Maternal and Perinatal Death Surveillance and Response (MPDSR) is a mandatory quality improvement process designed to track, review, and prevent maternal and newborn deaths. In Nigeria, high maternal and perinatal mortality ratios make MPDSR a vital tool for health systems strengthening. The primary objective is not to find culprits, but to understand the exact clinical, systemic, and social chain of events leading to a fatality. By routinely counting and analyzing every death, facilities can identify preventable gaps in care and transform tragedies into lessons that protect future mothers and babies. Midwives sit at the heart of this process because they manage the majority of normal and complicated labors across primary and secondary health facilities.
The MPDSR cycle begins the moment a maternal or perinatal death occurs within a facility or is identified in the community. Prompt notification is legally and ethically required to prevent data loss. Midwives and attending clinicians must immediately report every maternal death, as well as stillbirths and early neonatal deaths, to the facility MPDSR focal person or committee.
Once a death is notified, comprehensive data collection starts. Midwives pull the case notes, nursing charts, drug administration records, and laboratory results. The goal is to reconstruct the timeline of care using standardized abstraction forms.
The audit committee then convenes to analyze the three delays:
A successful MPDSR committee must foster a culture of safety and trust. If healthcare workers fear suspension, public humiliation, or legal prosecution, files will be falsified and deaths will go unreported. Confidentiality is equally paramount; patient names and staff identifiers are anonymized during facility reviews and national reports. Midwives and doctors must feel safe admitting human errors or system failures. The focus remains strictly on institutional improvements rather than personal fault, ensuring honesty during root-cause analysis.
Data collection and meetings are useless if they do not change clinical outcomes. The MPDSR committee must translate findings into SMART recommendations (Specific, Measurable, Achievable, Relevant, and Time-bound). For example, rather than recommending 'improve blood supply,' a proper recommendation states: 'The hospital management must procure a dedicated blood refrigerator and partner with the local blood bank by the end of next month.' Action plans are assigned to specific individuals with clear deadlines, bridging the gap between audit findings and actual bedside practice.
The final stage of MPDSR closes the loop by monitoring whether implemented recommendations actually resolved the identified problems. Committees must meet regularly to review tracking sheets and verify if procured equipment is working or if new protocols are being followed by junior and senior staff alike. Sustaining quality improvement requires continuous mentorship, supportive supervision, and feedback sessions where audit findings are shared openly with the entire clinical team. When midwives see their recommendations lead to tangible improvements in maternal survival, morale rises and quality care becomes institutionalized.