Audit Of Deaths Research Articles

Investigation of a child malaria death during COVID-19 pandemic in a hamlet of Angul district, Odisha (India)

Background: This study aimed to find out the cause of child death due to Plasmodium falciparum and associate co-morbidities in a hamlet of Garud village of central district of Odisha (India), Angul during the COVID-19 pandemic and to recommend necessary actions to prevent such unwanted death.Methods: A retrospective investigation was conducted bases on the death audit report of a female child belonging to Garud village of Angul district. Death was reported at the district headquarters hospital, Angul. Detailed history from the starting of first symptom till death with laboratory investigations were reviewed using the malaria death audit format of NVBDCP, Odisha. Along with in-depth interview with family members, mass screening using bivalent rapid test and slide test, treatment and malaria preventive measures were undertaken in the community.Results: During the COVID-19 pandemic, one child death was recorded due to falciparum malaria infection. Along with the child, all two family members were infected with falciparum. The family belongs to small hamlet with eight households and 39 population. All 39 populations were screened for malaria and out of these, 11 number people were found positive of falciparum.Conclusions: COVID-19 pandemic resulted the major societal disruption due to lockdown and shutdowns affecting routine health care which may be attributed to the death of a child even in a in a well-resource setting district of Odisha. In such pandemic situation much more attention need to be given on the traditional infectious diseases which may cause unnoticed death.

Modifiable Factors and Delays Associated with Neonatal Deaths and Stillbirths in Jordan: Findings from Facility-Based Neonatal Death and Stillbirth Audits.

This study employed the "three-delay" model to investigate the types of critical delays and modifiable factors that contribute to the neonatal deaths and stillbirths in Jordan. A triangulation research method was followed in this study to present the findings of death review committees (DRCs), which were formally established in five major hospitals across Jordan. The DRCs used a specific death summary form to facilitate identifying the type of delay, if any, and to plan specific actions to prevent future similar deaths. A death case review form with key details was also filled immediately after each death. Moreover, data were collected from patient notes and medical records, and further information about a specific cause of death or the contributing factors, if needed, were collected. During the study period (August 1, 2019-February 1, 2020), 10,726 births, 156 neonatal deaths, and 108 stillbirths were registered. A delay in recognizing the need for care and in the decision to seek care (delay 1) was believed to be responsible for 118 (44.6%) deaths. Most common factors included were poor awareness of when to seek care, not recognizing the problem or the danger signs, no or late antenatal care, and financial constraints and concern about the cost of care. Delay 2 (delay in seeking care or reaching care) was responsible for nine (3.4%) cases. Delay 3 (delay in receiving care) was responsible for 81 (30.7%) deaths. The most common modifiable factors were the poor or lack of training that followed by heavy workload, insufficient staff members, and no antenatal documentation. Effective actions were initiated across all the five hospitals in response to the delays to reduce preventable deaths. The formation of the facility-based DRCs was vital in identifying critical delays and modifiable factors, as well as developing initiatives and actions to address modifiable factors. · Death review committees play key roles in identifying critical delays and modifiable factors.. · The "three-delay" model was successful in identifying preventable neonatal deaths and stillbirths.. · Death review committees are central in developing actions to reduce preventable deaths..

Extended Perinatal Mortality Audit in a Rural Hospital in India.

The aim of the study is to describe the status of perinatal mortality (PM) in an Indian rural hospital. Retrospective analysis of data was compiled from PM meetings (April 2017 to December 2018) following "Making Every Baby Count: audit and review of stillbirths and neonatal deaths (ENAP or Every Newborn Action Plan)." The study includes 8,801 livebirths, 105 stillbirths (SBs); 74 antepartum stillbirths [ASBs], 22 intrapartum stillbirths [ISBs], and nine unknown timing stillbirths [USBs]), 39 neonatal deaths or NDs (perinatal death or PDs 144). The higher risks for ASBs were maternal age >34 years, previous history of death, and/or SBs. Almost half of the PDs could be related with antepartum complications. More than half of the ASB were related with preeclampsia/eclampsia and abruptio placentae; one-third of the ISB were related with preeclampsia/eclampsia and gestational hypertension, fetal growth restriction, and placental dysfunction. The main maternal conditions differed between PDs (p = 0.005). The main causes of the ND were infections, congenital malformations, complications of prematurity, intrapartum complications, and unknown. The stillbirth rate was 11.8/1,000 births, neonatal mortality rate 4.4/1,000 livebirths, and perinatal mortality rate 15.8/1,000 births. This is the first study of its kind in Andhra Pradesh being the first step for the analysis and prevention of PM. · Many conditions that lead to stillbirths are linked to neonatal deaths and PM has been outside of the global parameters from the last decades.. · This is the first study following International Classification of Disease perinatal mortality codes and the audit of ENAP in Andhra Pradesh.. · Extended PM and mortality are mainly caused by similar preventable and treatable conditions..

