UNDERREPORTING OF MATERNAL AND NEONATAL COMPLICATIONS: A REVIEW OF MATERNITY REGISTER AND CLIENT CHARTS AT A COMMUNITY HOSPITAL, MALAWI

Esnath Kapito¹ ², Ellen Chirwa¹, Alfred Maluwa¹, Chiyembekezo Kachimanga², Maria Openshaw², Sally Rankin³, Sharon Rose³, Kimberly Baltzell³

₁ University of Malawi, Kamuzu College of Nursing, Blantyre, Malawi

₂ Partners In Health / Abwenzi Pa Za Umoyo, Neno, Malawi

₃ University of California, San Francisco

Corresponding author: Mrs. Esnath Kapito, MSc RH. BSc Nsg Ed, Dip Nsg, UCM; University of Malawi, Kamuzu College of Nursing, P. O. Box 415, Blantyre, Malawi. Email: kapito2017esnath@kcn.unima.mw

Co-authors

Professor Ellen Chirwa, PhD Nsg Sc, Msc Nsg, BSc Nsg, UCM, Dip Nsg, University of Malawi, Kamuzu College of Nursing. P. O. Box 415, Blantyre, Malawi. Email: embweza@kcn.unima.mw

Dr. Alfred Maluwa, PhD Quantitative Genetics – Kamuzu College of Nursing Biostatistics Guest Lecturer, Malawi University of Science and Technology, P.O. Box 5196, Limbe, Malawi. Email: aomaluwa@must.ac.mw

Dr Chiyembekezo Kachimanga, MBBS, MPhil, Partners In Health / Abwenzi Pa Za Umoyo, P. O Box 56, Neno. Currently at Partners In Health Sierra Leone, 27 sahr  lebbie street, Koidu City, Kono. Email ckachimanga@pih.org

Miss Maria Openshaw, CNM, MS, Partners In Health, Boston, MA. Email: mopenshaw@pih.org

Sally Rankin, RN, PhD, FAAN, University of California, San Francisco, N431Y, Box 0606 2 Koret Way, San Francisco, CA 94143. Email: Sally.Rankin@ucsf.edu

Sharon Rose, University of California, San Francisco, N431Y, Box 0606 2 Koret Way, San Francisco, CA 94143 Sharon.Rose@ucsf.edu

Kimberly Baltzell, RN, PhD, MS, Associate Professor, University of California, San Francisco, Box 0606 2 Koret Way, San Francisco, CA 94143. Email: Kimberly.Baltzell@ucsf.edu

Author contributions

Name of author

Role

Signature

Esnath Kapito

Conceptualized the design, compiled and analysed data, and drafted the article

Chiyembekezo Kachimanga

Conceptualised the design, critically reviewed, revised the article and approved the version to be published

Maria Openshaw

Critically reviewed, revised the article and approved the version to be published

Ellen Chirwa

Critically, reviewed revised the article and approved the version to be published

Sally Rankin

Critically reviewed, revised the article and approved the version to be published

Kimberly Baltzell

Critically reviewed, revised the article and approved the version to be published

Alfred Maluwa

Worked on the study design and contributed to the statistical analysis of the results, critically reviewed, revised the article and approved the version to be published

Sharon Rose

Critically reviewed, revised the article and approved the version to be published

Disclaimer

The views expressed in the submitted article are the authors’ own and not an official institution.

Competing interests: The authors declare that no competing interest exist.

Abstract

Background: Maternal and neonatal complications are a major cause of concern globally as they contribute to maternal and neonatal morbidity and mortality. However, underreporting of maternal and neonatal complications has been noted in many regions, particularly in sub-Saharan Africa. Without a full understanding of both the number and type of complications, governments may allocate resources or prioritize training programs incorrectly. In Malawi, missing, inaccurate, or incomplete data has been noted in some facilities.

Aim: To determine the rate of unreported maternal and neonatal complications in a rural community hospital in Malawi during the first quarter of 2018.

Methods: A retrospective cross-sectional study was conducted at a rural community hospital. Maternity register records from January to March 2018 were compared to client charts during the same period to determine the accuracy of reported data. Descriptive statistics were computed for the data using SPSS v20.0 and are reported as percentages and frequencies.

