Table 1 Questions about Maternal Death Reviews

Types and sources of power among different stakeholders

 • Which of the duty bearers for maternal safety are officially part of the MDR system? Who is left out? Why?

  o Is the family of the deceased woman represented?

  o Are the attending doctor, nurse and other health providers involved?

  o Do health supervisors or hospital/health system administrators participate?

  o Are external experts (e.g., obstetrician/gynaecologist, anaesthetist) invited?

  o Are government officials (e.g., district commissioner), elected representatives, community health workers, civil society representatives included?

  o What are the implications of their inclusion or exclusion for how knowledge about each death is constructed and for what types of corrective actions are identified?

 • What types of power do each of the duty bearers wield? What are the sources of their power (e.g., access to and control over material resources, knowledge, the bureaucracy, the courts, the police, the media, elected representatives, government officials, or others; influence over decision-making affecting the community and/or the lives of others; social and/or cultural capital)? Which of these individuals have the power to prevent the MDR from achieving its goals?

 • What are the interests of each of the duty bearers who are officially part of the MDR? Are their interests aligned or at odds with each other? What resources can (and do) these individuals galvanise to protect their interests?

 • If any duty bearer is excluded from the MDR, what are his/her interests? Do these individuals try to exert their power over the review and its outcome? When and how do they do so?

‘Artefacts’ of the accountability strategy

 • What are the specific objectives of the MDR? Are the stated objectives to show that there is no impunity for maternal deaths? To prevent recurrence? Or to put systems in place to improve functioning?

 • Who is in charge of the MDR? What is the source of this person’s authority?

 • How is the MDR financed? Are the resources adequate to support the participation of all stakeholders? Who has to sign off on expenses? How soon are payments or reimbursements made? What does this mode of financing imply for the rigour and independence of the review process?

 • How and by whom are pregnancy-related deaths brought to the notice of the health bureaucracy and local administration? How do health managers and local administrators respond officially and unofficially to such deaths? How do communities respond?

 • Which of the pregnancy-related deaths occurring in an area are reviewed? Those occurring within or outside a healthcare facility? Those occurring while women are being taken from one facility to the other?

 • What instrument(s) are used to gather clinical data and information about the sequence of events leading to death? How comprehensive are these instruments? What biases are likely to creep in due to missing or partial questions?

Artefacts’ of the accountability strategy (continued)

 • How and by whom is information recorded in the MDR instrument(s)? Are there safeguards against misrepresentation of the facts by duty bearers who either have vested interests or have ended up contributing to the death? If so, what? What is the quality of the information that is gathered?

 • Who analyses the information gathered through the MDR instrument(s)? Are all sources of information considered, and is a 360-degree approach used? If not, how is the quality of the analytical outputs emerging from this exercise likely to be affected? (e.g., verdicts on the medical cause(s) of death, social and/or health system factors contributing to death)

 • How, where and by whom are the MDR results reviewed? In what spirit are the reviews conducted? How are medical errors and familial failures viewed by reviewer(s)? What responses do they typically evoke?

 • Are corrective actions identified for the health system and the community? How and by whom? What types of actions have tended to be identified?

 • How does the MDR reinforce or contest the power and/or position of individuals who bear the biggest responsibility for maternal safety?

Incentives and disincentives to different actors and their resulting behaviour patterns

 • What do family members as well as attending doctors, nurses and other health staff stand to lose if they are implicated in the death?

 • How do they respond to real or feared penalties that are meted out to “guilty parties” as part of the MDRs? (e.g., by misrepresenting facts; preventing others from reporting information; doctoring records to indicate causes of death that are unpreventable, etc.)? How is such behaviour justified?

 • What are the implications of a maternal death for the health care facility’s leadership (e.g., drop in the facility’s rating; scrutiny by peers or superiors in the health bureaucracy; loss of face among peers; no difference; etc.)?

 • How do these leaders respond to other obstetric emergencies occurring in their facilities (e.g., not admitting women in need of care that can be provided by the facility; referrals to ensure that women don’t die in their facility, etc.)? How is such behaviour justified?

 • Are there any incentives or disincentives for family members, attending health providers and other individuals who were directly involved to provide complete information about the death, as they know it, and to willingly participate in the MDR? If so, what?

Consequences for the accountability strategy

 • Do MDRs fairly recreate the sequence of events leading to death and to what extent? Why and how?

 • Do MDRs allow health systems and communities to learn from and become more accountable for preventable maternal mortality and to what extent? Why and how?

 • Do MDRs provide redress to families of the women whose deaths could have been prevented? Why, how and to what extent?