslo, Oslo, Norway

05 Nov 2024

Author Response

Dear Reviewer,
Thanks for your comprehensive feedback on the article, and much appreciated. I have corrected those in my new version and added more facts to boost further understanding of ... Continue reading Dear Reviewer,
Thanks for your comprehensive feedback on the article, and much appreciated. I have corrected those in my new version and added more facts to boost further understanding of the manuscript.

I have added more information in the introduction based on your comments.

Methods:
The ethics section has been relocated to a more appropriate position within the document to enhance clarity and coherence. In addition, the methods section has been thoroughly revised to improve its overall readability, and we have incorporated additional details to address your inquiries regarding both primary and secondary data collection methods.

I included qualitative analysis techniques, although I faced some constraints due to word limitations that prevented me from elaborating further on this aspect.

In the results section, I provided a comprehensive explanation of the RMNCAH (Reproductive, Maternal, Newborn, Child, and Adolescent Health) dashboard. This dashboard serves as an integrated data system that consolidates all relevant maternal and neonatal health information, enabling a better understanding of the outcome and impact-level indicators for Bangladesh.

Furthermore, the selection of districts for this study was based on specific criteria, which have been elaborated upon in the methods section to provide greater transparency regarding our approach.

Results:
The language and writing style of the results section have undergone a thorough revision to enhance clarity and precision. However, it was not possible to modify the Axis title, as it was sourced directly from the MPDSR dashboard, which has been cited in our reference materials.

Additionally, the explanation regarding the estimated population figures draws upon an Excel file that was provided by the World Health Organization (WHO) to the government. This Excel file contains comprehensive district-wise data, including detailed calculations that utilize the growth rate projections for each year. This meticulous methodology ensures accuracy and reliability in the population estimates presented.

Discussion:
It has been improved further.
Dear Reviewer,
Thanks for your comprehensive feedback on the article, and much appreciated. I have corrected those in my new version and added more facts to boost further understanding of the manuscript.

I have added more information in the introduction based on your comments.

Methods:
The ethics section has been relocated to a more appropriate position within the document to enhance clarity and coherence. In addition, the methods section has been thoroughly revised to improve its overall readability, and we have incorporated additional details to address your inquiries regarding both primary and secondary data collection methods.

I included qualitative analysis techniques, although I faced some constraints due to word limitations that prevented me from elaborating further on this aspect.

In the results section, I provided a comprehensive explanation of the RMNCAH (Reproductive, Maternal, Newborn, Child, and Adolescent Health) dashboard. This dashboard serves as an integrated data system that consolidates all relevant maternal and neonatal health information, enabling a better understanding of the outcome and impact-level indicators for Bangladesh.

Furthermore, the selection of districts for this study was based on specific criteria, which have been elaborated upon in the methods section to provide greater transparency regarding our approach.

Results:
The language and writing style of the results section have undergone a thorough revision to enhance clarity and precision. However, it was not possible to modify the Axis title, as it was sourced directly from the MPDSR dashboard, which has been cited in our reference materials.

Additionally, the explanation regarding the estimated population figures draws upon an Excel file that was provided by the World Health Organization (WHO) to the government. This Excel file contains comprehensive district-wise data, including detailed calculations that utilize the growth rate projections for each year. This meticulous methodology ensures accuracy and reliability in the population estimates presented.

Discussion:
It has been improved further.
Competing Interests: No competing interests were disclosed. Close
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VERSION 3 PUBLISHED 10 Apr 2024

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Version 1 10 Apr 24	read

Tahmina Begum, The University of Queensland, Saint Lucia, Australia
Theresa Diaz, World Health Organization, Geneva, Switzerland
Christelle Boyi Hounsou, Centre de Recherche en Reproduction Humaine et en Démographie,, Cotonou, Benin; Institute of Tropical Medicine, Antwerp, Belgium

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13 Aug 2025 | for Version 3

Tahmina Begum, Poche Centre for Indigenous Health, The University of Queensland, Saint Lucia, Queensland, Australia

1 Views Cite this report Responses(0)

Approved

I do not have further comments. The paper can be sent for indexing.

Competing Interests

No competing interests were disclosed.

Reviewer Expertise

Maternal and child health

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard.

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24 Jan 2025 | for Version 2

Christelle Boyi Hounsou, Centre de Recherche en Reproduction Humaine et en Démographie,, Cotonou, Benin; Institute of Tropical Medicine, Antwerp, Belgium

11 Views Cite this report Responses(1)

Approved With Reservations

Notification: Who is responsible for initiating the data entry at the grassroots level? What is the process for ensuring timely and accurate reporting?
Review: At what intervals are death review meetings conducted, and who participates in these discussions? How is the validation of data handled to ensure consistency and reliability?
Response: What mechanisms are in place to ensure that healthcare managers and other stakeholders at the national and subnational levels can access and act on the data? Are there specific timelines for integrating and disseminating data after entry into DHIS2?