Results and conclusion: A total of 360 client cases were identified during the study period, comprising 288 that were recorded in the maternity register and 72 additional cases that had charts but were not recorded in the maternity register. Final analysis was done on 327 cases. However, 59 (18%) maternal and 65 (19.9%) neonatal complications found in the charts were not recorded in the maternal register, indicating major discrepancies in the concordance of registry data and chart data. When the additional complications found on chart review were included, cases of maternal and neonatal complications increased from 31 and 33 to 90 and 98 respectively. Measures such as use of clerks in the maternity department to capture all records are needed to mitigate the gaps in record keeping and also formulating validation teams at the facility may improve the accuracy of data reporting.

Key words

Maternal complications, neonatal complications, maternity register, underreporting, record keeping, maternal outcomes, neonatal outcomes, Malawi

INTRODUCTION AND BACKGROUND

Maternal and neonatal complications, some of which are life-threatening, are a major cause of concern globally as they contribute to maternal and neonatal morbidity and mortality. Geller et al. reported an increase in severe maternal morbidity in both high-income and middle-and low-income countries despite the global reduction in maternal mortality rates [1]. However, underreporting of maternal and neonatal complications and outcomes has been noted in some high-income as well as middle-and low-income countries. For instance, research in New Zealand found fewer than 9% of maternal and perinatal severe adverse events were captured by the Perinatal and Maternal Mortality Reviews reported in the official documents published by the Health Equity and Safety Commission [2].

Similarly in Taiwan, two-thirds of maternal deaths were unreported in the officially published mortality data [3]. Underreporting in neonatal births and deaths has been recorded particularly in in low income countries. For instance in Vietnam, Malqvist et al. found that neonatal deaths were four times higher than the officially reported rates [4].

Limited availability, quality, and use of data inhibits the ability to track health progress and performance, to evaluate programs and policies, and to increase accountability at facility, country, and global levels [5]. In sub-Saharan Africa, low quality data has been documented in the health sector which limits its effective utilization [1,6]. In Malawi, uncaptured data, data errors, lack of accurate, complete, consistent, and timely data has been noted in some facilities [7,8,9].

The World Health Organisation recognizes a strong health information system as one of the building blocks of a functional health system [10]. Similarly, the Malawi Ministry of Health acknowledges the need for reliable data which forms evidence for making rational decisions [11]. Health management information systems (HMIS) registers and client records have been identified as the basic tools that guide clinical decision-making by healthcare workers. These tools enable systems to collect data, report, and plan for improving the quality and coverage of health services [12].

Malawi, a low-income country in southern Africa, has a total population of 17,563,749 [13] and maternal mortality ratio of 439/100,000 live births and neonatal mortality of 27/1,000 live births [14]. Despite adoption of the HMIS platform in 2002 in Malawi, the data system faces challenges such as missing and poorly recorded data [7]. Anecdotally, Malawian maternity nurses suggest that reported rates of obstetric and neonatal complications underestimate the true rate of intrapartum complications. To explore discrepancies in reporting and actual complication rates, this study reviewed maternity register and client charts to investigate the possibility of unreported maternal and neonatal complications at a rural community hospital in Malawi. The aim was to determine the rate of unreported cases of maternal and neonatal complications in the maternity register in the community hospital during the first quarter of 2018.

METHODOLOGY

A retrospective descriptive cross-sectional study was conducted using data from maternity registers and client charts. The primary outcome measure was the proportion of maternal and neonatal complications identified in the maternity register compared with the complications identified in the client charts. The study setting was a community hospital located in a rural mountainous district in southern Malawi.

The district is enriched by the presence of a large international non-governmental organization which supports the operations of the health facilities with human and material resources. The district has two hospitals (a district hospital and a community hospital), and 12 primary health facilities. In addition to serving about 45% of the population in the district as a referral facility for six of the primary health centers, the community hospital also serves patients from three nearby districts. As a facility which provides Comprehensive Emergency Obstetric and Neonatal Care (CEmONC), the hospital has an operating theatre, a laboratory and a maternity department consisting of the maternity waiting home, labor ward and postnatal ward where blood transfusion services are available. There was a total of nine nurse-midwives, nine clinical officers (who rotate through the department on call), and a medical officer (who is on cover) in the maternity/neonatal department. All clients who require further management are referred to the district hospital. A total of 1,120 deliveries were recorded at the community hospital in 2017.

