‘Maternal deaths should simply be 0’: politicization of maternal death reporting and review processes in Ethiopia

Abstract

The Maternal Death Surveillance and Response system (MDSR) was implemented in Ethiopia in 2013 to record and review maternal deaths. The overall aim of the system is to identify and address gaps in order to prevent future death but, to date, around 10% of the expected number of deaths are reported. This article examines practices and reasoning involved in maternal death reporting and review practices in Ethiopia, building on the concept of ‘practical norms’. The study is based on multi-sited fieldwork at different levels of the Ethiopian health system including interviews, document analysis and observations, and has documented the politicized nature of MDSR implementation. Death reporting and review are challenged by the fact that maternal mortality is a main indicator of health system performance. Health workers and bureaucrats strive to balance conflicting demands when implementing the MDSR system: to report all deaths; to deliver perceived success in maternal mortality reduction by reporting as few deaths as possible; and to avoid personalized accountability for deaths. Fear of personal and political accountability for maternal deaths strongly influences not only reporting practices but also the care given in the study sites. Health workers report maternal deaths in ways that minimize their number and deflect responsibility for adverse outcomes. They attribute deaths to community and infrastructural factors, which are often beyond their control. The practical norms of how health workers report deaths perpetuate a skewed way of seeing problems and solutions in maternal health. On the basis of our findings, we argue that closer attention to the broader political context is needed to understand the implementation of MDSR and other surveillance systems.

Beyond No Blame: Practical Challenges of Conducting Maternal and Perinatal Death Reviews in Eastern Ethiopia

“…In such environments, diverting accountability to factors out of control become the norm to avoid being blamed for poor outcomes. 8 Such situations have been reported in several death review practices. [9][10][11] Successful maternal death reviews require supportive political and policy environments, individual responsibility and ownership, a proactive institutional ethos, and promotion of learning as a crucial part of improving services and quality of care.…”

“…20 Often, factors contributing to bad outcomes (deaths or delays) are stated to be the result of factors outside the control of local health workers and policy makers. 8,15 In a recent qualitative study of MDSR implementation in Ethiopia, Melberg et al showed that highly politicizing maternal deaths, as indicated by the common slogan of "no mother should die while giving birth" everywhere hinders the identification, reporting, review, or assignment of causes to maternal deaths. Health workers and officers leading MDSRs are under so much pressure to meet the political requirement of zero maternal deaths that there is a strong incentive to substantially underreport.…”

“…Health workers and officers leading MDSRs are under so much pressure to meet the political requirement of zero maternal deaths that there is a strong incentive to substantially underreport. 8 The MDSR system functions without a national confidential enquiry to generate and recommend detailed lessons for practice and merely collates reports that arise from the bottom up reporting to generate annual MDSR reports. 19 Thus, a safe and just national system of confidential enquiries could be of added value.…”

“…15 Moreover, learning during the audit was hampered by political sensitivities surrounding maternal death-a desire for no maternal deaths by political leaders and higher officials in hospitals or health bureaus. 8 No or few maternal deaths were reported to occur in referring hospitals and health centers, while "(near-) death on arrival" was observed to be a common problem in the majority of the referral hospitals. At the lower-facility level, a woman in very critical condition sometimes appeared to be referred out immediately, sometimes without starting prereferral life-supporting care, out of fear that she would die at that facility.…”

“…Although ending preventable maternal mortality requires political priority, 34 direct interference in the health system may not accelerate progress and may even deter the situation. 8 In a country where maternal mortality is a highly political phenomenon, 8,35 meaningful reduction in maternal mortality requires a depoliticizing paradigm shift. Health care providers should work within a conducive environment that enables them to thoroughly evaluate the pathways to death and generate lessons using their own perspectives, rather than using the narrow political lens of achieving the "no mother should die while giving birth" slogan everywhere and every time.…”