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

ABOUT THE PROJECT

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) 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.  

PROJECT MEMBERS

The project is carried out in Ethiopia and Tanzania by an interdisciplinary research group from the social sciences, law, and medicine.

Project manager:
Photo: Astrid	Astrid Blystad, Professor, medical anthropologist and nurse, Centre for International Health, Department of Global Public Health and Primary Care (IGS).
The project group:
Photo: Alemnesh Mirkuzie Haile Mariam	Alemnesh Mirkuzie, senior researcher coordinator of the National Data Management Center for Health, Ethiopian Public Health Institute
Photo: Ali Said	Ali Saidi, MD, Postdoc, Muhimbili University of Health and Allied Sciences (MUHAS)
Photo: UiB	Andrea Melberg MD, Postdoc. Faculty of Medicine, University in Bergen, Norway
Photo: Asabneh Molla	Asabneh Molla, PhD candidate, Addis Ababa University
Photo: Damen Haile Mariam	Damen Haile Mariam, Professor of Public Health and Health Economics, School of Public Health, Addis Ababa University
Photo: Getnet Tadele	Getnet Tadele, Professor, Sociology of Health, Department of Sociology, Addis Ababa University
Photo: UiB	Haldis Haukanes, Professor, anthropology/gender studies, Faculty of Psychology, University in Bergen, Norway
Photo: UiB	Henriette Sinding Aasen, Professor, law/human rights, Faculty of Law, University in Bergen, Norway
Photo: UiB	Ingrid Miljeteig, Professor, MD, Deputy leader of Bergen Centre for Ethics and Priority Setting in Health (BCEPS),  Faculty of Medicine, University in Bergen, Norway
Photo: UiB	Ingvild Sandøy, Professor, MD/epidemiologist, Deputy leader of CISMAC (Centre for Excellence in Intervention Science in Maternal and Child Health),  Faculty of Medicine, University in Bergen, Norway
Photo: CMI	Kaja Skoftedalen, PhD candidate at Centre for International Health,  Faculty of Medicine, University in Bergen, Norway
Photo: UiB	Karen Marie Moland, Professor, Political Science/Nursing, Leader Global Health Anthropology Research Group,  Faculty of Medicine, University in Bergen, Norway
Photo: Privat	Kerstin Almdal, PhD candidate at Centre for International Health Faculty of Medicine, University in Bergen, Norway
Photo: Herstad	Kornelia Herstad, Research track student and medical student at UiB, Faculty of Medicine, University in Bergen, Norway
Photo: Latifa Mohamed	Latifa Mohamed, PhD candidate, University of Dar es Salaam
Photo: Maya Unnithan	Maya Unnithan, Professor, Social and Medical Anthropology, leader of CORTH, School of Global Studies, University of Sussex.
	Mitike Molla Sisay, Professor, Public Health, Vice President for Research and Technology Transfer at Addis Ababa University
Photo: UiB	Mulu Beyene Kidanemariam, PhD candidate, Faculty of Law, University in Bergen, Norway
Photo: Richard Sambaiga	Richard Sambaiga, Assistant Professor, Department of Sociology and Anthropology, University of Dar es Salaam
Photo: UiB	Siri Lange, Professor, anthropology/ development studies, Faculty of Psychology, University in Bergen, Norway
Photo: Tezera	Tezera M. Berheto, PhD candidate, Addis Ababa University
	Tsehai Wada, Assoc. Professor, Dep. of Law, Addis Ababa University

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.