Root cause analysis of maternal deaths at dr. Soetomo general academic hospital surabaya, Indonesia in 2019

Introduction: Maternal mortality in Indonesia especially in dr. Soetomo General Hospital is still very high, and the biggest problem is obstetric complications. It is possible that the mother who has obstetric complications is safe and recovered or died. This study aimed to identify the root cause of maternal death at Dr. Soetomo General Academic Hospital in 2019. Methods: This is a descriptive retrospective study with the Root Cause Analysis method to analyze total of 87 maternal deaths at Dr. Soetomo General Academic Hospital in 2019. Results: There were 87 cases of maternal death at Dr. Soetomo General Academic Hospital in 2019. Direct maternal death was the leading cause of maternal death, contributing 59 cases (67.8%). From 59 cases, 31 cases (35.6%) direct maternal deaths were caused by preeclampsia/eclampsia. Contributing factors that influence maternal mortality are including organizational management, medical personnel, equipment, materials, & ward, environmental, and family barriers factors. Organizational management factors, the most common factor that causes maternal death is a poor information sharing system at the referring hospital, as many as 17 cases (27.4%). Medical personnel factors, maternal death was mostly caused by lack of knowledge and skills during antenatal care, as many as 42 cases (44.2%). Equipment, materials, and ward factors, the most common cause was the unavailability of the ward, contributing 5 cases (55.6%). Family barrier factors, most maternal deaths were caused by the families that did not understand about the emergency condition of the patient, as many as 52 cases (67.5%). Conclusion: The maternal deaths at Dr. Soetomo General Academic Hospital in 2019 were mostly caused by the family barrier factor which did not understand about patient’s emergency condition, followed by the medical personnel factor which was lack of knowledge and skills during antenatal care.