Perinatal Audit Research Articles

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...

Еволюція малюкової смертності в Україні

Over the past decades in Ukraine, the unfavorable indicators of population reproduction, the state of health of women and children, acquired in the previous period, have become persistent, one of the integrative indicators of which is the mortality of children under one year of age. The infant mortality rate is a sensitive indicator of the general sanitary and socio$economic well-being of the country, a strategic indicator of the health and survival of children, the level and quality of medical and social care, and the effectiveness of obstetric and pediatric services. Purpose — to study, analyze and determine the general and regional features of the state and dynamics of infant mortality and its components in Ukraine. Materials and methods. A retrospective analysis and assessment of the dynamics of infant mortality in Ukraine for the period 1990–2019 was carried out in the context of regions and separate states according to state and industry statistics, perinatal audit for the methodology of the WHO «MATRIX-BABIES». Methods of a systematic approach, statistical, graphic representation are applied. Results. The study found that the unfavorable demographic situation in Ukraine is accompanied by a still high, with a positive trend, the mortality rate of children in the first year of life — 12.8‰ in 1990, and 7.0‰ in 2019 (loss rate — 30.9%), a direct dependence of infant mortality rates on indicators of total fertility (r=0.340) and morbidity in children in the first year of life (r=0.888) was found with an excess of mortality under 1 year in boys compared with girls (OR with 95% CI 1.1 (1.0–1.2). Infant mortality rates are relatively low, below the average for Ukraine, in Vinnitsa, Volyn, Kyiv, Lviv, Poltava, Ternopil, Khmelnitsky regions and City Kyiv, and above average — in Dnepropetrovsk, Donetsk, Transcarpathian, Kharkiv regions. The decrease in the overall infant mortality rate was due to the positive dynamics of all its components — early neonatal (5.8‰ in 1990, 3.04‰ in 2019), neonatal (7.3‰, 4.57‰) and postneonatal mortality (5.7‰, 2.52‰, respectively) with a more intensive decrease in postneonatal mortality (rate of decline — 55.8%). However, there are doubts that the registered data on neonatal mortality, as well as on infant mortality in general, are real, since according to the perinatal audit data, the «MATRIX-BABIES» method revealed an underestimation of early neonatal mortality — an underestimation of its real level in general by 2.1–2.3 times. It is shown that the infant mortality rate has decreased from all the main causes of mortality with a more accelerated rate of decrease in infant losses from exogenous, manageable causes — respiratory diseases (rate of decline — 83.7%), infectious and parasitic diseases (rate of decline — 80.7%). At the same time, the key causes of mortality in children under 1 year of age throughout the entire observation period remain separate conditions that arise in the perinatal period (52.8–38.4 per 10,000 live births) and congenital malformations, deformities, and chromosomal abnormalities (38,6–17.2 per 10,000 live births). It was found that against the background of a decrease in infant losses in the structure of infant mortality by 43.2%, the part of mortality from certain conditions of the perinatal period increased with a significant decrease in the part of losses from exogenous causes of death — respiratory diseases by 66.7%, some infectious and parasitic diseases by 57.8%. Conclusions. In general, despite the positive dynamics of all components of infant mortality, its level characterizes a pronounced lag behind developed countries, and according to the rating of the countries of the world as of 2018, Ukraine ranks 61st among 193 countries of the world and administrative territories without state status. The research was carried out in accordance with the principles of the Helsinki Declaration. The study protocol was approved by the Local Ethics Committee of these Institutes. The informed consent of the patient was obtained for conducting the studies. No conflict of interest was declared by the authors. Key words: infant mortality, morbidity, newborns, children in the first year of life.

Analysis of perinatal mortality at a teaching hospital in Dar es Salaam, Tanzania, 1999-2003.

