Midwives' Experiences of Maternal Death Surveillance and Response: Insights from Mwanza District Hospital, Malawi

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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. Methods 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). Results 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. Conclusion 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. maternal death midwives maternal death surveillance and response Malawi Figures Figure 1 BACKGROUND Maternal deaths remain a major public health issue, particularly in low- and middle-income nations ( 1 ). In 2013, WHO recommended that all countries establish maternal death surveillance and response systems to accelerate the reduction of maternal mortality. Maternal mortality ratios in Sub-Saharan Africa (SSA) range from 250 to 700 per 100,000 live births on average ( 2 ). Malawi, like many other low- and middle-income nations, remains far from meeting the Sustainable Development Goals (SDGs) for reducing maternal mortality ( 3 ). Despite the implementation of the Maternal Death Surveillance and Response (MDSR) system by the Malawi Government in 2002, preventable maternal deaths persist. For instance, data from Mwanza District Hospital recorded nine alarming maternal deaths in the year 2023/2024 ( 4 ). Midwives are occasionally subjected to traumatic birth situations, including maternal death, and are accountable for their actions while delivering care through the MDSR system ( 5 ). As integral members of the MDSR team, midwives play a central role in this initiative due to their continuous involvement in the care of pregnant women and their potential presence during critical maternal events. When a maternal death occurs, it is the responsibility of the attending midwife to complete a maternal death notification form and submit it within 24 to 72 hours, as stipulated by the MDSR guidelines ( 6 ). However, there is insufficient data on how these events affect midwives and their practice. Maternal death reviews (MDR) began in Malawi in 2002, and a framework was developed to conduct audits at district hospitals. Maternal deaths became a notifiable event in 2009, and the government established a national commission to conduct confidential investigations into maternal fatalities (NCCEMD) ( 7 ). The MDSR continuous action cycle relies on teams to gather and evaluate information on when, where, and why women die and to design steps to prevent such deaths, and midwives are crucial actors in the teams since they are actively involved in the care of pregnant women and may be present when most maternal deaths occur ( 8 ); ( 9 ). A Maternal Death Surveillance and Response (MDSR) system is a continuous cycle that aims to prevent future maternal deaths by learning from prior ones. This is achieved by detecting and investigating each death, then generating and applying recommendations to prevent future deaths from comparable causes ( 10 ). The strategy (Fig. 1 ) allows one to study the underlying causes and factors that contribute to maternal mortality and design life-saving solutions. The MDSR has four steps: (i) identification and notification of maternal death, which is an ongoing process; (ii) review of maternal deaths; (iii) analysis and interpretation of findings from the reviews; (iv) response and action ( 7 ). MDSR also offers a rapid cycle of notification, review, analysis, and response which enables governments to monitor maternal mortality in near real-time, both at the subnational and national levels, and can provide early warning of problems in a health institution or locality ( 11 ). It works to reduce unnecessary maternal mortality by integrating all stakeholders in the process of identifying maternal deaths, learning why they occurred, and taking action to prevent similar fatalities in the future ( 12 ). Midwives are key stakeholders in the process as they provide direct care to pregnant mothers at all levels and are also members of the MDSR team ( 7 ). Midwives play a pivotal role as members of the MDSR team, and there is potential for midwives to indirectly experience trauma from such roles. Understanding their experiences in MDSR is essential in order to provide adequate support for them to enhance their skills in providing appropriate maternity care, hence the need for this study ( 13 ). Furthermore, existing MDSR research in Malawi has predominantly focused on the procedural aspects of the program, with limited exploration of the experiences of healthcare professionals, particularly midwives, involved in its implementation. Hence, the primary objective of this study was to explore midwives' experiences regarding identification, notification, and reporting of maternal deaths in the MDSR cycle. Through this exploration, we aimed to uncover crucial themes and insights that can play a pivotal role in expediting the reduction of avoidable maternal deaths. METHODOLOGY Design This exploratory descriptive qualitative (EDQ) study employed a purposive sample of 19 midwives who agreed to participate after being informed of the purpose. Sample size was determined by data saturation. Data collection and analysis were completed until no new themes emerged from individual interviews( 14 ); ( 15 ) Participants Midwives who had worked in the maternity unit for at least six months and cared for at least one near-miss or a woman who experienced a maternal death, or were on duty when the maternal death occurred, were chosen to participate in the study. The researcher approached midwives at Mwanza District Hospital, explaining the study's purpose and inviting them to participate. Ethical Considerations The study protocol (P.10/23–0358) was reviewed and approved by the College of Medicine Research Ethics Committee (COMREC). Mwanza Hospital Research Review Committee approved the study at their facility. The participants were informed before the interviews that all data would be confidential and anonymous, and that no information would be traceable back to them, even though the midwifery management were aware of the midwives' participation in the research. Participants were also told that they can withdraw from the study at any moment, but none did, and consent forms were signed. Data Collection Individual semi-structured in-depth interviews were conducted with each participant at their convenience in the antenatal clinic, theatre, antenatal ward, labor and delivery ward, and postnatal wards where they worked. Four open-ended narrative questions were asked to enable participants to share their experiences with the implementation of maternal death surveillance and response. The interviews on average lasted one hour, and participants were permitted to relate their stories with little interference. The interviewer was an experienced midwife. All interviews were audio-recorded and transcribed. Data Analysis Two of the researchers conducted thematic analysis. Each researcher examined and analyzed the interview transcripts separately. First, the interview transcripts were examined line by line to capture and identify the initial categories that emerged from the data. NVivo 12 software was utilized at this point to produce the codes and themes based on the code book. The researchers continued to identify themes based on the relationships between the codes. During a second reading of the transcripts, the researchers eventually identified linkages between categories and subcategories based on context. The similarities involved thematic interpretation of meaning. Categories agreed upon by the two researchers were saved, which improved intercoder reliability. Those that were excluded were assessed to have a minor contribution to the study. Finally, the findings were classified into themes that included both the researchers' interpretations and citations from the participants' narratives. The study's quality was maintained through systematic data analysis using participant narratives. Participants' stories are conveyed in their own voices and subjective points of view through quotations, while personal information is not disclosed. All interviews were conducted and analyzed in English. Trustworthiness Data analysis was conducted inductively. To ensure the study's credibility during data analysis, researchers minimized any presumptions that may have influenced their interpretations of participants' experiences. Thus, the emergent themes were taken to represent the participants' experiences rather than the researchers' presumed classifications. FINDINGS Nineteen midwives (12 female, 7 male; aged 26–46 years, with 3–19 years of experience) participated in the study. Thematic analysis identified barriers and enablers across all four stages of the WHO MDSR cycle (Table 1 ). Table 1 Themes and Subthemes Mapped to the WHO MDSR Cycle MDSR Stage Themes/Subthemes Description Identification & Notification Psychological impact of witnessing maternal deaths Emotional toll including shock, trauma, burnout, and fear of blame from guardians. Coping mechanisms Reliance on peer support, improvisation with limited resources, and resilience strategies. Cross-border maternal care Challenges in managing referrals from Mozambique due to lack of antenatal records, late presentation, and resource strain. Identifying maternal death risk factors Recognition of bleeding, sepsis, and shock, but hampered by delays in clinician response and lack of diagnostics. Communication and coordination Notification pathways (clinicians, safe motherhood coordinators); evolving use of MARTSURV system vs. older fax/phone