Making Every Baby Count

• Family- or patient-related: e.g. late or no antenatal care; cultural inhibition to seeking
care; limited or no knowledge of danger signs; financial constraints; partner restricts
care-seeking; use of traditional/herbal medicine; alcohol use; attempted termination.
• Administration-related: e.g. lack of or insufficient neonatal facilities, theatre facilities
resuscitation equipment, blood products or training; insufficient staff numbers; delay in
anaesthesia; lack of antenatal documentation.
• Provider-related: e.g. the partograph was not used; timely action was not taken; inappropriate
action was taken; iatrogenic birth; delay in referral; inadequate monitoring; delay
in calling for assistance; inappropriate discharge.
Box 2.2. Assigning modifiable factors at the patient/family/community level:
a word of caution
Audit participants should be wary of placing “blame” on the patient or the family when
assigning modifiable factors to a particular case. While critical delays do occur at the
community level, and there can be real individual- or family-level behaviours that lead
to a death, audit teams should guard against placing the burden of responsibility on the
woman and/or her family. One way to guard against this is to calculate the proportion
of modifiable factors that occur at the facility level and at the district/community level. If
the patient-level factors are increasing or the issues remain constant over time, question
whether there were any other factors at the point of care or elsewhere that could have
played a role. The audit committee can also examine the recommendations that have
been made and what actions have been taken. When community-related modifiable
factors are identified through audit, it is important that communities are informed of
the findings and that active members are involved in determining and implementing
the solutions.
Identification of gaps at these three basic levels can be followed by root cause analysis to
better understand underlying deficiencies in care (37). A root cause analysis helps to identify
all the problems that led to or contributed to an event – in this case, the stillbirth or
neonatal death under review. The purpose of this analysis is to identify the factors that
contributed to the death and further assess whether there are any underlying causes to
the contributing factors. This analysis may help formulate integrated strategies and recommendations.
The diagrams that are created during root cause analysis are known as
Ishikawa diagrams or fishbone diagrams, because a completed diagram can look like the
skeleton of a fish (see Annex 4 for examples).
The root cause analysis approach is adaptable, and other methodologies have been used
successfully in different settings (35). For example, the process of determining whether
adequate care was provided can also be based on a criterion-based audit against national
standards, as implemented in Uganda (38) and South Africa (39). Assessing the care
provided against a limited set of existing standards for availability of equipment, medication
and staff by level of service has the potential to be less subjective than the methods
described above (38, 40). Additional guidance for classifying modifiable factors with varying
levels of complexity and detail is provided in Annex 4.
26 MAKING EVERY BABY COUNT: AUDIT AND REVIEW OF STILLBIRTHS AND NEONATAL DEATHS