Midwives' experiences of maternal death surveillance and response: insights from Mwanza District Hospital, Malawi

Despite the introduction of the Maternal Death Surveillance and Response (MDSR) program in Malawi in 2002, preventable maternal deaths remain a significant concern. Malawi's maternal mortality ratio (MMR) declined from 439 deaths per 100,000 live births in 2015 to 224 in 2024 (MDHS 2024) but remains well above the Sustainable Development Goal target of fewer than 70 deaths per 100,000 live births by 2030. In 2023/2024, Mwanza District Hospital recorded nine alarming maternal deaths. This study explored midwives' experiences in maternal death identification, notification, and reporting within the MDSR cycle.

An exploratory descriptive qualitative design was employed. Nineteen purposively selected midwives participated in semi-structured audio-recorded interviews. Data were analyzed thematically following Braun and Clarke's six steps, supported by NVivo 12 software. Ethical approval was obtained from the College of Medicine Research Ethics Committee (P.10/23-0358).

Midwives identified challenges across all stages of the MDSR cycle. During identification and notification, psychological distress and cross-border care complexities hampered accurate reporting. In the review and analysis stage, inconsistent documentation, weak coordination, and a prevailing culture of blame limited open discussion and learning. In the response and action stage, follow-up was fragmented, and fear of punishment discouraged active participation. In the monitoring and evaluation stage, feedback loops were weak, and lessons from reviews were not consistently shared with frontline providers, undermining system-wide improvement.

Midwives at Mwanza District Hospital experience significant emotional strain and systemic barriers in executing MDSR responsibilities. Strengthening support for timely identification and notification, promoting a blame-free culture in reviews, ensuring structured follow-up actions, and reinforcing feedback mechanisms are critical to improving maternal death surveillance and response.

Organizing midwives' experiences through the MDSR cycle highlights key intervention points. Addressing gaps in identification, review, response, and monitoring can enhance both provider well-being and system accountability, ultimately contributing to the reduction of preventable maternal mortality in resource-limited settings.