A Qualitative Inquiry Into Midwives’ Experiences of Participating in Maternal Death Audit in the Upper East Region of Ghana’

Abstract

Introduction

A maternal death audit is an in-depth systematic review of maternal deaths to delineate their underlying health and other contributory factors. The process of maternal death audits has been seen as a training and development opportunity for midwives. The lessons learned from such audits have been shown to be useful in helping midwives improve their care practices and significantly reduce labour-related maternal mortality.

Objective

This study explored the experiences of midwives engaged in Maternal Death Audits (MDAs) within the Upper East Region of Ghana.

Method

Using the qualitative descriptive design, thirteen purposively recruited midwives from selected health facilities within the Upper East Region of Ghana participated in the study guided by the concept of saturation. A semi-structured interview guide was used to gather information from participants. The audio-taped data was transcribed verbatim and analysed using a thematic analysis procedure.

Results

While some perceive MDA as a dynamic and growth-oriented experience, others find it challenging, mainly due to concerns about perceived blame and emotional distress. This ultimately undermine the original purpose for MDAs.

Conclusion

The study concluded that MDAs are currently conducted in a manner that subjects midwives to severe psychological distress, and this is exacerbated by the lack of institutional support for midwives during the process.

Keywords

midwives’ experience midwives’ participation maternal death audit midwifery

Introduction

Maternal health is a high-priority agenda for governments all over the world. As such, it is an important component of the global Sustainable Development Goals (SDGs) set in 2015 by the United Nations (World Health Organization, 2016). The SDG target for goal 3 includes an ambitious aim to reduce the global Maternal Mortality Ratio (MMR) to less than 70 per 100 000 births, with no country having a maternal mortality rate of more than twice the global average (Buse & Hawkes, 2015). There has been a slight decrease in the global maternal mortality ratio (MMR) from 227 deaths per 100,000 live births in 2015 to 223 in 2020 (Lawrence et al., 2022). Although this figure might seem a minimal reduction, it is still more than three times the SDG target of 70 deaths per 100,000 births by 2030. At the current mortality rate, it is projected that by 2030, about 800 women will be dying each day from pregnancy and childbirth-related avoidable causes, or one death every two minutes (United Nations, 2023). In the recent available maternal mortality data published by the World Health Organization (WHO), Sub-Saharan Africa accounted for around 70% of maternal deaths in 2020, followed by Central and Southern Asia with 17% and 38% respectively (United Nations, 2023).

Although Ghana has made significant progress in reducing maternal deaths, the country’s maternal mortality rate of 310 per 100,000 live birth continues to be unacceptably high despite several interventions put in place by the Ghana Health Service to achieve these SDG goals (Ghana News Agency, 2022). The SDG Progress Report special edition reveals that over 50% of the SDG targets are still unachieved, with progress being made toward achieving them only halfway through the 2030 Agenda deadline (United Nations, 2023).

To achieve this target of reducing maternal mortality, the WHO can contribute by increasing research evidence, providing evidence-based clinical and programmatic guidance, setting global standards, and providing technical support to member states in developing and implementing effective policies and programs. One such policy is the maternal death audit, an efficient method for identifying issues and determining how to address them (United Nations, 2023).

Review of Literature

Maternal death audits have been proposed by experts and international health agencies such as the WHO and the American Society of Obstetricians and Gynaecology as one of the best strategies to address high maternal mortality in low and middle-income countries Mahato et al. (2018)).

Audits of maternal deaths depend on thorough medical record data that can show the series of events leading to death (World Health Organisation (WHO), 2016). The Maternal Death Audit (MDA) system initiated by the WHO encourages using narrative summaries during maternal death reviews to examine the case, classify reasons for death, identify care gaps, and suggest action plans to prevent fatalities, which serve as a major approach in reducing maternal death (World Health Organization, (2013)). These (MDA) approaches in some countries have adopted WHO surveillance response as part of a follow up component on MDA called the maternal death surveillance response (MDSR), a type of ongoing monitoring that connects the health information system and processes for quality improvement at all levels, from community to national level (Willcox et al., 2023). It entails the routine detection, notification, quantification, and assessment of the causes and preventability of all maternal deaths, as well as the use of this information to react with steps that will stop such deaths from happening in the future. MDA and MDSR aim to eradicate maternal mortality, which can be prevented Endris & Tilahun (2023).

In countries where MDA is being implemented or is being launched, governments have frequently done so in the framework of a worldwide commitment to end maternal deaths. For instance, the Nigerian government authorized MDA as part of the country’s healthcare policy and provided additional financing to the country’s Ministry of Health as well as state-accredited hospitals to build robust systems that keep track of up-to-date data of maternal and neonatal mortality cases across the country (Smith et al., 2017). The government of Kenya recognizes MDA as a standard practice and mandate for maternal death notification with free maternity services program in aid of reducing maternal mortality incidence (Achem & Agboghoroma, 2014). However, not all Sub-Saharan African countries have the resources necessary to undertake death reviews. Dartey et al. (2019) reported that most low-income countries that have adopted MDAs as part of the healthcare delivery processes have encountered pertinent challenges such as lack of understanding among midwives on the complexities of maternal death auditing, often due to inadequate or no in-service training on the procedure, the burden of heavy workload on few healthcare staff, nurses’/midwives’ lack of knowledge on health policies, and difficulties of midwives in adhering to the MDA protocols. In certain instances, regional and international advocacy groups like International Federation of Gynecology and Obstetrics (FIGO) have aided national efforts to act and institute an MDA strategy.

