Percent of facilities that conduct case review/audits into maternal death/near miss

The number of facilities that conduct case review/audits into maternal death/near miss.

This indicator is calculated as:

# of facilities conducting case review/ audits into maternal death/near miss x 100
# of facilities at the appropriate level*

* Certain facilities will be too small to conduct their own audits, but may participate in established procedures.

Case review refers to a detailed review of the management of a particular patient or clinical case.

An audit is the systematic and critical analysis of the quality of care. Audit differs from case review because it looks at the whole process of care and at conformity with specified standards of care as part of an iterative cycle of quality improvement (Graham et al., 2000). The different types are as follows:

  • Maternal death audits are detailed reviews of the events leading up to a maternal death. The audit may encompass record reviews and staff reports or interviews as well as interviews of relatives/community members;
  • Criterion-based audits assess the quality of the clinical management of obstetric complications against defined standards of best practice;
  • "Near-miss" audits are performed after the occurrence of a life-threatening event in which a woman is deemed to have nearly died. A "maternal near-miss" is defined as a woman who nearly died but survived a complication that occurred during pregnancy, childbirth, or within 42 days of termination of pregnancy (WHO, 2011).  For more information on near-misses, see Evaluating the quality of care for severe pregnancy complications: The WHO near-miss approach for maternal health.

Number of facilities conducting or participating in audits of maternal death and near-miss cases; number of facilities in a specific geographic area.

Health-facility surveys; district health-management team records.

An audit is one of many established mechanisms for improving provider performance in developed countries, and studies have shown that it also applies to developing countries.  Case reviews or audits, which entail collecting and analyzing data, can be critical to improving the quality of obstetric care and thus reduce maternal morbidity and mortality.  An example of this is in Rwanda, where just six months after the government introduced the maternal death audit system in late 2009, the method revealed the major causes of maternal mortality (allAfrica, accessed May 2011). 

This indicator may be collected as part of a facility survey (MEASURE DHS+, 2001), although most programs will need to set up their own monitoring system for assessing the coverage and quality of effective audit practices.

This indicator measures only the proportion of facilities conducting audit or case reviews and does not measure the quality or the impact of the review process. Although case reviews are a routine part of many facility activities, effective audit is not. Firstly, data may be missing due to poor documentation of case notes.  Secondly, data regarding community factors leading to the woman's death in the facility may be difficult to obtain.  And thirdly, facility-based maternal death reviews are sometimes not conducted in a blame-free manner (Kongnyuy and van den Broek, 2008).  For these reasons, programs may want to collect complementary information on the quality and effectiveness of the process.

In most cases, smaller facilities will find it impractical to conduct their own audit or case reviews. Staff representatives from these facilities, however, should participate in the audit cycles of larger facilities or districts.

management, quality, safe motherhood (SM)

"Maternal Death Audit System Key to Curbing Mortality", May 20, 2010.Accessed in May, 2011 at allAfrica.  Available at: 

Kongnyuy E. and van den Broek N. The difficulties of conducting maternal death reviews in Malawi.   BMC Pregnancy and Childbirth 2008, 8:42.

WHO, 2011.  Evaluating the quality of care for severe pregnancy complications: The WHO near-miss approach for maternal health. 

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