The maternity register was developed by the Central Monitoring and Evaluation Division (CMED) in the Malawi Ministry of Health for documentation of clients’ data during intrapartum care in order to standardize the documentation of relevant information at facility level. The maternity register, which is paper-based, captures variables including the name of the client, age, date of admission and birth details including mode of delivery; HIV status, obstetric and neonatal complications and corresponding medical interventions, and maternal and neonatal survival outcomes. Obstetric complications stipulated in the register include antepartum hemorrhage (APH), postpartum hemorrhage (PPH), obstructed or prolonged labor (OPL), pre-eclampsia or eclampsia, sepsis, ruptured uterus, and “other”. Neonatal complications include birth asphyxia, neonatal sepsis, prematurity and low birth weight, and “other”. The national maternity register (version 3) used during this study required the reporter to choose one leading complication for mother and neonate. The register was revised in 2017 (version 4) to allow reporting of multiple complications as well as the inclusion of other complications, such as retained placenta and preterm labor.

Paper-based case records, including the Malawian national partograph, are used for all women during the intrapartum and postpartum period. The data from each client are recorded in the maternity and postnatal registers during hospitalization. Summaries of maternal and neonatal complications and outcomes are uploaded on a monthly basis directly from the facility to the District Health Information Software version 2 (DHIS 2) which is managed by the District Health Management Information office and later fed into the national database.

All maternity registers for the community hospital between January and March of 2018 were reviewed and compared with client charts for evidence of maternal and neonatal complications. The maternal complications listed in the register included antepartum/ postpartum hemorrhage (APH/PPH), obstructed/ prolonged labor (OPL), pre-eclampsia (ECL), ruptured uterus and others. The column labeled ‘other’ could be filled if there were complications not listed in the register. The neonatal complications listed in the register included neonatal sepsis, preterm, low birth weight, asphyxia and others which included congenital abnormalities and meconium aspiration. These complications were included in the analysis because they are the common causes of maternal and neonatal morbidity and mortality in Malawi.

With the assistance of some nurses and midwives working in the department, one member of the research team extracted data from the registers, crossed checked with client charts to note if there was any discrepancy in the maternal and neonatal complications identified in the maternity register compared with the complications identified in the client charts. Data analysis was done using SPSS version 20.0. Descriptive statistics were calculated to determine the frequencies and percentages of clients with unreported complications.

Ethical considerations

The study involved record review only. No identifying information was collected; therefore, it was considered exempt. Additionally, this work was within the scope of the hospital’s clinical protocol for routine data review and dissemination, however the permission to publish it was received from the district Research and Ethics Committee headed by the District Health Officer.

RESULTS

There were 360 deliveries identified from January to March, 2018, out of which 288 cases were recorded in the maternity register and 72 had charts but were not recorded in the maternity register. Out of 288 clients that were registered in the monthly maternity register during the study period, 33 were missing charts. Thus, 29.17% (n=105) of the total cases were either not registered or missing from the client charts that were reviewed. Between cases in the registers and cases with charts but not in the register, there were 327 client charts available for review, of which 71.3% (n=233) had no maternal complications recorded in the maternity register. An additional 59 maternal complications and an additional 65 neonatal complications were found in client charts, a two-fold increase from complications reported in the maternity register (Figure 1).

Figure 1: Flow diagram indicating the number of charts reviewed

Thirty-one maternal complications were reported in the maternity registers during the study period. However, an additional 59 maternal complications were found in client charts (not in the register), including seven cases of APH/PPH, 29 cases of OPL, five cases of pre-eclampsia, three cases of sepsis, and 18 cases of either malpresentation, previous scar, retained placenta, or ruptured uterus. Together with the maternal complications reported in the register, the total number of complications was 90 during the study period (Table 1).

Table 1: Percentages for reported and unreported maternal complications from January to March 2018 comparing client charts with monthly maternity register

Complication

January n=34

February n=26

March n=30

Total n=90 (%)

Reported (in register)

Not reported

Reported (in register)

Not reported

Reported (in register)

Not reported

Reported (in register)

Not reported

APH

1

2

1

0

0

0

2 (50)

2 (50)

PPH

2

3

4

1

1

1

7 (58.3)

5 (41.7)

OPL

4

8

7

7

4

14

15 (34.1)

29 (65.9)

(Pre)Eclampsia

2

3

0

1

0

1

2 (28.6)

5 (71.4)

Sepsis

1

1

0

1

1

1

2 (40)

3 (60)

Ruptured uterus

0

0

0

0

0

0

0

0

Other

1

6

0

4

2

5

3 (10)

15 (90)

TOTAL (%)

11 (32.4)

23 (67.6)

12 (46.2)

14 (53.8)

8 (26.7)

22 (73.3)

31 (34.4)

59 (65.6)

Similarly, 33 neonatal complications were reported in the monthly maternity register, but an additional 65 unreported complications were found in the client charts, bringing the actual number of neonatal complications to 98. Out of the 65 unreported neonatal complications, the following were identified: 29 neonatal sepsis, 13 LBW, 10 preterm birth, 7 asphyxia and 6 others (Table 2).

