Making Every Baby Count

6.1 Moving from single facilities to regional and national
levels
Once local systems for comprehensive and systematic review of stillbirths and neonatal
deaths have been institutionalized as routine practice with documented changes in practice
and quality of care, other facilities, districts or health regions within a country may
take note and explore the feasibility of adopting a similar approach. With some additional
resources to coordinate this standardized system, data can be centrally collated, tracked
and disseminated.
A larger number of deaths enables a more detailed analysis to be undertaken with a
broader population base, potentially enabling triangulation with other data sources such as
CRVS and the HMIS. In some cases, a central (national-level) committee may just gather
data from facility-based reviews and report broad trends, but in other cases a separate
review process might also be put in place at a district or regional (subnational) level. One
benefit of a regional-level review is that the forms can be made anonymous, and assessors
from other facilities can review cases, providing an independent opinion and recommendations.
At this level, general lessons may also be derived which reveal systemic bottlenecks
and thus highlight a path towards broader changes. For example, the results may point to
the need for regional review of pre-service training procedures or transport systems.
If a decision is made to undertake a national audit programme with leadership from the
central level, there are a number of factors to be considered in a phased approach (5),
including:
• Who leads? Will coordination take place at the national level or through regional committees,
or both? Will it be governed by the ministry of health exclusively, associations
of health professionals or a multistakeholder group that includes partners, civil society,
community representatives, etc.?
• Where are deaths identified? Does the system cover just public-sector health-care facilities
or all facilities? Are deaths that occur in the community included? If so, how is
information gathered about those deaths? How does the mortality audit system feed
into or get information from the HMIS and/or CRVS?
• What is the scope of implementation? Do single facilities conduct reviews on their own,
or are they done within practice groupings or districts, or both? Is implementation mandated
or voluntary?
• What is the depth and breadth of the review process? Does the committee review a
selected sample of cases, all deaths or all deaths and near misses? How does the committee
decide which cases to review and how often?
Figure 6.1 illustrates the dimensions of this phased introduction of mortality audits from
single facilities to the national level.
Experiences from high-income countries such as Australia (64, 65), New Zealand (66),
the Netherlands (67–69) and the United Kingdom have shown the potential for sustained,
widespread implementation when there is high-level national leadership. Where local drivers
exist without an overarching national or regional coordinating body, national systems
can still arise from the ground up, as seen in South Africa (13, 41).
MAKING EVERY BABY COUNT: AUDIT AND REVIEW OF STILLBIRTHS AND NEONATAL DEATHS
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