Uncovering the stories behind the numbers : a case study of maternal death surveillance and response in Goma, Democratic Republic of Congo.

Globally, 303 000 women die each year from preventable causes related to pregnancy, with the Democratic Republic of Congo (DRC) having the tenth highest maternal mortality rate. Maternal Death Surveillance and Response (MDSR) is a surveillance-action cycle that aims to eliminate preventable maternal mortality by linking actionable data on maternal deaths with multi-level actions. While countries are increasingly adopting MDSR, there are research gaps on its implementation, outcomes, and best practices in developing countries including the DRC. This study assessed MDSR implementation in Goma Health Zone (HZ), DRC, specifically its structure, process, quality, outcomes, and influencing factors. A qualitative case study design was utilized, comprising semi-structured interviews with 15 key informants from seven sites, a review of 52 MDSR documents, and an observation of a maternal death review. Data analysis was conducted in Dedoose using the constant comparative method. Findings suggest that MDSR integration into an existing Integrated Disease Surveillance and Response system in the DRC has facilitated its acceptability and institutionalization in integrated (i.e. government-affiliated) health facilities in Goma HZ, where it is sustained by existing organizational resources. However, the MDSR system had weak community and private health sector linkages. Additionally, this study revealed a systematic implementation of early MDSR phases (notification-review) but gaps in completing advanced MDSR functions such as response implementation. With respect to quality, the MDSR system’s major strengths were its simplicity, acceptability, and timeliness in integrated health facilities, while its major challenges were its acceptability, data quality, and timeliness in communities and non-integrated facilities. The political commitment to MDSR and strong support from the HZ and facility leadership were key enablers of MDSR implementation, while unregulated private facilities and the links between MDSR and disciplinary action were the most prominent barriers. While MDSR in Goma HZ has yielded some improvements in the quality of care at HZ and facility levels, its overall impact on maternal health outcomes remains reportedly weak due to limited response implementation at higher levels of the health system.To strengthen Goma’s MDSR, this study suggests the need for a non-threatening MDSR environment, multisectoral partnerships, and mechanisms to follow-up on recommendations