Table 3.

Data analytic framework

Theme	Categories	Sub-categories	Codes
Non-informative audit tool provides unreliable data for review	Inadequate instrument	Irrelevant information	Irrelevant information from maternal death instruments
		Inadequate forms	Inadequate and/or reliable maternal audit forms
		Incomplete instruments	Instruments cannot provide all the necessary information surrounding maternal death
	Supporting informative data	The need for supporting data	The reviewers urged supporting data
		Collecting additional document	Collecting data staff providing additional documents in maternal care
	Inaccurate information	Inaccuracy	Out of sync information in referral case
			Reviewers distrust the data provided by the hospital
			Unreliable data
			Accuracy of maternal death data
			Data falsification
Unstandardized clinical indicators and the practice of “sharp downward, blunt upward”	The ignorance of the reviewer to use clinical standards to identify the gap	Clinical experience	Review based on clinical experience only
		“Medicine is an art “perspective	Review based on the belief that medicine is an art
		Personal perception	Review based on the personal perceptions
		Tendency to associate the problem in the lower-level health facility	Reluctant to review the case involved senior colleagues
			“Sharp downward, blunt upward”
	Personal initiative to use clinical standards for an objective review	An objective review	The external reviewers are more objective
		A personal initiative by an external reviewer to use clinical guideline	An initiative of the external reviewer to use the national clinical guideline to identify the problem
Unaccountable hospital support and lack of leadership commitment	Lack of commitment to the implementation of the role of audit	Inadequate support of the management team to the role of audit	Failure to comply with the terms of agreement of MDA
			DHO needs an advocacy process involved the external review
		Failure to comply with proactivity in providing information	Failure to provide information of maternal death
			Challenging communication to obtain data from hospital
	Difficulty of DHO to implement the recommendation to the hospital	Lack of recognizance to DHO authority	Hospital decision-makers disrespect to the DHO team
			Poor awareness of DHO of their authority over the hospitals
		Lack of commitment to attend and understanding the audit feedback	Poor attendance of hospital decision-makers to audit meeting
			Absence of adapted practice based on recommendation
		Adherence	Collaboration to implement recommendation
			Challenges in the implementation
			Adherence of higher-level health facilities
			Recommendation to hospital
Blaming culture, minimal training, and insufficient MDA committee’ skills	Failure to internalize the principles of audit		‘Blaming culture’, leading to the reduction of a set of review processes into merely a ‘disciplinary process’
			Punitive actions by reviewers in terms of revealing personal and institutional information to the public
	Lack of knowledge to program an MDA		Insufficient training of audit committee Incompatible education background
			Lack of training
			Frequent staff rotation
	Failed to translate recommendation into policy		Lack of specificity of recommendation Absence of cross-sectoral partnership between stakeholders Poor budgeting allocation