Facility-based Maternal Death Reviews Research Articles

Challenges faced by midwives in the implementation of facility-based maternal death reviews in Malawi

BackgroundMaternal death reviews provide an in-depth understanding of the causes of maternal deaths. Midwives are well positioned to contribute to these reviews. Despite midwives’ participation as members of the facility-based maternal death review team, maternal mortality continues to occur, therefore, this study aimed to explore the challenges faced by midwives as they participate in maternal death reviews in the context of the healthcare system in Malawi.MethodsThis was a qualitative exploratory study design. Focus group discussions and individual face-to-face interviews were used to collect data in the study. A total of 40 midwives, who met the inclusion criteria, participated in the study. Data was analyzed manually using a thematic content procedure.ResultsChallenges identified were: knowledge and skill gaps; lack of leadership and accountability; lack of institutional political will and inconsistency in conducting FBMDR, impeding midwives’ effective contribution to the implementation of maternal death review. The possible solutions and recommendations that emerged were need-based knowledge and skills updates, supportive leadership, effective and efficient interdisciplinary work ethics, and sustained availability of material and human resources.ConclusionMidwives have the highest potential to contribute to the reduction of maternal deaths. Practice development strategies are required to improve their practice in all the areas they are challenged with.

A facility-based assessment of maternal mortality among all deaths in reproductive-aged women in Mzimba South District, Malawi.

Accurate reporting of maternal mortality is essential for effective health policy planning and achieving maternal death reduction in Sustainable Development Goals Target 3 (SDGs). This study aimed to identify gaps between facility-based maternal death reviews and the hospital Health Management Information System (HMIS) reports in Mzimba South District, Malawi from July 2013 to June 2018. A retrospective hospital-based medical record review was conducted to identify maternal deaths among women aged 15 to 49 years with all death causes. Out of 447 mortality records identified from the hospital wards, 89 maternal mortality cases were identified by the study review compared to 83 cases in the HMIS report. The HMIS report showed an underreporting rate of 6.7% (6/89) and a misclassification rate of 13.5% (12/89) within five years. These findings highlight the need for establishing mechanisms for the verification and monitoring of maternal mortality data reporting in health facilities. Improving the quality of maternal death reporting could help inform evidence-based interventions and policies that address the root causes of maternal mortality, and achieve SDGs in Malawi.

REVIEW OF MATERNAL MORTALITY AT A TERTIARY CARE HOSPITAL - A ONE YEAR STUDY

Background:Mothers are the nurturing pillar of the family. When a woman dies, the consequences have the potential to affect not only the woman herself, but her family, society and the nation as well.In 2015 globally 303,000 women died of various causes related to maternity. Aim:To determine the Maternal Mortality ratio at the tertiary care hospital for a period of one year and to identify the causes and factors leading to Maternal mortality. Material and Methods:This was a retrospective observational study carried out in the department of Obstetrics and Gynaecology at Andhra MedicalCollege and King George Hospital, Visakhapatnam, which is atertiary care centre of North Andhra.The hospital runs one ICU and Obstetric HDU, one blood bank and emergency operation theatre round the clock to provide emergencyobstetric services and critical care to their patients.The female deaths which met the WHO Criteria for Maternal Death were included in this study.The details of all the maternal deaths from January 2021 toDecember 2021 were collected from the individual case sheets and facility-based maternal death review forms. Results:During the study period January 2021 to December 2021, therewere 18,892 live births and 86 maternal deaths. The MMR in thestudy period was 455.2/100,000 live births.The maximum number of maternal deaths was seen in the age group 20-25 years, 61 cases (70.93%).The number of maternal deaths were maximum in the low socioeconomic status group with 71 cases (82.55%). Type I delay was seen in 49 cases (56.97 %). Direct causes of maternal death in the study was due to abortion in 3 cases (3.4%), hypertension in 37 cases (43.02%), obstetric hemorrhage in 22 cases (25.58%), infection/sepsis in 21 cases (24.41%) and embolism in 3 cases (3.4%) The most common indirect cause of maternal death was anemia seen in 51 cases (59.3%) Conclusion:Hypertension, hemorrhage and sepsis continue to be the leading causes of direct maternal deaths and anemia indirect cause of maternal death. Majority of deaths are preventable and with proper strategies and focusing on the 3 delays, maternal deaths can be reduced.

