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Year : 2017  |  Volume : 10  |  Issue : 6  |  Page : 1591-1595
Analysis of maternal mortality in Isfahan, Iran: Acase series study

1 Student Research Center, Faculty of Nursing and Midwifery, Isfahan University of Medical Sciences, Isfahan, Iran
2 Department of Midwifery and Reproductive Health, Faculty of Nursing and Midwifery, Isfahan University of Medical Sciences, Isfahan, Iran
3 Department of Anesthesiology, Faculty of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
4 Department of Midwifery and Reproductive Health, School of Nursing and Midwifery, Isfahan University of Medical Sciences, Isfahan, Iran

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Date of Web Publication11-Jan-2018


Introduction: According to international agreement, all pregnant women mortalities are unacceptable since many of them are preventable. Therefore, reviewing and analyzing the root causes of maternal mortality to find the causes prevents repetition of the possible defects and modifies processes. This study using root cause analysis(RCA) aims to determine the causes of maternal mortalities. Materials and Methods: This research is a case series study. The required data were collected from the files of dead mothers, and the interviews were conducted with the relevant human resources. The causes of maternal mortality were determined according to the opinions of the experts and through a checklist of RCA. The causes consisted of the factors related to health services(human and structural factors), sociofamilial status, and the medical conditions of the dead mothers. Results: In this study, human factors including factors related to health services were introduced as the main defects of services related to the death of the pregnant women. Structural factors, family status, and medical conditions were, respectively, the other influential factors. The root of all these errors was identified to be managerial factors at academic and ministerial levels. Discussion and Conclusion: According to the obtained results, the importance of human resources should be considered specifically to enhance job performance and minimize their errors through manager's planning. Doing this will promote health, and reduce morbidity, disability, and mortality in both mothers and newborns.

Keywords: Iran, maternal mortality, pregnancy, root cause analysis

How to cite this article:
Bahreini S, Beigi M, Rahimi M, Valiani M. Analysis of maternal mortality in Isfahan, Iran: Acase series study. Ann Trop Med Public Health 2017;10:1591-5

How to cite this URL:
Bahreini S, Beigi M, Rahimi M, Valiani M. Analysis of maternal mortality in Isfahan, Iran: Acase series study. Ann Trop Med Public Health [serial online] 2017 [cited 2020 Feb 21];10:1591-5. Available from:

   Introduction Top

Maternal mortality and disability plays an important role in the survival of newborns, family, and the society. Therefore, effort to maintain and promote the health of this vulnerable group is a global priority, and their mortality indicator is one of the important measures of health and development in societies.[1] The rate of maternal mortality during the recent years and in terms of development index is acceptable in Iran(30/100,000) and even lower than the national average in Isfahan Province(20/100,000). Although industrial and socioeconomic status of the province justifies this rate, there are still many opportunities to improve the health of mothers and women.[2] In this regard, it has been agreed that almost all maternal deaths are unacceptable since many causes of these mortalities are preventable, and in today's world, there are necessary facilities for the prevention of mortalities and having a safe pregnancy and childbirth. Thus, the detailed analysis of these mortalities prevents the possible defects and errors and finally leads to the processes modification.[3]

Death registration, its analysis, and proposition of interventional solutions is a successful and purposeful program of the Ministry of Health, Treatment, and Medical Education in Iran to reduce maternal mortality in pregnant women. Given the special place of clinical governance in health systems, this program has become more serious.[4] In this system, a root cause approach rather than a merely punitive one to the problem of medical error is considered. That is, instead of focusing on staff, the focus is on the system, and its problems are analyzed.[5] In other words, root cause analysis(RCA) is a process during which the previous errors are evaluated to prevent repetition of errors and help the administration of appropriate planning. Hence, it is effective to identify the causes of maternal mortalities and control them.[6]

With RCA of mortalities, it is thought that even if one of the deaths is analyzed properly and intervention and planning is conducted according to the results, and if people associated with the issue of maternal mortality reform processes appropriately and functionally, in addition to reduction of mortality rates, repeatable events can be prevented in similar conditions. Thus, a firm step can be taken toward the prevention of avoidable maternal deaths. In this regard, this study aimed to determine the RCA of maternal deaths.

