Counting every stillbirth and neonatal death through mortality audit to improve quality of care for every pregnant woman and her baby

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. In order to track policy progress for mortality audit overall, we assessed the status of maternal death notification in Countdown to 2015 for Maternal, Newborn and Child Health [9] priority countries since tracking began in 2008. We also collected and reviewed policy and strategy documents and national guidelines through database searches and key informant inquiries in these priority countries to determine whether a process for perinatal mortality audit implementation was in place or underway at national level. We also reviewed the current evidence for facility-based perinatal mortality audit with a focus on low- and middle-income countries where the majority of the world’s births and deaths occur. Challenges to introducing, sustaining and achieving impact with perinatal mortality audit were identified in published and grey literature and programme learning documentation. Given the limited published information about perinatal mortality audit, lessons learned from maternal audit was also considered. Challenges and context-specific solutions were identified and categorised into thematic areas and linked to the WHO health system building blocks framework, adding the additional build block of community ownership and participation [10]. We undertook a literature review to identify further case studies and evidence-based solutions for each defined thematic area.