Transforming Maternal Mortality Data into Actionable Insights: A Case Study from Sierra Leone, 2024

Transforming Maternal Mortality Data into Actionable Insights: A Case Study from Sierra Leone, 2024 | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Transforming Maternal Mortality Data into Actionable Insights: A Case Study from Sierra Leone, 2024 Kassim Kamara, Bridget Magoba, Tom Sesay, Zainab Bah, Musu Cole, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6572728/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 7 You are reading this latest preprint version Abstract Background: Sierra Leone has made tremendous progress in reducing maternal mortality since establishing the Maternal Deaths Surveillance and Response (MDSR) in 2016. Despite the gains made in the reduction of maternal mortality in the country, the availability of credible data and its use for evidence-based interventions remained a major challenge. To address these gaps, the Ministry of Health (MoH), with funding and technical support from Bloomberg Philanthropies’ Data for Health Initiative and technical support from Vital Strategies and the African Field Epidemiology Network (AFENET), implemented a project aimed at identifying and addressing maternal health services inequalities in maternal health services in Sierra Leone. Methods : We conducted a consultative meeting, reviewed, and updated existing data collection tools and standard operating procedure (SOP). We updated the electronic data management system developed on District Health Information System 2 (DHIS2) with the updated data collection tools and developed training materials for data capture, analysis, visualization, and troubleshooting. We also conducted training for health workers on mid and high-level data management and analysis. Finally, we supported the development of an MDSR interactive dashboard for real-time data visualization. Results : This project supported the Ministry of Health in developing and revising six maternal mortality data collection and reporting tools, SOPs. We also built the capacity of 25 staff on electronic maternal mortality data management and analysis at the national and district levels using DHIS2. This project also led to the migration of maternal mortality data reporting from Microsoft Excel to an electronic case-based disease surveillance system in the DHIS2 platform, providing real-time data for decision-making. The dashboard, based on key maternal mortality indicators, supported the monitoring of district and national performance. The quality of maternal mortality data has improved. The project also added SMS notifications for each maternal death reported into the eCBDS system. Conclusion : This project improved the quality of maternal mortality data, enhanced the knowledge and skills of health workers at the national and district levels on electronic data management and use, migrated reporting from paper to electronic reporting, and developed an interactive dashboard for real-time data monitoring, access, and use. Maternal mortality data use Sierra Leone Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Figure 7 Figure 8 Figure 9 Introduction Accurate and reliable data are essential for monitoring and evaluating the delivery of healthcare services and programs [ 1 , 2 ]. The primary goal of maternal death surveillance and response (MDSR) is to eliminate preventable maternal mortality by obtaining and strategically using information to guide public health actions and monitor their impact [ 3 ]. Maternal death surveillance is the process of continuous surveillance for maternal deaths, which includes the routine identification, reporting, and response to all reported maternal deaths. When a maternal death occurs, the health facility staff or a community health worker immediately (within 24 hours) reports the event to the district health management team (DHMT). The DHMT investigates all maternal deaths reported from health facilities within 24 hours or 72 hours for community deaths. All investigated maternal deaths are reviewed by the Maternal Perinatal Death Surveillance and Response (MPDSR) committee at the district level to determine the cause of death and take action to prevent future occurrences [ 4 ]. In 2015, the Sierra Leone Ministry of Health (MoH) began conducting maternal death reviews on an ad hoc basis to reduce maternal deaths in health facilities. The start of this process revealed several gaps, including poor data quality issues such as poor data management, incomplete data, missing data, and late reporting, among others [ 5 ]. The World Health Organization (WHO), 2013, developed and introduced the Maternal Death Surveillance and Response (MDSR) technical guidance information for action to prevent maternal deaths [ 6 ]. To follow international best practices, Sierra Leone adopted the MDSR strategy in 2015 to strengthen maternal health systems and structures in the country. The adoption of the MDSR guideline resulted in the formation of MDSR committees at the national and district levels. In 2016, health facilities started reporting maternal deaths weekly to the districts, prompting an investigation by the district staff. The district staff will then conduct investigations and or reviews of maternal deaths, collate, and submit monthly reports to the Directorate of Reproductive and Child Health (DRCH) using a line listing template in Microsoft Excel [ 7 ]. The monthly reports received by the National MDSR coordinator from the districts are collated into a national line list. This process had many drawbacks affecting the quality of data, such as delayed reports, incomplete data, inaccessibility of data by stakeholders, and missing variables. Accordingly, timely and evidence-based public health actions can be achieved by timely, complete, and reliable data [ 8 ]. The MoH in 2016 implemented the first electronic case-based disease surveillance reporting of about 20 diseases, events, and conditions, including maternal deaths via phone calls, SMS, and email. Due to the delay in reporting, poor data quality and storage, incompleteness, and inaccurate loss of data, DHSE started the development of the electronic Case-Based Disease Surveillance System (eCBDS) to capture detailed information on 21 selected priority diseases, events, and conditions. Furthermore, one of the DRCH mandates is to reduce maternal mortality, so it was the best-suited directorate to utilize the case-based maternal mortality data to make public health decisions [ 9 ]. In 2020, maternal and perinatal deaths case-based reporting was separated from the reporting form of the rest of the disease conditions, as shown in the data flow diagram. The design of the electronic maternal and perinatal deaths data collection form was based on the maternal deaths identification and notification form detailing the demographics of the case (Fig. 1 ) and the case investigation form which includes the admission and vital information, Antenatal care, risk factors, underlying conditions, laboratory tests, labor, delivery, barriers to care, interventions, causes of death, and death summary. This article focuses on maternal mortality. Maternal death is immediately notified by the health facility by filling out the paper and electronic maternal death identification and notification forms. A short message service (SMS) is automatically sent from DHIS2 to the national and district-responsible staff for response. This is followed by a physical investigation of the case by the district staff, a paper investigation form filled out, and later, the electronic form. National-level staff analyze and monitor data through a dashboard and report generation. Despite the implementation of the MDSR guidelines in Sierra Leone, major gaps existed in data collection and use at all levels of the healthcare system due to limited knowledge among healthcare personnel and a lack of data collection tools, among other factors. This gap attracted technical and financial support, especially from non-governmental organizations, including the United Nations Population Fund (UNFPA), the United Nations Children’s Fund (UNICEF), the African Field Epidemiology Network (AFENET), and the World Health Organization (WHO), among others. Therefore, in 2015, the MoH saw the need to use digital tools for data collection and analysis of aggregate and case-based maternal death data using the District Health Information System 2 (DHIS 2) [ 10 ]. Even though some health facilities were filling out the case-based notification form (Fig. 1 ), most of the data remained on paper, which was unusable for public health actions. According to the Performance of Routine Information System Management Series (PRISM) framework, data quality indicators such as timeliness and completeness are used to assess data collection and transmission processes [ 11 ]. Maternal death is one of the events that requires immediate (within 24 hours) reporting to the next level upon