title: Perinatal mortality audit: counting, accountability, and overcoming challenges in scaling up in low- and middle-income countries.
abstract: 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.
authors.affiliation: MRC Maternal and Infant Health Care Strategies Research Unit, University of Pretoria, Pretoria, South Africa. robert.pattinson@up.ac.za
authors.forename: Robert
authors.initials: R
authors.lastname: Pattinson
authors.forename: Kate
authors.initials: K
authors.lastname: Kerber
authors.forename: Peter
authors.initials: P
authors.lastname: Waiswa
authors.forename: Louise T
authors.initials: LT
authors.lastname: Day
authors.forename: Felicity
authors.initials: F
authors.lastname: Mussell
authors.forename: S K
authors.initials: SK
authors.lastname: Asiruddin
authors.forename: Hannah
authors.initials: H
authors.lastname: Blencowe
authors.forename: Joy E
authors.initials: JE
authors.lastname: Lawn
mesh_terms: 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