Measures

Failure mode

Consequence

Contributory factor

・ High risk screening

・ High risk pregnancy referral to Higher maternal care level

・ High risk pregnancy follow up

・ Missed high risk mothers

・ Delayed or non referral to high risk units

・ Maternal morbidity and mortality

・ Over crowded clinics

・ Transient staff

・ Poor counselling

・ Poverty, expensive lab tests and poor insurance coverage

・ Poor maternal cooperation due to socio-cultural belief

・ Poor follow up system in high risk mothers

・ Deficient file registration

・ Poor access to maternal health file data