Background
The Ministry of Health operates a national MPDSR (maternal and perinatal death surveillance and response) mechanism that coordinates multi-level committees to examine maternal and perinatal deaths and recommend clinical and system-level improvements. The national MPDSR committee convenes with hospital MPDSR teams and provincial maternal health units to ensure case reviews are linked to operational actions across referral facilities.
MPDSR reviews routinely apply the three delays framework to identify barriers in decision to seek care, reaching care, and receiving timely appropriate care at health facilities. The review process combines clinical case analysis with recommendations on triage, resource allocation, and follow-up supervision to reduce preventable maternal and neonatal mortality.
Key Developments
On 7 August 2026 the national MPDSR chair, supported by the Ministry of Health, led a review of a maternal death case referred from Chbar Ampov Hospital to Khmer-Soviet Friendship Hospital. The meeting brought together national hospital MPDSR committees, the eight national hospitals’ MPDSR teams, and three affiliated maternal hospitals with a total of 108 participants joining virtually.
Participants reiterated the MPDSR meeting code of conduct emphasizing a no-blame approach while maintaining clear accountability for corrective actions. The committee reviewed findings against the three delays and identified both effective practices and areas requiring improvement to strengthen perinatal and maternal services.
Institutional Role
The national MPDSR committee acts as a coordination and oversight body that aggregates hospital-level reviews and issues practical guidance for implementation at provincial and facility levels. Hospital MPDSR teams are expected to translate committee recommendations into local clinical protocols, referral pathways, and monitoring actions.
Operational Implications
The meeting produced targeted operational recommendations for hospitals and affiliated maternal facilities, including:
- Introduce and scale a color-coding system during antenatal screening to flag high-risk pregnancies and ensure regular follow-up.
- Accelerate implementation of the color-coding protocol across affiliated maternal health centers through reminders and supervision from national hospitals.
- Establish dedicated reception areas for high-risk obstetric cases and neonatal resuscitation capacity at national and level-2/level-3 hospitals.
- Create multidisciplinary ‘Pole Mere Enfant’ teams at national and CPA3 hospitals focused on integrated maternal and newborn care.
- Deploy a Light Assessment Tool (LAT) at all hospitals to assess human resources, equipment, and consumables at point-of-care locations.
These actions are practical steps for facility managers and regional health authorities to prioritize resource allocation, improve triage and referral, and monitor implementation progress.
Source
Ministry of Health announcement and MPDSR meeting summary, 7 August 2026. Original source: Ministry of Health social media post (link provided in metadata).
