Approaches, enablers, barriers and outcomes of implementing facility-based stillbirth and neonatal death audit in LMICs: a systematic review

PurposeTo identify approaches, enablers, barriers and outcomes of facility stillbirth and neonatal death audit in low-income and middle-income countries (LMICs).Data sourcesWe searched MEDLINE, CINAHL Complete, Academic Search Index, Science Citation Index, Complementary index and Global health electronic databases.Study selectionStudies were considered eligible when reporting the approaches, enablers, barriers and outcomes of facility-based stillbirth and neonatal death audit in LMICs.Data extractionTwo authors independently performed the data extraction using predefined templates made before data extraction.Results of data synthesisA total of 10 articles from 7 countries were included in the final analysis. Facility or external multidisciplinary teams performed death audits on a weekly or monthly basis. A total of 1018 stillbirths and neonatal deaths were audited. Of 18 audit enablers identified, nine were at the health provider level while 18 of 23 barriers to audit that were identified occurred at the facility level. The facility-level barriers cited by more than one study included: failure to implement change; inadequate training; limited time; increased workload; too many cases and poor documentation. Six studies reported that death audits resulted in structural improvements in physical structure, training, service organisation, supplies and equipment in the wards. Five studies reported that death audits improved the standard of care, with one study showing a significant improvement in measured standards. One study reported a significant reduction in newborn mortality rate of 29.4% (95% CI 0.6% to 2.4%; p=0.0015) and one study a reduction in perinatal mortality of 4.9% (52.8% in 2007 to 47.9% in 2008) before and after perinatal audit implementation.ConclusionStillbirth and neonatal death audit improves facility structures, processes of care and health outcomes in neonatal care. There is a need to enhance enablers and address barriers identified at both health provider and facility levels to improve the audit process.

Evolution of infant mortality in Ukraine

Over the past decades in Ukraine, the unfavorable indicators of population reproduction, the state of health of women and children, acquired in the previous period, have become persistent, one of the integrative indicators of which is the mortality of children under one year of age. The infant mortality rate is a sensitive indicator of the general sanitary and socio$economic well-being of the country, a strategic indicator of the health and survival of children, the level and quality of medical and social care, and the effectiveness of obstetric and pediatric services. Purpose — to study, analyze and determine the general and regional features of the state and dynamics of infant mortality and its components in Ukraine. Materials and methods. A retrospective analysis and assessment of the dynamics of infant mortality in Ukraine for the period 1990–2019 was carried out in the context of regions and separate states according to state and industry statistics, perinatal audit for the methodology of the WHO «MATRIX-BABIES». Methods of a systematic approach, statistical, graphic representation are applied. Results. The study found that the unfavorable demographic situation in Ukraine is accompanied by a still high, with a positive trend, the mortality rate of children in the first year of life — 12.8‰ in 1990, and 7.0‰ in 2019 (loss rate — 30.9%), a direct dependence of infant mortality rates on indicators of total fertility (r=0.340) and morbidity in children in the first year of life (r=0.888) was found with an excess of mortality under 1 year in boys compared with girls (OR with 95% CI 1.1 (1.0–1.2). Infant mortality rates are relatively low, below the average for Ukraine, in Vinnitsa, Volyn, Kyiv, Lviv, Poltava, Ternopil, Khmelnitsky regions and City Kyiv, and above average — in Dnepropetrovsk, Donetsk, Transcarpathian, Kharkiv regions. The decrease in the overall infant mortality rate was due to the positive dynamics of all its components — early neonatal (5.8‰ in 1990, 3.04‰ in 2019), neonatal (7.3‰, 4.57‰) and postneonatal mortality (5.7‰, 2.52‰, respectively) with a more intensive decrease in postneonatal mortality (rate of decline — 55.8%). However, there are doubts that the registered data on neonatal mortality, as well as on infant mortality in general, are real, since according to the perinatal audit data, the «MATRIX-BABIES» method revealed an underestimation of early neonatal mortality — an underestimation of its real level in general by 2.1–2.3 times. It is shown that the infant mortality rate has decreased from all the main causes of mortality with a more accelerated rate of decrease in infant losses from exogenous, manageable causes — respiratory diseases (rate of decline — 83.7%), infectious and parasitic diseases (rate of decline — 80.7%). At the same time, the key causes of mortality in children under 1 year of age throughout the entire observation period remain separate conditions that arise in the perinatal period (52.8–38.4 per 10,000 live births) and congenital malformations, deformities, and chromosomal abnormalities (38,6–17.2 per 10,000 live births). It was found that against the background of a decrease in infant losses in the structure of infant mortality by 43.2%, the part of mortality from certain conditions of the perinatal period increased with a significant decrease in the part of losses from exogenous causes of death — respiratory diseases by 66.7%, some infectious and parasitic diseases by 57.8%. Conclusions. In general, despite the positive dynamics of all components of infant mortality, its level characterizes a pronounced lag behind developed countries, and according to the rating of the countries of the world as of 2018, Ukraine ranks 61st among 193 countries of the world and administrative territories without state status. The research was carried out in accordance with the principles of the Helsinki Declaration. The study protocol was approved by the Local Ethics Committee of these Institutes. The informed consent of the patient was obtained for conducting the studies. No conflict of interest was declared by the authors. Key words: infant mortality, morbidity, newborns, children in the first year of life.

