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As defined by the World Health Organization, maternal mortality is the death of a woman due to pregnancy-related complications and childbirth or within 42 days of termination of pregnancy. The maternal mortality rate stands high in underdeveloped nations. It is directly associated with health deficiencies, illiteracy, early marriage, multiparity, and cultural practices. The root cause analysis shows the vital causes of maternal death and is listed below.
Maternal Mortality
Team/ individual

•         Untrained health workers
•         Nurse fatigue
•         Nurse distraction
•         Poor Communication

  Organizational and management factors

•         Lack of protocol
  • Retrieval/ administration
  • Epidural Meds.
•        Delayed placement of identification band
•        Casual to epidural  issues

Work environment

•         Working hours limit not clear
•         Faulty medication bar-coding system

Patient health/ condition

•         Unsafe abortion
•         High blood pressure
•         Infections
•         Severe bleeding
•         Primigravida
•         Young age/ early marriage

Other issue

•         Social stigma
•         Cultural practice
•         Illiteracy
•         Lack of quality health service

This fishbone is an illustration of an organized root cause analysis. We have tried to provide some optimized strategies for incident analysis. The cause arrangements are well structured, hierarchical, and comprehensive. This fishbone template narrates the contributing factors of maternal morbidity. It is a good reference for future incident/root cause analysis in any specific or general situation.

Who should use the Maternal Mortality template?

• This template is beneficial for anyone interested to learn the reasons for maternal morbidity or mortality. It enables you to explore the different things that should be taken care of while dealing with pregnancies and delivery. One can take necessary actions with advanced knowledge on the cause and effects of any process more efficiently. We welcome everyone to work with our templates.

Why use this template?

• It’s easy to understand the protocol followed during the analysis of factors that affect maternal health and consequently leads to untimely death.
• Shares knowledge on incident analysis.
• Create and change your template or use this for your own problem-solving.

Curated from community experience and public sources:

• https://www.who.int/news-room/fact-sheets/detail/maternal-mortality