Are Maternal and Neonatal Death Reviews a Feasible Approach to Study Gaps in Care: Findings from a Case Study

Abstract Reducing maternal and neonatal mortality is a global priority, yet the processes for retrieving and using death review data remain unclear. This study examined the practicality of collecting and applying maternal and neonatal death review information to assess care quality and identify gaps. We conducted a mixed-methods study in two districts in India (District A in Telangana and District B in Gujarat), reviewing records of 10 maternal and 10 neonatal deaths that occurred between April 2020 and March 2021. Data were extracted to assess completeness, and field notes documented operational challenges. Retrieving records was difficult due to fragmented storage, unclear responsibilities, and the need for multiple permissions and repeated visits. Reluctance among officials to share data further delayed access. Most review forms lacked sufficient detail to evaluate quality of care or determine preventability. Maternal deaths mainly involved young women aged 15–24 and occurred within 24 hours postpartum, often linked to delays in receiving appropriate care. Neonatal deaths frequently involved low-birthweight or preterm infants and were attributed to asphyxia or infection. Overall, operational barriers and incomplete documentation limit the usefulness of maternal and neonatal death reviews. Strengthening record management, data-sharing, and documentation practices is essential for improving care quality.