modalities. Timeliness Delays in transport, laboratory support, and hierarchical approval processes affecting prompt action and reporting. Review & Analysis Blame and shame culture Fear of punishment and negative feedback discouraged openness during maternal death reviews. Documentation inconsistencies Variable content and completeness of reports, affecting quality of case analysis. Response & Action Limited follow-up of recommendations Fragmented implementation of response actions; staff hesitant to propose changes due to fear of retribution. Monitoring & Evaluation Weak feedback loops Lessons from reviews not consistently shared with frontline staff. Cross-border system gaps No mechanisms to address cross-border maternal deaths despite the burden on local facilities. [Insert Table 1 here] 1. Identification and Notification of Maternal Deaths within the MDSR Framework In line with the WHO Maternal Death Surveillance and Response (MDSR) framework, timely identification and notification of maternal deaths are foundational to effective surveillance and response. Midwives described this stage as occurring under conditions of high emotional strain, limited resources, and constrained decision-making authority. Witnessing maternal deaths had a significant psychological impact, manifesting as shock, burnout, and emotional distress, which in turn affected confidence and morale in identifying and reporting adverse outcomes. One midwife expressed feeling physically and psychologically exhausted after repeated maternal deaths, noting that such experiences were demotivating and left them feeling professionally ineffective (IDI 14). Despite the expectation within MDSR that health workers promptly recognise and report maternal deaths, midwives often relied on informal coping strategies to continue functioning in high-pressure environments. These included peer support and improvisation with scarce resources, in the absence of structured institutional psychosocial support. As one participant explained “ teams worked together using whatever limited resources were available, although coping remained difficult and emotionally taxing ” (IDI 14). Cross-border maternal referrals, particularly from Mozambique, further complicated the identification of high-risk cases. Women frequently presented late and without antenatal records, undermining the MDSR emphasis on early risk detection and continuity of care. Midwives reported managing critically ill women requiring urgent interventions such as blood transfusions, often with poor outcomes despite rapid action, highlighting the limitations of identification processes when presentation is delayed and documentation is absent (IDI 18). Although midwives demonstrated strong awareness of key WHO-defined obstetric danger signs, especially haemorrhage, sepsis, and shock, their ability to act on early indicators was frequently constrained by systemic delays. Participants described situations where clinical deterioration became apparent only at advanced stages due to delayed clinician review, limited diagnostic capacity, and shortages of essential supplies, reducing opportunities for timely escalation as envisaged in MDSR guidelines (IDI 5). Notification of maternal deaths followed established MDSR pathways involving clinicians and Safe Motherhood Coordinators. Participants acknowledged improvements associated with the introduction of the MARTSURV digital reporting system, which was perceived as faster and more reliable than earlier fax- or phone-based methods. However, hierarchical approval processes continued to undermine the MDSR principle of rapid notification. Midwives reported lacking the mandate to directly contact senior clinicians, resulting in delays at critical moments when time-sensitive decisions and reporting were required. As one participant noted “ uncertainty over authority and rigid hierarchies meant that valuable time was lost while approval was sought, even as the patient’s condition deteriorated “(IDI 10). Overall, the findings indicate that while identification and notification processes broadly align with WHO MDSR structures, their effectiveness is compromised by emotional burden among providers, cross-border care challenges, resource limitations, and bureaucratic barriers. Strengthening psychosocial support for midwives, enhancing cross-border information sharing, and empowering frontline providers to initiate timely notification are essential to optimising the MDSR cycle and preventing future maternal deaths. 2. Review and Analysis within the MDSR Framework The WHO MDSR framework emphasises maternal death reviews as confidential, non-punitive processes aimed at learning and system improvement. However, participants described review meetings as constrained by a prevailing blame and shame culture, which undermined open reflection and critical analysis. Midwives reported feeling emotionally unsafe to fully disclose events, errors, or systemic gaps, particularly in hierarchical settings where adverse outcomes were closely scrutinised. “ This environment discouraged honest discussion and limited the depth of collective learning intended within MDSR processes “(IDI 18). Fear of punishment and negative feedback further shaped participation during reviews. Rather than fostering a culture of accountability and improvement, reviews were often perceived as fault-finding exercises. As a result, midwives reported withholding information or self-censoring contributions to protect themselves and colleagues from blame, weakening the analytical value of the review process (IDI 4). Inconsistent documentation practices further compromised the quality of case analysis. Participants described variability in the completeness, accuracy, and content of maternal death reports, raising concerns about data integrity and reliability. One midwife emphasised the need to personally secure patient files to prevent loss or alteration of information, noting that “the midwife should get hold of the file, to avoid it being lost or information altered” (IDI 10). Such inconsistencies limited the ability of review teams to reconstruct clinical timelines, identify modifiable factors, and generate evidence-informed recommendations, contrary to WHO guidance on standardised MDSR documentation. Overall, while maternal death reviews were routinely conducted, their effectiveness as learning tools was diminished by fear-driven participation and weak documentation systems, reducing their potential to inform meaningful action. 3. Response and Action following Maternal Death Reviews Within the MDSR cycle, the response and action phase is intended to translate review findings into concrete, monitored interventions. Participants, however, reported that implementation of recommendations was often fragmented and poorly coordinated. Although action points were routinely documented, follow-up mechanisms were weak, and responsibility for implementation was often unclear. As one midwife observed, recommendations were frequently recorded but rarely operationalised, with actions “ ending in the report rather than leading to tangible change ” (IDI 12). This lack of continuity contributed to frustration, disengagement, and scepticism among frontline staff regarding the value of the review process. The absence of accountability structures to track progress on agreed actions meant that systemic gaps identified during reviews, such as staffing shortages, supply constraints, or delayed referrals, persisted over time (IDI 17). Fear of retribution further inhibited active engagement in the response phase. Midwives described hesitating to propose system-level changes during review meetings due to concerns about being blamed, reprimanded, or perceived as challenging senior clinicians. One participant explained that “ silence was often a protective strategy, as speaking up could result in blame or strained hierarchical relationships ” (IDI 7). In response to these pressures, some midwives adopted emotional detachment as a coping mechanism, deliberately distancing themselves from the review and action processes. As one participant stated, “ emotional withdrawal was necessary for survival in the work environment, even though it reduced meaningful engagement in improvement efforts ” (IDI 15). While such strategies may protect individual wellbeing, they undermine collective responsibility and weaken the MDSR response function by limiting staff ownership of recommended actions. 