Overcoming blame culture: key strategies to catalyse maternal and perinatal death surveillance and response

Abstract

Maternal and perinatal death surveillance and response (MPDSR) is a health systems process entailing the continuous cycle of identification, notification and review of maternal and perinatal deaths (Surveillance), followed by actions to improve service delivery and quality of care (Response).1 Before the coronavirus disease 2019 (COVID-19) pandemic, there were an estimated 4.6 million maternal and neonatal deaths and stillbirths each year.2 During the pandemic, maternal and perinatal health outcomes have worsened, especially in low- and middle-income countries,3 highlighting the urgent need to galvanise MPDSR to end preventable mortality and strengthen health systems. The World Health Organization (WHO) has released global technical guidelines on MPDSR with operational guidance and tools,4 and has listed it among the essential interventions to mitigate the indirect effects of COVID-19 on maternal and perinatal outcomes.5 As countries adapt and apply these guidance, implementation gaps and challenges remain preventing successful MPDSR uptake.1 The organisational climate and culture relating to MPDSR, including elements of blame, have been identified as key factors requiring further attention.1, 6-8 This commentary presents strategies to identify, address and overcome the blame culture relating to MPDSR. It builds from Lewis’s 2014 framework on the cultural environment of maternal death and near-miss reviews published in the BJOG 2014 supplement on quality of care.8 Across all three levels, successful implementation of MPDSR requires a ‘No Name, No Blame and No Shame’ environment, which is grounded in three ethical principles: confidentiality, anonymity and respect. The concept of blame relating to MPDSR is complex; taking different forms, arising for different reasons and with varying perspectives between settings.1 ‘No blame’ is integral to ‘No name’ and ‘No shame’ in MPDSR and if a blame culture persists, MPDSR efforts will fail. ‘Blame culture’ linked to MPDSR widely exists at the micro and meso levels.1 Individuals can feel threatened during MPDSR review meetings – fearing punitive repercussions and legal action.1 Health-worker emotional fatigue and burnout with high workloads, exacerbated by the pandemic, can further exacerbate the culture of blame. The negative influence of professional hierarchies between health cadres can silence nurse-midwives and junior medical staff,6 and may even demotivate personnel from participating in MPDSR. Other contributing factors include a lack of clarity around the ‘no name, no blame, no shame’ principle, defensiveness regarding poor quality record-keeping, poor facilitation of review meetings and lack of staff time to participate.1 Ineffective management, communication and coordination across teams may also constrain the MPDSR process, when management or senior team members do not buy into or engage in the process. Finally, without national political commitment, government and clinical setting ownership and clear guidelines, MPDSR implementation will face many challenges.9 Despite the identification of some strategies to overcome the blame culture previously,8 blame remains a major barrier to effective implementation.1 To support frontline health workers, managers and planners at all levels to overcome this challenge, we present ten strategies using an adapted framework to promote a positive implementation culture of MPDSR (Figure 1). Adapted from Lewis,8 further investigated1 and vetted by the MPDSR Global Technical Working Group, the ten strategies integrate micro, meso and macro levels of the health system to reduce blame culture. This framework has also been included in the new WHO materials to support MPDSR implementation.10 Framework for overcoming blame culture to promote a positive implementation culture for MPDSR. Source: WHO Maternal and Perinatal Death Surveillance and Response: Materials to Support Implementation. Working document August 2021.10 Extract from the letter inviting staff to join the MPDSR committee: ‘The main objective of the committee is to discuss all maternal and perinatal death, which will happen to occur in our hospital and to make action plan for better improvement of maternal and perinatal care at our hospital as well as at the district level. This team will seat for discussion within seven days after occurrence of maternal or perinatal death. The rule of the Team is The COVID-19 pandemic highlights the urgent need to further strengthen MPDSR as part of the effort to reach the Sustainable Development Goals to end preventable maternal and neonatal deaths and stillbirths and improve health service delivery. Overcoming the blame culture that currently impedes MPDSR implementation requires action at all levels of the health system. Targeted strategies across the health system will create a healthier culture and environment for implementing MPDSR. Future research needs to go beyond identifying blame as a barrier, to understanding how effectively these strategies can change the blame culture across diverse contexts to scale-up MPDSR, strengthen health systems and ultimately save lives and prevent suffering. None declared. Completed disclosure of interests form available to view online as supporting information. This commentary was prepared by the MPDSR Technical Working Group’s subgroup assigned to further understand the blame culture. MVK, LTD, FP, DJ and AM conceptualised the idea. MVK wrote the first draft with inputs from LTD and DJ. All authors reviewed and provided edits to the manuscript. FP, AM and ASG supervised the process. All authors reviewed and approved the final version. This work is a commentary based on the literature and is not a scientific study in itself. Institutional Review Board approval was not required from any of the authors’ institutions. Asha George and Mary Kinney are supported by the South African Research Chair's Initiative of the Department of Science and Technology and National Research Foundation of South Africa (Grant No. 82769), the South African Medical Research Council and the Countdown 2030 project funded by the Bill and Melinda Gates Foundation. Any opinion, finding and conclusion or recommendation expressed in this material is that of the authors and funders do not accept any liability in this regard. The authors alone are responsible for the views expressed in this article and they do not necessarily represent the views, decisions or policies of the institutions with which they are affiliated. We thank the Global MPDSR Technical Working Group for their review and comments. We thank the authors of the scoping review of MPDSR implementation factors in low- and middle-income countries, which identified 42 studies that described the implementation climate and culture of MPDSR, including aspects of blame, as we drew from this manuscript for evidence (https://doi.org/10.1093/heapol/czab011). Data sharing not applicable to this article as no data sets were generated or analysed during the current study. Table S1. Ten strategies for promoting a ‘No Name, No Blame and No Shame’ culture and key resources with more information. Panel S1. Example of principles of facility-based case review meetings to ensure no blame. Panel S2. Examples of audit charter or non-disclosure agreements. Panel S3. Engaging the community to prevent blame. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. 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