I was interested to see this paper from Rwanda. What such analyses don’t tell us is *why* deaths occurred. We need a better understanding of what some commentators have called the ‘road to death’. This road typically starts from an environment of disadvantage, predisposing to illness, and then continuing through a sequence of decisions, actions and events, often including inappropriate treatments and/or delays in seeking care. These decisions, actions and events continue during the hospital stay and determine whether the mother (and her baby) will live or die.

Maternal death audit in Rwanda 2009-2013: a nationwide facility-based retrospective cohort study

BMJ Open 2016;6:e009734 doi:10.1136/bmjopen-2015-009734



Objective Presenting the results of 5 years of implementing health facility-based maternal death audits in Rwanda, showing maternal death classification, identification of substandard (care) factors that have contributed to death, and conclusive recommendations for quality improvements in maternal and obstetric care.

Design Nationwide facility-based retrospective cohort study.

Settings All cases of maternal death audited by district hospital-based audit teams between January 2009 and December 2013 were reviewed. Maternal deaths that were not subjected to a local audit are not part of the cohort.

Population 987 audited cases of maternal death.

Main outcome measures Characteristics of deceased women, timing of onset of complications, place of death, parity, gravida, antenatal clinic attendance, reported cause of death, service factors and individual factors identified by committees as having contributed to death, and recommendations made by audit teams.

Results 987 cases were audited, representing 93.1% of all maternal deaths reported through the national health management information system over the 5-year period. Almost 3 quarters of the deaths (71.6%) occurred at district hospitals. In 44.9% of these cases, death occurred in the post-partum period. Seventy per cent were due to direct causes, with post-partum haemorrhage as the leading cause (22.7%), followed by obstructed labour (12.3%). Indirect causes accounted for 25.7% of maternal deaths, with malaria as the leading cause (7.5%). Health system failures were identified as the main responsible factor for the majority of cases (61.0%); in 30.3% of the cases, the main factor was patient or community related.

Conclusions The facility-based maternal death audit approach has helped hospital teams to identify direct and indirect causes of death, and their contributing factors, and to make recommendations for actions that would reduce the risk of reoccurrence. Rwanda can complement maternal death audits with other strategies, in particular confidential enquiries and near-miss audits, so as to inform corrective measures.

Best wishes, Neil

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