4. Monitoring and Evaluation of the MDSR Process The monitoring and evaluation component of MDSR requires feedback loops that ensure lessons learned are disseminated to frontline providers and inform ongoing practice. Participants reported that such feedback mechanisms were weak or inconsistently applied. Although maternal deaths were identified and notified, frontline staff were often excluded from subsequent learning and system-level reflection. One midwife described feeling disconnected from the process, noting that “ while notifications were completed, feedback rarely reached those directly involved in care, making the process feel more like data collection than supportive system improvement ” (IDI 9).” The absence of regular feedback limited opportunities for reflective practice, skill development, and reinforcement of positive changes, further diminishing staff motivation to engage with MDSR activities. For instance, one midwife showed concern on what could happen if audits are indeed done but no feedback is given to responsible personnel for action (IDI 4). Persistent cross-border system gaps also highlighted limitations in monitoring and evaluation at higher system levels. Facilities in border districts continued to manage a substantial burden of maternal cases from neighbouring Mozambique, yet no formal mechanisms existed to capture, analyse, or respond to cross-border maternal deaths within national MDSR structures. Participants reported that this ongoing influx placed disproportionate strain on already limited resources, without corresponding adjustments in staffing, supplies, or policy support. As one participant noted, “ the facility served populations beyond its official catchment area, intensifying pressure on services without recognition at central levels ” (IDI 17). These findings suggest that weaknesses in feedback dissemination and the absence of cross-border MDSR coordination undermine the completeness and equity of monitoring and evaluation efforts. DISCUSSION This study explored midwives' experiences of maternal death surveillance and response (MDSR) at Mwanza District Hospital, Malawi. Organized around the stages of the WHO MDSR cycle, the findings highlight how psychological distress, systemic resource shortages, and cross-border complexities intersect to undermine effective identification, review, and response. Despite some improvements in notification processes, weak accountability and a prevailing culture of blame limit the potential of MDSR to prevent future maternal deaths. These findings carry implications for both national policy and regional cooperation. Identification and Notification of maternal deaths within the MDSR framework Identification and notification of maternal deaths were marked by emotional distress and professional uncertainty. Midwives described feelings of shock, guilt, and powerlessness, particularly when deaths occurred despite significant effort. These reactions are consistent with prior evidence showing that exposure to traumatic maternal events contributes to compassion fatigue, intrusive memories, and diminished professional confidence ( 16 – 18 ). In some cases, such experiences can precipitate defensive practice, with providers resorting to unnecessary interventions driven by fear of poor outcomes ( 5 ). Systemic factors amplified this distress. High workloads, shortages of staff and supplies, and limited refresher training in emergency obstetric care were common. Comparable findings have been reported in Ghana, where midwives often relied on experiential learning rather than formal training to manage maternal deaths ( 19 ). In Croatia, inadequate organizational support and poor communication with supervisors also increased vulnerability to burnout ( 20 ). Addressing these gaps requires embedding regular training and psychosocial support within the MDSR cycle. Notification processes had improved with the introduction of the MARTSURV platform, which enabled more timely reporting compared with fax and telephone. However, delays persisted for women referred from Mozambique without antenatal records. Similar challenges are observed in humanitarian and cross-border contexts, where fragmented data systems impede timely reporting and coordination ( 21 , 22 ). These findings underscore that effective notification is contingent not only on digital tools but also on system integration and regional collaboration. Review and Analysis within the MDSR framework The review stage was compromised by a culture of blame and fear of retribution. Midwives reported reluctance to participate fully in audit meetings, with some describing emotional withdrawal as a coping mechanism. This reflects evidence from sub-Saharan Africa, where punitive approaches undermine the quality of maternal death reviews ( 1 ). Rather than fostering collective learning, reviews risk becoming symbolic exercises that fail to address root causes. Documentation practices showed both strengths and weaknesses. Midwives demonstrated commitment to safeguarding patient files, recognizing the risk of tampering or loss. Yet, inconsistencies and omissions limited the depth of analysis. Previous Malawian studies have reported similar gaps, with incomplete files undermining the ability to identify systemic failures ( 6 , 23 ). Ensuring comprehensive documentation is vital, not only for accuracy of reviews but also for institutional memory and accountability. A no-blame review culture, as advocated by WHO, is essential to encourage candid participation and improve the quality of analysis. Peer-led reviews and supportive supervision may offer pathways to shift from punitive blame to constructive learning, as demonstrated in South Africa where participatory approaches improved audit engagement ( 1 ). Response and Action following maternal death reviews Perhaps the most significant finding of this study was the weak translation of review findings into action. Participants described fragmented follow-up, with recommendations often "ending in the report" without clear accountability for implementation. This undermines the credibility of the MDSR process and discourages staff engagement. Midwives who felt disillusioned sometimes withdrew emotionally, echoing patterns in Nigeria and Tanzania where poor follow-through eroded confidence in MDSR ( 1 ). Fear of blame further constrained the process, with some staff reluctant to propose changes that might expose them to criticism. Without systematic monitoring, recommendations risk becoming aspirational rather than actionable. Strengthening accountability mechanisms such as assigning responsibility for specific actions, ensuring managerial oversight, and providing feedback to frontline staff is critical. Evidence from South Africa suggests that locally owned response committees with strong leadership support can enhance adherence to recommendations and reduce preventable deaths ( 24 ). Monitoring and Evaluation of the MDSR process Monitoring and evaluation were the weakest links in Mwanza's MDSR cycle. Feedback loops were minimal, and midwives rarely received information about whether their recommendations led to change. This disconnect diminished the perceived value of their contributions and perpetuated disillusionment. Mwanza's border location added further complexity. Women frequently arrived from Mozambique in critical condition, often without antenatal documentation. Midwives expressed frustration at being unable to provide feedback to Mozambican facilities or address systemic delays in referral. These deaths were nonetheless recorded in Malawi's statistics, inflating the district's indicators while masking cross-border health system failures. Comparable jurisdictional challenges are observed in the United States, where state-level maternal mortality review committees face barriers to data-sharing across borders ( 21 ). In conflict-affected regions, fragmented governance and insecurity similarly disrupt surveillance and response systems ( 22 ). These findings suggest that maternal mortality in border districts cannot be addressed by national strategies alone. Bilateral agreements between Malawi and Mozambique on data-sharing, joint audits, and resource allocation are urgently needed. Without such cooperation, the burden will continue to fall disproportionately on frontline providers in border facilities. Implications for Policy and Practice Implications for Policy and Practice This study underscores that strengthening MDSR requires interventions across all four stages of the cycle. The findings identify emotional, structural, and procedural challenges to effective implementation, which must be addressed in order to enhance maternal health outcomes. Identification and Notification According to the study, midwives frequently face emotional anguish, fear of blame, and uncertainty while reporting maternal fatalities, resulting in delayed or incomplete notification. To resolve these issues embedding regular refresher training in emergency obstetric care and psychosocial debriefing can help reduce distress during reporting. In addition, establishing cross-border data sharing agreements with Mozambique can improve timeliness and completeness of notifications. Review and Analysis Midwives described review meetings as informative but emotionally draining, especially in circumstances where there is a fear of blaming. To promote a no-blame culture, reviews should be based on professional learning and accountability principles. This demands district and facility-level leadership involvement. Encouraging peer-led review methods that involve midwives can improve ownership, trust, and reflection during audits. Furthermore, utilising user-friendly audit templates assures completeness, depth, and system wide comparability of evaluations. Response and Action The study identifies a recurring gap between recognising problems and adopting corrective steps, which is often caused by a lack of resources and unclear accountability. Creating facility-level action plans with defined responsibilities, dates, and resource requirements; Ensuring hospital leadership receives audit results, tracks progress, and distributes resources appropriately for instance supplies, staffing, and maternity equipment; and Involving midwives in decision-making to guarantee feasible, acceptable, and coordinated actions with frontline realities. Monitoring and Evaluation Participants reported ineffective feedback mechanisms and limited visibility of adjustments made following maternal death reviews, which reduced motivation and learning. Creating effective feedback loops to convey audit results and actions to all workers, including those who were not present