Figure 1.

Cycle of maternal death audit. Maternal death audit (reviews) process consists of five steps. (a) Identification of maternal deaths: this can be difficult where many deaths take place outside health facilities. Even in health facilities, maternal deaths in other wards other than the maternity ward can be missed. (b) Data collection: data can be collected from many sources such as hospital registers, case notes, referral letters and interviews of family members and relatives. (c) Analysis of findings: data is analysed to identify the causes of maternal deaths and avoidable factors. (d) Recommendations and actions: recommendations are made to implement changes that will prevent the occurrence of similar deaths in the future. (e) Evaluation and refinement: the implementation of recommendations is followed up and evaluated and professional practice refined if necessary.