Making Every Baby Count

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If a “delay 1” is present, circle “delay 1” and describe the delay at the end of this line.
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If no delay 1 is identified, circle “not identified”.
• Delay 2: Delay in reaching care (e.g., a labouring woman may not be able to find or
afford expedient transportation to a care facility).
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If a “delay 2” is present, circle “delay 2” and describe the delay at the end of this line.
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If no “delay 2” is identified, circle “not identified”.
• Delay 3: Delay in receiving adequate care (e.g., a labouring woman may arrive at a hospital
where no clinicians are available to provide any care to her, or her transfer between
lower- and higher-level facilities may take too long to provide effective care and prevent
stillbirth).
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If a “delay 3” is present, circle “delay 3” and describe the delay at the end of this
line.
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If no “delay 3” is identified, circle “not identified”.
5.2: Modifiable factors: This section relates to modifiable factors in terms of levels of system
failure. These may be helpful to identify interventions to prevent future deaths.
• Family-level factors: Did the family of a victim of neonatal death not understand when
to seek care for their infant? Should families in their community receive any educational
campaign, or resources to help get them to a health-care facility sooner?
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If a family-level modifiable factor is present, circle “family-related” and describe the
factor(s) next to “specify”.
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If no family-level modifiable factor can be identified, circle “none identified”.
• Administration-level factors: Was transfer between lower- and higher-level facilities
inhibited by administrative barriers? Was there a stock out of any needed drugs or
equipment?
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If an administration-level modifiable factor is present, circle “administration-related”
and describe the factor(s) next to “specify”.
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If no administration-level modifiable factor can be identified, circle “none identified”.
Provider-level factors: Was a provider unable to give adequate resuscitation? Are there
needs for training or additional resources for provider use?
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If a provider-level modifiable factor is present, circle “provider-related” and describe
the factor(s) next to “specify”.
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If no provider-level modifiable factor can be identified, circle “none identified”.
Actions to address critical delays and avoidable factors:
This section is the least structured part of the form, but potentially the most important.
Participants in the perinatal death review should work together to highlight the critical
delays and avoidable factors that can be targeted by interventions to avoid similar deaths
in the future. It is particularly helpful to ask the question: What could actually be done to
prevent a critical delay or avoidable factor?
80 MAKING EVERY BABY COUNT: AUDIT AND REVIEW OF STILLBIRTHS AND NEONATAL DEATHS