during the review, and holding bilateral review sessions for cross-border deaths can enhance regional collaboration and learning. By reinforcing each stage of the MDSR cycle, Malawi can enhance the effectiveness of maternal death surveillance, improve frontline staff engagement, and contribute to achieving the Sustainable Development Goal of reducing maternal mortality to fewer than 70 deaths per 100,000 live births by 2030. CONCLUSION This study highlights how midwives at Mwanza District Hospital experience significant psychological, systemic, and structural challenges when implementing the MDSR cycle. At the identification and notification stage, emotional distress and cross-border referral gaps undermine timely and accurate reporting. During review and analysis, prevailing blame cultures and inconsistent documentation limit open discussion and robust case learning. The response and action stage is weakened by fragmented follow-up and the absence of accountability frameworks, while monitoring and evaluation remain underdeveloped, leaving midwives disengaged and uncertain whether their recommendations lead to change. Abbreviations EDQ Exploratory Descriptive Qualitative Research EmOC Emergency Obstetric Care FBMDR Facility Based Maternal Death Review FBMDSR Facility Based Maternal Death Surveillance and Response MDR Maternal Death Review MDSR Maternal Death Surveillance and Response MMR Maternal Mortality Ratio MPDSR Maternal and Perinatal Death Surveillance and Response Declarations Ethical Approval and Consent to Participate The College of Medicine Research Ethics Committee (COMREC) approved the study. This is a review board of the Kamuzu University of Health Sciences. Written informed consent was obtained from each participant prior to participation in the study. Permission to recruit participants was obtained from Mwanza District Health Office. Consent for Publication Not applicable. Competing Interests The authors have no competing interests to declare. Funding This project did not have any funding. Author Contribution Wakhonderachi undertook a literature search to identify gaps in the area of interest, designed the study, conducted the fieldwork, undertook analyses, and prepared the manuscript. Fikile Singano reviewed the manuscript, Gaily Lungu provided supervision throughout the process, whilst Martha Kamanga (PhD) provided supervision and scientific support throughout the process and edited the manuscript for content. Acknowledgements Special thanks to the Director of Health and Social Services and Director of Nursing and Midwifery Services at Mwanza District Hospital where the study was conducted for allowing access to the midwives and for the support in data collection. 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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-8908402","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":611623045,"identity":"c3aaf11b-1dfb-4646-8f20-a8c5ca6af127","order_by":0,"name":"Wakhonderachi Temweka Likha","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAApklEQVRIiWNgGAWjYDACdsZmZgYGGwYGCaK1MIO1pJGkhYEZqOUwCVoMDjM3GxfUnI/mn93+gOlmG1FaGJuTZxy7nTvjzhkD5lxitJgBtRzmYbudu0Eih4E5dxvRWv6dA2pJf0C8lmTetgNALQkGxGmxB2ox5u1Lzp1xI8fgcO4/IrRItrc/lub5ZpfbPyP94eOcM0RoQQEHSNUwCkbBKBgFowAHAABMljYvFz+48wAAAABJRU5ErkJggg==","orcid":"","institution":"Kamuzu University of Health Sciences","correspondingAuthor":true,"prefix":"","firstName":"Wakhonderachi","middleName":"Temweka","lastName":"Likha","suffix":""},{"id":611623046,"identity":"f18f1b05-819f-41ef-82c2-fa98fbf92ceb","order_by":1,"name":"Gaily Lungu","email":"","orcid":"","institution":"Kamuzu University of Health Sciences","correspondingAuthor":false,"prefix":"","firstName":"Gaily","middleName":"","lastName":"Lungu","suffix":""},{"id":611623047,"identity":"4c7de313-58e8-4d5a-9451-4e055264c68c","order_by":2,"name":"Fikile Singano","email":"","orcid":"","institution":"Kamuzu University of Health Sciences","correspondingAuthor":false,"prefix":"","firstName":"Fikile","middleName":"","lastName":"Singano","suffix":""},{"id":611623048,"identity":"57ca8f20-ff3a-474f-8271-99f0a0f76a04","order_by":3,"name":"Martha Kamanga","email":"","orcid":"","institution":"Kamuzu University of Health Sciences","correspondingAuthor":false,"prefix":"","firstName":"Martha","middleName":"","lastName":"Kamanga","suffix":""}],"badges":[],"createdAt":"2026-02-18 10:39:31","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8908402/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8908402/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":105506152,"identity":"7c54d3c4-bd7e-4469-8ac6-a750c312a042","added_by":"auto","created_at":"2026-03-26 19:03:28","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":51351,"visible":true,"origin":"","legend":"\u003cp\u003eMaternal Death Surveillance and Response (MDSR) system: a continuous-action cycle (adapted from WHO 2014)\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-8908402/v1/6370ec2ea16a753fc3347588.png"},{"id":105566885,"identity":"ba10d415-8709-4619-ad9a-49835bb07449","added_by":"auto","created_at":"2026-03-27 12:57:38","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1011481,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8908402/v1/710c174c-11aa-4c89-8e15-d85f43411e68.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Midwives' Experiences of Maternal Death Surveillance and Response: Insights from Mwanza District Hospital, Malawi","fulltext":[{"header":"BACKGROUND","content":"\u003cp\u003eMaternal deaths remain a major public health issue, particularly in low- and middle-income nations (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). In 2013, WHO recommended that all countries establish maternal death surveillance and response systems to accelerate the reduction of maternal mortality. Maternal mortality ratios in Sub-Saharan Africa (SSA) range from 250 to 700 per 100,000 live births on average (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). Malawi, like many other low- and middle-income nations, remains far from meeting the Sustainable Development Goals (SDGs) for reducing maternal mortality (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). Despite the implementation of the Maternal Death Surveillance and Response (MDSR) system by the Malawi Government in 2002, preventable maternal deaths persist. For instance, data from Mwanza District Hospital recorded nine alarming maternal deaths in the year 2023/2024 (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eMidwives are occasionally subjected to traumatic birth situations, including maternal death, and are accountable for their actions while delivering care through the MDSR system (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). As integral members of the MDSR team, midwives play a central role in this initiative due to their continuous involvement in the care of pregnant women and their potential presence during critical maternal events. When a maternal death occurs, it is the responsibility of the attending midwife to complete a maternal death notification form and submit it within 24 to 72 hours, as stipulated by the MDSR guidelines (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). However, there is insufficient data on how these events affect midwives and their practice.\u003c/p\u003e \u003cp\u003eMaternal death reviews (MDR) began in Malawi in 2002, and a framework was developed to conduct audits at district hospitals. Maternal deaths became a notifiable event in 2009, and the government established a national commission to conduct confidential investigations into maternal fatalities (NCCEMD) (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). The MDSR continuous action cycle relies on teams to gather and evaluate information on when, where, and why women die and to design steps to prevent such deaths, and midwives are crucial actors in the teams since they are actively involved in the care of pregnant women and may be present when most maternal deaths occur (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e); (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eA Maternal Death Surveillance and Response (MDSR) system is a continuous cycle that aims to prevent future maternal deaths by learning from prior ones. This is achieved by detecting and investigating each death, then generating and applying recommendations to prevent future deaths from comparable causes (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). The strategy (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e) allows one to study the underlying causes and factors that contribute to maternal mortality and design life-saving solutions. The MDSR has four steps: (i) identification and notification of maternal death, which is an ongoing process; (ii) review of maternal deaths; (iii) analysis and interpretation of findings from the reviews; (iv) response and action (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eMDSR also offers a rapid cycle of notification, review, analysis, and response which enables governments to monitor maternal mortality in near real-time, both at the subnational and national levels, and can provide early warning of problems in a health institution or locality (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). It works to reduce unnecessary maternal mortality by integrating all stakeholders in the process of identifying maternal deaths, learning why they occurred, and taking action to prevent similar fatalities in the future (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). Midwives are key stakeholders in the process as they provide direct care to pregnant mothers at all levels and are also members of the MDSR team (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eMidwives play a pivotal role as members of the MDSR team, and there is potential for midwives to indirectly experience trauma from such roles. Understanding their experiences in MDSR is essential in order to provide adequate support for them to enhance their skills in providing appropriate maternity care, hence the need for this study (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). Furthermore, existing MDSR research in Malawi has predominantly focused on the procedural aspects of the program, with limited exploration of the experiences of healthcare professionals, particularly midwives, involved in its implementation. Hence, the primary objective of this study was to explore midwives' experiences regarding identification, notification, and reporting of maternal deaths in the MDSR cycle. Through this exploration, we aimed to uncover crucial themes and insights that can play a pivotal role in expediting the reduction of avoidable maternal deaths.