Table 4

The analyses of the concerns about clinical management associated with maternal death stratified by the possibility of prevention in preventable cases (n=81)

Possibility to preventSlightlyModeratelyHighly
10–30%
n=44
40–70%
n=25
80%
n=12
Delayed diagnosis
 Owing to rare disease14% (6)0% (0)0% (0)
 However, not rare disease16% (7)60% (15)75% (9)
Delayed decision of maternal transport from primary hospital
30% (13)52% (13)33% (4)
Delayed blood transfusion
 RCC23% (10)44% (11)75% (9)
 FFP32% (14)52% (13)75% (9)
 Platelet2% (1)8% (2)8% (1)
Delayed treatment
 Medication23% (10)36% (9)67% (8)
 Surgical intervention21% (9)28% (7)42% (5)
 Delayed delivery6% (2)25% (4)11% (1)
Inappropriate resuscitation or anaesthesia
7% (3)20% (5)33% (4)
Insufficient preparation
30% (13)52% (13)33% (4)
Concerning system
 Maternal transport2% (1)8% (2)8% (1)
 Blood transfusion11% (5)4% (1)33% (4)
Communication
 Intrahospital16% (7)20% (5)50% (6)
 Interhospital2% (1)0% (0)17% (2)
  • FFP, fresh frozen plasma; RCC, red cell concentrates.