Eight-year experience of maternal death surveillance in Morocco: qualitative study of stakeholders' views at a subnational level

Background: Since 2009, Morocco has been implementing the Maternal Death Surveillance System (MDSS). The results obtained indicate significant regional variations in terms of implementation stage, completeness of maternal death reporting, and information use for action. The objective of this research is to better understand the contextual factors involved in the implementation process and use of MDSS, with a focus on the facilitators and barriers, as experienced by stakeholders in health regions. Methods: Evaluation research was conducted in 2017 based on a descriptive qualitative study using semi-structured in-depth interviews, in four out of the twelve health regions of Morocco. A total of thirty-one in-depth interviews were held with members of regional committees of maternal death reviews (RC-MDR) and other key informant staff. Interviews focused on participants' views and their experiences with the MDSS since the introduction in 2009. We conducted thematic analysis relied on inductive and deductive approaches. Applying the Consolidated Framework for Implementation Research guided data analysis and reporting findings. Findings: Engaging leadership at all health system levels, regular training of district and regional MDSS coordinators and supportive supervision at a national level were the most important MDSS implementation facilitators. Reported barriers were essentially related to the review system: Irregular review meetings, blame culture, high turn-over of RC-MDR members, lack of analytical capacity to inform the review process and formulate recommendations, finally limited accountability for recommendation follow-up. While financial incentives boosted MDSS adoption, they were nonetheless a substantial barrier to its sustainability.Conclusions: The MDSS is a complex process that requires taking numerous steps, including the commitment of multiple stakeholders with varying roles as well as information sharing across health system levels. Contextual factors that influence MDSS implementation at the sub-national level are to be considered. Horizontal and vertical communication about MDSS goals and feedback is crucial to strengthen stakeholders' commitment, hence improving quality and use of MDSS. Furthermore, health regions should place emphasis on making high-quality recommendations in partnerships between the regional management teams, RC-MDR members and external stakeholders