What are the critical challenges in using MPDSR information systems for planning?
How do the identified gaps and barriers affect evidence-based decision-making and actions?
Why is it important to compare the MPDSR systems in Bangladesh with those in other countries, and how will this comparison contribute to addressing the challenges identified?

For the qualitative strand, you could detail the use of in-depth interviews, specify the target participants (e.g., healthcare providers, health managers, policymakers), describe the interview guide, and mention how the interviews were conducted and analysed.
For the quantitative strand, you could explain the data sources (e.g., MPDSR dashboards), the type of data extracted, the tools or protocols used for data collection, and the personnel responsible for this process.

For the qualitative strand, after the data collection through in-depth interviews, the analysis involved thematic coding to identify key themes and patterns. The data were transcribed verbatim and then coded manually or using qualitative data analysis software (e.g., NVivo). Thematic analysis was employed to categorize the data into meaningful themes, which were then examined to understand the barriers and facilitators of MPDSR implementation. The findings were interpreted by the research team to ensure consistency and validity.
For the quantitative strand, after data collection from MPDSR dashboards and health records, the data were cleaned and processed to ensure accuracy and completeness. Descriptive statistics were used to summarise the data, and any trends or patterns were identified through statistical tests (e.g., chi-square, regression analysis). The data were analysed using statistical software (e.g., SPSS, STATA) to determine the frequency, timeliness, and completeness of data entry and reporting. The analysis also helped identify gaps in the system that may hinder effective use of MPDSR data.

How is the data from the MPDSR system integrated into the dashboard in real-time?
What types of data are displayed on the dashboard (e.g., maternal deaths, causes of death, response actions)?
How are the data updated and verified to ensure their accuracy and timeliness?
Who is responsible for monitoring the dashboard and how do they use the information to drive decision-making at the national and district levels?
How does the Ministry of Health (MOH) use the dashboard for monthly monitoring? Are there specific performance indicators or thresholds that are tracked?

Identification and Notification: Who is responsible for identifying and notifying maternal deaths at the community level? Are community health workers or other local healthcare providers responsible for this task? How are these deaths reported, and what is the process for ensuring timely notification?
Review Process: How are community maternal deaths reviewed, and who participates in these reviews? Are there specific teams or committees involved, and what is their role in the process? How does the review process differ between facility and community deaths?

Is the background of the case’s history and progression described in sufficient detail?

Partly
Is the work clearly and accurately presented and does it cite the current literature?

Partly
If applicable, is the statistical analysis and its interpretation appropriate?

Partly
Are all the source data underlying the results available to ensure full reproducibility?

Yes
Are the conclusions drawn adequately supported by the results?

Partly
Is the case presented with sufficient detail to be useful for teaching or other practitioners?

Partly

Competing Interests

No competing interests were disclosed.

Reviewer Expertise

Materna, perinatal and neoanatl health, complexity, realist evaluation, quality improvment strategies

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Author Response

18 Feb 2025

Abu Sadat Mohammad Sayem, University of Oslo, Oslo, Norway

ABSTRACT
1- “The health sector in Bangladesh is thriving, and the Maternal and Perinatal Death Surveillance and Response (MPDSR) program has been in place to investigate the causes of maternal and perinatal death. This study aimed to investigate the availability of information systems for measuring the status of an MPDSR program and the planning process and actions developed based on real-time information”

The first sentence show no link with health information system. Please review it accordingly to make it easy to understand the link with the second one.

Response: Thanks for this very important note. I have now changed to create a link with the information systems and MPDSR in the revised one. I have tried to remove unnecessary lines and focused more on the linkage between the information systems and programs.

2-"This study delved into innovative information systems that can be used to monitor and measure the impact of health programs"

Ok. But the link with the previous sentences still is missing.

Response: This study also revealed an innovative system to publishing MPDSR data in the website through a dashboard for health managers. I have revised the text to make a link.

INTRODUCTION
3-“ As a result, the health system’s quality of care has been enhanced by adopting tools such as Maternal and Perinatal Death Surveillance and Response (MPDSR), which the WHO and UNICEF recommend. “

Please, provide a reference “

Response: Sorry, we missed the reference, but it has now been provided. The reference was actually given in the later part and also was in the list of references at number 18. Thanks for this advice.

4"The adoption of DHIS2 has indeed been transformative for health information systems, as demonstrated by the example of Bangladesh. However, it is important to clarify that the adoption of DHIS2 in itself does not directly explain the adoption of MPDSR. While DHIS2 provides a robust platform for data management and analysis, MPDSR is a distinct initiative aimed at generating actionable information to improve the quality of care and strengthen the health system."

The justification provided, linking DHIS2 adoption to MPDSR adoption, may not fully capture the complexities and specific requirements of implementing MPDSR. Beyond the technical infrastructure, MPDSR requires a strong commitment to using the information generated to drive systemic improvements, which involves leadership, capacity building, and stakeholder engagement.
It would be more accurate to highlight how DHIS2 can serve as a supportive tool for MPDSR by facilitating the integration of MPDSR data into its platform. This integration can enhance the accessibility, analysis, and use of MPDSR data within broader health information systems, creating opportunities for more efficient monitoring and decision-making. Strengthening the justification in this way will better reflect the nuanced relationship between these two initiatives and the potential for synergy when MPDSR data is effectively integrated into DHIS2.