Death no.1: An out-of-hospital death because of thromboembolic events

A 39-year-old pregnant woman whose preconception and prenatal cares were performed by a general practitioner. At the gestational age of 9weeks, she complained of a unilateral progressive pain in her left leg which based on her husband's explanation had started 3days ago. She had been referred to an orthopedic surgery clinic. The orthopedist after performing physical examination and with a simple spasm diagnosis had prescribed diclofenac gel. He also advised her to refer to her physician that is the general practitioner.

In the same evening, the patient was referred to her GP and as her husband explained the physician prescribed two piroxicam injections and advised her to keep warm the pain area and rest.The patient returned home and one week later (at the gestational age of 9 weeks), followed by cyanosis and respiratory distress in the patient, the emergency team was called by her family. The emergency team was called by her family. The emergency team attended the patient at home and diagnosed venous thromboembolism. The patient was intubated and underwent cardiopulmonary resuscitation(CPR) for 20min. However, CPR was not effective and her death was reported.

Death no.2: Death because of peripartum cardiomyopathy

A 23-year-old woman with wanted first pregnancy who benefited from preconception and prenatal cares and at the gestational age of 40weeks and 3days complained of dyspnea. She referred to hospital and was hospitalized by the telephone order of the physician. She delivered 10h after hospitalization and was discharged the next day. 5days after delivery, she was referred to GP with the symptoms of common cold that the physician prescribed her antibiotic and dextromethorphan syrup. On the sixth day after delivery, for the first child-care, she was referred to the healthcare center where the physician noticed her hand was trembling and requested Inderal and TSH test for her.

In the same afternoon because of dyspnea, she was taken into the hospital where she was hospitalized by the telephone order of a gynecologist. The gynecologist then ordered oxygen therapy, cardiac monitoring, ECG, CXR, and counseling with an infectious disease specialist. The infectious consultant prescribed ceftriaxone and azithromycin. Moreover, because of crackles auscultation on lungs, productive cough, tachypnea, and tachycardia, heart consultation was requested. He also ordered an echocardiogram that was due to the possibility of myocarditis that after performing echo, cardiomyopathy was diagnosed for the patient. However, before taking necessary measures and cardiologist visit, she died.

Death no.3: Death because of portal vein thrombosis

A 31-year-old woman suffering from liver cirrhosis due to autoimmune hepatitis and also a liver transplant candidate. Her pregnancy was unwanted and thus did not benefit from preconception care. Her prenatal cares began from week 7 of pregnancy and from that very beginning, due to the complications of cirrhosis, had been repeatedly hospitalized. At the gestational age of 22weeks, she was brought to the hospital with very poor general conditions. This time, after ascites discharge and albumin injection, she was hospitalized in the maternity ward. She stayed about 2weeks in the ward and underwent different consultations for termination of pregnancy. However, her pregnancy was not terminated and at the gestational age of 23weeks, followed by dyspnea and embolism was transferred into ICU. In ICU after fetal death, followed by DIC due to portal vein thrombosis and she died.

Death no.4: Death because of hemorrhage caused by abdominal angiomyolipoma tumor

The patient in her third and unwanted pregnancy did not benefit from preconception cares, but her prenatal cares were performed in healthcare centers and a private clinic. At the gestational age of 33weeks, she complained of abdominal pain and severe weakness. She was referred to hospital at midnight. Her condition was reported as follows: pale, agitated, anuria, with nausea and vomiting, contracted uterine, abdominal tenderness, PR=120 and weak, BP = , nonaudible FHR, and vaginal examination: ripe and soft cervix. One hour later, the patient, suspected of internal bleeding, placental abruption, and intrauterine fetal death underwent cesarean section. The dead fetus was removed, placental abruption was not observed, and gynecologist at the end of surgery and during abdominal search found an abdominal mass which covered a large hematoma from epigastric to hypogastric areas. Therefore, after expulsion of the placenta and repair of the uterus, a surgeon continued the surgery. After evacuation of the hematoma as the surgeon was unable to find the origin of the tumor and repair the vessels, he packed the bleeding site and ended the operation.

According to anesthesiologist fetus, death had been due to bleeding caused by angiomyolipomas tumor; moreover, considering hematoma and cesarean section, volume of the lost blood was reported 3.5L, but the patient has received 4.5 L of crystalloid and 4 units pack cell.

