title: Persistence of Hemorrhage and Hypertensive Disorders of Pregnancy (HDP) as the Main Causes of Maternal Mortality: Emergence of Medical Errors in Iranian Healthcare System.
abstract: BACKGROUND
  This study aimed to assess factors affecting substandard care and probable medical errors associated with obstetric hemorrhage and HDP at a Northwestern Iranian health care system.
  
  
  METHODS
  In a community-based descriptive cross-sectional study, data on all maternal deaths occurred at West Azerbaijan Province, Iran during a period of 10 years from March 21, 2002 to March 20, 2011 was analyzed. The principal cause of death, main contributory factors, nature of care, main responsible staff for sub-standard care and medical error were determined. The data on maternal deaths was obtained from the national Maternal Mortality Surveillance System (MMSS) which were covered all maternal deaths. The "Three delays model" was used to recognize contributing factors of maternal deaths due to obstetric hemorrhage and HDP.
  
  
  RESULTS
  There were 183 maternal deaths, therefore the Mean Maternal Mortality Ratio (MMR) in the province was 32.8 per 100 000 live births (95% CI, 32.64-32.88). The most common causes of maternal deaths were obstetric hemorrhage in 36.6% of cases and HDP in 25.7%. The factors that most contributed to the deaths were all types of medical errors and substandard care with different proportions in management of obstetric hemorrhage and HDP.
  
  
  CONCLUSIONS
  A substandard care and medical error was the major contributing factor in both obstetric hemorrhage and HDP leading to maternal mortality, therefore, it is necessary to improve the quality of health care at all levels especially hospitals.
authors.affiliation: 1. Reproductive Health Research Center, School of Public Health, Urmia University of Medical Sciences , Urmia, Iran.
authors.forename: Hamidreza
authors.initials: H
authors.lastname: Farrokh-Eslamlou
authors.affiliation: 2. Social Determinants of Health Research Center, School of Public Health, Urmia University of Medical Sciences , Urmia, Iran.
authors.forename: Siamak
authors.initials: S
authors.lastname: Aghlmand
authors.affiliation: 1. Reproductive Health Research Center, School of Public Health, Urmia University of Medical Sciences , Urmia, Iran.
authors.forename: Sima
authors.initials: S
authors.lastname: Oshnouei
keywords: Iran; Maternal mortality; Medical error; Substandard care