Evaluation of a commissioned end-of-life care service in Australian aged care facilities

Residential aged care facilities (RACFs) face severe challenges in the provision of high-quality end of life care. A pilot of a nurse-led end-of-life palliative care consultative service (CiMaS) supporting RACFs was conducted in three RACFs in the West Moreton Region of Queensland, Australia, from May 2018. We conducted a mixed method evaluation comprising: a chart audit of deaths in the 12 months before and after the intervention; focus groups with RACF staff; and interviews with facility directors, primary family members and GPs. Quantitative and Qualitative data were assessed separately with statistical and thematic analyses respectively. The RACFs cared for 277 residents. There were 24 pre-intervention deaths and 44 in the intervention period (28 (64%) referred to CiMaS). There was widespread support for the service. Families felt supported and knowledgeable about what was happening. Care plans were almost always recorded in health records. Patients’ symptoms appeared to be better recognised and managed. Staff and Facility managers felt more support than previously, with more responsive and reliable out of hours support. There were significant care improvements in patients not referred to CiMaS, suggesting a learning effect. GPs observed improvements in nursing staff confidence and support to families. Transfers to hospitals fell by two-thirds for both referred and non-referred patients compared with the year before implementation. The program was both efficient and effective.

Making every birth count: Outcomes of a perinatal mortality audit program.

Stillbirth rates have shown little improvement for two decades in Australia. Perinatal mortality audit is key to prevention, but the literature suggests that implementation is suboptimal. To determine the proportion of perinatal deaths which are associated with contributing factors relating to care in Queensland, Australia. Retrospective audit of perinatal deaths≥34weeks gestation by the Health Department in Queensland was undertaken. Cases and demographic information were obtained from the Queensland Perinatal Data Collection. A multidisciplinary panel used the Perinatal Society of Australia and New Zealand (PSANZ) perinatal mortality audit guidelines to classify the cause of death and to identify contributing factors. Contributing factors were classified as 'insignificant', 'possible', or 'significant'. From 1 January to 31 December 2018, 65 deaths (56 stillbirths and nine neonatal deaths) were eligible and audited. Most deaths were classified as unexplained (51.8% of stillbirths). Contributing factors were identified in 46 (71%) deaths: six insignificant (all stillbirths), 20 possibly related to outcome (17 stillbirths), and 20 significantly (16 stillbirths). Areas for practice improvements mainly related to the care for women with risk factors for stillbirth, especially antenatal care. The PSANZ guidelines were applied and enabled a systematic approach. A high proportion of late gestation perinatal deaths are associated with contributing factors relating to care. Improving antenatal care for women with risk factors for stillbirth is a priority. Perinatal mortality audit is a valuable step in stillbirth prevention and the PSANZ guidelines allow a systematic approach to aid implementation and reporting.

Maternal and perinatal death surveillance and response in low- and middle-income countries: a scoping review of implementation factors.

Maternal and perinatal death surveillance and response (MPDSR), or any form of maternal and/or perinatal death review or audit, aims to improve health services and pre-empt future maternal and perinatal deaths. With expansion of MPDSR across low- and middle-income countries (LMIC), we conducted a scoping review to identify and describe implementation factors and their interactions. The review adapted an implementation framework with four domains (intervention, individual, inner and outer settings) and three cross-cutting health systems lenses (service delivery, societal and systems). Literature was sourced from six electronic databases, online searches and key experts. Selection criteria included studies from LMIC published in English from 2004 to July 2018 detailing factors influencing implementation of MPDSR, or any related form of MPDSR. After a systematic screening process, data for identified records were extracted and analysed through content and thematic analysis. Of 1027 studies screened, the review focuses on 58 studies from 24 countries, primarily in Africa, that are mainly qualitative or mixed methods. The literature mostly examines implementation factors related to MPDSR as an intervention, and to its inner and outer setting, with less attention to the individuals involved. From a health systems perspective, almost half the literature focuses on the tangible inputs addressed by the service delivery lens, though these are often measured inadequately or through incomparable ways. Though less studied, the societal and health system factors show that people and their relationships, motivations, implementation climate and ability to communicate influence implementation processes; yet their subjective experiences and relationships are inadequately explored. MPDSR implementation contributes to accountability and benefits from a culture of learning, continuous improvement and accountability, but few have studied the complex interplay and change dynamics involved. Better understanding MPDSR will require more research using health policy and systems approaches, including the use of implementation frameworks.

