E-MPATHY: Development, validation, reliability, and acceptability of a decision-support tool for district-level...

Maternal Death Review (MDR), the cornerstone of Maternal Death Surveillance and Response (MDSR), generates evidence to inform strategies for reducing maternal death. However, MDR is often constrained by blaming cultures and the lack of structured approaches for systematic case review. These limitations hinder the objectivity identification of causes, contributing factors, and actionable recommendations. To address this gap, we developed a novel structured decision-support tool (DST) integrating scientific evidence and clinical standards to formulate evidence-based recommendation. This study aimed to develop a DST for district-level MDR and to evaluate its validity, reliability, and acceptability.

The tool development comprised four steps: needs assessment, face and content validity, reliability, and acceptability assessment. We compared the review findings of 113 cases based on expert-decision constructed using a DST between district and provincial review teams in Central Java, Indonesia. Reviewers' acceptability was assessed through observations during the review and analyzed using the Theoretical Framework of Acceptability.

The needs assessment resulted in 1) naming the tool (E-MPATHY), reflecting a supportive learning environment, and 2) the development of a structured DST framework integrating scientific evidence with the three delays model across pregnancy periods. The tool guided reviewers in assigning underlying causes of death based on the International Classification of Diseases for Maternal Mortality (ICD-MM), assessing preventability, identifying contributing factors, and generating recommendations. Agreement between two reviewer teams was almost perfect for ICD-MM classification (κ = 0.86; 95%CI:0.76-0.96; p < 0.001). In the three delays assessment, the highest agreement observed in the postpartum period (κ = 0.58; 95%CI:0.42-0.74; p < 0.001), with substantial agreement in the third delay phase (κ = 0.61; 95%CI:0.46-0.75; p < 0.001). The reviewers' acceptability indicated the benefits of evidence-based review and encourages positive learning attitudes in their daily practices.

The E-MPATHY had almost perfect inter-rater reliability in assigning ICD-MM. In addition, there was convincing evidence of its validity and acceptability to be a support direct learning tool potentially applied to institutionalized workable district MDR in Indonesia. However, as the evaluation was conducted within one province, further studies are needed to assess the tool's applicability across diverse health system contexts.