The patient was transformed into the recovery room. Three hours later, the patient underwent another surgery by an on-call surgeon, and the tumor with kidney origin was removed; however, she died during the surgery.

Death no.5: Death because of thromboembolic events

A 33-year-old woman with her third and unwanted pregnancy who had benefited from preconception and prenatal cares. At the gestational age of 36weeks and complaining uterine contractions, she was referred to a general hospital and underwent emergency cesarean section. Eight days later, because of dyspnea, she referred to hospital, but after a visit by an emergency GP, she was discharged with a diagnosis of flu and prescription of medicine. The next day due to severe respiratory distress, she referred again to the hospital with a presumptive diagnosis of pulmonary embolism and was admitted and then referred to a teaching hospital by an anesthesia technician. At the teaching hospital, different residents visited the patient and treated her with embolism and cardiomyopathy diagnosis. In this hospital, the patient underwent therapeutic and supportive interventions for 8days and died with embolism cause.

   Materials and Methods Top

This research is a case series study. The required data were collected by referring to the medical files of the expired mothers and interviewing the related staff and family of the deceased. Data collection tool was a researcher-made checklist of RCA of the death which had been designed using the checklist of clinical governance department in the Ministry of Health, Treatment, and Medical Education. This checklist consists of 3 factors: healthcare, disease status, and sociofamilial status. Healthcare factors include factors related to human resources, equipment-related structural factors, and management and planning structural factors. Likewise, human resources-related factors include 4 factors of personality characteristics: staffs' mental and physical characteristics, communication and team, education, and task-related factors.

Given that some qualitative and quantitative changes were made in the checklist of clinical governance department in the Ministry of Health, Treatment, and Medical Education and the checklist was researcher-made, its validation was checked by the faculty members of Isfahan University of Medical Sciences(academic members of Gynecology and Midwifery Department). Data were evaluated and analyzed by RCA method during several sessions of focus group discussion and in the presence of RCA team members. This team consisted of a gynecologist, an academic member of midwifery department, and the authors of the article. The content of the sessions included reading the death reports, determination of death-related factors based on the checklist and brainstorming, and analysis of the factors with the tool of 5 whys. In this analysis, after approval of each defect, the root causes of each problem were detected by asking consecutive whys and all problems were investigated fundamentally and deeply. At the end, the suggested strategies and the final report were compiled.

   Results Top

In examining 5 maternal deaths, the most important results were identified as follows:

  • Healthcare services-related factors: insufficient knowledge and skills of physicians, inadequacy of in-service training for physicians, no compliance with referral process, inappropriate teamwork, patient's poor triage, lack of family planning consulting services, defects in administration of cares or counseling based on protocol-procedure or guidelines, physicians' lack of responsibility, physicians' risk aversion, inadequate ability in taking timely decisions by physicians and personnel, different service provision in different shifts, and disruption in the process of visiting patients in teaching hospitals
  • Sociofamilial factors: lack of family health services in healthcare centers, family's financial condition, and the patient's lack of support by family
  • Factors related to the disease status: lack of preconception counseling, lack of family planning clinics for mothers with chronic diseases, and noncommitment of physicians in nongynecological fields to family planning are the most important weaknesses.

According to these results, healthcare-related services including human services were introduced as the most important service defects related to maternal mortality.

According to the team of RCA, the most important roots of defects in the area of healthcare services included inappropriate planning in the implementation of family physician plan, inadequate supervision on teamwork protocol in hospitals, absence of a national inspection system to evaluate physicians' professional and academic activities,inappropriate educational needs assessment in official domain, inadequate supervision of the university's deputy of education on educational process of the academic members, lack of critical thinking among employees, unplanned management and managers' lack of sensitivity to maternal mortality, lack of a follow-up system, and lack of an appropriate supervision planning to assess inspectors' scientific(academic) performance.

Likewise, roots obtained from errors within the areas of sociofamilial and disease status included no use of collective strategies by planners to alert people about the need to benefit from health services preconception and prenatal care, lack of support for poor families, andlack of managed planning by authorities in order to increase physicians' awareness about and sensitivity to the death of pregnant women.