Impact of maternal death reviews at a rural hospital in Zambia: a mixed methods study

BackgroundMaternal mortality in sub-Saharan Africa remains high despite programmatic efforts to improve maternal health. In 2007, the Zambian Ministry of Health mandated facility-based maternal death review (MDR) programs in line with World Health Organization recommendations. We assessed the impact of an MDR program at a district-level hospital in rural Zambia.MethodsWe conducted a mixed methods convergent study using hospital data on maternal mortality and audit reports of 106 maternal deaths from 2007 to 2011. To evaluate the overall impact of MDR on maternal mortality, we compared baseline (2007) to late (2010–11) post-intervention inpatient maternal mortality indicators. MDR committee reports were coded and dominant themes were extracted in a qualitative analysis. We assessed potential risk factors for maternal mortality in a before-and-after design comparing the periods 2008–09 and 2010–11.ResultsIn-hospital maternal mortality declined from 23 per thousand live births in 2007 to 8 per thousand in 2010–11 (P < 0.01). Maternal case fatality for puerperal sepsis and uterine rupture decreased significantly from 63 and 32% in 2007 to 10 and 9% in 2010–11 (P < 0.01). No significant reduction was seen in case fatality due to postpartum hemorrhage. Qualitative analysis of risk factors for maternal mortality revealed four core themes: standards of practice, health systems, accessibility, and patient factors. Specific risk factors included delayed referral, missed diagnoses, intra-hospital delays in care, low medication inventory, and medical error. We found no statistically significant differences in the prevalence of risk factors between the before-and-after periods.ConclusionsImplementation of MDR was accompanied by a significant decrease in maternal mortality with reductions in maternal death from puerperal sepsis and uterine rupture, but not postpartum hemorrhage. Qualitative analysis of audit reports identified several modifiable risk factors within four core areas. Comparisons of potential explanatory factors did not show any differences over time. These results imply that MDR offers a means for hospitals to curtail maternal deaths, except deaths due to postpartum hemorrhage, suggesting additional interventions are needed. Documentation of MDR meetings provides an instrument to guide further quality improvements.

Quality Assessment of Maternal Death Review: A Pilot Study in 10 High Priority Districts of Odisha State, India.

Background:Maternal death review (MDR) is a strategy that helps in identifying gaps in the care of a pregnant mother.Objectives:The objective is to assess the quality of MDR, causes of maternal mortality, and finding corrective action in 10 high-priority districts of Odisha.Materials and Methods:MDR was undertaken by our team in 4-month timeline (August to November 2014). It included the development of tools, desk reviews, training of staffs, and data handling. The maternal deaths were estimated from the Annual Health Survey. It was compared to estimated maternal death of each district to get the under reporting/over reporting districts. A report was generated on MDR process indicators and program indicators after completion of the assessment.Results:Only 129 (52%) of the 247 deaths found suitable for community-based MDR. The proportion of maternal death reported versus estimated was 247 versus 367. Correct diagnoses were reported in 120 cases. The classification of deaths was not mentioned in 74 cases. Maximum deaths (55%) were in 18–25 years of age group (the most common cause being anemia). Majority (50%) of the deaths occurred during the postnatal period and majority (67%) at the health facility. Only 61 (47%) had received antenatal check-ups. Facility-based MDR showed, Type 1 delay (denotes about seeking care) being the most common (53%). Inaccurate and incomplete information available was also found to compound the above problems in addition.Conclusions:The present study could contribute to a larger extent to address some of the gaps in the MDR process in the Odisha state.

