This was a mixed-methods study with a comprehensive design (cross-sectional analytical for the quantitative, and phenomenological for the qualitative) covering the period from January 1, 2022 to December 31, 2024.

The study was conducted in Kasai Province (DRC). Health data describes a health pyramid comprised of 18 health zones, 18 general referral hospitals, 46 referral health centers, 500 health centers, and 639 health posts. Human resources include 246 general practitioners, 29 public health specialists, 187 midwives, and 677 nurses. The major clinical constraint is the complete absence of obstetrician-gynecologists and pediatricians.

Our study population consisted of maternal and perinatal death records, healthcare providers, and community members.

Sampling and Selection Criteria

For the quantitative component, the approach was exhaustive, including all 432 usable maternal and perinatal death records from the 18 health zones. The qualitative component used purposive sampling of healthcare providers, health zone managers, and community members, divided into 15 interview groups of 8 to 10 participants. The inclusion and exclusion criteria are presented in Table 1.

Table 1. Inclusion and exclusion criteria.

StudyVariables

The dependent variable was the functionality of the SDMPR committee. The independent variables were: providers trained in SDMPR; availability of SDMPR forms; existence of the SDMPR committee in the health zone; completion of death reviews; and holding of SDMPR meetings at the health zone level. These variables were cross-tabulated with the performance indicators of the health system pillars.

Quantitative data collection was based on a literature review (registers, partograms, review forms) validated by a pretest of 20 records. Deaths not reported in the review reports were identified using healthcare facility registers. The qualitative component employed semi-structured interview guides, with systematic triangulation to ensure internal validity. Focus groups of 8 to 10 people were organized, recorded, and then transcribed. Les données quantitatives ont été nettoyées sur Excel, puis analysées sur Epi Info (v7.2.6.0) via des statistiques descriptives et inférentielles (IC à 95%). A logistic regression was performed to exclude confounding factors and estimate odds ratios. Le qualitatif a fait l’objet d’une analyse thématique. The performance of a maternal and perinatal death surveillance system is its operational capacity to detect, report, and analyze each maternal death and, most importantly, to implement effective corrective actions to prevent similar deaths in the future. The unit of analysis was the provincial maternal and perinatal death surveillance committee. The performance evaluation criteria for the committee were the proportion of deaths reported, the completion of reviews, the completeness and timeliness of reports, the availability of review forms, and follow-up. The performance threshold was set at 80%. The pillars of the WHO constitute the resources and interventions that can support the death surveillance system.

The protocol has received approval from the Ethics Committee of the University of Lubumbashi (No. UNILU/CEM/036/2025).

The analytical assessment of the six pillars of the health system highlighted two distinct performance categories. The pillars in critical condition (<50%) were Infrastructure (19%, lowest score) and Financing (45%). The pillars in the middle range (53% - 56%) were Human Resources for Health (56%), Medicines, Inputs and Consumables (56%), Governance (54%), and the Health Information System (HIS, 53%). (See Figure 1Figure 1)

Figure 1.Six pillars of the health system highlighted two distinct performance categories.

Table 3. Factors associated with the performance of the SDMPR system.

The statistical cross-check demonstrates that the performance of the SDMPR system is significantly linked (p < 0.05) to nine major indicators: notification of deaths (OR = 34.38), review of deaths (OR = 66.87), implementation of the response (OR = 9.08), follow-up, completeness of reports, timeliness of reports (OR = 15.63), availability of SDMPR forms, availability of providers trained in SDMPR and regular holding of SDMPR meetings at the ZS level (OR = 38.90) (See Table 3).

Table 4.Factors associated with the performance of the maternal, perinatal death surveillance and response system.

After adjusting for variables, eight indicators remained associated with the performance of the maternal, perinatal death surveillance and response system. These were death notification, death review, report completeness, report timeliness, response implementation, follow-up, availability of trained providers, and regular holding of SDMPR meetings (p = 0.0000) (See Table 4).

The perceptions of healthcare providers and community members were gathered to understand the reasons for the non-completion of maternal and perinatal death reviews (by Registered Nurses and Hospital Physicians) and to identify corrective measures.

Regarding the main causes of the non-completion of these reviews, the analysis of the interviews highlights several structural, behavioral, and logistical barriers. Institutional weaknesses were identified (absence of functional SDMPR committees in some Health Zones and lack of follow-up on recommendations), health governance problems (proliferation of unregulated healthcare facilities that do not report to the Central Health Zone Office, leading to major delays in the transmission of alerts), psychological and behavioral factors (fear of reprisals or blame from superiors, confusion between “review” and “sanction,” coupled with a degree of negligence on the part of some providers or hospital managers), and logistical constraints (shortage of physical tools (review and notification forms) and excessive centralization of training).

The verbatim transcripts and testimonies of the providers note the following:

Regarding the lack of committees and the communication gap: “The problem is the absence of SDMPR committees in our health zones. If these committees were established and operational,it would allow for a review and follow-up of recommendations each time there is a death (...). In Kanzala,I note that this committee has never been established. Another factor is the proliferation of structures,which makes it difficult for IT teams to gather information. Sometimes,you learn of a death very late,even though the notification hasn’t been made at the local level.”

On fear of hierarchy and the role of reviews: “The IT staff believe that when there is a maternal death,they will be blamed or condemned. Therefore,they either withhold information or report it late. But the purpose of the review is not to condemn,but rather to improve the quality of services. (...) When there is a death,it is not an inevitability to condemn,but it must be reported so that a solution can be found.”

On the management of tools and responsibility: “The IT staff and the MDH (Medical Department) don’t conduct reviews. It’s simply negligence. (...) They say they don’t have blank forms (...). Often,they call the Central Office to conduct the reviews; they don’t realize they have this responsibility. At the Central Office,we are given these forms in electronic format. We have never had the physical forms.”However,I know that with the structures supported by the PMNS under PBF (Performance-Based Financing),they have an autonomy that allows them to reproduce these tools.

Several potential solutions and corrective measures have been proposed. Discussions with stakeholders on the ground have converged on seven priority areas for revitalizing the surveillance system:

1. Regulating healthcare provision: Establish a rigorous mapping of maternity wards and implement a strict legal framework to prohibit deliveries in unsuitable facilities.

2. Operationalizing committees: Establish and strengthen the SDMPR committees within all health zones.

3. Strengthening skills through pooling: Organize decentralized training sessions in pools (similar to vaccination campaign briefings) to reach isolated providers and expand the critical mass of trained professionals.

4. Raising awareness of cultural change: Remind healthcare professionals of the obligation to report all deaths within 48 hours, emphasizing the non-punitive and constructive nature of the reviews.

5. Rigorous monitoring of decisions: Systematically implement and evaluate the recommendations from the reviews to ensure they are not ignored.

6. Logistical empowerment: Encourage local reproduction of notification forms (particularly through FBP/PMNS funding) and ensure the provision of tools in physical format.

7. Local support: Provide guidance and managerial support to the MDHs and ITs regarding their core responsibilities.