Despite the challenges in MDA implementation, as with many healthcare system initiatives, finding a mechanism to boost the capability of the healthcare system’s readiness to implement MDA and its challenges has been the way forward to curb this situation (Smith et al., 2017). As primary care providers of pregnant and puerperal mothers and neonates, midwives play a key role during maternal death audit due to their continuous care and contact with clients during pregnancy through to post-partum (Bradfield et al., 2019; Bradford, 2021).

The inquiry into maternal death is deemed an important exercise by midwives as part of their commitment to save lives and prevent maternal mortality (Bradford, 2021). However, during unanticipated realities of stressful clinical circumstances such as maternal death, midwives report struggling to perform professionally (Pezaro et al., 2016).

The Ghana Health Service (GHS) has recognized the importance of MDA practice and has been actively promoting it across healthcare facilities (GHS, 2016). The involvement of midwives in these audits is particularly noteworthy as they often serve as the primary caregivers during childbirth, making their input vital for understanding the nuances of each case (Ngegbai, et al 2024). The collective findings from these audits have led to improvements in clinical practices and policy formulations aimed at reducing maternal mortality rates (Ministry of Health, 2014). Additionally, Ampofo (2016) noted that Midwifery is considered a relationship-based profession due to the intimate nature of the care provided, and this relationship creates a bond between the midwives and the client, which can result in psychological trauma when fatality occurs. The role of midwives in conducting maternal death audits in Ghana’s Upper East Region is pivotal to addressing the persisting issue of maternal mortality. The region’s maternal mortality ratio, which stands higher than the national average, underscores the need for rigorous audits (Ghana Statistical Service, 2014).

Midwives’ firsthand experiences and insights gained from these audits are invaluable for tailoring maternal health interventions to the local context. The literature further suggests that the active participation of midwives in these audits fosters a culture of accountability and continuous learning within healthcare facilities (Apanga & Awoonor-Williams, 2018). Moreover, the audits have been linked to enhanced community engagement in maternal health issues, as evidenced by increased community-based surveillance and reporting (Yakong et al., 2010). This collective effort is crucial for the development of targeted strategies that address the unique challenges faced by health care workers in this region (Ministry of Health, 2017).

In a survey involving 421 midwives after a traumatic event, a third of the midwives who answered the survey indicated they may have clinical posttraumatic stress disorder (PTSD). These experiences included feelings of fear, helplessness, and terror. Upon completing clinical examinations and challenging deliveries, these midwives recommended the need for a secure space to share their experiences with others, as they could not find a supportive community (Aydin & Aktas, 2021).

In as much as MDA is an important exercise to reduce maternal death and the midwives’ roles are key, there is not - enough empirical data describing Ghanaian midwives’ experiences in relation to maternal death audit. This present study explored the experiences of midwives drawn from facilities within the Upper East Region regarding maternal death audits.

Materials and Methods

Study Design

This study adopted the exploratory-descriptive qualitative (EDQ) design to explore and describe midwives’ experience of maternal death audits. In exploratory descriptive qualitative research, the researcher seeks to investigate the full nature of phenomena and provide insight into the issue or situation rather than simply observing and explaining the phenomena (Hunter et al., 2019).

Study Site

The study was conducted in the Upper East Region. The Region, located in the northern part of Ghana, is the third smallest of the 16 administrative regions in Ghana. The region contributed to the country’s institutional maternal mortality ratio with 90.7% and 98%, respectively in 2021 and 2022. (Ghana Health Service Annual General Report).

Study Population

The study population was midwives who had experienced maternal death and participated in maternal death audit proceedings in the last one-year prior to the study.

Inclusion Criteria

The population for the study was midwives who had experienced maternal death and participated in maternal death audit proceedings and midwives who were willing to participate in the study.

Exclusion Criteria

Midwives who have participated in MDA in the last one year prior to the study but were not emotionally ready to recount their experiences were excluded.

Sample Size and Sampling Technique

Purposive sampling technique was used to select 13 midwives from three districts including the Bolgatanga Municipality, the Kassena Nankana District, and the Bawku District. The midwives with the help of the hospital management were identified and purposefully recruited for the study following guidelines, ensuring voluntary participation, confidentiality, and respect for autonomy was observed throughout the study. Data was collected until saturation based on recommendation by Braun and Clark (2021).

Data Collection

Participants were contacted through the district health directorate which provided audit report with the names of healthcare workers who participated in the audit. The participants were selected from War Memorial Hospital, Bawku Hospital, Bolgatanga Hospital, and Bolgatanga health center. Potential participants were contacted through phone calls and/or in-person visit. An overview of the study was discussed with them and those who were willing to be part of the study were invited to sign a written consent form. The researchers negotiated with the participants a convenient time and conducive place devoid of interference to hold interviews. The interviews were conducted in a quiet room at the health facility based on participants preference. Individual in-depth face-to-face interviews were conducted by the first author using a semi-structured interview guide developed by the researchers based on the study objectives.

Each interview was tape recorded with the consent of participants, conducted in English, and lasted between 40 and 50 minutes. Probing questions were used to elicit detailed explanations where necessary. The researcher kept field notes to capture non-verbal expressions of participants. Data collection continued until data saturation was reached after 13 interviews. Data was collected between November 2023 and February 2024.

Ethical Consideration

Ethical approval was obtained from the Ghana Health Service Ethics Review Committee (NHRCIRB 545) and the Noguchi Memorial Institute for Medical Research (NMIMR) Institutional Review Board. Written informed consent was secured from all participants, confidentiality and anonymity were ensured, participation was voluntary, and all data were securely stored with access limited to the research team.

