• Imelda Namagembe, Noah Kiwanuka, Josaphat K Byamugisha, Sam Ononge, Jolly Beyeza-Kashesya, Dan K Kaye, Ashley Moffett, Catherine E Aiken, and Annettee Nakimuli.
• Department of Obstetrics and Gynaecology, School of Medicine, Makerere University College of Health Sciences, Uganda, P.O.Box 7072, Kampala, Uganda.
• Afr Health Sci. 2022 Jun 1; 22 (2): 489499489-499.

BackgroundReviewing maternal deaths and drawing out lessons for clinical practice is part of an effective cohesive intervention strategy to reduce future deaths.ObjectiveTo review maternal deaths at the National Referral hospital in Kampala over a 3-year period (2016-2018) to determine causes of death, extent of preventability, proportion of deaths notified and audited as per national guidelines.MethodsTrained-multidisciplinary panels (obstetricians and senior midwives) conducted retrospective reviews of maternal deaths that occurred.ResultsMajor causes of deaths: obstetric haemorrhage (158/350; 45%), hypertensive disorders of pregnancy (87/350; 25%) and infection (95/350; 27%). Overall, 294/350 (84%) of maternal deaths were considered preventable. In 95% (332/350) of cases, delays within healthcare facilities were identified (64%; 226/350). We note that only 115/350 (33%) cases had been audited. This proportion did not change during the studied period. In 48% (167/350) of cases, notification to the Ministry of Health occurred, but only 11% of deaths (39/350) were notified within the recommended 24-hours.ConclusionsA high proportion (84%) of deaths were preventable. Significant delays to care occurred within health-care facilities. Results suggest that a well-supported, and timely maternal death review process with targeted and pragmatic interventions might be effective in reducing maternal deaths in this setting.© 2022 Namagembe I et al.

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