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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]
PUBLISHED 18 Feb 2025
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This article is included in the Data: Use and Reuse collection.

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

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).

4a7b8ac9-b1bc-4d0a-9157-2d7f5f247397_figure1.gif

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.

4a7b8ac9-b1bc-4d0a-9157-2d7f5f247397_figure2.gif

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.

4a7b8ac9-b1bc-4d0a-9157-2d7f5f247397_figure3.gif

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).

4a7b8ac9-b1bc-4d0a-9157-2d7f5f247397_figure4.gif

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.

4a7b8ac9-b1bc-4d0a-9157-2d7f5f247397_figure5.gif

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.

4a7b8ac9-b1bc-4d0a-9157-2d7f5f247397_figure6.gif

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 deathsKey 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).

District20192021201920212019202120192021201920212019202120192021
% of registered pregnant women% of registered pregnant womenAntenatal Care 1 CoverageAntenatal Care 1 CoverageAntenatal Care 4 CoverageAntenatal Care 4 CoverageDelivery by Skilled birth attendant (SBA) (%)Delivery by SBA (%)Postnatal Care 1 CoveragePostnatal Care 1 CoverageNeonatal Mortality RateNeonatal Mortality RateMaternal Mortality Ratio (MMR) Maternal Mortality Ratio (MMR)
Bandarban District17.216.236.416.921.67.536.517.617.26.15.712.6260.4544.9
Coxs Bazar District12.815.569.97134.141.363.680.640.6483.51.189.586.4
Jamalpur District17.423.169.668.347.145.756.659.453.655.26.83.3442.4111
Maulavi Bazar District7.420.291.287.242.855.270.570.661.665.28.46.5165.6133.9
Netrokona District1513.451.254.532.734.755.859.223.433.24.36.79489
Sylhet District8.89748037.844.275.476.265.770.121.482.754.5
Gazipur District36.144.254.247.53040.29969.224.635.42.23.530.645

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.

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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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ApprovedThe 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 approvedFundamental flaws in the paper seriously undermine the findings and conclusions
Version 3
VERSION 3
PUBLISHED 18 Feb 2025
Revised
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Reviewer Report 13 Aug 2025
Tahmina Begum, Poche Centre for Indigenous Health, The University of Queensland, Saint Lucia, Queensland, Australia 
Approved
VIEWS 1
I do not have further comments. ... Continue reading
CITE
CITE
HOW TO CITE THIS REPORT
Begum T. Reviewer Report For: 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/10.5256/f1000research.178061.r367223)
NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article.
Version 2
VERSION 2
PUBLISHED 05 Nov 2024
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Reviewer Report 24 Jan 2025
Christelle Boyi Hounsou, Centre de Recherche en Reproduction Humaine et en Démographie,, Cotonou, Benin;  Institute of Tropical Medicine, Antwerp, Belgium 
Approved with Reservations
VIEWS 11
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 ... Continue reading
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CITE
HOW TO CITE THIS REPORT
Boyi Hounsou C. Reviewer Report For: 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/10.5256/f1000research.174178.r342075)
NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article.
  • 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
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
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13
Cite
Reviewer Report 21 Nov 2024
Theresa Diaz, Department of Maternal, Newborn, Child, Adolescent Health and Ageing,, World Health Organization, Geneva, Switzerland 
Not Approved
VIEWS 13
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 ... Continue reading
CITE
CITE
HOW TO CITE THIS REPORT
Diaz T. Reviewer Report For: 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/10.5256/f1000research.174178.r338439)
NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article.
  • 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
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
Version 1
VERSION 1
PUBLISHED 10 Apr 2024
Views
20
Cite
Reviewer Report 25 Jun 2024
Tahmina Begum, Poche Centre for Indigenous Health, The University of Queensland, Saint Lucia, Queensland, Australia 
Approved with Reservations
VIEWS 20
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.
... Continue reading
CITE
CITE
HOW TO CITE THIS REPORT
Begum T. Reviewer Report For: 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/10.5256/f1000research.156288.r280803)
NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article.
  • 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
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

Comments on this article Comments (0)

Version 3
VERSION 3 PUBLISHED 10 Apr 2024
Comment
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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