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Counting every stillbirth and neonatal death through mortality audit to improve quality of care for every pregnant woman and her baby
Open accessAbstract
BACKGROUND: While there is widespread acknowledgment of the need for improved quality and quantity of information on births and deaths, there has been less movement towards systematically capturing and reviewing the causes and avoidable factors linked to deaths, in order to affect change. This is particularly true for stillbirths and neonatal deaths which can fall between different health care providers and departments. Maternal and perinatal mortality audit applies to two of the five objectives in the Every Newborn Action Plan but data on successful approaches to overcome bottlenecks to scaling up audit are lacking. METHODS: We reviewed the current evidence for facility-based perinatal mortality audit with a focus on low- and middle-income countries and assessed the status of mortality audit policy and implementation. Based on challenges identified in the literature, key challenges to completing the audit cycle and affecting change were identified across the WHO health system building blocks, along with solutions, in order to inform the process of scaling up this strategy with attention to quality. RESULTS: Maternal death surveillance and review is moving rapidly with many countries enacting and implementing policies and with accountability beyond the single facility conducting the audits. While 51 priority countries report having a policy on maternal death notification in 2014, only 17 countries have a policy for reporting and reviewing stillbirths and neonatal deaths. The existing evidence demonstrates the potential for audit to improve birth outcomes, only if the audit cycle is completed. The primary challenges within the health system building blocks are in the area of leadership and health information. Examples of successful implementation exist from high income countries and select low- and middle-income countries provide valuable learning, especially on the need for leadership for effective audit systems and on the development and the use of clear guidelines and protocols in order to ensure that the audit cycle is completed. CONCLUSIONS: Health workers have the power to change health care routines in daily practice, but this must be accompanied by concrete inputs at every level of the health system. The system requires data systems including consistent cause of death classification and use of best practice guidelines to monitor performance, as well as leaders to champion the process, especially to ensure a no-blame environment, and to access change agents at other levels to address larger, systemic challenges.
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![Figure 3 Adoption of maternal and perinatal death notification in Countdown priority countries. Countries with perinatal mortality audit in policy or a national system for facility review of perinatal deaths in 2014: 17 (Angola, Azerbaijan, Bangladesh, Gabon, Gambia, Indonesia, Iraq*, Kenya, Liberia*, Mexico*, South Africa, Rwanda, Tanzania, Uganda, Uzbekistan, Zambia*, Zimbabwe). *refers to stillbirths only or early neonatal only; not both. Sources: [9,13,61,62] See additional file 1 for more details.](/paper-figures/a8aa9334c421473eae388f2cfc6866ca/counting-every-stillbirth-and-neonatal-death-through-mortality-audit-to-improve-figure-3.jpg)




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“A culture of trust is nurtured by strong leadership and continuous re-assurance of a “blame-free culture” [24].”
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 [24]
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“In low resource settings where the numbers of maternal and perinatal deaths are the highest, significant challenges have been identified in the MPDSR process, including the quality of mortality reviews and linkage to concrete actions [23, 24].”
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“Favourable policies for MPDSR are in place,(32) yet few countries have robust operational MPDSR systems,(32) and the likelihood for improvement only occurs if the audit cycle is fully implemented.(31) We examine the health systems drivers of MPDSR through service delivery, societal and systems lenses and across health…”
BackgroundImproving Rates of Early Entry Prenatal Care in an Underserved Population
Shah, J. S., Revere, L., & Toy, E. C. (2018) · Maternal and Child Health Journal · doi:10.1007/s10995-018-2569-z · Cited by 30
Laopaiboon, M., Lumbiganon, P., Rattanakanokchai, S., Chaiwong, W., Souza, J. P., Vogel, J. P., Mori, R., & Gülmezoglu, A. M. (2019) · BMC Pediatrics · doi:10.1186/s12887-019-1546-z · Cited by 30
Gutman, A., Harty, T., O’Donoghue, K., Greene, R. A., & Leitão, S. (2022) · Journal of Perinatal Medicine · doi:10.1515/jpm-2021-0363 · Cited by 32
“Although in the past decades 51 countries have implemented audit policies for maternal mortality and morbidity, only 17 countries have implemented similar policies for perinatal mortality and morbidity [14].”
