Table 2.
Summary of results
| Categories | Subcategories | Example of records | Summary of results |
|---|---|---|---|
| Data | Accessing data for MDSR | 2, 3, 23 | Through data sharing agreements, mandated by law |
| 5, 9, 21, 22 | Problems of accessing health data from facilities or information systems | ||
| 5, 8, 26, 27 | No formal mechanism of data sharing or mandate to access health information systems or vital event records | ||
| Identifiable health data | 4, 7, 28, 29 | Names of the deceased, health workers and facilities | |
| Tools for data collection, transfer, and storing | 5, 8, 10, 21, 22 | WhatsApp, SMS, telephone, case notes, paper-based, software, database | |
| Time of anonymization | 2, 22, 26, 27 | After local review or after the report is published | |
| Lack or breach of anonymity/confidentiality | 2, 4, 7, 8, 12, 16, 28 | Anonymity and confidentiality are violated | |
| 7, 21 | The identity of health workers and facilities revealed | ||
| Effect of breach | 4 | Poor dialogue during case reviews | |
| Solution suggested | 12 | Adopting laws | |
| People Involved | Extent of the blame challenge | 1, 2, 3, 6, 8,11, 15, 17, 18, 19, 24, 25, 27, 28, 29, 30 | Reported widespread blame or fear thereof |
| Factors reinforcing blame or fear thereof | 15, 16, 23 | Increasing malpractice cases | |
| 1 | Focus on institutional delivery inducing fear of reporting by community members | ||
| 1, 13 | Strong political will to reduce maternal death | ||
| 3, 4, 11, 20 | Lack of understanding about the process | ||
| 13, 16 | Hostile media coverage | ||
| Forms of blame experienced or feared | 11, 15, 17, 29 | Legal action, criminal and civil litigation, malpractice cases | |
| 10, 17 | Suspension from job | ||
| 17, 24 | Referral to labour office, disciplinary committee | ||
| 10, 21, 24, 25 | Oral and written warnings, reprimands | ||
| 24 | Disciplinary action | ||
| 11 | Feeling threatened | ||
| 2, 10, 13, 16, 19, 20, 29 | ‘Other punishments’, ‘punitive action’, negative consequences or repercussions | ||
| 2, 13 | Having to explain to officials | ||
| 15 | Inviting external investigation | ||
| 2, 4 | Being called out during review, considered unskilled | ||
| Targets of blame | 1, 2, 6, 10, 11, 14, 15, 16, 20, 27, 28, 29 | Health workers | |
| 7, 15, 16, 19, 22, 25 | Lower-level health workers, front-line workers, junior doctors | ||
| 20, 29 | Traditional birth attendants | ||
| 15, 22, 28 | Family members, community members, deceased women | ||
| Effects of blame or fear thereof | 1, 13, 15, 18, 19, 20, 25, 28, 29, 31 | Failure to report, under-reporting, selective reporting | |
| 19, 20, 25, 29, 31 | Severe under-reporting of abortion-related maternal deaths | ||
| 2, 20, 21, 29 | Avoiding reviews, resistance to speak freely | ||
| 6 | Low review completion rate | ||
| 2, 15, 16, 20, 25, 28 | Unnecessary referral, refusal to admit/treat patients | ||
| 2, 15, 16, 20, 28, 30 | Misclassification, falsification of documents, misattributing cause of death | ||
| 2, 14, 25 | Weak dissemination | ||
| 16, 28 | Demotivating students from choosing obstetrics as a career | ||
| Ways out adopted/ suggested to mitigate blame and its effects | 1, 12, 24, 25, 27, 28, 30 | Introducing legal protection, appropriate laws | |
| 8, 18, 21, 25, 26, 27, 29, 30, 31 | Training, orientation, sensitization, better information, commitment, assurance | ||
| 16 | Indemnity insurance | ||
| Use of findings | Reported use of MDSR results for other purposes | 21 | For legal proceedings |
| 7, 15, 20 | Reported connection between MDSR and disciplinary measures | ||
| 2 | For administrative purposes | ||
| 1, 7,16, 18, 20, 22, 26, 28, 31 | Understanding that it can be or is used in legal or disciplinary settings | ||
| Insulating the MDSR from punitive measures by law | 27, 28 | Strictly separated by law | |
| 14, 24 | Call for insulation by law | ||
| Legal regulation | Mandatory notification of maternal death | 1, 3, 5, 6,11, 14, 15, 16, 17, 22, 23, 26 | Maternal death is a notifiable event, including as a public health emergency |
| 22, 23, 29 | Mandated by law | ||
| Regulatory deficit | 1, 7, 8 | Unclear mandates and obligations in MDSR | |
| 2, 3, 4, 20, 31 | Ambiguity about the purpose of MDSR | ||
| Forms/tools of governing the MDSR or its parts | 3, 5, 6, 7, 13 | Ministerial order, decree, circular | |
| 7, 10, 24, 26, 28 | Audit charters, guidelines, codes of conduct, Memorandum of Understanding | ||
| Need for legal framework | 9, 10, 12, 31 | Law/legal framework as an enabler | |
| 2, 5, 11, 12, 22, 23, 26, 27, 28, 30 | Absence of law as a weakness or impediment; calls for legal framework | ||
| 5, 13, 22, 30 | Rules exist but are not complied with |