Table 2: Percentages of reported and unreported neonatal complications from January to March 2018 comparing client charts with monthly maternity register

Complication

January n=34

February n=22

March n=40

Total n=96 (%)

Reported (in register)

Not reported

Reported (in register)

Not reported

Reported (in register)

Not reported

Reported (in register)

Not reported

LBW (<2.5kg)

4

8

2

1

7

4

13 (50)

13 (50)

Prematurity

3

1

5

4

2

7

10 (45.5)

12 (55.5)

Asphyxia

1

2

0

1

4

4

5 (41.6)

7 (58.4)

Sepsis

1

10

0

8

1

9

2 (6.5)

29 (93.5)

Other

3

1

0

1

0

2

3 (42.8)

4 (57.2)

TOTAL (%)

12 (35.3)

22 (64.7)

7 (31.8)

15 (68.2)

14 (35)

26 (65)

33 (33.7)

65 (66.3)

DISCUSSION

This analysis revealed major discrepancies in maternal and neonatal complications documented in maternity registers and client charts. While information in the maternity records is shared at the district level, the additional information found in the client charts is not captured, leading to underreporting of key complications in mothers and neonates in the study setting. Accurate record keeping is key for improving the quality of health care through accurate and timely decision making and ensuring patient safety [15]. Poor reporting, on the other hand, leads to incorrect output, which in turn affects human, material, and financial resources. If complications were accurately reported, a plan to improve prevention measures could have been undertaken by the facility.

In this study, there were twice as many complications found in the client charts than were reported in the monthly maternity register. Underreporting was similarly noted on maternal mortality in New Zealand and Taiwan, where fewer than 9% and 33% of maternal deaths were reported in their official documents, respectively [2,3]. Underreporting may also affect equitable distribution of resources, especially in low resource settings like Malawi where distribution of resources depends on caseload. A facility may be misclassified and allocated inadequate resources based on underreporting of cases. Conversely, another study found that safe motherhood coordinators in some facilities were inflating figures in reports in order for the facilities to receive more resources [7].

The nurses and midwives at the hospital in this study are responsible for entering client records in the maternity register. According to the Malawi Health Workforce Observatory, the nurse-patient ratio is high in Malawi at 1: 2,643 populations [16]. Due to staffing shortages, two nurse-midwives are allocated to each shift to care for antepartum, intrapartum, postpartum including post-caesarian section clients and both healthy and sick neonates. Considering the high number of deliveries conducted in this facility, nurses likely prioritize giving care to the clients over record keeping and maintaining the register. Similar findings were noted in other parts of Malawi where nurses and midwives complained of having increased workload which resulted in committing data errors [7,9]. In addition, there is a high turnover of nurse-midwives in the maternity area, which, apart from creating staff shortages, results in the loss of experienced staff who may be more familiar with documentation and recording of data in the maternity register. High staff turnover was also noted in other resource limited facilities in Kenya and Uganda where challenges were noted in data completeness during an intervention to improve data quality in preterm birth measurement [17].

The use of non-clinical staff, such as ward clerks, to document client details in the register may improve comprehensive register reporting. This model is used in some facilities in Malawi, especially at district hospitals, where clerks are allocated in different wards to capture data for the hospital. Having a ward clerk who is accountable in the maternity department at this facility would not only improve data recording in the register but also in record keeping of client’s files. However, these data clerks should be provided with adequate supportive supervision to ensure there is registry of good quality data.

Among other things, records serve a vital educational and epidemiological purpose as they provide an opportunity for auditing the quality of services and care given to clients [18] and act as the basis for more accurate statistics [19]. Poor record keeping jeopardizes quality improvement efforts through clinical and death audits because such interventions require client records to assess patient care and make sound recommendations for improved care in future.

