title: Suboptimal care and perinatal mortality in ten European regions: methodology and evaluation of an international audit.
abstract: BACKGROUND
  A European concerted action (the EuroNatal study) investigated differences in perinatal mortality between countries of Europe. This report describes the methods used in the EuroNatal international audit and discusses the validity of the results.
  
  
  METHODS
  Perinatal deaths between 1993 and 1998 in regions of ten European countries were identified. The categories of death chosen for the study were singleton fetal deaths at 28 or more weeks of gestational age, all intrapartum deaths at 28 or more weeks of gestational age and neonatal deaths at 34 or more weeks of gestational age. Deaths with major congenital anomalies were excluded. An international audit panel used explicit criteria to review all cases, which were blinded for region. Subjective interpretation was used in cases of events or interventions where explicit criteria did not exist. Suboptimal factors were identified in the antenatal, intrapartum and neonatal periods, and classified as 'maternal/social', due to 'infrastructure/service organization', or due to 'professional care delivery'. The contribution of each suboptimal factor to the fatal outcome was listed and consensus was reached on a final grade using a procedure that included correspondence and plenary meetings.
  
  
  RESULTS
  In all regions combined, 90% of all known or estimated cases in the selected categories were included in the audit. In total, 1619 cases of perinatal death were audited. Consensus was reached in 1543 (95%) cases. In 75% of all cases, the grade was based on explicit criteria. In the remaining cases, consensus was reached within subpanels without reference to predefined criteria. There was reasonable to good agreement between and within subpanels, and within panel members.
  
  
  CONCLUSIONS
  The international audit procedure proved feasible and led to consistent results. The results that relate to suboptimal care will need to be studied in depth in order to reach conclusions about their implications for assessing the quality of perinatal care in the individual regions.
authors.affiliation: Department of Public Health, Erasmus Medical Center Rotterdam, Rotterdam, The Netherlands.
authors.forename: J H
authors.initials: JH
authors.lastname: Richardus
authors.forename: W C
authors.initials: WC
authors.lastname: Graafmans
authors.forename: P
authors.initials: P
authors.lastname: Bergsjø
authors.forename: D J
authors.initials: DJ
authors.lastname: Lloyd
authors.forename: L S
authors.initials: LS
authors.lastname: Bakketeig
authors.forename: E M
authors.initials: EM
authors.lastname: Bannon
authors.forename: M
authors.initials: M
authors.lastname: Borkent-Polet
authors.forename: L L
authors.initials: LL
authors.lastname: Davidson
authors.forename: P
authors.initials: P
authors.lastname: Defoort
authors.forename: A Esparteiro
authors.initials: AE
authors.lastname: Leitão
authors.forename: J
authors.initials: J
authors.lastname: Langhoff-Roos
authors.forename: A Moral
authors.initials: AM
authors.lastname: Garcia
authors.forename: N E
authors.initials: NE
authors.lastname: Papantoniou
authors.forename: M
authors.initials: M
authors.lastname: Wennergren
authors.forename: M P
authors.initials: MP
authors.lastname: Amelink-Verburg
authors.forename: S P
authors.initials: SP
authors.lastname: Verloove-Vanhorick
authors.forename: J P
authors.initials: JP
authors.lastname: Mackenbach
mesh_terms: D005060:Europe / Q000453:epidemiology; D005260:Female; D006801:Humans; D007226:Infant Mortality; D007231:Infant, Newborn; D008427:Maternal Health Services / Q000592:standards* / Q000706:statistics & numerical data*; D008485:Medical Audit / Q000379:methods / Q000592:standards*; D011247:Pregnancy; D011785:Quality Assurance, Health Care; D011795:Surveys and Questionnaires