We conducted a retrospective analysis of perinatal mortality at Muhimbili National Hospital (MNH), Dar es Salaam, Tanzania 1999-2003 in order to categorise/classify perinatal deaths as well as to identify key factors in perinatal care that could be improved. Data were retrieved from the MNH obstetric database and causes of early neonatal deaths were traced from the neonatal ward register. The study includes all foetuses weighing =500g. A modified Nordic-Baltic classification was used for classification of perinatal deaths. Over a 5-year period there were 77,815 babies born with a perinatal mortality rate of 124 per 1000 births, 78% of which was labour related stillbirth. The PMR was 913/1000 for singleton births and 723/1000 for multiple births for babies weighing less than 1500 grams and 65/1000 for singleton births and 116/1000 for multiple births for babies weighing 2500 grams or more. Babies weighing less than 1500 grams contributed 26% of PMR, whereas 41% occurred in babies weighing 2500 grams or more. The majority (79%) of neonatal deaths had Apgar score <7 at 5 minutes and the most common causes of neonatal mortality were birth asphyxia (37%) and prematurity (29%). Labour related deaths were more common in multiple pregnancies. The majority of the perinatal deaths should be essentially avoidable through improved quality of intrapartum care. Establishment of perinatal audit at MNH can help identify key actions for improved care.

Trends and Determinants of Perinatal Mortality in a Tertiary Care Hospital of Nepal

Introduction: Perinatal mortality rate (PMR) in Nepal is still very high. In major hospitals of Nepal, it is still ranging from 20 to 30 per thousand births. This study was carried out to review the different aspects of PMR and classifying them and identify the causes of perinatal and neonatal deaths and assessing the need for improvement in quality of pregnancy and newborn care. &#x0D; Methods: It was a retrospective study carried out in Bharatpur Hospital, Chitawan, Nepal. Data of all stillbirths from 22 weeks of pregnancy and neonatal deaths up to seven days of life was taken from monthly perinatal audit and annual mortality review. The data was taken from July 2017 to Jun 2019. All the perinatal deaths were then classified. &#x0D; Results: Over a two year period, there were total 25,977 births and total death was 369. Thus perinatal mortality rate was 12.3 per thousand births. Still births (fresh and macerated) contributed almost 82.4% of the perinatal deaths and neonatal death contributed 17.6% of total deaths. Deaths related to unexplained intrauterine fetal death (IUFD) showed an increasing trend and have increased by more than 20% in past two years from 39.1% to 60.8%. Deaths due to perinatal asphyxia, neonatal sepsis, respiratory distress syndrome and extreme prematurity were increased.&#x0D; Conclusions: PMR over the two years has shown increasing trend at our institute. There is need to improve antenatal, obstetric as well as intra-partum services to further reduce the still birth as well as deaths due to prematurity, RDS, neonatal sepsis and perinatal asphyxia.

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.&#x0D; 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.&#x0D; 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.&#x0D; 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.

What do the numbers say? - Introduction of the WHO ICD-PM classification and fetuses-at risk approach in perinatal audit, South India

Objective: In India, despite a reduction in perinatal mortality rate from 2014 to 2019, still birth rate is still the same at the national average of 4/1000 live births. As yet there is no nation-wide audit in India except for facility based audits. Hence the need for a simplified yet effective audit process exists. The aim of this study was to perform a qualitative perinatal audit and devise methods for future audits. Methods: We conducted a one year audit for all perinatal deaths using WHO ICD PM and 3-delay classification. Gestational age (GA) specific mortality was calculated for significant underlying factors using fetuses-at risk approach. Results: We recorded a perinatal mortality rate of 6.1/1000 births among booked cases and 21.32/1000 births among referred cases. Fetal growth restriction was the most common antenatal condition, accounting to 33.3% of antepartum deaths. Prematurity accounted to 52% of neonatal deaths. Phase 2 delay with delayed referrals in severe pre-eclampsia and Phase 1 delay with late visit (&gt; 24 h) to hospital after experiencing absent fetal movements were the most common identifiable delays. Hypertension stood out to be the single most common risk-factor. GA specific mortalities, calculated using fetuses-at risk approach, show a peak mortality rate at 30 weeks, 37 weeks and 38 weeks in pregnancies with early-onset preeclampsia, severe fetal growth restriction and medically treated gestational diabetes respectively. Conclusion: The audit identified significant contributing factors to the mortality. ICD-PM and 3-delay classification was simpler and easier to apply with wide areas of opportunities for secondary analysis.

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.

