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.
Highlights
In 2007, 95% of women in Botswana delivered in health facilities with 73% attending at least 4 antenatal care visits
Analysis of trends in maternal mortality ratios (MMR) may reveal weaknesses in health systems that lead to maternal deaths, to establish where changes can be made to improve outcomes, especially in resource-limited settings [1,2]
The root cause analysis (RCA) checklist is useful if adopted as a guide to enquiry for each woman’s death as it happens, while contributory factors are fresh in the minds of the healthcare team responsible
Summary
In 2007, 95% of women in Botswana delivered in health facilities with 73% attending at least 4 antenatal care visits. Techniques of investigating safety incidents in healthcare, adapted from industrial settings, include root cause analysis (RCA) to identify factors contributing to the safety incident (maternal deaths in this review) [3]. These factors are categorised as patient characteristics, task factors (for example lack of protocols), individual staff factors, work environment, team-working, and organisational or management factors [4]. The use of RCA as a method of continuous quality improvement provides opportunities to create a culture of patient-safety within which health professionals can be more effective in providing patientcentred care. In Australia, root cause analysis was used to improve work practices and patient safety, to facilitate teamwork and communication about patient care [5]
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