Maternal death reviews: A retrospective case series of 90 hospital-based maternal deaths in 11 hospitals in Indonesia.

To determine the factors contributing to hospital-based maternal deaths in Indonesia, given most women deliver with skilled birth attendants and in health facilities. A retrospective review of case records examined quality of care issues related to maternal mortality in hospital settings. The review abstracted information from blinded medical records of 90 women who died in 11 hospitals from January to June 2014. Specialists from the Indonesian Society of Obstetrics and Gynecology reviewed abstracted records to determine causes of death and identify contextual factors for these deaths. Seventy-five of the 90 maternal deaths (83%) reviewed were due to direct obstetric causes. Severe pre-eclampsia and eclampsia combined were the leading direct cause of death (42%). Human resource/health worker factors were more frequently identified than supply, facility, or infrastructure factors. Ninety percent of maternal deaths were classified as preventable. The review exercise yielded useful information on factors contributing to preventable maternal mortality in hospitals in Indonesia. Results helped focus quality improvement efforts and increased awareness of the value of routine, in-depth facility-based maternal death reviews.

Analyzing the etiology behind mortality associated with antepartum, intrapartum, and post-partum cases in a tertiary care teaching hospital of West Bengal

Objective:The study was undertaken to understand the causes and circumstances of maternal deaths in West Bengal.Material and Methods:One hundred ten maternal deaths were reported during the period December 2010 through June 2012 in the Maternity Ward of Medical College and Hospitals, West Bengal. These deaths were reviewed using a facility-based Maternal Death Review protocol. The number and percentages were calculated and binary logistic regression analysis was performed.Results:The majority of the deaths occurred in the 20-24 years’ age group, those with Hindu religion, in the first and second gravida, and the postpartum period. One third of mothers had cesarean sections. The majority (78.2%) of deaths were among referred cases. Eclampsia was the leading cause of maternal death (29.1%). Approximately half of the deceased women sought care after 10 hours of developing complications. More than one-third of maternal deaths were registered with type 1 delays.Conclusion:Our study demonstrates that maternal deaths occurred among young women, referred cases, with cesarean sections and type 1 delays. We recommend that imparting basic skills and improving awareness to the community about the danger signs of pregnancy could be an effective measure to detect maternal complications at an earlier stage.

Effective non-drug interventions for improving outcomes andquality of maternal health carein sub-Saharan Africa: a systematic review.

BackgroundMany interventions have been implemented to improve maternal health outcomes in sub-Saharan Africa (SSA). Currently, however, systematic information on the effectiveness of these interventions remains scarce. We conducted a systematic review of published evidence on non-drug interventions that reported effectiveness in improving outcomes and quality of care in maternal health in SSA.MethodsAfrican Journals Online, Bioline, MEDLINE, Ovid, Science Direct, and Scopus databases were searched for studies published in English between 2000 and 2015 and reporting on the effectiveness of interventions to improve quality and outcomes of maternal health care in SSA. Articles focusing on interventions that involved drug treatments, medications, or therapies were excluded. We present a narrative synthesis of the reported impact of these interventions on maternal morbidity and mortality outcomes as well as on other dimensions of the quality of maternal health care (as defined by the Institute of Medicine 2001 to comprise safety, effectiveness, efficiency, timeliness, patient centeredness, and equitability).ResultsSeventy-three studies were included in this review. Non-drug interventions that directly or indirectly improved quality of maternal health and morbidity and mortality outcomes in SSA assumed a variety of forms including mobile and electronic health, financial incentives on the demand and supply side, facility-based clinical audits and maternal death reviews, health systems strengthening interventions, community mobilization and/or peer-based programs, home-based visits, counseling and health educational and promotional programs conducted by health care providers, transportation and/or communication and referrals for emergency obstetric care, prevention of mother-to-child transmission of HIV, and task shifting interventions. There was a preponderance of single facility and community-based studies whose effectiveness was difficult to assess.ConclusionsMany non-drug interventions have been implemented to improve maternal health care in SSA. These interventions have largely been health facility and/or community based. While the evidence on the effectiveness of interventions to improve maternal health is varied, study findings underscore the importance of implementing comprehensive interventions that strengthen different components of the health care systems, both in the community and at the health facilities, coupled with a supportive policy environment.Systematic review registrationPROSPERO CRD42015023750Electronic supplementary materialThe online version of this article (doi:10.1186/s13643-016-0305-6) contains supplementary material, which is available to authorized users.