STATUS OF MEDICAL CARE FOR NEWBORNS IN UKRAINE

Introduction. In the context of continuing depopulation, and low birth rate, the formation and preservation of newborn generations’ health is the most important medical and social task and one of the main activities of the Ministry of Health of Ukraine and local health care institutions.&#x0D; The aim of the study was to analyze and evaluate the effectiveness of medical care for newborns in Ukraine and its impact on the main indicators of newborns’ health.&#x0D; Materials and research methods. A retrospective analysis and assessment of the dynamics of neonatal care in Ukraine was carried out according to state and industry statistics, perinatal audit according to the method of WHO “MATRIX - BABIES” for the period 2001-2019, monitoring and evaluation of the regionalization of perinatal care (for 2014-2017). Methods of a systematic approach, bibliographic, statistical data processing, and graphic representation were applied.&#x0D; Results of the study: the study showed that during the period of the research a number of newborns born in the facilities of the Ministry of Health of Ukraine decreased from 387900 in 2000 to 294100 in 2019, with a negative trend in the generalized objective criterion of the generation’s health and socio-economic well-being of the population - frequency of premature newborns with low birth weight including those with extremely low birth weight. At the same time, the frequency of newborns with congenital diseases or those who got sick after birth, decreased from 280.8 per 1000 live births in 2000 to 172.14 in 2019 with the wave-like nature of its dynamics.&#x0D; The existing state system of three-level neonatal care integrated into the perinatal service makes it possible to provide basic, qualified and highly qualified specialized medical care for newborns at all stages of its provision. During the observation period, the provision of newborns with pediatrician-neonatologists increased from 4.58 per 1000 live births to 5.34, and with hospital beds for premature and sick newborns - from 5.62 to 6.91, respectively.&#x0D; A slight increasing trend of significant criterion of newborns’ health condition was achieved (99.36% in 2001 vs 99.7% in 2019) along with the activities of the neonatological service in survival of newborns in the first 168 hours of life mainly due to a 2.6-fold increase in the survival of newborns with a birth weight of 500-999g. Sufficient efficiency of medical care for newborns was confirmed by a positive trend in early neonatal mortality from 4.71 ‰ in 2000 to 3.04 ‰ in 2019 and neonatal mortality from 6.65 ‰ to 4.57 ‰, respectively.&#x0D; At the same time, the increase of newborns’ incidence with diseases that have a direct impact on the development of chronic and disabling diseases is a cause for concern: cases of congenital pneumonia increased from 3.18 ‰ in 2000 to 5.46 ‰ in 2019, of neonatal sepsis - from 0.09 ‰ to 0.74 ‰, respectively. Also other disorders of newborns’ cerebral status increased from 18.5 ‰ in 2010 to 28.5 ‰, and neonatal jaundice - from 31.11 ‰ in 2015 to 43.65 ‰.&#x0D; An excess in 1.5 times of the standard recommended by the WHO of the proportional indicator of early neonatal mortality was revealed among infants weighing more than 1500 g. The excess of the real indicator of early neonatal mortality over the actual one was 2.2-2.3 times, which meant underestimation of the total rate of neonatal and infant mortality.&#x0D; Conclusions. Further improvement of the effectiveness of neonatal care and the decrease of early neonatal and neonatal mortality levels requires continued regionalization of perinatal care, completion of the perinatal care centers of the third level, revision and provision of patient routes, development and provision of state-guaranteed medical services/standards (such as a standard of child’s safety, safety of pregnant and postpartum woman), the reliability of determining body weight at birth, criteria for live birth and stillbirth, the introduction of follow-up monitoring of low-birth-weight newborns, the formation of a unified system for monitoring the activities of the maternal and child health services.

Strengthening Collaborative Governance in Efforts to Reduce The Mortality Rate of Mother and Baby

This research aims to learn the role of each government agency and community involved in the policy program for reducing maternal and infant mortality rate in Jember district. Then hope to come up with recommendations for strengthening the role of stakeholders in an effort to realize good governance. Given that in 2012, Jember district was listed as the district with the highest IMR and MMR in East Java. One of the collaborative policy programs launched to reduce the high IMR and MMR in Jember Regency is the Copy of Decision of Jember Regent Number: 188.45 / 101.1 / 012/2015 About Perinatal Maternal Audit Team of Jember Regency Year 2015. The descriptive qualitative research method used (before the C19 pandemic) was in-depth interviews, three FGDs with stakeholders. Data analysis by Spreadly analysis (taxonomic analysis, component analysis and cultural themes). The results showed that the ego-centricity of each government institution was still very prominent, and community participation was still mobilizing. Thus, efforts to strengthen collaborative governance roles are needed through the role of leading actors who are strongly committed to directing, controlling and monitoring policy programs that have been made.

