Document Type : Original Article


1 Department of Midwifery and Reproductive Health, Faculty of Nursing and Midwifery, Isfahan University of Medical Science, Isfahan, Iran

2 Department of Obstetrics and Gynecology, Faculty of Medicine, Isfahan University of Medical Science, Isfahan, Iran


INTRODUCTION: 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.
MATERIALS AND METHODS: 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.
RESULTS: 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.
CONCLUSION: 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.


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