Response: I completely agree, and we tried to explore these facts through the qualitative part of the study. We examined how information systems, as a tool, helped the managers conduct meetings and planning workshops using the existing information. The text has been revised as well.

5-“The program notifies the death of the mother and newborn, followed by a death review to identify causes and develop a response to prevent future deaths.³”

I suggest to use the original reference of MPDSR:
- World Health Organization. Maternal Death Surveillance and Response: Technical Guidance Information for Action to Prevent Maternal Death. WHO; 2013.

- World Health Organization, Maternal and perinatal death surveillance and response: materials to support implementation. Geneva: World Health Organisation; 2021. Licence: CC BY-NC-SA 3.0 IGO.

Response: Corrected

6-"The data for the MPDSR were initially collected in papers—a group of professionals reviewed the document to identify the cause of death and associated factors."

Please, explain the type of data
Response: The data was both quantitative and qualitative. Designated field workers completed a questionnaire through interviews with the deceased family members, and a specialist in gynecology and pediatrics analyzed this data. I have also added this in that section. Its really good to explain.

7-"Globally, there was a 44% reduction in maternal deaths, from 532,000 in 1990 to 303,000 in 2015.⁵ In Bangladesh, the Maternal Mortality Ratio (MMR) declined between 2001 and 2010, but has now plateaued compared to 2016. Although progress has been impressive in the past, it is necessary to achieve Sustainable Development Goals in ending preventable maternal deaths through a renewed focus on accountability and actions.⁶^"
Reference: WHO, UNICEF, UNFPA, World Bank Group, United Nations Population Division: Trends in Maternal Mortality: 1990 to 2015. Geneva: WHO; 2015.

7a- Please, use more acurate reference in addition:

Suggestion: World Health Organization,Trends in maternal mortality 2000 to 2020: estimates by WHO, UNICEF, UNFPA, World Bank Group and UNDESA/Population Division. Geneva: World Health Organszation; 2023. Licence: CC BY-NC-SA 3.0 IGO.

Response: Revised accordingly with the reference.

7b- This passage does not integrate well with the preceding sections. Firstly, it is not automatic to attribute (even partly) the reduction or plateau in maternal mortality to the implementation of MPDSR or the health information system. While these initiatives may contribute to improvements, such trends are influenced by a wide range of factors, including broader health system reforms, socio-economic changes, and other interventions.
To ensure coherence and accuracy, it would be beneficial to clarify the multifactorial nature of maternal mortality trends and avoid implying a direct causal link between these specific initiatives and the observed changes. This would better align the passage with the broader context and provide a more balanced perspective.

Response: I agree entirely and appreciate this. I have added more words to explain the facts.

8-The National Core Management Information Systems (MIS) committee, chaired by the directorates, meets monthly to obtain feedback on technical issues and monitor data from all the districts.¹⁴ The platform has helped reduce the administrative burden on the health system, reducing silos, and streamlining processes within a national data warehouse. Within the MPDSR program, a community healthcare provider enters data related to the death of a mother or newborn at the grassroots level into the DHIS2. By contrast, healthcare managers at national and subnational levels can learn about an event in real time from the same platform.¹⁵ The final causes of death are determined at the divisional level by Gynecologists, Obstetricians, and Neonatologists based on death review forms, and that information is also entered into the DHIS2.¹⁶

The section provides a valuable overview of the MPDSR program and its integration with DHIS2. However, it would be helpful to elaborate further on how each component of the MPDSR—notification, review, and response—is operationalised within the specific context. For example:

Notification: Who is responsible for initiating the data entry at the grassroots level? What is the process for ensuring timely and accurate reporting?
Review: At what intervals are death review meetings conducted, and who participates in these discussions? How is the validation of data handled to ensure consistency and reliability?
Response: What mechanisms are in place to ensure that healthcare managers and other stakeholders at the national and subnational levels can access and act on the data? Are there specific timelines for integrating and disseminating data after entry into DHIS2?

Providing this additional detail will clarify how the MPDSR program functions within the system and enhance understanding of the roles, responsibilities, and workflows involved. This will also help illustrate how the program supports timely decision-making and accountability.

Response: I agree with this point, and I have revised the section to be more detailed on the three processes mentioned. This also came up in the other findings section.

9- "This study thoroughly analyzed the current information systems utilized in the MPDSR program to understand how they help health managers plan maternal and neonatal health. The study offers comprehensive insights into the functionality of the MPDSR dashboard in Bangladesh, along with a comparative analysis of the MPDSR information systems utilized in other countries for the purposes of effective planning. The qualitative interviews revealed significant gaps and barriers impeding evidence-based planning and action"

The justification for this study is valuable, as it highlights the importance of understanding how MPDSR information systems support maternal and neonatal health planning. However, to strengthen the rationale, it may be helpful to explicitly address the specific problem or gap that the study seeks to resolve. For instance:

What are the critical challenges in using MPDSR information systems for planning?
How do the identified gaps and barriers affect evidence-based decision-making and actions?
Why is it important to compare the MPDSR systems in Bangladesh with those in other countries, and how will this comparison contribute to addressing the challenges identified?