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.

Results of the perinatal audit of the Northwestern Federal District

Aim. To assess the results of a perinatal audit of the Northwestern Federal District and to identify opportunities for a decrease in perinatal mortality.&#x0D; Methods. The audit of perinatal loss was conducted in two stages: (1) remote audit audit of perinatal mortality indicators; (2) medical history audit audit of cases of perinatal death of a child based on medical documentation. Held the copy of the data from the 925 medical records for 220 cases of perinatal death. The perinatal audit of the Northwestern Federal District used the Nordic-Baltic perinatal death classification. The following statistical methods were used for statistical data processing: incidence rate of a trait was determined by using frequency tables, the statistical significance of differences was tested by using contingency tables, the Chi-square criterion, along with the Pearson correlation coefficient. The statistical significance of differences in quantitative indicators was assessed by using Student's t-Test. The significance level was set at p 0.05.&#x0D; Results. It was found that in the Northwestern Federal District pregnancy losses III category of the Nordic-Baltic classification (gestational age newborn, more than 28 weeks, without congenital malformations and intrauterine growth restriction) is 27.5%, intranatal losses VI category of the Nordic-Baltic classification (gestational age newborn, more than 28 weeks, without congenital malformations and intrauterine growth restriction) 7.4%, the loss of newborns VIIIXI category of the Nordic-Baltic classification (gestational age newborn, more than 28 weeks, without congenital malformations and intrauterine growth restriction) 16.9%. Among children who died during the perinatal period, children of gestational age over 28 weeks significantly predominate (p=0.003). In the nosological structure of stillbirth, most of the diseases are associated with respiratory disorders (85.9%), infectious complications are 14.1%. The main causes of death of newborns in the early neonatal period are respiratory disorders 40.0% and infectious diseases specific to the perinatal period 36.0%. The assessment of the sexual prevalence of pregnancy losses did not reveal a statistically significant difference (p=0.29). The assessment of the sexual characteristics of intranatal losses showed that boys significantly predominate (p=0.003).&#x0D; Conclusion. The perinatal audit revealed that, in the Northwestern Federal District, the level of the mobile reserve of perinatal losses associated with managed causes is 51.8%.

Admissions to a Low-Resource Neonatal Unit in Malawi Using a Mobile App: Digital Perinatal Outcome Audit.

BackgroundMobile health (mHealth) is showing increasing potential to address health outcomes in underresourced settings as smartphone coverage increases. The NeoTree is an mHealth app codeveloped in Malawi to improve the quality of newborn care at the point of admission to neonatal units. When collecting vital demographic and clinical data, this interactive platform provides clinical decision support and training for the end users (health care professionals [HCPs]), according to evidence-based national and international guidelines.ObjectiveThis study aims to examine 1 month’s data collected using NeoTree in an outcome audit of babies admitted to a district-level neonatal nursery in Malawi and to demonstrate proof of concept of digital outcome audit data in this setting.MethodsUsing a phased approach over 1 month (November 21-December 19, 2016), frontline HCPs were trained and supported to use NeoTree to admit newborns. Discharge data were collected by the research team using a discharge form within NeoTree, called NeoDischarge. We conducted a descriptive analysis of the exported pseudoanonymized data and presented it to the newborn care department as a digital outcome audit.ResultsOf 191 total admissions, 134 (70.2%) admissions were completed using NeoTree, and 129 (67.5%) were exported and analyzed. Of 121 patients for whom outcome data were available, 102 (84.3%) were discharged alive. The overall case fatality rate was 93 per 1000 admitted babies. Prematurity with respiratory distress syndrome, birth asphyxia, and neonatal sepsis contributed to 25% (3/12), 58% (7/12), and 8% (1/12) of deaths, respectively. Data were more than 90% complete for all fields. Deaths may have been underreported because of phased implementation and some families of babies with imminent deaths self-discharging home. Detailed characterization of the data enabled departmental discussion of modifiable factors for quality improvement, for example, improved thermoregulation of infants.ConclusionsThis digital outcome audit demonstrates that data can be captured digitally at the bedside by HCPs in underresourced newborn facilities, and these data can contribute to a meaningful review of the quality of care, outcomes, and potential modifiable factors. Coverage may be improved during future implementation by streamlining the admission process to be solely via digital format. Our results present a new methodology for newborn audits in low-resource settings and are a proof of concept for a novel newborn data system in these settings.

