Root Cause Analysis (RCA) of a Maternal Death in Markazi Province: a Methodological Research in Clinical Epidemiology

Different studies performed in the world and Iran reported the educational level of the mother، history of more than four pregnancies، living in rural areas، receiving no prenatal health care، and lack of access to maternal emergency services as the most important factors affecting maternal mortality rate. Few studies have determined contribution of indirect causes of maternal deaths. This study aimed to determine the contribution of indirect causes of a maternal death in Markazi province. This is a retrospective and descriptive-analytical study. Case report method and Root Cause Analysis (RCA)، as an important method used in clinical epidemiology، were applied to describe and analyze a maternal mortality occurred in Markazi province، respectively. This approach deals with identification and solving the root causes of health problems (Sentinel Event). Data were collected by interview and inspection of written documents. Bayesian analysis and calculation of the conditional probabilities were applied using Netica 5. 08 software. Receiving no maternal prenatal care، not following the ministerial and provincial guidelines، lack of team working and coordination between medical specialists in the treatment of high-risk pregnant women in the hospital were identified as indirect causes of the maternal death. Indirect causes accounted for 43% of the maternal death. Indicating cardiomyopathy as a cause of death on death certificate of the mother was incorrect. Determining the principal cause of the death، Root Cause Analysis، and eliminating the indirect causes of the death play important roles on decreasing 50% of the maternal deaths.