The DOI matches its Crossref record; 58 of the 58 references it cites were found in a registry or an index.
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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Cites
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“Without adequate facilitation and guidance, blame may be transferred to the first delay (decision to seek care) [51], and community-related factors rather than to avoidable factors within the realm of the health provider [48].”
BackgroundEvery Newborn: progress, priorities, and potential beyond survival
Lawn, J. E., Blencowe, H., Oza, S., You, D., Lee, A. C., Waiswa, P., Lalli, M., Bhutta, Z., Barros, A. J., Christian, P., et al. (2014) · The Lancet · doi:10.1016/s0140-6736(14)60496-7 · Cited by 1,929 · cited 1×
“Each year, half of the world’s babies do not receive a birth certificate; most neonatal deaths and almost all stillbirths have no death certificate, let alone information on the causes and avoidable factors surrounding these deaths [4].”
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Lawn, J. E., Blencowe, H., Pattinson, R., Cousens, S., Kumar, R., Ibiebele, I., Gardosi, J., Day, L. T., & Stanton, C. (2011) · The Lancet · doi:10.1016/s0140-6736(10)62187-3 · Cited by 785 · cited 1×
“Disparate classification systems between CRVS, routine systems, and audit forms may result in duplication and inefficient documentation [45].”
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“Maternal deaths were notifiable by national policy in 51 of 71 (72%) high burden countries in 2014 [13], up from 22 of 55 countries (40%) in 2008 [14] (Figure 3) with more countries moving towards implementation in addition to policy (See Table S1, additional file 1).”
Background
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Cited by
Sorted by citations
Stillbirths: rates, risk factors, and acceleration towards 2030
Lawn, J. E., Blencowe, H., Waiswa, P., Amouzou, A., Mathers, C., Hogan, D., Flenady, V., Frøen, J. F., Qureshi, Z. U., Calderwood, C., et al. (2016) · The Lancet · doi:10.1016/s0140-6736(15)00837-5 · Cited by 1,778
Self-citationNarayan, A. J., Rivera, L. M., Bernstein, R. E., Harris, W. W., & Lieberman, A. F. (2017) · Child Abuse & Neglect · doi:10.1016/j.chiabu.2017.09.022 · Cited by 622
Stillbirths: ending preventable deaths by 2030
de Bernis, L., Kinney, M. V., Stones, W. R., ten Hoope‐Bender, P., Vivio, D., Leisher, S. H., Bhutta, Z. A., Gülmezoglu, M., Mathai, M., Belizán, J. M., et al. (2016) · The Lancet · doi:10.1016/s0140-6736(15)00954-x · Cited by 479
Self-citationCount every newborn; a measurement improvement roadmap for coverage data
Moxon, S. G., Ruysen, H., Kerber, K. J., Amouzou, A., Fournier, S., Grove, J. T., Moran, A. C., Vaz, L. M. E., Blencowe, H. K., Conroy, N., et al. (2015) · BMC Pregnancy and Childbirth · doi:10.1186/1471-2393-15-s2-s8 · Cited by 357
Self-citationFlannery, C., McHugh, S., Anaba, A. E., Clifford, E., O’Riordan, M., Kenny, L. C., McAuliffe, F. M., Kearney, P. M., & Byrne, M. (2018) · BMC Pregnancy and Childbirth · doi:10.1186/s12884-018-1816-z · Cited by 218
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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