Making Every Baby Count

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TABLE 2.1. Mortality rate definitions and data sources Indicator Numerator Denominator* Data sources Stillbirth rate For international comparison: Number of babies born per year with no signs of life weighing ≥ 1000 g and after 28 completed weeks of gestation (ICD-10 also recommends including the number of deaths in fetuses born after ≥ 22 weeks of gestation or weighing ≥ 500 g) 1000 total (live and stillborn) births • CRVS • Household surveys • HMIS and audit systems (often facility-based deaths only) • Estimation models Neonatal mortality rate Number of live born infants per year dying before 28 completed days of age 1000 live births Perinatal mortality rate Definitions vary: • Number of deaths in fetuses born weighing ≥ 1000 g and after 28 completed weeks of gestation, plus neonatal deaths through the first 7 completed days after birth • Number of deaths in fetuses born weighing ≥ 500 g and after 22 completed weeks of gestation, plus neonatal deaths through the first 7 completed days after birth • Some definitions include all neonatal deaths up to 28 days 1000 total (live and stillborn) births ICD-10: International Classification of Diseases version 10; CRVS: civil registration and vital statistics; HMIS: health management information system. * The time period is normally calculated per year. Source: Moxon et al., 2015 (9). Definitions also vary for the perinatal mortality rate. Perinatal mortality refers to the number of stillbirths and deaths within the first week of life (early neonatal mortality), but the stillbirth definition varies to include stillbirths of either greater than 22 completed weeks or greater than 28 completed weeks of gestation. Some definitions of perinatal mortality also include the late neonatal period, or even up to 6 weeks (29). 2.3 Medical causes of death It is important to emphasize the difference between audit data collected for review meetings and analysis, and routinely collected data that fit standard, official definitions. The official definitions – e.g. those that are used on death certificates – should not be changed for the purposes of audit. Rather, the flexibility in definitions should only be used for the purposes of death review, to generate the most effective learning cases which link to solutions and improvement of services. Annex 1 provides a death case review form with suggested programmatically relevant categories of causes of death for stillbirths and neonatal deaths. 20 MAKING EVERY BABY COUNT: AUDIT AND REVIEW OF STILLBIRTHS AND NEONATAL DEATHS
Classifying causes of stillbirths and neonatal deaths A globally unifying approach to the classification of stillbirths and neonatal deaths is important if we are to share a common language around the causes of stillbirths and neonatal deaths and make meaningful comparisons across settings. Thus perinatal deaths should be classified using The WHO application of ICD-10 to deaths during the perinatal period: ICD-PM (25), which builds on the features of many other classification systems (25, 30, 31) and is applicable in all settings (25, 32, 33). Application of ICD-PM to audit ICD-PM is an application of ICD-10 that groups the ICD codes used to classify perinatal causes of death and those used to classify the maternal condition at the time of death, to facilitate straightforward and consistent capture that makes it easy to identify where programme intervention should be targeted to impact the health of both mother and baby (25). Classifying a stillbirth or neonatal death using modified ICD-PM guidance applicable to perinatal mortality audit is a three-step process: 1. Classify the type of death based on timing as one of the following: • Antepartum (“macerated” stillbirth) • Intrapartum (“fresh” or “non-macerated” stillbirth) • Stillbirth, unknown timing • Neonatal death (hours and/or days since birth). 2. Identify the main disease or condition that caused the stillbirth or neonatal death. All of the ICD-10 codes that can be assigned to sections (a) and (b) on the death certificate (see Table 2.2) are represented in the following new broad categories, which are included on the Stillbirth and Neonatal Death Case Review Form (Annex 1) and in the Births and Deaths Summary Form (Annex 2): • congenital • antepartum complications • intrapartum complications • complications of prematurity • infection (select: tetanus, sepsis, pneumonia, meningitis, syphilis, diarrhoea, other) • other cause of stillbirth or neonatal death • unknown/unspecified. 3. Identify the disease or condition of the mother. The audit team should determine the maternal condition at the time of diagnosis of the perinatal death. The maternal condition at the time of perinatal death may not be the direct cause of the death but is the principal maternal condition at the time; it should be considered reasonably integrated into the pathway leading to perinatal death (e.g. hypertensive disease in a macerated stillbirth, urinary tract infection in preterm birth). If there is no maternal condition (i.e. mother is healthy), this should be documented. The definition of no contributory maternal condition identified at the time of perinatal death is “the absence of any maternal medical condition or deviation from standard intrapartum progress”. Specific conditions are grouped into the following broad categories, based on guidance in The WHO MAKING EVERY BABY COUNT: AUDIT AND REVIEW OF STILLBIRTHS AND NEONATAL DEATHS 21
Page 1 and 2: Making Every Baby Count Audit and r
Page 3: Making Every Baby Count Audit and r
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 22 and 23: 2 Definitions and classification Th
Page 24 and 25: There are also numerous ways to app
Page 28 and 29: application of ICD-10 to deaths dur
Page 30 and 31: Box 2.1. Background and contextual
Page 32 and 33: • Family- or patient-related: e.g
Page 34 and 35: 3 Auditing deaths that occur at the
Page 36 and 37: Within each facility, at least two
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
Page 50 and 51: (e.g. individuals who conduct routi
Page 52 and 53: The most effective mechanism for in
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
Page 62 and 63: will help facilitate the process fo
Page 64 and 65: Maternal and Perinatal Death Review
Page 66 and 67: 6 Scaling up audit for quality and
Page 68 and 69: FIGURE 6.1. Dimensions of a phased
Page 70 and 71: FIGURE 6.2. Example of data flow in
Page 72 and 73: References 1. Maternal death survei
Page 74 and 75: 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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