A Root Cause Analysis of Stillbirths Delivered in a Tertiary Care Hospital of India –Understanding the Gaps in Care Provided

Root cause analysis of stillbirths

Abstract

Objective:  To evaluate the stillbirths by Root cause analysis to address the causes in-depth, and understand the gaps in the accessibility to the existing health care system.

Methodology: A total of hundred cases of stillbirth were studied and Root cause analysis was performed and factors contributing to stillbirths were categorized mainly into the organization, personnel, equipment, barriers at the personal/family level in accessing health care, and underlying maternal and fatal causes.

 Results: A total of 367stillbirths delivered (out of 8157 total birth) over a period of 18 months and root cause analysis was performed successfully in a hundred cases. Common causes for stillbirth were Hypertensive disorder of pregnancy, abruption, fetal growth retardation, prematurity, and congenital malformations. Lack of recognization or seriousness at the family level (49%) ranked number one as a contributory factor, closely followed by the health care provider level like failure to follow best practices (44%) and failure to recognize seriousness or judgemental error (35%). A poor system of sharing information and weak referral was observed in 23% of cases.

Conclusion: Root cause analysis has highlighted the various avoidable and modifiable factors during the contact of a pregnant woman with her family, health care provider, and facility which ultimately attributed to the adverse outcome. Development of a strong referral system with a timely referral with proper communication, following standard treatment protocols, guidelines, and a sufficient number of staff and resources at health care facilities can go a long way in reducing these preventable stillbirths.