An audit of death due to poisoning: a retrospective study

Background: Poisoning is being more frequently encountered nowadays, both globally and locally. Knowing what poisons are involved more commonly and what kind of victims present with this condition, helps the clinicians to manage and treat the patients in a better manner and lessens the mortality rates.
 Objectives: To determine the age group and gender most vulnerable to fatal poisoning. To identify the agent used for poisoning.
 Material & Methods: The descriptive retrospective study was carried out King Edward Medical University, Lahore and reviewed the autopsy records of victims of fatal poisoning from January 2018 to December 2019. The data was analyzed using the SPSS software.
 Results: In the total 67 cases of poisoning that were studied, majority of the victims were males (85.07%).Most of the cases fell in the 21-30 years age group (53.73%), followed by the 31-40 years age group (23.88%).The overall mean age of the victims was calculated to be 32.597 years. Morphine was found to be the toxic agent in most cases (32 cases; 47.76%), followed by Dextromethorphan (26 cases; 38.80%) and codeine (19 cases; 28.35%).
 Conclusions: Poisoning is a serious issue that is more frequently encountered in our young adult and male population. Since narcotics were found in major share of the cases, measures should be taken for more strict control.
 Keywords: poisoning, autopsy, mortality, drug toxicity

Evaluation of neonatal mortality data completeness and accuracy in Ghana.

Cause-specific mortality data are required to set interventions to reduce neonatal mortality. However, in many developing countries, these data are either lacking or of low quality. We assessed the completeness and accuracy of cause of death (COD) data for neonates in Ghana to assess their usability for monitoring the effectiveness of health system interventions aimed at improving neonatal survival. A lot quality assurance sampling survey was conducted in 20 hospitals in the public sector across four regions of Ghana. Institutional neonatal deaths (IND) occurring from 2014 through 2017 were divided into lots, defined as neonatal deaths occurring in a selected facility in a calendar year. A total of 52 eligible lots were selected: 10 from Ashanti region, and 14 each from Brong Ahafo, Eastern and Volta region. Nine lots were from 2014, 11 from 2015 and 16 each were from 2016 and 2017. The cause of death (COD) of 20 IND per lot were abstracted from admission and discharge (A&D) registers and validated against the COD recorded in death certificates, clinician's notes or neonatal death audit reports for consistency. With the error threshold set at 5%, ≥ 17 correctly matched diagnoses in a sample of 20 deaths would make the lot accurate for COD diagnosis. Completeness of COD data was measured by calculating the proportion of IND that had death certificates completed. Nineteen out of 52 eligible (36.5%) lots had accurate COD diagnoses recorded in their A&D registers. The regional distribution of lots with accurate COD data is as follows: Ashanti (4, 21.2%), Brong Ahafo (7, 36.8%), Eastern (4, 21.1%) and Volta (4, 21.1%). Majority (9, 47.4%) of lots with accurate data were from 2016, followed by 2015 and 2017 with four (21.1%) lots. Two (10.5%) lots had accurate COD data in 2014. Only 22% (239/1040) of sampled IND had completed death certificates. Death certificates were not reliably completed for IND in a sample of health facilities in Ghana from 2014 through 2017. The accuracy of cause-specific mortality data recorded in A&D registers was also below the desired target. Thus, recorded IND data in public sector health facilities in Ghana are not valid enough for decision-making or planning. Periodic data quality assessments can determine the magnitude of the data quality concerns and guide site-specific improvements in mortality data management.

Approaches, enablers, barriers and outcomes of implementing facility-based stillbirth and neonatal death audit in LMICs: a systematic review

PurposeTo identify approaches, enablers, barriers and outcomes of facility stillbirth and neonatal death audit in low-income and middle-income countries (LMICs).Data sourcesWe searched MEDLINE, CINAHL Complete, Academic Search Index, Science Citation...

Audit of Early and Late Maternal Deaths in Georgia: Potential for Improving Substandard Obstetric Care.

