Centre for International Health
Research Project

Facilitating «real life» implementation of MDSR

MATRISET - Reporting in context: An interdisciplinary initiative to strengthen maternal health services and surveillance in Ethiopia and Tanzania. The Maternal Death Surveillance and Response System (MDSR) is a tool to enhance maternal mortality reporting and corrective action. The aim of the project is to strengthen reporting in maternal mortality surveillance systems to ensure relevant response in the contexts of Ethiopia and Tanzania

MPDSR quality assurance cycle
MPDSR quality assurance cycle

Main content

Maternal Mortality Ratio (MMR) is given substantial attention, particularly by aid and funding organisations as being an indicator and therefore a way of assessing how a country / region / community is doing in terms of development, health systems functioning, women’s position, and equity. However, closer examination reveals that the estimates are surrounded by substantial uncertainty and error, which is not taken into account.

In 2013 the World Health Organization initiated Maternal Death Surveillance and Response System (MDSR) as a global vital health service delivery intervention to address the problem of high maternal mortality figures.

Since 2013 MDSR systems have been implemented in a number of low income and middle income countries including in sub-Saharan Africa, and represents a huge potential for improved knowledge about the underlying causes and circumstances surrounding maternal deaths, enhanced accountability for maternal health and improved quality of healthcare for childbearing women.

The project will explore interactions between legal norms, policy recommendations, administrative systems and clinical practices in order to increase the understanding of the complex dynamics of accountability mechanisms, reporting procedures and decision making related to the MDSR system. We will use a Human Rights based approach to accountability in maternal health.


Through our inter-disciplinary ‘Reporting in context’ approach, we employ novel combinations of methods to the study of institutions, institutional routines and practices as well as legal frameworks.

Mixed methods designs will combine qualitative approaches (ethnography and qualitative interviews) with quantitative approaches (surveys) to generate in depth knowledge about clinical reporting and dynamics of accountability. Ethnographic approaches are rarely employed in mixed methods designs.

Ethnography: The team has substantial competence in ethnographic research which will be used as research method to gain unique insights into the procedures and practices of reporting. Observation- and participant observation (in ethnography) will be decisive to gain substantive knowledge on the managing of reported data within the health service bureaucracy.

Doctrinal research will in combination with the ‘law in context’-research generate beyond state-of-art knowledge to enhance the balance between health worker accountability and the protection of health workers who report maternal mortality identified as a key challenge in maternal mortality surveillance.

Stakeholder involvement: Through continuous collaboration with stakeholders in professional organisations and Community Based Organizations (CBOs) the team will develop concrete advice for improvements within the field of reporting, contributions that will boost implementation research in sub-Saharan Africa.




The project is carried out in Ethiopia and Tanzania by an interdisciplinary research group from the social sciences, law and medicine, and aims to improve the quality of maternal mortality reporting. Through a combination of ethnography, survey and analysis of register data, we investigate the relationship between observed and reported clinical practice.

Project manager:    
Prof. Astrid Blystad, medical anthropologist and nurse, Prof. at the Centre for International Health, Dep. of Global Public Health and Primary Care (IGS).
Astrid Blystad
The project group at University in Bergen, Norway:   
Faculty of Medicine:   

Prof. Ingvild Sandøy, MD/epidemiologist,
Deputy leader of CISMAC (Centre for Excellence
in Intervention Science in Maternal and Child Health);

Ingvild Fossgard Sandøy

Prof. Ingrid Miljeteig, MD, Deputy leader of Bergen Centre for Ethics and Priority Setting in Health (BCEPS);

Ingrid Miljeteig


Assoc. Prof. Karen Marie Moland, Political Science/Nursing, Leader Global Health Anthropology Research Group;
Karen Marie Moland


Andrea Melberg

MD, Post doc.

Andrea Melberg
Kornelia Herstad
Research track student and medical student at UiB

Kerstin Almdal, PhD Candidate at Centre for International Health 

Kerstin Almdal







Kaja Skoftedalen, PhD candidate at Centre for International Health
Kaja Skoftedalen
Faculty of Psychology   
Prof. Haldis Haukanes, anthropology/gender studies;
Haldis Haukanes
Prof. Siri Lange, anthropology/ development studies.
Siri Lange
Faculty of Law:   
Prof. Henriette Sinding Aasen, law/human rights;
Henriette Sinding Aasen

PhD cand. Mulu Beyene Kidanemariam, law. Project title: Accountability for Preventable Maternal Mortality: The legal setting of MDSR in Ethiopia 

Mulu Beyene Kidanemariam




Addis Ababa University:   
Prof. Getnet Tadele, Dep of Sociology;Assoc. Prof. Tsehai Wada, Dep. of Law,Prof. Damen Haile Mariam,  School of Public Health  
Asabneh Molla, PhD candidate.
Project title: Exploring Community Participation in
Maternal Death Reporting and Review in West Gojjam Zone,
Amhara Region, Ethiopia
Asabneh Molla
Asabneh Molla
Ethiopian Public Health Institute:   

Senior researcher Alemnesh Mirkuzie,
coordinator of National Data Management Center for Health;
Abduilhafiz Hassan, MA, National MDSR Response officer,PhD candidate; xx 
University of Dar es Salaam:   
Assistant professor Richard Sambaiga,
Department of Sociology and Anthropology;
D Baraka, Department of Law, post doc, Latifa Mohamed, PhD candidate, 

Project title: "Understanding the Experience of Actors Involved in Birth Care Audits: The Case of Maternal Death Reporting".

Muhimbili University of Health and Allied Sciences (MUHAS):   

Dr. Ali Saidi MD, post doc


Centre for Cultures of Reproduction, Technologies and Health (CORTH):    
Prof. Maya Unnithan, leader of CORTH, School of Global Studies, University of Sussex.
Maya Unnithan
Maya Unnithan



Up until now, most studies on maternal death surveillance and review systems implementation in sub-Saharan Africa have focussed on the existence of formal national and subnational death review structures, as guided by the WHO framework

Systematic underreporting has been linked to pressure to meet global maternal health goals, heavy workload and lack of legal protection for health workers. This results in impaired quality of the data material in the MDSR system and uncertain figures for maternal mortality globally.

By drawing on social science theory on the production of numbers and statistics (metrics) in areas with weak data registers, the project will contribute to increased knowledge about challenges in the reporting system. Importantly, based on this knowledge, it will also contribute to the development of a better framework for reporting and better legal protection of health personnel.