The maternal mortality review meeting: experiences from Kalabo District Hospital, Zambia.
We report on our experiences with a maternal mortality review meeting in Kalabo District Hospital between 1999 and 2001. Patient files and minutes of the maternal mortality review meetings of 15 cases of maternal death were reviewed. Causes of death, classification, substandard care factors, recommendations and implementation were analysed. In nine cases of maternal death 20 different substandard care factors were found; 12 caused by organizational weaknesses, eight by substandard clinical care. In nine cases, recommendations were formulated, which were completely implemented in five and partially implemented in two cases. A maternal mortality review meeting can be an important tool for improving essential obstetric services in a district hospital. It can easily and directly correct some substandard care factors, has a high educational value for staff and leads to a better understanding of maternal mortality for everyone involved.
Stekelenburg
Jelle
J
Leeuwarden Medical Centre, Department of Obstetrics & Gynaecology, The Netherlands. jelle.stekelenburg@wanadoo.nl
van Roosmalen
Jos
J
D000293:Adolescent; D000328:Adult; D002423:Cause of Death; D005260:Female; D006302:Health Services Research; D006744:Hospital Bed Capacity, 100 to 299; D017052:Hospital Mortality; D006767:Hospitals, District; D006780:Hospitals, Rural; D006801:Humans; D008428:Maternal Mortality; D008485:Medical Audit; D008505:Medical Staff, Hospital / Q000193:education; D020380:Needs Assessment; D009775:Obstetrics and Gynecology Department, Hospital / Q000592:standards*; D010342:Patient Acceptance of Health Care / Q000706:statistics & numerical data; D018024:Peer Review, Health Care; D011247:Pregnancy; D011367:Professional Staff Committees; D012017:Referral and Consultation; D015024:Zambia / Q000453:epidemiology