Juridification of maternal deaths in Ethiopia: a study of the Maternal and Perinatal Death Surveillance and Response (MPDSR) system.

Andrea Melberg,Henriette Sinding Aasen,Lidiya Teklemariam,Karen Marie Moland,Mitike Molla Sisay

doi:10.1093/heapol/czaa043

Andrea Melberg, Henriette Sinding Aasen + Show 3 more

Open Access

https://doi.org/10.1093/heapol/czaa043

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Abstract

Juridification of maternal health care is on the rise globally, but little is known about its manifestations in resource constrained settings in sub-Saharan Africa. The Maternal and Perinatal Death Surveillance and Response (MPDSR) system is implemented in Ethiopia to record and review all maternal and perinatal deaths, but underreporting of deaths remains a major implementation challenge. Fear of blame and malpractice litigation among health workers are important factors in underreporting, suggestive of an increased juridification of birth care. By taking MPDSR implementation as an entry point, this article aims to explore the manifestations of juridification of birth care in Ethiopia. Based on multi-sited fieldwork involving interviews, document analysis and observations at different levels of the Ethiopian health system, we explore responses to maternal deaths at various levels of the health system. We found an increasing public notion of maternal deaths being caused by malpractice, and a tendency to perceive the juridical system as the only channel to claim accountability for maternal deaths. Conflicts over legal responsibility for deaths influenced birth care provision. Both health workers and health bureaucrats strived to balance conflicting concerns related to the MPDSR system: reporting all deaths vs revealing failures in service provision. This dilemma encouraged the development of strategies to avoid personalized accountability for deaths. In this context, increased juridification impacted both care and reporting practices. Our study demonstrates the need to create a system that secures legal protection of health professionals reporting maternal deaths as prescribed and provides the public with mechanisms to claim accountability and high-quality birth care services.

Highlights

In February 2019, the Ethiopian Society of Obstetrics and Gynaecologists (ESOG) held their annual meeting in one of Addis Ababa’s conference venues
The initial aim of the study was to explain the current levels of low reporting of maternal deaths in the Maternal and Perinatal Death Surveillance and Response (MPDSR) system
We document how medicolegal issues impact the everyday life of health workers, and the choices they make when reporting maternal deaths and providing birth care

Summary

Introduction

In February 2019, the Ethiopian Society of Obstetrics and Gynaecologists (ESOG) held their annual meeting in one of Addis Ababa’s conference venues. In the market space outside the plenary hall, conference sponsors had set up their small booths. Among pharmaceuticals and providers of medical supplies and diagnostic services, an insurance company joined the conference for the first time, advertising a professional indemnity insurance. Several of the conference attendees expressed how the first-time attendance of an insurance firm was symptomatic of an increased presence and importance of medicolegal issues in clinical life. Juridification of healthcare provision seems to be an increasing global trend (Aasen et al, 2014; Van Belle et al, 2018). There is growing recognition of law being an important health determinant (Gostin et al, 2019).

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