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| Contributing factors | Recommendations |
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| Failure to follow best practice protocols | District Health Department should institute a system of closer supervision & support, with maternal health team having sufficient number of midwife-supervisors working closely with the health centre and private midwives |
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| Inability to manage deterioration | In hospitals, provide CME, and where possible place trainers on-site, retrain staff using standard courses particularly for preeclampsia and postpartum hemorrhage and effective use of early warning system. In primary care retrain staff for improved skills particularly for BP measurement and management |
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| Poorly resourced facilities | Strengthen midwifery at the sub-district hospitals. Review staffing needs and retrain staff at the centres particularly those that are two or more hours from the district hospital |
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| Missing essential service, such as blood products | Support the hospital management for decision to initiate or relocate services on premises |
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| Ineffective communication | Conduct focused training for midwifery supervisors and heads of primary care centres, to communicate and develop delivery plans with the women, document sufficient details of the condition, and effectively use hotline with calls to hospitals before and during transfer of women |
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| Unintegrated care and poor referrals | Develop protocols for early assessment and subsequent categorization into high, intermediate and low risk, with each category having a clear plan of where to deliver. Train staff using these protocols including information about capability of each of the district hospitals in terms of what services are available. Additionally, there is a need to train staff and emphasize on assessment of risks posed by concomitant illnesses with reference to the locally prevalent diseases such as TB, malaria and dengue, and provision of comprehensive and integrated care through a team approach. |
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| Ineffective family planning services | Reemphasize a strong focus on family planning as part of maternal health care services in both primary care and at the hospital. Retrain staff to provide care to women with unmet need and potential unplanned pregnancies with a particular focus on multipara and age beyond 30 |
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| Many women suffering from hypertensive conditions | Investigate eating & nutritional practices (e.g. salt intake) |
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