detection [ 12 ]. Investigation and review of maternal deaths are not usually done immediately following the report of the deaths to the District Health Management Team (DHMT). However, despite the availability of the DHIS2 system to collect and store case-based and aggregate maternal mortality data, there were several fragmented systems for reporting maternal deaths, limited knowledge of data management and analysis among staff, and poor quality data, leading to limited use of maternal mortality data for planning and policy development. Methods Maternal Health Services Inequalities Data Use Project. To address these gaps, the MoH, with funding and technical support from Vital Strategies and technical support from the African Field Epidemiology Network (AFENET), in March 2024, launched a project aimed at identifying and addressing maternal health services inequalities in maternal health services in Sierra Leone. The goal of this initiative was to enhance the use of data related to maternal mortality and health services to guide public health actions and improve maternal health outcomes. The project aimed to generate high-quality maternal mortality data to identify groups disproportionately affected and address these inequalities by March 2025. Project implementation We used mixed methods of qualitative and quantitative data review, including the use of the DHIS2 system. We collected data by reviewing maternal and perinatal death surveillance and response (MPDSR) guidelines, MDSR annual reports, Integrated Disease Surveillance and Response (IDSR) technical guidelines, digital health strategy, and eIDSR documentation. To document Sierra Leone's experience in digitizing its case-based maternal mortality data, qualitative data were analyzed using content and thematic analysis. Additionally, Microsoft Excel and the eCBDS system were utilized to manage quantitative data collected from 2019 to 2024. Review of data collection tools and standard operating procedures Following the launch of the data use project, a review of data collection, reporting tools, and standard operating procedures (SOPs) commenced. This was to develop and or update the data collection tools to capture key information on maternal deaths and the SOPs to standardize the processes in responding to maternal deaths, considering equity. The review of the tools and SOPs was conducted by key stakeholders, including physicians, public health professionals, and partners, through a one-day workshop with technical support from AFENET. Figure 1 shows the revised maternal death identification and notification form. Customization of reporting tools Following the review and finalization of the maternal death reporting tools, AFENET supported the RCH directorate in aligning the new tools such as the maternal death identification and notification form and the case investigation form to the existing electronic MPDSR tool in the DHIS2 system to facilitate real-time reporting and access to the data for timely decision making. The electronic form is shown in Fig. 4 . The electronic system can be accessed by a computer or laptop using the web application or an Android mobile device using the DHIS2 capture application for data entry. Data entry using the mobile application can be done offline and later synchronized to the server when connected to the internet. Training and capacity building A five-day training on data management and analysis focusing on equity disaggregation was conducted for national and district stakeholders, including data officers, clerks, district health sisters (DHSs), the national maternal mortality surveillance coordinator, and national monitoring and evaluation officers. The training covered key modules of the DHIS2 system, such as data entry, analysis, and visualization. The data entry session covered hard copy, electronic reporting notifications, and case investigation forms to ensure data completeness. To also improve their writing skills, nine (9) national staff including the RCH director, program manager for adolescent health, MDSR coordinator, M&E officer, and other technical staff were trained on scientific writing for five days with the aim of directorate using its data to support decision making and for sharing Sierra Leone’s story through publications. Mentorship sessions Five phases of mentorship sessions were conducted in all the districts and national level by AFENET and RCH national staff to enhance the knowledge and skills of district health sisters (DHS) following the training on using the system. These mentorship sessions were conducted by providing hands-on support to DHSs and the entry of real maternal death cases into the eCBDS system. The selection of the targeted district in each mentorship was made using data quality indicators, including timeliness and completeness of data entry, the proportion of missing variables for cases entered, and duplication of maternal deaths notified. Interactive dashboard development and data monitoring Maternal death data entry into the electronic case-based disease surveillance system (eCBDS) commenced following the training of the targeted individuals selected by the MoH through the RCH directorate. This was to facilitate the real-time display of maternal mortality performance indicators such as the number of maternal deaths reported by year and month, and district, Maternal mortality ratio by month, year and district, the proportion of cases investigated by month, year, and district among others to trigger timely public health actions at the national and district levels. The dashboard was developed based on the needs of the RCH directorate, and changes were made based on the needs of the directorate. The dashboard also facilitates monitoring data quality, including its timeliness and completeness, providing information for following up with districts for corrective actions to improve the quality of data. Results Project outputs Availability of updated maternal and perinatal data collection tools and SOPs The revised versions of the reporting tools, including the maternal death identification and notification form, the maternal death investigation form, and the weekly reporting form, were distributed to the districts. Using existing maternal mortality data from 2019 to 2024 generated before and during this project, we observed a significant variation in the MMR across districts. Districts such as Tonkolili and Western Area Urban recorded consistently high MMRs with an average of 303 and 359 per 100,000 live births, respectively, while districts like Kailahun and Karena recorded lower average MMRs of 89 and 111 deaths per 100,000 population. The MMRs recorded by Western Area Urban and Tonkolili districts are higher than the national average MMR of 216 per 100,000 live births. However, the MMR varies significantly across districts. Districts such as Karene and Moyamba had low MMRs in 2019 and 2020, while others, like Kenema and Western Area Rural, showed a relatively steady or fluctuating trend during the analysis period. The districts of Tonkolili and Western Area Urban reported consistently high MMRs throughout the six years, indicative of continuing challenges in addressing maternal mortality in these areas. Bo and Bombali districts, on the other hand, recorded relatively stable and lower MMR trends. This analysis revealed disparities among districts and offered recommendations to the MoH for improved maternal outcomes. Migration of reporting from manual to electronic-based reporting This project covered all sixteen districts and introduced the use of an electronic case-based disease surveillance reporting system (eCBDS) for maternal mortality data. During this project, the capacity building of 25 staff on the use of the eCBDS system from district health management teams (DHMT) and the RCH directorate was achieved through training and mentorships. Before the implementation of this project, reporting of maternal mortality data was possible through the use of an MS Excel template developed by the RCH directorate, no web-based system was in place to enter and store the data electronically. Currently, on average, over 98% of all reported maternal deaths from health facilities are notified through the eCBDS system, while about 95% on average of all investigated maternal death cases have been entered in the eCBDS system. This has facilitated real-time access and use of maternal mortality data by stakeholders for timely decision-making. Improved capacity on the eCBDS system, data use, and scientific writing In June 2024, 25 personnel, including district health sisters and national staff from the RCH directorate, were trained in data management and analysis using the eCBDS system. Data management covered data collection, and entry, while the data analysis module covered generating line lists of all maternal deaths with the preferred variables of the user, data visualizer for creating graphs, charts, and tables of aggregate