   Discussion Top

Analysis of 5 maternal mortalities in this study shows that although many specialized committees of death have been held over the last decade, it seems that inability to prevent avoidable causes of maternal mortality has been due to lack of analysis of the root causes of death. Not careful and meticulous investigation of deaths has led to inappropriate development of interventions and ineffective strategies that in turn has led to repeatable incidents of death in similar circumstances; this also has removed the planners of maternal mortality surveillance system from their idealistic goals.

In examining the defects of this study, it was revealed that healthcare-related human factors(physician or nursing and midwifery personnel) lead to maternal deaths more than any other factor while RCA of these factors was recognized to be the lack of management in managers' planning to enhance their skills. This brings us to the point that the cause of most deaths lies in managerial causes at governmental and ministerial levels. What is noteworthy in this study is that although the mentioned deaths are different in terms of type and structure, defects and root causes of them are identical. Therefore, managerial and systematic processes should be reformed. Several studies are in line with the results of the current study. In these studies, the role of improvement of managerial factors has been confirmed in reducing maternal mortality index.

Shen et al. concluded in their study that the government, through establishing a comprehensive managerial surveillance network, should play an active role in reduction of mortality and its related factors.[7] Liang et al. showed that the government's targeted interventions can reduce maternal mortality.[8] Ngongo et al. stressed the need for continuous support of personnel by authorities and documentation of policies and guidelines that are related to the management of health services.[9] Garba et al. acknowledged that socioeconomic factors in Nigeria are the main causes of high rate of maternal mortality in this country and thus emphasized on the role of managers in promotion of these factors.[10] Finally, Beigi et al. showed that professional and organizational cultures are systematic hidden threats in the incidence of medical errors. Therefore, it seems that the following interventional strategies can modify the managerial process and prevent such deaths.[11]

Factors related to sociofamilial status and mother's disease are the other variables examined in this study. Although influential role of these factors was detected on maternal mortality compared with healthcare factors, their impact was at a lower level; therefore, in none of deaths, even the death occurred out of hospital, insufficiency of cares or lack of patient's referral to physician was evident. Although this issue does not completely obviate the concerns about insensitivity of families, it shows the relative awareness of families to refer to health systems.

   Conclusion Top

Based on the results of this study, human resources that have an effective role in implementation and better monitoring of treatment and care processes should be considered. Therefore, providing an appropriate environment seems necessary to enhance job performance and minimize their errors through managers and authorities planning. Doing this will promote health and reduce morbidity, disability, and mortality in both mothers and newborns. Hence, before doing any intervention and applying any strategy in relation to human factors, this point should be accepted as a principle that no one is free from errors and no profession's immunity is absolute. Errors roots should be sought not only in human resources but also in the system and environment that policymakers and process owners design for their staff. As a result, to overcome the errors, instead of punishment and replacement of human resources, their working conditions should be modified. This can prevent fatal errors or minimize their effects and thereby improve national health indicators.


This article was derived from a master thesis of Somaye Bahreini with project number 392395, Isfahan University of Medical Sciences, Isfahan, Iran. The authors are grateful for the support of Treatment and Health adjutancy of Isfahan University of Medical Sciences.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

   References Top

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ShenFR, LiuM, ZhangX, YangW, ChenYG. Factors associated with maternal near-miss morbidity and mortality in Kowloon hospital, Suzhou, China. Int J Gynaecol Obstet 2013;123:64-7.  Back to cited text no. 7
LiangJ, ZhuJ, DaiL, LiX, LiM, Wang Y, et al. Maternal mortality in China, 1996-2005. Int J Gynecol Obstet 2010;110:93-6.  Back to cited text no. 8
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Beigi M, Bahreini S, Valiani M, Rahimi M, Danesh-Shahraki A. Investigation of the causes of maternal mortality using root cause analysis in Isfahan, Iran in 2013-2014. Iran J Nurs Midwifery Res. 2015;20:315-21.  Back to cited text no. 11

Correspondence Address:
Marjan Beigi
Department of Midwifery and Reproductive Health, Faculty of Nursing and Midwifery, Isfahan University of Medical Sciences, Isfahan
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ATMPH.ATMPH_535_17

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