Table 2 Documented clinical and non-clinical modifiable factors identified in 12 maternal deaths and 19 near-miss cases

Maternal deaths (N = 85)

Near-miss

(N = 66)

n (%)

n (%)

Delay in decision to seek care

2 (2.4)

3 (4.5)

 Late antenatal care

0

2

 Delay in deciding to seek appropriate medical help

2

1

Delay in reaching the GLOSS facility^a

5 (5.9)

1 (1.5)

 Delay in referral to a higher-level facility

5

1

Delay in receiving care

71 (83.4)

55 (83.3)

 Prior to arrival to the level 3 facility

6 (7.0)

8 (12.1)

  Delivered by a traditional birth attendant

1

3

  Inadequate management of preexisting conditions

2

3

  Missing referral information

3

2

 Clinical and laboratory examinations

20 (23.5)

17 (25.8)

  Inadequate clinical examination at admission

3

2

  Inadequate monitoring after admission

5

2

  Missing or delayed microbiological culture^b

7

7

  Missing or delayed other laboratory & diagnostics

5

6

 Diagnosis

13 (15.3)

12 (18.2)

  Incorrect working diagnosis during case management

6

2

  Incomplete main diagnosis

3

0

  Delayed diagnosis

0

1

  Criteria for diagnosis not met

4

4

  Source of infection not identified

0

2

  Near-miss criteria (based on WHO definition) not met^c

0

3

  Missing diagnosis

0

0

 Management

32 (37.6)

18 (27.3)

  Incomplete clinical management of infection^d

2

1

  Suboptimal use of antibiotics^e

9

6

  Delay or overuse of other medications^f

5

6

  Insufficient intravenous fluid

2

0

  Insufficient blood transfusion

2

0

  Delayed ICU/HDU admission^g

6

3

  Delayed control of the source of infection

3

1

  Missing or delayed interventions^h

3

1

Other clinical factors

1 (1.2)

4 (6.1)

 Antimicrobial resistance

1

1

 Unexplained prolonged hospitalizationⁱ

0

3

Non-clinical factors

6 (7.1)

3 (4.5)

 Incomplete multidisciplinary team^j

3

2

 Delayed mobilization of the managing team

1

0

 Restrictive abortion policies and legislation

1

0

 Stigma of preexisting condition as a potential care barrier

0

1

 Discharge against medical advice

1