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Cited by 88Global Maternal and Child HealthMaternal and fetal healthcareMaternal and Neonatal Healthcare

Death audits and reviews for reducing maternal, perinatal and child mortality

Open access
Willcox, Merlin L, Price, Jessica, Scott, Sophie, Nicholson, Brian D, Stuart, Beth, Roberts, Nia W, Allott, Helen, Mubangizi, Vincent +2 more·2020·Cochrane Database of Systematic Reviews
DOI 10.1002/14651858.cd012982.pub2PMC PMC7093891
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Abstract

BACKGROUND: The United Nations' Sustainable Development Goals (SDGs) include reducing the global maternal mortality rate to less than 70 per 100,000 live births and ending preventable deaths of newborns and children under five years of age, in every country, by 2030. Maternal and perinatal death audit and review is widely recommended as an intervention to reduce maternal and perinatal mortality, and to improve quality of care, and could be key to attaining the SDGs. However, there is uncertainty over the most cost-effective way of auditing and reviewing deaths: community-based audit (verbal and social autopsy), facility-based audits (significant event analysis (SEA)) or a combination of both (confidential enquiry). OBJECTIVES: To assess the impact and cost-effectiveness of different types of death audits and reviews in reducing maternal, perinatal and child mortality. SEARCH METHODS: We searched the following from inception to 16 January 2019: CENTRAL, Ovid MEDLINE, Embase OvidSP, and five other databases. We identified ongoing studies using ClinicalTrials.gov and the World Health Organization (WHO) International Clinical Trials Registry Platform, and searched reference lists of included articles. SELECTION CRITERIA: Cluster-randomised trials, cluster non-randomised trials, controlled before-and-after studies and interrupted time series studies of any form of death audit or review that involved reviewing individual cases of maternal, perinatal or child deaths, identifying avoidable factors, and making recommendations. To be included in the review, a study needed to report at least one of the following outcomes: perinatal mortality rate; stillbirth rate; neonatal mortality rate; mortality rate in children under five years of age or maternal mortality rate. DATA COLLECTION AND ANALYSIS: We used standard Cochrane Effective Practice and Organisation of Care (EPOC) group methodological procedures. Two review authors independently extracted data, assessed risk of bias and assessed the certainty of the evidence using GRADE. We planned to perform a meta-analysis using a random-effects model but included studies were not homogeneous enough to make pooling their results meaningful. MAIN RESULTS: We included two cluster-randomised trials. Both introduced death review and audit as part of a multicomponent intervention, and compared this to current care. The QUARITE study (QUAlity of care, RIsk management, and TEchnology) concerned maternal death reviews in hospitals in West Africa, which had very high maternal and perinatal mortality rates. In contrast, the OPERA trial studied perinatal morbidity/mortality conferences (MMCs) in maternity units in France, which already had very low perinatal mortality rates at baseline. The OPERA intervention in France started with an outreach visit to brief obstetricians, midwives and anaesthetists on the national guidelines on morbidity/mortality case management, and was followed by a series of perinatal MMCs. Half of the intervention units were randomised to receive additional support from a clinical psychologist during these meetings. The OPERA intervention may make little or no difference to overall perinatal mortality (low certainty evidence), however we are uncertain about the effect of the intervention on perinatal mortality related to suboptimal care (very low certainty evidence).The intervention probably reduces perinatal morbidity related to suboptimal care (unadjusted odds ratio (OR) 0.62, 95% confidence interval (CI) 0.40 to 0.95; 165,353 births; moderate-certainty evidence). The effect of the intervention on stillbirth rate, neonatal mortality, mortality rate in children under five years of age, maternal mortality or adverse effects was not reported. The QUARITE intervention in West Africa focused on training leaders of hospital obstetric teams using the ALARM (Advances in Labour And Risk Management) course, which included one day of training about conducting maternal death reviews. The leaders returned to their hospitals, established a multidisciplinary committee and started auditing maternal deaths, with the support of external facilitators. The intervention probably reduces inpatient maternal deaths (adjusted OR 0.85, 95% CI 0.73 to 0.98; 191,167 deliveries; moderate certainty evidence) and probably also reduces inpatient neonatal mortality within 24 hours following birth (adjusted OR 0.74, 95% CI 0.61 to 0.90; moderate certainty evidence). However, QUARITE probably makes little or no difference to the inpatient stillbirth rate (moderate certainty evidence) and may make little or no difference to the inpatient neonatal mortality rate after 24 hours, although the 95% confidence interval includes both benefit and harm (low certainty evidence). The QUARITE intervention probably increases the percent of women receiving high quality of care (OR 1.87, 95% CI 1.35 - 2.57, moderate-certainty evidence). The effect of the intervention on perinatal mortality, mortality rate in chi

