Identifying the ‘real cause of death’: the complexities of maternal death reviews in Tanzania

Identifying the causes of maternal deaths and contributing factors is essential for improving care. In 2015, Tanzania began implementing the maternal and perinatal death surveillance and response (MPDSR) system, including facility-based maternal death reviews. While most MPDSR studies highlight implementation and technical barriers, less is known about how systemic and institutional dynamics influence these reviews. This study examined stakeholders' experiences and perceptions of MPDSR in Tanzania, focusing on how clinical causes of death and contributing factors were identified. The study is based on five months of ethnographic fieldwork conducted in a Tanzanian region in 2023- 2024. It included 33 days of participatory observation of obstetric care, attending nine facility-based maternal death review meetings and conducting 20 in-depth interviews with health workers and administrative staff. Viewing MPDSR as a travelling model and drawing upon the concept of situated knowledge, we examined how institutional and professional factors influenced these reviews. Reviews were routinized and integrated into the regional health system, offering opportunities for teaching and defining standards of practice. However, participants disagreed on whether the reviews promoted quality improvement or focused on individual fault-finding, on how responsibility should be attributed, and whether reviews could accurately establish the causes of deaths. The facility-based death reviews were influenced by institutional and epistemic hierarchies, with responsibility often placed on individuals at the lowest health system level. While MPDSR aims to promote blame-free learning and quality improvement, the process narrowed attention to individual error, obscured systemic constraints, and hindered understanding of the 'real cause' of maternal deaths. To capture contextual complexity without adding reporting burden, we recommend expanding the free-text narrative fields in the official MPDSR maternal death report forms and increasing frontline representation in district- and regional reviews to strengthen links between facility and higher-level reviews.