data including disaggregations such as causes of death by district, age, marital status among others. Lastly, the staff were trained on how to generate a map using DHIS2, displaying the number of maternal deaths and the distribution of cases across the country or district, among others. Other modules covered included data quality checks such as filling mandatory fields, completing all the relevant variables, how to avoid duplications, ensuring consistency, and the timeliness of real-time reporting. After the one-year implementation of this project in the sixteen districts, all the 16 district health sisters (DHS), and nine (9) national staff of the RCH directorate continue using the eCBDS system for data reporting and monitoring of maternal mortality data. National technical officers currently use the eCBDS system to monitor the performance of districts on maternal deaths reported, investigated, timeliness, and completeness of maternal mortality data. The writing skills of nine (9) RCH staff have improved, this has been demonstrated through the ongoing writing of three manuscripts and presentations of program performance during stakeholder meetings. Five mentorship phases were conducted on 16 district staff by three (3) MoH staff and two AFENET staff. The capacity-building activities, including training and mentorships, built and enhanced the capacity of nine (9) national staff and 16 district staff. The majority of the district health sisters said they are knowledgeable in using the eCBDS system for data reporting, analysis, and monitoring of their performance. Similarly, the training was an opportunity to clear the data entry backlog for cases reported in 2024 across all the districts, which gave the trainees a hands-on experience. This project has improved the quality and use of maternal mortality data. This has been demonstrated through the use of the current data for programmatic reporting. The capacity of nine (9) national staff was enhanced in scientific writing. Currently, these staff are writing three manuscripts using maternal and perinatal mortality data. Figure 4 shows the status of maternal mortality data entry into the eCBDS system by year. Even though the eCBDS system was introduced in Sierra Leone in 2016, maternal mortality case-based data entry effectively started in 2024 during the implementation of the data use project funded by Vital Strategies and implemented by AFENET and the MoH. Data use for decision-making The quality of maternal mortality data has greatly improved, evidenced by improvement in the timeliness, completeness, and trustworthiness of the data. This led to the commencement of the weekly maternal and child death emergency meeting to discuss the data reported, identify resource gaps by district, and allocate resources by district based on the maternal deaths reported and reviews conducted. Discussion This manuscript describes the implementation of the project on identifying and addressing maternal health services inequalities in Sierra Leone through enhancing data quality and its use for decision-making. There is a marked improvement in the status of maternal mortality data entry for investigated cases from the district level through the eCBDS system, while timeliness and completeness have greatly improved [ 13 ]. “ This system has greatly improved the timely availability of maternal mortality data and use for decision making” ( Zainab Juheh Bah, National Maternal Mortality Coordinator ). The use of quality data to guide evidence-based decisions cannot be overstated since many health-implementing entities primarily rely on it for resource allocation and other health interventions to improve health outcomes [ 8 , 14 , 15 ]. The migration of the maternal mortality reporting from MS Excel to the eCBDS system has improved the quality of the data reported, including its timeliness and completeness, compared to the former way of reporting. Furthermore, the inclusion of the DHSs in reporting maternal mortality data into the eCBDS system improved ownership, accountability, as well as their capacity to use electronic systems. Using routine data and the high-quality data generated during this project, the disparities among districts were evidenced by the variation in the maternal mortality ratio (MMR) among districts, with Western Area Urban recording a high MMR compared to other districts. This finding is inconsistent with another study that has reported other districts having higher MMR [ 16 ]. This finding suggests the need to conduct in-depth research on disparities and inequalities accounting for this variation. Stakeholders' engagement through consultative meetings on the review of maternal mortality tools and SOPs improved collaborations, involvement, ownership, and accountability on maternal mortality-related issues [ 17 , 18 ] The creation of an interactive maternal mortality dashboard is critical for real-time monitoring of maternal mortality data and prompt evidence-based actions for the reduction of maternal mortality in Sierra Leone. Several studies have demonstrated the use of digital solutions in maternal healthcare delivery to improve maternal health outcomes [ 19 – 23 ]. The capacity building at the national and district levels in data management and analysis using the eCBDS and scientific writing is commendable. However, continuous training and mentorship are critical to sustaining the gains of this project and the maintenance of the eCBDS system [ 24 , 25 ]. Furthermore, this project supported the RCH directorate in digitizing the perinatal death surveillance forms into the eCBDS system as recommended by the MoH. However, this was not part of the project’s scope, and we are therefore recommending that the RCH directorate mobilize resources to roll out the perinatal aspect similar to what has been done for maternal deaths. Limitation This study documented the implementation of a project to improve data use for decision-making. The data used from the DHIS2 may not be representative, given the underreporting and overreporting of routinely collected data. In addition, documenting one year of project implementation may not show the actual impact of this project. Conclusion This project focused on identifying and addressing maternal health services inequalities in Sierra Leone through the identification of gaps in maternal mortality data quality and use. Through this project, reporting of maternal mortality data has shifted from MS Excel to a web-based system, which has greatly improved the quality of the data from the districts. This has further facilitated real-time access to quality data for decision-making. The capacity built on the use of the eCBDS system, scientific writing, mentoring, data management, and analysis will promote the sustainability of the gains made by this project. Real-time monitoring of district performance on key indicators is now possible through the dashboards developed through this project. To ensure the sustainability of this project, we recommend that the MoH, through the RCH directorate, lobby with other partners to provide resources to continue the implementation of key activities, including refresher training, mentoring, and data bundles for reporting. Declarations Availability of Data and Materials The data used is openly available in the DHIS2 system upon permission from the Ministry of Health (URL: Sierra Leone Integrated Disease Surveillance and Response (IDSR/eCBDS)). To obtain the data or get access to the data in the DHIS2 system, please contact: Name: Zainab Juheh Bah Designation: National Coordinator, Maternal Deaths Surveillance and Respose Email: [email protected] Ethics approval and consent to participate Ethical approval for this study was waived by the Sierra Leone Ethics and Scientific Review Committee, since this study uses routinely collected aggregate data and had requisite permission from the Ministry of Health. All the study participants provided informed consent to participate in this study. The documentation and publication of the project implemented were approved by the donors and the Sierra Leone Ministry of Health leadership. This study is also in compliance with the Helsinki Declaration on use of human subjects as study participants. Consent for publication Not applicable Availability of data and materials Not applicable Competing interest The authors declared no competing interests. Funding This project was supported by Bloomberg Philanthropies’ Data for Health Initiative through a cooperative agreement between AFENET and Vital Strategies. Authors’ contributions BM, GNG developed the protocol. KK and BM analyzed and interpreted the data. KK drafted the manuscript. BM, TS, ZB, MC, FM, and GNG reviewed several drafts of the manuscript and made significant contributions throughout the writing process. All the authors approved the submission of the manuscript for publication. Acknowledgment This project was funded by Bloomberg Philanthropies’ Data for Health Initiative. Vital Strategies provided technical support. The contents are solely the authors'. 