Changes in quality of care and perinatal outcomes after implementation of perinatal death audit in Uganda, 2008–15: a prospective study

Abstract

Abstract Background Every year, an estimated 2·7 million neonatal deaths and stillbirths occur worldwide. Neonatal mortality in Uganda has been 27 deaths per 1000 births between 2008 and 2018, despite an increase in the rate of institutional deliveries from 59% to 74% over this time. Suboptimal care still occurs in hospitals, resulting in maternal and neonatal morbidity. Globally, perinatal death audit has been shown to reduce perinatal mortality by 30%. However, there is paucity of data on the effect of audit on perinatal outcomes in Uganda. Here, we describe perinatal outcomes after introduction of perinatal death audit in a tertiary hospital in Kampala, Uganda. Methods We undertook a prospective review of deaths between January, 2008, and December, 2015. Cause of death was identified through consensus between midwives, intern doctors, postgraduates, paediatricians, and neonatologists. We assessed standard of care against existing guidelines. We used data on outcomes from January, 2006, to December, 2007, for comparison and recorded changes to clinical practice that were implemented in response to cause-of-death data. Findings A total of 58 997 births and 2616 perinatal deaths occured between 2008 and 2015. Of these, 603 [23%] perinatal deaths were selected for audit. Perinatal mortality decreased from 48·4 deaths per 1000 births before the intervention to 43 per 1000 births in 2015; stillbirths decreased from 32·9 per 1000 births to 22 per 1000 births. The proportion of neonatal deaths reduced from 11·2% to 4·9%. The most common causes of death in the study period were: hypoxia (186, 35·4%) and unknown (227, 43·2%). Interventions included: neonatal resuscitation training; building of a new maternity theatre; partograph training; increased human resource for maternity and the newborn care unit; and provision of equipment such as ambubags, bubble continuous positive air way pressure (CPAP) machines, and radiant warmers. Skills introduced included: kangaroo mother care; and use of antenatal steroids, CPAP, surfactant, and phototherapy. Case fatality rates decreased for hypoxia (21·1% to 15·5%) and complications of prematurity (26·4% to 11·1%) but increased for infections (1·9% to 5·7%). Interpretation Perinatal death audits are feasible in Uganda. Furthermore, the data from audits can inform decisions about new training and interventions and might lead to improved perinatal outcomes. Funding None.