Data Analysis

Data was analysed using Braun & Clarke’s (2019) six-step thematic analysis framework and analysis was done concurrently with data collection by the first, second and third authors. The researchers familiarised themselves with the data by listening to the recorded interviews over and over and reading the transcribed data independently and later compared to bring uniformity. This was followed by coding phase where the researchers looked across the data set and identified initial codes based on the research questions. Themes and sub-themes were subsequently generated. Member checking was integral to ensuring credibility of the research findings. Following the analysis of the data, summarized findings were shared with the participating midwives for them to validate the accuracy and interpretation of their contributions.

Results

Socio-Demographic Characteristics of Participants

Thirteen midwives who had been involved in MDA at least once in the last 5 years took part in the study. They were all females, with ages ranging from 27 to 52 years. Notably, each of them held at least a bachelor’s degree in Midwifery, indicating a high level of education. Additionally, 12 out of the 13 midwives were married. Their professional experience varied from 4 to 13 years, their ranks included midwifery officers, senior staff midwives, and advanced midwife specialists. The number of audits they participated in ranged from 2 to 6. This diversity in socio-demographic characteristics provides a solid basis for examining the varied experiences and perspectives of midwives in maternal death auditing within the unique context of the Upper East Region (Table 1).

Table 1.

Socio-Economic Characteristics of the Study Participants (N=13)

Participant	Age in years	Educational level	Years of experience	Rank	Religion	Marital status
P01	38	Bachelor’s degree	7	Midwifery officer	Christian	Married
P02	35	Diploma	6	Midwifery officer	Christian	Married
P03	39	Bachelor’s degree	7	Midwifery officer	Christian	Married
P04	37	Diploma	7	Midwifery officer	Christian	Married
P05	52	Diploma	26	Principal Midwifery Officer	Muslim	Married
P06	35	Diploma	5	Midwifery officer	Christian	Married
P07	32	Diploma	4	Senior Staff Midwife	Christian	Single
P08	36	Bachelor’s degree	13	Advance Midwife Specialist	Christian	Married
P09	27	Diploma	5	Senior Staff Midwife	Christian	Married
P10	32	Diploma	4	Staff Midwife	Muslim	Married
P11	33	Diploma	4	Senior Staff Midwife	Christian	Single
P12	28	Diploma	5	Senior Staff Midwife	Christian	Single
P13	37	Bachelor’s degree	12	Senior Midwifery Officer	Christian	Married

Source: Field Data (2023/24).

Organization of Themes and Subthemes

Two (2) main themes and eight (8) sub-themes as shown in table 2. Below are presented in this paper. The themes are: Midwives’ experiences in the participation of the maternal deaths audit and Psychological Influence of MDA. Table 2. Provides a summary of these main themes and sub-themes.

Table 2.

Themes and Sub-Themes

No.	Themes	Sub-themes
1	MDA experience	Feeling of Frustration
		Learning experience
		Perceived Blame
		Tribunal Interaction
		Midwives’ role during MDA
2	Psychological influence	Psychological Trauma
		Self-Blame
		Emotions

MDA Experience

Participants shared their unique subjective experiences of taking part in the MDA. The theme is further broken down into five sub-themes that highlight the diverse experiences of midwives, emphasizing the subjectivity of each midwife’s perception, description, and interpretation of the audit process. These sub-themes include frustration, the MDA as a learning experience, perceived blame by the audit team or superiors, the mixed feelings of guilt experienced by midwives, and the conduct of the MDA being likened to a tribunal. The following paragraphs provide detailed descriptions of the audit experience supported with relevant quotes from participants.

Feeling of Frustration

This sub-theme explores the perceptions of certain participants regarding their involvement in the audit. Some participants (N-5) expressed their frustration with the audit experience, attributing it to the volume and manner of the questions they were asked. Some participants had this to say:

‘Sometimes they make you feel as if you don’t know your left and rights … It’s like everything you have done once is not on paper is useless. Assuming the client comes, and you realize the client is gasping, and there is no time for you to sit down and do documentation. Immediately after the death occurred, the audit team will let you know all the sacrifice we gave to the client was useless I just felt stupid and worthless when I attended that audit’ (P03).

‘The Maternal death audit team will use frequent statements like, you didn’t do this” ‘you didn’t do that’ there was an instance where during my presentation, two of the panel team interrupted me by asking ‘what exactly did you do for this client, you are not providing the necessary information for this meeting. Stop reading and tell us what happened’. I was so confused because all the care I gave was narrated nicely on the power point presentation. I didn’t know where to read again. (P08).

Learning Experience

Majority of the participant expressed their perception in participation as a learning experience in maternal healthcare practices, articulating that audits serve as a platform for reflecting and learning from past experiences, identifying areas for improvement, and implementing corrective measures to enhance future maternal care. Participants 10 and 5 had this to say:

‘I would say it’s a good one, there were a lot of things that I never knew could lead to maternal mortality or could be sanctioned for neglect, so when I attended them, I got to know that’ (P10).

‘My experience was positive. During the audit, the leader of the team taught the midwives present how to prevent severe haemorrhage using balloon tamponade. I had never seen how to fix a tamponade; this was very helpful to me and my team. One of the gynaecologists also gave us an update on magnesium sulphate regime/protocol. A lot was learnt that day’ (P05).

Perceived Blame

Findings showed unfortunate pronouncements from some audit team members to midwives that spurred an opportunity to apportion blame. These were disturbing to midwives and led to lots of burdens on them. Some of these narrations include upfront comments which imply a blame game culture;

“We feel like they blame us too much because we are not the only ones in the ward. But when there is a case [death of a client], the Deputy Director of Nursing Services (DDNS) and all the people who come for the auditing are trying to put everything on we the midwives as the cause of everything (P01)”.