\u003c/p\u003e"},{"header":"METHODOLOGY","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eDesign\u003c/h2\u003e \u003cp\u003eThis exploratory descriptive qualitative (EDQ) study employed a purposive sample of 19 midwives who agreed to participate after being informed of the purpose. Sample size was determined by data saturation. Data collection and analysis were completed until no new themes emerged from individual interviews(\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e); (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e)\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eParticipants\u003c/h3\u003e\n\u003cp\u003eMidwives who had worked in the maternity unit for at least six months and cared for at least one near-miss or a woman who experienced a maternal death, or were on duty when the maternal death occurred, were chosen to participate in the study. The researcher approached midwives at Mwanza District Hospital, explaining the study's purpose and inviting them to participate.\u003c/p\u003e\n\u003ch3\u003eEthical Considerations\u003c/h3\u003e\n\u003cp\u003e The study protocol (P.10/23\u0026ndash;0358) was reviewed and approved by the College of Medicine Research Ethics Committee (COMREC). Mwanza Hospital Research Review Committee approved the study at their facility. The participants were informed before the interviews that all data would be confidential and anonymous, and that no information would be traceable back to them, even though the midwifery management were aware of the midwives' participation in the research. Participants were also told that they can withdraw from the study at any moment, but none did, and consent forms were signed.\u003c/p\u003e\n\u003ch3\u003eData Collection\u003c/h3\u003e\n\u003cp\u003e Individual semi-structured in-depth interviews were conducted with each participant at their convenience in the antenatal clinic, theatre, antenatal ward, labor and delivery ward, and postnatal wards where they worked. Four open-ended narrative questions were asked to enable participants to share their experiences with the implementation of maternal death surveillance and response. The interviews on average lasted one hour, and participants were permitted to relate their stories with little interference. The interviewer was an experienced midwife. All interviews were audio-recorded and transcribed.\u003c/p\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eData Analysis\u003c/h2\u003e \u003cp\u003eTwo of the researchers conducted thematic analysis. Each researcher examined and analyzed the interview transcripts separately. First, the interview transcripts were examined line by line to capture and identify the initial categories that emerged from the data. NVivo 12 software was utilized at this point to produce the codes and themes based on the code book. The researchers continued to identify themes based on the relationships between the codes. During a second reading of the transcripts, the researchers eventually identified linkages between categories and subcategories based on context.\u003c/p\u003e \u003cp\u003eThe similarities involved thematic interpretation of meaning. Categories agreed upon by the two researchers were saved, which improved intercoder reliability. Those that were excluded were assessed to have a minor contribution to the study. Finally, the findings were classified into themes that included both the researchers' interpretations and citations from the participants' narratives. The study's quality was maintained through systematic data analysis using participant narratives. Participants' stories are conveyed in their own voices and subjective points of view through quotations, while personal information is not disclosed. All interviews were conducted and analyzed in English.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eTrustworthiness\u003c/h2\u003e \u003cp\u003eData analysis was conducted inductively. To ensure the study's credibility during data analysis, researchers minimized any presumptions that may have influenced their interpretations of participants' experiences. Thus, the emergent themes were taken to represent the participants' experiences rather than the researchers' presumed classifications.\u003c/p\u003e \u003c/div\u003e"},{"header":"FINDINGS","content":"\u003cp\u003eNineteen midwives (12 female, 7 male; aged 26\u0026ndash;46 years, with 3\u0026ndash;19 years of experience) participated in the study. Thematic analysis identified barriers and enablers across all four stages of the WHO MDSR cycle (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eThemes and Subthemes Mapped to the WHO MDSR Cycle\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMDSR Stage\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eThemes/Subthemes\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDescription\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eIdentification \u0026amp; Notification\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003ePsychological impact of witnessing maternal deaths\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eEmotional toll including shock, trauma, burnout, and fear of blame from guardians.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eCoping mechanisms\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eReliance on peer support, improvisation with limited resources, and resilience strategies.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eCross-border maternal care\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eChallenges in managing referrals from Mozambique due to lack of antenatal records, late presentation, and resource strain.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eIdentifying maternal death risk factors\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRecognition of bleeding, sepsis, and shock, but hampered by delays in clinician response and lack of diagnostics.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eCommunication and coordination\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNotification pathways (clinicians, safe motherhood coordinators); evolving use of MARTSURV system vs. older fax/phone modalities.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eTimeliness\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDelays in transport, laboratory support, and hierarchical approval processes affecting prompt action and reporting.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eReview \u0026amp; Analysis\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eBlame and shame culture\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFear of punishment and negative feedback discouraged openness during maternal death reviews.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eDocumentation inconsistencies\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eVariable content and completeness of reports, affecting quality of case analysis.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eResponse \u0026amp; Action\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eLimited follow-up of recommendations\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFragmented implementation of response actions; staff hesitant to propose changes due to fear of retribution.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMonitoring \u0026amp; Evaluation\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eWeak feedback loops\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eLessons from reviews not consistently shared with frontline staff.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eCross-border system gaps\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNo mechanisms to address cross-border maternal deaths despite the burden on local facilities.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003e[Insert\u003c/b\u003e Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e \u003cb\u003ehere]\u003c/b\u003e\u003c/p\u003e \u003cp\u003e \u003cb\u003e1. Identification and Notification of Maternal Deaths within the MDSR Framework\u003c/b\u003e \u003c/p\u003e \u003cp\u003eIn line with the WHO Maternal Death Surveillance and Response (MDSR) framework, timely identification and notification of maternal deaths are foundational to effective surveillance and response. Midwives described this stage as occurring under conditions of high emotional strain, limited resources, and constrained decision-making authority. Witnessing maternal deaths had a significant psychological impact, manifesting as shock, burnout, and emotional distress, which in turn affected confidence and morale in identifying and reporting adverse outcomes. One midwife expressed feeling physically and psychologically exhausted after repeated maternal deaths, noting that such experiences were demotivating and left them feeling professionally ineffective (IDI 14).