title: Maternal death audit in Rwanda 2009-2013: a nationwide facility-based retrospective cohort study.
abstract: 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.
  
  
  METHODS
  Nationwide facility-based retrospective cohort study.
  
  
  METHODS
  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.
  
  
  METHODS
  987 audited cases of maternal death.
  
  
  METHODS
  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.
authors.affiliation: Maternal, Child and Community Health Division, Rwanda Ministry of Health, Rwanda Biomedical Center, Kigali, Rwanda.
authors.forename: Felix
authors.initials: F
authors.lastname: Sayinzoga
authors.affiliation: Department for Health Evidence, Radboud University Medical Centre Nijmegen, Nijmegen, The Netherlands.
authors.forename: Leon
authors.initials: L
authors.lastname: Bijlmakers
authors.affiliation: Department of Obstetrics and Gynaecology, Radboud University Medical Centre Nijmegen, Nijmegen, The Netherlands.
authors.forename: Jeroen
authors.initials: J
authors.lastname: van Dillen
authors.affiliation: Maternal, Child and Community Health Division, Rwanda Ministry of Health, Rwanda Biomedical Center, Kigali, Rwanda.
authors.forename: Victor
authors.initials: V
authors.lastname: Mivumbi
authors.affiliation: Maternal, Child and Community Health Division, Rwanda Ministry of Health, Rwanda Biomedical Center, Kigali, Rwanda.
authors.forename: Fidèle
authors.initials: F
authors.lastname: Ngabo
authors.affiliation: Department of Primary and Community Care, Radboud University Medical Centre Nijmegen, Nijmegen, The Netherlands.
authors.forename: Koos
authors.initials: K
authors.lastname: van der Velden
mesh_terms: D000293:Adolescent; D000328:Adult; D002423:Cause of Death; D005260:Female; D006801:Humans; D008427:Maternal Health Services / Q000592:standards*; D008428:Maternal Mortality; D008485:Medical Audit; D011247:Pregnancy; D011248:Pregnancy Complications / Q000401:mortality* / Q000517:prevention & control; D011785:Quality Assurance, Health Care; D058996:Quality Improvement; D012189:Retrospective Studies; D012432:Rwanda / Q000453:epidemiology; D055815:Young Adult
keywords: Avoidable death; Maternal death audit; Obstetric complications; Rwanda