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Cite Share Download PDF Status: Under Review Version 1 posted Reviews received at journal 10 Jul, 2025 Reviewers agreed at journal 25 Jun, 2025 Reviewers invited by journal 23 Jun, 2025 Editor assigned by journal 18 Jun, 2025 Editor invited by journal 27 May, 2025 Submission checks completed at journal 27 May, 2025 First submitted to journal 27 May, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6572728","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":476300232,"identity":"8c7e85a5-cabc-4682-9a42-97aff21f0f0d","order_by":0,"name":"Kassim 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Network","correspondingAuthor":false,"prefix":"","firstName":"Bridget","middleName":"","lastName":"Magoba","suffix":""},{"id":476300234,"identity":"ad3e7797-4a58-4299-8a79-d5601ca46f0d","order_by":2,"name":"Tom Sesay","email":"","orcid":"","institution":"Ministry of Health","correspondingAuthor":false,"prefix":"","firstName":"Tom","middleName":"","lastName":"Sesay","suffix":""},{"id":476300235,"identity":"6e513cc3-7f58-40b1-a2f3-0069798b8432","order_by":3,"name":"Zainab Bah","email":"","orcid":"","institution":"Ministry of Health","correspondingAuthor":false,"prefix":"","firstName":"Zainab","middleName":"","lastName":"Bah","suffix":""},{"id":476300236,"identity":"9bc4fd30-f78c-40be-9539-79b1b996ac5f","order_by":4,"name":"Musu Cole","email":"","orcid":"","institution":"Ministry of Health","correspondingAuthor":false,"prefix":"","firstName":"Musu","middleName":"","lastName":"Cole","suffix":""},{"id":476300237,"identity":"58bf6106-f114-4aa8-b993-00a18ddb696c","order_by":5,"name":"Francis Moses","email":"","orcid":"","institution":"Ministry of Health","correspondingAuthor":false,"prefix":"","firstName":"Francis","middleName":"","lastName":"Moses","suffix":""},{"id":476300238,"identity":"55fffa61-6689-406e-897e-2e16b1307e1b","order_by":6,"name":"Gebrekrstos Negash Gebru","email":"","orcid":"","institution":"African Field Epidemiology Network","correspondingAuthor":false,"prefix":"","firstName":"Gebrekrstos","middleName":"Negash","lastName":"Gebru","suffix":""}],"badges":[],"createdAt":"2025-05-01 15:08:03","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6572728/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6572728/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":85724165,"identity":"9032f687-a365-4c2c-ab58-980825cadbce","added_by":"auto","created_at":"2025-07-01 06:15:25","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":74546,"visible":true,"origin":"","legend":"\u003cp\u003eMPDSR data flow and feedback mechanism\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-6572728/v1/6ce74a487d6499a1aa7c1045.png"},{"id":85723446,"identity":"a29378a3-bd37-4e52-90e8-0dc552e03745","added_by":"auto","created_at":"2025-07-01 06:07:25","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":126092,"visible":true,"origin":"","legend":"\u003cp\u003eMaternal health services inequalities data use project timelines\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-6572728/v1/6984c07fdd66e63c2c908a5a.png"},{"id":85724167,"identity":"7a6a905a-9387-45cd-95b6-6aead5e7e50e","added_by":"auto","created_at":"2025-07-01 06:15:25","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":148373,"visible":true,"origin":"","legend":"\u003cp\u003eMaternal death identification and notification form, Sierra Leone\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-6572728/v1/920ff6545b2fa936b61badf0.png"},{"id":85723449,"identity":"3e3803e5-14f4-4a52-b6ce-41b038eae75f","added_by":"auto","created_at":"2025-07-01 06:07:25","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":76959,"visible":true,"origin":"","legend":"\u003cp\u003eMaternal death notification form in the eCBDS system\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-6572728/v1/1780fd195d2405160f97eade.png"},{"id":85724551,"identity":"19b4e275-fe0c-45e6-ab6a-79da8e5a2272","added_by":"auto","created_at":"2025-07-01 06:23:25","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":96600,"visible":true,"origin":"","legend":"\u003cp\u003eEntry status of maternal mortality data by districts as of 19 February 2025\u003c/p\u003e","description":"","filename":"5.png","url":"https://assets-eu.researchsquare.com/files/rs-6572728/v1/f0e3e075e76da3c75c4043b2.png"},{"id":85724166,"identity":"a95354f4-92c9-4af2-a0e8-4cf995dfebfe","added_by":"auto","created_at":"2025-07-01 06:15:25","extension":"png","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":34923,"visible":true,"origin":"","legend":"\u003cp\u003eProportion of maternal death cases investigated entered into the eCBDS system 2023 vs 2024\u003c/p\u003e","description":"","filename":"6.png","url":"https://assets-eu.researchsquare.com/files/rs-6572728/v1/b931fe782e4733087fa9e72e.png"},{"id":85723462,"identity":"fb151231-cfa3-41ed-9ad9-fbd29c33aa2f","added_by":"auto","created_at":"2025-07-01 06:07:26","extension":"png","order_by":7,"title":"Figure 7","display":"","copyAsset":false,"role":"figure","size":114031,"visible":true,"origin":"","legend":"\u003cp\u003eInteractive dashboard developed of key indicators based on available data as of 30 January 2025.\u003c/p\u003e","description":"","filename":"7.png","url":"https://assets-eu.researchsquare.com/files/rs-6572728/v1/9fd3101adb131fd3cb7c82a1.png"},{"id":85723457,"identity":"011012e2-be41-4830-b414-356d9d6a4e23","added_by":"auto","created_at":"2025-07-01 06:07:25","extension":"png","order_by":8,"title":"Figure 8","display":"","copyAsset":false,"role":"figure","size":207566,"visible":true,"origin":"","legend":"\u003cp\u003eCompleteness of reporting by districts before and after phase 4 and 5 mentorships\u003c/p\u003e","description":"","filename":"8.png","url":"https://assets-eu.researchsquare.com/files/rs-6572728/v1/1c4d466888b52a9ce2a6c503.png"},{"id":85724171,"identity":"acc7e548-6b0c-4aaa-8ea0-de1e47f3965a","added_by":"auto","created_at":"2025-07-01 06:15:26","extension":"png","order_by":9,"title":"Figure 9","display":"","copyAsset":false,"role":"figure","size":20989,"visible":true,"origin":"","legend":"\u003cp\u003eProportion of maternal deaths investigated entry status into eCBDS by year, 2018 \u0026nbsp;to 2025\u003c/p\u003e\n\u003cp\u003e2025: Data as of 10 March 2025\u003c/p\u003e","description":"","filename":"9.png","url":"https://assets-eu.researchsquare.com/files/rs-6572728/v1/2e80098d7eaf2b2bbe2868f4.png"},{"id":85724858,"identity":"383dac0f-0f4a-4a39-a797-ac9da3423cb8","added_by":"auto","created_at":"2025-07-01 06:23:51","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1471037,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6572728/v1/5cc6ec3c-15cc-4fca-a3c5-98a143a935ac.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Transforming Maternal Mortality Data into Actionable Insights: A Case Study from Sierra Leone, 2024","fulltext":[{"header":"Introduction","content":"\u003cp\u003eAccurate and reliable data are essential for monitoring and evaluating the delivery of healthcare services and programs [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. The primary goal of maternal death surveillance and response (MDSR) is to eliminate preventable maternal mortality by obtaining and strategically using information to guide public health actions and monitor their impact [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Maternal death surveillance is the process of continuous surveillance for maternal deaths, which includes the routine identification, reporting, and response to all reported maternal deaths. When a maternal death occurs, the health facility staff or a community health worker immediately (within 24 hours) reports the event to the district health management team (DHMT). The DHMT investigates all maternal deaths reported from health facilities within 24 hours or 72 hours for community deaths. All investigated maternal deaths are reviewed by the Maternal Perinatal Death Surveillance and Response (MPDSR) committee at the district level to determine the cause of death and take action to prevent future occurrences [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. In 2015, the Sierra Leone Ministry of Health (MoH) began conducting maternal death reviews on an ad hoc basis to reduce maternal deaths in health facilities. The start of this process revealed several gaps, including poor data quality issues such as poor data management, incomplete data, missing data, and late reporting, among others [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. The World Health Organization (WHO), 2013, developed and introduced the Maternal Death Surveillance and Response (MDSR) technical guidance information for action to prevent maternal deaths [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. To follow international best practices, Sierra Leone adopted the MDSR strategy in 2015 to strengthen maternal health systems and structures in the country.