Making Every Baby Count

5.1 Creating an enabling environment to effect change
Evidence from countries that have functional mortality audit systems for maternal deaths,
stillbirths and neonatal deaths shows the importance of an enabling environment for
implementation of change at all levels. Change is undertaken by individuals doing the right
thing at the right time. How does this change occur?
Interventions are not implemented in a vacuum; individuals must be held accountable
with appropriate follow-up, and change agents are needed to lead the way. At the national
level, support from senior managers in the ministry of health is essential. As individuals
within facilities or through a formal stewardship body at national level, leaders have the
ability to create a culture of accountability at all levels. This should involve correction but
also celebration, affirmation, encouragement and reward (47). Supportive administrators
and health professionals can make all the difference between success and failure (3).
In practical terms, one way of creating this environment at the national level is by linking
mortality audit for stillbirths and neonatal deaths to maternal audit where MDSR is
being implemented, in concert with national health goals and mortality reduction targets.
A national implementation plan may be guided by a working group at the ministry of
health, with involvement of other key experts. Understanding the linkages and interactions
between ministries and their partners is critical to the development of multisectoral programme
coordination and implementation. Under the guidance of the ministry of health,
the roles and responsibilities of various departments, ministries, professional associations,
the private sector and other relevant partners should be identified. The active involvement
of professional associations (e.g. neonatologists, obstetricians, paediatricians, midwives
and nurses) is critical, as is the participation of other stakeholders (e.g. hospital administrators,
social scientists, epidemiologists, information system specialists, health planners,
monitoring and evaluation personnel, civil society representatives).
5.2 Legal and ethical issues
Legal protection
To ensure that a mortality audit is initiated in a safe environment for open discussion
among staff, it is important to consider the legal and ethical issues that come into play
when investigating stillbirths and neonatal deaths. The laws and customs of a particular
country or culture can have a significant impact in terms of facilitating or hindering access
to information, the involvement of families and health professionals, the conduct of the
review, and the ways the findings are used. In some countries with a high level of malpractice
litigation, fear of lawsuits has limited data collection and the use of mortality audit
processes.
While the principles of mortality auditing may be standard across settings, legal aspects
can vary from one country to another. In addition to having participants agree to and
sign a code of practice before each review meeting (Annex 6), it may be beneficial to have
administrators seek local legal counsel early in the process of establishing a mortality audit
committee and process, to ensure the protection of staff and patients throughout the process.
If a supportive health policy framework already exists for maternal death review, this
MAKING EVERY BABY COUNT: AUDIT AND REVIEW OF STILLBIRTHS AND NEONATAL DEATHS
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