IntroductionQuality of care is an important factor in reducing preventable maternal deaths, yet it is a significant challenge in many countries. Substandard and poor quality of care is the leading factor in two-thirds of maternal deaths in European countries. Our study investigated the deaths of all women of reproductive age in 2012 in Georgia. The aim was to define the underlying causes of maternal deaths and to identify the factors in women’s care which contributed to the fatal outcomes.MethodsA national Reproductive Age Mortality Survey was conducted in Georgia in 2014–15. Data from multiple sources was triangulated to identify all deaths of women of reproductive age. This was followed by verbal autopsy diagnoses. Each case of early and late maternal death was investigated through interviews and medical record reviews at the last medical facility providing care for the deceased woman. A specialist panel reviewed and assigned underlying causes of death, assessed the management of each woman’s condition, and identified elements of suboptimal care.ResultsWe identified a total of 23 maternal deaths, including 15 (65%) early and eight (35%) late deaths. The maternal mortality ratio was 26.3 per 100 000 live births. The four leading causes of early maternal deaths were: sepsis, hemorrhage, embolism, and pregnancy-induced hypertension. Embolism and sepsis were the direct causes of the eight late maternal deaths. Cancer, tuberculosis, and postpartum suicide constituted the indirect causes of death. Improvements in care which would have made a difference to the outcomes were identified in 87% of early maternal deaths and 67% of late maternal deaths due to direct obstetric causes.DiscussionDelayed recognition and inappropriate management of maternal complications were common across almost all cases studied. The findings from Georgia highlight the conclusion that most maternal deaths were preventable and that improvement in obstetric care is urgently required.

Audit of Maternal Deaths in the Context of the Free Obstetrical Care at the Maternity of the Ignace Deen National Hospital of Conakry Chu

Objectives: To describe the evolution of half-yearly maternal mortality ratios, to describe the socio-demographic characteristics of the patients who died in the facility, to analyse the causes and determining factors of maternal deaths that have occurred in the facility, and to implement strategies to reduce this maternal mortality. Methodology: this was a descriptive, cross-sectional and analytical study carried out at the maternity ward of the Ignace Deen National Hospital of the Conakry University Hospital with data collection in two phases, including a retrospective lasting 6 months from July 1 to December 31, 2018, and the other prospective for a period of 18 months from January 1, 2019, to June 30, 2020. Result: During the study period, 224 deaths were recorded out of a total of 8,539 live births, for an intra-hospital maternal mortality ratio of 2,623.25 per 100,000 live births. The profile of women at risk of maternal death was as follows: patients aged 20-31 (56.26%), married (87.6%), low-income (41.96%), multiparous (33, 1%), evacuated from a peripheral maternity hospital (79.91%), multi guest (34.9%). The majority of deaths occurred within the first 24 hours (75%). The majority of deaths were due to direct obstetric causes: postpartum haemorrhage (52.68%), eclampsia (21.88%). Indirect obstetric causes were dominated by anaemia (16.07%). But in some cases, two or even three factors were associated with the occurrence of the same maternal death. The most frequently encountered obstetric period of death was postpartum (77.68%). The average recovery time was 31.96 minutes. The lack of blood products and the inadequacy of the technical platform were the main associated factors. Also, it appears that all our cases of death were preventable. The causes of the dysfunctions were attributable: to the person by their attitude (delay in specific care); in the hospital for the lack of equipment and blood products and in the consultation. Free obstetric care was not complete in some cases. Conclusion: maternal mortality is a major health problem in our structure. Its reduction requires the mobilization of all actors in society involving good health education; improving the quality of prenatal consultations and emergency obstetric care by consciously taking charge of staff and strengthening the technical platform.

The application of WHO ICD-PM: Feasibility for the classification of timing and causes of perinatal deaths in a busy birth centre in a low-income country.

