Making Every Baby Count

2.5 Modifiable factors
A modifiable factor is something that may have prevented the death if a different course
of action had been taken. Many modifiable factors involve missed opportunities within the
health system. Identifying these modifiable factors, therefore, can offer potential for positive
change. For example, in the case of a neonatal death it may be noted that the birth
attendant did not provide bag and mask resuscitation when the baby did not respond to
vigorous stimulation. In this case, there may have been a missed opportunity to avoid the
situation or provide corrective action – failure to train birth attendants on resuscitation, or
to provide a bag and mask in the delivery room.
Documenting the contributing and potentially modifiable factors related to each death
is a priority in a mortality audit for stillbirths and neonatal deaths because it provides
an opportunity to change behaviours and systems. Although at first glance a death may
appear to be due to a single biological cause, further analysis usually reveals a number of
contributing factors or underlying causes. Often by exploring the event and gaining a better
understanding of the root causes, solutions and strategies become more apparent.
Examination of these factors provides insight into whether each death may have been preventable
and potential solutions that may prevent similar deaths in the future.
The terminology used to describe this concept varies, including “avoidable factors”, “elements
of substandard care”, among others. “Modifiable factors” is the term used in this
guide, to limit the opportunity for blame and point to elements of care that are potentially
amenable to change.
There are also multiple systems and approaches for classifying modifiable factors (35). The
death case review form (Annex 1) proposes a simple approach which identifies and categorizes
modifiable factors in a few ways. The first proposed method uses the well-known
“three delays” model (36):
• Delay 1: Were the mother, father or other family members unaware of the need for skilled
care for the mother during pregnancy and birth, and for mother and baby in the neonatal
period? Were they unaware of the warning signs of problems during pregnancy or
in newborn infants, or were they reliant on harmful traditional medicine and practices?
Were there any other sociocultural factors or barriers? (see Box 2.2)
• Delay 2: The necessary maternal and/or neonatal health services did not exist, or were
inaccessible for other reasons. Was distance or cost a factor? If there was a delay in travelling
to the health-care facility after a problem was identified, what were the reasons for
this?
• Delay 3: The care the mother and baby received at the health-care facility was not timely
or was of poor quality. Was this due to provider error, lack of supplies or equipment, or
poor management?
In addition, identifying the level at which a system breakdown may have occurred provides
more detail on the potential for action to prevent future deaths. The levels detailed in the
death case review form in Annex 1 include:
MAKING EVERY BABY COUNT: AUDIT AND REVIEW OF STILLBIRTHS AND NEONATAL DEATHS
25