Making Every Baby Count

time frames for each. It is also important that the responsibility for implementing and/or
monitoring each recommendation arising from the mortality audit meeting is assigned to
one or more team members. While recommendations based on modifiable factors that fall
under the purview of administration may be acted on quickly within a responsive management
structure (e.g. ambulance availability or lack of resuscitation equipment), it may be
more effective to first focus on the modifiable causes that are within the control of health
workers (e.g. detailed history taking and correct partograph use) and then use successes
emerging from subsequent mortality audit meetings as an advocacy tool to prompt management
to further action. In addition to following up on items that have not been completed, it
is important to celebrate progress and identify successful changes when they occur.
Lessons learnt through experience with maternal mortality audits point to three interdependent
factors contributing to recommendations resulting in successful solutions. These
factors were (i) individual responsibility and sense of ownership; (ii) a proactive institutional
ethos that promotes learning as a crucial part of improving services and quality of
care; and (iii) a supportive political and policy environment at the national and/or local
level (46, 51). In programmes where staff members were disinterested, uncooperative or
even obstructive, failure and disenchantment followed. Disenfranchisement and thus failure
to fully participate and engage with the recommended changes has been shown to arise
from an environment lacking in professionalism and self-reflective learning, where there is
a fear of blame and punishment, and disillusionment with a persistent lack of action on the
recommendations made in earlier meetings or reports (3). If, on the other hand, the audit
takes place in a forward-looking and safety conscious culture, long-lasting improvements
can be made. Healthy hospitals that support their staff understand that errors are unintentional,
and in these settings learning from adverse events is encouraged, and the leadership
open and fair. The importance of leadership within the enabling environment is discussed
in more detail in Chapter 5. Overarching conditions that lead to implementation of recommendations
from audits include good leadership, task-oriented minutes (Annex 8), staff
stability, good communication with academic departments and clinics, and the existence
of guidelines and protocols (52). Similarly, conditions hindering implementation included
poor communication between health workers and the community, frequent staff rotation,
staff shortages, unresponsive management, inadequate financial resources, poor attendance
at review meetings and an absence of skilled supervisors.
Experience from maternal death reviews indicates that a multifaceted approach is needed
to translate recommendations into action. In the QUARITE trial (53, 54), which showed a
substantial reduction in maternal mortality in low-resource facilities in Senegal and Mali, a
bundle of three interventions was implemented:
• involving opinion leaders to champion the process, the findings and the actions for
change in the local health-care facility;
• engaging a quality improvement committee that would conduct case reviews and determine
whether recommendations are being acted on; and
• strengthening the capacity of health-care professionals, using drills and simulations.
MAKING EVERY BABY COUNT: AUDIT AND REVIEW OF STILLBIRTHS AND NEONATAL DEATHS
39