Clarifying these aspects will provide a stronger foundation for the study and better communicate its relevance and potential impact.

Response: This is a great comment, and I have organized the content in a more systematic way. I revised it while considering the word limit. Some sentences were moved to other sections to incorporate all points clearly.

METHODS
10- Overall comments
The explanation of the study’s methodology is clear, but the terminology could be refined to better reflect standard practices in mixed-methods research. Specifically, it may be more accurate to refer to the qualitative and quantitative strands or data rather than describing them as primary and secondary data. This distinction is important because mixed-methods research typically involves integrating qualitative and quantitative approaches, each of which may include both primary and secondary data sources.
Here are some ideas:
"The study used a mixed-methods approach to understand the given research problem. Mixed-methods research has emerged as a major methodological approach across the social sciences, often regarded as a third paradigm alongside qualitative and quantitative research.17 The study integrated qualitative and quantitative strands, collecting and analysing data from both approaches to provide a comprehensive understanding of the research problem."
This revision ensures clarity and aligns with widely accepted terminology in mixed-methods research.

Response: Corrected accordingly. The method here was a bit different, as the study mainly captured the evolving transformation of information systems and how this helped the managers efficiently plan based on the information system.

11- "Key Informant Interviews (KII) were conducted in 2021 using a standardized guideline as part of the primary data collection to complement the findings of the secondary data.²⁵ The KII guidelines were provided by the author. It was pilot-tested before the interview."

11a- Please, describe a little bit the guideline.
Specify which author in this section.

Response: Provided

11b- Your explanation of the study's mixed-methods approach is clear, but the structure could be improved by grouping all information related to the qualitative and quantitative strands. Additionally, it would be helpful to specify, for each type of data collected, the tools used, who collected the data, and how it was collected.
For instance:

For the qualitative strand, you could detail the use of in-depth interviews, specify the target participants (e.g., healthcare providers, health managers, policymakers), describe the interview guide, and mention how the interviews were conducted and analysed.
For the quantitative strand, you could explain the data sources (e.g., MPDSR dashboards), the type of data extracted, the tools or protocols used for data collection, and the personnel responsible for this process.

Response: Done

12- Data analysis
12a- Quantitative data on death notifications were also analyzed in a Microsoft Excel (Version 2308) spreadsheet, shown in the Figures 2,3 and 4.

The figures should be in the result section.

Response: Agreed and revised accordingly.

12b- It is not entirely clear from the document how the data analysis was conducted. To improve clarity, it would be helpful to provide more specific information on the analysis process for each strand of data, immediately following the data collection description. For example:

For the qualitative strand, after the data collection through in-depth interviews, the analysis involved thematic coding to identify key themes and patterns. The data were transcribed verbatim and then coded manually or using qualitative data analysis software (e.g., NVivo). Thematic analysis was employed to categorize the data into meaningful themes, which were then examined to understand the barriers and facilitators of MPDSR implementation. The findings were interpreted by the research team to ensure consistency and validity.
For the quantitative strand, after data collection from MPDSR dashboards and health records, the data were cleaned and processed to ensure accuracy and completeness. Descriptive statistics were used to summarise the data, and any trends or patterns were identified through statistical tests (e.g., chi-square, regression analysis). The data were analysed using statistical software (e.g., SPSS, STATA) to determine the frequency, timeliness, and completeness of data entry and reporting. The analysis also helped identify gaps in the system that may hinder effective use of MPDSR data.

Response: Thanks for detailing this section. I have included your recommendations and revised it accordingly to enhance it reader-friendly.

RESULTS
13- It would be helpful to provide a more detailed explanation of how the MPDSR dashboard works, especially in terms of its real-time functionality and its role in monitoring. Maybe in the method sections, It could also be in the result section. For example, you could clarify the following points:

How is the data from the MPDSR system integrated into the dashboard in real-time?
What types of data are displayed on the dashboard (e.g., maternal deaths, causes of death, response actions)?
How are the data updated and verified to ensure their accuracy and timeliness?
Who is responsible for monitoring the dashboard and how do they use the information to drive decision-making at the national and district levels?
How does the Ministry of Health (MOH) use the dashboard for monthly monitoring? Are there specific performance indicators or thresholds that are tracked?

Response: All points above are integrated. Thanks for this very comprehensive feedback. This section was removed due to word limitations.

14-Some result parts sound like discussion, not result. Please check and address in the whole document.
Examples
“This indicates the need for health workers to visit the deceased mother’s home to increase notifications and review the cause of death”
"According to the national MPDSR guidelines, it is recommended that 10% of neonatal deaths be reviewed to determine the causes of death and to identify social barriers. However, the performance of neonatal death surveillance in capture
We attempted to examine how the performance of MPDSR could be evaluated using data from the dashboard"

Response: Agreed. Corrected accordingly.

