Making Every Baby Count

1.1 What is this guide about?
The timely dissemination of reliable data about the numbers and causes of death to those
who need them for taking action is essential for planning and implementing health services
(1). A systematic analysis of mortality trends and events leading to deaths can help
identify system breakdowns and provide information on local solutions to address deficiencies
in service delivery. This process of mortality audit and feedback shows a greater
impact on health-care practices and outcomes than other quality improvement strategies,
particularly in settings where the audit process includes an action plan and clear targets
and when there is greater opportunity for improvement in all sectors and at all levels (2).
Maternal death surveillance and response (MDSR) is becoming an increasingly popular
strategy for collecting data linked to routine health systems recording how many maternal
deaths occurred, where the women died, why they died, and what could be done differently
to prevent similar deaths in the future (1, 3). The process of routine identification and timely
notification of deaths is a continuous action cycle that can link quality improvement from
the local to the national level. Although women and their babies share the same period of
highest risk, often with the same health workers present, less information has been captured
for stillbirths and neonatal deaths than for maternal deaths. Even basic information about
each birth and death is limited, and the practice of reviewing deaths is not widespread.
This guide sets out key steps towards introducing a system for capturing the number and
causes of all stillbirths and neonatal deaths, and reviewing selected individual cases for
systematic, critical analysis of the quality of care received, in a no-blame, interdisciplinary
setting. The steps of the audit cycle are described, namely: identifying cases, collecting
information, analysing data, recommending solutions, implementing changes, and evaluating
and refining the process. When information on deaths is aggregated to demonstrate
trends, and individual deaths are systematically reviewed to identify common modifiable
factors, solutions emerge to address bottlenecks that may not be otherwise apparent when
individual cases are viewed in isolation.
With regard to terminology used in this guide, some readers will be more familiar with the
term “audit”, which is an established term in clinical practice, while others are more familiar
with the term “review” as used in the context of MDSR (1). Experts who contributed
to the development of this guide have suggested that the use of both of these terms is
acceptable and thus they are used essentially interchangeably in many parts of this guide.
A mortality audit can have multiple entry points into the health system, ranging from a single
hospital to a nationally mandated programme covering all health-care facilities and
communities. This guide presumes that, at a minimum, all health-care facilities that provide
care during childbirth can institute interdisciplinary review of stillbirths and neonatal
deaths as part of standard practice. Around the world, more births are taking place in
health-care facilities than ever before (4). This guide uses the review of deaths in healthcare
facilities as an entry point to a broader system-wide approach. Generally, there is more
information available about deaths that occur in facilities than those that happen in the
community, and it is easier for health-care providers to review and learn from them. However,
there is a need to ensure that all births and deaths are counted – and count – no
matter where they occur.
MAKING EVERY BABY COUNT: AUDIT AND REVIEW OF STILLBIRTHS AND NEONATAL DEATHS
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