Evaluating the Quality of Recommendations From Maternal Death Reviews—Fort Portal, Uganda [13R

INTRODUCTION: Facility-based Maternal Death Reviews (MDRs) aim to identify contributors to maternal deaths, generate recommendations to prevent future deaths, and implement and follow-up those recommendations. Globally, MDR committees' recommendations lack clearly-defined achievable and measureable actions, and an internationally-recognized standard framework for evaluating recommendations does not exist. METHODS: We developed a scoring framework for MDR recommendations based on International Federation of Gynecology and Obstetrics recommendation structuring guidelines. We piloted the framework to evaluate the quality of 2014 MDR recommendations generated by three facility-based MDR committees in Fort Portal, Uganda. We developed a composite score for grading quality of recommendations (0–6) composed of: specificity (0-vague, 1-clear, 2-explicit), relevance to a committee identified “avoidable factor” (0-no, 1-yes), presence of implementation method (0-no, 1-yes), individual responsibility for implementation (0-no, 1-yes), and timeline (0-no, 1-yes). Two scorers coded recommendations independently and reviewed differences to reach consensus. RESULTS: Committees generated 83 recommendations during 42 MDRs; 61% prescribed facility-based changes. The mean composite score was poor (1.8, range 0–5). Recommendation specificity was “vague” in 20% of recommendations, “clear” in 58%, and “explicit” in 22%. Half (51%) of recommendations were relevant, although 81% of recommendations lacked a method of implementation, and 88% had no implementer assigned. All recommendations lacked a timeline. CONCLUSION: A framework for evaluating the quality of MDR recommendations was developed and identified specific areas for improvement. Clearly defining method, implementer and timeline, and improving recommendations' specificity and relevance should lead to better implementation which will help to reduce maternal mortality.

An analytical study of maternal death at tertiary care hospital

Background: Maternal mortality is one of the important public health challenges faced by India today. Being a country with highest number of maternal deaths worldwide, i.e. 63, 000 per year and having a Maternal Mortality Ratio of 230/1,00,000 live births, it is a matter of grave concern and high priority. Objective: To study the MMR and common causes leading to death, so that improving maternal health and reducing maternal mortality rate significantly. Methods: We have done Retrospective Observational study in Department of Obstetrics & Gynecology, P.D.U. Medical College, Rajkot between 1st August 2012 to 31st July 2014. Results: There were 30 Maternal Deaths during Study Period of 2 years in the Institute. Maternal Mortality Ratio of the Study Centre was 219 per lakhs live births. Out of 30 maternal deaths 21-30 yrs age group having 77% of maternal death while 67% belongs to lower socio-economical class. Out of 30, 15 (50%) died within 24 hrs of delivery. Hemorrhage was the most common cause in 15(50%) cases while others were Eclampsia (13%), septicemia (11%), ARDS (13%), others (13%). Conclusions: Maternal Mortality Ratio of the Study Centre was 219 per lakhs live births. Hemorrhage was the most common cause. Early registration, regular antenatal care, early referral are key things in reduction of maternal deaths. Facility based maternal death review (FBMDR) should be done at every institute level to find out the deficit and thus helping in reduction of maternal deaths.

Achievements and lessons learnt from facility-based maternal death reviews in Cameroon.

Achievements and lessons learnt from facility-based maternal death reviews in Cameroon.