15- " Facility maternal deaths are notified and reviewed, with much better performance compared to community MPDSR. 76% of the cases were reviewed at the facility"
It would be beneficial to provide a more detailed explanation of how MPDSR functions in the context of both facility and community maternal deaths. Specifically, it would be helpful to clarify the following points:

Identification and Notification: Who is responsible for identifying and notifying maternal deaths at the community level? Are community health workers or other local healthcare providers responsible for this task? How are these deaths reported, and what is the process for ensuring timely notification?
Review Process: How are community maternal deaths reviewed, and who participates in these reviews? Are there specific teams or committees involved, and what is their role in the process? How does the review process differ between facility and community deaths?

Response: Described in that section to further clarify.

16- It seems that the three-delay model is introduced in the results section without prior mention or explanation in the methodology or background sections. To ensure clarity and coherence, it would be helpful to briefly introduce the model earlier in the paper, ideally in the background or theoretical framework section. This would provide the reader with context before it is referenced in the results.

Response: This has been removed as this is not related to the findings to Corelate. It has created a confusion as it was not described before.

17 - It would be beneficial to incorporate a theoretical framework to guide the study. This framework would provide a clear line of connection between the research questions, the tools used for data collection and analysis, and the structuring of the results. A well-defined framework helps to ensure that the study remains focused and coherent, linking the theoretical concepts with the empirical findings.
In this case, integrating a relevant framework could help in aligning the study’s objectives with the data analysis process and in structuring the results in a way that directly addresses the research questions. This would also strengthen the study's overall validity by providing a consistent lens through which the findings are interpreted and discussed.

Response: Thanks for these excellent comments. This study was part of my PhD, which has a theoretical framework. It fully aligns with the overall objective of my PhD. However, due to limitations, we kept it to using information to measure the impact for MPDSR.

18- It would be helpful to avoid using acronyms such as DGHS and DGFP without first providing their full names. While acronyms are commonly used in technical documents, they can create confusion for readers who may not be familiar with them. To ensure clarity, I recommend spelling out the full names of these organizations at their first mention, followed by the acronym in parentheses

Response: Corrected.

19- It seems that the connection between the recommendations (in the result sections—Key recommendations for MPDSR ) and the research question could be made clearer. To strengthen this link, I suggest explicitly relating each recommendation to the specific aspects of the research question it addresses. This will help readers understand how the findings directly inform the recommendations and how they contribute to answering the research question.
Additionally, it would be useful to briefly describe the tools used for data collection and explain how they were chosen to address the research question. For example, were the in-depth interviews, surveys, or data from the MPDSR dashboard selected because they directly relate to specific components of the research question? This will provide more context for the recommendations and show how the data collection methods align with the study’s objectives.
It would be helpful to clarify that the recommendation for revising the National MPDSR guidelines was not previously identified as part of the gaps in the health system information. For instance, the suggestion to revise the guidelines to include stillbirth and align with new WHO standards seems crucial, but it wasn’t explicitly mentioned earlier in the paper as a gap in the MPDSR framework or health information system.
To strengthen the connection between the findings and the recommendations, I suggest explicitly linking this revision to the main objective of the paper, which is focused on maternal and perinatal death surveillance and response in Bangladesh. Highlighting that the absence of stillbirth inclusion in the MPDSR guidelines limits the effectiveness of maternal and perinatal death surveillance would provide more context for the need for revision.

Response: I appreciate your concerns, and I've taken your recommendations into account in this response. It's important to note that the revision of the MPDSR guideline was not identified as a gap since our focus was primarily on addressing the existing program's gaps through the current information systems that are in use. During discussions with health managers, they expressed that the outdated guideline is contributing to operational challenges within the program. This guideline was established when the country had not yet fully digitized its information systems.
The primary aim of this paper is to explore how information systems can assist managers in evidence-based planning using routine data. We chose to evaluate the MPDSR specifically in this context. However, it's worth mentioning that the health managers we interviewed provided recommendations that were quite comprehensive and aimed at improving the program more broadly. Thank you for your understanding.

DISCUSSION
20- Restructuring the results section using the previous comments would significantly enhance the overall structure of the discussion.

Response: Revised and adjusted as much as possible.

21- It seems that some of the results discussed in the paper, such as the identification of common actions to prevent maternal and perinatal deaths, may not be fully aligned with the overall objective of the study. The focus of the paper is on measuring impact through health information systems, specifically the maternal and perinatal death surveillance and response (MPDSR) system in Bangladesh.
While preventing maternal and perinatal deaths is certainly a key goal, it would be helpful to more explicitly connect these identified actions to how they relate to or are facilitated by the health information systems in place. For example, how do the actions to prevent deaths link to the effectiveness of the MPDSR system or the use of data from the system.