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  • Maternal and perinatal death reviews, when implemented alongside training and development of local leadership, might lead to significant reductions in maternal and perinatal mortality.

    “There is evidence to suggest that maternal and perinatal death reviews, when implemented alongside training and development of local leadership might lead to significant reductions in maternal and perinatal mortality [20–22]”

    From Implementation of maternal and perinatal death surveillance and response (MPDSR) in humanitarian settings: insights and experiences of humanitarian health practitioners and global technical expert meeting attendees (2022) · cites this paper as [22]

    The Authors’ conclusions report that maternal death reviews combined with training and local leadership development reduced inpatient maternal mortality in district hospitals of low-income countries. But the Results find little or no difference in overall perinatal mortality in the perinatal-review trial; the review does not establish a significant reduction in that outcome. The claim therefore extends the supported maternal finding to perinatal mortality. (LLM, conf=0.90)

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Cited by

Sorted by citations

Authors
Willcox, M. L., Price, J., Scott, S., Nicholson, B. D., Stuart, B., Roberts, N. W., Allott, H., Mubangizi, V., Dumont, A., & Harnden, A.
Affiliations
  • University of Southampton (GB)
  • University of Oxford (GB)
  • Liverpool School of Tropical Medicine (GB)
  • Mbarara University of Science and Technology (UG)
  • Institut de Recherche pour le Développement (FR)
Corresponding author
Willcox, Merlin L
ORCID
Venue
Cochrane Database of Systematic Reviews
Publisher
Wiley
Published
2020-03-25
Volume
2020
Issue
3
Pages
CD012982-CD012982
ISSN
  • 1361-6137 (ISSN-L)
  • 1465-1858
DOI
10.1002/14651858.cd012982.pub2
PMC
PMC7093891
OpenAlex
W2790202348
Cited by
88
References
5
Citations by year
2026: 6 · 2025: 5 · 2024: 18 · 2023: 21 · 2022: 19 · 2021: 9 · 2020: 8 · 2019: 1 · 2018: 1
FWCI
3.13
Type
journal article
Language
en
Open access
Locations
  • Cochrane Database of Systematic Reviews (publishedVersion)
  • Europe PMC (PubMed Central) (publishedVersion, cc-by-nc)
  • PubMed Central (publishedVersion, cc-by-nc)
  • PubMed (publishedVersion)
  • LSTM Online Archive (Liverpool School of Tropical Medicine) (acceptedVersion)
  • HAL (submittedVersion)
  • ePrints Soton (University of Southampton) (submittedVersion)
Funders
  • World Health Organization
  • McMaster University
  • National Institute for Health and Care Research (CL-2016–26–005)
Topics
  • Health Sciences › Medicine › Pediatrics, Perinatology and Child Health › Global Maternal and Child Health
  • Health Sciences › Medicine › Pediatrics, Perinatology and Child Health › Maternal and fetal healthcare
  • Health Sciences › Health Professions › General Health Professions › Maternal and Neonatal Healthcare
Keywords
maternal death audit, child mortality, verbal autopsy, social autopsy, significant event analysis, confidential enquiry into maternal deaths, healthcare quality improvement, avoidable causes of death, maternal mortality, perinatal mortality, neonatal mortality, cost-effectiveness, Sustainable Development Goals, maternity ward, hospital quality improvement
MeSH terms
Child, Child, Preschool, Female, Humans, Infant, Infant Mortality, Infant, Newborn, Pregnancy, Pregnancy Complications, Randomized Controlled Trials as Topic, Child Mortality, Stillbirth, Perinatal Mortality, Clinical Audit

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