Table 3 Top 10 audit-identified avoidable factors in maternal and perinatal deaths
Factor | Category | Datasets in which factor was an identified cause of death; n = 44 (%) | Estimate of the factor’s contribution to deaths in datasets in which it was identified; % (CI) | Total number of attributable deaths due to factor in the entire sample; n = 6205 (%) |
|---|---|---|---|---|
Substandard health worker practice | Health worker-oriented factor | 18 (40.9) | 28.5 (19.5 – 39.7) | 688 (11.1) |
Patient delay | Patient-oriented factor | 23 (52.3) | 22.2 (16.0 – 30.0) | 665 (10.7) |
Poor blood transfusion capacity or inappropriate administration | Administrative/ supply factor | 21 (47.7) | 24.9 (18.5 – 32.6) | 634 (10.2) |
Delay in care on admission to birth facility | Health worker-oriented factor | 20 (45.5) | 26.6 (18.5 – 36.6) | 628 (10.1) |
Undefined lack of or delay in transport | Transport/ referral factor | 23 (52.3) | 23.7 (16.2 – 33.4) | 546 (8.8) |
Delayed operative delivery | Health worker-oriented factor | 12 (27.3) | 23.1 (11.0 – 42.1) | 442 (7.1) |
Inadequate intrapartum monitoring of mother/fetus | Health worker-oriented factor | 10 (22.7) | 24.3 (13.8 – 39.1) | 374 (6) |
Inadequate initial maternal assessment/ management | Health worker-oriented factor | 10 (22.7) | 20.0 (10.5 – 34.7) | 339 (5.5) |
Poor antenatal care | Patient-oriented factor | 11 (25.0) | 14.3 (7.0 – 27.0) | 301 (4.9) |
Unavailability of health worker for key intervention | Health worker-oriented factor | 10 (22.7) | 22.4 (10.6 – 41.2) | 251 (4) |