A root-cause analysis of maternal deaths in Botswana: towards developing a culture of patient safety and quality improvement

Abstract

BackgroundIn 2007, 95% of women in Botswana delivered in health facilities with 73% attending at least 4 antenatal care visits. HIV-prevalence in pregnant women was 28.7%. The maternal mortality ratio in 2010 was 163 deaths per 100 000 live births versus the government target of 130 for that year, indicating that the Millennium Development Goal 5 was unlikely to be met. A root-cause analysis was carried out with the aim of determining the underlying causes of maternal deaths reported in 2010, to categorise contributory factors and to prioritise appropriate interventions based on the identified causes, to prevent further deaths.MethodsCase-notes for maternal deaths were reviewed by a panel of five clinicians, initially independently then discussed together to achieve consensus on assigning contributory factors, cause of death and whether each death was avoidable or not at presentation to hospital. Factors contributing to maternal deaths were categorised into organisational/management, personnel, technology/equipment/supplies, environment and barriers to accessing healthcare.ResultsFifty-six case notes were available for review from 82 deaths notified in 2010, with 0–4 contributory factors in 19 deaths, 5–9 in 27deaths and 9–14 in nine. The cause of death in one case was not ascertainable since the notes were incomplete. The high number of contributory factors demonstrates poor quality of care even where deaths were not avoidable: 14/23 (61%) of direct deaths were considered avoidable compared to 12/32 (38%) indirect deaths. Highest ranking categories were: failure to recognise seriousness of patients’ condition (71% of cases); lack of knowledge (67%); failure to follow recommended practice (53%); lack of or failure to implement policies, protocols and guidelines (44%); and poor organisational arrangements (35%). Half the deaths had some barrier to accessing health services.ConclusionsRoot-cause analysis demonstrates the interactions between patients, health professionals and health system in generating adverse outcomes for patients. The lessons provided indicate where training of undergraduate and postgraduate medical, midwifery and nursing students need to be intensified, with emphasis on evidence-based practice and adherence to protocols. Action plans and interventions aimed at changing the circumstances that led to maternal deaths can be implemented and re-evaluated.

Assessment of Maternal Mortality and its Associated Causes at Shinyanga Regional Hospital in Tanzania

“…A few number of the patients underwent assisted vaginal delivery, removal of retained products and surgery. All this misdirected managements are a result of improper management skills and lack of welltrained personnel, this findings are in agreement with studies conducted by WHO, Muhimbili National Hospital in Tanzania as well as in Botswana (4,10,17). The treatments provided in the study setting were also accessible for a few proportions of mothers due to their low income and lack of resources in the particular setting.…”

Maternal near miss and mortality in a tertiary care hospital in Rwanda

“…Sepsis was the second leading cause of maternal death. The average cesarean section rate for all hospitals increased from 35 % in 2010 to 45 % in 2011 [ 5 ]. Access to cesarean deliveries is associated with improved maternal and perinatal outcomes in countries with poor access to obstetric care, however, high cesarean rates may contribute to increased maternal morbidity and mortality [ 6 ].…”

Effective strategies for reducing maternal mortality in Isfahan University of Medical Sciences, 2014

“…According to these studies, some effective strategies in preventing maternal deaths consist of review of maternal mortalities,[ 20 21 ] women's knowledge about the risks of cesarean section, induction of labor and childbirth preparation classes, painless delivery, consulting sessions and elimination of fear of and anxiety about vaginal delivery,[ 22 23 ] students' training with an emphasis on evidence-based practice, adherence to the protocols, simulation of managing acute diseases, early detection and referral management of mothers,[ 24 25 ] planning based on research to identify the obstacles to access high-quality clinical services and cares,[ 26 27 ] design and implementation of an effective system of risk management to improve safety,[ 28 29 ] raising the level of public awareness, and increasing the level of women's education. [ 30 31 32 33 34 35 ]…”