Underreporting of deaths in the maternal deaths surveillance system in one region of Morocco

<div><p>Objective</p><p>To assess the reliability of maternal deaths surveillance system (MDSS) and to determine the factors that influence its completeness in one region of Morocco.</p><p>Methods</p><p>We conducted a retrospective survey in “Gharb Chrarda Bni Hssen” region (GCBH) between January the 1st, 2013 and September the 30th, 2014 using multiple sources approach. All deaths of women of reproductive age (WRA) were investigated using certificates with medical cause, medical records and interviews with household members and relatives to ascertain a pregnancy-related or maternal death. An External Expert Committee reviewed the information collected to assign a cause for each death. Our results were compared to those reported in the same period by the MDSS.</p><p>Findings</p><p>Our study identified 690 deaths of WRA and 69 maternal deaths of which 34.8% occurred outside health facilities. The MDSS recorded during the study period 538 deaths of WRA and 29 maternal deaths (including only one outside health facility) representing respectively an underreporting of 22.0% and 58.0%. Late maternal deaths represented 11.4% of all deaths of women with a registered pregnancy within 12 months prior to the death, while the MDSS identified none. The maternal mortality ratio (MMR) was estimated at 103, approximately 2.5 times higher than that reported in the MDSS.</p><p>Conclusion</p><p>Our study has shown weaknesses in the current notification system for maternal deaths in the region of GCBH. Therefore, more attention must be given to the regional committees in charge of auditing the cases and defining actions to be implemented to prevent further maternal deaths.</p></div

Deaths among WRA after record linkage between data sources (N = 690).

<p>*including 2 other deaths identified by both health offices and local authorities.</p

Causes of deaths among WRA (N = 690).

<p>Causes of deaths among WRA (N = 690).</p

Time and place of deaths (N = 79).

<p>Time and place of deaths (N = 79).</p

PRDs recorded in hospitals, those identified as PRDs and those missed.

<p>PRDs recorded in hospitals, those identified as PRDs and those missed.</p

Deaths among WRA identified by data source (N = 690).

<p>*One death not recorded by data source in GCBH but identified through verbal autopsies in Sidi Kacem. It was a woman resident in GCBH but who died outside of the region thus not recorded in any of the four data sources mentioned.</p

Deaths of WRA by place, identified by the study and the MDSS, 2013–2014.

<p>Deaths of WRA by place, identified by the study and the MDSS, 2013–2014.</p

Funnel plot analysis for publication bias.

<p>(a) rs12423791 allelic contrast model (C vs. G). (b) rs6214 allelic contrast model (A vs. G).</p

Flow chart of the study selection process.

<p>Literature search flow.</p

Main results of the pooled ORs in the meta-analysis.

<p>*The Q statistic was used to estimate heterogeneity, and a <i>P</i>≤0.10 was considered statistically significant for the Q-statistic test.</p><p>Main results of the pooled ORs in the meta-analysis.</p