Root-Cause Analysis of Maternal Mortality in Fars Province, Southern Iran 2014: Negligence Is the Prime Suspect
Objective: we aimed to carry out an applied methodological tool, using Root-Cause Analysis (RCA), to determine the main causes of maternal mortality in Fars province, south of Iran, in 2014.
Materials and methods: This is a case-series study and was conducted based on a careful examination of records and verbal autopsy with the family of the deceased person and their medical care team. Using RCA, quantitative dynamic modeling was done to display the overall impacts of different causes on maternal mortality. Finally, sensitivity analysis was done to determine the magnitude of contribution of each root-cause of maternal mortality.
Results: Totally, all 10 maternal deaths with Maternal Mortality Rate (MMR) of 13.4 per 100.000 births, were recorded in the maternal surveillance system during 2014. The RCA results revealed that the root-causes of maternal mortality were ignorance and negligence (50%), delay in diagnosis (30%), delay in service provision in the first 24 hours after delivery (10%), and undesirable health care (10%). The results of sensitivity analysis in different scenarios revealed that medical negligence had the highest contribution to maternal mortality.
Conclusion: Although maternal surveillance system stated some causes such as hemorrhage to be responsible for maternal deaths, the RCA showed that root-causes such as medical neglects had a fundamental role. Therefore, maternal mortality can be prevented by reforming the health care system and training all service providers, especially for high-risk mothers
2. Changizi N, Rezaeizadeh G, Janani L, Shariat M, Habibelahi A. In Depth Analysis of the Leading Causes of Maternal Mortality Due to Cesarean Section in Iran. J Family Reprod Health 2017; 11: 1-6.
3. Hogan MC, Foreman KJ, Naghavi M, Ahn SY, Wang M, Makela SM, et al. Maternal mortality for 181 countries, 1980-2008: a systematic analysis of progress towards Millennium Development Goal 5. Lancet 2010; 375: 1609–23.
4. Kaur H, Kaur Sh, Singh S. Trends in Maternal Mortality Ratio in a Tertiary Referral Hospital and the Effects of Various Maternity Schemes on It. J Family Reprod Health 2015; 9: 89-92.
5. Vahiddastjerdy M, Changizi N, Habibollahi A, Janani L, Farahani Z, Babaee F. Maternal Mortality Ratio and Causes of Death in IRI Between 2009 and 2012. J Family Reprod Health 2016; 10: 154-62.
6. Moghani Lankarani M, Changizi N, Rasouli M, AmirKhani MA, Assari S. Prevention of pregnancy complications in iran following implementing a national educational program. J Family Reprod Health 2014; 8: 97-100.
7. Dadipor S, Ramezankhani A, Alavi A, Aghamolaei T, Safari-Moradabadi A. Pregnant Women’s Health Literacy in the South of Iran. J Family Reprod Health 2017; 11: 211-8.
8. Harper MA, Byington RP, Espeland MA, Naughton M, Meyer R, Lane K. Pregnancy-related death and health care services. Obstet Gynecol 2003; 102: 273-8.
9. Andersson T, Bergstrom S, Hogberg U. Swedish maternal mortality in the 19th century by different definition: Previous but not multiparty risk factor for maternal death. Acta Obstet Gynecol Scand 2000; 79: 679-86.
10. Neal S, Mahendra SH, Bose K, Camacho AV, Mathai M, Nove A, et al. The causes of maternal mortality in adolescents in low and middle income countries: a systematic review of the literature. BMC Pregnancy Childbirth 2016; 16: 352.
11. MacDorman MF, Declercq EU, Thoma ME. Trends in Maternal Mortality by Socio-Demographic Characteristics and Cause of Death in 27 States and the District of Columbia. Obstet Gynecol 2017; 129: 811–8.
12. Abouzahr C. Global burden of maternal death and disability. British Medical Bulletin 2003; 67: 1-11.
13. Franks AL, Atrash HK, Lawson HW, Colberg KS. Obstetrical pulmonary embolism mortality, United States, 1970-85. Am j Public Health 1990; 80: 720-2.
14. Toglia MR, Weg JG. Venous thromboembolism during pregnancy. N Engl J Med 1996; 335: 108-114.
15. Thaddeus S, Maine D. Too far to walk: maternal mortality in context. Soc Sci Med 1994; 38:1091-110.
16. Barnes-Josiah D, Myntti C, Augustin A. The “three delays” as a framework for examining maternal mortality in Haiti. Soc Sci Med 1998; 46: 981-93.
17. South Africa Every Death Counts Writing Group, Bradshaw D, Chopra M, Kerber K, Lawn JE, Bamford L, et al. Every death counts: use of mortality audit data for decision making to save the lives of mothers, babies, and children in South Africa. Lancet 2008; 371: 1294-304.
18. Centers for Disease Control and Prevention (CDC). Ectopic pregnancy–United States, 1990- 1992. MMWR Morb Mortal Wkly Rep 1995; 44: 46-8.
19. Goldner TE, Lawson HW, Xia Z, Atrash HK. Surveillance for ectopic pregnancy–United States, 1970-1989. MMWR CDC Surveill Summ 1993; 42: 73-85.
20. Chang J, Elam-Evans LD, Berg CJ, Herndon J, Flowers L, Seed KA, et al. Pregnancy-related mortality surveillance–United States, 1991-1999. MMWR Surveill Summ 2003; 52: 1-8.
21. Wu AW, Lipshutz A.K.M, Pronovost P.J. Effectiveness and efficiency of root-cause analysis in medicine. JAMA 2008: 299: 685-7.
22. Zalvand R, Tajvar M, Pourreza A, Asheghi H. Determinants and causes of maternal mortality in Iran based on ICD-MM: a systematic review. Reprod Health 2019; 16: 16.
23. Mahlon Vollmer Ch, Sanchez N, Gondek S, McAuliffe J, Kent TS, Christein JD, et al. A root-cause analysis of mortality following major pancreatectomy. J Gastrointest Surg 2012; 16:89-102.
24. Garnerin1 P, Schiffer1 E, Van Gessel E, Clergue F. Root-cause analysis of an airway filter occlusion: a way to improve the reliability of the respiratory circuit. Br J Anaesth 2002; 89: 633-5.
25. Perkins JD, Levy AE, Duncan Julie B, Carithers Jr RL. Using Root Cause Analysis to Improve Survival in a Liver Transplant Program. J Surg Res 2005; 129: 6-16.
26. Lee A, Mills P.D, Watts B.V. Using Root Cause Analysis to reduce falls with injury in the psychiatric unit. Gen Hosp Psychiatry 2012; 34: 304–11.
27. Nicolini D, Waring J, Mengis J. Policy and practice in the use of root cause analysis to investigate clinical adverse events: Mind the gap. Soc Sci Med 2011; 73:217-25.
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