How complete were maternal death reviews in Central Kenya 2015 - 2018?

In response to high maternal mortality ratio (MMR) Kenya implemented mandatory maternal death reviews (MDR) in 2004. This retrospective study used MDR data to assess the completeness of MDR process in seven hospitals of Thika sub-county, central Kenya from January 2015 to June 2018. Of all 43 maternal deaths that occurred, 98% were notified while 64% were audited. MDR forms were filled in 55% of the cases of which only 7% had complete documentation. The median age of patients was 30 years majority of whom died within 24 hours of admission. Caesarean sections were associated with 48% of deaths, with haemorrhage accounting for most of the direct causes. Data on hospital-related delays, missed opportunities and action points were most frequently omitted in MDR forms. Capacity building for audit teams is recommended to improve quality of MDR process particularly focusing on identifying causes of preventable maternal deaths.