\u003c/p\u003e \u003cp\u003e The adoption of the MDSR guideline resulted in the formation of MDSR committees at the national and district levels. In 2016, health facilities started reporting maternal deaths weekly to the districts, prompting an investigation by the district staff. The district staff will then conduct investigations and or reviews of maternal deaths, collate, and submit monthly reports to the Directorate of Reproductive and Child Health (DRCH) using a line listing template in Microsoft Excel [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. The monthly reports received by the National MDSR coordinator from the districts are collated into a national line list. This process had many drawbacks affecting the quality of data, such as delayed reports, incomplete data, inaccessibility of data by stakeholders, and missing variables. Accordingly, timely and evidence-based public health actions can be achieved by timely, complete, and reliable data [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe MoH in 2016 implemented the first electronic case-based disease surveillance reporting of about 20 diseases, events, and conditions, including maternal deaths via phone calls, SMS, and email. Due to the delay in reporting, poor data quality and storage, incompleteness, and inaccurate loss of data, DHSE started the development of the electronic Case-Based Disease Surveillance System (eCBDS) to capture detailed information on 21 selected priority diseases, events, and conditions. Furthermore, one of the DRCH mandates is to reduce maternal mortality, so it was the best-suited directorate to utilize the case-based maternal mortality data to make public health decisions [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn 2020, maternal and perinatal deaths case-based reporting was separated from the reporting form of the rest of the disease conditions, as shown in the data flow diagram. The design of the electronic maternal and perinatal deaths data collection form was based on the maternal deaths identification and notification form detailing the demographics of the case (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e) and the case investigation form which includes the admission and vital information, Antenatal care, risk factors, underlying conditions, laboratory tests, labor, delivery, barriers to care, interventions, causes of death, and death summary. This article focuses on maternal mortality. Maternal death is immediately notified by the health facility by filling out the paper and electronic maternal death identification and notification forms. A short message service (SMS) is automatically sent from DHIS2 to the national and district-responsible staff for response. This is followed by a physical investigation of the case by the district staff, a paper investigation form filled out, and later, the electronic form. National-level staff analyze and monitor data through a dashboard and report generation.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e Despite the implementation of the MDSR guidelines in Sierra Leone, major gaps existed in data collection and use at all levels of the healthcare system due to limited knowledge among healthcare personnel and a lack of data collection tools, among other factors. This gap attracted technical and financial support, especially from non-governmental organizations, including the United Nations Population Fund (UNFPA), the United Nations Children\u0026rsquo;s Fund (UNICEF), the African Field Epidemiology Network (AFENET), and the World Health Organization (WHO), among others.\u003c/p\u003e \u003cp\u003eTherefore, in 2015, the MoH saw the need to use digital tools for data collection and analysis of aggregate and case-based maternal death data using the District Health Information System 2 (DHIS 2) [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Even though some health facilities were filling out the case-based notification form (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e), most of the data remained on paper, which was unusable for public health actions. According to the Performance of Routine Information System Management Series (PRISM) framework, data quality indicators such as timeliness and completeness are used to assess data collection and transmission processes [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Maternal death is one of the events that requires immediate (within 24 hours) reporting to the next level upon detection [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Investigation and review of maternal deaths are not usually done immediately following the report of the deaths to the District Health Management Team (DHMT). However, despite the availability of the DHIS2 system to collect and store case-based and aggregate maternal mortality data, there were several fragmented systems for reporting maternal deaths, limited knowledge of data management and analysis among staff, and poor quality data, leading to limited use of maternal mortality data for planning and policy development.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e \u003cb\u003eMaternal Health Services Inequalities Data Use Project.\u003c/b\u003e \u003c/p\u003e \u003cp\u003eTo address these gaps, the MoH, with funding and technical support from Vital Strategies and technical support from the African Field Epidemiology Network (AFENET), in March 2024, launched a project aimed at identifying and addressing maternal health services inequalities in maternal health services in Sierra Leone. The goal of this initiative was to enhance the use of data related to maternal mortality and health services to guide public health actions and improve maternal health outcomes. The project aimed to generate high-quality maternal mortality data to identify groups disproportionately affected and address these inequalities by March 2025.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eProject implementation\u003c/h2\u003e \u003cp\u003e We used mixed methods of qualitative and quantitative data review, including the use of the DHIS2 system. We collected data by reviewing maternal and perinatal death surveillance and response (MPDSR) guidelines, MDSR annual reports, Integrated Disease Surveillance and Response (IDSR) technical guidelines, digital health strategy, and eIDSR documentation.\u003c/p\u003e \u003cp\u003eTo document Sierra Leone's experience in digitizing its case-based maternal mortality data, qualitative data were analyzed using content and thematic analysis. Additionally, Microsoft Excel and the eCBDS system were utilized to manage quantitative data collected from 2019 to 2024.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eReview of data collection tools and standard operating procedures\u003c/h3\u003e\n\u003cp\u003e Following the launch of the data use project, a review of data collection, reporting tools, and standard operating procedures (SOPs) commenced. This was to develop and or update the data collection tools to capture key information on maternal deaths and the SOPs to standardize the processes in responding to maternal deaths, considering equity. The review of the tools and SOPs was conducted by key stakeholders, including physicians, public health professionals, and partners, through a one-day workshop with technical support from AFENET. Figure\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e shows the revised maternal death identification and notification form.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e\n\u003ch3\u003eCustomization of reporting tools\u003c/h3\u003e\n\u003cp\u003eFollowing the review and finalization of the maternal death reporting tools, AFENET supported the RCH directorate in aligning the new tools such as the maternal death identification and notification form and the case investigation form to the existing electronic MPDSR tool in the DHIS2 system to facilitate real-time reporting and access to the data for timely decision making. The electronic form is shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e.\u003c/p\u003e \u003cp\u003eThe electronic system can be accessed by a computer or laptop using the web application or an Android mobile device using the DHIS2 capture application for data entry. Data entry using the mobile application can be done offline and later synchronized to the server when connected to the internet.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e\n\u003ch3\u003eTraining and capacity building\u003c/h3\u003e\n\u003cp\u003eA five-day training on data management and analysis focusing on equity disaggregation was conducted for national and district stakeholders, including data officers, clerks, district health sisters (DHSs), the national maternal mortality surveillance coordinator, and national monitoring and evaluation officers. The training covered key modules of the DHIS2 system, such as data entry, analysis, and visualization. The data entry session covered hard copy, electronic reporting notifications, and case investigation forms to ensure data completeness. To also improve their writing skills, nine (9) national staff including the RCH director, program manager for adolescent health, MDSR coordinator, M\u0026amp;E officer, and other technical staff were trained on scientific writing for five days with the aim of directorate using its data to support decision making and for sharing Sierra Leone\u0026rsquo;s story through publications.