Table 2 Summary of the 42 avoidable factors, listed by category and in descending order of attributable deaths

Substandard health worker practice

Patient delay

Poor blood transfusion capacity or inappropriate administration

Unidentified lack or delay in transport

Delay in care on admission to birth facility

Poor antenatal care

Medication shortage

Poor transport between facilities

Delayed operative delivery

Use of herbal medicine

General supply/ equipment shortage

Poor transportation from home to facility

Inadequate intrapartum monitoring of mother/fetus

Cultural inhibitions causing delay in seeking care

Unsanitary environment

Inadequate initial maternal assessment and management

Financial constraints

Inadequate operating theatre facilities

Unavailability of health worker for key intervention

No knowledge of danger symptoms

Poor communication between health workers

Missed or unskilled breech delivery

Substandard health worker antenatal care practices

Inadequate monitoring of mothers in hypovolemic or septic shock

Poor neonatal resuscitation

Inadequate management of hypertensive related disorders

Failure to diagnose/ treat neonatal infection

Failure to diagnose preterm labor

Failure to diagnose/ treat syphilis

Health worker related referral delay

Inadequate management of 3^rd stage of labor

Poor postpartum maternal monitoring

Inappropriate indication for operative delivery

Inadequate partogram usage

Failure to diagnose/treat maternal/fetal infection

Anesthesia complications during operative delivery

Inadequate response to poor labor progress

Inadequate action taken for fetal distress

Inadequate assessment of fetal distress

Inadequate assisted vaginal delivery

Inappropriate discharge when patient not well

Health worker industrial strike