Similarly, Participants P02 and P09 expressed their experience in participating in the maternal death audit as perceived blame.

‘During the period where all members give comment after I finish presenting, some strange comments from two visiting doctors and a laboratory technician made me feel so sad. I was blamed although I did the right things. They said ‘You all contributed to this woman’s death ‘don’t you know you should have done this procedure for the woman?’’ yet we did other important things to safe the woman” (P02).

‘Everything is always the midwife’s fault, not the doctor’s fault, even if it’s the doctor who made the mistake. But they’ll say the midwife didn’t monitor immediately. I feel like most doctors are trying to always create that notion we caused and make most mistakes during client care’ (P09).

Tribunal Interaction

This sub-theme provides a description of the audit process and the atmosphere within which this happens. The midwives explained that a tribunal-like interaction occurred, making it tense and uncomfortable for the staff involved in the MDA process. These are depicted in the expressions below.

‘The midwife is always positioned in front of the panel being interrogated and answering questions in the audit room, as if in court. There is a special chair assigned for the high-table people that is the lead of the audit session’. I was called in front of the room to present the death issues to the team, the arrangement of the room brings a court room appearance, I was afraid’ (P03).

‘In one of the audits I attended, after I presented the case to the house, the leader of the team called a public health nurse who was not working in my hospital to give her account on the woman’s death. The public health nurse gave a report on what the community is saying about the death not what happened at the facility’ (P12).

Midwives’ Role During MDA

All participants underscored the important role midwives play in the MDA process. These included preparation of the audit venue, presentation slides, making the presentation and taking notes for action plans. The rudiments of these roles indicate how important midwives are in maternal health issues. Especially in ensuring that the lessons from these deaths are used to draw action points to foretell future occurrences and develop the best strategies to address them. Below are excerpts from participant accounts. One participant said:

“I did the presentation on the care given to the woman in the ward, I prepared the PowerPoint preparations myself even though I struggled to prepare it, I had to go online to learn how to put the presentation on the power-point and it took me more than 4hours. I took the audit meeting’s minutes. Lastly, I documented the action plan by the team.” (P07).

Another had this to say:

“…I didn’t get the courage to present during the audit, but I did a lot of work such as minute writing, action plan. I had to be sending document round for all members to review. None of the other cadre perform any task during the audit. Even photocopying of document, I had to ran and make copies for everyone’ (P08).

Psychological Influence

The participants overwhelmingly narrated how the dual burden of experiencing death of a client and undergoing the tribunal-like audit process brought stress and anxiety (emotions) on them. According to their accounts, the audits brought them memories of the painful and stressful ordeal they had gone through to care for their clients trying to save lives only to lose them. They expressed flashes of the situation making them relive the grief and ordeal.

Psychological Trauma

Psychological trauma was a leading concern among participants regarding the MDA process, manifesting in stress, anxiety, and depression. This was partly due to the tensed atmosphere during the audit and the unfriendliness of the other team members. It was noted by participants that the manner in which the audits are conducted poses serious concerns for the mental health of midwives and their ability to perform their duties confidently afterwards.

This is how participants expressed their concerns:

“The audit process brings so much anxiety and stress. Everything is flashing back again like the way you felt at the initial stage when the woman died” (P08).

“Sometimes after a doctor spoke it was difficult for me to respond because the questions were overwhelming and everyone in the room was silently waiting for my answer.” (P01).

“I can’t forget that audit, and the doctor ‘who said we killed the woman’’ It kept ringing in my ears for a long time. I still remember every now and then (P03).

“The flashback of how the client died hurts me even till now talking about it brings so much pain to me.” (P07).

One midwife narrated how she broke down upon receiving the sad news of the passing of a client she had cared for at her facility. The emotional toll and trauma of the experience was so heavy on her that she was unable to concentrate on anything.

“There was a particular client who died, in fact, this particular death was difficult. I was in church when I heard the news of the audit and frankly it broke me down. I had to leave the church before service could end. Imagine, already you have gone through some of the emotions, and you are informed again that the woman’s death is to be audited. Hmmm, every Good Friday (Easter Friday), it’s like the client’s death keeps reflecting’ (P08).

Self-Blame

This sub-theme shows narrations of midwives where self-doubt and blame were at the center of their experiences. They blamed themselves for death of their clients, these feelings were exacerbated by the unfriendliness of audit team members, tensed atmosphere, and the unfortunate blame game by members. As they blame themselves for taking or not taking some actions. Some of their concerns were expressed in the following quotes.

“When I go home, I always wonder whether I should have done a particular procedure which could have saved the woman and we didn’t do. After the maternal death audit, it took me days before I came back to myself, especially my sleep and eating pattern are altered.” (PO4).

“Most at times when I’m lying down, I just remember all the care I gave to this woman who died. Was there something that I was supposed to do at this time and didn’t do?” …… “I should have checked this woman’s BP more than what I did?” (P10).

“ I keep thinking I should have called the doctor early, If I had called earlier I think the woman wouldn’t have died. There was so much work to do that night prior to the woman passing.” (P05).

Emotions

This theme delves into the various emotional responses’ participants’ encounter with MDA. These emotional responses ranged from anxiety, stress, tension and alteration in mood/depression. Participants expressed concern about the MDA process affecting their mood, relationship with family and depressive tendencies.

Majority of the participants expressed anxiety and stress before, during and after experiencing MDA. The feeling of anxiety and stress were attributed to the fear of being blamed and the anxiousness of the unknown after the MDA.

