Barriers to Implementation of Maternal and Perinatal Death Surveillance and Response in Three Referral Hospitals in Edo State, Nigeria

Abstract

Despite Nigeria's formal adoption of maternal and perinatal death surveillance and response (MPDSR) guidelines, implementation remains suboptimal, prompting this study to identify barriers to MPDSR implementation in three Edo State referral hospitals from healthcare worker and policy stakeholder perspectives. This mixed-methods study involved 221 healthcare workers from three hospitals and 11 key informant interviews with administrators and policymakers, with quantitative data assessing 14 barrier domains through structured questionnaires while qualitative data explored implementation challenges through in-depth interviews using descriptive statistics and thematic analysis. Multiple interrelated barriers emerged across individual, organizational, and system levels, with individual-level barriers including poor MPDSR knowledge (83.3% inadequate), lack of training (91.4% untrained), heavy workload, and fear of blame, while organizational barriers encompassed absent written policies, unavailable standardized forms, inadequate staffing, weak committee structures, poor record-keeping, and insufficient management support. Systemlevel barriers included inadequate guideline dissemination (only 12.7% accessed guidelines), poor funding, weak community engagement, absent supervision, non-implementation of recommendations, lack of feedback mechanisms, and inadequate political commitment, with qualitative findings revealing synergistic barrier interactions creating implementation bottlenecks. MPDSR implementation faces substantial multilevel barriers spanning knowledge deficits, organizational infrastructure weaknesses, and systemic resource gaps, and their complex, interrelated nature suggests piecemeal interventions will fail, indicating that comprehensive, multilevel strategies are essential, simultaneously addressing capacity building, organizational strengthening, system-level support, and enabling environments through management commitment and quality improvement integration, without which MPDSR will remain suboptimal, leaving its mortality-reduction potential unrealized.