Response: The purpose of this study is to thoroughly investigate the role of information systems and their potential to improve the planning processes utilized by health managers. I have significantly revised the text to enhance its structure and clarity, ensuring that it effectively conveys the key concepts and findings. I greatly appreciate the detailed feedback provided, which has been instrumental in improving not only this paper but also future research projects in this field. This revision aims to provide deeper insights into how information systems can be leveraged for more efficient health management planning, ultimately contributing to better health outcomes. Thank you once again for your valuable input.

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Competing Interests

No competing interests were disclosed.

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Reviewer Report

13 Views

21 Nov 2024 | for Version 2

Theresa Diaz, Department of Maternal, Newborn, Child, Adolescent Health and Ageing,, World Health Organization, Geneva, Switzerland

13 Views Cite this report Responses(1)

Not Approved

I would first start with maternal death data and please update it with the latest estimates from 2020
Then I would explain what MPDSR is and how it is suppose to work in Bangladesh
Finally I would explain DHIS2 followed by the current information system in Bangladesh
Then the specific objectives of the study

Is the background of the case’s history and progression described in sufficient detail?

No
Is the work clearly and accurately presented and does it cite the current literature?

Partly
If applicable, is the statistical analysis and its interpretation appropriate?

Partly
Are all the source data underlying the results available to ensure full reproducibility?

Partly
Are the conclusions drawn adequately supported by the results?

Partly
Is the case presented with sufficient detail to be useful for teaching or other practitioners?

Partly

Competing Interests

No competing interests were disclosed.

Reviewer Expertise

Epidemiology and Monitoring and Evaluation

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Responses (1)

Author Response

18 Feb 2025

Abu Sadat Mohammad Sayem, University of Oslo, Oslo, Norway

Reviewer Comments:
This is an extremely important topic, however, as written is quite confusing without an overall diagram explaining how the entire system is supposed to work, it is difficult to understand this paper. I know MDPSR well but as written I could not understand how it is supposed to function in Bangladesh. I found the order of paragraphs could be changed and that there are some mixings of methods in results, results in methods and discussion in results and these should be fixed. There should be a separate section on analysis to understand how all these mixed methods are brought together.

Response: Thanks for the suggestion. I am adding an diagram in the introduction section

Reviewer Comments:
Additionally, I have highlighted issues and provided some possible solutions

Although all the information is in the introduction I find the order and presentation a bit confusing.

I would first start with maternal death data and please update it with the latest estimates from 2020
Then I would explain what MPDSR is and how it is suppose to work in Bangladesh
Finally I would explain DHIS2 followed by the current information system in Bangladesh
Then the specific objectives of the study

The objectives of the study listed in the last paragraph are vague. It is unclear as to why you need this study and what are the specific objectives.
You wrote page 3 para 7
“This study thoroughly analyzed the current information systems utilized in the MPDSR program to understand how they help. The study offers comprehensive insights into the functionality of the MPDSR dashboard in Bangladesh, along with a comparative analysis of the MPDSR information systems utilized in other countries for the purposes of effective planning. The qualitative interviews revealed significant gaps and barriers impeding evidence-based planning and action”

I think something like this instead might be helpful
Although MPDSR reporting has been incorporated into DHIS2 in Bangladesh we do not know how effective this has been to assist health managers plan for maternal and neonatal health programs. Using a mix method approach of data from 2019 to 2021 we examined the how this inclusion of MPDSR findings into DHIS2 was used to report deaths, inform program reviews, create MDSPR action plans and link to outcomes on key indicators. Additionally, we collected recommendations for improving the MDPSR program.

Response: This is great feedback, and I have tried to incorporate all of it in my way to keep the objective aligned with the research question.

Reviewer Comments:
Methods
The research question is not clear, please see my suggestion to refine the research question but you also need to state the specific objectives in the first paragraph. Not just say to “understand the given research problem”.

The methods or introduction should include a diagram as to who the current system works is supposed to work so we can better understand the results.

Response: I have revised it accordingly.

Reviewer Comments:
Page 4 para 3
A thematic analysis is not part of primary data collection but rather analysis. Please mention any software that might have been used to do this analysis. Please create a separate section in methods that is just analysis and how the mixed methods were brought together.

Response: I have not used software like NVIVO for thematic analysis. This was done based on the interviews and the emerging discussion points to organize it into different themes. I am added few lines in the method section.

Reviewer Comments:
Page 4 para 2
Similarly in Secondary data collection you mix the data collection with the analysis and it becomes confusing for example for public health websites you discuss using baseline 2019 data compared with 2021 from the score card but exactly what was compared and how statistically?
But I don’t understand what were the analysis methods used?

Response: The MPDSR dashboard includes various indicators, such as ANC and PNC coverage, which were compared between 2019 and 2021. This was a descriptive statistical analysis of the dashboard findings on MPDSR.