ObjectiveTo assess the feasibility of the application of International Classification of Diseases-10—to perinatal mortality (ICD-PM) in a busy low-income referral hospital and determine the timing and causes of perinatal deaths, and associated maternal conditions.DesignProspective application of ICD-PM.SettingReferral hospital of Mnazi Mmoja Hospital, Zanzibar, United Republic of Tanzania.PopulationStillbirths and neonatal deaths with a birth weight above 1000 grams born between October 16th 2017 to May 31st 2018.MethodsClinical information and an adapted WHO ICD-PM interactive excel-based system were used to capture and classify the deaths according to timing, causes and associated maternal complications. Descriptive analysis was performed.Main outcome measuresTiming and causes of perinatal mortality and their associated maternal conditions.ResultsThere were 661 perinatal deaths of which 248 (37.5%) were neonatal deaths and 413 (62.5%) stillbirths. Of the stillbirths, 128 (31%) occurred antepartum, 129 (31%) intrapartum and for 156 (38%) the timing was unknown. Half (n = 64/128) of the antepartum stillbirths were unexplained. Two-thirds (67%, n = 87/129) of intrapartum stillbirths followed acute intrapartum events, and 30% (39/129) were unexplained. Of the neonatal deaths, 40% died after complications of intrapartum events.ConclusionProblems of documentation, lack of perinatal death audits, capacity for investigations, and guidelines for the unambiguous objective assignment of timing and primary causes of death are major threats for accurate determination of timing and specific primary causes of perinatal deaths.

Prioritization of interventions in pursuit of maternal health policy objectives to mitigate stillbirth risks. An exploratory qualitative study at subnational level in Uganda

BackgroundGlobal calls for renewed efforts to address stillbirth burden highlighted areas for policy and implementation resulting in national level translations. Information regarding adapted strategies to effect policy objectives into service delivery by frontline health workers remains scanty especially at subnational level. The study explored strategies prioritized to mitigate stillbirth risk in the context of operationalizing recommendations from the global campaigns at a subnational level in Uganda.MethodsA cross-sectional qualitative exploratory study was conducted among a purposively selected sample of sixteen key informants involved in delivery of maternal and child health services in Mukono district. Analysis followed thematic content analysis deductively focusing on those policy priorities highlighted in the global stillbirth campaigns and reflected at the national level in the different guidelines. Results.Interventions to address stillbirth followed prioritization of service delivery aspects to respond to identified gaps. Efforts to increase uptake of family planning services for example included offering it at all entry points into care with counseling forming part of the package following stillbirth. Referrals were streamlined by focusing on addressing delays from the referring entity while antenatal care attendance was boosted through provision of incentives to encourage mothers to comply. Other prioritized aspects included perinatal death audits and improvements in data systems while differentiated care focused on aligning resources to support high risk mothers. This was in part influenced by the limited resources and skills which made health workers to adapt routine to fit implementation context.ConclusionsThe resource availability determined aspects of policy to prioritize while responding to stillbirth risk at subnational level by frontline health workers. Their understanding of risk, feasibility of implementation and the desire for optimal health systems performance worked to define the nature of services delivered calling for purposeful consideration of resource availability and implementation context while prioritizing stillbirth reduction at subnational level.

Audit of Neonatal Outcome in Tertiary Care Hospital.

Background: Every year, 2.7 million stillbirths occur worldwide, mostly in developing countries. The United Nations Sustainable Development Goals (SDGs) include reducing childhood mortality under five years of age. Perinatal death audit is an intervention to reduce preventable neonatal mortality. The aim of this study was to determine the Perinatal Mortality Rate (PMR) and the factors responsible for perinatal deaths at a Tertiary Care Hospital in Karachi-Pakistan.
 Methodology: This was a prospective study of all the stillbirths and early neonatal deaths in Abbasi Shaheed Hospital Karachi, Gynecology Unit I. Details of each perinatal death were filled in the standard form. We used Aberdeen Obstetric classification to classify causes of perinatal deaths.
 Results: There were 1627 deliveries and 43 perinatal deaths during the study period. Our study's perinatal mortality rate was 27.14/1000 births, and the stillbirth rate was 13.25/1000 births. Antepartum hemorrhage (APH), pregnancy-induced hypertension (PIH) and anemia were the common causes of perinatal deaths.
 Conclusion: Antepartum hemorrhage, pregnancy-induced hypertension and anemia are the leading causes of perinatal deaths. Most of these complications can be reduced by educating women and providing effective antenatal care.

Are numbers deceptive? Is death auditing a solution for death analysis, among the COVID-19 deceased?: A study from a dedicated COVID-19 hospital in Faridabad, Haryana.

