This report was published in May 2016 and is based on information collected of perinatal deaths in the UK for births from January to December 2014. The document focuses on deaths reported through the secure online reporting system, which include all late foetal losses (22nd to 23rd weeks of gestational age), stillbirths (a baby delivered at or after 24 weeks of gestational age with no signs of life) and neonatal deaths (a liveborn baby delivered at 20 weeks of gestational age or later, or weighing 400g or more when gestation is unavailable) who died within 28 days of being born. The findings are displayed in mortality rates for stillbirths, neonatal deaths and extended perinatal deaths (both stillbirths and neonatal deaths). The report offers key findings and recommendations, as well as describing causes of death and factors that influence rates of perinatal death.
Pattinson et al (2009), published by the International Journal of Gynaecology and Obstetrics, conducted a systematic review and meta-analysis of perinatal mortality audit at the facility level in low- and middle-income countries. The results showed a reduction in perinatal mortality by 30% with the establishment of a perinatal audit system.
The findings suggest that an audit system may be helpful in reducing perinatal deaths in facilities and improving the quality of care. Pattinson and colleagues also reviewed information about community audits and verbal/social autopsy drawing on examples from Africa (Guinea and Uganda) and Asia (Uttar Pradesh, India). Furthermore, two country case studies were presented on scaling up perinatal audit in South Africa and Bangladesh.
The authors identify areas that merit further research and conclude that successful implementation of perinatal audit to improve the quality of care relies on closing the audit cycle.
In this article, published in 2011 by the BMC Health Services Research, Belizan and colleagues set out to examine the implementation and management of the Perinatal Problem Identification Programme (PPIP) in South Africa. The authors conducted two workshop sessions to draw on the experiences of clinical care providers. An analytical framework was applied, divided into three phases: ‘pre-implementation’, ‘implementation’ and ‘institutionalisation’. Each phase has two stages of change.
The authors identified four themes that are key to sustaining the implementation of an audit system across the stages of change. These include:
- Drivers of change and teamwork
- Outreach visits and supervisory meetings
- The review of perinatal deaths and feedback meetings
- Communicating and networking
The six stages that correspond to the three phases – before implementation, during implementation and the institutionalisation of the audit programme – include:
- Building awareness
- Committing to audit implementation
- Preparing for audit implementation
- Implementing the audit programme
- Making audit routine practice
- Sustaining the programme
These findings may be applied to other low- and middle-income settings that have high neonatal mortality and are planning on adapting a perinatal audit system. The authors also provide a comprehensive tool to reflect on the implementation and management of a perinatal audit system.
This article, published by the International Journal of Obstetrics and Gynecology in 2014, discusses the development of the Perinatal Problem Identification Programme (PPIP) in South Africa, which was first implemented in a few hospitals in 1990 as a facility audit tool to improve the quality of maternal and newborn care. By 2012, PPIP became a requirement for all public health facilities delivering newborns and was introduced to all districts across the country.
The article describes the various functions of PPIP, including the audit cycle, data entry, verification and analysis, and training. Rhoda and colleagues detail the experiences of two facilities – Western Cape and Mpumalanga – that have been implementing PPIP the longest and offer two differing experiences that may be helpful to other facilities interested in using perinatal death audit. Finally, the authors draw on the strengths, challenges and opportunities of PPIP, concluding that with adequate support, training and guidance, PPIP can help mothers and their newborns survive in South Africa.
This qualitative Master’s thesis from the University of the Western Cape, South Africa, highlights findings from the Ashanti region in Ghana, where midwives are actively involved in all stages of the implementation of facility-based maternal death review, including:
- reporting and certifying maternal deaths
- collecting and documenting evidence in order to notify the public health units
- processing and preparing evidence for the audit meetings
- participating in the audit meetings
- helping to formulate recommendations as part of the audit team,
- disseminating, implementing and monitoring the recommendations of the audit report.
The author found that midwives play a vital role, especially in facilities where there were no other clinical cadres of staff. The author recommends:
- Junior midwives be included in MDR meetings to build their confidence and involvement in MDR
- Continuous in-service training on issues related to MDR for nurses and midwives
- Inclusion of MDR in the Nurses and Midwifery Council of Ghana curriculum
- Specific training for midwives on their particular role within the MDR process
This mixed-methods study emphasised the value of teamwork, commitment and champions at health facility level to facility-based MDR in Nigeria.
The authors found that where key members of MDR committees transferred, where facilities were understaffed or there was a lack of supportive supervision, these problems significantly undermined the sustainability of the MDR process.
They recommend MDR be institutionalised in the Ministry of Health to provide adequate support to staff.
This paper proposes a community-based approach to measuring maternal mortality based on a feasibility study conducted in 2010-2011 in Tigray, Ethiopia, based on the concept of ‘task shifting’.
Priests, traditional birth attendants and community-based reproductive health agents were given responsibility for locating and reporting all births and deaths, and they assisted mid-level providers to locate key informants for verbal autopsy.
From there, nurses and nurse-midwives were trained to administer verbal autopsies and assign cause of death according to WHO ICD-10 classifications.
The study highlights the feasibility of using existing community and health structures to implement MDR.
This article uses a strengths, weaknesses, opportunities and threats (SWOT) analysis to assess the difficulties faced in conducting MDR in Malawi.
It highlights the importance of the multi-disciplinary team in promoting collaboration and in ensuring issues relating to different disciplines are addressed.
Good leadership, an emphasis on building staff capacity and ensuring the motivation of different members of the MDR committees are vital for sustainability and success.
This analysis of the findings of the national confidential enquiry around maternal deaths conducted the Ministry of Health in Morocco shows that 54.3% of the deaths analysed in 2009 could have been avoided if appropriate action had been taken at health facilities.
This contradicted previous beliefs that the main causes of maternal death were due to women delaying seeking care. Lack of competence or motivation of staff were linked to the majority of cases of substandard care these women received.
The authors recommend that the managers of local health systems and practitioners themselves received the information and means to support them to implement the recommendations of the audits.
This study highlights the importance of involving hospitals and health providers in the audit process and particularly in supporting them to respond to findings.
This mixed-methods study conducted in five hospitals in Senegal found that the implementation of maternal death reviews were hampered by issues such as the non-participation of the head of department at audit meetings and the lack of feedback about the audit meetings to staff who did not attend.
Factors which supported the MDRs included the involvement of the head of the maternity unit who acted as a moderator during audit meetings and the participation of managers in the audit meeting to plan appropriate and achievable actions to prevent future maternal deaths.
The authors conclude that leadership is vital to secure MDR success.