Table 3 Identified barriers to the implementation of maternal death reviews

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