Maternal health improvement through root cause analysis of severe maternal morbidity (maternal near miss) in Isfahan, Iran

Investigating severe maternal morbidity and near‑miss cases are applied internationally as a new indicator to examine the quality of maternal care and as an effective strategy to reduce maternal mortality. This study aimed to determine the root causes of severe maternal morbidity in order to improve maternal health.

The present research is a descriptive case series study. The data was obtained from the hospital and health records of mothers admitted to hospitals affiliated to Isfahan University of Medical Sciences due to severe morbidity in the first 6 months of 2018, which were selected randomly. The data collection was completed by interviews with the mentioned mothers and 14 related health‑care staffs and that led to the development of the morbidity story. The compiled story of each case was evaluated by the root analysis team’s opinion. Causes of morbidity were determined according to a root cause analysis checklist composing of factors such as health‑care services (human and structural factors), family‑social status, and disease status of maternal morbidity.

The findings indicated that human factors related to the health system led to severe maternal morbidity more than any cause. Inadequate knowledge and skills of service providers, disregard for guidelines and protocols, lack of teamworking, and lack of considering competency were the most important human factors. Disease condition, family, and social status were the other related factors, respectively.

Human factors are the most important cause of maternal morbidity based on the results of this study. Therefore, modifying the health structure can be one of the most important reducing factors for maternal mortality in order to improve the services for these individuals.