Making Every Baby Count

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2 Definitions and classification This chapter provides definitions for the key terms relating to stillbirth and neonatal death outcomes. It also introduces systems for classifying causes of death and modifiable factors, with more information and tools provided in the accompanying annexes.
2.1 Notes on terminology Before implementing a mortality audit system, it is helpful to understand the definitions and classification systems used for reporting deaths, as well as the contextual factors surrounding these deaths. As in other mortality surveillance systems, mortality audit for stillbirths and neonatal deaths includes basic descriptive analyses that include rates and proportions relating to pregnancy outcomes, medical causes, non-medical factors and contributing factors. This chapter provides an overview of these concepts. In recent years, increasing attention has been paid to neonatal survival (4, 15) and, to a lesser but still notable extent, to stillbirths (16, 17). One of the key reasons for this has been increased visibility arising from improved data and improved analysis and presentation of these data for use in policy-making and programme planning, such as the generation of annual, country-reviewed estimates of the national neonatal mortality rate. These estimates are included in global reporting and tracked in accountability frameworks, now with a longrange goal detailed in ENAP to track and drive a reduction in neonatal mortality to 12 or fewer per 1000 live births, as well as a reduction in stillbirths to 12 or fewer per 1000 total births, by 2030 (18). Determining cause of death in the absence of a post-mortem examination is challenging, particularly for stillbirths (19). Yet even in better-resourced settings, the assigned cause of death may not be programmatic or linked to obvious solutions (13, 20). The availability of programmatically relevant and technically credible estimates of what proportions of deaths are attributable to specific causes of death in each country has been another critical step in working to prevent millions of neonatal deaths (21, 22). Disparate classification systems between CVRS systems, routine HMISs and audit forms may result in duplication and inefficient documentation (23, 24). In one systematic review of 142 studies, seven different classification systems were identified for stillbirths but were applied in only 22% of studies that could have used a classification system (24). Clear guidelines and a unified, relevant classification system to assign cause of death are needed. An emerging approach that has been used in some high-income countries is to link maternal and perinatal conditions, to better address the barriers to care affecting both mother and baby. The development of The WHO application of ICD-10 to deaths during the perinatal period: ICD-PM aims to link stillbirths and neonatal deaths to contributing maternal conditions, where applicable, in a way that is consistent across all settings (25). This will help standardize and increase information on causes of death around the critical time of childbirth. The process to assign cause of death in the context of a mortality audit should be easy to apply, comparable across settings, have a good level of agreement between observers, and result in a high percentage of classifiable cases and a low percentage of unexplained causes of death. Please note that while ICD-PM is designated to be used for all antepartum, intrapartum and early neonatal deaths, it can also be used for late neonatal deaths, which – although falling outside the perinatal period as defined in ICD-10 – may be a consequence of events in the perinatal period. MAKING EVERY BABY COUNT: AUDIT AND REVIEW OF STILLBIRTHS AND NEONATAL DEATHS 17
Page 1 and 2: Making Every Baby Count Audit and r
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Page 6 and 7: 4.3 The six-step mortality audit cy
Page 8 and 9: Acknowledgements The World Health O
Page 10 and 11: Foreword Pregnancy is a time of gre
Page 12 and 13: in the future. The process of routi
Page 14 and 15: Key messages of this guide • Audi
Page 16 and 17: 1 Getting started
Page 18 and 19: 1.2 Why is this guide important? Co
Page 20 and 21: Importantly, it is not sufficient t
Page 24 and 25: There are also numerous ways to app
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Page 28 and 29: application of ICD-10 to deaths dur
Page 30 and 31: Box 2.1. Background and contextual
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Page 34 and 35: 3 Auditing deaths that occur at the
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Page 38 and 39: compared to the actual numbers of r
Page 40 and 41: of events that led to death, text b
Page 42 and 43: • the number of antepartum (or ma
Page 44 and 45: Possible actions include interventi
Page 46 and 47: Step 6: Evaluating and refining The
Page 48 and 49: 4 Auditing deaths that occur in the
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Page 54 and 55: Step 1.2: Notification and reportin
Page 56 and 57: It may be easier for an information
Page 58 and 59: Geospatial analyses may be very ben
Page 60 and 61: 5 Creating an enabling environment
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Page 66 and 67: 6 Scaling up audit for quality and
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References 1. Maternal death survei
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39. Bradshaw D, Chopra M, Kerber K,
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Annexes Annex 1 Stillbirth and Neon
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3.6 Fetal heart sounds on admission
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Annex 1b. Guidance for completing t
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• “unknown” if the total numb
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• If fetal heart sounds were not
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-- If a “delay 1” is present, c
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. antepartum complications Annex 2:
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2.1b: Cause of death - intrapartum
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Annex 3b. Guidance for collecting t
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3) If there is no gestational age e
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Annex 4. Approaches for classifying
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There are multiple tools available
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to their occurrence - are entered o
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Annex 6. Sample mortality audit mee
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Annex 8: Stillbirth and Neonatal Mo
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Steps 1. Understand the steps of th
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INFORMED CONSENT FORM (INTERVIEWEE
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SEQUENTIAL NUMBER SECTION 1. INTER
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SECTION 3. INFORMATION ON THE DECEA
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ASK THE RESPONDENT: What do you thi
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4.4.2 Before the woman became pregn
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4.16.2 During the last 3 months of
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5.5 How many hours or days passed b
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5.18 Would you say the baby’s siz
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5.33 Did the baby ever move, even a
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SECTION 6. NEONATAL ILLNESS HISTORY
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6.17 Did the baby have a swollen st
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SECTION 7. HISTORY OF INJURIES/ACCI
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8.7 What were the reasons the baby
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8.15.2 What difficulties did you ha
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SECTION 9. DATA ABSTRACTED FROM REC
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VA Supervisor comments and observat
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