\u003c/p\u003e \u003cp\u003eDespite the expectation within MDSR that health workers promptly recognise and report maternal deaths, midwives often relied on informal coping strategies to continue functioning in high-pressure environments. These included peer support and improvisation with scarce resources, in the absence of structured institutional psychosocial support. As one participant explained \u0026ldquo;\u003cem\u003eteams worked together using whatever limited resources were available, although coping remained difficult and emotionally taxing\u003c/em\u003e\u0026rdquo; (IDI 14).\u003c/p\u003e \u003cp\u003eCross-border maternal referrals, particularly from Mozambique, further complicated the identification of high-risk cases. Women frequently presented late and without antenatal records, undermining the MDSR emphasis on early risk detection and continuity of care. Midwives reported managing critically ill women requiring urgent interventions such as blood transfusions, often with poor outcomes despite rapid action, highlighting the limitations of identification processes when presentation is delayed and documentation is absent (IDI 18).\u003c/p\u003e \u003cp\u003eAlthough midwives demonstrated strong awareness of key WHO-defined obstetric danger signs, especially haemorrhage, sepsis, and shock, their ability to act on early indicators was frequently constrained by systemic delays. Participants described situations where clinical deterioration became apparent only at advanced stages due to delayed clinician review, limited diagnostic capacity, and shortages of essential supplies, reducing opportunities for timely escalation as envisaged in MDSR guidelines (IDI 5).\u003c/p\u003e \u003cp\u003eNotification of maternal deaths followed established MDSR pathways involving clinicians and Safe Motherhood Coordinators. Participants acknowledged improvements associated with the introduction of the MARTSURV digital reporting system, which was perceived as faster and more reliable than earlier fax- or phone-based methods. However, hierarchical approval processes continued to undermine the MDSR principle of rapid notification. Midwives reported lacking the mandate to directly contact senior clinicians, resulting in delays at critical moments when time-sensitive decisions and reporting were required. As one participant noted \u0026ldquo;\u003cem\u003euncertainty over authority and rigid hierarchies meant that valuable time was lost while approval was sought, even as the patient\u0026rsquo;s condition deteriorated\u003c/em\u003e \u0026ldquo;(IDI 10).\u003c/p\u003e \u003cp\u003eOverall, the findings indicate that while identification and notification processes broadly align with WHO MDSR structures, their effectiveness is compromised by emotional burden among providers, cross-border care challenges, resource limitations, and bureaucratic barriers. Strengthening psychosocial support for midwives, enhancing cross-border information sharing, and empowering frontline providers to initiate timely notification are essential to optimising the MDSR cycle and preventing future maternal deaths.\u003c/p\u003e \u003cp\u003e \u003cb\u003e2. Review and Analysis within the MDSR Framework\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThe WHO MDSR framework emphasises maternal death reviews as confidential, non-punitive processes aimed at learning and system improvement. However, participants described review meetings as constrained by a prevailing blame and shame culture, which undermined open reflection and critical analysis. Midwives reported feeling emotionally unsafe to fully disclose events, errors, or systemic gaps, particularly in hierarchical settings where adverse outcomes were closely scrutinised. \u0026ldquo;\u003cem\u003eThis environment discouraged honest discussion and limited the depth of collective learning intended within MDSR processes\u003c/em\u003e \u0026ldquo;(IDI 18).\u003c/p\u003e \u003cp\u003eFear of punishment and negative feedback further shaped participation during reviews. Rather than fostering a culture of accountability and improvement, reviews were often perceived as fault-finding exercises. As a result, midwives reported withholding information or self-censoring contributions to protect themselves and colleagues from blame, weakening the analytical value of the review process (IDI 4).\u003c/p\u003e \u003cp\u003eInconsistent documentation practices further compromised the quality of case analysis. Participants described variability in the completeness, accuracy, and content of maternal death reports, raising concerns about data integrity and reliability. One midwife emphasised the need to personally secure patient files to prevent loss or alteration of information, noting that \u003cem\u003e\u0026ldquo;the midwife should get hold of the file, to avoid it being lost or information altered\u0026rdquo;\u003c/em\u003e (IDI 10). Such inconsistencies limited the ability of review teams to reconstruct clinical timelines, identify modifiable factors, and generate evidence-informed recommendations, contrary to WHO guidance on standardised MDSR documentation.\u003c/p\u003e \u003cp\u003eOverall, while maternal death reviews were routinely conducted, their effectiveness as learning tools was diminished by fear-driven participation and weak documentation systems, reducing their potential to inform meaningful action.\u003c/p\u003e \u003cp\u003e \u003cb\u003e3. Response and Action following Maternal Death Reviews\u003c/b\u003e \u003c/p\u003e \u003cp\u003eWithin the MDSR cycle, the response and action phase is intended to translate review findings into concrete, monitored interventions. Participants, however, reported that implementation of recommendations was often fragmented and poorly coordinated. Although action points were routinely documented, follow-up mechanisms were weak, and responsibility for implementation was often unclear. As one midwife observed, recommendations were frequently recorded but rarely operationalised, with actions \u0026ldquo;\u003cem\u003eending in the report rather than leading to tangible change\u003c/em\u003e\u0026rdquo; (IDI 12).\u003c/p\u003e \u003cp\u003e This lack of continuity contributed to frustration, disengagement, and scepticism among frontline staff regarding the value of the review process. The absence of accountability structures to track progress on agreed actions meant that systemic gaps identified during reviews, such as staffing shortages, supply constraints, or delayed referrals, persisted over time (IDI 17).\u003c/p\u003e \u003cp\u003eFear of retribution further inhibited active engagement in the response phase. Midwives described hesitating to propose system-level changes during review meetings due to concerns about being blamed, reprimanded, or perceived as challenging senior clinicians. One participant explained that \u0026ldquo;\u003cem\u003esilence was often a protective strategy, as speaking up could result in blame or strained hierarchical relationships\u003c/em\u003e\u0026rdquo; (IDI 7). In response to these pressures, some midwives adopted emotional detachment as a coping mechanism, deliberately distancing themselves from the review and action processes. As one participant stated, \u0026ldquo;\u003cem\u003eemotional withdrawal was necessary for survival in the work environment, even though it reduced meaningful engagement in improvement efforts\u003c/em\u003e\u0026rdquo; (IDI 15).\u003c/p\u003e \u003cp\u003eWhile such strategies may protect individual wellbeing, they undermine collective responsibility and weaken the MDSR response function by limiting staff ownership of recommended actions.\u003c/p\u003e \u003cp\u003e \u003cb\u003e4. Monitoring and Evaluation of the MDSR Process\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThe monitoring and evaluation component of MDSR requires feedback loops that ensure lessons learned are disseminated to frontline providers and inform ongoing practice. Participants reported that such feedback mechanisms were weak or inconsistently applied. Although maternal deaths were identified and notified, frontline staff were often excluded from subsequent learning and system-level reflection. One midwife described feeling disconnected from the process, noting that \u0026ldquo;\u003cem\u003ewhile notifications were completed, feedback rarely reached those directly involved in care, making the process feel more like data collection than supportive system improvement\u003c/em\u003e\u0026rdquo; (IDI 9).\u0026rdquo;\u003c/p\u003e \u003cp\u003eThe absence of regular feedback limited opportunities for reflective practice, skill development, and reinforcement of positive changes, further diminishing staff motivation to engage with MDSR activities. For instance, one midwife showed concern on what could happen if audits are indeed done but no feedback is given to responsible personnel for action (IDI 4).