BackgroundPaternal post-partum depression: How has it been assessed? A literature review
Pérez C., F., Brahm, P., Riquelme, S., Rivera, C., Jaramillo, K., & Eickhorst, A. (2017) · Mental Health & Prevention · doi:10.1016/j.mhp.2017.07.001 · Cited by 28
Adinew, Y. M., Asseffa, N. A., & Adinew, Y. M. (2018) · BioMed Research International · doi:10.1155/2018/3249786 · Cited by 28
Russell, N., Tappis, H., Mwanga, J. P., Black, B., Thapa, K., Handzel, E., Scudder, E., Amsalu, R., Reddi, J., Palestra, F., et al. (2022) · Conflict and Health · doi:10.1186/s13031-022-00440-6 · Cited by 27
Orobaton, N., Austin, A. M., Abegunde, D., Ibrahim, M. A., Mohammed, Z., Abdulazeez, J., Ganiyu, H., Nanbol, Z., Fapohunda, B. M., & Beal, K. (2016) · Malaria Journal · doi:10.1186/s12936-016-1578-x · Cited by 27
“Nonetheless, the true magnitude of stillbirths in Nigeria is difficult to estimate in the absence of standardized national policies or protocols that enjoin facilities and communities to record, audit or to review causes of stillbirth [18].”
BackgroundShogren, M. D., Harsell, C., & Heitkamp, T. (2017) · Journal of Midwifery & Women s Health · doi:10.1111/jmwh.12659 · Cited by 29
Community, M., Packer, J. M., Rangers, Y., Turpin, G., Ens, E. J., Venkataya, B., & Hunter, J. (2019) · Journal of Ethnobiology and Ethnomedicine · doi:10.1186/s13002-019-0348-6 · Cited by 26
Perinatal mortality audits and reviews: Past, present and the way forward
Helps, Ä., Leitão, S., Greene, R. A., & O’Donoghue, K. (2020) · European Journal of Obstetrics & Gynecology and Reproductive Biology · doi:10.1016/j.ejogrb.2020.04.054 · Cited by 28
Hoque, M., Hoque, M. E., Hal, G. F. V., & Buckus, S. (2021) · Southern African Journal of Infectious Diseases · doi:10.4102/sajid.v36i1.296 · Cited by 26
Bottom-up development of national obstetric guidelines in middle-income country Suriname
Verschueren, K. J. C., Kodan, L. R., Brinkman, T. K., Paidin, R. R., Henar, S. S., Kanhai, H. H. H., Browne, J. L., Rijken, M. J., & Bloemenkamp, K. W. M. (2019) · BMC Health Services Research · doi:10.1186/s12913-019-4377-6 · Cited by 25
Kortekaas, J. C., Scheuer, A. C., de Miranda, E., van Dijk, A. E., Keulen, J. K. J., Bruinsma, A., Mol, B. W., Vandenbussche, F. P. H. A., & van Dillen, J. (2018) · BMC Pregnancy and Childbirth · doi:10.1186/s12884-018-1973-0 · Cited by 24
(2023) · doi:10.1186/s12884-023-05536-2 · Cited by 21
“On the other hand, the establishment of a central national administrative support system, the availability of support structures and policies, training and resources (financial, human and materials) ensured smooth performance of the FMDR committees in countries such as Malaysia, the Republic of South Africa and the Un…”
BackgroundInvolvement of Male Partners in Skilled Birth Care in the North Dayi District, Ghana
Saah, F. I., Tarkang, E. E., Komesuor, J., Osei, E., Acquah, E., & Amu, H. (2019) · International Journal of Reproductive Medicine · doi:10.1155/2019/2852861 · Cited by 22
Waiswa, P., Wanduru, P., Okuga, M., Kajjo, D., Kwesiga, D. K., Kalungi, J., Nambuya, H., Mulowooza, J., Tagoola, A., & Peterson, S. (2021) · Global Health Science and Practice · doi:10.9745/ghsp-d-20-00156 · Cited by 22
“Many countries report that the implementation of recommendations is a missing link in the MPDR process.(16,17) Another key achievement was linking the MPDR to the plan-dostudy-act cycle to help devise feasible solutions to address identified bottlenecks and solve the lack of action onMPDR recommendations.”