Results of the perinatal audit of the Northwestern Federal District

Aim. To assess the results of a perinatal audit of the Northwestern Federal District and to identify opportunities for a decrease in perinatal mortality. Methods. The audit of perinatal loss was conducted in two stages: (1) remote audit audit of perinatal mortality indicators; (2) medical history audit audit of cases of perinatal death of a child based on medical documentation. Held the copy of the data from the 925 medical records for 220 cases of perinatal death. The perinatal audit of the Northwestern Federal District used the Nordic-Baltic perinatal death classification. The following statistical methods were used for statistical data processing: incidence rate of a trait was determined by using frequency tables, the statistical significance of differences was tested by using contingency tables, the Chi-square criterion, along with the Pearson correlation coefficient. The statistical significance of differences in quantitative indicators was assessed by using Student's t-Test. The significance level was set at p 0.05. Results. It was found that in the Northwestern Federal District pregnancy losses III category of the Nordic-Baltic classification (gestational age newborn, more than 28 weeks, without congenital malformations and intrauterine growth restriction) is 27.5%, intranatal losses VI category of the Nordic-Baltic classification (gestational age newborn, more than 28 weeks, without congenital malformations and intrauterine growth restriction) 7.4%, the loss of newborns VIIIXI category of the Nordic-Baltic classification (gestational age newborn, more than 28 weeks, without congenital malformations and intrauterine growth restriction) 16.9%. Among children who died during the perinatal period, children of gestational age over 28 weeks significantly predominate (p=0.003). In the nosological structure of stillbirth, most of the diseases are associated with respiratory disorders (85.9%), infectious complications are 14.1%. The main causes of death of newborns in the early neonatal period are respiratory disorders 40.0% and infectious diseases specific to the perinatal period 36.0%. The assessment of the sexual prevalence of pregnancy losses did not reveal a statistically significant difference (p=0.29). The assessment of the sexual characteristics of intranatal losses showed that boys significantly predominate (p=0.003). Conclusion. The perinatal audit revealed that, in the Northwestern Federal District, the level of the mobile reserve of perinatal losses associated with managed causes is 51.8%.

Investigating the benefits and challenges of including bereaved women in research: a multifaceted perinatal audit in a socially disadvantaged French district

ObjectivesTo describe experiences including interviews with bereaved women in a clinical audit.DesignThe data come from an audit of all stillbirths and neonatal deaths at ≥22 weeks of gestation in Seine-Saint-Denis, a disadvantaged French district in 2014. We included bereaved women using a questionnaire that also contained open-ended questions administered in an interview format by a midwife-investigator several weeks after the death. The study included a referral protocol for bereaved women with unmet needs revealed during the interviews. A psychological support for the three midwife-investigators was set-up, in the form of a support group.SettingThe 11 maternity hospitals in the district.Participants218 women (227 deaths).AnalysesData come from medical records, maternal interviews, the reviews of the audit’s expert panel and written narratives of their experiences provided by the midwife-investigators. Quantitative data were analysed statistically, and qualitative data thematically.ResultsOne-third (75) of the women agreed to an interview, but acceptance ranged from 6% to 60% by maternity unit. Characteristics of respondents and non-respondents were similar. Members of the audit’s expert panel reported that 41% of the interviews contained new information relevant to their assessment. Of the women interviewed, 35% were referred to a medical professional, psychologist or social worker. Midwife-investigators’ experiences illustrated the benefits of a support group with three main themes identified: improving their interactions with bereaved women as well as medical teams and protecting their psychological well-being.ConclusionThese results showed that including interviews with bereaved women in audit designs was feasible and provided valuable information on women’s care and social circumstances that were not available in medical records. They also highlight the importance of implementing referral protocols for the bereaved women, used in over one-third of cases, as well as providing support for study investigators.

