Facilitators and barriers to the implementation of maternal and perinatal death surveillance and response in Ethiopia: a systematic review

Ethiopia was one of the pioneer countries to implement the World Health Organization's Maternal and Perinatal Death Surveillance and Response (MPDSR) system to accelerate the reduction in maternal and perinatal mortality. However, there has been no systematic evaluation of its implementation in Ethiopia and that's why we conducted this systematic review. A systematic review was conducted to synthesize the evidence on coverage, facilitators or barriers to MPDSR implementation in Ethiopia. We searched PubMed, Embase, Web of Science, PubMed Central, and Google Scholar using relevant key terms. In addition, Ethiopian Public Health Institute websites searched for additional data. Articles published before 2013 excluded from this review. The methodological quality of the studies assessed using the Joanna Briggs Institute's quality appraisal tool. For quantitative studies, descriptive analysis conducted; thematic synthesis used for qualitative studies. From twenty studies included, 12 only reported maternal death reviews while eight included maternal and perinatal death reviews. During the reporting period, the coverage of maternal and perinatal deaths remained less than 22.1% and 12.1% of the expected deaths respectively. Reported facilitators were community involvement, sufficient capacity building, and supportive supervision. Reported barriers were lack of conducive learning environment, fear of blame and litigation, lack of financial resources, high staff turnover, and defensive attitudes and practices. Despite all efforts, the uptake of MPDSR has been low. Addressing identified barriers and utilizing identified facilitators essential for optimising MPDSR implementation in Ethiopia. PROSPERO Registration Number: CRD42022315199. Ethiopia was one of the pioneer countries to adopt the World Health Organization's Maternal and Perinatal Death Surveillance and Response (MPDSR) system to accelerate the reduction in maternal and perinatal mortality. Although several studies on MPDSR implementation and/or barriers and facilitators to MPDSR in Ethiopia have been conducted, there is no comprehensive assessment of data to inform decision-making on the future of MPDSR. This review was conducted according to the Preferred Reporting Items for Systematic reviews and Meta-Analysis (PRISMA) guidelines. The review protocol was registered in PROSPERO (CRD42022315199). The PubMed (Medline), Embase (OVID), Web of Science (Core Collection), CINAHL, Cochrane Library (incl. CENTRAL), Google Scholar, PubMed Central, Academic Search Premier, Preprint Citation Index and Ethiopian Public Health Institute websites were used for searching. All identified articles exported to Covidence, and duplicates removed. Two reviewers (MY and CS) independently screened and reviewed the studies and reports against the inclusion criteria, and independently extracted information using predetermined inclusion criteria. The descriptive analysis conducted for quantitative studies while thematic synthesis done for qualitative studies and presented the main (sub-) themes in text and quotes. Over the reporting period, the coverage of maternal and perinatal deaths remained less than a quarter approximately of the expected deaths. Reported facilitators were community involvement, sufficient capacity building, and supportive supervision. Reported barriers were lack of conducive learning environment, fear of blame and litigation, lack of financial resources, high staff turnover, and defensive attitudes and practices. Therefore, addressing the identified barriers and utilizing identified facilitators paramount to optimise the MPDSR implementation in Ethiopia.