‘The audit brings so much anxiety and stress. Everything is flashing back again like the way you felt at the initial stage when the woman died. The day my in-charge informed me on the date for the audit, I had diarrhea and was restless’ (P08).

‘‘I experienced palpitation of the heart when I stepped foot into the audit room. When the audit proceeding started, I felt cold and warm at the same time also I find it difficult to eat even two square meal unless I am done presenting what happened and know the cause of the client’s death’’ (P07).

Additionally, few of the participants indicated the frequent alteration in mood (depression) and tension as a major worry to their emotional wellbeing. They explained how they lost their balance and could not hold themselves together.

“I become moody, so my interaction with my husband and my children is always different. And sometimes get angry to the point I would just shout at my child for no reason and later realize that what I did was wrong’’. (P07).

‘‘I participated in an MDA and after I got to the maternity, I felt like working alone without my colleagues, I realized that an extrovert person like me started talking less. I become highly alert with trivial issues concerning client’. (P12).

Discussion

Midwives’ Experiences of Participating in Maternal Death Audits

The work of midwives is an integral part of the audit process. Participants explained that the audits were carried out in a court -like manner where they the midwives were made to face a panel comprising the audit team, with a Chair seated upfront. This tribunal-like nature made them tensed and uncomfortable because it was as though they were summoned before a court to face prosecution for committing a crime. The tense and uncomfortable atmosphere reported by midwives during these interactions raises questions about the effectiveness of such settings. Comparisons to a courtroom appearance and the subsequent call for a more friendly seating arrangement by the midwives highlight the need for thoughtful consideration of the physical and psychological environment during MDAs. Literature on effective audits emphasizes creating an atmosphere conducive to open communication and collaborative problem-solving (Ivers et al., 2012; Rycroft-Malone et al., 2016).

One of the sub-themes that emerged from the interviews of the midwives regarding their experiences of participating in the MDAs is that it was frustrating, being subjected to intense criticism and probing by the audit team. Additionally, the study revealed that despite the methodical account given by midwives on events leading up to the death of clients, they were often still unjustifiably blamed for the deaths even when women came in too late. This created a tense atmosphere during audits, as the midwives felt unfairly treated, and the interrogations were always centred on their actions while other members of the medical team (doctors and lab technicians) were less scrutinized. These findings are inconsistent with other studies suggesting that a blame-free and open culture is essential for effective audits (Dixon-Woods et al., 2011; Wu et al., 2017). Also, these findings resonate with Shorey et al. (2017) study, which brought to light the frustration and burnout midwives encounter during maternal and perinatal audits.

Furthermore, the study found various roles midwives performed before and during the MDA sessions. Midwives indicated how such workloads have intense stress on their lives. The assumption is that sharing duties among all audit committee members will foster collaborative participation. These findings is consistent with Dartey (2012)’s study outcome which outlined the wide range of roles performed by midwives identified as; identifying cases of maternal deaths, gathering information about these deaths, analysing the information gathered, formulating suggestions and actions to prevent maternal deaths, and assessing the effects of putting those suggestions and actions into practice. Also, misrepresentation and undefined roles of audit committee members in Indonesia negatively impacted obstetric care (Supratikto et al., 2020).

The study highlights the interactive and situational nature of the MDA process. Some midwives perceived the experience as a learning avenue, presenting an opportunity for professional growth and adaptation to unfamiliar situations. A participant’s positive experience during her first audit reflects the potential for MDAs to be perceived as valuable learning experiences. Past studies have similarly acknowledged the positive impact of audits on healthcare professionals, emphasizing continuous learning and improvement (Idrissa et al., 2022; Ivers et al., 2012).

The study reveals that some midwives experienced feelings of nervousness and fear during and after audits, particularly due to the anticipation of blame or indictment for negligence. This emotional toll on midwives aligns with existing literature that discusses the anxiety and stress healthcare professionals may experience during adverse event investigations (Sarin et al., 2018; Wu et al., 2017).

The fear of blame can contribute to a tense atmosphere during audits, affecting the overall effectiveness of the process. Comparatively, findings from previous studies suggest that a blame-free and open culture is essential for effective audits (Dixon-Woods et al., 2011; Wu et al., 2017). Creating an environment that encourages learning from mistakes rather than attributing blame is crucial for fostering a positive and constructive approach to the MDA process. Most midwives feel unfairly blamed during MDAs, with the focus often fixed on their actions, while other healthcare professionals, such as doctors and lab technicians, are less scrutinized. This perception of bias aligns with previous studies, emphasising the need for a comprehensive audit approach that includes all relevant healthcare professionals (Dartey, 2012). The consistent sentiment among midwives that they are unfairly singled out for blame is a worrying trend that must be addressed to ensure a fair and balanced approach to audits.

Some midwives perceived the MDA process as challenging due to constraints and barriers. This resonates with existing literature that recognizes challenges in implementing effective audits, including inadequate resources, lack of understanding from other healthcare professionals, and resistance to change (Ivers et al., 2012; Rycroft-Malone et al., 2016). The participant’s frustration with the lack of recognition of the midwife’s role echoes concerns raised in previous studies about the need for a shared understanding of professional responsibilities within healthcare teams (Sarin et al., 2018).

Psychological Impacts of Maternal Death Audits on the Midwives

Like all other medical reviews, the maternal death audit process is stressful (Ivers et al., 2012). The study shed light on the psychological implications that participation in Maternal Death Audits (MDA) had on the midwives. The emotional toll of the audits on the psychological well-being of the midwives was profound as most of the participants had to reel through intense anxiety prior to audit sessions, stress, feelings of heartbreak, guilt, emotional trauma, and even personal relationships. Evidence in the literature suggests that midwives who have witnessed several maternal deaths have a higher chance of developing death anxiety, especially those who work in a rural setting (Abraham et al., 2020; Muliarini & Sumarsono, 2021). A good number expressed fear of being found at fault, and the anticipation of blame contributes to emotional stress, a sentiment that has been documented in studies on the emotional impact of adverse events in healthcare (Sarin et al., 2018).

