title: Audit-identified avoidable factors in maternal and perinatal deaths in low resource settings: a systematic review.
abstract: BACKGROUND
  Audits provide a rational framework for quality improvement by systematically assessing clinical practices against accepted standards with the aim to develop recommendations and interventions that target modifiable deficiencies in care. Most childbirth-associated mortality audits in developing countries are focused on a single facility and, up to now, the avoidable factors in maternal and perinatal deaths cataloged in these reports have not been pooled and analyzed. We sought to identity the most frequent avoidable factors in childbirth-related deaths globally through a systematic review of all published mortality audits in low and lower-middle income countries.
  
  
  METHODS
  We performed a systematic review of published literature from 1965 to November 2011 in Pubmed, Embase, CINAHL, POPLINE, LILACS and African Index Medicus. Inclusion criteria were audits from low and lower-middle income countries that identified at least one avoidable factor in maternal or perinatal mortality. Each study included in the analysis was assigned a quality score using a previously published instrument. A meta-analysis was performed for each avoidable factor taking into account the sample sizes and quality score from each individual audit. The study was conducted and reported according to PRISMA guidelines for systematic reviews.
  
  
  RESULTS
  Thirty-nine studies comprising 44 datasets and a total of 6,205 audited deaths met inclusion criteria. The analysis yielded 42 different avoidable factors, which fell into four categories: health worker-oriented factors, patient-oriented factors, transport/referral factors, and administrative/supply factors. The top three factors by attributable deaths were substandard care by a health worker, patient delay, and deficiencies in blood transfusion capacity (accounting for 688, 665, and 634 deaths attributable, respectively). Health worker-oriented factors accounted for two-thirds of the avoidable factors identified.
  
  
  CONCLUSIONS
  Audits provide insight into where systematic deficiencies in clinical care occur and can therefore provide crucial direction for the targeting of interventions to mitigate or eliminate health system failures. Given that the main causes of maternal and perinatal deaths are generally consistent across low resource settings, the specific avoidable factors identified in this review can help to inform the rational design of health systems with the aim of achieving continued progress towards Millennium Development Goals Four and Five.
authors.affiliation: The Hospital for Sick Children, 555 University Avenue, Toronto ON M5G 1X8, Canada. Hasan_Merali@post.harvard.edu.
authors.forename: Hasan S
authors.initials: HS
authors.lastname: Merali
authors.forename: Stuart
authors.initials: S
authors.lastname: Lipsitz
authors.forename: Nathanael
authors.initials: N
authors.lastname: Hevelone
authors.forename: Atul A
authors.initials: AA
authors.lastname: Gawande
authors.forename: Angela
authors.initials: A
authors.lastname: Lashoher
authors.forename: Priya
authors.initials: P
authors.lastname: Agrawal
authors.forename: Jonathan
authors.initials: J
authors.lastname: Spector
mesh_terms: D001803:Blood Transfusion; D003906:Developing Countries; D005260:Female; D006801:Humans; D007231:Infant, Newborn; D063130:Maternal Death / Q000209:etiology / Q000517:prevention & control*; D008485:Medical Audit; D019300:Medical Errors / Q000009:adverse effects*; D010342:Patient Acceptance of Health Care; D066087:Perinatal Death / Q000209:etiology / Q000517:prevention & control*; D058996:Quality Improvement