\u003c/p\u003e \u003cp\u003ePersistent cross-border system gaps also highlighted limitations in monitoring and evaluation at higher system levels. Facilities in border districts continued to manage a substantial burden of maternal cases from neighbouring Mozambique, yet no formal mechanisms existed to capture, analyse, or respond to cross-border maternal deaths within national MDSR structures. Participants reported that this ongoing influx placed disproportionate strain on already limited resources, without corresponding adjustments in staffing, supplies, or policy support. As one participant noted, \u0026ldquo;\u003cem\u003ethe facility served populations beyond its official catchment area, intensifying pressure on services without recognition at central levels\u003c/em\u003e\u0026rdquo; (IDI 17).\u003c/p\u003e \u003cp\u003eThese findings suggest that weaknesses in feedback dissemination and the absence of cross-border MDSR coordination undermine the completeness and equity of monitoring and evaluation efforts.\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eThis study explored midwives' experiences of maternal death surveillance and response (MDSR) at Mwanza District Hospital, Malawi. Organized around the stages of the WHO MDSR cycle, the findings highlight how psychological distress, systemic resource shortages, and cross-border complexities intersect to undermine effective identification, review, and response. Despite some improvements in notification processes, weak accountability and a prevailing culture of blame limit the potential of MDSR to prevent future maternal deaths. These findings carry implications for both national policy and regional cooperation.\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eIdentification and Notification of maternal deaths within the MDSR framework\u003c/h2\u003e \u003cp\u003eIdentification and notification of maternal deaths were marked by emotional distress and professional uncertainty. Midwives described feelings of shock, guilt, and powerlessness, particularly when deaths occurred despite significant effort. These reactions are consistent with prior evidence showing that exposure to traumatic maternal events contributes to compassion fatigue, intrusive memories, and diminished professional confidence (\u003cspan additionalcitationids=\"CR17\" citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). In some cases, such experiences can precipitate defensive practice, with providers resorting to unnecessary interventions driven by fear of poor outcomes (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eSystemic factors amplified this distress. High workloads, shortages of staff and supplies, and limited refresher training in emergency obstetric care were common. Comparable findings have been reported in Ghana, where midwives often relied on experiential learning rather than formal training to manage maternal deaths (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). In Croatia, inadequate organizational support and poor communication with supervisors also increased vulnerability to burnout (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). Addressing these gaps requires embedding regular training and psychosocial support within the MDSR cycle.\u003c/p\u003e \u003cp\u003eNotification processes had improved with the introduction of the MARTSURV platform, which enabled more timely reporting compared with fax and telephone. However, delays persisted for women referred from Mozambique without antenatal records. Similar challenges are observed in humanitarian and cross-border contexts, where fragmented data systems impede timely reporting and coordination (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). These findings underscore that effective notification is contingent not only on digital tools but also on system integration and regional collaboration.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eReview and Analysis within the MDSR framework\u003c/h2\u003e \u003cp\u003eThe review stage was compromised by a culture of blame and fear of retribution. Midwives reported reluctance to participate fully in audit meetings, with some describing emotional withdrawal as a coping mechanism. This reflects evidence from sub-Saharan Africa, where punitive approaches undermine the quality of maternal death reviews (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). Rather than fostering collective learning, reviews risk becoming symbolic exercises that fail to address root causes.\u003c/p\u003e \u003cp\u003eDocumentation practices showed both strengths and weaknesses. Midwives demonstrated commitment to safeguarding patient files, recognizing the risk of tampering or loss. Yet, inconsistencies and omissions limited the depth of analysis. Previous Malawian studies have reported similar gaps, with incomplete files undermining the ability to identify systemic failures (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). Ensuring comprehensive documentation is vital, not only for accuracy of reviews but also for institutional memory and accountability.\u003c/p\u003e \u003cp\u003eA no-blame review culture, as advocated by WHO, is essential to encourage candid participation and improve the quality of analysis. Peer-led reviews and supportive supervision may offer pathways to shift from punitive blame to constructive learning, as demonstrated in South Africa where participatory approaches improved audit engagement (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eResponse and Action following maternal death reviews\u003c/h2\u003e \u003cp\u003ePerhaps the most significant finding of this study was the weak translation of review findings into action. Participants described fragmented follow-up, with recommendations often \"ending in the report\" without clear accountability for implementation. This undermines the credibility of the MDSR process and discourages staff engagement. Midwives who felt disillusioned sometimes withdrew emotionally, echoing patterns in Nigeria and Tanzania where poor follow-through eroded confidence in MDSR (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eFear of blame further constrained the process, with some staff reluctant to propose changes that might expose them to criticism. Without systematic monitoring, recommendations risk becoming aspirational rather than actionable. Strengthening accountability mechanisms such as assigning responsibility for specific actions, ensuring managerial oversight, and providing feedback to frontline staff is critical. Evidence from South Africa suggests that locally owned response committees with strong leadership support can enhance adherence to recommendations and reduce preventable deaths (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eMonitoring and Evaluation of the MDSR process\u003c/h2\u003e \u003cp\u003eMonitoring and evaluation were the weakest links in Mwanza's MDSR cycle. Feedback loops were minimal, and midwives rarely received information about whether their recommendations led to change. This disconnect diminished the perceived value of their contributions and perpetuated disillusionment.\u003c/p\u003e \u003cp\u003eMwanza's border location added further complexity. Women frequently arrived from Mozambique in critical condition, often without antenatal documentation. Midwives expressed frustration at being unable to provide feedback to Mozambican facilities or address systemic delays in referral. These deaths were nonetheless recorded in Malawi's statistics, inflating the district's indicators while masking cross-border health system failures. Comparable jurisdictional challenges are observed in the United States, where state-level maternal mortality review committees face barriers to data-sharing across borders (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). In conflict-affected regions, fragmented governance and insecurity similarly disrupt surveillance and response systems (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThese findings suggest that maternal mortality in border districts cannot be addressed by national strategies alone. Bilateral agreements between Malawi and Mozambique on data-sharing, joint audits, and resource allocation are urgently needed. Without such cooperation, the burden will continue to fall disproportionately on frontline providers in border facilities.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eImplications for Policy and Practice\u003c/h2\u003e \u003cdiv id=\"Sec16\" class=\"Section3\"\u003e \u003ch2\u003eImplications for Policy and Practice\u003c/h2\u003e \u003cp\u003eThis study underscores that strengthening MDSR requires interventions across all four stages of the cycle. The findings identify emotional, structural, and procedural challenges to effective implementation, which must be addressed in order to enhance maternal health outcomes.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eIdentification and Notification\u003c/h2\u003e \u003cp\u003eAccording to the study, midwives frequently face emotional anguish, fear of blame, and uncertainty while reporting maternal fatalities, resulting in delayed or incomplete notification. To resolve these issues embedding regular refresher training in emergency obstetric care and psychosocial debriefing can help reduce distress during reporting. In addition, establishing cross-border data sharing agreements with Mozambique can improve timeliness and completeness of notifications.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003eReview and Analysis\u003c/h2\u003e \u003cp\u003eMidwives described review meetings as informative but emotionally draining, especially in circumstances where there is a fear of blaming. To promote a no-blame culture, reviews should be based on professional learning and accountability principles. This demands district and facility-level leadership involvement. Encouraging peer-led review methods that involve midwives can improve ownership, trust, and reflection during audits. Furthermore, utilising user-friendly audit templates assures completeness, depth, and system wide comparability of evaluations.