Setting up facility-based maternal death reviews in Nigeria.

Setting up facility-based maternal death reviews in Nigeria.

Experiences with facility-based maternal death reviews in northern Nigeria

ObjectiveTo evaluate the effectiveness of the maternal death review (MDR) system and process in improving quality of maternal and newborn health care in northern Nigeria. MethodsA combination of quantitative and qualitative methods was used, including review of MDR forms and of health management information system data on maternal deaths (MDs), as well as semi-structured interviews with members of 11 MDR committees. ResultsFacility-based MDRs were initiated in 75 emergency obstetric and newborn care facilities in northern Nigeria and were initially conducted in the 33 hospitals; however, the process stopped after some time and had to be revitalized. Main reasons were transfer of key members of MDR committees, lack of supportive supervision, and shortage of staff. Ninety-three (12.1%) of 768 identified MDs were recorded on MDR forms and 52 (6.7%) had been reviewed. MDRs resulted in improved quality of care, including mobilization of additional resources. Challenges were fear of blame, shortage of staff, transfer of MDR team members, inadequate supportive supervision, and poor record keeping. ConclusionMDR requires teamwork, commitment, and champions at health facility level to spearhead the process. MDR needs to be institutionalized in the Ministry of Health, which provides oversight, policy guidance, and support, including supportive supervision.

Obstetric competence among referral healthcare providers in Mali

ObjectiveTo determine the factors associated with obstetric competency and clinical practice among obstetric care providers in referral health centers in Mali. MethodsThe present cross-sectional study was conducted between March and May 2012 among 140 obstetric care providers (obstetric nurses, midwives, and physicians) working in referral health centers in Mali. Emergency obstetric care knowledge and skills were evaluated with clinical vignettes developed using national Malian guidelines. The vignettes covered 5 areas of emergency obstetric care, and the results were used to generate a competency score. A backward stepwise random-effects model using a maximum likelihood estimator was applied to evaluate variables independently associated with competency score. ResultsOut of 100, the mean±SD score was 57.8±11.2 for obstetric nurses, 66.4±14.7 for midwifes, and 78.6±13.4 for physicians (P<0.001). Three variables were significantly associated with a higher competency score: professional qualification, working in an urban setting, and working in a health center with a smaller number of obstetric care providers. ConclusionIncreasing the in-service training of both rural staff and lower-level healthcare workers working in larger health centers via facility-based maternal death reviews might help to improve clinical practice and maternal health outcomes.

Easier said than done!: methodological challenges with conducting maternal death review research in Malawi

BackgroundMaternal death auditing is widely used to ascertain in-depth information on the clinical, social, cultural, and other contributing factors that result in a maternal death. As the 2015 deadline for Millennium Development Goal 5 of reducing maternal mortality by three quarters between 1990 and 2015 draws near, this information becomes even more critical for informing intensified maternal mortality reduction strategies. Studies using maternal death audit methodologies are widely available, but few discuss the challenges in their implementation. The purpose of this paper is to discuss the methodological issues that arose while conducting maternal death review research in Lilongwe, Malawi.MethodsCritical reflections were based on a recently conducted maternal mortality study in Lilongwe, Malawi in which a facility-based maternal death review approach was used. The five-step maternal mortality surveillance cycle provided the framework for discussion. The steps included: 1) identification of cases, 2) data collection, 3) data analysis, 4) recommendations, and 5) evaluation.ResultsChallenges experienced were related to the first three steps of the surveillance cycle. They included: 1) identification of cases: conflicting maternal death numbers, and missing medical charts, 2) data collection: poor record keeping, poor quality of documentation, difficulties in identifying and locating appropriate healthcare workers for interviews, the potential introduction of bias through the use of an interpreter, and difficulties with locating family and community members and recall bias; and 3) data analysis: determining the causes of death and clinical diagnoses.ConclusionConducting facility-based maternal death reviews for the purpose of research has several challenges. This paper illustrated that performing such an activity, particularly the data collection phase, was not as easy as conveyed in international guidelines and in published studies. However, these challenges are not insurmountable. If they are anticipated and proper steps are taken in advance, they can be avoided or their effects minimized.

