Investigation of the causes of maternal mortality using root cause analysis (RCA) in Isfahan-Iran in 2013-2014

Beigi, M.; Bahreini, S.; Valiani, M.; Rahimi, M.; Danesh Shahraki, A.
June 2014
Iranian Journal of Reproductive Medicine;Jun2014 Supplement, Vol. 12, p46
Academic Journal
Introduction: Many maternal deaths are due to preventable causes during pregnancy and childbirth. Therefore, the detailed analysis of the root causes, was provides develop a plan and appropriate interventions to prevent these deaths occurring in the health system. This study aims to determine the causes of maternal mortality using by "RCA" method. Materials and Methods: This research is a descriptive study of a case series. The data and information required in the case collected from; and file maternal health center, interviews with relevant personnel. The causes of maternal mortality and related reasons were determined by team expert's opinions and standard check list's root analysis. Results: Reasons of research were classified in human factors, structural factors in the area of planning and management and social status of mothers. The results show that human factors were consist of; lack of knowledge and skills in the medical team, personnel not familiar with their duties, lack of care or advice based on health protocols, non-compliance with referral system and abstinence of using procedures and policies. Structural factors in the area of planning and management including were; shortage of specialized personnel, lack of follow-up care after discharge, inadequate supervision of inspectors on academic qualified doctors, or how to visit of the patients by doctors. Maternal social and family status, affected on mother admitted to the health center for care work. Conclusion: Based on the root cause analysis process, the most fundamental factor in creating these deaths was management errors in level universities and the Ministry of Health.


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