Making Every Baby Count

to their occurrence – are entered onto the fishbone diagram as the “subveins” coming off
each vein or cause line.
Step 7: Create action targets and develop actionable solutions
By this stage of the root cause analysis exercise, the fishbone diagram should show many
possible causes, problems and factors that likely contributed to the perinatal death (see
Figure A4–1). From here, the team should be able to develop actionable solutions. There
may be many problems and solutions that can be explored, but teams may choose to
focus on gaps that are actionable within their sphere of influence in the short term, while
advocating for more long-term systemic change.
To be most effective, a perinatal death review meeting can take this fishbone diagram one
step further and circle the contributing causes and subcauses that will be targeted with
action. These items are called action targets. Only causes and subcauses that can be
addressed by participants in the perinatal death review may be designated as action
targets. For example, “poverty” may be listed as a contributing factor on one of the bones.
Causes written on veins for that bone may include “lack of income”, “family poverty” and
“cost of health care”. Subveins for “cost of health care” may include “delivery fees”, “hospital
debt” and “cost of gloves”. Of all these causes and subcauses, participants in the
perinatal death review should only circle those things that they believe they can address
through intervention. For example, “cost of gloves” may be circled as an action target
if there is a programme or nongovernmental organization that may be approached for
free gloves. Alternatively, “delivery fees” may even be circled as an action target if one of
the participants is an administrator with the power to reduce or eliminate those fees. In
contrast, “lack of income” should never be circled, because the perinatal death review
participants have no way to intervene in that particular issue. To provide an even more
extreme example, “poverty” itself should never be circled as an action target: this would
unfortunately be unrealistic.
Step 8: Create action spears
The perinatal death review meeting participants can then add arrows or “action spears”
to the fishbone diagram that point to these action target circles and specify on the end of
these spears:
1. who will take the action
2. what action will be taken
3. when will the action be taken.
These action spears represent the power to prevent future perinatal deaths.
96 MAKING EVERY BABY COUNT: AUDIT AND REVIEW OF STILLBIRTHS AND NEONATAL DEATHS