Facility‐based review of 296 maternal deaths at a tertiary centre in India: Could they be prevented?

The aim of this study was to identify causes of maternal mortality at the facility and to assess the standard of care, deficiencies in health services and preventability of these deaths using facility-based maternal death reviews. This was a prospective study at a tertiary care hospital that included all women who died during pregnancy or within 42 days of being pregnant during 2005-2010. A review of 296 maternal deaths revealed that 59% of these occurred in medical wards. Indirect maternal deaths (54%) outnumbered the direct deaths (46%). Main causes were hepatitis (18%), hemorrhage (10%) and puerperal sepsis (10%). Only 5% of the women had received antenatal care at the facility. One-third (34%) were referred from other centers. The majority (74%) were critically sick at admission. Most of the women (62%) died postpartum. Substandard care and deficient health services were identified in 8% and 20% of the cases, respectively. Sixteen (5%) maternal deaths were deemed preventable and another 36 (12%) possibly preventable. Since most of the preventable deaths (12/16) were due to hemorrhage, measures to control postpartum hemorrhage were promoted at the facility. Findings of the maternal death reviews were regularly conveyed to the State Health Department for prioritization and resource allocation to prevent maternal mortality. More maternal deaths occurred in the medical than in the obstetrics wards at the facility. The leading causes were hepatitis, hemorrhage and puerperal sepsis. Most of the deaths were non-preventable as the women were critically sick at admission; however, substandard care and health service deficiency were contributory in some of the cases.

HIV-AIDS related maternal mortality in Benin city, Nigeria

To determine the causes and characteristics of maternal deaths in HIV-infected women. A retrospective study of maternal deaths in a cohort of HIV-infected women. A facility-based maternal death review using case records and mortality summaries. Thirty seven maternal deaths which occurred in HIV-infected women were reviewed in a university teaching hospital in southern Nigeria over a 4-year period. Causes and circumstances surrounding each maternal death were identified. One in every four maternal deaths occur in women with HIV infection. Majority (64.9%) of the women presented in advanced stage (WHO stage III/IV) of HIV syndrome while 86.5% had missed opportunities for antiretroviral programme. Pregnancy-related sepsis was the commonest cause of maternal death. Other common causes were death from tuberculosis and pneumonia. HIV-related maternal death is emerging as a leading cause of pregnancy related death in Nigeria. There is need to scale-up preconception care and ensure comprehensive and sustainable prevention of mother -to-child transmission service for all pregnant women throughout Nigeria to reduce the burden of HIV/AIDS infection and minimize avoidable deaths from opportunistic infections.

Improving obstetric care in low-resource settings: implementation of facility-based maternal death reviews in five pilot hospitals in Senegal

BackgroundIn sub-Saharan Africa, maternal and perinatal mortality and morbidity are major problems. Service availability and quality of care in health facilities are heterogeneous and most often inadequate. In resource-poor settings, the facility-based maternal death review or audit is one of the most promising strategies to improve health service performance. We aim to explore and describe health workers' perceptions of facility-based maternal death reviews and to identify barriers to and facilitators of the implementation of this approach in pilot health facilities of Senegal.MethodsThis study was conducted in five reference hospitals in Senegal with different characteristics. Data were collected from focus group discussions, participant observations of audit meetings, audit documents and interviews with the staff of the maternity unit. Data were analysed by means of both quantitative and qualitative approaches.ResultsHealth professionals and service administrators were receptive and adhered relatively well to the process and the results of the audits, although some considered the situation destabilizing or even threatening. The main barriers to the implementation of maternal deaths reviews were: (1) bad quality of information in medical files; (2) non-participation of the head of department in the audit meetings; (3) lack of feedback to the staff who did not attend the audit meetings. The main facilitators were: (1) high level of professional qualifications or experience of the data collector; (2) involvement of the head of the maternity unit, acting as a moderator during the audit meetings; (3) participation of managers in the audit session to plan appropriate and realistic actions to prevent other maternal deaths.ConclusionThe identification of the barriers to and the facilitators of the implementation of maternal death reviews is an essential step for the future adaptation of this method in countries with few resources. We recommend for future implementation of this method a prior enhancement of the perinatal information system and initial training of the members of the audit committee – particularly the data collector and the head of the maternity unit. Local leadership is essential to promote, initiate and monitor the audit process in the health facilities.

