Table 3.

Identified barriers to the implementation of maternal death reviews

Topics
Factors influencing the identification of maternal death cases:
• Death occurring during the transportation of the woman to hospital or shortly after admission
• Death occurring outside the maternity unit (i.e. in the intensive care unit)
Factors influencing the data collection:
• Poor quality of information in medical files*
• Data collection divided between numerous workers
• Non-permanent collector in a health structure (medical student, resident)
• Non-motivated collector
• Inaccurate address in the medical files, preventing community inquiry
Factors influencing the audit meetings:
• Head of department not involved in the audit meetings*
• Poor quality of the collected information
• Collector is not invited to the audit meetings
• Employees made to feel guilty after audit meetings
Factors influencing the use of the findings:
• Lack of feedback to the staff who did not attend the audit meetings*
• Settings where most of deaths occur because of poor access

*Barriers that were the most frequently mentioned by the interviewed personnel