\u003c/p\u003e\n\u003ch3\u003eMentorship sessions\u003c/h3\u003e\n\u003cp\u003eFive phases of mentorship sessions were conducted in all the districts and national level by AFENET and RCH national staff to enhance the knowledge and skills of district health sisters (DHS) following the training on using the system. These mentorship sessions were conducted by providing hands-on support to DHSs and the entry of real maternal death cases into the eCBDS system. The selection of the targeted district in each mentorship was made using data quality indicators, including timeliness and completeness of data entry, the proportion of missing variables for cases entered, and duplication of maternal deaths notified.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eInteractive dashboard development and data monitoring\u003c/h2\u003e \u003cp\u003eMaternal death data entry into the electronic case-based disease surveillance system (eCBDS) commenced following the training of the targeted individuals selected by the MoH through the RCH directorate. This was to facilitate the real-time display of maternal mortality performance indicators such as the number of maternal deaths reported by year and month, and district, Maternal mortality ratio by month, year and district, the proportion of cases investigated by month, year, and district among others to trigger timely public health actions at the national and district levels. The dashboard was developed based on the needs of the RCH directorate, and changes were made based on the needs of the directorate.\u003c/p\u003e \u003cp\u003eThe dashboard also facilitates monitoring data quality, including its timeliness and completeness, providing information for following up with districts for corrective actions to improve the quality of data.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e\n \u003ch2\u003eProject outputs\u003c/h2\u003e\n \u003cdiv id=\"Sec11\" class=\"Section3\"\u003e\n \u003ch2\u003eAvailability of updated maternal and perinatal data collection tools and SOPs\u003c/h2\u003e\n \u003cp\u003eThe revised versions of the reporting tools, including the maternal death identification and notification form, the maternal death investigation form, and the weekly reporting form, were distributed to the districts. Using existing maternal mortality data from 2019 to 2024 generated before and during this project, we observed a significant variation in the MMR across districts. Districts such as Tonkolili and Western Area Urban recorded consistently high MMRs with an average of 303 and 359 per 100,000 live births, respectively, while districts like Kailahun and Karena recorded lower average MMRs of 89 and 111 deaths per 100,000 population. The MMRs recorded by Western Area Urban and Tonkolili districts are higher than the national average MMR of 216 per 100,000 live births.\u003c/p\u003e\n \u003cp\u003eHowever, the MMR varies significantly across districts. Districts such as Karene and Moyamba had low MMRs in 2019 and 2020, while others, like Kenema and Western Area Rural, showed a relatively steady or fluctuating trend during the analysis period. The districts of Tonkolili and Western Area Urban reported consistently high MMRs throughout the six years, indicative of continuing challenges in addressing maternal mortality in these areas. Bo and Bombali districts, on the other hand, recorded relatively stable and lower MMR trends. This analysis revealed disparities among districts and offered recommendations to the MoH for improved maternal outcomes.\u003c/p\u003e\n \u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\n \u003ch2\u003eMigration of reporting from manual to electronic-based reporting\u003c/h2\u003e\n \u003cp\u003eThis project covered all sixteen districts and introduced the use of an electronic case-based disease surveillance reporting system (eCBDS) for maternal mortality data. During this project, the capacity building of 25 staff on the use of the eCBDS system from district health management teams (DHMT) and the RCH directorate was achieved through training and mentorships.\u003c/p\u003e\n \u003cp\u003eBefore the implementation of this project, reporting of maternal mortality data was possible through the use of an MS Excel template developed by the RCH directorate, no web-based system was in place to enter and store the data electronically. Currently, on average, over 98% of all reported maternal deaths from health facilities are notified through the eCBDS system, while about 95% on average of all investigated maternal death cases have been entered in the eCBDS system. This has facilitated real-time access and use of maternal mortality data by stakeholders for timely decision-making.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\n \u003ch2\u003eImproved capacity on the eCBDS system, data use, and scientific writing\u003c/h2\u003e\n \u003cp\u003eIn June 2024, 25 personnel, including district health sisters and national staff from the RCH directorate, were trained in data management and analysis using the eCBDS system. Data management covered data collection, and entry, while the data analysis module covered generating line lists of all maternal deaths with the preferred variables of the user, data visualizer for creating graphs, charts, and tables of aggregate data including disaggregations such as causes of death by district, age, marital status among others. Lastly, the staff were trained on how to generate a map using DHIS2, displaying the number of maternal deaths and the distribution of cases across the country or district, among others. Other modules covered included data quality checks such as filling mandatory fields, completing all the relevant variables, how to avoid duplications, ensuring consistency, and the timeliness of real-time reporting.\u003c/p\u003e\n \u003cp\u003eAfter the one-year implementation of this project in the sixteen districts, all the 16 district health sisters (DHS), and nine (9) national staff of the RCH directorate continue using the eCBDS system for data reporting and monitoring of maternal mortality data. National technical officers currently use the eCBDS system to monitor the performance of districts on maternal deaths reported, investigated, timeliness, and completeness of maternal mortality data. The writing skills of nine (9) RCH staff have improved, this has been demonstrated through the ongoing writing of three manuscripts and presentations of program performance during stakeholder meetings. Five mentorship phases were conducted on 16 district staff by three (3) MoH staff and two AFENET staff.\u003c/p\u003e\n \u003cp\u003eThe capacity-building activities, including training and mentorships, built and enhanced the capacity of nine (9) national staff and 16 district staff. The majority of the district health sisters said they are knowledgeable in using the eCBDS system for data reporting, analysis, and monitoring of their performance. Similarly, the training was an opportunity to clear the data entry backlog for cases reported in 2024 across all the districts, which gave the trainees a hands-on experience.\u003c/p\u003e\n \u003cp\u003eThis project has improved the quality and use of maternal mortality data. This has been demonstrated through the use of the current data for programmatic reporting. The capacity of nine (9) national staff was enhanced in scientific writing. Currently, these staff are writing three manuscripts using maternal and perinatal mortality data.\u003c/p\u003e\n \u003cp\u003eFigure \u003cspan class=\"InternalRef\"\u003e4\u003c/span\u003e shows the status of maternal mortality data entry into the eCBDS system by year. Even though the eCBDS system was introduced in Sierra Leone in 2016, maternal mortality case-based data entry effectively started in 2024 during the implementation of the data use project funded by Vital Strategies and implemented by AFENET and the MoH.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\n \u003ch2\u003eData use for decision-making\u003c/h2\u003e\n \u003cp\u003eThe quality of maternal mortality data has greatly improved, evidenced by improvement in the timeliness, completeness, and trustworthiness of the data. This led to the commencement of the weekly maternal and child death emergency meeting to discuss the data reported, identify resource gaps by district, and allocate resources by district based on the maternal deaths reported and reviews conducted.