Table 3 Data analytic framework

Non-informative audit tool provides unreliable data for review

Inadequate instrument

Irrelevant information

Irrelevant information from maternal death instruments

Inadequate forms

Inadequate and/or reliable maternal audit forms

Incomplete instruments

Instruments cannot provide all the necessary information surrounding maternal death

Supporting informative data

The need for supporting data

The reviewers urged supporting data

Collecting additional document

Collecting data staff providing additional documents in maternal care

Inaccurate information

Inaccuracy

Out of sync information in referral case

Reviewers distrust the data provided by the hospital

Unreliable data

Accuracy of maternal death data

Data falsification

Unstandardized clinical indicators and the practice of “sharp downward, blunt upward”

The ignorance of the reviewer to use clinical standards to identify the gap

Clinical experience

Review based on clinical experience only

“Medicine is an art “perspective

Review based on the belief that medicine is an art

Personal perception

Review based on the personal perceptions

Tendency to associate the problem in the lower-level health facility

Reluctant to review the case involved senior colleagues

“Sharp downward, blunt upward”

Personal initiative to use clinical standards for an objective review

An objective review

The external reviewers are more objective

A personal initiative by an external reviewer to use clinical guideline

An initiative of the external reviewer to use the national clinical guideline to identify the problem

Unaccountable hospital support and lack of leadership commitment

Lack of commitment to the implementation of the role of audit

Inadequate support of the management team to the role of audit

Failure to comply with the terms of agreement of MDA

DHO needs an advocacy process involved the external review

Failure to comply with proactivity in providing information

Failure to provide information of maternal death

Challenging communication to obtain data from hospital

Difficulty of DHO to implement the recommendation to the hospital

Lack of recognizance to DHO authority

Hospital decision-makers disrespect to the DHO team

Poor awareness of DHO of their authority over the hospitals

Lack of commitment to attend and understanding the audit feedback

Poor attendance of hospital decision-makers to audit meeting

Absence of adapted practice based on recommendation

Adherence

Collaboration to implement recommendation

Challenges in the implementation

Adherence of higher-level health facilities

Recommendation to hospital

Blaming culture, minimal training, and insufficient MDA committee’ skills

Failure to internalize the principles of audit

‘Blaming culture’, leading to the reduction of a set of review processes into merely a ‘disciplinary process’

Punitive actions by reviewers in terms of revealing personal and institutional information to the public

Lack of knowledge to program an MDA

Insufficient training of audit committee

Incompatible education background

Lack of training

Frequent staff rotation

Failed to translate recommendation into policy

Lack of specificity of recommendation

Absence of cross-sectoral partnership between stakeholders

Poor budgeting allocation