The Social Diagnosis and Maternal Mortality Review: An Institutional Ethnography

Background and Purpose: Maternal Mortality Review Committees (MMRCs) are state and city-level, interprofessional bodies that regularly convene to examine pregnancy-related deaths in their jurisdiction. MMRCs use the social determinants of health (SDH) framework into case review, analysis, and recommendations. Meanwhile, maternal mortality rates, MMRC contexts, and health policy differ between states. The objective of this study was to obtain an in-depth understanding of Louisiana, California, and New York MMRC member perspectives and experiences around identifying, examining, and discussing the social determinants of maternal death in case review and recommendations, with particular attention to deaths from cardiovascular conditions (CVC), a leading cause of death in each state.

Methods: The current study is an institutional ethnography, a qualitative research method that examines how work is regulated, organized, and coordinated between participants. This ethnography uses content analysis of key documents, participant-observation in MMRC conferences and trainings, and semi-structured interviews with key informants, including current and former MMRC members from each state.

Results: First, MMRCs rely on the medical tools of diagnosis and case narratives to make sense of root causes and make recommendations for action on maternal mortality, especially for deaths from CVC. MMRCs fit social factors contributing to CVC into these tools. I advance the concepts of the social diagnosis and the encased patient. Committees perform social diagnoses in two ways: diagnoses identify the nature of an illness or other problem by examining “symptoms” in the social world and they are also dependent on member interactions. Second,

Conclusions and Implications: Diagnostic processes influence social processes and vice-versa. MMRCs are shaped by medical hierarchies where physicians, and tools associated with medicine, manage uncertainty. At times, the medical model forecloses alternative understandings of maternal mortality as well as ways to address it.