\u003c/p\u003e\n\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis manuscript describes the implementation of the project on identifying and addressing maternal health services inequalities in Sierra Leone through enhancing data quality and its use for decision-making.\u003c/p\u003e \u003cp\u003eThere is a marked improvement in the status of maternal mortality data entry for investigated cases from the district level through the eCBDS system, while timeliness and completeness have greatly improved [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. \u0026ldquo;\u003cem\u003eThis system has greatly improved the timely availability of maternal mortality data and use for decision making\u0026rdquo;\u003c/em\u003e (\u003cem\u003eZainab Juheh Bah, National Maternal Mortality Coordinator\u003c/em\u003e). The use of quality data to guide evidence-based decisions cannot be overstated since many health-implementing entities primarily rely on it for resource allocation and other health interventions to improve health outcomes [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe migration of the maternal mortality reporting from MS Excel to the eCBDS system has improved the quality of the data reported, including its timeliness and completeness, compared to the former way of reporting. Furthermore, the inclusion of the DHSs in reporting maternal mortality data into the eCBDS system improved ownership, accountability, as well as their capacity to use electronic systems.\u003c/p\u003e \u003cp\u003eUsing routine data and the high-quality data generated during this project, the disparities among districts were evidenced by the variation in the maternal mortality ratio (MMR) among districts, with Western Area Urban recording a high MMR compared to other districts. This finding is inconsistent with another study that has reported other districts having higher MMR [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. This finding suggests the need to conduct in-depth research on disparities and inequalities accounting for this variation.\u003c/p\u003e \u003cp\u003eStakeholders' engagement through consultative meetings on the review of maternal mortality tools and SOPs improved collaborations, involvement, ownership, and accountability on maternal mortality-related issues [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eThe creation of an interactive maternal mortality dashboard is critical for real-time monitoring of maternal mortality data and prompt evidence-based actions for the reduction of maternal mortality in Sierra Leone. Several studies have demonstrated the use of digital solutions in maternal healthcare delivery to improve maternal health outcomes [\u003cspan additionalcitationids=\"CR20 CR21 CR22\" citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe capacity building at the national and district levels in data management and analysis using the eCBDS and scientific writing is commendable. However, continuous training and mentorship are critical to sustaining the gains of this project and the maintenance of the eCBDS system [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. Furthermore, this project supported the RCH directorate in digitizing the perinatal death surveillance forms into the eCBDS system as recommended by the MoH. However, this was not part of the project\u0026rsquo;s scope, and we are therefore recommending that the RCH directorate mobilize resources to roll out the perinatal aspect similar to what has been done for maternal deaths.\u003c/p\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eLimitation\u003c/h2\u003e \u003cp\u003eThis study documented the implementation of a project to improve data use for decision-making. The data used from the DHIS2 may not be representative, given the underreporting and overreporting of routinely collected data. In addition, documenting one year of project implementation may not show the actual impact of this project.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis project focused on identifying and addressing maternal health services inequalities in Sierra Leone through the identification of gaps in maternal mortality data quality and use. Through this project, reporting of maternal mortality data has shifted from MS Excel to a web-based system, which has greatly improved the quality of the data from the districts. This has further facilitated real-time access to quality data for decision-making. The capacity built on the use of the eCBDS system, scientific writing, mentoring, data management, and analysis will promote the sustainability of the gains made by this project. Real-time monitoring of district performance on key indicators is now possible through the dashboards developed through this project.\u003c/p\u003e \u003cp\u003eTo ensure the sustainability of this project, we recommend that the MoH, through the RCH directorate, lobby with other partners to provide resources to continue the implementation of key activities, including refresher training, mentoring, and data bundles for reporting.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAvailability of Data and Materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data used is openly available in the DHIS2 system upon permission from the Ministry of Health (URL: Sierra Leone Integrated Disease Surveillance and Response (IDSR/eCBDS)). To obtain the data or get access to the data in the DHIS2 system, please contact:\u003c/p\u003e\n\u003cp\u003eName: Zainab Juheh Bah\u003c/p\u003e\n\u003cp\u003eDesignation: National Coordinator, Maternal Deaths Surveillance and Respose\u003c/p\u003e\n\u003cp\u003eEmail: [email protected]\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical approval for this study was waived by the Sierra Leone Ethics and Scientific Review Committee, since this study uses routinely collected aggregate data and had requisite permission from the Ministry of Health. All the study participants provided informed consent to participate in this study. The documentation and publication of the project implemented were approved by the donors and the Sierra Leone Ministry of Health leadership. This study is also in compliance with the Helsinki Declaration on use of human subjects as study participants.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declared no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis project was\u0026nbsp;supported\u0026nbsp;by Bloomberg Philanthropies’\u0026nbsp;Data for Health Initiative\u0026nbsp;through a cooperative agreement between AFENET and\u0026nbsp;Vital\u0026nbsp;Strategies.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors’ contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eBM, GNG developed the protocol. KK and BM analyzed and interpreted the data. KK drafted the manuscript. BM, TS, ZB, MC, FM, and GNG reviewed several drafts of the manuscript and made significant contributions throughout the writing process. All the authors approved the submission of the manuscript for publication.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgment\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis project was funded by Bloomberg Philanthropies’ Data for Health Initiative. Vital Strategies provided technical support. The contents are solely the authors'. The authors express their gratitude to \u003cstrong\u003eCynthia Driver\u003c/strong\u003e for her contributions to the manuscript's conceptualization, analysis, interpretation, and review, and to \u003cstrong\u003eSarah Ward\u003c/strong\u003e for administrative support. AFENET was the principal implementing partner in collaboration with the Ministry of Health, Directorate of Reproductive and Child Health.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eAbouZahr C, Boerma T. Health information systems: the foundations of public health. Bull World Health Organ. 2005 Aug;83(8):578\u0026ndash;83.\u003c/li\u003e\n \u003cli\u003eChan M, Kazatchkine M, Lob-Levyt J, Obaid T, Schweizer J, Sidibe M, Veneman A, Yamada T. Meeting the Demand for Results and Accountability: A Call for Action on Health Data from Eight Global Health Agencies. PLoS Med. 2010 Jan 26;7(1):e1000223.\u003c/li\u003e\n \u003cli\u003eWorld Health Organization. Maternal death surveillance and response: technical guidance [Internet]. 2013 [cited 2025 Apr 4]. Available from: https://www.who.int/publications/i/item/9789241506083\u003c/li\u003e\n \u003cli\u003eMinistry of Health. 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Available from: https://www.bing.com/ck/a?!\u0026amp;\u0026amp;p=06d8eede2b278320JmltdHM9MTcyODQzMjAwMCZpZ3VpZD0yYzM4OWMyNS0w\u003cbr\u003eNjIzLTZjOTMtMWRhZS04OGZjMDc0NDZkZjkmaW5zaWQ9NTIyNg\u0026amp;ptn=3\u0026amp;ver=2\u0026amp;hsh=3\u0026amp;fclid=2c389c25-0623-6c93-1dae-88fc07446df9\u0026amp;psq=MDSR+strategy\u0026amp;u=a1aHR0cHM6Ly9tb2hzLmdvdi5zbC9kb3dubG9hZC80My9wdWJsaWNhdGlvbi8xNz\u003cbr\u003eMwOS9tZHNyLTIwMjAtYW5udWFsLXJlcG9ydF9maW5hbF8xMDA1MjAyMi0yLnBkZg\u0026amp;ntb=1\u003c/li\u003e\n \u003cli\u003eNutley T, Reynolds HeidiW. Improving the use of health data for health system strengthening. Glob Health Action. 