Root-Cause Analysis of Persistently High Maternal Mortality in a Rural District of Indonesia: Role of Clinical Care Quality and Health Services Organizational Factors
Table 5
Factors contributing to maternal death.
Contributing factors
Total deaths
Immediate cause of maternal death
Unsure if the factor played a role
Direct
Indirect
Unknown
30
20
3
7
Organization
28 (93%)
Poor organization/management (both in primary and tertiary care)
9
7
1
0
5
Lack of policy/protocol/guidelines
13
12
1
0
2
Inadequate staff
4
4
0
0
1
Inadequate access to senior clinical staff
13
9
2
2
2
Failure/delay in emergency response
15
11
1
3
2
Delay in procedures
11
8
0
3
4
Poor system/process for sharing information (between primary and tertiary care)
7
4
1
3
4
Delay in Access to Test Results
2
1
1
0
4
Personnel
30 (100%)
Knowledge and skills lacking
24
15
3
6
4
Delay in emergency response
14
9
1
4
2
Poor communication
9
6
2
1
3
Failure to seek supervision/help
13
7
2
4
3
Failure to follow best practice (hospital for 13 women, primary care for 12)
25
18
3
4
3
Lack of recognition of seriousness
20
13
2
5
4
Equipment & supplies
7 (23%)
Malfunction/failure
1
1
0
0
1
Supplies (blood, FFP, drugs, etc.) out of stock, unavailable on premises
7
6
0
1
0
Environment
14 (47%)
Geography as contributory factor
14
9
1
4
1
Barriers at personal/family
16 (53%)
Lack of recognition of seriousness
16
9
2
5
1
Not Eligible for free care/financial difficulty
5
3
1
1
0
Adapted from Farquhar et al. 2011 and Madzimbamuto et al. 2014.
