title: Prospective Audit of Avoidable Factors in Institutional Stillbirths and Early Neonatal Deaths at Tikur Anbessa Hospital in Addis Ababa, Ethiopia.
abstract: Mortality audits are being used with increasing frequency to improve health outcomes by pinpointing precisely where deficiencies in clinical care exist. We conducted a prospective audit of stillbirths and early neonatal deaths at Tikur Anbessa Hospital in Addis Ababa, Ethiopia, as part of a broader initiative to reduce perinatal mortality in the labor room and neonatal intensive care unit. Out of 1,225 deliveries that took place during the six-month study period, there were 30 stillbirths and 31 early neonatal deaths (PMR 50/1,000). A multi-disciplinary Audit Team was established and convened monthly to review standardized data collection forms that were completed for each death. It was determined that avoidable factors were present in 70% of perinatal deaths. Health worker-related factors were the most common avoidable factors identified (accounting for 84% of avoidable factors identified), followed by patient-related factors (11%) and administrative-related factors (5%). Based on the study findings, quality improvement programs that target gaps in care are being implemented on the hospital's labor room and in the neonatal intensive care unit.
authors.forename: Asrat
authors.initials: A
authors.lastname: Demise
authors.forename: Yirgu
authors.initials: Y
authors.lastname: Gebrehiwot
authors.forename: Bogale
authors.initials: B
authors.lastname: Worku
authors.forename: Jonathan M
authors.initials: JM
authors.lastname: Spector
mesh_terms: D054869:Clinical Audit; D005002:Ethiopia / Q000453:epidemiology; D005260:Female; D017052:Hospital Mortality; D006801:Humans; D007231:Infant, Newborn; D007363:Intensive Care Units, Neonatal / Q000592:standards / Q000706:statistics & numerical data; D066087:Perinatal Death / Q000517:prevention & control*; D011247:Pregnancy; D058996:Quality Improvement; D012308:Risk Management / Q000379:methods / Q000592:standards; D050497:Stillbirth / Q000453:epidemiology