Table 4.

Examples of factors contributing to maternal deaths and recommendations for actions to be taken

Category	Problem identified	Recommendation	Action taken (number of cases affected)
Case management	-Junior doctors working unsupervised -Complicated cases undiagnosed -Incorrect case management -Deaths during caesarean section	Obstetricians required for tertiary hospital	Obstetrician allocated to the hospital (recommended for 52 cases)
	-Deaths during operation for routine Caesarean sections in women who had already multiple (up to 5) previous Caesarean sections	Counselling for bilateral tubal ligation at antenatal clinics for all clients having three previous Caesarean sections	Midwives sensitised on the need for counselling for women who already had three caesarean sections to obtain consent for sterilisation for the next delivery during routine antenatal clinics Counselling introduced in all health centres (recommended for 4 cases)
	Patients die undiagnosed	Conduct post mortems when maternal death cause is unknown	Post mortem was conducted when cause of death was not clearly identified (recommended for 38 cases)
Communication	Short time for preparing referred patients for emergency operations	Monitor the preparation of women who are referred from health centres, keep chart in labour ward DHMT to orientate midwives in safe referrals during midwives routine monthly meeting DHMT Reproductive Health Officer to collect monitoring sheet and provide feedback and support to health centres	A monitoring chart relating to communication between a referring clinic and the labour ward of the tertiary hospital regarding referral cases introduced and monitored by District reproductive health officer (recommended for 54 cases)
Resources	No antibiotics available for treatment of post partum or post abortion sepsis	Maintain a supply in ICU for maternal cases	A stock of antibiotics established in Intensive Care Unit (ICU) for use for septic abortion and post partum sepsis (recommended for 28 cases)
	-Blood units not always available on request especially during school holidays -No documented system of ordering and receiving blood	Establish a Blood transfusion committee to discuss blood collection and distribution Diversify the register of blood donors Review and document ordering system.	Campaigns to collect blood from regular donors resulted in adequate stocks -Regular meetings with Zambia Blood Transfusion Services and its stakeholders held -Ordering system put in place to document requests and receipts of blood units. There were no shortages of blood for transfusion in subsequent years (recommended for 15 cases)
	-Clients do not have readily available cash for transport to attend health centre for delivery. -Patients do not have supplies required by health centre resulting in home deliveries.	Advice and support for birth planning for all pregnant women - design strategies to include male partners. -Re-introduce safe birthing kits for pregnant women at antenatal clinics	-Birth planning sessions, both group and individual, introduced at all antenatal clinics -Safe birthing kits not re-introduced at the end of pilot (recommended for 28 cases)
Client High risk	Deaths of women who were HIV positive or suspected AIDS patients	Full ART for all pregnant women	Regime for HIV positive pregnant women changed from Niverapine only to full ART (recommended for 15 cases)
	Septic abortions due to self induced abortions	-Extend access to family planning services to women aged >35 and under 20 -Provide Post Abortion Care services at hospital	Midwives ortiented -Post abortion care services introduced (recommended for 9 cases)