Client clinical records can also be used for investigating serious incidents and client complaints. In this event of litigation, poor record-keeping implies poor care because any care that was done very well but was not documented is treated as care not done [20]. Poor record keeping, including missing or irretrievable records, increases medico-legal risks and can serve as the basis of legal cases brought against health care professionals. Therefore, good record keeping serves as a defense for healthcare providers in cases of allegations of malpractice.

Monthly data reports at the facility level informs the district which, in turn, informs the national information system. Therefore, under-reporting at facility level may affect the national statistics. It is unclear whether the reported data is checked for quality at the facility level as per guidelines in the 2015 Malawi National Health Information System Policy [11]. The policy mandates that health facilities perform their own independent data quality assessments on a regular basis as part of the continuous quality improvement efforts. In a study assessing the implementation of HMIS at the district level, it was found that there were no structures for authentication of data at facility level [7]. Findings from another study in Pakistan led to the development of a standard and simplified reporting procedure to manage under-reporting [21]. Similar efforts can be done at the facility level to prevent and manage under-reporting. For instance, building a team comprising clinical and data management staff to validate the data for completeness and accuracy would ensure improved quality of data before reporting is finalized at facility level.

Neonatal sepsis was highest among complications that were under-reported during the study period. It is possible that neonates who developed sepsis later after birth were not captured in the register. As a community hospital without a nursery for sick infants, there is no register for sick infants despite the fact that sick infants are cared for in the maternity department. In 2015, neonatal sepsis contributed 18.6% of the total neonatal deaths in Malawi [22]. Currently neonatal death rate is 27 per 1,000 live births [14]. These figures may be very conservative if other facilities are also underreporting.

Almost half to three quarters of maternal complications were not documented in the register during the first quarter of 2018. Importantly, the primary complications found missing from the maternity register in this study, including (pre)eclampsia, postpartum hemorrhage and sepsis, are the common causes of maternal morbidity in Africa [23], including Malawian settings [24].

Strengths of this study include investigator’s access and familiarity with the study site and staff. All maternity registers and available client charts were accessible to the study team. Limitations include the fact that only one community hospital was evaluated during the study period. Outcomes may be different in the district hospital or at the health center level. However, given the staff shortages throughout the district, it is likely that the problem is pervasive. There is need to improve in the quality of data captured in the maternity department.

CONCLUSION

There was poor record keeping and under-reporting of maternal and neonatal complications in the first quarter of 2018 at a rural community hospital in Malawi. Underreporting of maternal and neonatal complications undermines efforts to monitor the quality, safety, and experience of maternity services at local level. Given the level of unreported maternal and neonatal complications in this study, there is need for a review process to assess potential ways to improve documentation of patient experiences. Measures such as use of clerks in the maternity department to capture all records are needed to mitigate the gaps in record keeping and also formulating validation teams at the facility may improve the accuracy of data reporting.

Acknowledgments

The authors would like to acknowledge the hospital clinical and nursing in-charge, sister in-charge and staff in the maternity department for their support during data compilation for the review. The clinical and nursing teams who provide care to mothers and neonates in the hospital deserve special appreciation.

References

1. Geller SE, Koch AR, Garland CE, MacDonald EJ, Storey F, Lawton B. A global view of severe maternal morbidity: Moving beyond maternal mortality. Reprod Health. 2018;15(1), 98. https://doi.org/10.1186/s12978-018-0527-2

2. Farquhar C, Armstrong S, Kim B, Masson V, Sadler L. Under-reporting of maternal and perinatal adverse events in New Zealand. BMJ Open. 2015;5(7) https://doi.org/10.1136/bmjopen-2015-007970

3. Wu T-P, Huang Y-L, Liang F-W, Lu T-H. Underreporting of maternal mortality in Taiwan: A data linkage study. Taiwan J Obstet Gynecol. 2015;54(6), 705–708. https://doi.org/10.1016/j.tjog.2015.10.002

4. Malqvist M, Eriksson L, Nga N T, et al. Unreported births and deaths, a severe obstacle for improved neonatal survival in low-income countries: A population-based study. BMC Int Health and Hum Rights, 2008;8(4) https://doi.org/10.1186/1472-698X-8-4

5. Chan M, Kazatchkine M, Lob-Levyt J et al. Meeting the Demand for Results and Accountability: A Call for Action on Health Data from Eight Global Health Agencies. PLoS Med. 2010;7(1), e1000223. https://doi.org/10.1371/journal.pmed.1000223

6. Elmula Z F, Bolad A K. Standard documentation of paper-based medical records at four main hospitals in Khartoum state, Sudan, 2014–2015. Al-Basar Int J Ophthalm. 2017;4(3), 75. https://doi.org/10.4103/bijo.bijo_9_17

7. Kasambala A, Kumwenda S, Kalulu K et al. Assessment of implementation of health management information sysyem at district level in Southern Malawi. Malawi Med J. 2017;29(3), 240–246.