Most of them felt a sense of guilt when the audit identified lapses in the care they provided, which may have contributed to the death of the client. Furthermore, the constant self-questioning and mental distress described by midwives is an indication of the ongoing emotional burden they carry, impacting their mental well-being. According to Dixon-Woods et al. (2011), healthcare providers often internalize a sense of responsibility for adverse events, even when systemic factors partly cause the particular event. The feeling of grief, guilt and shame after the death of a mother has a long-lasting effect on midwives, which requires additional training to enable them to be well equipped for such situations (Chirwa et al., 2023).

Implications for Midwifery Practice

The value of health research is determined by its potential to contribute to current and future professional practice in the specified field (Munhall, 2010; Renjith et al., 2021; Tingen et al., 2009). The study’s findings have significant implications for midwifery practice and policy. Since maternal death audits directly impact professional growth, they must be structured to facilitate learning rather than cause harm. Participants reported intense stress, guilt and trauma following audits, revealing a critical lack of institutional support. To improve the quality of care, policy frameworks and practice of MDAs must transition from blame-oriented models to non-judgmental, collaborative environments that prioritize collective problem-solving. Furthermore, integrating MDA exposure into midwifery curricula and mentorship programs will better equip students for the complexities of these proceedings in future. By fostering a supportive culture, that enables midwives to leverage these audits as learning opportunities instead of seeing it as a way of subjecting them to trial for doing their work, healthcare systems can transform MDAs into constructive tools for professional development, enhancing both midwife well-being and maternal health outcomes.

Strengths and Limitations

The study’s primary strength lies in the use of a qualitative design, which captures the nuanced MDA experiences of midwives in the Upper East Region. This offers authentic insights into the psychological till of MDAs offering critical evidence for local policy improvements. However, the study has notable limitations. The small sample size, restricted to a single region, limits the generalizability of the finding to broader context. Furthermore, the focus is exclusively on midwives’ perspectives, neglecting other healthcare professionals thus missing a holistic understanding of the audit process. Despite these, constraints, the findings are very relevant for developing a supportive, non-judgemental framework to provide a more holistic understanding of the implications of maternal death audits.

Recommendations

To address the challenges identified in this study, several recommendations are proposed to the Ghana Health Service, Ministry of Health, and educational institutions. First, there is the need to Strengthen supportive and fair MDA systems by ensuring MDAs are conducted in a supportive, non-blaming manner that includes timely counselling for midwives, equitable consideration of all healthcare team members, and regular review of MDA protocols to reduce stress and improve maternal care. Additionally, the healthcare system should focus on building midwives’ capacity through continuous training where lessons derived directly from MDAs inform ongoing professional development and capacity-building programmes to strengthen midwives to skills and confidence. Finally, Nursing and midwifery educational institutions should integrate MDA education and formal mentorship into curricula while providing regular in-service training to prepare and support midwives both psychologically and professionally.

Conclusion

While the Maternal death audit is recognised as an innovative strategy by WHO to reduce maternal mortalities and morbidities, Its implementation remains challenging in lower income countries. This study demonstrates how midwives manage various stressors, including the psychological toll of maternal death audits, personal feelings of frustration, and the sense of being unfairly blamed for their roles during clinical tragedies. If lest unaddressed, the emotional impact of MDA process can severely compromise the well-being of midwives, who ironically must remain resilient to continue providing care for women. Since the aim of MDAs is prevent future unfortunate deaths, the process must evolve into supportive, collaborative endeavour rather than a punitive exercise that appears to target specific healthcare providers. Future research should explore the ramifications of these stressors on midwives’ personal and professional lives, while expanding the scope to include perspectives from other critical healthcare team players.

Supplemental Material

Supplemental Material - A Qualitative Inquiry Into Midwives’ Experiences of Participating in Maternal Death Audit in the Upper East Region of Ghana’

Supplemental Material for A Qualitative Inquiry Into Midwives’ Experiences of Participating in Maternal Death Audit in the Upper East Region of Ghana’ by Eugenia Mensah, Evelyn Asamoah Ampofo, Adiza Atoko Mumuni, Aquel Rene Lopez, Mary Ani-Amponsah and Benjamin Oppong-Twumasi in Sage Open Nursing.

Footnotes

Acknowledgements

The authors would like to acknowledge the support of the midwives who participated in the study, for their time and also sharing their experiences with us.

ORCID iDs

Evelyn Asamoah Ampofo

Aquel Rene Lopez

Mary Ani-Amponsah

Benjamin Oppong-Twumasi

Ethical Considerations

Consent to Participate

Written informed consent was obtained from all participants prior to data collection, with assurances of confidentiality, voluntary participation, and the right to withdraw at any time without consequence.

Authors’ Contribution

EM conceived the idea, was involved in designing of the study, data collection, transcription analysis and preparing of the manuscript. EAA was involved in designing the study, took part in data analysis and review of the manuscript. AAM was involved in designing the study, took part in data analysis and review of the manuscript. ARL, BOT and MA contributed to Writing and revising of the manuscript. All authors read and approved the final manuscript.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Declaration of Conflicting Interests

The authors declare that they have no potential conflict of interest with respect to the research, authorship, and /or publication of article.

Data Availability Statement

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Use of AI Software

AI was not used in writing this manuscript.