2013 Dec 1;6(1):20001.\u003c/li\u003e\n \u003cli\u003eBridget M, Gebru GN, Odongo GS, Hedberg C, Elduma AH, Kanu JS, Bangura J, Squire JS, Foster MA. Digitalizing disease surveillance: experience from Sierra Leone. Health Policy Plan. 2025 Jan 11;40(1):85\u0026ndash;96.\u003c/li\u003e\n \u003cli\u003eMartin DW, Sloan M, Gleason BL, de Wit L, Vandi MA, Kargbo DK, Clemens N, Kamara AS, Njuguna C, Sesay S, Singh T. Implementing nationwide facility-based electronic disease surveillance in Sierra Leone: Lessons Learned. Health Secur. 2020 Jan;18(Suppl 1):S72\u0026ndash;80.\u003c/li\u003e\n \u003cli\u003eAqil A, Lippeveld T, Hozumi D. PRISM framework: a paradigm shift for designing, strengthening and evaluating routine health information systems. Health Policy Plan. 2009 May 1;24(3):217\u0026ndash;28.\u003c/li\u003e\n \u003cli\u003eMinistry of Health. Integrated Disease Surveillance and Response strategy. 2020.\u003c/li\u003e\n \u003cli\u003eSierra Leone Integrated Disease Surveillance and Response (IDSR/eCBDS). Dashboard | DHIS2 [Internet]. 2025 [cited 2025 Feb 19]. Available from: https://staging.dhis.hisp.org/sl-idsr/dhis-web-dashboard/#/qn10ebIobC8\u003c/li\u003e\n \u003cli\u003eDave P. How Digital Health is Revolutionizing Healthcare and Contributing to Positive Health Outcomes. J Drug Deliv Ther. 2024 Jun 15;14(6):287\u0026ndash;93.\u003c/li\u003e\n \u003cli\u003eOlver IN. Linking data to improve health outcomes. Med J Aust. 2014 Apr;200(7):368\u0026ndash;9.\u003c/li\u003e\n \u003cli\u003eJuhehBah Z, Sheriff AA, Kamara K, Elduma AH, Sesay U, Sogbeh SA, Cole M, Sesay T, Gebru GN. SIERRA LEONE REDUCING MATERNAL MORTALITY IN THE LAST SIX YEARS, 2016 \u0026ndash; 2021: A SECONDARY DATA ANALYSIS ON MATERNAL DEATH SURVEILLANCE AND RESPONSE SYSTEM. Sierra Leone J Biomed Res [Internet]. 2024 Dec 26 [cited 2025 Jan 13];15(2). Available from: https://www.sljbr.org/index.php/sjbmr/article/view/210\u003c/li\u003e\n \u003cli\u003eGausman J, Langer A, Jolivet RR. Understanding effective approaches to addressing the common challenges faced by global health networks: Mobilising multi-stakeholder networks to address the upstream determinants of maternal health in five low- and middle-income countries. J Glob Health. 2023 Jun 9;13:04044.\u003c/li\u003e\n \u003cli\u003eMuthoni RN, Muchelule DY. STAKEHOLDERS PARTICIPATION AND PERFORMANCE OF MATERNAL HEALTH PROGRAM IN KENYA. Int J Soc Sci Manag Entrep IJSSME [Internet]. 2023 Apr 20 [cited 2025 Feb 21];7(1). Available from: https://www.sagepublishers.com/index.php/ijssme/article/view/223\u003c/li\u003e\n \u003cli\u003eGirmay M. Digital Health Divide: Opportunities for Reducing Health Disparities and Promoting Equitable Care for Maternal and Child Health Populations. Int J Matern Child Health AIDS. 2024 Dec 20;13:e026.\u003c/li\u003e\n \u003cli\u003eGuo C, Ashrafian H, Ghafur S, Fontana G, Gardner C, Prime M. Challenges for the evaluation of digital health solutions\u0026mdash;A call for innovative evidence generation approaches. Npj Digit Med. 2020 Aug 27;3(1):1\u0026ndash;14.\u003c/li\u003e\n \u003cli\u003eJournal of Medical Internet Research - Association of Digital Health Interventions With Maternal and Neonatal Outcomes: Systematic Review and Meta-Analysis [Internet]. [cited 2025 Apr 9]. Available from: https://www.jmir.org/2025/1/e66580/\u003c/li\u003e\n \u003cli\u003eMoise IK, Ivanova N, Wilson C, Wilson S, Halwindi H, Spika VM. Lessons from digital technology-enabled health interventions implemented during the coronavirus pandemic to improve maternal and birth outcomes: a global scoping review. BMC Pregnancy Childbirth. 2023 Mar 20;23(1):195.\u003c/li\u003e\n \u003cli\u003eWang J, Tang N, Jin C, Yang J, Zheng X, Jiang Q, Li S, Xiao N, Zhou X. Association of Digital Health Interventions With Maternal and Neonatal Outcomes: Systematic Review and Meta-Analysis. J Med Internet Res. 2025 Mar 14;27(1):e66580.\u003c/li\u003e\n \u003cli\u003eJones SA, Sam B, Bull F, James M, Ameh CA, van den Broek NR. Strengthening pre-service training for skilled birth attendance \u0026mdash; An evaluation of the maternal and child health aide training programme in Sierra Leone. Nurse Educ Today. 2016 Jun 1;41:24\u0026ndash;9.\u003c/li\u003e\n \u003cli\u003eMerry L, Castiglione SA, Rouleau G, L\u0026eacute;tourneau D, Larue C, Desch\u0026ecirc;nes MF, Gonsalves DM, Ahmed L. Continuing professional development (CPD) system development, implementation, evaluation and sustainability for healthcare professionals in low- and lower-middle-income countries: a rapid scoping review. BMC Med Educ. 2023 Jul 6;23(1):498.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Maternal mortality, data use, Sierra Leone","lastPublishedDoi":"10.21203/rs.3.rs-6572728/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6572728/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground: \u003c/strong\u003eSierra Leone has made tremendous progress in reducing maternal mortality\u003cstrong\u003e \u003c/strong\u003esince establishing the Maternal Deaths Surveillance and Response (MDSR) in 2016.\u003cstrong\u003e \u003c/strong\u003eDespite the gains made in the reduction of maternal mortality in the country, the availability of\u003cstrong\u003e \u003c/strong\u003ecredible data and its use for evidence-based interventions remained a major challenge. To address\u003cstrong\u003e \u003c/strong\u003ethese gaps, the Ministry of Health (MoH), with funding and technical support from Bloomberg Philanthropies’ Data for Health Initiative and technical support from Vital Strategies and the African Field Epidemiology Network (AFENET), implemented a project aimed at identifying and addressing maternal health services inequalities in maternal health services in Sierra Leone.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e: We conducted a consultative meeting, reviewed, and updated existing data collection tools and standard operating procedure (SOP). We updated the electronic data management system developed on District Health Information System 2 (DHIS2) with the updated data collection tools and developed training materials for data capture, analysis, visualization, and troubleshooting. We also conducted training for health workers on mid and high-level data management and analysis. Finally, we supported the development of an MDSR interactive dashboard for real-time data visualization.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e: This project supported the Ministry of Health in developing and revising six maternal mortality data collection and reporting tools, SOPs. We also built the capacity of 25 staff on electronic maternal mortality data management and analysis at the national and district levels using DHIS2. This project also led to the migration of maternal mortality data reporting from Microsoft Excel to an electronic case-based disease surveillance system in the DHIS2 platform, providing real-time data for decision-making. The dashboard, based on key maternal mortality indicators, supported the monitoring of district and national performance. The quality of maternal mortality data has improved. The project also added SMS notifications for each maternal death reported into the eCBDS system.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e: This project improved the quality of maternal mortality data, enhanced the knowledge and skills of health workers at the national and district levels on electronic data management and use, migrated reporting from paper to electronic reporting, and developed an interactive dashboard for real-time data monitoring, access, and use.\u003c/p\u003e","manuscriptTitle":"Transforming Maternal Mortality Data into Actionable Insights: A Case Study from Sierra Leone, 2024","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-07-01 06:07:20","doi":"10.21203/rs.3.rs-6572728/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2025-07-10T05:30:23+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"89560016465622317850606060512460230172","date":"2025-06-25T11:52:26+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-06-23T09:02:03+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-06-18T07:53:49+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-05-27T14:15:21+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-05-27T10:55:29+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Health Services Research","date":"2025-05-27T10:54:23+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"8745db22-6a8f-4732-a8ca-efe9214ce0ad","owner":[],"postedDate":"July 1st, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-07-01T06:07:21+00:00","versionOfRecord":[],"versionCreatedAt":"2025-07-01 06:07:20","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6572728","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6572728","identity":"rs-6572728","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}