Reviewer Comments:
Page 4, para 3
Similarly, this belongs in an analysis section of methods
“Frequency analysis was used for MPDSR key actions in the seven districts and presented in a tabulated form. Quantitative data on death notifications were also analyzed in a Microsoft Excel (Version 2308) spreadsheet, shown in the Figures 2,3 and 4”

Response: We listed the interventions planned in the MPDSR action plans and analyzed the frequency of activities that were planned in most of the districts, highlighting the common actions based on the information available in the DHIS2. This analysis provides an impression of whether the information was used for planning, as the actions are linked to the reported number of deaths and causes of death.

Reviewer Comments:
Results
Overall, it is hard to understand what data sources were used for each research question and how each finding links to your original research questions. Also this section includes only results but some of the aspects written in this section should be in methods or introduction or discussion.
For example, suddenly you mention that Bangladesh is one of the few countries uses real time MPSDR data through a dashboard. That should have been mentioned in the introduction.

Then you add a method “The study team examined data to measure performance in 27 districts
and identify gaps in information system” These methods. Also the statement is vague, examine what data? To measure what performance, based on what measure?

Response: While inquiring about the data, the MOH directed us to the available dashboard where we could download the information. The team accessed the MPDSR dashboard to retrieve performance indicators such as death notification rates, death review rates, and other metrics like ANC and PNC coverage to evaluate district performance. This exercise was conducted for 27 districts.

Reviewer Comments:
Page 8 para 2
You don’t describe in methods how you would statistically determine an association.
“This study reviewed the scorecard of the MPDSR program and found that its key performance indicators were linked with maternal and neonatal mortality rates. The program’s performance dashboard can visualize its impact based on surveys and routine data. Most indicators showed positive changes, except in the Bandarban and Gazipur districts, where mortality and service coverage decreased. Pregnancy registration, delivery antenatal 4th visits coverage, and postnatal care increased in Jamalpur and Maulvibazar, where the impact of reducing MMR was the highest. The data were subject to verification but could be discussed during the MPDSR meetings”
Table 3 shows you results by district with no information as to what was happening with the MDSPR during these years, but to link the two you need to include this in the table how many MSDPR reviews occurred in each district in which years and what actions were actually taken up. All you are showing it the dashboard, the changes overtime could have occurred for many reasons other than MPDSR.

Response: Thank you again for critically examining this data. We had several discussions with the team on this topic, and we ultimately agreed to document our findings from the study. I understand that some of the findings were vague, but it is true that there was no further information on those issues, and the study faced limitations in further investigating the districts with higher mortality rates. However, we provided an analysis of the overall reporting performance of the MPDSR at the start, including the rate of death notifications and a review of those districts. Then, we attempted to review the MPDSR action plans to understand their strategies and their connection to the existing information. I acknowledge that many factors impacted the MMR and NMR, but the aim of the study was to determine whether the information was being utilized and to assess the dashboard's effectiveness in measuring what is happening.

Reviewer Comments:
Key recommendations
These findings are from the qualitative component key informant interviews, correct? Or are you putting some conclusions here?
Again it is confusing

Response: The recommendation came from the interview and I just mentioned what they mentioned during the interview. We are not trying any conclusion. But based on your advice, we are revising the language, which has created confusion.

Reviewer Comments:
Discussion
I could better understand the dashboards if I had a better explanation on how the overall system works. I am finding it confusing to know when the dashboards come into the process. Perhaps a diagram earlier on in methods would have helped.

Para 1 page 12
“The Southeast Asia region WHO report revealed that out of 10 countries, only three hold national-level meetings twice early on MPDSR committees. In Bangladesh, health managers recommend that the government and partners collaborate to implement the MPDSR and establish accountability and laws for death notification”
Without a explanation or diagram on how the system should work in Bangladesh, including frequency of meetings, this recommendation from Bangladesh is very vague. What is even the point of this paragraph if you do not mention the frequency in Bangladesh.

For example Page 11 para 8
In Bandarban, a hilly terrain, the interventions listed in the plan did not work out, and as per the scorecard, the MMR went up. The managers mentioned conducting video conferences to monitor progress regularly and to improve health managers’ accountability”
Was this ever mentioned in the results?
Not sure that the poor documentation mentioned in the discussion was highlighted in the results section

Response: I completely agree, but there were few papers on the MPDSR information system, including a dashboard. We tried to link other papers related to this study. There is definitely future scope to have more papers on MPDSR information systems and their impact. We have revised the points that you mentioned above.

Reviewer Comments:
Conclusion
Until the specific objectives and methods and results are re written it is hard to tell if these conclusions are linked to the findings.

Response: We have revised it completely.

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Competing Interests

No competing interests were disclosed.

