Article Text

Maternal death audit in Rwanda 2009–2013: a nationwide facility-based retrospective cohort study
  1. Felix Sayinzoga1,
  2. Leon Bijlmakers2,
  3. Jeroen van Dillen3,
  4. Victor Mivumbi1,
  5. Fidèle Ngabo1,
  6. Koos van der Velden4
  1. 1Maternal, Child and Community Health Division, Rwanda Ministry of Health, Rwanda Biomedical Center, Kigali, Rwanda
  2. 2Department for Health Evidence, Radboud University Medical Centre Nijmegen, Nijmegen, The Netherlands
  3. 3Department of Obstetrics and Gynaecology, Radboud University Medical Centre Nijmegen, Nijmegen, The Netherlands
  4. 4Department of Primary and Community Care, Radboud University Medical Centre Nijmegen, Nijmegen, The Netherlands
  1. Correspondence to Dr Leon Bijlmakers; leon.bijlmakers{at}


Objective Presenting the results of 5 years of implementing health facility-based maternal death audits in Rwanda, showing maternal death classification, identification of substandard (care) factors that have contributed to death, and conclusive recommendations for quality improvements in maternal and obstetric care.

Design Nationwide facility-based retrospective cohort study.

Settings All cases of maternal death audited by district hospital-based audit teams between January 2009 and December 2013 were reviewed. Maternal deaths that were not subjected to a local audit are not part of the cohort.

Population 987 audited cases of maternal death.

Main outcome measures Characteristics of deceased women, timing of onset of complications, place of death, parity, gravida, antenatal clinic attendance, reported cause of death, service factors and individual factors identified by committees as having contributed to death, and recommendations made by audit teams.

Results 987 cases were audited, representing 93.1% of all maternal deaths reported through the national health management information system over the 5-year period. Almost 3 quarters of the deaths (71.6%) occurred at district hospitals. In 44.9% of these cases, death occurred in the post-partum period. Seventy per cent were due to direct causes, with post-partum haemorrhage as the leading cause (22.7%), followed by obstructed labour (12.3%). Indirect causes accounted for 25.7% of maternal deaths, with malaria as the leading cause (7.5%). Health system failures were identified as the main responsible factor for the majority of cases (61.0%); in 30.3% of the cases, the main factor was patient or community related.

Conclusions The facility-based maternal death audit approach has helped hospital teams to identify direct and indirect causes of death, and their contributing factors, and to make recommendations for actions that would reduce the risk of reoccurrence. Rwanda can complement maternal death audits with other strategies, in particular confidential enquiries and near-miss audits, so as to inform corrective measures.

  • Maternal death audit
  • Obstetric complications
  • Avoidable death
  • Rwanda

This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:

Statistics from

Supplementary materials

  • Supplementary Data

    This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.