Community engagement in maternal and perinatal death surveillance and response: a realist review

Community engagement in maternal and perinatal death surveillance and response (MPDSR) could support health systems in providing people-centred care and ensure accountability for the prevention of maternal and perinatal deaths. Although community engagement activities in MPDSR have been described, the literature does not adequately explain which community engagement in MPDSR strategies succeed, the contexts in which they work, the outcomes they produce, and for whom.

We conducted a realist review, which involved the identification and refinement of programme theories. An initial literature search identified four initial programme theories (IPTs) that explain how community engagement works in the different parts of the MPDSR cycle. Six databases (Medline, Embase, Scopus, Global Health, CINAHL Plus and Web of Science) and Google were searched for papers and grey literature published between 2004 and August 2022. We used retroductive analysis on included articles to support the identification of generative causation using the heuristic of 'context-mechanism-outcome configuration' (CMOCs), which explained what mechanisms were triggered in different contexts and the outcomes that were produced. The findings were then used to refine the IPTs and produce final programme theories.

Forty-five articles from 40 studies reported some form of community engagement in MPDSR. We identified 20 CMO configurations that were synthesised into five programme theories: (1) Fear of blame demotivates community members and health professionals from engaging in MPDSR. (2) Dialogue between health professionals and community members improves collaboration and empowers community members to propose innovative solutions. (3) Trusted social connections between bereaved families and community volunteers enables them to identify and report deaths. (4) Financial and non-financial incentives motivate community members and health professionals to engage in MPDSR. (5) Community engagement is more sustainable when it is routinised and integrated into the health system.

Implementing community engagement in MPDSR requires a systems approach that addresses the five Programme Theories collectively, rather than implementing community engagement in specific parts of the MPDSR cycle as our initial programme theories had suggested. Establishing conducive participatory spaces that promote dialogue, trust and minimise blame culture is critical for the success of community engagement in MPDSR programmes. Community members can be engaged in MPDSR processes in health facilities and community settings and high- and low-income countries.