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Table 4 Contributory factors for each cause of maternal death

From: A root-cause analysis of maternal deaths in Botswana: towards developing a culture of patient safety and quality improvement

Cause of maternal death

No of cases (N = 55)

Total no. of contributory factors present for that cause of death*

Potentially avoidable deaths

Total Direct deaths (42%)

23

22

14

Hypertension (Eclampsia)

5

16

3

Haemorrhage

10

17

 

 APH

1

9

0

 Vagina/cervix trauma

2

11

2

 Bleeding during or after C-section

2

11

1

 Ectopic haemorrhage

1

8

1

 Non-traumatic haemorrhage

2

8

0

 Uterine trauma

2

8

2

Pregnancy related sepsis

3

9

 

 Chorioamnionitis

1

7

Unknown

 Puerperal sepsis after NVD

1

4

1

 Septic miscarriage

1

1

0

General anaesthetic

2

6

2

Pulmonary embolus

2

8

2

Acute collapse

1

1

0

 Death at home – cause unknown

1

1

0

Total Indirect deaths (58%)

32

24

12

HIV

19

21

7

 Pneumonia

3

12

2

 TB

2

11

0

 Meningitis

3

14

0

 GI tract

3

13

3

 Complications of ARVs (including one with IRIS**)

4

15

2

 Other (multiple organ systems)

4

9

0

Medical –Surgical

13

20

5

 Cardiac

7

17

1

 Endocrine/metabolic

3

12

3

 Other adverse effects of treatment

3

5

1

  1. **IRIS immune reconstitution inflammatory syndrome.
  2. *Each contributory factor is only counted once for each group so the number of factors for each category is not the sum of the individual cases.