The maternal mortality review meeting: experiences from Kalabo District Hospital, Zambia.

We report on our experiences with a maternal mortality review meeting in Kalabo District Hospital between 1999 and 2001. Patient files and minutes of the maternal mortality review meetings of 15 cases of maternal death were reviewed. Causes of death, classification, substandard care factors, recommendations and implementation were analysed. In nine cases of maternal death 20 different substandard care factors were found; 12 caused by organizational weaknesses, eight by substandard clinical care. In nine cases, recommendations were formulated, which were completely implemented in five and partially implemented in two cases. A maternal mortality review meeting can be an important tool for improving essential obstetric services in a district hospital. It can easily and directly correct some substandard care factors, has a high educational value for staff and leads to a better understanding of maternal mortality for everyone involved.