Perinatal mortality audit: counting, accountability, and overcoming challenges in scaling up in low- and middle-income countries.
BACKGROUND
In high-income countries, national mortality audits are associated with improved quality of care, but there has been no previous systematic review of perinatal audit in low- and middle-income settings.


OBJECTIVE
To present a systematic review of facility-based perinatal mortality audit in low- and middle-income countries, and review information regarding community audit.


RESULTS
Ten low-quality evaluations with mortality outcome data were identified. Meta-analysis of 7 before-and-after studies indicated a reduction in perinatal mortality of 30% (95% confidence interval, 21%-38%) after introduction of perinatal audit. The consistency of effect suggests that audit may be a useful tool for decreasing perinatal mortality rates in facilities and improving quality of care, although none of these evaluations were large scale. Few of the identified studies reported intrapartum-related perinatal outcomes. Novel experience of community audit and social autopsy is described, but data reporting mortality outcome effect are lacking. There are few examples of wide-scale, sustained perinatal audit in low-income settings. Two national cases studies (South Africa and Bangladesh) are presented. Programmatic decision points, challenges, and key factors for national or wide scale-up of sustained perinatal mortality audit are discussed. As a minimum standard, facilities should track intrapartum stillbirth and pre-discharge intrapartum-related neonatal mortality rates.


CONCLUSIONS
The effect of perinatal audit depends on the ability to close the audit loop; without effectively implementing the solutions to the problems identified, audit alone cannot improve quality of care.
Pattinson
Robert
R
MRC Maternal and Infant Health Care Strategies Research Unit, University of Pretoria, Pretoria, South Africa. robert.pattinson@up.ac.za
Kerber
Kate
K
Waiswa
Peter
P
Day
Louise T
LT
Mussell
Felicity
F
Asiruddin
S K
SK
Blencowe
Hannah
H
Lawn
Joy E
JE
D003906:Developing Countries; D005260:Female; D005313:Fetal Death / Q000453:epidemiology* / Q000517:prevention & control; D006801:Humans; D008427:Maternal Health Services / Q000458:organization & administration; D008485:Medical Audit / Q000458:organization & administration*; D007744:Obstetric Labor Complications / Q000453:epidemiology* / Q000517:prevention & control; D018743:Perinatal Care / Q000458:organization & administration; D054238:Perinatal Mortality; D011247:Pregnancy