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Root-Cause Analysis Of Persistently High Maternal Mortality In A Rural District Of Indonesia: Role Of Clinical Care Quality And Health Services Organizational Factors, Mohammad Afzal Mahmood, Ismi Mufidah, Steven Scroggs, Amna Rehana Siddiqui, Hafsa Raheel, Koentijo Wibdarminto, Bernardus Dirgantoro, Jorien Vercruyssen, Hayfaa A. Wahabi

Community Health Sciences

Background: Despite significant reduction in maternal mortality, there are still many regions in the world that suffer from high mortality. District Kutai Kartanegara, Indonesia, is one such region where consistently high maternal mortality was observed despite high rate of delivery by skilled birth attendants.
Method: Thirty maternal deaths were reviewed using verbal autopsy interviews, terminal event reporting, medical records' review, and Death Audit Committee reports, using a comprehensive root-cause analysis framework including Risk Identification, Signal Services, Emergency Obstetrics Care Evaluation, Quality, and 3 Delays.
Findings: The root causes were found in poor quality of care, which caused …