8. Khwima, E, Msiska N, Kumitawa A, Kumwenda B. Factors affecting utilization of electronic medical records system in Malawian central hospital. Malawi Med J 2017;29(3), 247–253.

9. Tough A G, Lihoma P. Medical record keeping systems in Malawi: Is there a case for hybrid systems and intermediate technologies? Rec Man J. 2018;28(3), 265–277.

10. World Health Organisation. 2007 Everybody’s Business: Strengthening Health Systems to Improve Health Outcomes: WHO’s Framework for Action. Retrieved from WHO website: http://www.who.int/ healthsystems/strategy/everybodys_business.pdf

11. Malawi Ministry of Health. Malawi National Health Information System Policy. 2015 MOH.

12. Dwivedi V, Drake M, Rawlins B, Strachan M, Monga T, Unfried K. A Review of the Maternal and Newborn Health Content of National Health Management Information Systems in Sub-Saharan Africa and South Asia. MCHIP. 2017.

13. National Statistical Office (NSO). 2018 Population and Housing Census Preliminary Report. Government of Malawi 2018.

14. National Statistical Office (NSO), ICF International. Malawi Demographic Health Survey 2015-16. Final Report 2017. Retrieved from http://www.nsomalawi.mw/images/stories/data_on_line/demography/mdhs2015_16/MDHS%202015-16%20Final%20Report.pdf

15. Schaeffer J. Poor documentation: How it happens and how to fix it. For the Record. 2016; 28(5), 12.

16. Malawi Health Workforce Observatory. Human Resource for Health Country Profile Malawi. The Republic of Malawi 2010

17. Keating R, Merai R, Mubiri P et al. Assessing effects of a data quality strengthening campaign on completeness of key fields in facility-based maternity registers in Kenya and Uganda. East Afr J Appl Health Monitor Eval. 2019 (3). Retrieved from http://eajahme.com/assessing-effects-of-a-data-quality-strengthening-campaign-on- completeness-of-key-fields-in-facility-based-maternity-registers-in-kenya-and-uganda/

18. Mathioudakis A, Ilona R, Anertamli G, Neil S, Geogia H. How to keep good clinical records. Breathe (Shelf). 2016;12(4), 369–373.

19. Pirkle C, Dumont A, Zunzunegui M. Medical record keeping: Essential but overlooked aspect of quality of care in resource-limited settings. Int J Qual Health Care. 2012;24(6), 564–567.

20. Abdelrahman W, Abdelmageed A. Medical record keeping: Clarity, accuracy and timeliness are essential. Br Med J. 2014;348.

21. Zakar MZ, Zakar R, Mustafa M, Jalil A, Fischer F. Under-reporting of stillbirths in Pakistan: Perspectives of the parents, community and healthcare providers. BMC Pregnancy Childbirth. 2018;18(22).

22. UNICEF. Malawi: Maternal and Newborn Health Disparities, country profile_MWI. 2016. Retrieved May 4, 2018, from https://data.unicef.org/wp-content/uploads/country_profiles/Malawi/country%20profile_MWI.pdf

23. Khan KS, Wojdyla D, Say L, Gülmezoglu AM, Van Look PF. WHO analysis of causes of maternal death: A systematic review. Lancet. 2006;367(9516), 1066–1074. https://doi.org/10.1016/S0140-6736(06)68397-9

24. Combs Thorsen V, Sundby J, Malata A. Piercing together the maternal death puzzle through narratives: The three delays model revisited. PLoS One. 2012; 7(12), e52090.

Total deliveries Jan - March 2018 (register + charts)

360

Registered in maternity register

288

Not registered in maternity register but chart present

72

Chart unavailable/missing

33

Charts present

255

Charts reviewed

327

No complication found

223

Complication, previously reported

Maternal = 31

Neonatal = 33

Complication, not previously reported

Maternal = 59

Neonatal = 65

Underreporting of maternal and neonatal complications

10