Background:COVID-19 pandemic has havocked the entire world and India has not been spared. The focus is not only on the containment but on the reduction in mortality also. The objective of the study was to know the trend of COVID-19 deaths in a 510-bedded dedicated COVID-19 hospital and to determine the cause of death and various factors associated with these deaths.Method:A descriptive study was conducted in a COVID-dedicated hospital setting to analyze deaths occurring during April--July, 2020 using a standard death audit proforma.Results:A total number of 95 COVID-19 patients died in ICU. The mortality rate among ICU patients varied from 24.6% to 52.9%. Most of the cases were referred from other hospitals. About 64% of the deceased was admitted in severe condition and 34% of cases were referred on ventilator support. The week-wise trend revealed a positive association between the number of deaths and the number of referred cases as well as the number of patients received on ventilator support and in severe condition. About one-third of cases were late in seeking treatment at health centers with the same weekly trend. Being unaware of the condition (1%) and the stigma associated with the disease (32%) were the reasons behind it. Common direct causes of death were pneumonia (73%), pneumonia complicated with sepsis (16%), and acute respiratory disease syndrome (ARDS) (7%).Conclusion:High case fatality rate in the ICU of a referral COVID-dedicated hospital is mainly because of the admission of patients in severe conditions.

Factors Affecting Maternal Mortality at the Komfo Anokye Teaching Hospital Using the Audit Committee Report

Objective: The aim of the study aimed at identifying maternal mortality at the Komfo Anokye Teaching Hospital (KATH), using the audit committee report. Design: The study adopted a retrospective descriptive study by reviewing the folders of women who died in KATH using maternal mortality audit committee report. Settings: The study included all cases of maternal death audited by the KATH audit report committee between January and December 2017. Population: The study involved audited cases of maternal death at KATH. Main Outcome Measures: The main variables measured were demographics and characteristics of deceased women, the timing of onset of complications, place of death, antenatal clinic attendance, reported cause of death, service factors and individual factors identified by committees as having contributed to death, and recommendations made by audit committee. Results: 101 cases of maternal deaths were audited from January to December 2017. Out of these cases, deaths occurred mostly in the post-partum period. Fifty-three, representing 52.48% were due to direct causes, with post-partum hemorrhage as the leading cause (49.06%), followed by sepsis (28.3%) then amniotic fluid embolism (9.43%). Indirect causes reported were cardiovascular disease, hepatitis B and, anemia with a percentage of 37.5%, 14.58% and, 6.25% respectively. Conclusions: Accessing maternal death using an audit approach will help the teams in the hospital to identify the direct and indirect causes of death, and their contributing factors, and to make recommendations for actions that would reduce the risk of reoccurrence. KATH can balance maternal death audits with other strategies to inform corrective measures.

Development and Utility of Tools to Identify Preventable Perinatal Deaths: Results from a Community-based Interventional Study in Two Districts of Karnataka State, India.

Background:The presently used perinatal death certificate devised by the World Health Organization is incomplete and does not help in identifying “preventability.”Objective:To develop tools that can help identify (1) preventable perinatal death and (2) preventable and/or avoidable cause for perinatal deaths.Materials and Methods:As a prerequisite for conduct of a community-based interventional study in two different districts of Karnataka state, two information tools, Perinatal death reporting form (PeNDReF) and perinatal death audit report (PeNDAR), were designed. The process involved series of preparatory and review meetings, before and after the field work to list facilities available, categorize facilities, identify causality, assess risk factors, and assert preventability of a perinatal death. The process was repeated over a period of 6 months and the information tools, PeNDReF and PeNDAR, were finalized. Doctors and paramedical personnel of both the districts were trained to fill the tools, which were analyzed to ascertain contributing risk factors and identify preventable perinatal death.Results:The use of PeNDAR led to identification of 5.7% of perinatal deaths as “preventable” and 19% as “possibly preventable.” The use of PeNDReF helped in the identification of risk factors (maternal anemia 49.6%, age of marriage <20 years 18.7%, and maternal weight <50 kg 9.1%), avoidable/preventable factors related to quality of care, transport, and referral.Conclusions:These tools are useful for identifying “preventable” perinatal deaths and avoidable/preventable factors.