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003eResponse and Action\u003c/h2\u003e \u003cp\u003eThe study identifies a recurring gap between recognising problems and adopting corrective steps, which is often caused by a lack of resources and unclear accountability. Creating facility-level action plans with defined responsibilities, dates, and resource requirements; Ensuring hospital leadership receives audit results, tracks progress, and distributes resources appropriately for instance supplies, staffing, and maternity equipment; and Involving midwives in decision-making to guarantee feasible, acceptable, and coordinated actions with frontline realities.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003eMonitoring and Evaluation\u003c/h2\u003e \u003cp\u003eParticipants reported ineffective feedback mechanisms and limited visibility of adjustments made following maternal death reviews, which reduced motivation and learning. Creating effective feedback loops to convey audit results and actions to all workers, including those who were not present during the review, and holding bilateral review sessions for cross-border deaths can enhance regional collaboration and learning.\u003c/p\u003e \u003cp\u003eBy reinforcing each stage of the MDSR cycle, Malawi can enhance the effectiveness of maternal death surveillance, improve frontline staff engagement, and contribute to achieving the Sustainable Development Goal of reducing maternal mortality to fewer than 70 deaths per 100,000 live births by 2030.\u003c/p\u003e \u003c/div\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eThis study highlights how midwives at Mwanza District Hospital experience significant psychological, systemic, and structural challenges when implementing the MDSR cycle. At the identification and notification stage, emotional distress and cross-border referral gaps undermine timely and accurate reporting. During review and analysis, prevailing blame cultures and inconsistent documentation limit open discussion and robust case learning. The response and action stage is weakened by fragmented follow-up and the absence of accountability frameworks, while monitoring and evaluation remain underdeveloped, leaving midwives disengaged and uncertain whether their recommendations lead to change.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eEDQ\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eExploratory Descriptive Qualitative Research\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eEmOC\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eEmergency Obstetric Care\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eFBMDR\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eFacility Based Maternal Death Review\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eFBMDSR\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eFacility Based Maternal Death Surveillance and Response\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eMDR\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eMaternal Death Review\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eMDSR\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eMaternal Death Surveillance and Response\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eMMR\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eMaternal Mortality Ratio\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eMPDSR\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eMaternal and Perinatal Death Surveillance and Response\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e \u003cstrong\u003eEthical Approval and Consent to Participate\u003c/strong\u003e \u003cp\u003e The College of Medicine Research Ethics Committee (COMREC) approved the study. This is a review board of the Kamuzu University of Health Sciences. Written informed consent was obtained from each participant prior to participation in the study. Permission to recruit participants was obtained from Mwanza District Health Office.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eConsent for Publication\u003c/strong\u003e \u003cp\u003eNot applicable.\u003c/p\u003e \u003c/p\u003e\u003cp\u003e \u003ch2\u003eCompeting Interests\u003c/h2\u003e \u003cp\u003eThe authors have no competing interests to declare.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e \u003cp\u003eThis project did not have any funding.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eWakhonderachi undertook a literature search to identify gaps in the area of interest, designed the study, conducted the fieldwork, undertook analyses, and prepared the manuscript. Fikile Singano reviewed the manuscript, Gaily Lungu provided supervision throughout the process, whilst Martha Kamanga (PhD) provided supervision and scientific support throughout the process and edited the manuscript for content.\u003c/p\u003e\u003ch2\u003eAcknowledgements\u003c/h2\u003e \u003cp\u003eSpecial thanks to the Director of Health and Social Services and Director of Nursing and Midwifery Services at Mwanza District Hospital where the study was conducted for allowing access to the midwives and for the support in data collection.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eData will be available from the authors upon request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eWillcox ML, Okello IA, Maidwell-Smith A, Tura AK, van den Akker T, Knight M. Maternal and perinatal death surveillance and response: a systematic review of qualitative studies. 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Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.who.int/teams/sexual-and-reproductive-health-and-research-(srh)/areas-of-work/adolescent-and-sexual-and-reproductive-health-and-rights\u003c/span\u003e\u003cspan address=\"https://www.who.int/teams/sexual-and-reproductive-health-and-research-(srh)/areas-of-work/adolescent-and-sexual-and-reproductive-health-and-rights\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChirwa MD, Nyasulu J, Modiba L, Limando MG. Challenges Faced by Midwives in the Implementation of Facility-Based Maternal Death Reviews in Malawi. [Internet]. In Review; 2022 Feb [cited 2023 Mar 29]. 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BJOG Int J Obstet Gynaecol. 2014;121(s4):53\u0026ndash;60.\u003c/span\u003e\u003c/li\u003e\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-pregnancy-and-childbirth","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"prch","sideBox":"Learn more about [BMC Pregnancy and Childbirth](http://bmcpregnancychildbirth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/prch/default.aspx","title":"BMC Pregnancy and Childbirth","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"maternal death, midwives, maternal death surveillance and response, Malawi","lastPublishedDoi":"10.21203/rs.3.rs-8908402/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8908402/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cb\u003eBackground\u003c/b\u003e\u003c/p\u003e \u003cp\u003eDespite 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.\u003c/p\u003e\u003cp\u003e\u003cb\u003eMethods\u003c/b\u003e\u003c/p\u003e \u003cp\u003eAn 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\u0026ndash;0358).\u003c/p\u003e\u003cp\u003e\u003cb\u003eResults\u003c/b\u003e\u003c/p\u003e \u003cp\u003eMidwives 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.\u003c/p\u003e\u003cp\u003e\u003cb\u003eConclusion\u003c/b\u003e\u003c/p\u003e \u003cp\u003eMidwives 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.\u003c/p\u003e","manuscriptTitle":"Midwives' Experiences of Maternal Death Surveillance and Response: Insights from Mwanza District Hospital, Malawi","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-03-26 19:03:19","doi":"10.21203/rs.3.rs-8908402/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2026-04-15T08:40:14+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"48958175754453266869753349303852708369","date":"2026-04-10T21:13:21+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-29T21:46:49+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"96692855443913513639692173918900433681","date":"2026-03-24T18:05:51+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-03-24T10:53:55+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-02-23T15:20:50+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-02-20T00:59:12+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-02-20T00:57:53+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Pregnancy and Childbirth","date":"2026-02-18T10:29:58+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-pregnancy-and-childbirth","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"prch","sideBox":"Learn more about [BMC Pregnancy and Childbirth](http://bmcpregnancychildbirth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/prch/default.aspx","title":"BMC Pregnancy and Childbirth","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"899a4056-3116-4838-9038-a421285eb714","owner":[],"postedDate":"March 26th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-03-26T19:03:20+00:00","versionOfRecord":[],"versionCreatedAt":"2026-03-26 19:03:19","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8908402","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8908402","identity":"rs-8908402","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}