Maternal death review in Africa

Objective WHO, UNICEF, and UNFPA with other development partners have supported African Ministries of Health to institutionalize maternal death review (MDR) since 2003. To evaluate the program, its status, lessons learned, and the challenges to success were reviewed in 2007. Methods A standard self-administered questionnaire was sent to Ministries of Health in 46 Sub-Saharan African countries in May 2007. Completed questionnaires were returned by e-mail, processed, and analyzed. Results Thirty countries completed the survey questionnaire. Maternal death is a notifiable condition in 21 (67%) counties. A national committee has been set up to plan, coordinate, and implement MDR activities in 7 countries. Fifteen countries stated that facility-based MDR is the main method selected for conducting reviews of the causes of maternal death. Fourteen (47%) countries reported that national MDR guidelines had been developed and 12 (40%) had implemented the guidelines. Fifteen (50%) countries reported that maternal deaths were reviewed and analyzed. Only 7 countries reported that the government had allocated a budget for MDR. Implementation of MDR has led to local policy changes and improvement in quality of maternal health services in several countries. Ten of the 15 countries in which analysis has been conducted reported that recommendations have been implemented at least at the health facility level. Conclusion Although use of MDR is increasing in African countries, effective coverage is still low. The institutionalization of MDR requires political commitment, legal and administrative back-up, financial support, capacity development, simplified reporting forms and procedures, coordinated support of development partners, involvement of professional bodies, and regular supportive follow-up.

Facility-Based Maternal Death Review In Three Districts In The Central Region of Malawi: An Analysis of Causes and Characteristics of Maternal Deaths

We sought to determine the causes and characteristics maternal deaths that occur in health facilities in Malawi. Forty-three maternal deaths were reviewed in 9 hospitals in 3 districts in Central Malawi over a 1-year period. Causes and avoidable factors of maternal deaths were identified during the review, and recommendations made and implemented. There were 28 (65.1%) direct obstetric deaths and 15 (34.9%) indirect obstetric deaths. The major causes of maternal deaths were postpartum hemorrhage (25.6%), postpartum sepsis (16.3%), HIV/AIDS (16.3%), ruptured uterus (7.0%), complications of abortion (7.0%), anemia (7.0%), antepartum hemorrhage (4.7), and eclampsia (4.7). Two thirds of the women were referred either from another health facility (51.2%) or by a traditional birth attendant (TBA; 11.6%), and up to 79.1% were critically ill on admission. Four groups of factors that contributed to maternal deaths were identified: 1) health worker factors, 2) administrative factors, 3) patient/family factors, and 4) TBA factors. The major health worker factors were inadequate resuscitation (69.8%), lack of obstetric life-saving skills (60.5%), inadequate monitoring (55.8%), initial assessment incomplete (46.5%), and delay in starting treatment (46.5%). The most common administrative factor was lack of blood for transfusion (20.9%). The major problems encountered include shortage of staff and other resources, difficulty in maintaining anonymity, poor quality of data, and difficulty in implementing recommendations. Adequate training on obstetric life-saving skills, addressing HIV/AIDS, and raising community awareness could be important factors for reducing maternal mortality in Malawi and countries with similar socioeconomic profiles.