Beyond No Blame: Practical Challenges of Conducting Maternal and Perinatal Death Reviews in Eastern Ethiopia

Lack of a professional body to address patients’ complaints regarding quality of health care and absence of clear medicolegal guidance hamper maternal death reviews in Ethiopia. Performing effective maternal death reviews as part of the maternal death surveillance and response program has been hindered by challenges including poor attendance, defensive attitudes, and blame shifting. Reviews of maternal and perinatal deaths should be based on a “no blame” principle. Emphasis should be on learning lessons and health professionals should feel safe to discuss the circumstances surrounding death. Meaningful reduction in maternal mortality requires a depoliticizing paradigm shift, a professional body to address patients’ worries, and clear medicolegal guidance to encourage providers to identify care deficiencies.