Achieving accountability through maternal death reviews in Nigeria: a process analysis.

Maternal death reviews (MDRs) are part of the drive to increase accountability for maternal deaths and reduce their occurrence by identifying barriers to effective, quality care. However, conducting MDRs well is difficult; staff commitment and establishing a blame free environment are key challenges. By examining the communication strategies used in MDRs this study sought to understand how MDR members implement policy imperatives (e.g. 'no blame, no name') and manage the inevitable sensitivities of discussing a client's death in a multidisciplinary team. We observed and recorded four MDRs in Nigerian teaching hospitals and used conversation and discourse analysis to identify patterns in verbal and non-verbal interactions. MDRs were conducted in a structured way and had multidisciplinary representation. We grouped discursive strategies observed into three overlapping clusters: 'doing' no-name no-blame; fostering participation; and managing personal accountability. Within these clusters, explicit reminders, gentle enquiries and instilling a sense of togetherness were used in doing no-name, no-blame. Strategies such as questioning and invoking protocol were only partially successful in fostering participation. Regarding managing accountability, forms of communication which limit personal responsibility ('pass the buck') and resist passing the buck were observed. Detailed, lengthy eye witness accounts of dramatic events appeared to reduce staff's personal accountability. We conclude that interactional processes affect the meaningfulness of MDRs. In-depth, critical analysis depends on resisting 'passing the buck' by practitioners and chairs especially, who are also key to fostering participation and extracting value from multidisciplinary representation. Our innovative methods provide detailed insights into MDRs as an interactional process, which can inform design of training aimed at enhancing MDR members' skills. However, given the multitude of systemic challenges we should also adjust our expectations of MDRs and the individual practitioners tasked to perform them in the name of enhancing accountability for maternal death reduction.