MATRISET - Studying «real time» implementation of maternal death reporting and review

Numerous medical interventions and technologies have been introduced into health systems around the world in recent years to reduce persistently high maternal mortality rates. Yet, in 2015 an estimated 300 000 women died globally from causes related to pregnancy and childbirth. Globally, the story of maternal deaths is one of staggering inequity; an overwhelming majority of maternal deaths occur among poor, uneducated women living in the rural areas of sub-Saharan Africa and South Asia.

National Maternal Mortality Ratios (MMR) are given substantial attention as indicators of a country's or region's level of development, health systems functioning, women’s position, and not the least, health equity. Despite their significance, research indicates that the global MMR estimates are surrounded by uncertainty and error - particularly in contexts with high maternal mortality burdens. This is rarely made explicit in the literature.

Maternal Death Surveillance and Response System (MDSR) (external link) is a WHO-developed tool introduced in 2013 to enhance maternal mortality reporting and corrective action. However, significant weaknesses in reporting routines, accountability structures, and data flow have been documented. In a context of politicization of maternal mortality numbers and pressure to meet global maternal goals, systematic underreporting has been linked to the tension between high workloads, demands for health worker accountability, and lack of legal protection of health workers who fear blame and litigation. The result is impaired quantity and integrity of the data, and instances of defensive medical practices.

The present project titled: Reporting in Context: An Interdisciplinary Initiative to Strengthen Maternal Health Services and Surveillance in Ethiopia and Tanzania (MATRISET) aims to strengthen the reporting in maternal mortality surveillance systems in the contexts of Ethiopia and Tanzania through research employing approaches from social science, law and medicine. 

Project Methods

Through an inter-disciplinary approach termed ‘reporting in context’, we employ novel combinations of methods to the study of institutional routines and practices as well as legal frameworks. Through a combination of ethnography, survey, and analysis of register data, we investigate the relationship between observed and reported clinical practice. 

Ethnography: The team has substantial competence in ethnographic research which will be used as a research method to gain unique insights into the procedures and practices of reporting. Observation- and participant observation (in ethnography) will also be decisive in gaining substantive knowledge on the management of reported data within the health service bureaucracy.

Mixed methods designs will combine qualitative approaches (ethnography and qualitative interviews) with quantitative approaches (surveys and use of register data) to generate in-depth knowledge about clinical reporting and the dynamics of accountability. Ethnographic approaches are rarely employed in mixed methods designs but will be extensively used in the present project.

Doctrinal research will, in combination with the ‘law in context ’ research method, generate beyond state-of-art knowledge regarding the legal dimension of the MDSR activities to enhance the balance between health worker accountability and the protection of health workers who report maternal mortality.

Stakeholder involvement: Through continuous collaboration with stakeholders in professional organizations and Community-Based Organizations (CBOs), the team will develop concrete advice for improvements within the field.

Project Sites

The project’s sub-components are located at both the national level and at urban and rural study sites in Ethiopia and Tanzania.

Impact

Most studies on maternal death surveillance and review systems’ implementation in sub-Saharan Africa have focused on the existence of formal national and subnational death review structures, as guided by the WHO framework. 

By drawing on social science theory on the production of numbers and statistics (metrics) in areas with weak registration systems, the project aims to generate knowledge on the intersection between maternal care provision and its reporting. It, moreover, aims to enhance reporting practices through improved legal protection of health personnel.