Cargando…

Investigation of the causes of maternal mortality using root cause analysis in Isfahan, Iran in 2013-2014

BACKGROUND: Many maternal deaths caused are due to preventable causes during pregnancy and childbirth. Therefore, the detailed analysis of the root causes provides developing a plan and appropriate interventions to prevent these deaths occurring in the health system. This study aims to determine the...

Descripción completa

Detalles Bibliográficos
Autores principales: Beigi, Marjan, Bahreini, Somaye, Valiani, Mahboubeh, Rahimi, Mojtaba, Danesh-Shahraki, Azar
Formato: Online Artículo Texto
Lenguaje:English
Publicado: Medknow Publications & Media Pvt Ltd 2015
Materias:
Acceso en línea:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4462055/
https://www.ncbi.nlm.nih.gov/pubmed/26120330
_version_ 1782375604594671616
author Beigi, Marjan
Bahreini, Somaye
Valiani, Mahboubeh
Rahimi, Mojtaba
Danesh-Shahraki, Azar
author_facet Beigi, Marjan
Bahreini, Somaye
Valiani, Mahboubeh
Rahimi, Mojtaba
Danesh-Shahraki, Azar
author_sort Beigi, Marjan
collection PubMed
description BACKGROUND: Many maternal deaths caused are due to preventable causes during pregnancy and childbirth. Therefore, the detailed analysis of the root causes provides developing a plan and appropriate interventions to prevent these deaths occurring in the health system. This study aims to determine the causes of maternal mortality using root cause analysis (RCA) method. MATERIALS AND METHODS: This research is a descriptive explorative study. The data were collected from the files in the maternal health center and the interviews conducted with relevant personnel. The causes of maternal mortality and related reasons were determined by experts’ team opinions and through a standard checklist of RCA. Causes consisted of the factors related to health services (human factors and structural factors), maternal family and social status, and maternal disease status. For each of these factors, analysis was performed to determine the root. In the end, interventional suggestions were developed to prevent the recurrence of similar deaths. RESULTS: Causes were classified into human factors, and structural factors in the area of planning and management and social status of mothers. The results showed that human factors were composed of lack of knowledge and skills in the medical team, unfamiliarity with their duties, lack of health care–based on protocols, etc. Structural factors included lack of follow-up after discharge and inadequate supervision of inspectors on academic qualified doctors. Maternal social and family status factor included lack of referral the mothers’ to the health care center. CONCLUSIONS: Based on the RCA process, the most fundamental factor in creating these deaths was management errors at the level of universities and the Ministry of Health. These errors included inadequate supervision of medical education, failure to identify and introduce the instructions and guidelines related to the care of pregnant mothers by the health workers and experts, and lack of collective strategies to inform the public about the type and model of self-care in health centers. Based on the obtained results, the solutions proposed for elimination of root causes of maternal death are organizing sequential training courses tailored for the staff taking care of pregnant women, sending guidelines related to maternal health care to all private and public institutions, and informing the community to receive health care services by health centers and mass media.
format Online
Article
Text
id pubmed-4462055
institution National Center for Biotechnology Information
language English
publishDate 2015
publisher Medknow Publications & Media Pvt Ltd
record_format MEDLINE/PubMed
spelling pubmed-44620552015-06-26 Investigation of the causes of maternal mortality using root cause analysis in Isfahan, Iran in 2013-2014 Beigi, Marjan Bahreini, Somaye Valiani, Mahboubeh Rahimi, Mojtaba Danesh-Shahraki, Azar Iran J Nurs Midwifery Res Original Article BACKGROUND: Many maternal deaths caused are due to preventable causes during pregnancy and childbirth. Therefore, the detailed analysis of the root causes provides developing a plan and appropriate interventions to prevent these deaths occurring in the health system. This study aims to determine the causes of maternal mortality using root cause analysis (RCA) method. MATERIALS AND METHODS: This research is a descriptive explorative study. The data were collected from the files in the maternal health center and the interviews conducted with relevant personnel. The causes of maternal mortality and related reasons were determined by experts’ team opinions and through a standard checklist of RCA. Causes consisted of the factors related to health services (human factors and structural factors), maternal family and social status, and maternal disease status. For each of these factors, analysis was performed to determine the root. In the end, interventional suggestions were developed to prevent the recurrence of similar deaths. RESULTS: Causes were classified into human factors, and structural factors in the area of planning and management and social status of mothers. The results showed that human factors were composed of lack of knowledge and skills in the medical team, unfamiliarity with their duties, lack of health care–based on protocols, etc. Structural factors included lack of follow-up after discharge and inadequate supervision of inspectors on academic qualified doctors. Maternal social and family status factor included lack of referral the mothers’ to the health care center. CONCLUSIONS: Based on the RCA process, the most fundamental factor in creating these deaths was management errors at the level of universities and the Ministry of Health. These errors included inadequate supervision of medical education, failure to identify and introduce the instructions and guidelines related to the care of pregnant mothers by the health workers and experts, and lack of collective strategies to inform the public about the type and model of self-care in health centers. Based on the obtained results, the solutions proposed for elimination of root causes of maternal death are organizing sequential training courses tailored for the staff taking care of pregnant women, sending guidelines related to maternal health care to all private and public institutions, and informing the community to receive health care services by health centers and mass media. Medknow Publications & Media Pvt Ltd 2015 /pmc/articles/PMC4462055/ /pubmed/26120330 Text en Copyright: © Iranian Journal of Nursing and Midwifery Research http://creativecommons.org/licenses/by-nc-sa/3.0 This is an open-access article distributed under the terms of the Creative Commons Attribution-Noncommercial-Share Alike 3.0 Unported, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
spellingShingle Original Article
Beigi, Marjan
Bahreini, Somaye
Valiani, Mahboubeh
Rahimi, Mojtaba
Danesh-Shahraki, Azar
Investigation of the causes of maternal mortality using root cause analysis in Isfahan, Iran in 2013-2014
title Investigation of the causes of maternal mortality using root cause analysis in Isfahan, Iran in 2013-2014
title_full Investigation of the causes of maternal mortality using root cause analysis in Isfahan, Iran in 2013-2014
title_fullStr Investigation of the causes of maternal mortality using root cause analysis in Isfahan, Iran in 2013-2014
title_full_unstemmed Investigation of the causes of maternal mortality using root cause analysis in Isfahan, Iran in 2013-2014
title_short Investigation of the causes of maternal mortality using root cause analysis in Isfahan, Iran in 2013-2014
title_sort investigation of the causes of maternal mortality using root cause analysis in isfahan, iran in 2013-2014
topic Original Article
url https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4462055/
https://www.ncbi.nlm.nih.gov/pubmed/26120330
work_keys_str_mv AT beigimarjan investigationofthecausesofmaternalmortalityusingrootcauseanalysisinisfahaniranin20132014
AT bahreinisomaye investigationofthecausesofmaternalmortalityusingrootcauseanalysisinisfahaniranin20132014
AT valianimahboubeh investigationofthecausesofmaternalmortalityusingrootcauseanalysisinisfahaniranin20132014
AT rahimimojtaba investigationofthecausesofmaternalmortalityusingrootcauseanalysisinisfahaniranin20132014
AT daneshshahrakiazar investigationofthecausesofmaternalmortalityusingrootcauseanalysisinisfahaniranin20132014