Social accountability for reproductive, maternal, newborn, child and adolescent health: A review of reviews.

Globally, increasing efforts have been made to hold duty-bearers to account for their commitments to improve reproductive, maternal, newborn, child and adolescent health (RMNCAH) over the past two decades, including via social accountability approaches: citizen-led, collective processes for holding duty-bearers to account. There have been many individual studies and several reviews of social accountability approaches but the implications of their findings to inform future accountability efforts are not clear. We addressed this gap by conducting a review of reviews in order to summarise the current evidence on social accountability for RMNCAH, identify factors contributing to intermediary outcomes and health impacts, and identify future research and implementation priorities. The review was registered with the International Prospective Register of Systematic Reviews (PROSPERO CRD42019134340). We searched eight databases and systematic review repositories and sought expert recommendations for published and unpublished reviews, with no date or language restrictions. Six reviews were analysed using narrative synthesis: four on accountability or social accountability approaches for RMNCAH, and two specifically examining perinatal mortality audits, from which we extracted information relating to community involvement in audits. Our findings confirmed that there is extensive and growing evidence for social accountability approaches, particularly community monitoring interventions. Few documented social accountability approaches to RMNCAH achieve transformational change by going beyond information-gathering and awareness-raising, and attention to marginalised and vulnerable groups, including adolescents, has not been well documented. Drawing generalisable conclusions about results was difficult, due to inconsistent nomenclature and gaps in reporting, particularly regarding objectives, contexts, and health impacts. Promising approaches for successful social accountability initiatives include careful tailoring to the social and political context, strategic planning, and multi-sectoral/multi-stakeholder approaches. Future primary research could advance the evidence by describing interventions and their results in detail and in their contexts, focusing on factors and processes affecting acceptability, adoption, and effectiveness.

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.

Investigating the benefits and challenges of including bereaved women in research: a multifaceted perinatal audit in a socially disadvantaged French district

ObjectivesTo describe experiences including interviews with bereaved women in a clinical audit.DesignThe data come from an audit of all stillbirths and neonatal deaths at ≥22 weeks of gestation in Seine-Saint-Denis,...

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.

Prospective study to explore changes in quality of care and perinatal outcomes after implementation of perinatal death audit in Uganda

ObjectiveTo assess the effects of perinatal death (PND) audit on perinatal outcomes in a tertiary hospital in Kampala.DesignInterrupted time series (ITS) analysis.SettingNsambya Hospital, Uganda.ParticipantsLive births and stillbirths.InterventionsPND audit.Primary and secondary...

Documentation and Reporting of Perinatal Deaths in Two Districts of Karnataka, India: A Situational Analysis

In Karnataka state, perinatal mortality rate is almost equal to infant mortality rate. This preliminary study was conducted in two districts of Karnataka to study potential problems to start of perinatal death audit. Hospitals providing maternal and child health care services, which met study inclusion criteria, in Dakshina Kannada and Koppal Districts were included. Following variables were studied: (i) Documentation and reporting systems in these hospitals; (ii) Role of health care personnel in documentation and reporting (iii) Existing system of audit, if any. Totally 94 hospitals met our criteria with Dakshina Kannda District having 63 (67.02%) and the rest in Koppal District. Documentation and reporting was poor in Koppal District and inadequate in Dakshina Kannada district. Health care personnel were apprehensive about perinatal death audit. Problems identified need to be addressed before starting perinatal death audit.