Background <p>Effective implementation of the Maternal Death Surveillance and Response (MDSR) framework is critical for reducing maternal mortality. In Aceh Province, Indonesia, maternal mortality remains high, with rates exceeding the national average. Despite national policy adoption, limited evidence exists on how MDSR is implemented at the subnational level. This study assessed the implementation of the MDSR framework in North Aceh District by examining its five stages using eight implementation outcome variables.</p> Methods <p>A qualitative study was conducted using in-depth interviews with 60 participants, including policymakers, health practitioners, and community representatives across multiple administrative levels. In addition, five policy and program documents were reviewed. Data were analysed thematically using NVivo 12, guided by predefined implementation outcome variables (acceptability, adoption, appropriateness, feasibility, compliance, implementation cost, coverage, and sustainability). Findings were further interpreted using the Consolidated Framework for Implementation Research (CFIR) to identify multi-level factors influencing policy implementation.</p> Results <p>MDSR implementation was largely concentrated in the initial stage of maternal death identification, with limited progression to reporting, review, response, and monitoring and evaluation. While the framework was highly accepted and considered appropriate among policymakers, its implementation was constrained by inadequate public communication, low community engagement, limited capacity among frontline health workers, weak accountability and governance mechanisms, and frequent staff rotation. These challenges negatively affected adoption, coverage, compliance, and sustainability of the framework.</p> Conclusions <p>MDSR implementation in North Aceh remains incomplete and uneven across stages, highlighting critical gaps in full-cycle implementation. Strengthening public communication, workforce capacity, accountability systems, and leadership commitment is essential to improve implementation performance. This study contributes to implementation science by demonstrating how implementation outcomes vary across MDSR stages and are shaped by multi-level determinants. The findings provide important insights for strengthening maternal death surveillance systems in Aceh and other similar decentralised health system contexts and may support efforts to accelerate progress towards maternal mortality reduction targets under the Sustainable Development Goals (SDGs).</p>