Supplemental Material

Supplemental material for this article is available online.

References

Abraham

S. A.

Berchie

G. O.

Druye

A. A.

Prempeh

C. A.

Okantey

Agyei-Ayensu

(2020). A paradox: Midwives’ Experiences of Attending a Birth Resulting in Maternal Death in a Ghanaian Context. Journal of Midwifery and Reproductive Health, 8(4), 2447–2455. https://doi.org/10.22038/jmrh.2020.47288.1579

Achem

F. F.

Agboghoroma

C. O.

(2014). Setting up facility-based maternal death reviews in Nigeria. BJOG: An International Journal of Obstetrics and Gynaecology, 121(s4), 75–80. https://doi.org/10.1111/1471-0528.12817

Ampofo

E. A.

(2016). Ethical Issues in Childbirth: The Need for Relational Ethics. West African Journal of Nursing, 27(1), 46–55. https://doi.org/10.5897/IJNM2017.0265

Apanga

P. A.

Awoonor-Williams

J. K.

(2018). Maternal Death in Rural Ghana: A Case Study in the Upper East Region of Ghana. Frontiers in Public Health, 6(April), 1–6. https://doi.org/10.3389/fpubh.2018.00101

Aydin

Aktaş

(2021). An investigation of women ’ s pregnancy experiences during the 19 pandemic: A qualitative study. International Journal of Clinical Practice, 75(e14418), 1–11. https://doi.org/10.1111/ijcp.14418

Bradfield

Hauck

Kelly

Duggan

(2019). “It’s what midwifery is all about”: Western Australian midwives’ experiences of being ‘with woman’ during labour and birth in the known midwife model. BMC Pregnancy and Childbirth, 19(1), 29. https://doi.org/10.1186/s128840182144-z

Bradford

(2021). The Essential Role of Nurse Practitioners and Midwives on Maternal Mortality Review Committees. Nursing for Women’s Health, 25(2), 107–111. https://doi.org/10.1016/j.nwh.2021.01.005

Braun

Clarke

(2019). Thematic analysis revised. Journal of Chemical Information and Modeling, 53(9), 1689–1699.

Braun

Clarke

(2021). To saturate or not to saturate? Questioning data saturation as a useful concept for thematic analysis and sample-size rationales. Qualitative Research in Sport, Exercise and Health, 13(2), 201–216. https://doi.org/10.1080/2159676X.2019.1704846

10.

Buse

Hawkes

(2015). Health in the sustainable development goals: Ready for a paradigm shift? Globalization and Health, 11(1), 1–8. https://doi.org/10.1186/s12992-015-0098-8

11.

Chirwa

M. D.

Nyasulu

Modiba

Ganga-Limando

(2023). Challenges faced by midwives in the implementation of facility-based maternal death reviews in Malawi. BMC Pregnancy and Childbirth, 23(1), 1–23. https://doi.org/10.1186/s12884-023-05536-2

12.

Dartey

A. F.

(2012). The Role of Midwives in the Implemenation of Maternal Death Review (MDR) in Health Facilities in Ashanti Region. (Doctoral Dissertation) .

13.

Dartey

A. F.

Phetlhu

D. R.

Phuma-Ngaiyaye

(2019). Coping with Maternal Deaths: The Experiences of Midwives. Ethiopian Journal of Health Sciences, 29(4), 495–502. https://doi.org/10.4314/ejhs.v29i4.11

14.

Dixon-Woods

McNicol

Martin

(2011). Ten challenges in improving quality in healthcare: Lessons from the Health Foundation’s programme evaluations and relevant literature. BMJ Quality & Safety, 21(10), 876–884. https://doi.org/10.1136/bmjqs-2011-000760

15.

Endris

A. A.

Tilahun

(2023). Health system readiness to manage maternal death data and avail evidence for decision-making through the Maternal Death Surveillance System in Ethiopia, 2020. BMC Health Services Research, 23(1), 318. https://doi.org/10.1186/s12913-023-09321-x

16.

Ghana Statistical Service . (2014). Ghana Demographic and Health Survey 2014. Ghana Statistical Service. https://dhsprogram.com/pubs/pdf/FR307/FR307.pdf

17.

Ghana Health Service . (2016). Maternal Death Audit Annual Report 2016. Ghana Health Service.

18.

Ghana News Agency . (2022). Ghana Health Service intensifies efforts to reduce maternal mortality. Ghana News Agency. https://gna.org.gh/2022/ghana-health-service-intensifies-efforts-to-reducematernal-mortality/

19.

Upper East Regional annual performance review 2022. Ghana Health Service. https://gna.org.gh/2023/03/upper-east-region-records-27-maternal-deaths-in-2022/ , 2023.

20.

Hunter

McCallum

Howes

(2019). Defining exploratory-descriptive qualitative (EDQ) research and considering its application to healthcare. Journal of Nursing and Health Care, 4(1). https://doi.org/dl6.globalstf.org/index.php/jnhc/article/view/1260.

21.

Idrissa

Nestor

Dieudonne

Gustave

Patrice

A. N.

Ahmed

Clovis

A. T.

Maxime

(2022). Midwives experiences in the practice of maternal death audits in Burkina Faso: A qualitative study. International Journal of Nursing and Midwifery, 14(1), 10–13. https://doi.org/10.5897/ijnm2021.0488

22.

Ivers

Jamtvedt

Flottorp

Young

J. M.

Odgaard-Jensen

French

S. D.

O’Brien

M. A.

Johansen

Grimshaw

Oxman

A. D.

(2012). Audit and feedback: Effects on professional practice and healthcare outcomes. The Cochrane Database of Systematic Reviews, 6, CD000259. https://doi.org/10.1002/14651858.CD000259.pub3

23.