BackgroundSilver, R. M., & Reddy, U. M. (2024) · American Journal of Obstetrics and Gynecology · doi:10.1016/j.ajog.2024.05.042 · Cited by 22
Mesfin, S., Dheresa, M., Fage, S. G., & Tura, A. K. (2021) · International Journal of Women s Health · doi:10.2147/ijwh.s300143 · Cited by 21
Musabwasoni, M. G. S., Kerr, M. S., Babenko‐Mould, Y., Nzayirambaho, M., & Ngabonzima, A. (2020) · International Journal of Nursing Education Scholarship · doi:10.1515/ijnes-2020-0010 · Cited by 19
Doherty, E., Kingsland, M., Wolfenden, L., Wiggers, J., Dray, J., Hollis, J., Elliott, E., Daly, J., Bailey, K., Attia, J., et al. (2019) · Systematic Reviews · doi:10.1186/s13643-019-1193-3 · Cited by 5
Mersha, A. M., Shibiru, S., Gultie, T., Degefa, N., & Bante, A. (2019) · BMC Health Services Research · doi:10.1186/s12913-019-4772-z · Cited by 19
Tsegaye, R., Etafa, W., Wakuma, B., Mosisa, G., Mulisa, D., & Tolossa, T. (2020) · BMC Public Health · doi:10.1186/s12889-020-09903-y · Cited by 19
Attention to women in situation of intrauterine fetal death: experiences of health professionals
Serafim, T. C., Camilo, B. H. N., Carizani, M. R., Gervasio, M. D. G., Carlos, D. M., & Salim, N. R. (2021) · Revista gaúcha de enfermagem · doi:10.1590/1983-1447.2021.20200249 · Cited by 22
Accountability for improving maternal and newborn health
Scott, H. M., & DANEL, I. A. (2016) · Best Practice & Research Clinical Obstetrics & Gynaecology · doi:10.1016/j.bpobgyn.2016.05.009 · Cited by 19
Johnson, M., Whelan, B., Relton, C., Thomas, K. J., Strong, M., Scott, E., & Renfrew, M. J. (2018) · BMC Pregnancy and Childbirth · doi:10.1186/s12884-017-1651-7 · Cited by 19
Vandyousefi, S., Davis, J. N., & Gunderson, E. P. (2021) · Diabetologia · doi:10.1007/s00125-020-05379-y · Cited by 26
Saarikko, J., Niela‐Vilén, H., Rahmani, A. M., & Axelin, A. (2021) · BMC Pregnancy and Childbirth · doi:10.1186/s12884-021-03689-6 · Cited by 19
Advances to diminish global newborn kernicterus mortality
Bhutani, V. K., Vidavalur, R., & Wong, R. J. (2023) · Journal of Perinatology · doi:10.1038/s41372-023-01862-7 · Cited by 18
“Indices of adverse events of EHB, such as mortality, chronic athetoid cerebral palsy by the age of 5 years, and sensorineural hearing loss at school age, have however been dif fi cult to standardize, collect, and monitor [25, 26].”
Non-maleficence and the ethics of consent to cancer screening
Elton, L. (2020) · Journal of Medical Ethics · doi:10.1136/medethics-2020-106135 · Cited by 18
Implementation of maternal and perinatal death reviews: a scoping review protocol
Kinney, M. V., Walugembe, D. R., Wanduru, P., Waiswa, P., & George, A. S. (2019) · BMJ Open · doi:10.1136/bmjopen-2019-031328 · Cited by 15
Squires, F., Hilber, A. M., Cordero, J. P., Boydell, V., Portela, A. G., Sabin, M. L., & Steyn, P. S. (2020) · PLoS ONE · doi:10.1371/journal.pone.0238776 · Cited by 20
“(2015) [41] Two definitions of community perinatal audits are described: 1) Surveillance of community births and deaths, in which trained community workers visit households following a death and conduct social and/or verbal autopsy to feed back into a local or centralised data collection system 2) Involvement in facil…”
BackgroundMethodInfluentialCampbell, P. T., Geard, N. L., & Hogan, A. B. (2020) · BMC Medicine · doi:10.1186/s12916-020-01783-8 · Cited by 17
The remarkable stability of fertility desires during the Colombian armed conflict 2000–2016
Svallfors, S. (2021) · Population, Space and Place · doi:10.1002/psp.2514 · Cited by 16
Subedi, N., Kandel, D., Ghale, T., Gurung, B., Shrestha, B., & Paudel, S. (2022) · BMC Pregnancy and Childbirth · doi:10.1186/s12884-022-04596-0 · Cited by 16
“The mechanism of counting and accounting for deaths in a systematic manner is important and it can provide evidence to determine changes in clinical practice and to develop guidelines and training packages for preventive measures as well [13].”
