A new study examining maternal death reviews in Tanzania is raising important questions about how health systems identify and learn from maternal deaths, and whether current approaches may be overlooking the bigger picture.
The study, led by Kerstin Almdal and published in the journal Health Policy and Planning, focuses on the implementation of the Maternal and Perinatal Death Surveillance and Response (MPDSR) system, a globally endorsed approach designed to ensure that every maternal death is reviewed, understood, and used to improve care. In Tanzania, MPDSR has been successfully integrated into the national health system, with routine facility-based review meetings held to assess each case.
However, findings from the study suggest that the reality on the ground is more complex. While these reviews are intended to promote learning in a “no blame” environment, many frontline health workers experience them differently. Instead of serving purely as opportunities for reflection and quality improvement, review processes are often perceived as spaces where individual fault is scrutinised.
The study highlights how institutional hierarchies and power dynamics shape discussions during these reviews. Senior clinicians and administrators often dominate conversations, while lower-level facilities, particularly those referring critically ill patients, tend to bear the brunt of responsibility. This can lead to a pattern where blame is directed downward within the health system rather than prompting deeper examination of systemic constraints such as resource shortages or staffing limitations.
Researchers also found a disconnect between the intended purpose of MPDSR and the lived experiences of those involved. Although the system is designed to foster accountability without blame, fear of criticism can influence how cases are discussed and documented. In some instances, this may discourage open dialogue or lead to incomplete reporting, ultimately limiting the ability to fully understand what happened.
Another key challenge lies in how maternal deaths are recorded. The official reporting tools require causes of death and contributing factors to be categorised into predefined boxes. While this standardisation supports data aggregation and national-level analysis, the study suggests it can oversimplify complex care pathways. Maternal deaths often result from a chain of interconnected clinical and systemic factors, which may be difficult to capture within rigid reporting structures.
Despite these challenges, the study underscores that maternal death reviews remain a vital component of health system learning. The authors argue that strengthening these processes, by encouraging more inclusive participation, addressing power imbalances, and allowing greater space for narrative detail, could help ensure that reviews better reflect the realities of care and lead to more effective improvements.
Ultimately, the findings point to a broader issue. Understanding maternal deaths requires more than identifying a single cause. It demands deeper engagement with the complex, context-specific factors that shape care delivery, and a shift from assigning blame to fostering meaningful system-wide learning.