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Reviewer Report

21 Views

25 Jun 2024 | for Version 1

Tahmina Begum, Poche Centre for Indigenous Health, The University of Queensland, Saint Lucia, Queensland, Australia

21 Views Cite this report Responses(1)

Approved With Reservations

Ethics would come next after describing the study design and setting.
This is not justified to explain mixed method as 3^rd, it is better to drop this line, at best author can say qual findings were used to explain the data gap……….. observed in quantitative findings.
Be specific about what you mean by primary and secondary data. Publicly available data from the DGHS dashboard is your secondary data source here. Did the patients provide consent to use their data for research? The research is focused on MPDSR, but the justification of analysis RMNCAH data is not clear from the methods section.
Though the author specifies the primary data source in 3^rd paragraph, different terminology “Document review was used to explain the quantitative data source. What documents did the author review as part of the Quan data source has not been specified before.
Nothing was mentioned about the analysis plan for the qualitative data. How did they divide data under the theme, what themes were used, how did you code, a-priori/reflexive /inductive …… manual /software?
What is the RMCH scorecard, and what are the components? How did u analyze them?
Figure 1.27 The study site seems clustered on the south side of the map, which means the rest of the sites are well-performing. Did the author use convenient sampling, if so, how it is going to affect the generalizability of your findings?

Result:

The result section is only to present findings, we can not add any argument or justification, For example, the below 2 lines do not fit in the result section. “It is also important to mention that the WHO provides projection-based population data to estimate the number of children born to each administrative unit”.
For all the figures Axis titles are not unique and check for spelling mistakes. Does not make sense to specify that Bangladesh and the intervention district are in the same graph with different bars.
Please explain how the estimated maternal and neonatal death numbers were calculated/projected in your method section.

Discussion:

Please add an opening paragraph with key findings from your paper.

Is the background of the case’s history and progression described in sufficient detail?

Partly
Is the work clearly and accurately presented and does it cite the current literature?

Partly
If applicable, is the statistical analysis and its interpretation appropriate?

Not applicable
Are all the source data underlying the results available to ensure full reproducibility?

Partly
Are the conclusions drawn adequately supported by the results?

Partly
Is the case presented with sufficient detail to be useful for teaching or other practitioners?

Partly

Competing Interests

No competing interests were disclosed.

Reviewer Expertise

To make this article reproducible by other researchers, a detailed description of the study methodology, data source, analysis plan needs to be well described

Respond to this report

Responses (1)

Author Response

05 Nov 2024

Abu Sadat Mohammad Sayem, University of Oslo, Oslo, Norway

Dear Reviewer,
Thanks for your comprehensive feedback on the article, and much appreciated. I have corrected those in my new version and added more facts to boost further understanding of the manuscript.

I have added more information in the introduction based on your comments.

Methods:
The ethics section has been relocated to a more appropriate position within the document to enhance clarity and coherence. In addition, the methods section has been thoroughly revised to improve its overall readability, and we have incorporated additional details to address your inquiries regarding both primary and secondary data collection methods.

I included qualitative analysis techniques, although I faced some constraints due to word limitations that prevented me from elaborating further on this aspect.

In the results section, I provided a comprehensive explanation of the RMNCAH (Reproductive, Maternal, Newborn, Child, and Adolescent Health) dashboard. This dashboard serves as an integrated data system that consolidates all relevant maternal and neonatal health information, enabling a better understanding of the outcome and impact-level indicators for Bangladesh.

Furthermore, the selection of districts for this study was based on specific criteria, which have been elaborated upon in the methods section to provide greater transparency regarding our approach.

Results:
The language and writing style of the results section have undergone a thorough revision to enhance clarity and precision. However, it was not possible to modify the Axis title, as it was sourced directly from the MPDSR dashboard, which has been cited in our reference materials.

Additionally, the explanation regarding the estimated population figures draws upon an Excel file that was provided by the World Health Organization (WHO) to the government. This Excel file contains comprehensive district-wise data, including detailed calculations that utilize the growth rate projections for each year. This meticulous methodology ensures accuracy and reliability in the population estimates presented.

Discussion:
It has been improved further.

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Competing Interests

No competing interests were disclosed.

Alongside their report, reviewers assign a status to the article:

Approved - the paper is scientifically sound in its current form and only minor, if any, improvements are suggested

Approved with reservations - A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit.

Not approved - fundamental flaws in the paper seriously undermine the findings and conclusions

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Maternal and perinatal death surveillance and response in Bangladesh: A case study on measuring impact through health information systems

Abstract

Keywords

Revised Amendments from Version 2

Introduction

Figure 1. Workflow of the existing MPDSR death notification, review and planning process.

Methods

Primary data collection

Table 1. List of key organizations involved in the MPDSR committee for primary data collection.

Secondary data collection

Figure 2. 27 districts for secondary data (dark shaded).

Results

Performance review through routine health information system

Figure 3. Gaps in capturing maternal death and review.

Figure 4. Gaps in capturing neonatal death and review.

Figure 5. Percentage of maternal and neonatal death notifications by country and intervention districts 2019 (Source: MPDSR dashboard).

Qualitative information through routine data

Figure 6. Major maternal and neonatal causes of death (Source MPDSR dashboard 2021).

MPDSR action plans

Table 2. List of interventions to prevent maternal and neonatal deaths identified in plans.

Impact measurement and comparing performance trends

Table 3. Comparison between key indicators from 2019 and 2021 (Source: RMNCAH Scorecard- DGHS).

Key recommendations for MPDSR

Discussion

Conclusion

Data availability

Underlying data

Extended data

References

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