Making Every Baby Count

3.1 Setting up the system
In many health-care facilities, local in-house mortality reviews are conducted as standard
clinical practice and risk management. This is not always the case, however, even in facilities
where there are large, multidisciplinary teams operating in well-resourced settings;
but often some form of review is part of an ongoing quality improvement processes. A
good principle is to review what already exists, start small and scale up gradually. A phased
approach to scaling up may be applied: following introduction and institutionalization in
one or a few facilities, expand the audit system to other locations, moving towards greater
coverage (Figure 3.1). This chapter describes the process of introducing the mortality audit
approach at an individual health-care facility, while the process of scaling up to a regionalor
national-level system is described in Chapter 6.
A positive enabling environment at the national and/or regional level will make it easier to
move through the various phases of the mortality audit process, but it is possible for an inhouse
process to start and thrive without initial external support from authorities at that
level. In the pre-implementation phase, the right stakeholders need to be involved to establish
the programme and raise awareness about it. In some settings, audits may be linked
to existing quality improvement initiatives. If a quality improvement committee is already
in place, it can be engaged to support the formation of a facility-level steering committee
that will prepare cases for review and rotate facilitation of the audit meetings (Annex 5).
This committee could be combined with an existing maternal death review committee, or
just closely linked to it (Box 3.1), but either way, the committee should be well institutionalized
within the system. The steering committee’s role includes the overall responsibility for
operationalizing the audit policy, providing technical assistance for the implementation of
audit systems, and monitoring recommendations and follow-through.
Midwives and obstetricians are in a natural position to lead the audit process, given
their knowledge of the burden of intrapartum deaths. In South Africa, midwives drive the
national mortality audit process, called the Perinatal Problem Identification Programme
(PPIP) (41). However, recording the details of first-day and later neonatal deaths also
requires crossover with other departments and specialities such as paediatrics, neonatal
nursing, emergency, outpatients and pharmacy. In Brazil, for example, paediatricians
hold leadership positions on perinatal review committees. In Uganda, stillbirth and neonatal
death review has been successfully initiated and sustained by midwives and community
representatives (42). A facility-based mortality audit committee should include representatives
of various departments, and stakeholders from among the facility’s management
team and the district medical office as well as a community liaison, if applicable. In some
settings, the range of committee participants may be even further expanded (43). In the
United States, multi-agency child death review involves coroners, law enforcement officers,
child protective services and health-care providers (44), and in England, each local authority
has established a multidisciplinary child death overview panel to review all child deaths
(from birth to age 18) in their area (45). However, such a wide stakeholder group is not
essential. Involving the legal system, in particular, can undermine a collaborative environment
in which shortcomings in care are openly discussed. While accountability is needed,
the mortality audit process should focus on the ability of health professionals to identify
opportunities to improve the health system, not assign blame.
MAKING EVERY BABY COUNT: AUDIT AND REVIEW OF STILLBIRTHS AND NEONATAL DEATHS
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