Perinatal death audit and classification of stillbirths in two provinces in Papua New Guinea: A retrospective analysis

To undertake a retrospective perinatal death audit and assessment of avoidable factors associated with stillbirths among a cohort of women in two provinces in Papua New Guinea. We used data from an ongoing cluster-randomized crossover trial in 10 sites among 4600 women in Papua New Guinea (from 2017 to date). The overarching aim is to improve birth outcomes. All stillbirths from July 2017 to January 2020 were identified. The Perinatal Problem Identification Program was used to analyze each stillbirth and review associated avoidable factors. There were 59 stillbirths among 2558 births (23 per 1000 births); 68% (40/59) were classified "fresh" and 32% as "macerated". Perinatal cause of death was identified for 63% (37/59): 30% (11/37) were due to intrapartum asphyxia and traumatic breech birth and 19% (7/37) were the result of pre-eclampsia. At least one avoidable factor was identified for 95% (56/59) of stillbirths. Patient-associated factors included lack of response to reduced fetal movements and delay in seeking care during labor. Health personnel-associated factors included poor intrapartum care, late diagnosis of breech presentation, and prolonged second stage with no intervention. Factors associated with stillbirths in this setting could be avoided through a package of interventions at both the community and health-facility levels.

Averting Maternal Death and Disability in an Urban Network of Care in Dar es Salaam, Tanzania: A Descriptive Case Study

ABSTRACT The non-governmental organization Comprehensive Community Based Rehabilitation in Tanzania (CCBRT) developed a multi-facility maternal and neonatal Network of Care (NOC) among 22 government hospitals and catchment facilities operating across Dar es Salaam. While facility delivery rates were above 90% in the Dar es Salaam region, the quality of services was substandard, leading to an excess of preventable maternal and neonatal morbidity and mortality. In partnership with the Dar es Salaam regional health authorities CCBRT developed a plan to improve the quality of service delivery at childbirth by through a system strengthening approach, capacitating lower-level facilities to provide routine care during pregnancy and uncomplicated deliveries, as well as improving care at secondary level referral hospitals and developing an inter-connected strengthened referral system. The Regional–CCBRT partnership implemented interventions across the continuum of care that included clinical training in basic and comprehensive emergency obstetric care, investments in infrastructure, and a rigorous maternal and perinatal death audit and follow-up program. Routine data generated were reflected upon at quarterly quality improvement meetings to follow up on problems identified. The government has initiated the replication of the model. This descriptive case study uses the four domains of the Networks of Care framework to document the wide-ranging efforts made to build and maintain the CCBRT Network of Care in order to solve for specific challenges in maternal and neonatal health service delivery in the urban context of the Dar es Salaam region.

Investigation of stillbirth causes in Suriname: application of the WHO ICD-PM tool to national-level hospital data

ABSTRACT Background Suriname has one of the highest stillbirth rates in Latin America and the Caribbean. To facilitate data comparison of perinatal deaths, the World Health Organization developed the International Classification of Diseases-10 Perinatal Mortality (ICD-PM). Objective We aimed to (1) assess characteristics and risk indicators of women with a stillbirth, (2) determine the timing and causes of stillbirths according to the ICD-PM with critical evaluation of its application and (3) propose recommendations for the reduction of stillbirths in Suriname. Methods A hospital-based, nation-wide, cross-sectional study was conducted in all hospitals within Suriname during one-year (2017). The medical files of stillbirths (gestation ≥28 weeks/birth weight ≥1000 grams) were reviewed and classified using ICD-PM. We used descriptive statistics and multiple logistic regression analyses. Results The stillbirth rate in Suriname was 14.4/1000 births (n=131 stillbirths, n=9089 total births). Medical files were available for 86% (n=113/131) of stillbirths. Women of African descent had the highest stillbirth rate and two times the odds of stillbirth (OR 2.1, 95%CI 1.4–3.1) compared to women of other ethnicities. One third (33%, n=37/113) of stillbirths occurred after hospital admission. The timing was antepartum in 85% (n=96/113), intrapartum in 11% (n=12/113) and unknown in 4% (n=5/113). Antepartum stillbirths were caused by hypoxia in 46% (n=44/96). In 41% (n=39/96) the cause was unspecified. Maternal medical and surgical conditions were present in 50% (n=57/113), mostly hypertensive disorders. Conclusion Stillbirth reduction strategies in Suriname call for targeting ethnic disparities, improving antenatal services, implementing perinatal death audits and improving diagnostic post-mortem investigations. ICD-PM limited the formulation of recommendations due to many stillbirths of ‘unspecified’ causes. Based on our study findings, we also recommend addressing some challenges with applying the ICD-PM. Abbreviations CTG: Cardiotocography; ENAP: Every Newborn Action Plan (ENAP); ICD-PM: The WHO application of ICD-10 to deaths during the perinatal period – perinatal mortality; SBR: Stillbirth rate; SGA: Small for gestational age; WHO: World Health Organization; LMIC: Low- and middle-income countries; FHR: foetal heart rate.