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Vallely, L. M., Smith, R., Bolnga, J. W., Babona, D., Riddell, M. A., Mengi, A., Au, L., Polomon, C. P., Vogel, J. P., Pomat, W. S., et al. (2020) · International Journal of Gynecology & Obstetrics · doi:10.1002/ijgo.13431 · Cited by 16
“1001–1500 2 (14) 1 (10) 0 0 3 (7) 1501–2000 3 (21) 1 (10) 2 (12) 0 6 (13) 2001–2500 4 (29) 4 (40) 3 (18) 1 (20) 12 (26) 2501–3000 2 (14) 2 (20) 4 (24) 3 (60) 11(24) 3001–3500 1 (7) 1 (10) 5 (29) 0 7 (15)”
BackgroundInfluentialTao, W., Wang, X., Li, J., Wang, Z., Wang, L., Du, H., Yang, W., Chen, X., Wang, W., & Sun, Y. (2020) · Atmospheric Pollution Research · doi:10.1016/j.apr.2020.10.018 · Cited by 15
Metadata
- Authors
- Kerber, K. J., Mathai, M., Lewis, G., Flenady, V., Erwich, J. J. H., Segun, T., Aliganyira, P., Abdelmegeid, A., Allanson, E., Roos, N., Rhoda, N., Lawn, J. E., & Pattinson, R.
- Affiliations
- Save the Children (US)
- World Health Organization (CH)
- University College London (GB)
- The University of Queensland (AU)
- University Medical Center Groningen (NL)
- Jhpiego (US)
- The University of Western Australia (AU)
- University of Cape Town (ZA)
- South African Medical Research Council (ZA)
- Corresponding author
- Kerber, Kate J
- ORCID
- Venue
- BMC Pregnancy and Childbirth
- Published
- 2015-09-11
- Volume
- 15
- Issue
- S2
- Pages
- S9-S9
- ISSN
- 1471-2393 (ISSN-L)
- PMC
- PMC4577789
- OpenAlex
- W1924529051
- Cited by
- 231
- References
- 58
- Citations by year
- 2026: 6 · 2025: 11 · 2024: 21 · 2023: 8 · 2022: 16 · 2021: 46 · 2020: 26 · 2019: 33 · 2018: 24 · 2017: 17 · 2016: 15 · 2015: 8
- FWCI
- 3.22
- Type
- journal article
- Language
- en
- Open access
- gold
- doi.org
- Licence
- Locations
- BMC Pregnancy and Childbirth (publishedVersion, cc-by)
- PubMed Central (publishedVersion, cc-by)
- PubMed (publishedVersion)
- LSHTM Research Online (London School of Hygiene and Tropical Medicine) (acceptedVersion)
- UWA Profiles and Research Repository (UWA) (submittedVersion, other-oa)
- Open University of Cape Town (University of Cape Town) (submittedVersion, cc-by)
- University of Groningen research database (University of Groningen / Centre for Information Technology) (submittedVersion, cc-by)
- Funders
- World Health Organization
- Topics
- Health Sciences › Medicine › Pediatrics, Perinatology and Child Health › Global Maternal and Child Health
- Health Sciences › Medicine › Pediatrics, Perinatology and Child Health › Maternal and Neonatal Healthcare
- Health Sciences › Medicine › Pediatrics, Perinatology and Child Health › Maternal and fetal healthcare
- Keywords
- stillbirth, neonatal death, Every Newborn Action Plan, cause of death classification, health information systems, health system leadership, avoidable causes of death, quality of care, low- and middle-income countries, health policy implementation
- MeSH terms
- Africa, Asia, Developing Countries, Female, Health Policy, Humans, Infant, Newborn, Leadership, Medical Audit, Postnatal Care, Pregnancy, Prenatal Care, Practice Guidelines as Topic, Stillbirth, Perinatal Mortality, Quality Improvement, Healthcare Financing, Health Information Systems, Maternal Death, Perinatal Death
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