Beyond the guidelines: participants' perspectives on sustained MPDSR implementation in Nigeria, North Macedonia, and Sri Lanka

BACKGROUND: Maternal and perinatal death surveillance and response (MPDSR) was developed as a quality improvement intervention to reduce preventable maternal and newborn deaths and stillbirths. To gain deeper insight into the key components enabling sustained MPDSR implementation, we examined how MPDSR systems are organized and function in Nigeria, North Macedonia, and Sri Lanka. METHODS: We conducted 61 interviews with participants who were knowledgeable about the MPDSR system of their country, including policymakers, healthcare providers, and public health officials, at the national, subnational and facility levels. We applied content analysis to inductively identify themes and categories. RESULTS: Our findings suggest that participants perceive the goal of MPDSR as going beyond local quality improvement to encompass broader healthcare system strengthening. Four enabling components supporting sustained implementation were identified in all three countries: 1. coordination of the MPDSR “programme” through committees across levels; 2. adoption and integration of a data management and analysis system; 3. a confidential, nonpunitive approach supported by committed leadership; and 4. a multilevel, country-specific response strategy integrated with a broader health system strengthening. Sri Lanka demonstrated a highly centralized and structured approach, whereas Nigeria’s federal system showcased more diverse, multilevel stakeholder engagement. North Macedonia’s facility-based approach focused on the immediate implementation of quality improvements. CONCLUSIONS: The findings reveal that a structured, multilevel approach that is interconnected with the broader health system is supporting sustained MPDSR implementation. The potential of MPDSR as a health system programme that goes beyond facility-level mortality reduction links to an integrated health system strengthening and accountability at multiple levels.