ASSESSMENT OF RISK FACTORS AND DETERMINING THE LEVEL OF PREVENTABLE FETAL DEATH IN WOMEN WITH TROUBLED PREGNANCY

Objective: To examine the risk factors of stillbirth in the Republic of Tajikistan. Methods: Maps of individual observation of the course of pregnancy and the history of births of women with antenatal and intranatal fetal death in institutions of III and II levels have been studied. Retrospectively has been conducted the clinical audit of 187 cases of stillbirth. Results: The main causes of stillbirths were intrauterine growth retardation syndrome and fetal malformations. The most common risk factors for stillbirth were factors associated with inadequate medical care and factors related to family and women. At the same time, most of the cases of antenatal fetal death (83%) and intranatal fetal death (74%) were preventable or conditionally preventable. Conclusions: Our research confirms the need for perinatal audit, which aims to find the causes and risk factors of stillbirth with the subsequent implementation of solutions to prevent such cases of stillbirths in the future. Keywords: Stillbirths, antenatal fetal death, intranatal fetal death, classification of the ReCoDe, risk factors, levels of, levels of preventable stillbirth

A qualitative perinatal audit at a rural health facility in Eldoret, Kenya

Background: Objectives of the study were to ascertain the pattern of occurrence of perinatal mortality by applying the World Health Organization (WHO), International Classification of Diseases, tenth revision (ICD-10) to deaths during the perinatal period, ICD perinatal mortality (ICD-PM), following the introduction of a qualitative perinatal audit process at a rural health facility in Kenya.Methods: A single centre retrospective analysis demonstrating the application of the WHO, ICD-PM. Data pertaining to perinatal deaths for the period from 1st May 2017 to 31st August 2018 was obtained from Plateau Mission Hospital perinatal audit records.Results: There were 22 perinatal deaths during the study period, 17 were included in the study. The overall perinatal death rate was 11 per 1000 births. Antepartum deaths were as a consequence of fetal growth related problems (33.3%), infection (33.3%) or unexplained (33.3%) with pregnancy-related hypertensive disorders (gestational hypertension, pre-eclampsia and eclampsia) being the most frequent medical condition associated with the mortalities. Neonatal deaths (47.1%) were the most frequent in the study and were a consequence of low birth weight and prematurity (25.0%), Convulsions and disorders of cerebral status (25.0%). The maternal condition in most of these cases being complications of placenta, cord and membranes. Acute intrapartum events and were least in this setting accounting for 17.4% of deaths.Conclusions: The ICD-PM is generalizable and its use in perinatal death classification emphasises focus on both mother and baby. Our study showed the majority of perinatal deaths occurred in the early neonatal period & affected mostly preterm infants.

The Relationship of Rates and Causes of Stillbirth to Obstetric Facility Level

Study Objective: To compare the rates and causes of stillbirth in level 2 and 3 obstetric institutions. Study Design: This was a retrospective group study. Materials and Methods: Statistical data and labor and delivery histories of women who experienced stillbirth and were admitted to obstetric facilities (two level 2 facilities and one level 3 facility) between January and June 2019 were reviewed. Retrospective analysis was done of their labor and delivery histories, and the cases of stillbirth were clinically analyzed, using the ReCoDe classification. Study Results: The frequency of stillbirth was higher in the level 3 hospital. Irrespective of the level of hospital, mortality in the antenatal period dominated (four out of six cases in the level 2 facilities and 104 out of 129 in the level 3 facility); it was more often due to congenital malformations in the level 2 facilities and to intrauterine growth restriction (IUGR) or placental insufficiency in the level 3 facility. In the level 3 hospital, the most common causes of intranatal fetal death included maternal (pre-eclampsia and extragenital diseases) and fetal (IUGR) disorders that developed before labor. The risk factors for stillbirth were inadequate quality of medical services and factors related to the woman or family, such as late registration for prenatal care, non-compliance with doctors’ recommendations, etc. Conclusion: The actual causes, as established in this study, of negligence leading to stillbirth demonstrate that there is potential for reducing perinatal mortality. Keywords: stillbirth, antenatal and intranatal fetal death, ReCoDe classification, causes of stillbirth, perinatal audit.