Lawrence

E. R.

Klein

T. J.

Beyuo

T. K.

(2022). Maternal Mortality in Low and Middle-Income Countries. Obstetrics and Gynecology Clinics of North America, 49(4), 713–733. https://doi.org/10.1016/j.ogc.2022.07.001

24.

Mahato

P. K.

Waithaka

van Teijlingen

Pant

P. R.

Biswas

(2018). Social autopsy: A potential health-promotion tool for preventing maternal mortality in low-income countries. WHO South-East Asia Journal of Public Health, 7(1), 24–28. https://doi.org/10.4103/2224-3151.228424

25.

Ministry of Health, Ghana . (2014). Maternal Health Strategy 2014–2018. Ministry of Health.

26.

Ministry of Health, Ghana . (2017). National Health Policy: Ensuring healthy lives for all. Accra: Ministry of Health. Aydin, R., & Aktas, S. 2021. Midwives’ experiences of traumatic births: A systematic review and meta-synthesis. European Journal of Midwifery, 5, 1–10. https://doi.org/10.18332/ejm/138197

27.

Muliarini

Sumarsono

(2021). Faktor Organisasi yang Mempengaruhi Pelaksanaan Audit Maternal. Journal of Management and Business Review, 18(2), 274–284. https://doi.org/10.34149/jmbr.v18i2.279

28.

Munhall

P. L.

(2010). Nursing Research: A Qualitative Perspective. Jones & Bartlett Publishers.

29.

Ngegbai

A.S.

Kuma

G.K.

Noora

C.L.

Maya

E.T.

Guure

(2024). Evaluating maternal death surveillance and response system in Sunyani Municipality of Bono region in Ghana from 2017-2021. BMC Health Service Research, 24(1), 578. https://doi.org/10.1186/s12913-024-12023-7

30.

Pezaro

Clyne

Turner

Fulton

E. A.

Gerada

(2016). “Midwives Overboard!” Inside their hearts are breaking, their makeup may be flaking but their smile still stays on. Women and Birth, 29(3), e59–e66. https://doi.org/10.1016/j.wombi.2015.10.006

31.

Renjith

Yesodharan

Noronha

J. A.

Ladd

George

(2021). Qualitative Methods in Health Care Research. International Journal of Preventive Medicine, 12(1), 20. https://doi.org/10.4103/ijpvm.IJPVM_321_19

32.

Rycroft-Malone

Seers

Chandler

Hawkes

Crichton

Allen

Bullock

Strunin

(2016). The role of evidence, context, and facilitation in an implementation trial: Implications for the development of the PARIHS framework. Implementation Science, 11(1), 1–17. https://doi.org/10.1186/s13012-016-0398-2

33.

Sarin

Lunsford

S. S.

Sood

Rai

S. K.

(2018). The role of team-based competency standards in strengthening the midwifery profession. Human Resources for Health, 16(1), 19. https://doi.org/10.1186/s12960-018-0281-6

34.

Shorey

André

Lopez

(2017). The experiences and needs of healthcare professionals facing perinatal death: A scoping review. International Journal of Nursing Studies, 68, 25–39. https://doi.org/10.1016/j.ijnurstu.2016.12.007

35.

Smith

Ameh

Roos

Mathai

van den Broek

(2017). Implementing maternal death surveillance and response: A review of lessons from country case studies. BMC Pregnancy and Childbirth, 17(1), 1–11. https://doi.org/10.1186/s12884-017-1405-6

36.

Supratikto

Wirth

M. E.

Achadi

Cohen

Ronsmans

(2020). A district-based audit of the causes and circumstances of maternal deaths in South Kalimantan, Indonesia. Bulletin of the World Health Organization, 80(3), 228–234.

37.

Tingen

M. S.

Burnett

A. H.

Murchison

R. B.

Zhu

(2009). The Importance of Nursing Research. The Journal of Nursing Education, 48(3), 167–170. https://doi.org/10.3928/01484834-20090301-10

38.

United Nations . (2023). The Sustainable Development Goals Report 2023 (Special Edition). United Nations. https://unstats.un.org/sdgs/report/2023/

39.

Willcox

Okello

Maidwell-Smith

Tura

Van Den Akker

Knight

(2023). Maternal and perinatal death surveillance and response: A systematic review of qualitative studies. Bulletin of the World Health Organization, 101(1), 62–75G. https://doi.org/10.2471/BLT.22.288703

40.

World Health Organization . (2013). Maternal death surveillance and response: Technical guidance Information for action to prevent maternal death. World Health Organization, 38, 117 p. https://iris.who.int/handle/10665/87340

41.

World Health Organisation (WHO) . (2016). Making Every Baby Count: Audit and review of stillbirths and neonatal deaths (p. 144). WHO Library Cataloguing-in-Publication Data.

42.

X. V.

Enskär

Lee

C. C. S.

Wang

(2017). A systematic review of the use of theory in randomized controlled trials of healthcare innovations. Journal of Advanced Nursing, 73(12), 2864–2878. https://doi.org/10.1111/jan.13375

43.

Yakong

V. N.

Rush

K. L.

Bassett‐Smith

Bottorff

J. L.

Robinson

(2010). Women’s experiences of seeking reproductive health care in rural Ghana: challenges for maternal health service utilization. Journal of advanced nursing, 66(11), 2431–2441. https://doi.org/10.1111/j.1365-2648.2010.05404.x

Supplementary Material

Please find the following supplemental material available below.

For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.

For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.

0.15 MB

0.00 MB