TABLE 3.

Number of identified substandard care factors in the 24 obstetric hemorrhage‐related maternal deaths that were reported to the AMSM (Dutch audit committee maternal mortality and morbidity) in the Netherlands between 2006 and 2019 ^c

	n
Patient‐related
Delay in consulting a doctor	1
Refusing medical treatment	1
Communication difficulties	1
Primary obstetric care‐related a
Inadequate antenatal visit	1
Delay in referral to hospital	1
Delay in diagnosis	2
Secondary or tertiary care‐related b
Delay in diagnosis	10
Inadequate management	18
Communication difficulties between obstetricians and other specialists	2
Failure to stabilize before transport	2

^a Care provided by community midwives and/or general practitioners.

^b Care provided by obstetricians and/or other medical specialists.

^c Multiple substandard care factors could be identified per maternal death.